Management of pediatric OSA Suchada Sritippayawan, MD Div. Pulmonology & Critical Care Dept. Pediatrics, Faculty of Medicine Chulalongkorn University
Treatment modalities Surgery Medications NIV during sleep Orthodontic procedures
Surgical treatment Adenotonsillectomy Others - Maxillofacial surgey - Nasal turbinectomy - Tracheostomy
Adenotonsillectomy Most common surgical procedure in pediatric OSA Would be helpful in OSA caused by other etiologies: CP, Down syndrome, obesity Can be done safely in young infant if indicated
Adenotonsillectomy Efficacy OSA symptoms and AHI in 90% Complete resolution of OSA (AHI < 1/hr) in 27% Risk factors of residual OSA - Obesity - Severe OSA -Asthma AJRCM 2010; 182:676-83.
Adenotonsillectomy Risk factors of recurrent OSA Family Hx of OSA Craniofacial anomalies Down syndrome Need PSG F/U Nasal septal deviation Enlarged nasal turbinates Surgical technique??? Proc Am Thorac Soc 2008; 5:274-82. Int J Pediatr Otorhinolaryngol 2010; 74:241-4. Indian J Med Res 2010; 131:311-20.
Adenotonsillectomy Post-op op complications (18-34%;more in OSA) Early (within 1 week) Laryngospasm Local bleeding ----> Be careful with NSAIDS use Pain ----> Be careful with pain control therapy Dehydration Respiratory complications Pediatr Pulmonol 2008; 43:837-43. Paediatr Respir Rev 2006; 7S:S58-61. Anesth Analg 2009; 109:60-75.
Adenotonsillectomy Late complications: rare Velopharyngeal incompetence Nasopharyngeal stenosis Paediatr Respir Rev 2006; 7S:S58-61. Mortality rate: 1:10,000 in risked group Age < 2 yrs Severe OSA esp. associated abnormal ABG Other comorbids: Obesity Pediatr Pulmonol 2008; 43:837-43.
Adenotonsillectomy Post-op op respiratory complications : incidence 20% in risked group Desaturation Increased WOB Pulmonary edema Atelectasis Pneumothorax Anesth Analg 2009; 109:60-75. Pneumomediastinum Pneumonia PHT crisis Laryngospasm Apnea Rebound REM (after 24 hr post-op)
Adenotonsillectomy High risk for post-op op respiratory complications (need specialist and PICU care) Age < 3 yrs Severe OSA (AHI > 10, nadir SpO 2 < 70-80%) Cor pulmonale, Systemic HT FTT Morbid obesity Pediatrics 2002; 109:704-12. Premie Thorax 2005; 60: 511-6. Anesth Analg 2009; 109:60-75.
Adenotonsillectomy High risk for post-op op respiratory complications (need specialist and PICU care) URI within 4 wks prior to T&A Craniofacial anomalies Genetics & chromosomal disorders NMD Pediatrics 2002; 109:704-12. Thorax 2005; 60: 511-6. Anesth Analg 2009; 109:60-75.
Adenotonsillectomy High risk for post-op op respiratory complications (need specialist and PICU care) Mallampati score 3, 4 Associated nasal problems Enlarged lingual tonsils Pediatrics 2002; 109:704-12. Thorax 2005; 60: 511-6. Anesth Analg 2009; 109:60-75.
Medical treatment for OSA Intranasal corticosteroid High α and β glucocorticoid receptors in adenotonsillar tissues Anti-inflammatory and lympholytic actions LTRA High level of cysteinyl leukotriene in exhaled breath condensate of OSA children High expression of LTR in adenotonsillar tissues Pediatr Pulmonol 2008; 43:837-43. Chest 2004; 126:13-8. Chest 2006; 130:143-8.
Medical treatment for OSA Intranasal corticosteroid Duration of Px: 4-24 wks (mostly 4-8 wks) Various types and doses Used in mild OSA, moderate-to-severe OSA ----> OSA severity, adenoid size, T&A procedure Benefits can be lasted until 8 wks Pediatrics i 2008; 122:e149-55. 149
Medical treatment for OSA LTRA: Monteleukast Used in mild OSA for 16 wks ----> OSA severity, adenoid size Used with BUD in residual mild OSA post T&A for 12 wks ---> resolved of OSA AJRCCM 2005; 172:364-70. Pediatrics 2006; 117:e61-6.
Medical treatment for OSA Unknown issues of INS and LTR used in OSA Use in mild OSA?? Use for prevention of recurrent OSA after T&A? Use in residual OSA post T&A? Only benefit in adenoid hypertrophy, AR? Dose and duration of Px? Combine Px is better?
NIV in OSA Indications Residual OSA after surgery Obesity during weight control Craniofacial anomalies
NIV in OSA CPAP Initial CPAP 4 cmh 2 O max CPAP - 15 cmh 2 O in aged < 12 yrs - 20 cmh 2 O in aged 12 yrs Need more CPAP ----> use BPAP J Clin Sleep Med 2008; 4:157-71.
NIV in OSA BPAP Initial IPAP 8 cmh 2 O, EPAP 4 cmh 2 O max IPAP - 20 cmh 2 O in aged < 12 yrs - 30 cmh 2 O in aged 12 yrs Δ IPAP and EPAP : at least 4 cmh 2 O J Clin Sleep Med 2008; 4:157-71.
NIV in OSA Goals of CPAP and BPAP titration RDI < 5 (for at least 15 min., include REM and supine sleep) no arousal J Clin Sleep Med 2008; 4:157-71.
Oxygen therapy in OSA Use with CPAP or BPAP in CLD Temporal use only in - Prior to T&A - Post-op T&A Beware of hypoventilation ---> Need PSG or at least CO 2 monitoring during oxygen titration Clin Chest Med 2003; 24: 261-82. Pediatr Pulmonol 2008; 43:837-43.
Other Px in OSA Orthodontic procedures : Rapid maxillary expansion Clinical uses Residual OSA after T&A due to high arch palate, narrow nasal passage, deviated nasal septum Indian J Med Res 2010; 131:311-20.
Other Px in OSA Clinical uses Pediatric OSA with maxillary contraction, no ATH, no obesity Effectively reduced AHI after 4-month Px Unknown duration of Px Sleep 2004; 27:761-6. 761 6 Sleep 2007; 8:12-34
Other Px in OSA Oral appliances Tongue retaining device Mandibular repositioning device No definite indication and benefits and still need further investigations in pediatric OSA Sleep Med Rev 2009; 13:123-31.