Adult and Pediatric Obstructive Sleep Apnea

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Adult and Pediatric Obstructive Sleep Apnea

• Kevin Katzenmeyer, MD
• Ronald W. Deskin, MD
• June 5, 2002

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Obstructive Sleep Apnea

• 1-4 of population
• Pickwick Papers (1837)
• Osler (1906)
• Guilleminault (1973) - OSAS

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Obstructive Sleep Apnea

• 85 of adult patients are male
• Men 4, Female 2
• 2/3rd obese
• Contributes to HTN and cardiovascular disease
• Increased motor vehicle accidents

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Pathophysiology

• Pharyngeal collapse
• Decreased airway patency
• Increase in negative pressure
• Becomes a vicious cycle

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Pathophysiology

• Anatomic narrowing
• Requires increased inspiratory pressures
• Abnormal neuromuscular control
• Reflex activation of dilators in response to
  airway obstruction often fails

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Diagnosis
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Diagnosis

• History
• Physical examination
• Radiographs
• Polysomnogram

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History

• Snoring
• Excessive daytime sleepiness
• Restless sleep
• Personality changes
• Headaches
• Sexual dysfunction
• Job performance
• Sleep hygiene
• Bed partners input

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Physical Exam

• Vital signs
• Head Neck exam
• Flexible endoscopy

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Vital signs

• Height
• Weight
• Collar size
• Blood pressure
• Calculate BMI
• Wt (kg) / Ht (meters) squared
• Men gt27.8, Women gt27.3

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Examination

• Tongue
• Palate
• Uvula
• Tonsils
• Nasal cavity
• Hyoid
• Mandible
• Maxilla

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Mallampati classification
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Mullers Maneuver
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Exam
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Radiography

• Cephalometrics
• Computed tomography
• Magnetic resonance imaging

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Cephalometrics

• Standardized lateral radiographs
• Examines bony and soft-tissue structure
• Two-dimensional evaluation
• Lack of volumetric data
• Maxillomandibular surgery, oral appliances

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Computed tomography

• Supine
• Volumetric reconstruction
• Disadvantages
• Cost
• Weight limitations
• Ionizing radiation

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Magnetic Resonance Imaging

• Excellent soft tissue anatomy
• Multiple planes
• No ionizing radiation
• Disadvantages
• Cost
• Weight limitations
• Noisy
• claustrophobia

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Polysomnogram

• EEG
• EKG
• Submental EMG
• Anterior tibialis EMG
• EOG

• Nasal/oral airflow
• Pulse oximetry
• Respiratory movement
• Sleeping position
• Esophageal manometry

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Polysomnogram

• Obstructive apnea cessation of airflow for at
  least 10 seconds with respiratory effort
• Central apnea cessation of airflow for at least
  10 seconds without respiratory effort
• Mixed apnea characteristics of both for at
  least 10 seconds
• Hypopnea hypoventilation secondary to partial
  obstruction

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Polysomnogram

• Apnea index
• Apnea-Hypopnea index respiratory disturbance
  index
• Arousal index

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Treatment

• Nonsurgical modalities
• Surgical modalities

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Nonsurgical Treatment

• Weight loss
• Sleep hygiene
• Pharmacotherapy
• Nasal continuous positive airway pressure
• Oral appliances

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Nonsurgical Treatment

• Weight loss
• Get below trigger weight
• Diet, exercise, bariatric surgery, medications
• Sleep hygiene
• Avoidance of sedatives
• Positional changes

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Pharmacotherapy

• Protriptyline decreases REM sleep
• Xanthine based drugs
• Steroids
• Antibiotics
• Nasal medications

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CPAP

• 1981
• Very effective
• Can be modified and used on a trial basis

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CPAP
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CPAP

• Titrated to limit all respiratory events
• 50-90 acceptance better if daytime symptoms
  improved
• Side effects in 40-50

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CPAP
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CPAP
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CPAP
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Oral appliances

• Advances the mandible
• Retains the tongue anteriorly

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Oral appliances

• Most effective in nonobese patients with retro or
  micrognathia
• Better for mild to moderate cases
• 51 achieve normal sleep, 61 improved RDI lt 20
• Consider TMJ dysfunction and occlusal changes

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Surgical Treatment

• Retropalatal obstruction
• Retrolingual obstruction

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UPPP

• Fujita (1981)
• Most common procedure
• 1st line tx for retropalatal collapse
• 10-50 success

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UPPP
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UPPP
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Tongue reduction

• Lingual tonsillectomy
• Laser midline glossectomy
• Lingualplasty
• Radiofrequency volumetric tissue reduction

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Mandibular Osteotomy with Genioglossus
Advancement

• Enlarges the retrolingual airway without
  disturbing dentition
• Prevents retrolingual collapse

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Hyoid Myotomy and Suspension

• Enlarges retrolingual airspace
• Advances the tongue base and epiglottis anteriorly

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Maxillomandibular Osteotomy and Advancement

• Severe disease
• Failure with more conservative measures
• Midface, palate, and mandible advanced anteriorly
• Limited by ability to stabilize the segments and
  aesthetic facial changes

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Nasal surgery

• Improved symptoms and CPAP
• Septoplasty
• Turbinate reduction
• Functional nasal reconstruction

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Tracheostomy

• Bypasses all areas of obstruction
• Virtually 100 effective
• Two indications
• Temporary procedure during airway reconstruction
• Severe OSA when CPAP refused, ineffective, or not
  tolerated or if other conditions exacerbated by
  the apneas
• Line the tract with skin flaps
• Lack of social acceptance

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Algorithm

• Weight loss
• CPAP
• Consider oral appliances for milder cases

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Riley-Powell-Stanford Protocol
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Riley-Powell-Stanford Protocol

• Post operative PSG at 6 months
• Phase I 61 success
• Phase II 95-100 success

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Pediatric OSAS

• Many features are different
• 2 of children
• Males Females
• Peak at age 2-5
• Peak OSA Peak ATH

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Pediatric OSAS

• Snoring severity not predictive
• Many are mouth breathers
• Adenoid facies (15 have OSAS)
• Excessive daytime sleepiness
• Obesity vs. FTT
• Increased respiratory effort

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Pediatric OSAS

• Parasomnias
• Restless sleep
• Aggressive behavior
• Learning disabilities
• Enuresis

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Pediatric OSAS

• Impaired growth
• Possible impairment of release or end-organ
  response to GH
• Increased caloric effort with respiration
• Difficulty with eating
• Cor pulmonale
• Associated with GERD

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Diagnosis

• History
• Physical exam
• The child who always snores, has restless sleep
  secondary to obstruction, has apneic episodes
  per the parents virtually always has PSG
  confirmation (Brouillette)

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Polysomnogram

• Not cost effective
• Considerations
• CNS disease
• Age lt 2
• Increased surgical risks
• Family desires
• Discordant exam

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Polysomnogram
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Diagnosis

• Lateral neck radiographs
• Chest x-rays
• EKG

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Treatment

• Tonsillectomy adenoidectomy

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Treatment

• UPPP
• genioglossus advancement
• Maxillomandibular advancement
• CPAP
• Tracheotomy

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Down Syndrome

• OSAS 54-100
• Physical factors
• Small midface and cranium
• Narrow nasopharynx
• Large tongue
• Muscular hypotonia
• Obesity
• Small larynx
• Congenital heart disease / cor pulmonale
• UPPP

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Craniofacial anomalies

• Mandibular hypoplasia
• Pierre-Robin sequence
• Maxillary hypoplasia
• Treacher-Collins
• Crouzons
• Tracheotomy

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Case report

• 1 month old baby presents to ER with difficulty
  breathing, feeding, and cyanotic episodes

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