Pediatric OSA: new therapeutic insightshopital-necker.aphp.fr/wp-content/blogs.dir/180/... · potentially fat deposition in the upper airway may play a significant role in obese children

Pediatric OSA: new therapeutic insights

Stijn Verhulst, MD, PhD

Pediatric Pulmonology and Pediatric Sleep Medicine

Antwerp University Hospital

Belgium

stijn.verhulst@uantwerp.be

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Introduction

OSAS

Adenotonsillectomy

Repeat PSG

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Introduction

• This presentation will focus on 2 parts of the pathogenesis/treatment that are becoming increasingly clinically relevant:

- Personalized treatment (focusing on obesity)

- NIV

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PERSONALIZED TREATMENT - OBESITY

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Prevalence

• Childhood obesity is associated with an increased prevalence of obstructive sleep apnea.

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Prevalence

Verhulst et al., Sleep Medicine Reviews, 2008.

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Anatomical correlates

• The exact contributions of both adenotonsillar hypertrophy and obesity to the pathogenesis of OSAS are still controversial.

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The scope of the problem

Kohler et al., Sleep Medicine Reviews, 2008.

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Anatomical correlates

• However, the relation between obesity and sleep apnea in children is complex…

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Anatomical correlates• AHI is not a unique marker of OSAS: BMI often

correlates better with other markers of the severity of sleep apnea, i.e. oxygen desaturation.

Verhulst et al., Archives of Disease in Childhood, 2007

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Anatomical correlates

Van Eyck et al., Sleep Medicine, 2014

oAHI < 2 2 < oAHI < 5 oAHI ≥ 5 P

VC (%pred)106 ± 13 103 ± 13 95 ± 15 0.01

FEV1 (%pred)104 ± 13 101 ± 14 95 ± 17 0.05

FEV1/VC (%pred) 99 ± 8 98 ± 7 101 ± 7 0.4

RVHe (%pred)89 ± 36 86 ± 35 85 ± 26 0.6

TLCHe (%pred)101 ± 21 101 ± 11 91 ± 20 0.03

FRCHe (%pred)82 ± 21 76 ± 31 65 ± 21 0.008

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Anatomical correlates

• Second, BMI is not the only marker of obesity. However, there is limited data on the association between OSAS and markers of visceral adiposity in children.

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Canapari et al., The Journal of Clinical Sleep Medicine, 2011

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Anatomical correlates

• Furthermore, the association seems to be age-dependent:

- Obese children: Adenotonsillar hypertophy > Obesity

- Obese teenagers: Obesity > Adenotonsillar hypertrophy

Kohler et al., Sleep Medicine Reviews, 2008.

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Anatomical correlates

Dayyat et al., Chest, 2009

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Anatomical correlates

Dayyat et al., Chest, 2009

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Anatomical correlates

Dayyat et al., Chest, 2009

• The magnitude of adenotonsillar hypertrophy is more likely to be smaller in obese children compared to nonobese children with comparable AHI.

• Increased Mallampati scores in obese children suggest that soft-tissue changes and potentially fat deposition in the upper airway may play a significant role in obese children with OSA.

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Anatomical correlates

Arens et al., AJRCCM, 2011

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Anatomical correlates

Arens et al., AJRCCM, 2011

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Anatomical correlates: treatment data

Costa et al., Otolaryngology–Head and Neck Surgery, 2009

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Anatomical correlates: treatment data

Costa et al., Otolaryngology–Head and Neck Surgery, 2009

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Anatomical correlates: treatment data

Bhattacharjee et al., American Journal of Respiratory and Critical Care Medicine, 2010

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Anatomical correlates: treatment data

Kalra et al., Obesity Research, 2005

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Anatomical correlates: treatment data

Definition of success Success rate (%)

Apnea hypopnea index ≤ 2 62

Oxygen desaturation index ≤ 2 81

Apnea hypopnea index ≤ 5 91

Verhulst et al., Obesity, in press

Verhulst et al., Obesity, 2009.

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Anatomical correlates: treatment data

Verhulst et al., Obesity, in press

Van Hoorenbeeck et al., PhD thesis, 2013

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Obesity - conclusion

• The pathogenesis of OSA in obese children is complex illustrated by suboptimal response to adenotonsillectomy.

• In view of the established link with metabolic and cardiovascular morbidity, there is a clear need to validate tools that identify the anatomical contributors in the individual child.

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Obese child with OSA

Weight management

Work up site of

obstruction

T&A

Non-invasive ventilation

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Functional imaging

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Obese child with OSA

Weight management

Work up site of

obstruction

T&A

Non-invasive ventilation

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• Older children have lower adherence

- Limited data on infants/toddlers

• Full face masks

• Lower maternal education

• Improvement in symptoms

• Support system

• No influence of disease severity, ventilation mode, developmental delay

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Adherence

• Detailed information to parents and patients.

• Specific patient information flyers.

• Behavioural therapy approach.

• Mask and machine are used at home with low pressures before the actual titration.

• Intense follow-up especially in the first weeks/months after starting therapy

• Comfortable mask

• Good care of interface and equipment

• Role of medication

• Close follow-up

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