OSA SYNDROME AND ALLERGIC RESPIRATORY DISEASES Upper Airway Diseases A. Kaditis, MD

OSA SYNDROME AND ALLERGIC RESPIRATORY DISEASES

Upper Airway Diseases

A. Kaditis, MD

Pediatric Pulmonology Unit, Sleep Disorders Laboratory

First Department of Pediatrics

University of Athens School of Medicine

and Aghia Sophia Children’s Hospital

Athens, Greece

Obstructive Sleep-Disordered Breathing (SDB)

Spectrum of abnormal respiratory patterns during sleep characterized by snoring and increased respiratory effort

Primary snoring Upper airway resistance syndrome Obstructive hypoventilation Obstructive sleep apnea (OSA)

Multiple Disorders affecting components of the Upper Airway (e.g. tonsils, facial structures, dilator muscles)

Upper Airway Dysfunction over time may lead to overt morbidity (e.g. hypertension, enuresis, EDS)

Genes, environment

Genes, environment

Upper Airway Resistance

OSA: Syndrome of Upper Airway Dysfunction

Apnea Hypopnea

Step 1: Recognize the child at risk for obstructive SDB

Step 2: Identify SDB-related morbidity or conditions co-existing with SDB (probably common pathogenesis)

Step 3: Recognize factors predicting persistence of SDB

Step 4: Assess severity of SDB objectively (if equipment available)

Step 5: Determine indications for treatment

Step 6: Stepwise treatment approach for SDB

Step 7: Follow-up, diagnosis and management of persistent SDB

Step 1: Recognize the child at risk for obstructive SDB

Assess by history + exam

Symptoms of nocturnal airway obstruction1. Snoring2. Reported apneas during sleep3. Difficulty breathing during sleep4. Restless sleep5. Frequent arousals

Abnormalities predisposing to upper airway obstruction 1. Adenotonsillar hypertrophy/allergic rhinitis 2. Obesity 3. Craniofacial abnormalities 4. Neuromuscular disorders

History increasing the risk for SDB 1. Premature birth2. Family history of SDB

Upper Airway Dysfunction and Adenotonsillar Hypertrophy

Villa et al. Randomized controlled study of an oral jaw-positioning device for treatment of OSA in children with malocclusion. AJRCCM 2002;165:123-7

Step 2: Identify SDB-related morbidity or conditions co-existing with SDB (probably common pathogenesis)

Morbidity Cardiovascular system Central nervous system Enuresis, inadequate

somatic growth

Conditions co-existing with SDB

Metabolic syndrome Recurrent otitis media,

serous otitis Recurrent wheezing

Amin et al. Activity-adjusted 24-hour ambulatory BP and cardiac remodeling in children with SDB.

Hypertension 2008;51:84-91

Obstructive SDB in Childhood and CNS Morbidity

Hyperactivity Inattention Excessive daytime sleepiness Learning problems

Evidence from population-based studies

Kaditis et al. Enuresis and Snoring in Healthy Children. Urology 2006; 68:406-9

Variables Children with

enuresis

n = 43

Children without

enuresis

n = 1778

Adjusted odds ratio

(95% CI)Age≤ 9 y.o.> 9 y.o.

32 (74.4 %)11 (25.6 %)

904 (50.8 %)874 (49.2 %)

2.87 (1.43-5.76)baseline

GenderMaleFemale

34 (79.1 %)9 (20.9 %)

891 (50.1 %)887 (49.9 %)

3.73 (1.77-7.86)baseline

Habitual snoring†

YesNo

10 (23.3 %)33 (76.7 %)

125 (7 %)1653 (93 %)

3.54 (1.68-7.44)baseline

Risk factors adjusted for race, obesity

Occasional wheeze

Persistent wheeze

Cough

History of asthma

AHI>10 OR (95% CI) p

3.29(1.24-8.94)

<0.05

7.45 (2.03-27.39)

<0.05

8.83(2.29-34.05)

<0.05

3.83(1.39-10.55)

<0.05

Redline et al. Risk Factors for SDB in Children. AJRCCM 199;159:1527

Step 3: Recognize factors predicting persistence of SDB in the long term

Male gender Obesity Increasing body mass index

percentile

Goodwin et al. Incidence and Remission of SDB and Related Symptoms in 6- to 17-y.o children.

J Pediatr 2010;157:57-61

6-11 y.o. Over 5 years 10-18 y.o.

Snore 15%

-70.8% remission

+10% new cases

9.7%

AHI ≥ 1 23.9%

-60% remission

+4.1% new cases

15.3%

Goodwin et al. Incidence and Remission of SDB and Related Symptoms in 6- to 17-y.o children.

J Pediatr 2010;157:57-61

Step 4: Assess severity of SDB objectively (if equipment available)

Nocturnal polysomnography Nocturnal polygraphy Nocturnal oximetry

Step 5: Determine indications for treatment

Clinically important upper airway obstruction even during wakefulness

AHI>5 episodes/h (or positive screening method) irrespective of morbidity

AHI 1-5 and morbidity or treatable co-existing condition

AHI 1-5 and craniofacial abnormalities or neuromuscular disorders

AHI 1-5 and risk for long-term SDB persistence

Step 6: Stepwise treatment approach for SDB

Wt control for obesity Antiinflammatory medications for mild

SDB prior to AT AT for adenotonsillar hypertrophy Orthodontic devices for mandibular

malpositioning, narrow maxilla nCPAP for i) residual SDB after AT or

orthodontic devices; ii) SDB related to obesity, craniofacial abnormalities; iii) neuromuscular disorders unresponsive to other measures

Craniofacial surgery if SDB not responsive to orthodontic devices, nCPAP

Tracheostomy if all other measures fail or while waiting for craniofacial surgery

Berlucchi et al. The Role of Mometasone Nasal Spray in the Treatment of Adenoidal Hypertrophy.

Pediatrics 2007;119:e1392-1397

Mometasone 100 mcg/d (40 days)

vs. Placebo (40 days)

Villa et al. Randomized controlled study of an oral jaw-positioning device for treatment of OSA in children with malocclusion. AJRCCM 2002;165:123-7

Villa et al. Randomized controlled study of an oral jaw-positioning device for treatment of OSA in children with malocclusion. AJRCCM 2002;165:123-7

Before After

Step 7: Follow-up, diagnosis and management of persistent SDB

Follow up after each therapeutic intervention and if no response move to the next intervention

Consider objective testing for selected children for selected children:

-High AHI pre-treatment

-post AT in children with obesity, craniofacial abnormalities, neuromuscular disorders

-post orthodontic treatment

-post nCPAP

-prior to craniofacial surgery or tracheostomy

Bhattarjee et al. AT outcomes in Treatment of OSA in Children. AJRCCM 2010; 182:676-683

Conclusions

Intermittent upper airway obstruction

during sleep in childhood:

Is associated with disorders affecting upper airway resistance and pharyngeal neuromotor tone

Is related to morbidity from the CNS and the cardiovascular system

Severe upper airway obstruction during sleep and mild obstruction with morbidity or risk factors for persistence should be treated

All disorders leading to upper airway obstruction should be addressed in a stepwise fashion