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Pediatric OSA, what

cannot we see?!S. SHAHZEIDI, MD, FAAP, FCCP, FAASM

GRAND HEALTH INSTITUTE

Objectives

� Understanding of

Physiology of the upper

airways in pediatrics

� Etiology of OSA in

pediatrics

� Control of breathing &

upper airway patency in

pediatrics

Outcome

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Airway shape in pediatric

and growth

Upper airway muscles in

OSA

Awake NREM

� Genioglosus (Normal)

� Tensor palatini

� Air flow

� Genioglosus (OSA)

� Tensor palatini

� Air flow

Tongue position in airway

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Airway patency in Normal

and OSA during sleep

Hypoglossal N:

Orexin

Alpha 1 B R (Norepinephrine)

5HT2 alpha R (Serotonin)

Glosso-pharyngeal N:

Hypopharyngeal proprioception

(– ve pressure)

Control of upper airway

Infantile airway

disadvantages� Upper airway

� Greater difficulty switching from nasal to oral breathing

� Laryngeal reflexes with cardio- respiratory depressant responses

� Chest wall properties impairing load compensation

� Increased chest wall compliance

� Circular “barrel‐shaped” chest wall with horizontal rib position

� Smaller diaphragmatic zone of apposition

� Sober, cartilaginous ribs

� Greater REM sleep time with inhibition of stabilizing intercostal muscles

� Lower resting functional residual capacity; low specific lung compliance

� Higher metabolic rate

� Immature respiratory control

� • Respond to ↓ pH or ↓ Cl‐ at

laryngeal entrance

� • Laryngeal chemoreflex

� Startle, rapid swallowing, laryngnealconstriction,

� hypertension, and bradycardia

� Via superior laryngeal nerve (X)

� Blunted with maturation

Laryngeal

Chemoreceptors

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Chemo-reflex

dysfunction

Central breathing instability

High loop gain is

required

Central Breathing Control

Instability CompSA and the Apneic

Threshold

Central apneas occur

CompSA patient not treated

CompSA patienton Servo

Respiratory Effort Related

Arousal (RERA)

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EEG in RERA

OSA demographics

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� 1. Some children have a pattern of persistent partial upper airway obstruction associated with gas exchange abnormalities, rather than discrete, cyclic apneas (“obstructive hypoventilation”2).

� 2. These children will not manifest pauses and gasps in their snoring, and therefore, the condition may be misdiagnosed as PS

� Study Conclusions:

� 1. In the pediatric age range, abnormalities include oxygen desaturation under 92%, more than one obstructive apnea per hour, and elevations of ET CO2 measurements of more than 50 mm Hg for more than 9% of sleep time or a peak level of greater than 53 mm Hg.

� Goh DY, Galster P, Marcus CL. Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am J Respir C rit Care Med.2000;162 :682– 686

Task force conclusions:

� 1. AHI of 1.5 is normal, 1.5-3 is mild, 3-5 is moderate and >5 is severe (CHOPS)

� Note:3 RERA for <12 years or 5 RERA for>12 years are equal to 1 obstructive event.

� 2. There is the option of using adult respiratory scoring rules for children ≥ 13 years.

� AASM Task force, 2012

Diagnostic criteria of OSA

in children

Consequences of untreated

Disordered breathing in

children� Behavioral disorders

(ADHD, ADD, dyslexia, memory ditch)

� Metabolic disorders (

Obesity, diabetes )

� Cardiovascular disorders

(Hypertension)

Common presentation of sleep problems in school age

children

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Mouth breathingPalatne & Adenoidal

tonsils Tonsillar hypertrophy Normal

Crowded oropharynx Adenoids +&-

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� Neurobehavioral Implications of Habitual Snoring in Children

� Louise M. O’Brien, Carolyn B. Mervis, Cheryl R. Holbrook, Jennifer L. Bruner, Carrie J. Klaus, Jennifer Rutherford, Troy J. Raffield, David Gozal

� Behavior Problems Associated with Sleep Disordered Breathing in School-Aged Children—the Tucson Children’s Assessment of Sleep Apnea Study

� Shelagh A. Mulvaney, PhD 1 , James L. Goodwin, PhD 2 Wayne J. Morgan, MDGerald R. Rosen, MD 4 Stuart F. Quan, MD 5 Kristine L. Kaemingk, PhD 6

� Neurocognitive and behavioral impact of sleep disordered breathing in children†

� Judith A. Owens MD, MPH*

� Version of Record online: 20 APR 2009

� DOI: 10.1002/ppul.20981

� Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy

� Ronald D. Chervin, Deborah L. Ruzicka, Bruno J. Giordani, Robert A. Weatherly, James E. Dillon, Elise K. Hodges, Carole L. Marcus, Kenneth E. Guire

Key articles Questions?