Allergic(Rhini,s( - Ballad Health...ALLERGIC(RHINITIS(AND(OTHER COMORBIDITIES( • Up(to(80%(of(paents(with(bilateral(chronic(sinusi,s(have(AR • O,,s(media • Conjuncvis • Lower(respiratory

Allergic Rhini,s

Dr. Larry Smith, MD

Allergic Rhini,s Defini,on �  Defined as inflamma,on of the nasal mucosa characterized

by two or more of the following symptoms: –  nasal conges,on –  anterior/posterior rhinorrhoea –  sneezing –  itchy nose

Introduc,on

Allergic Rhini,s

� occurs when these nasal symptoms are the result of IgE-‐mediated inflamma,on following exposure to an allergen

Prevalence

400 million suffers worldwide > 20% of popula,on in US All ages are affected, peaks in teens Boys more affected than girls but equalizes aTer puberty

ALLERGIC RHINITIS and ASTHMA

•  30% of pa,ents with AR have asthma •  The majority of pa,ents with asthma have AR •  AR is a major risk factor for poor asthma control

•  All pa,ents with AR should be assessed for asthma

ALLERGIC RHINITIS AND OTHER COMORBIDITIES

•  Up to 80% of pa,ents with bilateral chronic sinusi,s have AR

•  O,,s media •  Conjunc,vi,s •  Lower respiratory tract infec,ons •  Dental problems – malocclusion, discolora,on •  Sleep disorders

ALLERGIC RHINITIS AND ITS IMPACT ON QUALITY OF LIFE

�  In USA 2 million school days lost per year 4 million work days lost per year 28 million impaired work days

ALLERGIC RHINITIS (ARIA)

Moderate-‐severe one or more items Abnormal sleep. Impairment of daily ac,vi,es, sport, leisure. Problems caused at school or work. Troublesome symptoms.

Intermi\ent symptoms

< 4 days per week

Or < 4 weeks Mild Normal sleep. Normal daily ac,vi,es. Normal work and school. No troublesome symptoms.

Persistent symptoms

> 4 days per week and > 4 weeks

DIAGNOSIS •  History and Examina,on •  Skin prick test •  Radioallergoabsorbent tests for specific IgE (RAST)

•  (Nasal allergen challenge)

TREATMENT

•  EDUCATION/ALLERGEN AVOIDANCE •  PHARMACOTHERAPY •  IMMUNOTHERAPY •  SURGERY •  Others – Nasal douching

IMMUNOTHERAPY •  Involves repeated administra,on of an allergen extract to induce a state of immunological tolerance

•  More effec,ve in limited spectrum of allergies in par,cular seasonal pollen allergy

•  Severe symptoms failing to respond to usual Px •  Subcutaneous injec,on/sublingual route •  Studies indicate that 3 years therapy necessary

ARIA RECOMMENDATIONS •  Topical cor,costeroids and oral an,histamines (non-‐seda,ng) form the mainstay of treatment

•  The newer topical steroids e.g. Mometasone furoate and Flu,casone propionate were highest recommended

•  Other drugs should only be considered as second-‐line treatment

•  Immunotherapy in selected pa,ents can be highly effec,ve.

SPECIAL CIRCUMSTANCES PAEDIATRIC ALLERGIC RHINITIS

•  4 years and older should be treated as for adults •  Children (>4) with AR and Asthma can be treated with combina,on of newer genera,on topical and inhaled cor,costeroids with low risk of complica,ons

•  Diagnosis in smaller children is difficult as can have up to 6 to 8 colds per year

•  Small children – oral an,histamines, saline sprays and cor,costeroids if symptoms severe

•  > 2 years fortunately rare

Bringing Diabetes to School Regional School Health Conference

July 27, 2017

Evan Los, MD East Tennessee State University

Pediatric Endocrinology Mountain States Medical Group

Disclosures

• No financial conflicts of interest to disclose

Outline

• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school

• Discuss pearls and piLalls of diabetes management at school

• Diabetes technology and brief look at future of diabetes management

• QuesOons

Outline




• QuesOons

Diabetes is a team sport

• High burden of disease management placed on child/family

• Requires advanced planning for basic tasks: eaOng, physical acOvity

• Can complicate rouOne illnesses

•  Life experience with diabetes influenced by family dynamics, socioeconomics, coping skills

Diabetes at school: Student role

• Depends on developmental stage

•  Expect to parOcipate in (and contribute to) school care plan

•  Take diabetes seriously but don’t use it as an excuse •  Show up ready to learn like everyone else •  Treat your low and get back to class •  If struggling, ask for help

Diabetes at school: Family role

• ParOcipate in and formulate school care plan with RN •  Discuss frequency of BG checks, whether/when parent wants to be noOfied, remote monitoring*

• Provide all necessary supplies including low treatments and snacks

•  Listen to your feedback

Diabetes at school: Medical provider role

• Provide “school orders” direcOng the diabetes care of each student

• Update orders as needed

• Be available as resource if orders unclear or do not address situaOon

Diabetes at school: RN role

Diabetes at school: RN role

Use your excellent training to provide and direct the hands-‐on care of students with diabetes at school while navigaOng the requests of students, parents, school administraOon and medical providers.

“School orders”

• Please don’t send extra school orders for us to fill out, if possible

Outline


• Discuss pearls and pi8alls of diabetes management at school


• QuesOons

Typical schoolday paBerns

• Arrive at school

•  If breakfast at school: check BG, dose insulin, eat

•  +/-‐ mid-‐morning snack

• At lunch: check BG, dose insulin, eat

•  +/-‐ extra BG checks per student/family request (PE, before geang on bus, etc., and with sx of low BG

• Depart school

Supplies

• My preference: Student keeps all supplies with them all the Ome • BG meter, strips, lancets, ketosOx, glucagon, low supplies, insulin, syringes/pens/pump, CGM •  Sharps need to be safely disposed of

Glucagon

•  I think all school nurses, teachers of students with diabetes should know how to give glucagon • Probably PE teachers, recess monitors and sports coaches too

Legal stuff (from a non-‐lawyer)

Tennessee Virginia

Can school staff (not medical professionals) administer insulin? Yes Yes

Can school staff (not medical professionals) administer glucagon? Yes Yes

Can students self-‐manage diabetes at school? Yes Yes

Can students carry all supplies with them at all Omes? Yes Yes

Legal stuff, conLnued

Must a school provide a trained school staff member while students par?cipate in field trips and extracurricular ac?vi?es? Yes. Failure to provide this care would exclude students from these acOviOes for safety reasons. Schools are required to provide needed care to ensure a student's full and safe parOcipaOon in school-‐sponsored acOviOes. Who is responsible for training school staff? The school is responsible for providing appropriate training to school staff. ‘Safe at School’ training materials available on American Diabetes AssociaOon website.

Bus drivers?

•  Some states have clear policies recognizing bus drivers as school officials who are responsible for providing medical care to students • Most states are either vague or have no specific regulaOons • American Diabetes AssociaOon clearly supports the training of bus drivers in the basics of diabetes care including glucagon use •  Strong legal protecOons for school officials who help “in good faith”

Ketones

• A sign the body is burning fat instead of carbs for energy • Why? Not enough insulin, not enough carbs, body stress (e.g. illness, menses)

•  Some kids get ketones more frequently than others

•  Some kids get ketones a lot •  Usually this means a student is missing insulin doses on a regular basis

Ketones -‐ conLnued

•  Trace-‐small •  Assess for causes, noOfy family •  Give water, more frequent BGs/insulin/carbs/ketone checks •  May be able to go back to class

• Moderate-‐large •  Assess for causes, noOfy family •  Give water, more frequent BGs/insulin/carbs/ketone checks • Will need extra insulin doses – noOfy family; if needed, noOfy provider •  Probably won’t feel well enough to go back to class (but might) •  If vomiOng, heavy breathing, altered mental status; likely need to go to ED

Extra insulin/Dose stacking

•  Scenario: It’s 10:30am, BG 319 mg/dL, lunch is at 12:00. Tummyache.

• Ask what last BG was. If >300 or unknown, check ketones. •  If ketones +, noOfy family (and if needed, noOfy provider); will need insulin •  If ketones -‐, have a choice:

• Don’t give extra insulin. Check again at lunch, follow usual plan. • Give high BG correcOon if >3 hours since last insulin. Check BG at lunch; cover carbs but DON’T give high BG correcOon.

(<3 hours since last dose)

Outline




• QuesOons

Diabetes technology

CGM -‐ now

Diabetes technology – what’s coming

Technology in school: My recommendaLons

•  Student, parent, RN and teachers all need to have same understanding of what technology is present and who’s in charge (include in 504 plan) •  CGM:

•  Lows should be treated based on fingersOck •  OK to dose insulin using CGM number if part of school orders; fingersOck preferred •  If parents want CGM “trend arrows” to be a part of school orders, they should go through provider

•  Device problems: •  TroubleshooOng a device is up to the student and parent •  If not resolved, contact device helpline •  We usually respond in couple hours; device errors usually can’t wait that long

Device burden

Outline




• Ques?ons

QuesLons

MSMG Pediatric Diabetes Evan Los, MD George Ford, MD MS Alexis Duty, FNP Morgan Armentrout, RN CDE Amy Kehely, RN Donna Brookshear, LPN

PEGS, G-TUBES & BUTTONS

ALL YOU NEED TO KNOW...

Anjali Malkani M.D. Professor Pediatric Gastroenterology

.....AND WISH YOU HADN’T ASKED!

PEGS, G-TUBES & BUTTONS-GOALS

 Indications  Methods of placement  Types of tubes  Care of G- tubes  Complications of G- tubes

WHAT IS A GASTROSTOMY TUBE?

•  A flexible tube or

“button”

•  Placed into the stomach

•  Through an opening in the abdominal wall

Candidates for a G - Tube

IN- Nutrition

Medications OUT- Decompression of gastric contents

Indications for G-tubes

  FTT   cardiac disease  CF

  Swallowing dysfunction  neurologically impaired   esophageal stricture

 Administer special formula  metabolic disease  Crohn’s disease

 Decompression of stomach  motility disorders

Purpose of the G-Tube

To ensure : •  Normal growth

and development

•  Maintenance of health and wellness

Types of G-tubes

 Conventional catheters  MIC  Foley

 PEG catheter-including one step

 Low Profile Devices  Balloon-secured

  MIC-KEY   HIDE-A-PORT   MINI-BUTTON

 Non-balloon secured   BARD   AMT

G-tube placement

 OPEN SURGICAL  ENDOSCOPIC

(PEG)  LAPAROSCOPIC

Surgical or Open G-tube

 Requires laparotomy and general anesthesia  Placed under direct vision  Sutured into place  Low -profile tube can be placed initially  Feedings started after post-op ileus resolves

(24-48 hours)  Can change conventional tube to low profile

device sooner than with PEG

G tube- Surgical Technique

Percutaneous Endoscopic Gastrostomy (PEG)

Pull Technique

 Guidewire placed in stomach

 Guidewire brought retrograde through patient’s mouth

  PEG tube pulled through abdominal wall

Percutaneous Endoscopic Gastrostomy placement (PEG)

  Based on the principle of sutureless approximation of a hollow viscus to the peritoneum by a catheter

 Does not require general anesthesia  No post-op ileus - feeds started 6 hours after

placement  Less post-op pain  Less expensive with shorter hospital stay  Changed to low profile device when track matures

- 3 months (except one step PEG)

PEG tube – gastric view

Immediate post -op care after PEG placement

 Decompression of stomach initially  Flush tube to ensure patency  Rotate and clean tube site with peroxide  NSAIDs for pain  Start feeds at 6 hours post op. Begin with

clears at half maintenance rate and advance to goal by 18 hours after initiation.

PEG : Influence on GERD

 Wheatley, J Ped Surg,1991  Of 43 MR pts with no GERD pre PEG (UGI &pH

probe),14% (6)developed GER 10 mos after PEG placement

 Anti-reflux procedure not recommended prophylactically if there is no pre PEG GERD.

 Launay,Pediatrics, 1996  Of 20 pts(50% MR) ,65% had pre-PEG reflux  2/10 GER worsened after PEG ,trted medically  1/10 developed GER after PEG,trted medically

PEG Removal

 Removed when indication for placement resolved

 Changed to low profile Gutbe in 3 months  Gastrocutaneous fistula should be mature  Removal technique dependent on PEG

features

PEG change to Low Profile Device

  When?  3 months after placement, so track can mature

  How?  Endoscopically: as FB removal under GA  Traction: confirm with fluoroscopy

  Type of tube?  Always balloon secured: NEVER “button” which needs

obturator for placement  Only with 16 Fr or larger PEGs

  Confirm placement?  Fluoroscopy if traction method used

PEG Removal

 Malleable internal bumper  Remove via

traction technique  Initially rotate

tube to disengage from fibrous tract

Types of G-tubes

 Conventional catheters  MIC  Foley

 PEG catheter-including one step

 Low Profile Devices  Balloon-secured

  MICKEY   HIDE-A-PORT   MINI-BUTTON

 Non-balloon secured   BARD   GENIE (20 FR PEG )   AMT

Low Profile G-tubes

 Non Balloon  Balloon

Low Profile Gtubes

  Balloon or Non- Balloon Balloon secured tube can be replaced by parent Non-balloon needs obturator- ONLY by physician

  Length  Of shaft  In cm

  Diameter  In French

  Brand  “Mickey”  “Mini”

 “Cubby”

Changing Balloon secured Gtubes

  INITIAL CHANGE   ONLY BY SURGEON/ GI DOC

  Check size of balloon secured tube   Length   French

  Use smaller French if unable to replace   Don’t use force   Send to ER ASAP as the site can close within 30 mins

Insertion of Non-Balloon

 Click here for Non-Balloon Insertion

G-J tube

  Through gastrostomy into jejunum  Primary or thru previous Gtube site   Interventional Radiology or endoscopy

  Single or Double lumen  Single lumen- only J port  Double lumen- G and J port- feed via J and decompress via G

  Type of tube  Always balloon secured  Low profile or conventional

  Size  Length of stoma, size of balloon, and length of J tube

Gastrostomy Care

 Cleaning  peroxide for the first week, then daily bath

 Rotate daily  to avoid skin growth and irritation

 Dry and open to air  OK to swim in pool & ocean; avoid lakes

and ponds  Out of reach

 “onsie” or pin to diaper if conventional tube

G – Tube Site Care

 Cleanse site with mild soap and water  Keep area clean & dry  Observe the site for:

Redness Swelling Warmth Drainage/leakage Bleeding Unusual color or odor

 Check site for granulation tissue

Complications of G-tubes

  Skin   Infection   Irritation   Granulation tissue

  Tube   Blockage   Leakage   Dislodgement   Displacement

Complications of G-tubes- Skin

  Infection fungal

bacterial   Granulation tissue   Irritation

  Allergy to soap   Irritation by tape   Burn

Skin: Infection-Bacterial

 Erythema, gradually spreading

 Tenderness  Warmth  Foul green/pus +/-T  Boil

Skin: Infection-Bacterial

 Causes  Staph/strep  Poor hygiene  Tight tube

 Tx  Antibiotics

 Systemic/topical

 Clean with saline

Skin: Infection-Fungal

  Red papular rash satellite lesions spreading away from site

Causes Excessive moisture Gtube in deep skin fold Immune suppression, steroids , DM Tx Anti-fungal Keep area clean and dry

Skin- Irritant Dermatitis

Redness, swelling Leakage of gastric contents Overuse of cleaners, antibacterial meds Tx Acid blocking meds Barrier products Proper tube size Water in balloon

Skin- Allergic Dermatitis

Papules, vesicles Crusting Itching Skin care products Latex New meds or foods touching skin Tx Remove irritant Barrier cream/powder

Skin-Granulation tissue

 Causes  Opening too big  Pivoting  Excessive moisture, occlusive dressings  Too much hydrogen peroxide

 Pink cauliflower like ,beefy tissue  Bleeds easily  Yellow brown drainage

Granulation Tissue – treatment

 Silver nitrate sticks for 3 days  Kenalog cream  Stabilise tube  Change size of tube  DO NOT leave extensions on

when not in use  Barrier powder-alum

Tube-Blockage of tube

 Causes  Thick formulas  Pill fragments  Failure to flush- prevent this!!  Defective tubing Tx Try milking tube , check for kinks Push and pull plunger Flushing with diet soda or 1/2 strength vinegar, baking soda, viokase

Tube

 Dislodgement - migrates into tract  traction,seizure,wt gain  painful, won’t flush,won’t turn, protrudes

 Displacement- balloon deflates or falls out  Needs to be replaced within 30 mins with any

tube  If less than 12 weeks since placement call surgeon  Care-giver can use same tube and tape into place if

they don’t have replacement tube  Refer to ER even if site appears closed

Tube -Leakage

 Leakage through the center of tube  valve broken- change tube   failure to reset valve in button- flush tube  Blood through the center of the tube requires medical

attention

 Leakage around the tube  Water in balloon isn’t enough- check amount  Tube too long  Don’t increase Fr of tube- makes stoma bigger  Can leave tube out for 10 mins daily

Buried Bumper Syndrome

  Excessive traction on PEG tube   Overtightening of skin disk

  Ischemic necrosis of the gastric mucosa   Migration of the internal bolster into the gastric or

abdominal wall

  Prevention   Confirm some laxity at initial insertion


 Findings  Resistance to flow  PEG tube fixed, with surround subcutaneous

erythema  Endoscopy

 Ulceration, mucosal dimpling  Nonvisualization internal bumper


 Treatment  Dissection of the buried appliance from the

abdominal wall  Replace with new gastrostomy tube  Large gastrocutaneous fistula may warrant

laparotomy/resection

Different Methods of Tube Feeding

•  Intermittent gravity -bolus •  Timed intermittent-pump •  Continuous-pump

Farrell Valve Bag

Enteral Gastric Pressure Relief System

A patient suffering from poor gastric motility faces many problems; constant pain and discomfort due to the buildup of fluids and gas, the

threat of aspiration pneumonia, and often the inability to tolerate enteral nutrition.

Provides a channel to constantly decompress the stomach, allowing the stomach to empty at its own pace.

Mouth Care

Maintain oral hygiene

 Brush teeth after each meal  Lubricate lips as needed  Dental care as directed

Parents/CareGivers ......

 Hands on Teaching  Handouts/ videos  GI nurses - a phone call away  Support groups - insideoutsidecare.com

Push Technique

  PEG tube advanced via modified Seldinger approach

 May involve dilators, peel away introducer

Push Technique

Advantages   Single endoscope

passage  Decreased “seeding”

from oropharynx (bacteria, malignant cells w/ head & neck ca.)

Disadvantages  Loss of

pneumoperitoneum  May require additional

T-fasteners

Relative Contraindications

 Coagulopathy  Portal hypertension  Peritoneal dialysis  Large hiatal hernia  Fundoplication required for preexisting

GERD  Another intraabdominal procedure required

at the same time

PEG: Basics

 Gastric insufflation to bring stomach in apposition

 Placement of catheter into gastric lumen  Passage of guidewire into stomach  Placement of gastrostomy tube  Verification of proper position

Factors to consider when selecting an enteral formula.

Patient-related factors Formula-related factors 1.Age 1.Caloric density 2.Underlying diagnosis 2.Osmolality 3.Digestive and absorptive capacity of the GI tract 3.Ease of preparation 4.Fluid, nutrient, and 4.Cost caloric needs 5.Food allergies 5.Insurance coverage 6.Route of administration 6.Availability at home

Patient Preparation

 Bite block  May leave NG,

feeding tube  Can follow tube down

esophagus  Must take NG off

suction to allow for insufflation

Upper Endoscopy

 Routine flexible fiberoptic upper endoscopy

 Complete endoscopy recommended  36% incidence of

anomalies  Some may affect

procedure (ulcer, gastric outlet obstruction)

Confirm safe position

 Transillumination through skin suggests no other viscera interposed

 Transillumination button (“high beams”) on light source

 May be difficult in obesity  Can assist with digital

pressure

Confirm Position

  Endoscopist watches while assistant indents abdominal wall at proposed insertion

  Should see simultaneous indentation of gastric mucosa

  Failure to see   Reassess position   Intervening viscerae   Impossible apposition   Inadequate insufflation

Site Preparation

  PEG kit opened after endoscopic confirmation of entry site

  Select anticipated PEG insertion site   Entry ~2 cm below costal

margin

  Prep left upper quadrant with antiseptic prep of choice   May be included in kit

Surgical Technique

 Kit contains:  Local/syringe   introducer  Prep & drape  Guidewire  Endoscopic snare  Scalpel  Hemostat  PEG  External Bumper

Surgical Technique

 With area prepped and draped, reconfirm insertion site

  Inject local anesthetic  Skin and SQ  Fascia

 Make incision  Alternate: incision

after wire placed

Endoscopist

 Retrieves snare, PEG tube from kit

 Advances snare into

biopsy channel of endoscope

Access

  Insert needle/catheter assembly

  Safe tract technique  Continuous aspiration

via syringe  Return of air without

visualization of needle in stomach signifies malposition

 Remove, retry

Endoscopist

 While puncture performed, advance snare near intended puncture site

  Snare the catheter prior to removal of needle to prevent loss

Access

 Remove syringe/needle

 Cover catheter to prevent loss of insufflation

 Advance guidewire into stomach   Incision at insertion

site if not placed previously

Endoscopist

 After wire passed through catheter, endoscopist uses snare to grasp wire

 Wire advanced   Snare/wire pulled out

of mouth with endoscope as a unit

Endoscopist

 Endoscopist secures PEG tube to mouth end of guidewire

  PEG internal bumper can be snared to allow easy passage of endoscope

 Assembly passed back into stomach

PEG Tube Position

 Guidewire pulled through skin incision

  PEG follows, tract dilated by conical dilator at end of PEG

 Countertraction at skin level with non-dominant hand facilitates passage

PEG Tube Position

  PEG tube advanced  Two resistance points

  GE Junction   Final position @ gastric

mucosa

 Usually in position when external marker between 2-4 cm at skin level

PEG Tube Position

  Guidewire cut at tapered end of tube

  Skin disk/external bumper applied over introducer and slid to skin surface

  Bumpers should prevent movement but not blanch skin

  Endoscopy may confirm no blanching of mucosa

Completion of Procedure

 Endoscope removed  Option: place antibiotic ointment and/or

dressing under skin disk  Tube cut to appropriate length  Adapter secured to cut end of tube  Leave to gravity

Complications & Pitfalls

Complications of PEG

 Direct, major complications: 4%  Mortality from complications: 25%  High mortality attributed to patient

population  Debilitated  Cannot tolerate additional insult

Complications of PEG placement

 Pneumoperitoneum  Peritonitis and sepsis  Gastrocolic fistula  Other organ injury-liver, small bowel  Esophageal injury  Wound infection  Dislodgement of tube  Development of, or worsening GE reflux

Pneumoperitoneum after PEG

 Expected event  Up to 36%

 Contributing factors  Excessive air insufflation  Prolonged procedure time  Multiple percutaneous needle punctures of the stomach

  Peritonitis  <1% of PEGs  ~30% mortality

Pneumoperitoneum after PEG

 No additional studies warranted unless signs of inflammation, peritonitis

 Contrast study  May detect gross extravasation

 CT Scan Abdomen  Extravasation  Lack of apposition with abdominal wall  Free fluid, suggestive of visceral perforation,

hemorrhage

Dislodgement of PEG Tube

 Concern when occurs prior to maturation of gastrocutaneous tract

 Initial Rx  Nasogastric suction  Broad spectrum antibiotics

 Surgery  Failure to improve  Overt peritonitis, sepsis

PEG Removal

 Rigid internal bumper  Mandates repeat endoscopy  PEG tube cut at skin  Bumper snared endscopically  Bumper may be obstructive, must be removed

PEG Removal

  Secure tube in one hand

 Continuous steady traction  Caution: “spray” of

gastric fluids  May wrap tube around

hand  Bumper inverts and

PEG removed

PEG Removal

 Fistula closes within 24 hours  Persistent fistula

 Granulation tissue/inflammation  Silver nitrate sticks  Anti acid therapy  Rarely require resection/operative closure

Peristomal Wound Infection

 5-30% of cases  Prophylactic Antibiotics

 Single dose 30 minutes before procedure  Narrow spectrum (e.g. cefazolin)

 Skin incision  Large enough to easily admit tube  Smaller incision allows entrapment of bacteria ⇒ postop infection

Necrotizing Fasciitis

 Rare, devastating complication  43% mortality  Initial presentation with cellulitis  Source control essential

 May mandate surgical closure of PEG site

Gastrocolocutaneous Fistula

 Early presentation  Drainage of feculant material at PEG site

 Late  Detected after tube replacement: diarrhea

 Colonic interposition during placement  Dx: gastrograffin study, CT scan

Hemorrhage

 2.5% of cases  Repeat endoscopy indicated for Dx,

possible Rx  Often related to gastric ulceration under

internal bumper  Pressure necrosis  Friction

 Caution in patients with coagulopathy

Tube Migration

 Inadequate stabilization  Proximal migration

 Vomiting, aspiration  Migration into distal stomach

 Gastric outlet obstruction  Distention, vomiting

 Distal migration (small bowel)  Dumping syndrome

PEG : Influence on GERD

  Andrew, J of Ped Surg,1997  28%(n=39) with no GER pre PEG (onUGI/GES)

developed GER; 20% of these required Nissen within 6mos

 Of 8 with pre PEG GER 25% required Nissen and 25% improved post PEG

 Current practice for evaluation prior to PEG  UGI-R/O anatomical problem eg malrotation  pH probe -if symptomatic or neurologically

impaired

Postoperative Nursing

 Local care to prevent complications  Especially important while gastrocutaneous

fistula is maturing  Allow slack on tubing to prevent pressure/

traction complications

Resumption of Enteral Nutrition

  Postop “ileus” may be related to degree of insufflation

 Orders Post PEG placement

Drainage for 4 hours Clamp for 2 hours Pedialyte for 6 hours( ½, then full maint) Formula for 6 hours continuous (1/2 str then full) Hold feeds for 3 hours Give first bolus.

Timing of Feeding after PEG placement

 Werlin ,GI endoscopy,1994  24 pts had feeding started 6 hrs after PEG. All had

feeds advanced with no intolerance  Malkani,NASPGN,1996

 Randomised 52 pts (after successful NG feeds) to early and late feeding groups post PEG

 No difference in tolerance to feeds or catheter related problems in both groups

 90% in early group were ready for discharge at 24 hrs, when the late group were starting feeds.

Objectives

 Indications and contraindications of PEG  Upper flexible fiberoptic gastroscopy

 Principles  Procedures

 Monitoring, sedation  Surgical procedure

Contraindications

 Inability to perform upper endoscopy  Obstructing esophageal tumor  Stricture

 Ascites  Inability to appose gastrotomy to anterior

abdominal wall  Previous subtotal gastric resection  Hepatomegaly, esp left lobe

 Abdominal wall infection or peritonitis

Legal Issues in School Health

Regional Nurses Conference Kingsport, Tennessee

July 27, 2017 PresentaBon by Mike Billingsley, City AHorney for Kingsport, Tennessee

LEGAL DISCLAIMER

• Nothing in this handout or presentaBon consBtutes legal advice. It is for general informaBon only, and no aHorney-‐client relaBonship is created. • Always contact your aHorney should you have any specific quesBons about any legal maHer. • Never rely on this informaBon as an alternaBve to legal advice from your aHorney. • Do not delay seeking legal advice, commence or disconBnue any legal acBon or disregard legal advice, or due to informaBon contained in this handout or presentaBon.

Guidelines for Use of Health Care Professionals And Health Care Procedures in a School SeTng • hHp://www.tennessee.gov/assets/enBBes/educaBon/aHachments/csh_guidelines_healthcare_prof_proc.pdf

• A 121 pages documents that is vital for any school nurse to have and use. •  It is free and available for prinBng or download at the website set out above.

School Nurses are the Gatekeepers of School Children Health

• Do you agree or disagree?

Privacy of Student Medical and Treatment Records and the Public School Nurse • What law applies Health Insurance Portability and Accountability Act of 1996 (HIPAA) or Family EducaBonal Privacy Rights Act (FERPA)?

Health Insurance Portability and Accountability Act of 1996 (HIPAA) or Family Educa>onal Privacy Rights Act (FERPA)

•  Joint Guidance on the ApplicaBon of the Family EducaBonal Rights and Privacy Act (FERPA) And the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To Student Health Records

• hHps://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-‐hipaa-‐guidance.pdf

Helpful InformaBon

• Dear Colleague LeHer to School Officials at InsBtuBons of Higher EducaBon issued August 24, 2016

• hHp://familypolicy.ed.gov/sites/fpco.ed.gov/files/DCL_Medical%20Records_Final%20Signed_dated_9-‐2.pdf

HIPAA or FERPA

• Does the HIPAA Privacy Rule apply to an elementary or secondary school? •  In most cases, the HIPAA Privacy Rule does not apply to an elementary or secondary school because the school either: (1) is not a HIPAA covered enBty or (2) is a HIPAA covered enBty but maintains health informaBon only on students in records that are by definiBon “educaBon records” under FERPA and, therefore, is not subject to the HIPAA Privacy Rule.

HIPAA and the Public School Nurse

• Generally, a public school is not a HIPAA covered enBty because it does not engage in transacBons covered under HIPAA. • Covered enBBes are a health plan; a health care clearinghouse; or a health care provider who transmits any health informaBon in electronic form in connecBon with a transacBon pertaining to financial or administraBve acBviBes related to health care transacBons. 45 CFR § 160.103 – definiBon of transacBon. • Most schools do not engage in any transacBons covered by the definiBon of transacBon, which includes things such as billing a health plan electronically for payment of service.

HIPAA and the Public School Nurse

• A school would be subject to a part of HIPAA (SimplificaBon Rules for TransacBons and Code Sets and IdenBfiers with respect to its transacBons -‐ 45 C.F.R. part 162 ) if it employs a health care provider that conducts electronic transacBons covered by HIPAA. • However, many schools, even those that are HIPAA covered enBBes, are not required to comply with the HIPAA Privacy Rule because the only health records maintained by the school are “educaBon records” or “treatment records” of eligible students under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule.

Family EducaBonal Privacy Rights Act (FERPA)

•  FERPA is a Federal law that protects the privacy of a student’s “educaBon records.” (See 20 U.S.C. § 1232g; 34 CFR Part 99). FERPA applies to educaBonal agencies and insBtuBons that receive funds under any program administered by the U.S. Department of EducaBon. This includes virtually all public schools and school districts and most private and public postsecondary insBtuBons, including medical and other professional schools.

FERPA Applies to Public School Records

• At the elementary or secondary level, a student’s health records, including immunizaBon records, maintained by an educaBonal agency or insBtuBon, as well as records maintained by a school nurse, are “educaBon records” subject to FERPA. In addiBon, records that schools maintain on special educaBon students, including records on services provided to students under the Individuals with DisabiliBes EducaBon Act (IDEA), are “educaBon records” under FERPA.

FERPA

•  EducaBon records include a range of informaBon about a student that is maintained in schools in any recorded way, such as handwriBng, print, computer media, video or audio tape, film, microfilm, and microfiche •  It prohibits a school from disclosing personally idenBfiable informaBon from students’ educaBon records without the consent of a parent or eligible student (18 or older), unless an excepBon to FERPA’s general consent rule applies. •  HIPAA specifically excludes educaBon records, including shared treatment records, and unshared treatment records. (See 45 C.F.R. 160.103 definiBon of "Protected Health InformaBon")

HIPAA or FERPA

•  Even though a school employs school nurses, physicians, psychologists, or other health care providers, the school is not generally a HIPAA covered enBty because the providers do not engage in any of the covered transacBons, such as billing a health plan electronically for their services.

• Where a school does employ a health care provider that conducts one or more covered transacBons electronically, such as electronically transmiTng health care claims to a health plan for payment, the school is a HIPAA covered enBty and must comply with the HIPAA TransacBons and Code Sets and IdenBfier Rules with respect to such transacBons. However, even in this case, many schools would not be required to comply with the HIPAA Privacy Rule because the school maintains health informaBon only in student health records that are “educaBon records” under FERPA and, thus, not “protected health informaBon” under HIPAA.

HIPAA or FERPA

•  The school would have to comply with FERPA’s privacy requirements with respect to its educaBon records, including the requirement to obtain parental consent (34 CFR § 99.30) in order to disclose to Medicaid billing informaBon about a service provided to a student.

•  If the nurse is hired as a school official (or contractor), the records maintained by the nurse or clinic are “educaBon records” subject to FERPA.

HIPAA or FERPA

• Does HIPAA or FERPA or apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school? •  If a person or enBty acBng on behalf of a school subject to FERPA, such as a school nurse that provides services to students under contract with or otherwise under the direct control of the school, maintains student health records, these records are educaBon records under FERPA, just as they would be if the school maintained the records directly. This is the case regardless of whether the health care is provided to students on school grounds or off-‐site.

Disclosure of Records Under FERPA

•  Parents have a right under FERPA to inspect and review these health and medical records because they are “educaBon records” under FERPA. See 34 CFR §§ 99.10 – 99.12. •  Parents may also seek to amend educaBon records believed to be inaccurate; and •  Parents may consent to the disclosure of personally idenBfiable informaBon from educaBon records, except as specified by law.

•  In addiBon, these records may not be shared with third parBes without wriHen parental consent unless the disclosure meets one of the excepBons to FERPA’s general consent requirement.

DefiniBon of Parent Under FERPA

• Under FERPA, a “parent” means a parent of a student and includes a natural parent, a guardian, or an individual acBng as a parent in the absence of a parent or guardian. 34 CFR § 99.3 definiBon of “Parent.” AddiBonally, in the case of the divorce or separaBon of a student’s parents, schools are required to give full rights under FERPA to either parent, unless the school has been provided with evidence that there is a court order, State statute, or legally binding document relaBng to such maHers as divorce, separaBon, or custody that specifically revokes these rights. 34 CFR § 99.4.

Disclosure of Records Under FERPA without Parental Consent • A school may disclose a student’s health and medical informaBon and other “educaBon records” to teachers and other school officials, without wriHen consent, if these school officials have “legiBmate educaBonal interests” in accordance with school policy. See 34 CFR § 99.31(a)(1). • A school may permit disclosure of educaBon records, without consent, to appropriate parBes in connecBon with an emergency, if knowledge of the informaBon is necessary to protect the health or safety of the student or other individuals. See 34 CFR §§ 99.31(a)(10) and 99.36. Instances of abuse or neglect. •  Instances of abuse or neglect.

Disclosure to Medical Providers Under FERPA

•  The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school nurses, physicians, or other health care providers for treatment purposes, without the authorizaBon of the student or student’s parent. • Disclosures under FERPA can only be made with the consent of a parent or eligible students or under one of the excepBon listed in 34 C.F.R. § 99.31.

Disclosure to Medical Providers Under FERPA

•  Disclosure may be made to appropriate parBes, if the disclosure is in connecBon with a health or safety emergency. See 34 CFR §§ 99.31(a)(10) and 99.36. •  hHps://www2.ed.gov/policy/gen/guid/fpco/pdf/ferparegs.pdf

•  A student’s treatment records may be shared with health care professionals who are providing treatment to the student, including health care professionals who are not part of or not acBng on behalf of the educaBonal insBtuBon (i.e., third-‐party health care provider), as long as the informaBon is being disclosed only for the purpose of providing treatment to the student. Only allowed as long as the informaBon is being disclosed only for the purpose of providing treatment to the student.

Consent to Disclose Records Under FERPA

•  Under FERPA, a parent or eligible student (i.e., a student who has reached 18 years of age) generally must provide a signed and dated wriHen consent before the agency or insBtuBon discloses personally idenBfiable informaBon ("PII") from the student's educaBon records. 34 CFR § 99.30. •  FERPA allows a parent to consent to the disclosure of a minor child’s educaBonal records, which includes personally idenBfiable informaBon, to third parBes. • Model Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents •  hHps://www2.ed.gov/policy/gen/guid/fpco/ferpa/safeschools/modelform2.html

Disclosures Under FERPA Without Consent (parBal list) •  Schools are generally prohibited from disclosing personally idenBfiable informaBon about a student without the parent’s wriHen consent. •  ExcepBons to this rule include: • disclosures made to school officials, including teachers, with legiBmate educaBonal interests; •  In an emergency "if knowledge of the informaBon is necessary to protect the health or safety of the student or other individuals" (See 34 C.F.R. §99.36(a)).

Disclosures under FERPA

• Can a list of students' health issues be distributed to teachers or other staff?

• A school-‐wide health concerns distribuBon list violates FERPA.

Disclosures under FERPA

• Can school personnel talk to a student's health care provider without consent?

• Generally, schools must have wriHen permission from the parent or eligible student in order to release any informaBon from a student's educaBon record to outside parBes including providers. However, a school nurse may call a student's health care provider to clarify facts surrounding a student's condiBon or treatment plan.

AdministraBon Of Meds and Procedures

•  For the most part, the statutory authorizaBons are found in Tennessee Code Annotated (T.C.A.) secBon 49-‐50-‐1601 et seq.

AdministraBon of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1601 •  T.C.A. § 49-‐50-‐1601 allows the self-‐administraBon of pancreaBc enzymes with wriHen authorizaBon from the healthcare provider and parent. A student with pancreaBc insufficiency or cysBc fibrosis is allowed to carry and self-‐administer prescribed pancreaBc enzymes.

AdministraBon Of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1602 •  T.C.A. § 49-‐50-‐1602 requires certain health care procedures, including the administraBon of medicaBons during the school day or at related events, to be performed by appropriately licensed health care professionals. •  T.C.A. § 50-‐1602 allows “...school personnel who volunteer under no duress or pressure and who have been properly trained by a registered nurse” to administer Glucagon in the event of a diabetes emergency in the absence of the school nurse. The guidelines were revised to address this change in law and to provide further clarificaBon for medical and nursing procedures performed in the school seTng. •  T.C.A. § 49-‐50-‐1602 permits possession and self-‐administraBon of a prescribed, metered dosage, asthma-‐reliever inhaler by any asthmaBc student.

AdministraBon Of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1602 (conBnued) •  T.C.A. § 49-‐50-‐1602 permits “school personnel to volunteer to assist with the care of students with diabetes, excluding the administraBon of insulin; •  T.C.A. § 49-‐50-‐1602 allows school staff, who under no duress, volunteer to be trained in the administraBon of anB-‐seizure medicaBon, including diazepam rectal gel as prescribed by a licensed health care provider. •  T.C.A. § 49-‐50-‐1602 provides that each school is authorized to maintain at least two epinephrine auto-‐injectors so that epinephrine may be administered to any student believed to be having a life-‐threatening allergic or anaphylacBc reacBon.

AdministraBon Of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1602 (conBnued) •  T.C.A. § 49-‐50-‐1602 allows “...school personnel who volunteer under no duress or pressure and who have been properly trained by a registered nurse” to administer daily insulin to a student based on the student’s individual health plan in the absence of the school nurse. The guidelines were revised to address this change in law and to provide further clarificaBon for medical and nursing procedures performed in the school seTng.

AdministraBon Of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1603 •  T.C.A. § 49-‐50-‐1603 (2017 Public Chapter 84) -‐ State Board of EducaBon will adopt rules for the administraBon of adrenal insufficiency medicaBon by school personnel if the healthcare provider is not immediately available. The school system is only required train personnel if noBfied by a parent/guardian that a student has the condiBon. The school system must adopt a policy. Removes liability when administering the medicaBon. EffecBve July 1, 2017.

• hHp://publicaBons.tnsosfiles.com/acts/110/pub/pc0084.pdf

AdministraBon Of Meds and Procedures – 2017 Public Chapter 256 •  2017 Public Chapter 256 (likely to be added as T.C.A. § 49-‐50-‐1604) -‐ State Board of EducaBon will develop guidelines for the administraBon of an opioid antagonist for students experiencing an opioid overdose. The prescripBon will be held in the name of the school system. The school nurse, SRO, or other trained personnel may administer the medicaBon. There are provisions removing liability if a student is injured due to the administraBon of the medicaBon. This is effecBve July 1, 2017.

• hHp://publicaBons.tnsosfiles.com/acts/110/pub/pc0256.pdf

Administra>on Of Meds and Procedures – Related Statutes •  T.C.A. § 49-‐5-‐414 encourages LEAs to have CPR -‐ cerBfied individuals in their employment or as a volunteer. •  T.C.A. § 49-‐3-‐359(b)(2) each public school nurse employed or contracted by an LEA will maintain current CPR cerBficaBon consistent with the guidelines of the American Heart AssociaBon •  T.C.A. § 49-‐6-‐5004 authorizes health care professionals to indicate the need for a dental or vision screening on any report or form used in relaBonship to reporBng immunizaBon status for a child. Health care professionals shall provide a copy of the report or form to the parents or guardians indicaBng the need to seek appropriate follow up.

Other Legisla>on – Telehealth Services

• Changes made by Public Chapter 130 to T.C.A. § 56-‐7-‐1002 -‐ Telehealth services •  (ii) The paBent is at a qualified site or at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunicaBons described in this secBon; and equipped to engage in the telecommunicaBons described in this secBon; and, or at a public elementary or secondary school staffed by a healthcare services provider and

Proposed Legisla>on S>ll Under Considera>on

• Changes by proposed SB534/HB503 would amend T.C.A. § 49-‐3-‐359 -‐ BEP funding for teacher's supplies, duty-‐free lunch periods, and school nurses.

•  There is included in the Tennessee BEP an amount of money sufficient to fund one (1) full-‐Bme public school nurse posiBon for each three thousand (3,000) seven hundred fi9y (750) students or one (1) full-‐Bme posiBon for each LEA, whichever is greater.


• Changes by proposed SB1055/HB1099 would amend T.C.A. § 68-‐55-‐501 -‐ Part definiBons.

•  (3) "Health care provider" means a Tennessee licensed medical doctor (M.D.), osteopathic physician (D.O.), clinical neuropsychologist with concussion training, or physician assistant (P.A.) with concussion training who is a member of a health care team supervised by a Tennessee licensed medical doctor or osteopathic physician; or nurse prac??oner with concussion training who is a member of a health care team supervised by a Tennessee licensed medical doctor or osteopathic physician.


• Changes by Proposed SB190/HB145 would amend T.C.A. § 68-‐11-‐313 -‐ AuthenBcaBon of verbal orders.

•  (d) For the purposes of this secBon, telephone orders and orders by electronic means are considered verbal orders.

Pediatric Sleep Apnea

Kelly Hare, FNP-‐BC Indian Path Center for Sleep Disorders

July 27, 2017

Objectives:

1.  Review Pediatric sleep architecture norms. 2.  Define and describe Pediatric ObstrucKve

Sleep Apnea. 3.  IdenKfy treatment opKons for Pediatric OSA. 4.  Detail “CHAT” study findings. 5.  Case Studies

Sleep Architecture

A.  NREM Sleep 1.  Includes Stages 1, 2, SWS 2.  Occupies 75% of TST

B.  REM Sleep 1.  AcKvated EEG (similar to wake) with

decreased or no muscle tone 2.  Alternates with NREM every 90-‐100 minutes

with progressive lengthening in the la]er 1/3 on the night

American Thoracic Society defines OSA

•  A disorder of breathing during sleep characterized by prolonged parKal airway obstrucKon and/or intermi]ent complete obstrucKon that disrupts normal venKlaKon during sleep and normal sleep pa]erns.

Pediatric OSA Incidence and Prevalence

1.  Occurs in all ages with peak between 2-‐8 years

2.  Occurs in 1-‐4% of the general pediatric populaKon

3.  More likely to be seen in boys versus girls

Risk Factors for OSA

1.  Adenotonsillar Hypertrophy 2.  Obesity 3.  Craniofacial Anomalies 4.  Familial PredisposiKon 5.  Ethnicity 6.  Prematurity

Nocturnal Symptoms

1.  Snoring 2.  Paradoxical Breathing 3.  Witnessed Apnea

4.  Restless Sleep 5.  Frequent Awakenings 6.  Nocturnal Enuresis 7.  Night SweaKng

Most sensiKve and specific

DayKme Symptoms

1.  Abnormal DayKme FuncKoning -‐ Less than 15% report dayKme sleepiness -‐ May present in children as irritability, nervousness, and aggressiveness. -‐ Impaired cogniKve funcKon

2.  ADHD 3.  Poor School Performance

DayKme Symptoms – other consideraKons

1.  Mouth breathing due to hypertrophied tonsils

and adenoids.

2.  Recurrent URI

3.  Hearing and speech difficulties

4.  Morning headaches much less common than

adults but may be reported.

Clinical Consequences – likely resulKng from intermi]ent hypoxia, sleep fragmentaKon, and inflammaKon. 1. RV and LV dysfunction

2. Systemic Hypertension

3. Pulmonary Hypertension

4. Poor Growth

5. Behavioral and Cognitive Impairment

6. ADHD

EvaluaKon

1.  Sleep Consultation

-focused sleep history

-physical exam including detailed exam of oropharynx

2.  Polysomnography- the “Gold Standard” for diagnosis

of OSA. The only tool capable of definitively identifying

obstructive events and quantifying severity of OSA, including

gas exchange abnormalities and sleep disruption.

Polysomnography

1.  Nasal and oral airflow sensors

2.  Snore microphone

3.  Respiratory impedance plethysmography

(RIP Belts)

4. Pulse oximetry

5. EKG

6. Capnography

7. EEG

8. Body position

9. Muscle tone (chin and lower extremities)

Diagnosis

1.  Clinical Criteria – one or more of the following: snoring,

labored, paradoxical, or obstructed breathing in sleep

WITH

2. Polysomnographic criteria – one obstructive apnea,

mixed apnea or hypopnea per hour of sleep and/or

obstructive hypoventilation with at least 25% TST with

hypercapnia (PaCO2>50mmHg) with snoring, flattening of

the nasal pressure waveform, paradoxical

thoracoabdominal motion.

Assessment of Severity – no clear cut classificaKon of OSA in children has gained uniform acceptance. PSG findings should be interpreted by a Sleep Medicine Physician using all the PSG parameters and in the context of the child’s symptoms and contribuKng risk factors.

1. Mild OSA –AHI 1-4.9

2. Moderate OSA – AHI 5-9.9

3. Severe OSA – AHI >10

ObstrucKve Sleep Apnea •  Treatment OpKons

•  Tonsillectomy and Adenoidectomy •  CPAP (conKnuous posiKve airway pressure) •  “Watchful WaiKng?”

ObstrucKve Sleep Apnea •  The Childhood Adenotonsillectomy Trial (CHAT) 2013

–  Hypothesis: In children with OSA without prolonged

oxyhemoglobin desaturation, early AT, as compared

to “watchful waiting” would result in improved

outcomes.

–  Multi-center, single blind, randomized, controlled trial

–  464 children ages 5-9

–  Excluded for Severe OSA and/or oxyhemoglobin

saturations <90% for 2% TST or longer, recurrent

tonsillitis, meds for ADHD, and z score based on BMI

of 3 or greater

–  PSG and cognitive/behavioral testing at baseline and

then again at 7 months. Caregiver surveys and

behavioral assessments from teachers also collected

ObstrucKve Sleep Apnea

•  The Childhood Adenotonsillectomy Trial (CHAT)

2013

Early AT group: improvements in symptoms, behavior,

QOL, and PSG findings

Effect size: moderate to large indicating clinical

significance

ObstrucKve Sleep Apnea

BUT-

No significant improvements in attention or

executive function and no decline in the “watchful

waiting” group.

SO-

Medical management and reassessment after a

period of observation may be a valid therapeutic

option.

CASE STUDY 1

Case Studies

B.M. 3y/o male

CC: “He stops breathing in the

middle of the night.”

Case Studies Hx:

Little witness to sleep until moved into grandparents

home in a shared bedroom with mom in his own bed.

Snores in all sleep positions.

Sleeps with mouth open.

+Sleeptalking

Mom questions effort to breathe.

Breathes “funny.”

Bedtime 9p/10p weekend

Rise time 0615 / 1000 weekend

Case Studies

Social history:

Headstart

No behavioral problems

Behind in learning for age

Grandparents smoke “outside”

Case Studies

Past Medical History:

Abnormal chromosome analysis

Microcephaly

RAD

Small Stature

Speech Delay

Case Studies FH: Sleep apnea in 1 cousin

Meds: None

PE:

BP 100/65

HR 123

O2 sats 98%

Ht: 38in

Wt: 26lbs

Case Studies PSG Findings

Sleep Eff: 88.4%

N1: 0.1%

N2: 33.4%

SWS: 56.6%

REM: 9.8%

Arousals: 27.4/hr


OH: 113

OA: 5

CA: 32

MA: 7

**AHI: 23.1

REM AHI: 69

Supine AHI: 17.9


PLMS: 1.6

EKG: NSR/SA

Capnography: WNL

Lsat 50%

Sat<88% 50min TST

PLAN: ENT evaluation for T&A

CASE STUDY 2

Case Studies

A.L. 7 y/o male

-Referred by ENT for snores

-Snores in all sleeping positions

-Oral breathing in sleep and wake

-Restless in sleep/moves frequently

-Whines and whimpers in sleep

-Rare bedwetting

Case Studies

-Bedtime 830p/10p on weekends

-LSO 30 minutes

-Uses tablet and TV before bed

-Shares bedroom with 14y/o brother

-Rise time 7a/8a weekend – difficult to wake

-No problems at school

-FT/no delivery complications

Case Studies PMH

-PE Tubes

-ADHD

-Obesity

-New onset absence seizures

FH

-RLS – Aunt, GGM.

-OSA - GF

Case Studies SOC

-Mom deceased/Grandmother with custody

-2nd

grade

-No tobacco exposure

MEDS

-Keppra

-Loratadine

-Fluticasone

Case Studies

EXAM

BP: 112/67

HR: 98

Pulse Ox: 99%

Ht: 56.5in

Wt: 140lbs

Remainder of exam unremarkable except for 3+ tonsils

Case Studies

PSG

SE 91%

OH 118

MA 12

OA 1

CA 82

Case Studies PSG

AHI 33

LSAT 86%

2% TST with CO2 56-60mmHg

PLMI 2/hr

No arrhythmia

No seizure activity

Case Studies

PLAN: Referred to ENT for T & A.

Repeat PSG:

AHI 5.2

CO2 never above 50mmHg

Plan: CPAP at 5cm with full face mask

Sleeping better, Likes cpap, No snores on therapy,

No restlessness, Easier to wake

Pediatric Sleep Disorders

References:

www.uptodate.com

www.aasmnet.org American Academy of Sleep Medicine

www.sleepfoundation.org National Sleep Foundation

Principles and Practice of Pediatric Sleep Medicine. 2nd

ed.

Sheldon, DO FAAP, Stephen H.

“A Randomized Trial of Adenotonsillectomy for Childhood Sleep

Apnea.” Carol L. Marcus, et al. NEJM 2013; 368; 2366-76.

Documents

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