Management of pediatric OSAManagement of pediatric OSA

Suchada Sritippayawan, MD

Div. Pulmonology & Critical Caregy

Dept. Pediatrics, Faculty of MedicineChulalongkorn UniversityChulalongkorn University

Treatment modalities

• Surgery

• Medications

• NIV during sleep• NIV during sleep

• Orthodontic proceduresOrthodontic procedures

Surgical treatmentg

• Adenotonsillectomy

• Others

Maxillofacial surgey- Maxillofacial surgey

- Nasal turbinectomyNasal turbinectomy

- Tracheostomy

Adenotonsillectomyy

M t i l d i• Most common surgical procedure in

pediatric OSApediatric OSA

• Would be helpful in OSA caused by p y

other etiologies: CP, Down syndrome,

obesity

• Can be done safely in young

f finfant if indicated

Adenotonsillectomyy

EfficacyEfficacy

• ↓ OSA symptoms and AHI in 90%

• Complete resolution of OSA (AHI < 1/hr) in 27%

• Risk factors of residual OSA

- Obesity- Obesity

- Severe OSA

- Asthma

AJRCM 2010; 182:676-83.

Adenotonsillectomyy

Risk factors of recurrent OSARisk factors of recurrent OSA

• Family Hx of OSA

• Craniofacial anomaliesN d PSG F/U• Down syndrome

• Nasal septal deviation

Need PSG F/U

Nasal septal deviation

• Enlarged nasal turbinates

• Surgical technique???Proc Am Thorac Soc 2008; 5:274-82.

Int J Pediatr Otorhinolaryngol 2010; 74:241-4.Indian J Med Res 2010; 131:311-20.

Adenotonsillectomyy

Post op complications (18 34%;more in OSA)Post-op complications (18-34%;more in OSA)

Early (within 1 week)

• Laryngospasm

• Local bleeding ----> Be careful with NSAIDS use

• Pain ----> Be careful with pain control therapyPain ----> Be careful with pain control therapy

• Dehydration

• Respiratory complications Pediatr Pulmonol 2008; 43:837-43.

Paediatr Respir Rev 2006; 7S:S58-61.Anesth Analg 2009; 109:60-75.

Adenotonsillectomyy

Late complications: rareLate complications: rare

• Velopharyngeal incompetence

• Nasopharyngeal stenosis Paediatr Respir Rev 2006; 7S:S58 61Paediatr Respir Rev 2006; 7S:S58-61.

Mortality rate: 1:10,000 in risked group

• Age < 2 yrs

Severe OSA esp associated abnormal ABG• Severe OSA esp. associated abnormal ABG• Other comorbids: Obesity

Pediatr Pulmonol 2008; 43:837-43.

Adenotonsillectomyy

Post op respiratory complications : incidence 20% inPost-op respiratory complications : incidence 20% in

risked group

• Desaturation • Pneumomediastinum

• Pneumonia• Increased WOB

• Pulmonary edema

• Pneumonia

• PHT crisisPulmonary edema

• Atelectasis• Laryngospasm

• Apnea• Pneumothorax

Apnea• Rebound REM (after 24

Anesth Analg 2009; 109:60-75.hr post-op)

Adenotonsillectomyy

High risk for post op respiratory complicationsHigh risk for post-op respiratory complications

(need specialist and PICU care)

• Age < 3 yrs

• Severe OSA (AHI > 10, nadir SpO2 < 70-80%)

• Cor pulmonale Systemic HTCor pulmonale, Systemic HT

• FTT

• Morbid obesity

P iPediatrics 2002; 109:704-12.

Th 2005 60 511 6• Premie Thorax 2005; 60: 511-6.Anesth Analg 2009; 109:60-75.

Adenotonsillectomyy

High risk for post op respiratory complicationsHigh risk for post-op respiratory complications

(need specialist and PICU care)

• URI within 4 wks prior to T&A

• Craniofacial anomalies

• Genetics & chromosomal disordersGenetics & chromosomal disorders

• NMD

Pediatrics 2002; 109:704-12.

Th 2005 60 511 6Thorax 2005; 60: 511-6.Anesth Analg 2009; 109:60-75.

Adenotonsillectomyy

High risk for post op respiratory complicationsHigh risk for post-op respiratory complications

(need specialist and PICU care)

• Mallampati score 3, 4

• Associated nasal problems

• Enlarged lingual tonsilsEnlarged lingual tonsils

Pediatrics 2002; 109:704-12.

Th 2005 60 511 6Thorax 2005; 60: 511-6.Anesth Analg 2009; 109:60-75.

Medical treatment for OSA

Intranasal corticosteroidIntranasal corticosteroid

• High α and β glucocorticoid receptors in adenotonsillar

tissues

• Anti-inflammatory and lympholytic actions

LTRA

• High level of cysteinyl leukotriene in exhaled breath• High level of cysteinyl leukotriene in exhaled breath

condensate of OSA children

• High expression of LTR in adenotonsillar tissues

Pediatr Pulmonol 2008; 43:837-43.

Chest 2004; 126:13-8.Chest 2006; 130:143-8.

Medical treatment for OSA

Intranasal corticosteroidIntranasal corticosteroid

• Duration of Px: 4-24 wks (mostly 4-8 wks)

• Various types and doses

• Used in mild OSA, moderate-to-severe OSA

----> ↓OSA severity ↓adenoid size ↓T&A procedure----> ↓OSA severity, ↓adenoid size, ↓T&A procedure

• Benefits can be lasted until 8 wks

P di t i 2008 122 149 55Pediatrics 2008; 122:e149-55.

Medical treatment for OSA

LTRA: MonteleukastLTRA: Monteleukast

• Used in mild OSA for 16 wks ----> ↓OSA severity,

↓adenoid size

• Used with BUD in residual mild OSA post T&A for 12

wks ---> resolved of OSAwks ---> resolved of OSA

AJRCCM 2005; 172:364-70AJRCCM 2005; 172:364-70. Pediatrics 2006; 117:e61-6.

Medical treatment for OSA

Unknown issues of INS and LTR used in OSAUnknown issues of INS and LTR used in OSA

• Use in mild OSA??

• Use for prevention of recurrent OSA after T&A?

• Use in residual OSA post T&A?

• Only benefit in adenoid hypertrophy AR?Only benefit in adenoid hypertrophy, AR?

• Dose and duration of Px?

• Combine Px is better?

NIV in OSA

I di tiIndications

• Residual OSA after surgeryResidual OSA after surgery

• Obesity during weight controly g g

• Craniofacial anomalies

NIV in OSA

CPAPCPAP

• Initial CPAP 4 cmH2OInitial CPAP 4 cmH2O

• max CPAP

- 15 cmH2O in aged < 12 yrs

- 20 cmH2O in aged ≥ 12 yrs

• Need more CPAP ----> use BPAP

J Clin Sleep Med 2008; 4:157-71.

NIV in OSA

BPAPBPAP

• Initial IPAP 8 cmH2O EPAP 4 cmH2OInitial IPAP 8 cmH2O, EPAP 4 cmH2O

• max IPAP

- 20 cmH2O in aged < 12 yrs

- 30 cmH2O in aged ≥ 12 yrs

• Δ IPAP and EPAP : at least 4 cmH2O

J Clin Sleep Med 2008; 4:157-71.

NIV in OSA

G l f CPAP d BPAP tit tiGoals of CPAP and BPAP titration

• RDI < 5 (for at least 15 min include REM andRDI < 5 (for at least 15 min., include REM and

supine sleep)p p)

• no arousal

J Clin Sleep Med 2008; 4:157-71.

Oxygen therapy in OSAyg py

U ith CPAP BPAP i CLD• Use with CPAP or BPAP in CLD

• Temporal use only inTemporal use only in

- Prior to T&A

- Post-op T&A

• Beware of hypoventilation ---> Need PSG

or at least CO2 monitoring during oxygen Clin Chest Med 2003; 24: 261-82titration Clin Chest Med 2003; 24: 261-82.

Pediatr Pulmonol 2008; 43:837-43.

Other Px in OSA

Orthodontic procedures : Rapid maxillaryOrthodontic procedures : Rapid maxillary

expansion

Clinical uses

• Residual OSA after T&A

due to high archdue to high arch

palate, narrow nasal

passage, deviated nasal

tseptum Indian J Med Res 2010; 131:311-20.

Other Px in OSA

Clinical usesClinical uses

• Pediatric OSA with

maxillary contraction,

no ATH, no obesity

• Effectively reduced AHI afterEffectively reduced AHI after

4-month Px

• Unknown duration of Px

Sl 2004 27 761 6Sleep 2004; 27:761-6.Sleep 2007; 8:12-34

Other Px in OSAOral appliancesOral appliances

• Tongue retaining device

• Mandibular repositioning

d idevice

• No definite indication and

benefits and still

need further investigations

in pediatric OSAin pediatric OSA Sleep Med Rev 2009; 13:123-31.