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PPC Interdisciplinary Case: Obstructive Sleep Apnea in an Obese Child. LaKiesha Bonham, CRT, MAE Trainee Patrick Maeng , MD, Pulmonary Fellow Casey Mathews, BS, MSW/MPH Trainee. Outline. Rationale Multiple medical, respiratory care, and social work issues - PowerPoint PPT Presentation
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LAKIESHA BONHAM, CRT, MAE TRAINEE PATRICK MAENG, MD, PULMONARY
FELLOWCASEY MATHEWS, BS, MSW/MPH TRAINEE
PPC Interdisciplinary Case:Obstructive Sleep Apnea in an
Obese Child
Outline
Rationale Multiple medical, respiratory care, and social work issues Severity and complexity of each factor requires an
interdisciplinary approach for optimal managementMedical overview
Morbid obesity Severe obstructive sleep apnea Respiratory insufficiency
Non-medical barriers to care Family resources Social history Psychosocial factors related to obesity
Group discussion What is her optimal medical therapy? How do we overcome her barriers to care? How can we improve adherence?!?!
Case Presentation
CW is an 18 y/o morbidly obese AAF Referred for overnight polysomnogram from the Children’s Center
for Weight Management Sleep study
Severe obstructive sleep apnea (OSA) Apnea/hypopnea index (AHI) 50.8 Significant oxygen desaturations
Hospital admission Titration of significant BiPAP settings
23/12 cm H2O with rate 20 2-3 LPM oxygen
Assessment of respiratory and other healthcare issues PMH
Obesity OSA Insulin resistance syndrome Polycystic ovarian disease
Case Presentation
Meds Metformin Ibuprofen PRN pain
ROS Gen: obese with recent weight gain CV: diminished exercise tolerance, sleeps with head
elevated, occasional chest pain and tenderness Resp: SOB at rest, daytime sleepiness, snoring with pauses
in breathing GI: abd pain related to menstruation MSK: joint, back pain and tenderness, moderate joint
swelling GU: regular menstrual cycles Neuro: headache related to sleep patterns
Further History
FH Obesity Type 2 diabetes Cardiovascular disease Thyroid disease
SH Lives in public housing apartment with mother and other
extended family Dropped out of high school
Physical Examination
Vitals: T 98 P 97 BP 130/66 (119/74 thigh cuff) R 20 SaO2 95%
RA Wt 180.3 kg Ht 166 cm BMI (wt kg/ht m2) = 65.5 (BMI% = 99.7%)
Gen: obese, alert, interactive, appropriate, NADHEENT: NCAT, no LADResp: distant breath sounds, CTACV: distant heart sounds, no murmurs, pulses 2+Abd: soft, NT, no organomegaly appreciated due
body habitusExt: no joint swelling or tenderness, edema, digital
clubbing
Clinical Course
Assessment Morbid obesity with insulin resistance Severe OSA Respiratory insufficiency
Nocturnal hypoxia Hypercarbia
BiPAP Difficulty obtaining BiPAP machine Multiple strategies to improve tolerance of high settings Mother to manually titrate from low pressures to goal Repeat PSG
Goal home settings: 25/13 with rate of 20 and 3 LPM oxygen Follow-up
Sleep clinic – 4 weeks, seen by interdisciplinary team Weight management clinic – seen by interdisciplinary and
multidisciplinary teams
The Pediatric Obesity Epidemic
Obese = BMI > 95th percentile (BMI ~30) Severe obesity = BMI 35-40 Morbid obesity = 40-45 or 50 Super obesity = >45 or 50
US during the last 30 yrs (2007-2008 NHANES) Increase from 5 to 10.4% in 2-5 year olds 6.5 to 19.6% in 6-11 year olds 5 to 18.1% in 12-19 year olds
Biggest risk factors for adult obesity Obese as a child Parent(s) with obesity
Adverse effects Psychological, neurological, endocrine, cardiovascular, respiratory, GI,
orthopedic Metabolic syndrome
Dyslipidemia, hypertension, insulin-resistant diabetes, prothrombotic and inflammatory states
Independent role in the development of OSAS
Obstructive Sleep Apnea Syndrome (OSAS)
Prolonged, intermittent complete or partial obstruction (obstructive apnea or hypopnea) May occur with obstructive hypoventilation
Arterial oxygen desaturation Hypercarbia
Movement, autonomic, or cortical arousals from sleep Associated sx
Hypoxemia, hypercarbia Adenotonsillar hypertrophy Excessive daytime sleepiness Snoring +/- pauses and gasps Movements or arousal from sleep Paradoxical breathing, retractions Sleep in unusual positions Diaphoresis Morning headaches Parental concern, sleep with their child, shake to awaken to terminate
apnea
International Classification of Sleep Disorders, 2nd Edition, 2005, American Academy of Sleep Medicine
OSAS Demographics
2% of children Boys = girls Increased prevalence in African-
American children Predisposing Factors
Larger tonsils and adenoids Size of adenotonsillar tissue does not
predict disease Obesity Craniofacial abnormalities
Down Syndrome, Pierre Robin Sequence
Hypotonia/neuromuscular disorders Infants with GERD Familial patterns
Complications Growth failure
Increase in height and weight following treatment in all weight categories, including obese patients
Cognitive and behavioral Developmental delay Poor school performance ADHD Aggressive behavior
Severe Asphyxial brain damage, seizures Pulmonary htn, cor pulmonale,
systemic htn Pathophysiology
Combination of upper airway narrowing and hypotonia Narrowing
Adenotonsillar hypertrophy Obesity
Hypotonia Pharyngeal dilating muscles (naturally
decreases with sleep onset)
International Classification of Sleep Disorders, 2nd Edition, 2005, American Academy of Sleep Medicine
Childhood Obesity and OSA
Obesity may increase risk of OSA four-fold 10% of those with OSA were obese 20-50% of obese children have evidence of OSA
Pathophysiology of OSA in obese children Anatomic factors
Adenotonsillar hypertrophy (45%) Hormonal changes Inflammatory changes
Soft tissue obstruction Fat pads, soft palate, lateral pharyngeal wall, tongue
Functional factors Higher critical airway pressure needed by dilator muscles to prevent airway
collapse Chest wall mechanics
Increased chest wall mass effect Decreased lung compliance Decreased FRC from abdominal visceral fat Decreased lung volumes leading to decreased tethering of trachea and easier
collapse Ventilatory drive
Decreased ventilatory responses to hypoxia and hypercapnea
Arens and Muzumdar, J Appl Physiol. 2010
Approach to the Obese Child with OSAS
Arens and Muzumdar, J Appl Physiol. 2010
Treatment of OSA in the Obese Child
T&A Treatment of choice when there is adenotonsillar hypertrophy Resolves OSA in ~50% Can resolve or decrease severity of OSA in 75% Much less effective in obese adults
Oral appliances Expand upper airway Mild OSA or do not tolerate CPAP Efficacy in children not well established
Positional therapy Promotes lateral, prone, or upright position
Uvulopalatopharyngoplasty Trim lateral pharygeal pillars, excise uvula and posterior palate Improves mild to moderate OSA in 40-50% Significant complications
Arens and Muzumdar, J Appl Physiol. 2010
Treatment of OSA in the Obese Child
Weight loss Greater degrees of weight loss associated with significant
reductions in OSA Most have residual OSAS Decreased CPAP requirements Dieting alone successful in adults 5-15% of the time over the first
8 years of treatment (Kohler 2009) Bariatric surgery
Unclear benefits in obese children after 10 years Rao et al. (2009) showed 50% resolution of OSA following lap
band surgery with loss of 20 kg excess weight Adult studies show resolution of OSA after gastric bypass in 25-
75% of cases (Fritscher et al. 2007; Peluso and Vanek 2007) Reasonable candidates for surgery:
Morbidly obese Skeletally mature Failed organized attempts at weight loss
Arens and Muzumdar, J Appl Physiol. 2010
CW
18 year old African American female diagnosed with Morbid Obesity
Initial sleep study was performed at the age of 12 Apnea/hypopnea index (AHI) of 23 Started on CPAP and titrated to a pressure of 8 cm
H2O
Hospital
Repeat sleep study 9/16/10 revealed an AHI of 50
Pt was started on CPAP 14 and found to be inadequate
Pt was then placed on BiPAP 14/6 and titrated up to 22/12 with a rate of 20
Hospital
Supplemental oxygen was titrated from 1 lpm to 3 lpm
Sleep study performed prior to discharge revealed optimal settings of 25/13 with a rate of 20
Home
Pt didn’t tolerate IPAP pressure of 22Mother started at a low setting of 12/6
increasing her dial throughout the nightMax level achieved was 18/8Target goal 22/13 (highest level on machine)
CPAP vs. BiPAP
Continuous positive airway pressure (CPAP) delivers a set pressure to lungs
Bi-level positive airway pressure (BiPAP) helps deliver pressure to the lungs at higher levels
Comparison
Flow generator (delivery mechanism)Hose (linkage between interface/generator)Interface (facial or nasal mask)
Contrast (CPAP)
CPAP delivers a set pressure (4-20 cm H2O)Works by releasing the amount of
compressed air through the hose to the interface (mask) and keeps the upper airway opened under continuous air pressure
Increases the oxygen flow by keeping airway opened
Contrast (BIPAP)
Delivers two levels of pressure (IPAP/EPAP)IPAP (20-30 cm H2O)EPAP (4-20 cm H2O)Preferred over CPAP to treat CSA or OSA and
heart diseasesBIPAP has a set rate
Comparison
Side effects: Headache Skin irritation Abdominal bloating Nasal congestion Runny nose
What is BiPAP?
Pushes air into the lungsHolds the lungs open to allow more oxygen to
enter into it
Qualifications for BiPAP
Initial ventilatory crisis and avoid intubation and ventilation
Home ventilation for patients with neuromuscular dysfunction, obstructive sleep apnea, and other conditions resulting in hypoventilation
BiPAP Settings
IPAP Once inspiration begins, a preset Inspiratory
Positive Airway Pressure (IPAP) is reachedEPAP
Expiratory Positive Airway Pressure (EPAP) is preset to maintain airway patency and oxygenation
Frequency Determines the timed breath rate and is adjustable Synchronizes to patients own breaths
Criteria for BiPAP
Stable hemodynamicsCooperative patientMinimal airway secretions
Goals for CW’s BiPAP Use
Adherence Better fitting mask for comfort Auto titration Incentives (gift card)
Achievement of optimal pressure settings New BiPAP machine (25/13)
Adolescent Obesity
Under age 19, obesity is determined by BMI percentile Obese = >95th percentile
16.8% of girls ages 12-19 are obese 29.2% of black adolescent girls
19.3% of boys ages 12-19 are obeseRisk factors for adolescent obesity
Low SES Minority race/ethnicity Obese family member
80% of obese adolescents with an obese parent will become obese adults
Centers for Disease Control (2010). Childhood obesity. http://www.cdc.gov/HealthyYouth/obesity/
Psychosocial Effects of Obesity
“There is no doubt that obesity is an undesirable state of existence for a child. It is even more
undesirable for an adolescent, for whom being overweight acts as a damaging barrier in a
society obsessed with slimness.” – Hilde Bruch
Psychosocial Effects of Adolescent Obesity
Higher prevalence of depressive symptoms and lower self-esteem than non-overweight peers
Associated with adverse social and economic status in adulthood Particularly strong association in women
Report fewer reciprocal friendships than non-overweight peers
Reported more hours of television viewing per dayLess involvement in formal activities
Strauss, Pollack (2003). Social marginalization of overweight children. Pediatric and adolescent medicine 157. p 746-752.
Family Composition/History
Lives with mother, two siblings, aunt, cousin Public housing apartment
Father passed away 1 year ago Obesity-related complications
Long family history of obesity Mom – diabetes PGF – gastric bypass surgery
School History
Dropped out at age 16 as an eighth graderReasons for dropping out
Teasing Not feeling well Bad grades Embarrassment about weight
Currently attending GED classesBoth parents graduated from high school
Economic Factors
Sources of income Mother’s unemployment Food Stamps
Father’s death worsened financial burden of the family Significant decrease in income Family moved into public housing Mother lost her job shortly after his death
Funding for Medical Care
MedicaidReceives Oxygen through Pediatric Services
of AmericaMedicaid is not funding her BiPap machine
PSA donated an old machine
Mental Health
Denies suicidal ideation or intentShe perceives that she has been left out of
activities because of her weightHas lost most of her friends as she has
become more overweightTeased by siblings, adult family members,
and other children at schoolExpresses that she intensely dislikes herself
and her body
Adherence to Treatment
Has a history of non-adherence with CPapStates that there is a “50/50” chance that she
will wear the BiPap at homeStates that she does enjoy the activities in
Weight Management Clinic Fun exercises to do at home
Weight Management Clinical Nutrition Assessment Low adherence predicted
Adherence
Strategies to encourage adherence Gift card incentives If mask is irritating the patient at night, encourage
her to wear it while watching television during the day
Reinforce how serious her OSA is, and the consequences that will likely come if she does not use BiPap regularly
Lead the patient to articulate for herself reasons that the BiPap is good for her and ways that it helps her
Help her formulate her own realistic goals for her health, then teach her what is required to reach them
Barriers to Care
Transportation issues Rely on public transportation Frequent doctor’s appointments, Weight Management
appointments
Stigma of wearing BiPap at age 18 Related teasing from family members, siblings
Financial burden Out of pocket expenses for medical care Increased cost of eating fresh food
Barriers to Care
Culture of neighborhood Convenient foods are fatty foods “Food Desert” Lack of safe opportunities for exercise
Family culture Obesity is the norm Traditional southern cooking
Sleep Clinic Follow-Up
Seen by interdisciplinary team2-3+ Adenotonsillar hypertrophyAdmits to poor adherence
Using BiPAP ~2-3x/week Takes off BiPAP after a few hours due discomfort
from high pressures Intermittent discomfort due to mask Embarrassment due to teasing
Old Respironics ST BiPAP machine Mother manually titrating from 12/6 to 18/8 Maximum IPAP 22 cm H2O
Sleep Clinic Follow-Up
Plan New BiPAP
Start at low settings 12/5 Autotitrate to goal 25/13 rate 20, with 3 LPM oxygen Download usage at next f/u to gauge adherence
Attempt different mask fitting (ResMed Quattro, small)
Refer to otolaryngology for T&A Repeat sleep study 6 weeks post-op Anesthesia risk
Ongoing psychosocial support Strongly recommend continued weight
management clinic follow-up