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.