Pediatric Sleep Problems Flashcards
BEARS problems
bedtime problems
excessive day time sleepiness
awakenings at night
regularity/duration of sleep
snoring
3 types of respiratory sleep disorders
- hypoventilation
- OSA
- CSA
- can have more than one
6 year old boy
– History of snoring, restless sleep
– Concerns regarding attention and focus in school
Tonsillar hypertrophy on examination
type of respiratory sleep disorder?
obstructive sleep apnea
Obstructive Sleep Apnea (OSA)
• Recurrent events of partial or complete upper
airway obstruction during sleep
• Disruption of normal gas exchange (hypoxia,
hypercapnia)
• Sleep fragmentation
anatomic factors that cause OSA
- Adenotonsillar hypertrophy
- Pharyngeal tissue
- Mandible size/position
- Airway size
- Fatty infiltration
functional factors of OSA
• Reduced tone of pharyngeal
dilator muscles
• Ventilatory control
variability
• Upper airway reflexes and
arousal response blunted
pathway to OSA from snoring
- snoring
- upper airway resistance syndrome
- OSA
biggest risk factor in typical child for oSA
adenotonsillar hypertrophy
how does pierre robin sequence, premature infant, or obese child get predisposed to OSA
these syndromes affec airway structure
how do children with cerebral palsy have a higher risk factor for OSA
it affects airway tone
how do kids with downs sydnrome get predisposed with ISA
combo of adenotonsillar hypertrophy, they have more airway compressibilities and they have alterations in air way structure
consequences of OSA
- systemic inflammatory condition
- cardiovascular – systemic, pulmonary hypertension
- metabolic – lipid abnormalities, insulin resistance
- somatic growth impairment
- neurobehaviroual (hyperactivity, impulsivity, depression)
- cognitive impairments
- decreased quality of life
- increased health care utilization
clinical presentation of nocturnal OSA
day time presentation of OSA
- Difficulty waking
- Morning headaches
- Nasal obstruction •
Mouth breathing •
Daytime fatigue
- Daytime sleepiness
- Hyperactivity
things to do on PE for OSA
- oropharyngeal/nasal assessment and malampatti score
- facial structure assessment
- height/weight
- vitals, screening cardiorespiratory exam
T?F: Clinical history and physical exam are poor predictors
of OSA
true.
• Home sleep apnea testing is often not feasible, is not
validated, and is not recommended in children
• Gold standard test for diagnosis is the overnight
polysomnogram (PSG)
• So why didn’t we refer this patient for PSG?
factors that are measured by PSG
- sleep quality
- respiratory pattenr
- gas exchange
- limb movements
gold standard test for OSA
• Gold standard test for diagnosis is the overnight
polysomnogram (PSG)
what does each lead represent
• Obstructive apnea = “trying to breathe and can’t”
– Absent airflow despite continued respiratory effort
– Lasts ___ breaths or longer
___ = “poor quality breathing causing and/or arousal on EEG troubles”
– Decrease in airflow by >___% of baseline
– Lasts two breaths or longer
– Associated with a 3% drop in oxygen saturation
• Obstructive apnea = “trying to breathe and can’t”
– Absent airflow despite continued respiratory effort
– Lasts 2 breaths or longer
hypopnea = “poor quality breathing causing and/or arousal on EEG troubles”
– Decrease in airflow by >30% of baseline
– Lasts two breaths or longer
– Associated with a 3% drop in oxygen saturation
normal and severe OSA
we have huge accessibility problems for PSG in children. Who needs a PSG? Who must have one?
- children who are high risk for adenotonsillectomy: less than 2-3 years old, syndromic children
- diagnostic dilemma (small/absent tonsils issue)
- recommended screening (achondroplasia, trisomy 21)
- children with classic OSA presentation– just refer to ENT
___ remains first line treatment
for obese children with OSA
Adenotonsillectomy remains first line treatment
for obese children with OSA
- encourage weight stabilization/weight loss
central apnea
Central apnea = “not trying to breathe, either for a long time, or long enough to cause troubles”
• Central apneas are common in healthy infants
and children, especially during ___ sleep
– Central apnea index (CAI) derived from PSG data
– 0 – 6 events/hr in healthy children > 1 year old
– More frequent in infants under a year of age
• Clinical cutoffs for significance vary from 1 – 5
• Central apneas are common in healthy infants
and children, especially during REM sleep
praimary vs secondary CS
management of CSA
NIPPV, IPPV
note; kids with CSA don’t have nocturnal symptoms– no snoring, but they’re so still and not breathing. because of sleep distrurbances, they have daytime symptoms (irritability)
What counts as hypoventilation?
Elevation of carbon dioxide greater than ___ mmHg for 25% of the night
- • Can be an isolated issue, or in combination with
obstructive or central sleep apnea
• An additional group at high risk is children with
decreased muscle tone (eg __
disorders)
What counts as hypoventilation?
Elevation of carbon dioxide greater than 50 mmHg for 25% of the night
- • Can be an isolated issue, or in combination with
obstructive or central sleep apnea
• An additional group at high risk is children with
decreased muscle tone (eg NEUROMUSCULAR
disorders)
management of hypoventilaton
T/F – Snoring is a good predictor for sleep disordered
breathing in children with Trisomy 21
false.•
Sleep disordered breathing is very common in
children with Trisomy 21
– Snoring is NOT a good predictor for sleep disordered
breathing in children with Trisomy 21
in trisomy21, ___ ____ is the most common abnormality on PSG
obstructive hypoventilation (a mix of OSA and hypoventilation)
in trisomy 21, ___ curative in ~50%, so follow-
up is required
Adenotonsillectomy curative in ~50%, so follow-
up is required
