Pediatric obstructive sleep apnea as a model for the technologists role in the assessment and management of sleep problems

in children

Dominic B. Gault, M.D. Assistant Professor, University of South Carolina Medical Director, Division of Pediatric Sleep Medicine Greenville Hospital System Children's Hospital

Objectives:
To understand some of the unique issues which arise in the assessment and management of sleep disorders in children To understand the role and importance of the sleep technologist in the assessment and management of sleep disorders in children

Children are NOT Little Adults

Continuum across development Differences amplified at younger ages Additional developmental issues may arise in association with specific medical disorders
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Different Disorders, Different Assessments, Different Treatments

Sleep disorders are common in children Prevalence = 25%
Owen, Prim Care Clin Office Pract, 2008; 35: 533-46

Prevalence rates are higher in children with developmental issues, psychiatric disorders and chronic medical conditions Sleep disorders which affect adults can affect children

Sleep disorders presenting more commonly or differently in children

Night Terrors Sleep Enuresis Nightmares Rhythmic Movement Disorder Kleine-Levin Syndrome Delayed Sleep Phase
ICSD-2, AASM

Some sleep disorders are unique to childhood

Apnea of Infancy Apnea of Prematurity Behavioral Insomnia of Childhood Pediatric Obstructive Sleep Apnea
Differences in physiology result in differences in presentation and adverse effects Distinct polysomnographic characterization Prevalence 2%
Redline, Am J Respir Crit Care,.1999; 159:1572-32
ICSD-2, AASM

Assessment of sleep disorders in children

History and Physical Sleep Log Actigraphy Polysomnography Multiple Sleep Latency Testing (MSLT) Maintenance of Wakefulness Test (MWT) Not every child with a sleep complaint requires assessment in the sleep lab

Pediatric Obstructive Sleep Apnea

Diagnostic Criteria: Pediatric Obstructive Sleep Apnea

A. The caregiver reports snoring, labored or obstructed breathing, or both snoring and labored or obstructed breathing during the childs sleep. The caregiver of the child reports observing at least one of the following:
i. ii. iii. iv. v. vi. vii. viii. Paradoxical inward rib-cage motion during inspiration Movement arousals Diaphoresis Neck hyperextension during sleep Excessive daytime sleepiness, hyperactivity, or aggressive behavior A slow rate of growth Morning headaches Sleep enuresis

B.

ICSD-2, 2005

Diagnostic Criteria: Pediatric Obstructive Sleep Apnea

C. Polysomnographic recording demonstrates one or more scorable respiratory events per hour (i.e., apnea or hypopnea of at least 2 respiratory cycles in duration). Polysomnographic recording demonstrates either i. or ii.
i. At least one of the following is observed:
a. b. c. d. Frequent arousals from sleep associated with increased respiratory effort Arterial oxygen desaturation in association with apneic episodes Hypercapnia during sleep Markedly negative esophageal pressures points

D.

ii.

Periods of hypercapnia, desaturation or hypercapnia and a desaturation during sleep associated with snoring, paradoxical inward rib cage motion during inspiration, and at least one of the following:
a. b. Frequent arousals from sleep Markedly negative esophageal pressures wings
ICSD-2, 2005

Diagnostic Criteria: Pediatric Obstructive Sleep Apnea

E. The disorder is not better explained by another current sleep disorder, medical or neurologic disorder, medication use, or substance use disorder

ICSD-2, 2005

Assessment of obstructive sleep apnea in children

Direct Observation Videotape/Audiotape Oximetry Nap Polysomnography Polysomnography, Gold Standard

Polysomnography:
Its more than an assessment of obstructive sleep apnea
Obstructive sleep apnea Central sleep apnea Central alveolar hypoventilation syndromes
Congenital Acquired

Nocturnal seizures
Nocturnal Frontal Epilepsy Lobe

Sleep-related hypoxemia Periodic limb movement disorder Sleep myoclonus Narcolepsy Idiopathic Hypersomulence

REM behavior disorder Confusional arousals Sleep Architecture Abnormalities

Mood Disturbances Pain Syndromes Sleep fragmentation

Sleep State Misperception

Polysomnography is NOT a static test

Full EEG Montage Multiple Sleep Latency Testing +/- Gastroesophageal Reflux Monitoring
Gastroesophageal reflux as a cause of apnea in children Issues:
Difficulty correlating reflux with specific respiratory events Increases upper airways resistance, which may increase obstructive respiratory event frequency Increases posterior oropharyngeal stimulation, which may increase oral secretions and decrease central respiratory event frequency

Performing Polysomnography in Children

The sleep lab Preparing the child Running the study Scoring the study Interpretation

by Carlton Jemmett oden@xmission.com

Sleep lab environment

Child Friendly, Child Safe Child-proofing outlets, chemicals, equipment Dcor Distraction objects/Entertainment Parent space

Equipment
Do you have the appropriately sized equipment? Cannula, thermistor, effort belts, oximeter probes, CPAP masks Do you have the right equipment? Crib CO2 monitoring Videography

Sleep lab procedures and protocols

Lab hours Staffing Issues which may arise pacifier use, bottles, bed-wetting, diapers, emesis Montages Bilateral EEG Assessment Titration Emergency Protocols Appropriately trained staff (pediatric advanced life support) and appropriate equipment AAP Safe Sleep Recommendations

Performing the study

Preparing the child for the study begins prior to the child arriving in the sleep lab Books or Videos Discussions with family and child Use age/developmentally appropriate language to discuss the sleep study

Flexibility
Timing of set-up Order of set-up Adequate time to perform set-up Use distraction, comforting and information to your advantage Requires understanding the goal of the study BEFORE approaching the child
If there are any questions about the goal, discuss them with the ordering physician

Sleep technologists observations

Important to make an accurate and successful diagnosis All observations are important May provide an explanation for events seen in the study May identify other possible sleep disorders Examples of important observations:
Associations Snoring (patient, caregiver) Timing of feedings Pacifier use Patient and caregiver use of cell phones, TV, personal videogames Parent-Child Interactions

Scoring of Pediatric Polysomnography

The AASM Manual for the Scoring of Sleep and Associated Events, 2007
Unique pediatric criteria:
Visual Rules Cardiac Rules Respiratory Rules

Does not include visual rules for children less than 2 months of age post-term (Quiet versus Active) Pediatric rules can be used for children <18 years, but an individual sleep specialist can choose to score children >/= 13 years using adult criteria

Sleep EEG activity as a developmental continuum

4 y.o., Stage N2

17 y.o., Stage N2

Sleep EEG activity as a developmental continuum

4 y.o., Stage N3

17 y.o., Stage N3

Arousals
Types of arousals Spinal/Reflex Autonomic Cortical Children have less cortical arousals with respiratory events than adults

Breathing during sleep

Respiratory events
Obstructive Apnea
at least 2 missed breaths, 90% decrease in signal with evidence of respiratory effort

Central Apnea
lasts 20 seconds OR lasts at least 2 missed breaths AND is associated with arousal, awakening or >/= 3% desaturation

Obstructive Hypopnea
at least 2 breaths, >/= 50% decrease in signal, associated with an arousal, awakening or >/= 3% desaturation

Periodic breathing
> 3 episodes central apnea lasting > 3 seconds each and seperated by no more than 20 seconds on normal breathing

Ventilation
>25% of total sleep time spent with EtCO2 or TCO2 greater than 50 mm Hg AASM Manual for Scoring of Sleep and Associated Events. 2007

Interpreting Polysomnography in Children

Need to take into consideration the unique definition of obstructive sleep apnea for children Need to take into consideration differences in presentation and adverse effects compared to adult obstructive sleep apnea

After diagnosis the work just begins

Successful diagnosis does little to help the child and family other than to make them aware of the presence of the disorder Remember, you are treating both the child and the caregiver
Sleep problems which affect children, also affect those caring for them Both child and caregiver need to be engaged in the treatment plan

The Sleep Technologists Role in Treatment

Must be aware of the wide array of treatment options Understand that the treatment plan depends on clinical history as well as the pattern and severity of obstructive sleep apnea present on polysomnography Understand the adverse effects of obstructive sleep apnea, in order to be able to reinforce the importance of following through with the physicians treatment plan

Treatment Options for Pediatric Obstructive Sleep Apnea

Tonsillectomy and Adenoidectomy Typically first line treatment CPAP Orthodontics Pharmacologic agents Weight management Other surgical options in specific cases Tracheostomy, mandibular advancement, supraglottoplasty

Non-Invasive Positive Pressure Ventilation (CPAP/Bi-Level)

Machines to deliver non-invasive positive pressure ventilation are FDA approved down to 7 years of age and for a weight of at least 40 lbs. There is a non-invasive positive pressure ventilation mask which has received approval down to 2 years of age CPAP has been shown to be safe and effective even in children younger than 2 years of age
Downey, Chest. 2000; 117(6):1608-12

The Technologists role in CPAP/Bi-Level

Fitting Developing relationships and educating durable medical equipment providers and home healthcare companies Development of desensitization and transition plans Titration Assessment of issues affecting tolerance and compliance with therapy Reinforce therapeutic plan

Mask Fit
There are limited mask options available for children Familiarity with a the available mask options, their strengths and limitations Comfort and appropriateness of fit of the CPAP interface plays a significant role in the patients acceptance of therapy
Massie, Chest. 2003; 123(4);1112-18

Relationships with DME providers

Develop a close relationship with a DME provider who is comfortable with working with children Educate them about differences in definitions of obstructive sleep apnea between children and adults, in order to prevent delays in initiation of therapy Educate them about differences in initiation plans, and the use of desensitization to positive pressure ventilation prior to titration polysomnography, when appropriate Assure that they are aware of and have ready access to appropriate equipment for pediatric patient

Desensitization
In fact both adults and children benefit from education about CPAP/Bi-Level prior to titration polysomnography
Silva, Sleep Breath. 2008; 12(1):85-9

Desensitization considerations: Desensitization to mask Desensitization to headgear Desensitization to airflow Individualized treatment plan
Kirk, Sleep Med Rev. 2006; 10:119-27

Titration
Develop and utilize a protocol for titration, which is appropriate for pediatric patients, taking into consideration the definition of pediatric obstructive sleep apnea, and the differences in generation of arousals, and airway dynamics Assess hindrances to CPAP Reinforce importance of therapy

Differences in children which effect titration: Airway stability

Airway stability as assessed by the slope of the pressure flow response to subatmospheric pressure
Bandla et al. Sleep. 2008; 31(4):534-41

Differences in children which effect titration: Airway size

ResMed Corp

Follow-up
Ongoing growth and development results in requirements for reassessments CPAP/Bi-Level interface persistence/evolution of sleep-disordered breathing appropriateness of current therapy and settings Compliance and hindrances to therapy compliance and efficacy downloads

Summary
The sleep technologists role in the assessment and management of sleep disorders in pediatric patients begins prior to the child presenting to the sleep lab and continues throughout the childs assessment, treatment and long-term management

Summary
The sleep technologist plays a critical role in the assessment and management of sleep disorders in children. By being prepared to perform this role, the sleep technologist can assure the safe and efficacious assessment and treatment of the pediatric patient

Thank you!