Pediatric Sleep Problems

Question 1

BEARS problems

Answer 1

bedtime problems

excessive day time sleepiness

awakenings at night

regularity/duration of sleep

snoring

Question 2

3 types of respiratory sleep disorders

Answer 2

1. hypoventilation
2. OSA
3. CSA
   - can have more than one

Question 3

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?

Answer 3

obstructive sleep apnea

Question 4

Obstructive Sleep Apnea (OSA)

Answer 4

• Recurrent events of partial or complete upper
airway obstruction during sleep

• Disruption of normal gas exchange (hypoxia,
hypercapnia)

• Sleep fragmentation

Question 5

anatomic factors that cause OSA

Answer 5

• Adenotonsillar hypertrophy
• Pharyngeal tissue
• Mandible size/position
• Airway size
• Fatty infiltration

Question 6

functional factors of OSA

Answer 6

• Reduced tone of pharyngeal
dilator muscles

• Ventilatory control
variability

• Upper airway reflexes and
arousal response blunted

Question 7

pathway to OSA from snoring

Answer 7

1. snoring
2. upper airway resistance syndrome
3. OSA

Question 8

Question 9

biggest risk factor in typical child for oSA

Answer 9

adenotonsillar hypertrophy

Question 10

how does pierre robin sequence, premature infant, or obese child get predisposed to OSA

Answer 10

these syndromes affec airway structure

Question 11

how do children with cerebral palsy have a higher risk factor for OSA

Answer 11

it affects airway tone

Question 12

how do kids with downs sydnrome get predisposed with ISA

Answer 12

combo of adenotonsillar hypertrophy, they have more airway compressibilities and they have alterations in air way structure

Question 13

consequences of OSA

Answer 13

1. systemic inflammatory condition
2. cardiovascular – systemic, pulmonary hypertension
3. metabolic – lipid abnormalities, insulin resistance
4. somatic growth impairment
5. neurobehaviroual (hyperactivity, impulsivity, depression)
6. cognitive impairments
7. decreased quality of life
8. increased health care utilization

Question 14

clinical presentation of nocturnal OSA

Answer 14

Question 15

day time presentation of OSA

Answer 15

• Difficulty waking
• Morning headaches
• Nasal obstruction •

Mouth breathing •

Daytime fatigue

• Daytime sleepiness
• Hyperactivity

Question 16

things to do on PE for OSA

Answer 16

1. oropharyngeal/nasal assessment and malampatti score
2. facial structure assessment
3. height/weight
4. vitals, screening cardiorespiratory exam

Question 17

T?F: Clinical history and physical exam are poor predictors
of OSA

Answer 17

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?

Question 18

factors that are measured by PSG

Answer 18

1. sleep quality
2. respiratory pattenr
3. gas exchange
4. limb movements

Question 19

gold standard test for OSA

Answer 19

• Gold standard test for diagnosis is the overnight
polysomnogram (PSG)

Question 20

what does each lead represent

Answer 20

Question 21

• 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

Answer 21

• 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

Question 22

normal and severe OSA

Answer 22

Question 23

we have huge accessibility problems for PSG in children. Who needs a PSG? Who must have one?

Answer 23

• 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

Question 24

___ remains first line treatment
for obese children with OSA

Answer 24

Adenotonsillectomy remains first line treatment
for obese children with OSA

• encourage weight stabilization/weight loss

Question 25

central apnea

Answer 25

Central apnea = “not trying to breathe, either for a long time, or long enough to cause troubles”

Question 26

• 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

Answer 26

• Central apneas are common in healthy infants and children, especially during **REM** sleep

Question 27

praimary vs secondary CS

Answer 27

Question 28

management of CSA

Answer 28

NIPPV, IPPV

Question 29

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)

Question 30

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)

Answer 30

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)

Question 31

management of hypoventilaton

Answer 31

Question 32

T/F – Snoring is a good predictor for sleep disordered breathing in children with Trisomy 21

Answer 32

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

Question 33

in trisomy21, ___ \_\_\_\_ is the most common abnormality on PSG

Answer 33

``` obstructive hypoventilation (a mix of OSA and hypoventilation) ```

Question 34

in trisomy 21, ___ curative in ~50%, so follow- up is required

Answer 34

Adenotonsillectomy curative in ~50%, so follow- up is required