1. OSA SYNDROME AND ALLERGIC RESPIRATORY DISEASES Upper Airway Diseases A. Kaditis, MD Pediatric Pulmonology Unit, Sleep Disorders Laboratory First Department of Pediatrics University of Athens School of Medicine and Aghia Sophia Children’s Hospital Athens, Greece

2. Obstructive Sleep-Disordered Breathing (SDB) Spectrum of abnormal respiratory patterns during sleep characterized by snoring and increased respiratory effort Primary snoring Upper airway resistance syndrome Obstructive hypoventilation Obstructive sleep apnea (OSA)

3. Multiple Disorders affecting components of the Upper Airway (e.g. tonsils, facial structures, dilator muscles) Upper Airway Dysfunction over time may lead to overt morbidity (e.g. hypertension, enuresis, EDS) Genes, environment Upper Airway Resistance OSA: Syndrome of Upper Airway Dysfunction

4. ApneaHypopnea

5. Step 1: Recognize the child at risk for obstructive SDB Step 2: Identify SDB- related morbidity or conditions co-existing with SDB (probably common pathogenesis) Step 3: Recognize factors predicting persistence of SDB Step 4: Assess severity of SDB objectively (if equipment available) Step 5: Determine indications for treatment Step 6: Stepwise treatment approach for SDB Step 7: Follow-up, diagnosis and management of persistent SDB

6. Step 1: Recognize the child at risk for obstructive SDB Assess by history + exam  Symptoms of nocturnal airway obstruction 1. Snoring 2. Reported apneas during sleep 3. Difficulty breathing during sleep 4. Restless sleep 5. Frequent arousals  Abnormalities predisposing to upper airway obstruction 1. Adenotonsillar hypertrophy/allergic rhinitis 2. Obesity 3. Craniofacial abnormalities 4. Neuromuscular disorders  History increasing the risk for SDB 1. Premature birth 2. Family history of SDB

7. Upper Airway Dysfunction and Adenotonsillar Hypertrophy

8. Villa et al. Randomized controlled study of an oral jaw-positioning device for treatment of OSA in children with malocclusion. AJRCCM 2002;165:123-7

9. Step 2: Identify SDB- related morbidity or conditions co- existing with SDB (probably common pathogenesis) Morbidity  Cardiovascular system  Central nervous system  Enuresis, inadequate somatic growth Conditions co-existing with SDB  Metabolic syndrome  Recurrent otitis media, serous otitis  Recurrent wheezing

10. Amin et al. Activity-adjusted 24-hour ambulatory BP and cardiac remodeling in children with SDB. Hypertension 2008;51:84-91

11. Obstructive SDB in Childhood and CNS Morbidity Hyperactivity Inattention Excessive daytime sleepiness Learning problems Evidence from population-based studies

12. Kaditis et al. Enuresis and Snoring in Healthy Children. Urology 2006; 68:406-9 VariablesChildren with enuresis n = 43 Children without enuresis n = 1778 Adjusted odds ratio (95% CI) Age ≤ 9 y.o. > 9 y.o. 32 (74.4 %) 11 (25.6 %) 904 (50.8 %) 874 (49.2 %) 2.87 (1.43-5.76) baseline Gender Male Female 34 (79.1 %) 9 (20.9 %) 891 (50.1 %) 887 (49.9 %) 3.73 (1.77-7.86) baseline Habitual snoring † Yes No 10 (23.3 %) 33 (76.7 %) 125 (7 %) 1653 (93 %) 3.54 (1.68-7.44) baseline

13. Risk factors adjusted for race, obesity Occasional wheeze Persistent wheeze Cough History of asthma AHI>10 OR (95% CI)p 3.29 (1.24-8.94) <0.05 7.45 (2.03-27.39) <0.05 8.83 (2.29-34.05) <0.05 3.83 (1.39-10.55) <0.05 Redline et al. Risk Factors for SDB in Children. AJRCCM 199;159:1527

14. Step 3: Recognize factors predicting persistence of SDB in the long term  Male gender  Obesity  Increasing body mass index percentile

15. Goodwin et al. Incidence and Remission of SDB and Related Symptoms in 6- to 17-y.o children. J Pediatr 2010;157:57-61 6-11 y.o.Over 5 years10-18 y.o. Snore15% -70.8% remission +10% new cases 9.7% AHI ≥ 123.9% -60% remission +4.1% new cases 15.3%

16. Goodwin et al. Incidence and Remission of SDB and Related Symptoms in 6- to 17-y.o children. J Pediatr 2010;157:57-61

17. Step 4: Assess severity of SDB objectively (if equipment available)  Nocturnal polysomnography  Nocturnal polygraphy  Nocturnal oximetry

18. Step 5: Determine indications for treatment  Clinically important upper airway obstruction even during wakefulness  AHI>5 episodes/h (or positive screening method) irrespective of morbidity  AHI 1-5 and morbidity or treatable co-existing condition  AHI 1-5 and craniofacial abnormalities or neuromuscular disorders  AHI 1-5 and risk for long-term SDB persistence

19. Step 6: Stepwise treatment approach for SDB  Wt control for obesity  Antiinflammatory medications for mild SDB prior to AT  AT for adenotonsillar hypertrophy  Orthodontic devices for mandibular malpositioning, narrow maxilla  nCPAP for i) residual SDB after AT or orthodontic devices; ii) SDB related to obesity, craniofacial abnormalities; iii) neuromuscular disorders unresponsive to other measures  Craniofacial surgery if SDB not responsive to orthodontic devices, nCPAP  Tracheostomy if all other measures fail or while waiting for craniofacial surgery

20. Berlucchi et al. The Role of Mometasone Nasal Spray in the Treatment of Adenoidal Hypertrophy. Pediatrics 2007;119:e1392-1397 Mometasone 100 mcg/d (40 days) vs. Placebo (40 days)

21. Villa et al. Randomized controlled study of an oral jaw- positioning device for treatment of OSA in children with malocclusion. AJRCCM 2002;165:123-7

22. BeforeAfter

23. Step 7: Follow-up, diagnosis and management of persistent SDB  Follow up after each therapeutic intervention and if no response move to the next intervention  Consider objective testing for selected children for selected children: -High AHI pre-treatment -post AT in children with obesity, craniofacial abnormalities, neuromuscular disorders -post orthodontic treatment -post nCPAP -prior to craniofacial surgery or tracheostomy

24. Bhattarjee et al. AT outcomes in Treatment of OSA in Children. AJRCCM 2010; 182:676-683

25. Conclusions Intermittent upper airway obstruction during sleep in childhood:  Is associated with disorders affecting upper airway resistance and pharyngeal neuromotor tone  Is related to morbidity from the CNS and the cardiovascular system  Severe upper airway obstruction during sleep and mild obstruction with morbidity or risk factors for persistence should be treated  All disorders leading to upper airway obstruction should be addressed in a stepwise fashion