pediatric osa: new therapeutic insightshopital-necker.aphp.fr/wp-content/blogs.dir/180/... ·...
TRANSCRIPT
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Pediatric OSA: new therapeutic insights
Stijn Verhulst, MD, PhD
Pediatric Pulmonology and Pediatric Sleep Medicine
Antwerp University Hospital
Belgium
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Introduction
OSAS
Adenotonsillectomy
Repeat PSG
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Introduction
• This presentation will focus on 2 parts of the pathogenesis/treatment that are becoming increasingly clinically relevant:
- Personalized treatment (focusing on obesity)
- NIV
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PERSONALIZED TREATMENT - OBESITY
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Prevalence
• Childhood obesity is associated with an increased prevalence of obstructive sleep apnea.
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Prevalence
Verhulst et al., Sleep Medicine Reviews, 2008.
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Anatomical correlates
• The exact contributions of both adenotonsillar hypertrophy and obesity to the pathogenesis of OSAS are still controversial.
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The scope of the problem
Kohler et al., Sleep Medicine Reviews, 2008.
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Anatomical correlates
• However, the relation between obesity and sleep apnea in children is complex…
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Anatomical correlates• AHI is not a unique marker of OSAS: BMI often
correlates better with other markers of the severity of sleep apnea, i.e. oxygen desaturation.
Verhulst et al., Archives of Disease in Childhood, 2007
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Anatomical correlates
Van Eyck et al., Sleep Medicine, 2014
oAHI < 2 2 < oAHI < 5 oAHI ≥ 5 P
VC (%pred)106 ± 13 103 ± 13 95 ± 15 0.01
FEV1 (%pred)104 ± 13 101 ± 14 95 ± 17 0.05
FEV1/VC (%pred) 99 ± 8 98 ± 7 101 ± 7 0.4
RVHe (%pred)89 ± 36 86 ± 35 85 ± 26 0.6
TLCHe (%pred)101 ± 21 101 ± 11 91 ± 20 0.03
FRCHe (%pred)82 ± 21 76 ± 31 65 ± 21 0.008
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Anatomical correlates
• Second, BMI is not the only marker of obesity. However, there is limited data on the association between OSAS and markers of visceral adiposity in children.
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Canapari et al., The Journal of Clinical Sleep Medicine, 2011
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Anatomical correlates
• Furthermore, the association seems to be age-dependent:
- Obese children: Adenotonsillar hypertophy > Obesity
- Obese teenagers: Obesity > Adenotonsillar hypertrophy
Kohler et al., Sleep Medicine Reviews, 2008.
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Anatomical correlates
Dayyat et al., Chest, 2009
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Anatomical correlates
Dayyat et al., Chest, 2009
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Anatomical correlates
Dayyat et al., Chest, 2009
• The magnitude of adenotonsillar hypertrophy is more likely to be smaller in obese children compared to nonobese children with comparable AHI.
• Increased Mallampati scores in obese children suggest that soft-tissue changes and potentially fat deposition in the upper airway may play a significant role in obese children with OSA.
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Anatomical correlates
Arens et al., AJRCCM, 2011
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Anatomical correlates
Arens et al., AJRCCM, 2011
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Anatomical correlates: treatment data
Costa et al., Otolaryngology–Head and Neck Surgery, 2009
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Anatomical correlates: treatment data
Costa et al., Otolaryngology–Head and Neck Surgery, 2009
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Anatomical correlates: treatment data
Bhattacharjee et al., American Journal of Respiratory and Critical Care Medicine, 2010
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Anatomical correlates: treatment data
Kalra et al., Obesity Research, 2005
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Anatomical correlates: treatment data
Definition of success Success rate (%)
Apnea hypopnea index ≤ 2 62
Oxygen desaturation index ≤ 2 81
Apnea hypopnea index ≤ 5 91
Verhulst et al., Obesity, in press
Verhulst et al., Obesity, 2009.
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Anatomical correlates: treatment data
Verhulst et al., Obesity, in press
Van Hoorenbeeck et al., PhD thesis, 2013
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Obesity - conclusion
• The pathogenesis of OSA in obese children is complex illustrated by suboptimal response to adenotonsillectomy.
• In view of the established link with metabolic and cardiovascular morbidity, there is a clear need to validate tools that identify the anatomical contributors in the individual child.
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Obese child with OSA
Weight management
Work up site of
obstruction
T&A
Non-invasive ventilation
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Functional imaging
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Obese child with OSA
Weight management
Work up site of
obstruction
T&A
Non-invasive ventilation
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• Older children have lower adherence
- Limited data on infants/toddlers
• Full face masks
• Lower maternal education
• Improvement in symptoms
• Support system
• No influence of disease severity, ventilation mode, developmental delay
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Adherence
• Detailed information to parents and patients.
• Specific patient information flyers.
• Behavioural therapy approach.
• Mask and machine are used at home with low pressures before the actual titration.
• Intense follow-up especially in the first weeks/months after starting therapy
• Comfortable mask
• Good care of interface and equipment
• Role of medication
• Close follow-up
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