 Hi, good evening and welcome. We're going to wait just a few more minutes for everyone to log on and then we'll begin our webinar. Good evening and thank you for joining us for the second in our webinar series of addressing pediatric respiratory issues. Tonight's webinar focuses on obstructive sleep apnea in children. When is snoring a problem? I'm Cassie Pulse, position liaison with the University of Maryland Children's Hospital. Before I introduce our speaker, I have a few housekeeping items. You may submit your questions at any time during the presentation using the chat box feature. Erin Rummel, our pediatric marketing manager, will be monitoring the chat box and Dr. Lasso will answer all of your questions at the end of the presentation. Please note that this seminar will be recorded and an email with a link to this recording will be sent out next week. Our speaker this evening is Dr. Anna Lasso. Dr. Lasso is an assistant professor of pediatrics for the University of Maryland School of Medicine and division head of pediatric pulmonology, allergy, and sleep. She went to medical school at the University of Panama School of Medicine and did her pediatric residency at Monmouth Medical Center in New Jersey. She went on to complete her pediatric pulmonary fellowship at St. Christopher's Hospital for Children in Philadelphia, Pennsylvania. Dr. Lasso has been with us at the University of Maryland Children's Hospital since 2006. Dr. Lasso, the floor is yours. I'm not sure if you see the slides properly. Cassie, can you just make sure that the screen looks good before I get started? Yes, there we go. So what I would like to do tonight is give you basically an overview of pediatric sleep apnea, but really trying to focus really on a practical approach and thinking, you know, get snore, but when is snoring a problem? So we can come up with hopefully some recommendations on when to refer, when to send patients for a sleep study. Basically, you know, when to worry about the patient. So starting with simple definitions, obstructive sleep apnea is considered a syndrome. The definition is one where a patient has prolonged partial or intermittent complete obstructions of the upper hairway. And this obstructions or the problem basically causes disruption of normal ventilation and sleep continuity. It is a spectrum of disease that goes from primary snoring that we really don't consider harmful and can be present in up to 13% of preschool and school children and goes all the way to what we consider the true presentation of the disease, which is the obstructive sleep apnea that causes pathology. And it's present depending on the literature you review somewhere between 1 to 5% of preschool children and kind of changes as the kids get to be in the adult group. Big prevalence is between two to eight years and this peak really has to do with the time when kids have enlarged tonsils and abnormalities. When you get to the pre-prevital male-female ratio, it's about the same. But by the teenage years, the pathology starts to resemble more that pathology that's seen in adults, where it's more common in boys. Risk factors. It's important to think of sleep apnea in all kids, but it's more common, if you will, in kids that have a family history of sleep apnea, in kids that have recurrent wheezing, kids with a history of recurrent sinusitis, premature babies have a 3 to 5 times the risk of a full-term baby. Babies and kids with poor tone. So all syndromes, if you will, that cause hypotonia can cause obstructive sleep apnea. Kids that have upper airway and make basal-oficial anomalies, children with syndromes that affect the face and the midline in particular are at a higher risk for OSA. It appears that African Americans have a higher risk and obesity, I highlight it because it is definitely a risk and it's something that we see more and more these days. So it's something to think about for sure in patients that have gained weight quickly. We think of the consequences of OSA as neurobehavioral growth-related and cardiovascular sequelae and it's felt to be related to under diagnosis or under treatment, if you will, of the condition. It appears that there is an association with hyperactivity, aggressiveness, destructibility, and learning problems, and this has been shown in multiple studies over the years. A study that was published in 1988 was a while ago by David Guzall who is an expert in the topic of pediatric OSA showed that in kids in first grade that were not performing well, the incidence of OSA was six to nine fold compared to kids that were doing well. It is such an important cause of neurobehavioral growth and problems that we should think of considering the sleep study in kids that are being evaluated for conditions like ADHD and other behavioral and attention problems before medications are started. The best predictors for thought problems, phonological processing problems, externalizing problems, aggressive behavior, verbal comprehension problems are two things. One is the apnea-hypotnea index, which is the number of apneas and hypotenias per hour of sleep during the sleep study and the needier saturation during that sleep study. So those two factors or those two signals, if you will, in a sleep study are the best predictors of the list that I showed below where there is definitely significant findings. I apologize because there is a lag time between my advancing the slides and Erin, it's not responding. Would you be able to advance the slide there? Erin, if you don't mind, I might ask you to advance the slides for me because it seems to not be responding very well to my keyboard. No problem. Thank you. So the other thing that we have to think about is, the concept I think that is interesting and important to think about is that perhaps snoring, not by itself, but the association with sleep apnea and school performance issues in the early years might actually have a long-lasting effect or perhaps with Dr. Gozall in a pediatrics article in two dozen ones suggested, which is a learning depth where kids that have this problem early in life develop neurocognitive morbidity that if not treated properly might actually cause long-lasting effects with school performance. He also looked at kids in middle school and the opposite looked at what he'd looked at if the patients in first grade were also looked then at kids in middle school where he saw that kids that were not performing well in middle school were more likely to have snored as younger kids and have had a tonsillectomy and an endectomy. So again, showing that perhaps there is this long-lasting effect of having OSA in early life. Next slide. Cardiovascular consequences are a little bit harder to assess. It's been felt for years that OSA causes cardiovascular sequelae, but this is driven mostly by adult data. In fact, a recent study published by one of our Dr. Peria, Kevin Peria from the University of Maryland and Dr. Amal Isaiah from the University of Maryland showed that pre-operatively right before a TNA, when patients had an echocardiogram, it didn't actually show even in kids that had CBROS, say, significant abnormalities. So the concern that we have had does not appear to materialize, at least not in the pre-op echocardiograms. And so it's something that we consider not doing, which we were doing pretty consistently before in our institution. There is also another study that looked at the prevalence of pulmonary hypertension in pediatric OSA and also found low end and low incidence. So again, it's a concern that we have had that untreated or under-treated OSA causes cardiovascular sequelae, but in pediatric, which would actually be a good thing, that it doesn't seem to materialize early in life. So perhaps it's not something that occurs quickly, but perhaps over a long time and that is why we see it born in adults. So this is something to think about, we don't see it, doesn't mean that we shouldn't worry that in the long term it'll cause problems. Erin, next slide, please. So piece of information that's a really important point that I like to always remind people of is that your exam awake doesn't predict airway obstruction with sleep. So on the right hand side here, you can see that patient awake will have perhaps good tone and have good airflow into the airway, but that same patient that awake might maintain, the patent airway might block their airway when they lose their tone secondary to sleep. So to remember that what you see in the office during your visit might not truly help you understand if the patient has OSA and how severe it is. The other thing that also doesn't correlate is the size of the tonsils and adjuvants. So a patient might have large tonsils and very minimal if any OSA and the opposite industry might have a patient who has very small tonsils with significant OSA. So that's something to remember. Next slide. Another thing that's interesting is that in the past we have talked a little bit about scores where you could try to figure out if a patient that was snoring had OSA and how severe it was and there's been studies looking at a few questions, if you will, that could help with this. In fact, those scores tend to misclassify patients at least a quarter of the time. And here you have a list of the things that typically used to be asked that do not seem to be very helpful. So is the patient having daytime math breathing? You know, is that helpful? Doesn't seem to be the P values or not significantly affected, observed apnea, parent shaking the child to try to wake them because they look scary, child struggling to breathe, parent afraid of the apnea that they observe. None of those things seems to be good enough if you will to give you significant data. So they're not something we recommend. We ask them on physical and during our Asian peace, but they're not by themselves enough to give us the data that we require without a sleep study. So as a statement, if you will, it's basically said at this point that the clinical history and physical examination are not reliable for diagnosing OSAs by themselves. Next slide. So there's practice guidelines that have tried to help pediatricians and providers on how to think of sleep apnea and who to treat. The first one was in 2002. And the second one in 2012 both were published by the pediatric journal. The first one is, I think, very clear to all of us that we should be screening all children and adolescents for snoring that complex high-risk patients like the ones that I mentioned before that have bit line abnormalities, low tone, down syndrome, preemies. Any of those kids, if there is a concern for OSA should be referred to a specialist that the history, if you will, is not good enough in really differentiating primary snoring from sleep apnea. So polysomnography is what is recommended. That's what it's meant by diagnostic evaluation. But that if that's not available, a referral to a specialist for more extensive evaluation may be considered. That a TNA or adenotensilectomy is a treatment of choice for children with adenotensilore hypertrophy. That high-risk patients should be monitored after surgery in the hospital. And that includes kids under the age of three or kids that have severe sleep apnea reported by the sleep study. So more than more people or more than 10 obstructions per hour or an oxygen saturation need year of less than 80% or both. Patients should be followed. So we should be thinking of checking on our patients after surgery and reordering a sleep study if there is if the patient was severe at baseline or if there is significant symptomatology after surgery. CPAP is recommended if the TNA is not performed or if the symptoms persist after surgery and weight loss should be recommended for all kids and adolescents who are overweight or obese. Next slide. So diagnosis basically what we think or how we call it an obstructive apnea is a complete cessation of air flow with respiratory effort. An obstructive hypopnea is when there is a partial obstruction in a central apnea as you well know is no respiratory effort so no central signal to breathe if you will. Next slide. So another way to think of it is the way that ENT if you will thinks of it. And I think that that's useful in primary care because you might not really have the opportunity to do a sleep study in all your patients that have snoring and so I think it is important to think of if you have a child with tonsill hypertrophy what do the guidelines say and this is a guideline by ENT in 2019 that tells us that if a patient has tonsill hypertrophy clinicians should be asking about comorbid conditions that might improve after tonsillatomy. So they would like to know if the patient has had growth or a tradition if they have poor unspeakable performance, if they have aneurysies, if they are asthmatics, if they're presenting with behavioral problems. They will in that guideline they're recommending a sleep study for kids with tonsill hypertrophy if they're very young less than two years of age. The other guideline talks about less than three. If they're obese, if they have Down syndrome, if they have craniofacial abnormalities, neuromuscular disorders, sickle cell disease, and the full cycle reduces. And that is because that list of kids is much more likely to have severe disease that they would like to know about before surgery. So ENT is recommending not to do surgery on kids without a sleep study in that age group because of the risk of having severe OSA without knowing about it. Next slide. So sleep studies in children are commonly done. They're not fine if you will, but kids tolerate them pretty well. And pediatric sleep labs are well equipped to deal with kids. Kids, the technicians typically will train in treatment or how to deal with younger kids. And it is all about the environment. So one thing that I will say is that when ordering a sleep study, it is important to consider where you're ordering your study to make sure that the facility that you use has experience with kids. Because it's not the same to do a sleep study in a facility that deals with mostly adults. Because one is that the night in the lab that is different, the experience that the technician feels comfortable with kids, that the parents feel comfortable there in how their kids are handled. But also who's reading your study, do they have experience with pediatric sleep studies? And are they reading according to guidelines for pediatrics? The guidelines tend to call, if you will, kids below the age of 13. And 13 and above gets read as an adult. So for older teenagers, it's, I think, safer to send them to an adult lab. I think for younger kids, it's really important to think of the pediatric lab. Next slide. So I'm giving you a couple of cases here just to highlight what we're talking about. This is a five-year-old with history of snoring, respiratory pauses, history of chronic nasal congestion, morning headaches, difficult to arouse, has been underweight and is referred for a PSG. So here, just to show you, you know, this kid had a apnea, hypopnea index that, to remind you, is again at the index of the number of apneas and hypopneas per hour. So 35 obstructions per hour with a knee deer in the oxygen saturation to 72 and saturation under 90% for 20, 27 minutes. So this is a kid who's having an obstruction very, very frequently, you know, more than every two minutes they're having an obstruction. So the quality of sleep for this patient is very poor. And as you can see, this kid's frequently in that age group don't grow well because they're really having significant work of reading if you will every night. Next slide. And I'll show you, I believe my next slide has just might be a little bit hard to see. But basically, the idea is this is the epaulom that you get from a sleep study where you're tracking also symmetry at the top, you track the movement, basically, chest movement, abdominal movement, and then you get flow. So you can see there is nasal flow or not and then an entitled CO2 level. So when you have a pause, like over here, you see a pause. And this is about 20 second pause. You can see, you know, this is probably a little bit small for you. But basically, when there is a pause in the lab, the reading you get will tell you one if it's central or not. And if it is in central, you'll know if it's a complete obstruction or a partial obstruction called a hypopnea. And then what happens with that, you know, is the entitled CO2 increasing during the pause? Are you having deceptorations during the pause? And how long is the period, if you will, that that there is a problem? It also gives you a heart rate. So you'll also see sometimes radiocardia in response to the pause. So there is patients like this one that we talk about a five year old with 35 obstructions per hour, they're having 35 obstructions every hour of their sleep with naps with nighttime sleep. So obviously, those kids don't grow well, they do poorly, they basically don't sleep. So they have a lot of behavioral problems that tend to show, like I said, with learning issues and also hyperactivity. One thing to remember is that in adult medicine, sleep apnea tends to cause fatigue and sleepiness in younger kids. We see the opposite, we tend to see hyperactivity. So they're usually kind of wired up, they're not really, they don't look fatigued, they just don't stop. Next slide. So here's 10 year old girl, she's referred to us after having a TNA and actually had a pretty large surgery, a Google of plastic, which is basically a surgery where the soft palate and the uvula is removed. And so for the rest of surgery, with the idea of opening up the upper airway, she clearly failed that surgery, still falling asleep at school, had an eresis, and she gets a PSG, and that's one of the little bit easier, I think, for you guys to see. She has multiple pauses. You know, here there's a pause, a little bit of breathing, another pause. So she kept doing that. She had frequent obstructions, also due to the secretions and entitles you to in the mid-50s, so significant hypoxia with her events. She was treated with positive airway pressure, did well with resolution of symptoms. In this case, surgery definitely wasn't enough, and she required CPAP basic. Next slide. So just to touch a little bit more on the interpretations, if you get a report from a sleep lab, you're going to get basically what we use the most is the hypopnea index, which is normal. It's considered 1 to 1.5 per hour. Some labs will give you just the obstructive apnea index that doesn't include hypopneas, and then there is the respiratory disturbance index that will add apnea, hypopneas, and arousals. Like I said, we typically use, in Hopkins, that's the same, the apnea hypopnea index, which is really counting the number of apneas and hypopneas. They'll also give you a saturation nadir, an oxygen saturation nadir. They'll also give you the amount of time that the patient is spending under 90%. They'll give you the number of arousals, and when you're checking your results, you need to make sure that the patient had REN sampled and that the patient slept at least 80% of the night to make sure that it was a good quality sleep study. Next slide. So the same in a table form, and you guys will receive this in the link later on, but basically this is a simple table to just show that normal on the left mild would be 1.5 to 5 structures per hour, saturation somewhere in the high 80s, I'm sorry, and entitled CO2s in the mid 50s. Moderate OSA 6 to 10, a little bit lower sets, and higher entitled CO2, and severe OSA is more than 10 structures per hour, less than 75 equal or less than 75 in the saturation index and the entitled CO2 above 65. What we tell people is that say that you have, for example, 6 to 10 obstructions per hour, but your CO2 is over 65, I would place that patient in the severe category, even though by the number of obstructions you're not having, you're not meeting criteria to be in the severe category, the fact that you have significant difficulties with gas exchange makes you a more severe patient. So basically, you place the patient in the worst category of your count. Next slide. Do remember that a TNA is a treatment of choice in pediatrics, but that there is a risk, you know, that has to do with surgery. So it is important that patients that have severe OSA be treated with CPAP or BiPAP around surgery that anesthesia is involved. So for patients with severe OSA, it is important to make sure that they are known by anesthesia as having severe OSA prior to surgery. Precustomy and uvaloplasticity, as I said, are very rare procedures for OSA. I have seen them done. We are always trying to avoid them. And in fact, these days we have a much more, we have a larger group of options, if you will, for PAP therapy. So we really in the last five years have not sent anybody for a three-calistomy for OSA. Next slide. Systemic steroids in OSA, not recommended. So years ago, there was an open legal study looking at five days of prednisone in a few children with OSA, no improvement in sleep measures, the risk of thinking oral steroids, as you know, is significant. So definitely not recommended. Just wanted to make a point to say that. Next slide. Much more commonly used those days, intranasal steroids. However, I wanted to make a point to say that there is a recent cocaine database review of 2020 that says that there is really insufficient evidence to be, you know, for the efficacy of intranasal steroids. So not something I would recommend at this point. It's something that we used to do. But at this point, I don't think it makes a lot of sense to go for it. And I would not waste time treating patients with intranasal steroids if they have clear OSA, I would just send them for therapy. That's helpful. So next slide. So spending a little bit of time on the complications after a TNA. In a study of 44 children that was done a while ago in the 1980s. But it is important to realize that in that study, 32% of a third of the kids had complications and significant complications in 16% of the patients. So to remember that even though TNA is the treatment of choice, it's not risk free. So patients that have red flags, if you will, young age, then have it as severe OSA with low CO2, low oxygen and high CO2, or syndromic features like we talked about, down syndrome patients. Anybody who is raising the flag as having a severe case of OSA should be done in a pediatric hospital where there is pediatric anesthesia and stay in the hospital overnight after surgery. Next slide. Another study basically showing the same thing. In this case, 23% of patients had severe respiratory compromise after a TNA. And some of them had shown during the procedure of having significant dysenteration and hypercapnia and or hypercapnia requiring intervention. So again, this is another study, the same idea, craniofacial abnormalities, young age, severe OSA. So to remember that if a vision has this factors that they should never be done in a community facility where they won't have the ability to be in a pediatric ICU if there is a problem. Next slide. So current guidelines are pretty clear on recommending inpatient monitoring of high risk groups. Just to remember that. Next slide. Now, if TNA, if the TNA fails or if the patient is not a candidate for a TNA because they do not have large dumpsoles and adenoids or because the family refuses surgery, I actually recently had a case of that. We then should consider continuous positive air with pressure or CPAP. It is well tolerated and safe in infants and children. It's frequently used. It is more common to need it in children with congenital facial abnormalities. Its studies showed that CPAP therapy for about 15 months minus plus minus three months with a pressure of 7.9 centimeters water eliminated the signs of OSA in 90% of the children's studies. So very effective therapy when used properly. Another study to show that the respiratory disturbance index decreased from 27 plus minus 20 to 2, it gets treated with CPAP. So patiently proven symptoms, the findings on the sleep study also improve. And to remember that compliance with CPAP is actually better in children than adults. So it's a therapy that's used. It's not first line, but it's definitely second line in an option. I would definitely consider referring to specialty care if patients fail PNAs because the management of their CPAP tends to be by specialty teams. Next slide. So when or why do we order a polysommogram? So I would think of it if we have to confirm OSA if clinically suspected, particularly in high risk groups. So if you have a patient who has enlarged tonsils, clinical history, if you will, for OSA and is not in one of the high risk groups, I think you could go directly to surgery. This is a little bit controversial because the guidelines aren't very clear. And not everybody has the option of the average sleep study is not available everywhere or at least not close by. So I would not worry too much about kids that are healthy otherwise. I would definitely think of a sleep study if there is concerns for a very severe disease or if the patients are in a high risk group. Like we said, young kids, kids with syndromic features, kids that are morbidly obese, have low tone. In those patients, we do it because we want to know the severity because like we said, the management won't be the same by the pediatric anesthesia team if the patient has moderate OSA or if they have severe OSA. It's also an option for us to test the efficacy of the surgical interventions for patients where there's been a TNA. It can be considered if there is still symptomatology or if the patients were extremely severe to start with and we want to make sure there has been significant improvement. And then PSGs are also used for titration of non-invasive support to see if happen by then. Next slide. We consider referral for a specialty appointment if your patient has moderate to severe OSA, particularly if they have comorbid conditions. They'll be children, kids with chronic facial abnormalities, very young children or if patients are not candidates for surgical intervention. Next slide. Quickly touching on parasomias. I think you guys know more about it than I do, but I just wanted to make a point that it's been shown that a lot of kids with parasomias have OSA. In fact, the study done a while ago published in pediatrics in 2003 showed that 61% of kids with parasomias had a diagnosis of an additional sleep disorder and more than 50% of those kids their disorder or their additional sleep disorder was OSA. To think about it, so if you have a kid who has night terrors, sleepwalking, disorders of arousal, it can be normal. It's something that may be triggered by fatigue or illness and still be considered normal. But to remember that if it's an unusual case that there is an association with OSA and so to think about it, those patients might need a sleep study to check on that. Next slide. So I think we're close to the end of the lecture, but I just wanted to tell you that the topic is pretty controversial. So not everything is written in stone in pediatrics sleep. There's some confusing data and there'll be more to come in the future about this. A recent study showed that if you had a sleep study to start in seven months later, about almost half the kids had actually normalized without therapy. So that's quite a large number, you know, about half the kids just got better on their own. And so it is important to think as a pediatrician that this does happen, that about half the kids just improves. So I think it's safe if a kid is pretty healthy and doesn't have a lot of other problems that you give them some time before you commit to a PSG and therapy. So I think it's safe to think about this, but not act on it right away if there isn't significant concerns other ways. The other thing that is difficult is that there's study, a recent study actually, showing that the treatment, so the improvement that we see in symptoms in patient's treated with a TNA is not always measurable in a sleep study. So it isn't always very clear. So you might get a history that the parents give you that major improvement in clinical symptomatology, but when you look at a sleep study before and after, you don't always see that much of a difference. So again, sleep studies are not perfect. They're worked in progress, I would say. For some patients, they're very clear. For some, they're not. And so more to come on that, if you will. And the last thing that I wanted to say, because it hasn't been used as standard of care, but it might become more common in the next few years, is that there is a pretty clear picture, if you will, that an abnormal pulse oximetry highly predicts the indication for a TNA. So we could potentially be using home pulse oximetry to predict the need for surgery instead of sending patients for a sleep study. This is something that isn't fully clear and written in stone. It's definitely something that has been shown recently. I think there's gonna be more to come on that because clearly, pulse oximetry at home is a lot cheaper than a sleep study. So there'll be, I think over the next few years, more people looking at this more seriously, particularly for areas where there isn't quick access to a pediatric sleep lab. Next slide. So to conclude, OSA is common in children and adults. Peak prevalence for OSA in childhood is early. It is typically associated with enlargement of the tonsils and adenoids. There is, we think, long-term neurocognitive consequences if OSA is undying, is un-treated. The most common therapy can be effective, is it tonsillectomy and adeninectomy. The procedure isn't risk-free. There is comparative risk of surgery. Remembering that watchful waiting is an option, particularly for your patients that are not at high risk or that have no other comorbidity. And that home oximetry might actually become a tool to diagnose OSA in the near future, in particular for children with tonsillar hypertrophy and in the context where PSG is not readily available. It might actually become standard of care, but it's definitely more likely to become standard of care quickly, if you will, in areas where PSGs are difficult to obtain for pediatric patients. And I think that's all I have to review, so if anybody has a question. Thank you, Dr. Lasso. Again, as a reminder, please feel free to type your questions into the chat box and Erin will read the questions for Dr. Lasso. Okay, great. If you have any questions, please feel free to submit them now. Okay, great. What degree of OSA requires a TX? What degree of OSA requires... Lee Norton has asked, what degree of OSA requires a TX? Therapy, probably. What degree of OSA, I think that's what we're trying to say, right? So, it is a good question and a controversial question to answer. I think we all agree that severe OSA needs treatment. So, 10 obstructions per hour or more, we should be thinking of treatment. Mild OSA, most people at this point would recommend waiting, watchful waiting and not going for therapy because like I highlighted, things aren't that clear. I think the gray zone is in the moderate group that has 5 to 10 obstructions per hour, 6 to 10 obstructions per hour. So, my suggestion or the way I think of it is, if the patient is having moderate OSA, so 5 to 10 obstructions per hour, but they're also dropping their oxygen saturation, they're also potentially retaining CO2 and have symptoms, I would treat. If they're not having a lot of symptoms and their gas exchange is pretty normal, I would wait. I would give them at least 7 months to see if things settle down. A lot of this isn't set in stone, unfortunately, because a lot of those things over the years have changed and I think over the last 5 years there's a lot of data saying that we don't know for sure what to do with some of those kids. So, that's the kind of population where I would follow closely with families and make sure that symptomatology isn't getting worse and potentially consider a repeat slave study over time. Thank you, Dr. Lasso. Are there any other questions? That is all that we have today. All right. So, this will conclude our webinar. Thank you for joining us this evening and we hope that you found the webinar series informative. Thank you again for attending and have a great rest of your evening. Take care. Thank you.