eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Obstructive Sleep Apnea Syndrome: Treatment & Medication

Author: Timothy D Murphy, MD, Assistant Professor, Department of Pediatrics, Division of Pulmonology, University of Pittsburgh; Consulting Staff, Division of Pulmonology, Children's Hospital of Pittsburgh
Coauthor(s): Andrew J Lipton, MD, MPH and TM, Staff Pediatric Pulmonologist, Assistant Professor of Pediatrics, Department of Pediatrics, Walter Reed Army Medical Center; David Gozal, MD, Vice-Chairman of Research and Director, Kosair Children's Hospital Comprehensive Sleep Medicine Center, Professor, Department of Pediatrics, University of Louisville
Contributor Information and Disclosures

Updated: Feb 27, 2009

Treatment

Medical Care

• Medical therapy
  • In general, medical therapy is of limited value in the typical pediatric patient with obstructive sleep apnea (OSA).
  • Antihistamine or antimuscarinic therapy may lead to relief in cases of nasal congestion, although sustained benefit is uncertain. For allergic rhinitis or conditions associated with decreased nasal airflow, efforts to improve nasal patency may be beneficial.
  • An oral leukotriene modifier may eliminate residual obstructive sleep apnea following surgery, and these agents may have a role in improving clinical outcomes without surgery. Although systemic steroids do not improve obstructive sleep apnea, topical budesonide used for 6 weeks has been demonstrated to lead to a sustained improvement in mild obstructive sleep apnea. Such preparations are unproven as therapy for severe obstructive sleep apnea. Topical therapy as a primary treatment for obstructive sleep apnea remains largely investigational.
• Positive-pressure ventilation
  • In recent years, positive-pressure ventilation administered via a noninvasive interface (nasal mask) has become a safe, efficient, and viable alternative to further surgery or tracheotomy in children and infants with unresolved obstructive sleep apnea after tonsillectomy and adenoidectomy (T&A).
  • An important distinction must be made between continuous positive airway pressure (CPAP) and bilevel (or biphasic) positive airway pressure (BiPAP).
    • In CPAP, airway pressure is maintained above atmospheric pressure throughout the respiratory cycle.
    • In BiPAP, pressure is delivered during the inspiratory cycle; exhalation then occurs at either atmospheric pressure or at a preset positive airway pressure, such that differences between inspiratory and expiratory pressures are usually greater than 10 cm H₂ O. The BiPAP device may be set to control ventilation entirely (control mode), to deliver breaths only when triggered by a threshold negative pressure or nasal flow generated by the patient (assist mode), or both (assist/control mode).
    • Because CPAP does not involve a respiratory phase change in pressure, no control or assist modes are available.
  • Another important aspect of these interventions involves the patient-machine interface. The use of nasal prongs, nasal masks, or facemasks requires individualized case-by-case consideration. However, when a silicone mask is selected, particular care to ensure that the mask fits snugly and is comfortable to the patient is essential for ensuring successful intervention. Pediatric masks are currently available in several sizes and for particular clinical conditions, such as craniofacial syndromes. Custom-made masks can be ordered to fit the facial contours.
  • Inappropriately fit masks inevitably leak, and efforts to seal these leaks frequently result in pressure sores on the bridge of the nose. Bubble-cushioned masks have been developed and sometimes palliate the severity of the air leak while adding to the patient's comfort. In addition, air leaks are more frequently directed upward and may irritate the conjunctiva, leading to increased lacrimation and eye discomfort. Tolerance of CPAP or BiPAP may be greatly increased by devoting a period of time to condition the patient to use the mask during waking hours, particularly in young or developmentally delayed patients.
  • Pay attention to the mask manifold to ensure that no pressure vectors are generated. Multiple techniques may be used to secure the mask and primarily include Velcro, elastic straps, or a tissue cap. Again, the importance of the patient's comfort cannot be overemphasized. Finally, implement adequate parental training and behavioral techniques designed to improve the acceptance and tolerance to these devices in order to increase patient and family compliance. Over the last decade, CPAP has been increasingly used in children as a successful alternative to upper airway surgery or tracheotomy. However, midfacial hypoplasia may develop with long-term use, particularly in children with neuromuscular weakness. In other situations, temporary palliation using supplemental oxygen may be implemented until surgery, provided that sufficient attention is given to the possibility that severe hypercapnia may develop.

Surgical Care

• Tonsillectomy and adenoidectomy
  • Although obstructive sleep apnea has multiple etiologies in children, once the diagnosis of obstructive sleep apnea has been established and its severity assessed, T&A is usually the first line of treatment. Tonsillotomy, rather than tonsillectomy, has been recently advocated as equally effective with less postoperative morbidity. Most of these surgical procedures can be performed safely on an outpatient basis.
  • Notwithstanding the surgery being planned, carefully consider the existence of risk factors for perioperative morbidity and adverse outcomes in the surgical planning. Children with severe obstructive sleep apnea, children younger than 2 years, and children with craniofacial syndromes or other conditions that contribute to the pathophysiology of obstructive sleep apnea are at a higher risk for surgical complications. For example, in children with severe obstructive sleep apnea, the existence of pulmonary hypertension and right ventricular dysfunction has been linked to the onset of cardiac arrhythmias during the process of anesthesia induction. Thus, preoperative echocardiographic assessment is indicated in these patients.
  • Similarly, for all of the risk categories mentioned above, an obtunded patient in whom the anesthetic effects on upper airway tone and reflexes are still compromised has a high risk of postsurgical upper airway obstruction. Finally, the development of idiopathic pulmonary edema following the relief of upper airway obstruction has also been noted. Therefore, in this high-risk group of patients, pursue overnight cardiorespiratory monitoring in the intensive care unit.
• Other surgical procedures: Additional surgical options may include uvulopharyngopalatoplasty, epiglottoplasty, and mandibular advancement procedures. However, most facilities lack extensive experience with these procedures in children, and the overall outcomes from these interventions have not been appropriately documented in the pediatric population. Extensive surgical intervention in the upper airway of the child may lead to decreased oral-motor functioning (ie, increased risk of aspiration) and, thus, multiple long-term complications. Therefore, seriously consider nonsurgical alternatives before recommending additional surgery.
• Tracheotomy: In the past, when surgery did not relieve the degree of sleep-associated respiratory disturbance, a tracheotomy was frequently performed. Currently, this alternative is rarely needed because of the development of noninvasive approaches to maintain upper airway patency during sleep.
• Bariatric surgery: Although bariatric surgery is primarily performed in patients who are obese, the associated weight loss may be of value in reducing obstructive sleep apnea because obesity predicts a lower success rate in treatment of obstructive sleep apnea by T&A. The effects of weight loss surgery on health problems associated with morbid obesity include decreases in severity or incidence of obstructive sleep apnea, diabetes, asthma, hypertension, infertility, arthritis, heart disease, reflux, stress incontinence, and pseudotumor cerebri.

Consultations

• For the otherwise healthy child with enlarged tonsils and adenoids, consultation with a pediatric sleep specialist and referral to a pediatric sleep laboratory for diagnosis are usually sufficient.
• When findings support the existence of obstructive sleep apnea, refer the patient to a pediatric otolaryngologist for T&A and take appropriate perioperative and postoperative precautions in higher-risk groups. When obesity is present, refer the patient to a nutritional interventional program. Similarly, pursue echocardiography and input from a pediatric cardiologist when pulmonary hypertension is clinically suspected.
• When craniofacial syndromes or neuromuscular disorders are the major cause of obstructive sleep apnea, a multidisciplinary approach is mandatory for improved outcomes.

Diet

• Introduce an appropriate diet in patients who are obese to facilitate weight reduction.
• Weight reduction is most successful with the aid of a nutritionist or an established weight reduction program. However, such programs have a low success rate, and surgical intervention for severe obesity is increasingly considered in older children.
• Although bariatric surgery is primarily thought of as a treatment option for adults, it is increasingly considered in adolescents (see Surgical Care).

Medication

Preliminary studies suggest an oral leukotriene modifier therapy may reduce the severity of obstructive sleep apnea (OSA); however, this intervention is currently considered investigational. Intranasal budesonide used for 6 weeks has been demonstrated to lead to a sustained improvement in mild obstructive sleep apnea but is unproven as therapy for severe obstructive sleep apnea.¹³

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