Childhood Sleep Apnea Treatment & Management

Adenotonsillectomy

Obstructive sleep apnea in pediatric patients generally responds to adenotonsillectomy. However, not all children with obstructive sleep apnea (OSA) are surgical candidates.

Adenotonsillectomy, along with weight normalization, is considered the first line of therapy in children and adolescents with obstructive sleep apnea. Surgically removing the tonsils and adenoids increases cross-sectional airway caliber in patients, although it does not directly affect the fatty infiltration of the soft tissues of the velopharynx and hypopharynx that occurs in children who are obese. Children with obstructive sleep apnea who are obese generally require follow-up polysomnography 8-12 weeks following adenotonsillectomy to assess for residual sleep apnea and determine whether other interventions (eg, continuous positive airway pressure [CPAP]) are needed.

Children with severe obstructive sleep apnea require overnight hospital observation following adenotonsillectomy, especially if they fall into one of the high-risk groups.

Absence of snoring following surgery does not equal an absence of obstructive apnea.

Dietary restrictions

Caloric intake limitation and dietary counseling are necessary if obesity complicates obstructive apnea. Obstructive sleep apnea may aggravate gastroesophageal reflux. Children and adolescents with significant sleep apnea should avoid eating large amounts just before bedtime. This is especially the case if children are being treated with CPAP, which can lead to air swallowing and gastric distention.

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 being considered in adolescents.

Activity restrictions

Many individuals with obstructive sleep apnea have daytime sleepiness with reduced attention span and difficulty focusing their concentration. Warn teenagers who drive about the potential danger of falling asleep at the wheel; advise them to avoid driving long distances without a break or driving when they are unusually tired. Numerous epidemiologic studies link obstructive sleep apnea to motor vehicle accidents.^[18]

Avoidance of certain drugs and alcohol

Patients should avoid alcohol and other depressant recreational drugs, which may worsen their sleep apnea. They should avoid sedating medications when possible; if necessary appropriate monitoring and medical supervision is required.

Infants and children with obstructive sleep apnea may have serious respiratory embarrassment when given any sedative medication. Caution is necessary during any medical or dental procedures requiring conscious sedation.

Drug therapy

In general, medical therapy is of limited value in the typical pediatric patient with obstructive sleep apnea (OSA). Oxygen therapy should not be prescribed as the primary therapy for 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.

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.

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. CPAP is the mainstay of therapy for most adults with obstructive sleep apnea, as well as a large number of children and adolescents. Continuous distending airway pressure is applied during sleep using a nasal mask and small compressor. CPAP acts as a pneumatic splint to maintain airway patency. By simultaneously increasing the functional residual capacity, this pressure also helps prevent oxygen desaturation even if airway obstruction breaks through.

Various patient interfaces are available, including nasal masks, facemasks, gel masks, and nasal pillows to help facilitate a comfortable fit and adherence to therapy. The amount of CPAP pressure must be individualized for each patient and is determined during a CPAP titration study in the sleep laboratory. The goal is to find an optimal pressure that eliminates apnea and minimizes snoring but is still comfortable and does not lead to excessive air swallowing, gastric distention, and air leak around the mask or through the mouth. Long-term effects of nasal CPAP therapy on maxillofacial structure development in children are unknown.

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 fitting 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 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 of 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.

Some children have profound craniofacial deformities that are not easily remedied. Occasionally, surgical procedures undertaken to remedy obstructive sleep apnea only help the problem but do not completely eliminate it. In these situations, therapy is usually best accomplished with devices that deliver CPAP.

Numerous commercially available oral (PO) appliances assist in bringing the lower jaw and tongue forward during sleep, thus improving obstructive sleep apnea. These devices are expensive, require special dental expertise, and are associated with frequent adverse effects such as jaw pain and temporal mandibular joint dysfunction. Small growing children are likely to outgrow appliances, necessitating refitting and replacement. In general, PO appliances have extremely limited usefulness, if any, in pediatric patients.

Go to Oral Appliances in Snoring and Obstructive Sleep Apnea for complete information on this topic.

Over-the-counter, disposable, adhesive covered nasal strips purported to decrease nasal airflow resistance have been promoted as a treatment for snoring and obstructive apnea. These have not been proven to be effective in pediatric sleep apnea, and their use should be discouraged.

Obstructive apnea is generally worse in supine sleeping than in prone sleeping. Measures to encourage patients to sleep prone, such as sewing a pocket to the back of the pajama shirt and putting a tennis ball into it, have some minimal success among adults who snore or have very mild obstructive apnea. This strategy is generally not helpful in managing significant childhood sleep apnea.

Nasal fluticasone administered daily for 6 weeks is shown to ameliorate the frequency of obstructive events in children with mild-to-moderate obstructive sleep apnea due to tonsil or adenoid hypertrophy by about one half.

Nasal steroids offer an opportunity to reduce obstructive events pending surgery or can be an alternative remedy for children with mild disease whose parents are reluctant to pursue surgical treatment.^[19]

Steroids are not shown to decrease obstructive symptoms, eliminate the need for surgery, prevent oxygen desaturation, or shrink tonsil or adenoid tissue.

No long-term studies are available to assess the duration of steroid effect, and whether beneficial aspects persist even if therapy is continued is unknown.

A trial of topical steroid therapy should not delay surgical treatment of obstructive apnea in children with severe tonsillar hypertrophy or moderate-to-severe obstructive sleep apnea.

No studies have assessed the efficacy of topical steroid therapy in children with craniofacial abnormalities and obstructive sleep apnea.

Short courses of systemic steroids (prednisone, 1 mg/kg/d PO for 5 d) have been shown to be ineffective in the treatment of childhood obstructive sleep apnea due to tonsil or adenoid hypertrophy.

In the pediatric population, most obstructive sleep apnea is related to tonsillar hypertrophy or adenoid hypertrophy. Adenotonsillectomy is curative in most instances. Children with obstructive sleep apnea who undergo adenotonsillectomy demonstrate improvement in measures of neurocognitive function.

Certain children who are known to have a high risk of postoperative complications should only undergo surgery at institutions that possess pediatric intensive care facilities (PICUs). This high-risk group includes children younger than 3 years and those with craniofacial abnormalities, failure to thrive, hypotonia, morbid obesity, a history of previous airway trauma, and severe abnormalities on polysomnography (respiratory disturbance index [RDI] >40 or oxygen desaturations < 70%).

Although obstructive sleep apnea has multiple etiologies in children, once the diagnosis of obstructive sleep apnea has been established and its severity assessed, adenotonsillectomy 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.

Additional surgical options may include uvulopalatopharyngoplasty (see below), 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.

Go to Surgical Approach to Snoring and Obstructive Sleep Apnea for complete information on this topic.

Uvulopalatopharyngoplasty (UPPP [ie, UP3]) is not commonly performed in children. During the procedure, the uvula, posterior margins of the soft palate, and lateral pharyngeal wall mucosa are removed via scalpel or laser ablation. UPPP surgery is likely to be successful in relieving obstructive sleep apnea only if the major site of obstruction is localized to the soft palate. This surgery carries a risk of velopharyngeal insufficiency, which may be increased among pediatric patients. Although UPPP may effectively eliminate most snoring, the procedure does not always cure obstructive sleep apnea. Follow-up polysomnography 2-3 months after surgery is warranted to reassess for residual apnea.

Go to Surgical Approach to Snoring and Obstructive Sleep Apnea for complete information on this topic.

Tongue reduction procedures (midline partial glossectomy) may have some use in a small number of carefully selected pediatric patients (eg, Beckwith-Wiedemann syndrome).

Tracheotomy remains an effective surgical option for life-threatening obstructive apnea that is not amenable to other therapies.

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.

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 adenotonsillectomy.

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.

Go to Surgical Approach to Snoring and Obstructive Sleep Apnea for complete information on this topic.

Children with severe obstructive sleep apnea may develop postobstructive pulmonary edema within a few hours of surgery to relieve upper airway obstruction.

Risk factors for postoperative pulmonary edema include the following:

• Age younger than 3 years
• Craniofacial anomalies affecting the pharyngeal airway, especially midfacial hypoplasia, micrognathia, or retrognathia
• Failure to thrive
• Hypotonia
• Morbid obesity
• Previous upper airway trauma
• Severe abnormalities on polysomnography, with a respiratory disturbance index (RDI) of more than 40 events per hour or oxygen desaturations less than 70%
• Patients undergoing uvulopalatopharyngoplasty (UPPP) in addition to tonsillectomy or adenoidectomy
• Complicating cardiac or pulmonary disease

Teams of pediatric specialists often collaborate in the care of infants and children with sleep apnea. Members of the following specialty groups have specific expertise that may help the primary care physician coordinate the care of their patient with sleep apnea:

• Pediatric sleep medicine
• Pediatric otolaryngology
• Pediatric plastic surgery
• Orthognathic surgery
• Pediatric neurosurgery
• Pediatric anesthesia
• PICU
• Pediatric endocrinology
• Pediatric pulmonology
• Pediatric cardiology

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 adenotonsillectomy and take appropriate perioperative and postoperative precautions in higher-risk groups. When obesity is present, refer the patient to a nutritional intervention 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.

Some children with severe obstructive apnea continue to have apneas in the immediate postoperative period until surgery-related edema subsides. For these children, continuous positive airway pressure (CPAP) therapy can serve as a bridge treatment after surgery until operative swelling subsides.

In most otherwise healthy children with obstructive sleep apnea, adenotonsillectomy results in complete resolution of the problem, and a postsurgical evaluation in the sleep laboratory is usually not recommended. However, residual mild sleep-disordered breathing is found in more than one third of these patients after adenotonsillectomy, particularly those included in the high-risk category. Thus, adenotonsillectomy alone may not suffice, and polysomnographic evaluation 6-8 weeks after adenotonsillectomy may confirm the need for additional treatment, including the use of intranasal steroids and oral leukotriene modifier therapy or CPAP and/or bilevel positive airway pressure (BiPAP).

Individuals undergoing surgical treatment for moderate-to-severe obstructive sleep apnea should have follow-up polysomnography 2-3 months after their operations to ensure that the surgery successfully eliminated their obstructive apnea. Some patients continue to have significant obstructive apnea after surgery even though their snoring improves dramatically or disappears altogether. This is especially true for individuals who undergo uvulopalatopharyngoplasty (UPPP) alone.

Daytime fatigue and somnolence may persist after successful treatment for obstructive sleep apnea if the patient continues to follow a chaotic sleep schedule at home. Use outpatient contacts as an opportunity to reinforce good sleep hygiene, which is the phrase used to describe the conditions and habits that foster effective, satisfying sleep. Stress the importance of maintaining a regular bedtime and rise time and of allowing an adequate period for overnight sleep.

Patients should maintain a healthy weight with good eating habits and appropriate exercise. Although numerous factors influence the development of obstructive sleep apnea, obesity has been associated with a 4-fold to 5-fold risk in children aged 2-18 years.

Patients treated with noninvasive ventilation require close follow-up by a pediatric pulmonologist and may periodically require a repeat polysomnographic evaluation. Treat patients who are found to have significant hypoxemia during polysomnography as soon as possible with overnight supplemental oxygen until adenotonsillectomy can be performed. Carefully assess the patient when using oxygen because of the rare possibility that significant hypercapnia may develop during the night