Sleep Apnoea

Upper Airway Obstructive Sleep Normal Sleep Resistance Apnoea Syndrome Presentation

Nocturnal Symptoms Daytime symptoms

 Loud, habitual snoring  Nonrestorative sleep  Witnessed apnoeas followed  Lethargy by a gasp / snort  Poor concentration  Nocturia  Disruptive behaviour  Restless sleep  Struggling at school  Extended position  Mouth breathing

Incidence

 UK: (Arch Dis Child 1993; 68(3): 360-6)  12% of children are snorers  0.7% of children have OSA  Most common age 3 – 6 years

 Risk factors  Adenotonsillar hypertrophy  Obesity  Craniofacial abnormalities Pathology

Central sleep apnoea Obstructive sleep apnoea

 Cyclical reduction in respiratory  Temporary airway effort during sleep obstruction during sleep

 Relatively small airway  Medication (eg opiates)  Large tongue base, tonsils,  Neuromuscular disorders adenoids, micrognathia,  Hypotonia  Chemoreceptor failure  Reduced muscle tone during sleep  High altitude  Preserved central respiratory  Head injury drive

Differential diagnosis

Gastroesophageal reflux Nocturnal Heart failure Panic attacks Investigations

 Overnight oximetry  Can only detect moderate / severe sleep apnoea  False positives secondary to loss of sensor position  Can be performed at home Investigations

 Overnight oximetry Investigations

 Polysomnography  Gold standard for diagnosis  Overnight stay in hospital required  Child may not go to sleep Investigations

 Polysomnography  Airflow  SpO2  EEG  EOG (eye movement)  ECG  Chin muscle tone  Chest wall movement  Abdominal movement  Leg movement  Microphone, video

Investigations

 Polysomnography

Sleep onset latency Time from lights out to onset of sleep Sleep efficiency Proportion of time spent sleeping Sleep stages Awake Stage 1 – 2 NREM sleep REM sleep Arousals Sudden shifts in brainwave activity Desaturation Frequency, depth & duration of desaturation Movement Body position Leg movement Apnoea / hypopnea Investigations  Polysomnography  Apnoea  Pause in breathing for >10 seconds  Associated with desaturation  Hypopnea  50% reduction in ventilation  4% decrease in saturation

AHI Interpretation  Apnoea / hypopnea index Number of apnoea or <5 Normal hypopnea events per hour 5 – 15 Mild sleep aponea 15 – 30 Moderate sleep aponea > 30 Severe sleep aponea Investigations

 When to request polysomnography (Clin Otolaryngol 2009; 34: 61-3)

 Weight <15kg  Age <2 years  Serious comorbidity  Unclear diagnosis Treatment

Snoring Conservative managment Rhinitis Antihistamine, nasal steroid Reflux PPI or H2 receptor anagonist Adenotonsillar hypertrophy, OSA Adenotonsillectomy

Complications of untreated OSA: • Disturbed sleep • Poor behaviour • Educational delay • Cardiac arrhythmia • Adenotonsillectomy Post op management

 Test dose of opiate during GA to assess opiate sensitivity

 Adequate analgesia, avoid codeine

 Inpatient overnight SpO2 monitoring  PICU bed available if severe sleep apnoea  3 months follow-up, consider central sleep apnoea if partial / no improvement Codeine metabolism Stridor in children Case 1

Case 2

Case 3

Inspiration Expiration Case 4

Stridor in children

 High pitched sound  Inspiratory: associated with breathing  Laryngeal obstruction  Produced by narrowing in airway  Biphasic  Diagnostic clues from tone,  Glottic obstruction phase, volume, duration  Expiratory  Tracheobroncheal obstruction Basic principles

Poiseuille’s law Bernoulli principle  flow rate is inversely  Increase in speed of flow proportional to viscosity, associated with decrease in length and radius pressure  higher resistance with turbulent flow

Resistance = 8x viscosity x length π x radius4 Adult vs Paediatric Airway

http://paediatricem.blogspot.co.uk/2013/07/the-airway-in-children.html Acute stridor aetiology

Laryngotracheobronchitis () Barking cough, worse at night Low grade fever Age 6 months – 2 years Bacterial High fever Stridor Sore throat, fever Reduced range of neck movement Preceeded by Anaphylaxis Associated with rash Swelling of lips and face Exposure to allergen High fever Drooling Splinted posture Chronic Stridor Aetiology

Laryngomalacia Inspiratory stridor Presents age 6 months – 1 year Self limiting, resolves by age 2 Inspiratory / expiratory stridor Intrinsic / extrinsic compression Chronic biphasic stridor May be history of intubation Weak cry, biphasic stridor Stridor louder when awake Forceps delivery, Arnold-Chiari Arteriovenous malformation, Progressive stridor laryngeal cyst May have skin lesions Laryngeal papillomatosis Dysphonia Progressive biphasic stridor Laryngeal examination

 Larngeal mirror  Difficult in children  Allows direct dynamic view of Investigations

 Flexible nasendoscopy  Dynamic examination of whole upper airway to subglottis  Assessment of vocal cord mobility  Requires cooperation Ventilating bronchoscope

 Under general anaesthetic  Examination to main stem bronchi  Instruments (eg forceps) can be passed through lumen Epiglottitis

 Inflammation of supraglottic structures

 Rare since H. vaccine  High fever, severe sore throat, drooling, inspiratory stridor

 High index of suspicion if sore throat but normal oral examiation

Epiglottitis  Airway emergency, keep calm

 Ambient humidified O2  Clinical diagnosis, no radiology  Involve senior, paediatric anaesthetist, ENT  Transfer to theatre, plan for ET intubation with tracheostomy kit on standby  IV broad spectrum antibiotics

Retropharyngeal abscess

 Spread of bacterial infection from pharyngitis to retropharyngeal space

 Presents with worsening sore throat, neck stiffness, reduced range of movement, dry barking cough

 Difficult to diagnose clinically Anaphylaxis / Angioedema

 Facial swelling  Rash  Shock  Facial swelling  Rash  Shock

 Most common cause of stridor in infancy  Usually normal breathing at birth  Symptoms worsen until age 6 months  Improves by 1 year. 10% require surgery

 Common symptoms:  Severe symptoms:  Inspiratory stridor  Growth retardation  Worse when feeding,  Cyanosis crying, lying supine  Apnoea  Cor pulmonale

Laryngomalacia

Omega shaped Short aryepiglottic folds Redundant supraglottic tissue Supraglottic collapse on inspiration Inflammation (reflux )

Classification  Type I:  Shortened aryepiglottic folds  Type II:  redundant supraglottic soft tissue  Type III:  Other disorders, eg neuromuscular disease, gastroesophageal reflux

Usually a combination of the above

Management  Conservative management with reassurance  If adequate feeding, weight, no other comorbidity  Treatment for reflux  May be empirical  Gulping at night is a sign of reflux  Erythema / granulation in larynx &  Surgery  If failure to thrive  laryngotrachobronchoscopy  If laryngomalacia confirmed  supraglottoplasty  Risks: aspiration, stricture, damage to teeth  Close communication between surgeon & anaesthetist Tracheomalacia

 Flaccidity or compression of tracheal cartilage  If intrathoracic: expiratory stridor  If extrathoracic: inspiratrory stridor

 Rarely coexists with laryngomalacia  Usually affects distal third of

Tracheomalacia

Tracheomalacia

 Classification  Type I: congenital intrinsic trachal abnormalities eg tracheocutaneous fistula, esophageal atresia

Type II: Extrinsic abnormalities eg vascular ring

Type III: Acquired tracheomalacia eg. Prolonged intubation, chronic tracheal infection

Tracheomalacia

 Presentation  Expiratory stridor within first few weeks  Worse when supine, crying  Occasionally associated with feeding difficulty  Examination  Supraclavicular & subcostal recession  Normal air entry on inspiration, widespread harsh breath sounds on expiration

Tracheomalacia

 Treatment depends on the cause  Extrinsic compression (eg vascular rings) tends to worsen as the child grows

 MRI under GA  Tracheostomy is only an option when proximal trachea affected Inhaled foreign body

 Children at risk because no molar teeth, tendancy to talk while eating, parygneal incoordination

 May present with acute cholking, or increasing cough  Review of 1068 cases:  3% in larynx  13% in trachea  52% in right main  18% in left main bronchus  Peak age: 3 years

Ann Trop Paediatr. Mar 2003;23(1):31-7 Inhaled foreign body

Unstable patient Stable patient

 Not cholking  Arrange immediate transfer  Emergency transfer to theatre for to centre with paediatric ENT bronchoscopy and paediatric cardiothoracic  Cholking cover  Effective cough: encourage to cough  Consider anaesthetic  Ineffective cough: transfer 5x backslaps, 5x chest thrusts (infant)  Bronchoscopy and removal 5x abdominal thrusts (child) of FB on arrival  Unconsious:  Look for FB in mouth  CPR Choanal atresia

 Presents with difficulty feeding  Feeds for a few seconds then gasps

 Emergency if bilateral Laryngeal web

 Incomplete re-canalisation during third month of gestation

 Dysphonia in most cases

 Dyspnoea depends of extent of web

 Stridor rare, only with posterior web

 One third have other structural abnormalities, eg subglottic stenosis, DiGeorge syndrome Laryngeal web

 Management:  Surgical division with scalpel or laser  High risk of recurrence  Silastic stent placement and mitomicin C injection may reduce recurrence  Tracheostomy

Benmansour N, Eur Arch Otorhinolaryngol. Sep 2012;269(9):2075-80 Laryngeal cysts

 Saccular cyst: retention of secretions in laryngeal saccule oraphis

 Ductal cysts: obstruction of submucosal mucous glands

 Dysphonia / abnormal cry  Aspiration of cyst is a temporary measure, requires formal excision Vascular malformation

 Stridor may be present at birth, worsens until six months

 Haemangioma regress spontaneously. Regular propanolol accellerates regression

 Tracheostomy may be required

Vocal cord paralysis

 Aetiology  Central nervous system:  Peripheral nerves:  Cerebral palsy  Forceps delivery / birth trauma  Hydrocephalus  Neck or mediastinal lesions  Myelomeningocoele  Arnold-Chiari malformation Vocal cord paralysis

 Presents with weak, breathy cry  Increased risk of aspiration  Usually no other physical signs  Bilateral palsy: inspiratory stridor, worse when agitated Vocal cord paralysis

 Management  Conservative  Speech therapy  Tracheostomy if bilateral VC palsy  Lateralisation procedure if fails to resolve Laryngeal cleft

 Failure of fusion of laryngotracheal groove

 Associated with tracheomalacia (80%), tracheoesophageal fistula (20%)

 Feeding difficulties, aspiration  Managed with tracheostomy, gastrostomy, repair of cleft