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 neck 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 rhinitis Chemoreceptor failure Reduced muscle tone during sleep High altitude Preserved central respiratory Head injury drive
Differential diagnosis
Gastroesophageal reflux Nocturnal asthma 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 • Pulmonary hypertension 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 (croup) Barking cough, worse at night Low grade fever Age 6 months – 2 years Bacterial tracheitis High fever Stridor Retropharyngeal abscess Sore throat, fever Reduced range of neck movement Preceeded by pharyngitis Anaphylaxis Associated with rash Swelling of lips and face Exposure to allergen Epiglottitis High fever Drooling Splinted posture Chronic Stridor Aetiology
Laryngomalacia Inspiratory stridor Presents age 6 months – 1 year Self limiting, resolves by age 2 Tracheomalacia Inspiratory / expiratory stridor Intrinsic / extrinsic compression Subglottic stenosis Chronic biphasic stridor May be history of intubation Vocal cord dysfunction 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 larynx 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.Influenza 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 Laryngomalacia
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 epiglottis Short aryepiglottic folds Redundant supraglottic tissue Supraglottic collapse on inspiration Inflammation (reflux laryngitis)
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 & pharynx 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 trachea
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 bronchus 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