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,