OSAS is a condition of partial or total obstruction in the upper airway during sleep resulting in intermittent hypoxemia , hypoventilation with retention of co2 in blood and sleep fragmentation.It occurs repeatedly during sleep.This condition is a sleep related breathing disorder-SBD
In different studies, the prevalence has been found to be 1-4 % in children and the peak age of this disorder is between 2-8 years of age
OSAS occurs more frequently in children who are obese,who already have Down syndrome, Prader Willi Syndrome, Mucopolysaccharidosis,Achondroplasi,craniofacial anomalies or neuromuscular disease
PATHOPHYSIOLOGY– Upper airway muscle tone decrease during sleep making the space narrow. If the upper airway space ias already narrow due to preexisting Adenotonsillar hypertrophy ,it becomes critical during sleep with increase in upper airway resistance leading to excessive respiratory efforts-hypoxemia-hypoventilation-arousal -restoration of patency of upper airway. This cycle repeats several times during sleep
RISK FACTORS-Adenotonsilar hypertrophy, Allergic Rhinitis, Chronic nasal obstruction,Deviated nasal septum,Laryngomalacia,obesity,craniofacial anomaly ,reduced tone of upper airway muscle
Clinical Examination Findings Signs during night-Regular snoring. excessive sweating,abnormal body posturing like keeping neck hyperextended, restless sleep,mouth breathing, Enuresis. During day-hyperactivities as against excessive sleepiness in older children and adolescents, Learning disability,attention defici, failure to thrive. On throat and mouth examination- Adenoid and tonsillar hypertrophy,high arches palate,
DIAGNOSIS– The Gold standard is overnight attented Polysomnography also called Level 1 PSG
Pediatric PSG criteria-American Academy of Sleep Medicine -ObstructivAPNEA-90% or more reduction in nasal airflow for 2 or more missed breaths with increased respiratory efforts. Central APNEA-no airflow, no respiratory effort.HYPOPNEA-30% or more reduction in airflow for 2 or missed breaths and or desturation of 3% or more and or arousal
AHI -Apnea hypopnea index-Total number of apnea and hyponea events per hour of sleep. It is calculated to asses the severity of OSAS in children
Assessment of Severity-Pediatric Criteria– Normal- if AHI is 1 or no event, Mild disease-AHI 1 to 5, Moderate Disease-AHI 5 to <10 and Severe Disease if AHI is 10 or more
Complications-Growth failure, Learning disability,congnitive impairment, Attention deficit Hyperactivity, Systemi hypertension, Pulmonary hypertension, Metabolic syndrome
TREATMENT – In case of mild disease specially with allergic rhinitis-Intranasal steroid and or oral Montelukast.It is aslo indicated in residual disease after surgery. In case of moderate to severe disease specially associated with Aenotonsillar hypertrophy-Treatment is Adenotonsillectomy
Indication of CPAP/BiPAP– This is indicated in presence of residual disease after surgery, where surgery is contraindicated, neuromuscular disease, craniofacial anomaly or obesity
Other Treatment modalities-Rapid maxillary expansion surgery.Supraglottoplasty in presence of laryngomalacia, hypoglossal nerve stimulation in selected adolescents with Down syndrome
Indications of repeat PSG-Severe pre operative OSAS, Down syndrome,Neuromuscular disease,persistent symptoms after surgery,obesity
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