LAKIESHA BONHAM, CRT, MAE TRAINEE PATRICK MAENG, MD, PULMONARY

FELLOWCASEY MATHEWS, BS, MSW/MPH TRAINEE

PPC Interdisciplinary Case:Obstructive Sleep Apnea in an

Obese Child

Outline

Rationale Multiple medical, respiratory care, and social work issues Severity and complexity of each factor requires an

interdisciplinary approach for optimal managementMedical overview

Morbid obesity Severe obstructive sleep apnea Respiratory insufficiency

Non-medical barriers to care Family resources Social history Psychosocial factors related to obesity

Group discussion What is her optimal medical therapy? How do we overcome her barriers to care? How can we improve adherence?!?!

Case Presentation

CW is an 18 y/o morbidly obese AAF Referred for overnight polysomnogram from the Children’s Center

for Weight Management Sleep study

Severe obstructive sleep apnea (OSA) Apnea/hypopnea index (AHI) 50.8 Significant oxygen desaturations

Hospital admission Titration of significant BiPAP settings

23/12 cm H2O with rate 20 2-3 LPM oxygen

Assessment of respiratory and other healthcare issues PMH

Obesity OSA Insulin resistance syndrome Polycystic ovarian disease

Case Presentation

Meds Metformin Ibuprofen PRN pain

ROS Gen: obese with recent weight gain CV: diminished exercise tolerance, sleeps with head

elevated, occasional chest pain and tenderness Resp: SOB at rest, daytime sleepiness, snoring with pauses

in breathing GI: abd pain related to menstruation MSK: joint, back pain and tenderness, moderate joint

swelling GU: regular menstrual cycles Neuro: headache related to sleep patterns

Further History

FH Obesity Type 2 diabetes Cardiovascular disease Thyroid disease

SH Lives in public housing apartment with mother and other

extended family Dropped out of high school

Physical Examination

Vitals: T 98 P 97 BP 130/66 (119/74 thigh cuff) R 20 SaO2 95%

RA Wt 180.3 kg Ht 166 cm BMI (wt kg/ht m2) = 65.5 (BMI% = 99.7%)

Gen: obese, alert, interactive, appropriate, NADHEENT: NCAT, no LADResp: distant breath sounds, CTACV: distant heart sounds, no murmurs, pulses 2+Abd: soft, NT, no organomegaly appreciated due

body habitusExt: no joint swelling or tenderness, edema, digital

clubbing

Clinical Course

Assessment Morbid obesity with insulin resistance Severe OSA Respiratory insufficiency

Nocturnal hypoxia Hypercarbia

BiPAP Difficulty obtaining BiPAP machine Multiple strategies to improve tolerance of high settings Mother to manually titrate from low pressures to goal Repeat PSG

Goal home settings: 25/13 with rate of 20 and 3 LPM oxygen Follow-up

Sleep clinic – 4 weeks, seen by interdisciplinary team Weight management clinic – seen by interdisciplinary and

multidisciplinary teams

The Pediatric Obesity Epidemic

Obese = BMI > 95th percentile (BMI ~30) Severe obesity = BMI 35-40 Morbid obesity = 40-45 or 50 Super obesity = >45 or 50

US during the last 30 yrs (2007-2008 NHANES) Increase from 5 to 10.4% in 2-5 year olds 6.5 to 19.6% in 6-11 year olds 5 to 18.1% in 12-19 year olds

Biggest risk factors for adult obesity Obese as a child Parent(s) with obesity

Adverse effects Psychological, neurological, endocrine, cardiovascular, respiratory, GI,

orthopedic Metabolic syndrome

Dyslipidemia, hypertension, insulin-resistant diabetes, prothrombotic and inflammatory states

Independent role in the development of OSAS

Obstructive Sleep Apnea Syndrome (OSAS)

Prolonged, intermittent complete or partial obstruction (obstructive apnea or hypopnea) May occur with obstructive hypoventilation

Arterial oxygen desaturation Hypercarbia

Movement, autonomic, or cortical arousals from sleep Associated sx

Hypoxemia, hypercarbia Adenotonsillar hypertrophy Excessive daytime sleepiness Snoring +/- pauses and gasps Movements or arousal from sleep Paradoxical breathing, retractions Sleep in unusual positions Diaphoresis Morning headaches Parental concern, sleep with their child, shake to awaken to terminate

apnea

International Classification of Sleep Disorders, 2nd Edition, 2005, American Academy of Sleep Medicine

OSAS

Demographics 2% of children Boys = girls Increased prevalence in African-

American children Predisposing Factors

Larger tonsils and adenoids Size of adenotonsillar tissue does not

predict disease Obesity Craniofacial abnormalities

Down Syndrome, Pierre Robin Sequence

Hypotonia/neuromuscular disorders Infants with GERD Familial patterns

Complications Growth failure

Increase in height and weight following treatment in all weight categories, including obese patients

Cognitive and behavioral Developmental delay Poor school performance ADHD Aggressive behavior

Severe Asphyxial brain damage, seizures Pulmonary htn, cor pulmonale,

systemic htn Pathophysiology

Combination of upper airway narrowing and hypotonia Narrowing

Adenotonsillar hypertrophy Obesity

Hypotonia Pharyngeal dilating muscles (naturally

decreases with sleep onset)

International Classification of Sleep Disorders, 2nd Edition, 2005, American Academy of Sleep Medicine

Childhood Obesity and OSA

Obesity may increase risk of OSA four-fold 10% of those with OSA were obese 20-50% of obese children have evidence of OSA

Pathophysiology of OSA in obese children Anatomic factors

Adenotonsillar hypertrophy (45%) Hormonal changes Inflammatory changes

Soft tissue obstruction Fat pads, soft palate, lateral pharyngeal wall, tongue

Functional factors Higher critical airway pressure needed by dilator muscles to prevent airway

collapse Chest wall mechanics

Increased chest wall mass effect Decreased lung compliance Decreased FRC from abdominal visceral fat Decreased lung volumes leading to decreased tethering of trachea and easier

collapse Ventilatory drive

Decreased ventilatory responses to hypoxia and hypercapnea

Arens and Muzumdar, J Appl Physiol. 2010

Approach to the Obese Child with OSAS

Arens and Muzumdar, J Appl Physiol. 2010

Treatment of OSA in the Obese Child

T&A Treatment of choice when there is adenotonsillar hypertrophy Resolves OSA in ~50% Can resolve or decrease severity of OSA in 75% Much less effective in obese adults

Oral appliances Expand upper airway Mild OSA or do not tolerate CPAP Efficacy in children not well established

Positional therapy Promotes lateral, prone, or upright position

Uvulopalatopharyngoplasty Trim lateral pharygeal pillars, excise uvula and posterior palate Improves mild to moderate OSA in 40-50% Significant complications

Arens and Muzumdar, J Appl Physiol. 2010

Treatment of OSA in the Obese Child

Weight loss Greater degrees of weight loss associated with significant

reductions in OSA Most have residual OSAS Decreased CPAP requirements Dieting alone successful in adults 5-15% of the time over the first

8 years of treatment (Kohler 2009) Bariatric surgery

Unclear benefits in obese children after 10 years Rao et al. (2009) showed 50% resolution of OSA following lap

band surgery with loss of 20 kg excess weight Adult studies show resolution of OSA after gastric bypass in 25-

75% of cases (Fritscher et al. 2007; Peluso and Vanek 2007) Reasonable candidates for surgery:

Morbidly obese Skeletally mature Failed organized attempts at weight loss

Arens and Muzumdar, J Appl Physiol. 2010

CW

18 year old African American female diagnosed with Morbid Obesity

Initial sleep study was performed at the age of 12 Apnea/hypopnea index (AHI) of 23 Started on CPAP and titrated to a pressure of 8 cm

H2O

Hospital

Repeat sleep study 9/16/10 revealed an AHI of 50

Pt was started on CPAP 14 and found to be inadequate

Pt was then placed on BiPAP 14/6 and titrated up to 22/12 with a rate of 20

Hospital

Supplemental oxygen was titrated from 1 lpm

to 3 lpm

Sleep study performed prior to discharge revealed optimal settings of 25/13 with a rate of 20

Home

Pt didn’t tolerate IPAP pressure of 22Mother started at a low setting of 12/6

increasing her dial throughout the nightMax level achieved was 18/8Target goal 22/13 (highest level on machine)

CPAP vs. BiPAP

Continuous positive airway pressure (CPAP) delivers a set pressure to lungs

Bi-level positive airway pressure (BiPAP) helps deliver pressure to the lungs at higher levels

Comparison

Flow generator (delivery mechanism)Hose (linkage between interface/generator)Interface (facial or nasal mask)

Contrast (CPAP)

CPAP delivers a set pressure (4-20 cm H2O)Works by releasing the amount of

compressed air through the hose to the interface (mask) and keeps the upper airway opened under continuous air pressure

Increases the oxygen flow by keeping airway opened

Contrast (BIPAP)

Delivers two levels of pressure (IPAP/EPAP)IPAP (20-30 cm H2O)EPAP (4-20 cm H2O)Preferred over CPAP to treat CSA or OSA and

heart diseasesBIPAP has a set rate

Comparison

Side effects: Headache Skin irritation Abdominal bloating Nasal congestion Runny nose

What is BiPAP?

Pushes air into the lungsHolds the lungs open to allow more oxygen to

enter into it

Qualifications for BiPAP

Initial ventilatory crisis and avoid intubation and ventilation

Home ventilation for patients with neuromuscular dysfunction, obstructive sleep apnea, and other conditions resulting in hypoventilation

BiPAP Settings

IPAP Once inspiration begins, a preset Inspiratory

Positive Airway Pressure (IPAP) is reachedEPAP

Expiratory Positive Airway Pressure (EPAP) is preset to maintain airway patency and oxygenation

Frequency Determines the timed breath rate and is adjustable Synchronizes to patients own breaths

Criteria for BiPAP

Stable hemodynamicsCooperative patientMinimal airway secretions

Goals for CW’s BiPAP Use

Adherence Better fitting mask for comfort Auto titration Incentives (gift card)

Achievement of optimal pressure settings New BiPAP machine (25/13)

Adolescent Obesity

Under age 19, obesity is determined by BMI percentile Obese = >95th percentile

16.8% of girls ages 12-19 are obese 29.2% of black adolescent girls

19.3% of boys ages 12-19 are obeseRisk factors for adolescent obesity

Low SES Minority race/ethnicity Obese family member

80% of obese adolescents with an obese parent will become obese adults

Centers for Disease Control (2010). Childhood obesity. http://www.cdc.gov/HealthyYouth/obesity/

Psychosocial Effects of Obesity

“There is no doubt that obesity is an undesirable state of existence for a child. It is even more

undesirable for an adolescent, for whom being overweight acts as a damaging barrier in a

society obsessed with slimness.” – Hilde Bruch

Psychosocial Effects of Adolescent Obesity

Higher prevalence of depressive symptoms and lower self-esteem than non-overweight peers

Associated with adverse social and economic status in adulthood Particularly strong association in women

Report fewer reciprocal friendships than non-overweight peers

Reported more hours of television viewing per dayLess involvement in formal activities

Strauss, Pollack (2003). Social marginalization of overweight children. Pediatric and adolescent medicine 157. p 746-752.

Family Composition/History

Lives with mother, two siblings, aunt, cousin Public housing apartment

Father passed away 1 year ago Obesity-related complications

Long family history of obesity Mom – diabetes PGF – gastric bypass surgery

School History

Dropped out at age 16 as an eighth graderReasons for dropping out

Teasing Not feeling well Bad grades Embarrassment about weight

Currently attending GED classesBoth parents graduated from high school

Economic Factors

Sources of income Mother’s unemployment Food Stamps

Father’s death worsened financial burden of the family Significant decrease in income Family moved into public housing Mother lost her job shortly after his death

Funding for Medical Care

MedicaidReceives Oxygen through Pediatric Services

of AmericaMedicaid is not funding her BiPap machine

PSA donated an old machine

Mental Health

Denies suicidal ideation or intentShe perceives that she has been left out of

activities because of her weightHas lost most of her friends as she has

become more overweightTeased by siblings, adult family members,

and other children at schoolExpresses that she intensely dislikes herself

and her body

Adherence to Treatment

Has a history of non-adherence with CPapStates that there is a “50/50” chance that she

will wear the BiPap at homeStates that she does enjoy the activities in

Weight Management Clinic Fun exercises to do at home

Weight Management Clinical Nutrition Assessment Low adherence predicted

Adherence

Strategies to encourage adherence Gift card incentives If mask is irritating the patient at night, encourage

her to wear it while watching television during the day

Reinforce how serious her OSA is, and the consequences that will likely come if she does not use BiPap regularly

Lead the patient to articulate for herself reasons that the BiPap is good for her and ways that it helps her

Help her formulate her own realistic goals for her health, then teach her what is required to reach them

Barriers to Care

Transportation issues Rely on public transportation Frequent doctor’s appointments, Weight Management

appointments

Stigma of wearing BiPap at age 18 Related teasing from family members, siblings

Financial burden Out of pocket expenses for medical care Increased cost of eating fresh food

Barriers to Care

Culture of neighborhood Convenient foods are fatty foods “Food Desert” Lack of safe opportunities for exercise

Family culture Obesity is the norm Traditional southern cooking

Sleep Clinic Follow-Up

Seen by interdisciplinary team2-3+ Adenotonsillar hypertrophyAdmits to poor adherence

Using BiPAP ~2-3x/week Takes off BiPAP after a few hours due discomfort

from high pressures Intermittent discomfort due to mask Embarrassment due to teasing

Old Respironics ST BiPAP machine Mother manually titrating from 12/6 to 18/8 Maximum IPAP 22 cm H2O

Sleep Clinic Follow-Up

Plan New BiPAP

Start at low settings 12/5 Autotitrate to goal 25/13 rate 20, with 3 LPM oxygen Download usage at next f/u to gauge adherence

Attempt different mask fitting (ResMed Quattro, small)

Refer to otolaryngology for T&A Repeat sleep study 6 weeks post-op Anesthesia risk

Ongoing psychosocial support Strongly recommend continued weight

management clinic follow-up