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Eighth Biennial Pediatric Sleep Medicine Conference

November 12-15, 2015Omni Amelia Island Plantation Resort

Amelia Island, Florida

Sponsored byThe Warren Alpert Medical School

of Brown University

Manisha Witmans, MD, FRCPC, FAASM

Associate Clinical Professor, University of Alberta

Adjunct Professor, TRU, Kamloops

Previous sleep and research funded by: AIHW, CIHR

Medical Director: Sound Sleep Solutions

Consultative Services for Sleep Medicine:◦ Stollery Children’s Hospital and Glenrose rehab

hospital

◦ Peak Medical Consultative Services

◦ Braebon Inc

◦ Home care companies: home sleep testing for children and adults

Review evidence for diagnosis of OSAS using HST or other alternative techniques

Discuss evidence for use of auto titrating devices in children

Discuss challenges in diagnosing children in different countries

Adult data with established morbidity and mortality related to OSAS

Emerging data in children also supports morbidity and mortality in children with OSAS

Potential childhood origins for adult OSAS warrants early identification and treatment of OSAS

Age: 16Height: 71 (in) 180 (cm) Weight: 335 (lb) 152.1 (kg) BMI: 46.94 kg/m2

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◦ Accurately identify OSAS and treat it in a meaningful fashion that would impact long term morbidity and mortality of the affected individual

◦ End organ dysfunction – would affect the diagnostic cutoff point

◦ To whom and how that child presents may affect access to care and potentially outcome

◦ “Wrap around care”

OSAS is a spectrum of disorders ranging in presentation, severity and sequalue

Worldwide restricted access to testing, or not available

Nocturnal PSG is laborious and cost prohibitive – not even accounting for the different nuances that are involved in making the diagnosis

1) symptoms and signs

2) questionnaires

3) abbreviated testing – single channel◦ Physiological

Oximetry, PAT, etc.

◦ Neurocognitive assessment

4) polygraphy

5) polysomnography

6) biomarkers

7) ? Machine learning - computer generated algorithms

More access to testing facilities and ambulatory equipment

Interpretation of results:◦ What rules?

Technical components?

Understanding of the data – what rules? What age?

Interpretation of the information? What is critical?

The balancing act: positive and negative predictive values, sensitivity and specificity

◦ Pediatric Sleep Questionnaire (Chervin)

Considers only past month

22 items: yes / no / don’t know questions

8 or more “yes’ = positive Dx

Validated against PSG

Sensitivity: 81-85%; Specificity 87%

◦ Caveats:

Limited operator curve properties overall (0.7-0.8)

Doesn’t account for other factors – craniofacial features etc., asthma, atopy

No account for seasonal pattern or risk factors

May improve when used with other tools

De Luca Canto G, JADA 2014: 145:165-178; Ishman Laryngoscope 2015

Retrospective chart review: n=158, age 10 yrs

Tonsil Size (2 fold increased risk of OSA)

Mallampati Score sitting and supine (6 fold increased risk)

Kumar HV et al, J Clin Sleep Medicine, 2015

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The quest for optimal tools

OSA-18,

SDIS

PSQ

Brazilian-Portuguese SDSC

HK-CSQ

Children’s Sleep Quality Assessment

Questionnaire CASQ and

Gozal’s questionnaire

Spruyt et al, Sleep Medicine Reviews, 2011

Initial studies: Brouillette et al◦ Used to identify clinical populations with more

severe OSAS with clustered desaturations

Scholle et al: normative values ODI3% for children:◦ < 2 yrs: 2.2 episodes/hr

◦ 2-10 yrs 1.2 episodes/hr

◦ 11-18 yrs: 0.5 episoodes/hr

Saito et al: normative values

McGill score:◦ Clustering of desaturation events: 3 drops of

desaturations to less than 90%, increasing in score with the severity of the desaturation clusters

◦ No night to night variability

◦ Expect seasonal variability? As with snoring

Low sensitivity (about 40%) for AHI > 1/hr

Many children have OSAS with a normal McGill score but that may reflect other conditions

Tsai et al:◦ ODI4 > 2 events/hr PPV 98.1%, high sensitivity 77%,

and specificity 88.9% for predicting AHI at least 1/hr

Other developments:◦ Chang et al

ODI4 and symptoms of SBD better PPV but low sensitivity for AHI > 5/hr for TST

Attempts to work with this further to improve tool metrics◦ Limited value for children who have good

pulmonary reserve

Advantages:◦ Inexpensive and simple

◦ Objective data

◦ Little experience required

Disadvantages:◦ Can’t distinguish central versus obstructive sleep

apnea

◦ Doesn’t account for those with OSA with little desaturations

◦ Doesn’t account for other considerations

This is used as a surrogate for heart rate variability as a function of respiratory effort, and arousals

◦ It appears that it may not be able to detect AHI< 3 events/hr and therefore the sensitivity may not be better

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Nasal flow signals, and mandibular motionare other options

Craniofacial profile may be factor◦ Mandibular hypoplasia

◦ Micrognathia

Neuromotor tone and role of central chemoreceptor response may also vary and affect diagnosis

Home polygraphy can be done successfully at home but it still requires substantial resources and expertise which has not been articulated (human power)

Acceptable recordings in 93%

However, the hPSG underestimates OSAS and limited sensitivity and specificity but area under the curve of 0.88

Alvarez et al, Chest 2015◦ 27 boys and 23 girls, mean age 5.3 yrs (range 3-17

yrs)

◦ 66% diagnosed with OSAS based on PSG defined RDI>3 events/hr for total sleep time

◦ The AHI on the HRP corresponding to the PSG defined OSAS criterion was > 5.6 events/hr

◦ Sensitivity 90.9% and specificity 94.1%

◦ These were children referred to a sleep unit for OSAS, pulse averaging time (4 beat), a nurse with training in pediatric sleep techniques and placed sensors

May be a role for screening for OSAS but there are limitations for what is can do for children with complex and comorbid conditions

This approach can likely be incorporated into a sleep program that is able to direct the patient

If end organ dysfunction matters, what should be the defining parameter?

CRP – too much variability in children

Urinary protein biomarkers – developed by Gozal et al and shows promising results.

Clusters of biomarkers may be helpful in conjunction with genes (single nucleotide polymorphisms) may yield better results in being to predict morbidity

Machine learning – combination of clinical risk factors, objective data, biomarkers and genetic analyses

Complexity of OSAS in children will involve comprehensive assessments using multiple parameters, with various different considerations for treatment

Long term follow up will be required but that also requires further study

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There are various tools available for identifying OSAS in children

Treatment strategies and modalities of treatment are evolving beyond the traditional adenotonsillectomy

Consideration of individual genetics and risk factors for treatment will be necessary to prevent morbidity and mortality

Anti-inflammatory therapy

CPAP

Weight loss

Mandibular advancement device

? Exercise

? Treat comorbid disorders

? Nasal expiratory valves

Auto PAP

Bilevel ventilation

Consecutive polygraphy in 26 children who were on CPAP for mean of 10.6 months, mean age 7.8 yrs

Partial flow limitation with arousal or desat were most frequent, but not common in children. These were not picked up on polygraphy

No “normal” kids

Ammaddeo et al, Sleep Medicine, 2014

Reported usage by Stanford, Pediatrics 2004

Role in adults is established

Role in pediatrics – yes, but….

Treatment trial

Adjust pressures

Short term or long term

Optimize adherence

Presurgery

Perioperatively

Options -

Randomized trial, used stardust equipment, n=24, average age 11 yrs, mean use 7.2 hrs

Used auto PAP and oxygen if necessary

6 weeks treatment – improved cognitive functioning and processing speed

Marshall et al, Hematologica, 2009

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It has and can be used at home and in the lab

Familiarity with the technology and insurance coverage may determine the choice

PAP adherence is adult and children is similar – early use predicts long term use

Education is key to its success

Randomized, double blind, placebo controlled crossover pilot study

Mean age 13.4 yrs, significant improvement in OAHI 4.2 events/hr

Variable response – older children did better

Nasal obstruction - ? Septal deviation? Nasal obstruction?

Kureshi et al. JCMI, 2014

Polysomnography

• AHI – 39.7 events/hr

• RDI – 41.1 events/hr

• Hypopneas – 76 with a mean duration of 12.9 seconds

• Total Arousal Index – 31.3 events/hr

Titration Study: 5-10 cmH20

• AHI – 5.8 events/hr

• Hypopneas – 12 with a mean duration of 14.5 seconds

• Incomplete Study due to limited absence of REM

Treatment – Auto CPAP 6-13 cmH20

How and when should we intervene?

What is the treatment in view of everything heard at the conference?

Missing gaps:◦ Sleep schedule

◦ Sleep timing

◦ Timing of interventions

◦ ? Social determinants of health