Pediatric Obstructive Sleep Apnea
Introduction
Introduction to pediatric obstructive sleep apnea Sleep apnea or sleep-disordered breathing refers to breathing disorders that occur during sleep, including sleep apnea syndrome, hypopnea syndrome, upper airway resistance syndrome, and related sleep-disordered breathing caused by chronic lung and neuromuscular disorders. Wait. It refers to sleep in the mouth, nasal air flow stopped for more than 10s (children 6s or more), divided into central (central sleepapnea, CSA), obstructive sleep (obstructive sleepapnea (OSA) and mixed three types, of which the most common obstructive, accounting for 90 %, central apnea refers to the snoring of the mouth and nose, without respiratory movements; obstructive apnea refers to the snoring of the mouth and nose, but there is respiratory movement; mixed apnea refers to obstructive apnea with central apnea, more than Caused by chronic lesions in the ear, nose and throat. basic knowledge The proportion of illness: 0.005% Susceptible people: children Mode of infection: non-infectious Complications: hypertension, pulmonary edema, pulmonary heart disease, arrhythmia, congestive heart failure, respiratory failure, sudden infant death syndrome
Cause
Causes of obstructive sleep apnea in children
Causes:
The causes of OSA include anatomical factors, congenital diseases and other factors. Most children with OSA are caused by adenoid and tonsil hypertrophy, which are the most common causes of OSA in children. In infant OSA, 52% of obstruction is in the upper jaw, 48 % is behind the tongue.
Pathogenesis:
Children's OSAS is caused by abnormalities of the nose, nasopharynx, oropharynx or jaw, and the upper airway stenosis caused by the fall of the tongue root during sleep at night. Due to the anatomical stenosis of the upper airway and the disorder of respiratory regulation, the upper air is caused. The strength of the openness of the tract is mainly the tension of the pharyngeal dilatation muscle, including the genioglossus muscle, the pharyngeal diaphragm muscle and the lingual sacral muscle. During sleep, especially during the rapid eye movement sleep (REM) period, the pharyngeal dilatation muscle tension is significantly reduced, plus the pharyngeal cavity. Its own stenosis makes it easy to close, and OSA occurs. The main pathophysiological changes of OSA are repeated apnea during sleep, leading to hypoxemia and hypercapnia, which can cause imbalance of neuromodulation, catecholamine, renin-vessel Angiotensin, increased secretion of endothelin, endocrine dysfunction, hemodynamic changes, abnormal microcirculation, etc., causing ischemia and hypoxia of tissues and organs, leading to multiple organ dysfunction, especially to heart, lung, brain damage, can cause high Blood pressure, pulmonary hypertension, nocturnal arrhythmia, heart failure, etc., brain damage can be manifested as daytime fatigue, drowsiness, memory loss, and even mental retardation .
Prevention
Pediatric obstructive sleep apnea prevention
With oral appliance or tongue support during sleep, it has the advantages of simplicity, mildness and low cost. The treatment indications are appropriate, and the recent effective rate is about 70%. After the belt, the mandible can be moved forward and/or the tongue can be moved forward. The airway is enlarged or increased in stability, so that the posterior airway space of the soft palate sag is increased, preventing the tongue from sinking, and alleviating OSAS to varying degrees. It is suitable for mild to moderate patients to prevent complications. The disadvantage is that The patient's discomfort is obvious, and more than 50% of the patients cannot tolerate it.
Complication
Pediatric obstructive sleep apnea complications Complications Hypertension Pulmonary edema Pulmonary heart disease Arrhythmia Congestive heart failure Respiratory failure Infant sudden death syndrome
Because OSAS children have long-term hypoxia, it can affect their growth and development, 30% to 40% of developmental delay, can be complicated by hypertension, pulmonary edema, pulmonary heart disease, arrhythmia, congestive heart failure, respiratory failure, and even sudden infant death syndrome.
Symptom
Pediatric obstructive sleep apnea symptoms common symptoms fatigue double inhalation wheezing mouth breathing lack of deep sleep irritability snoring breathing difficulties snoring baby sleep less
The main clinical manifestations of sleep apnea in children, with increased activity as the main performance, accompanied by language defects, loss of appetite and difficulty swallowing, often appear non-specific behavioral difficulties, such as abnormal shyness, development delay, rebellion and aggressive behavior.
An important feature of pediatric OSAS is the presence of a range of clinical syndromes.
1. Nocturnal symptoms: The most obvious symptom at night is snoring. Almost all children with OSAS have snoring, and most of them are loud, but severe OSAS can be snoring or high-pitched snoring when sleeping. Upper respiratory tract infection The snoring is exacerbated by OSAS or sleep-related lung dysfunction in children with OSAS. Pediatric manifestations are two major forms of snoring: continuous snoring and intermittent snoring, and intermittent snoring with quiet periods. The quiet period is usually terminated by a loud gasping or snoring sound.
Almost all children with OSAS have poor breathing performance. The esophageal pressure of children with sleep airway obstruction ranges from -4.90 to -6.87 kPa. The respiratory effort during obstructive breathing is intercostal, sternal, sternal and supraclavicular. , the marginal abduction, can detect the activity of the auxiliary respiratory muscles, and can also see the inspiratory abnormal thoracic adduction, but the inspiratory abnormal thoracic adduction in the REM sleep of newborns, infants and older children is normal.
OSAS apnea episodes are periodic and can be stopped by themselves. The snoring suddenly stops when insulting, and the inspiratory force is forced, but there is no airflow in the mouth and nose into the respiratory tract. If the duration is long, there may be cyanosis and heart rate slowing down, and the snoring will appear again. Stop, breathing resumes, loud jets, awakenings and posture changes.
Most OSAS children had no significant obstructive symptoms. In moderate to severe OSAS, the mean frequency of obstructive attacks was 20 beats/h, and the duration of obstructive and mixed apneas averaged 17.3 s.
The effect of OSAS on sleep in children is different from that in adults. Children with OSAS have a normal number of delta sleep. Children with persistent airway obstruction during sleep do not show fragmentation of sleep, but children with OSAS often have nighttime restlessness or Overturned in bed, OSAS children's sleep posture is abnormal, usually neck overextension, can be expressed as neck overstretched, head slipping or sitting up from the pillow (usually obese), 96% of OSAS children sleep Excessive sweating, enuresis is a common manifestation of pediatric OSAS. A number of studies have suggested that in children with upper airway obstruction and nocturnal enuresis, 3/4 patients have significantly improved enuresis after upper airway surgery.
2. Daytime symptoms: Symptoms of OSAS children in the morning awakening include mouth breathing, morning headache, dry mouth, disorientation, confusion and irritability; school-age children are characterized by lack of concentration in class, daydreaming, fatigue, learning The scores decreased, and 8% to 62% of children also had symptoms of excessive daytime sleepiness. Daytime behavior problems were more common in children's OSAS, mainly in poor performance, hyperactivity, mental retardation, emotional problems, shyness or withdrawal behavior. , offensive behavior and learning problems, many of the children of OSAS have stunting. It is now clear that adult OSAS can impair attention, memory, alertness and motor skills, but there are few studies on the impact of childhood cognitive ability. Most OSAS children have hypertrophic tonsils and proliferative bodies, most of which are characterized by mouth breathing, and some are accompanied by eating, difficulty swallowing and bad breath, and showing a certain degree of language barrier.
3. Accompanying symptoms: Hypoxemia usually occurs in many children with OSAS. In some children with severe OSAS, SaO2 can be reduced to less than 50%. SaO2 in children with continuous partial obstruction declines at the beginning of obstruction and remains low for a long time. Level, hypercapnia is also a feature of pediatric OSAS, with half of hypercapnia (end tidal CO2 > 6.0 kPa) associated with OSAS or persistent partial obstruction, and low body weight seen in most children with obstructive pulmonary ventilatory dysfunction In addition, children with airway obstruction during sleep are prone to gastroesophageal reflux, sudden awakening, crying, screaming and other symptoms. Other studies have found that OSAS children may have some behavioral disorders such as impulsiveness, violation, or abnormal shyness. And social withdrawal.
4. Signs include difficulty breathing, nasal fan, intercostal and clavicle depression, contralateral movement of chest and abdomen during inhalation; night sweating (limited to the neck and back, especially infants and young children), parents may notice that the child is not willing to cover at night By the way, the breathing stops and then wheezes. The typical sleeping posture is the prone position, the head turns to one side, the neck is overstretched with the mouth, and the knee flexes to the chest.
Some craniofacial features often suggest the presence of sleep-disordered breathing, such as the triangular mandible, the mandibular plane is too steep, the mandible moves backward, the long face, the high hard palate and/or the soft palate.
Examine
Pediatric obstructive sleep apnea check
Monitor blood oxygen saturation, end-tidal carbon dioxide partial pressure, low arterial oxygen saturation, hypercapnia and erythrocytosis. Reduce airflow by more than 30% or blood oxygen saturation by more than 4%, which is insufficient ventilation; apnea >10s with blood oxygen saturation decreased by 4%, this disease can be considered.
1. Polysomnography (PSG) is considered the gold standard for the diagnosis of sleep-disordered breathing. Marcus et al. pointed out that the diagnostic criteria for obstructive sleep apnea in children over 1 year old are: the number of obstructive sleep apneas per hour of sleep. 1 time, accompanied by SaO2 53mmHg, or more than 60% of sleep time PETCO2>45mmHg is abnormal, all-night polysomnography should be continuously monitored at night for more than 6-7h, including EEG, electrooculogram, squat Electromyography, leg motion and electrocardiogram, while monitoring blood oxygen saturation, end-tidal carbon dioxide partial pressure, chest and abdominal wall movement, nose and mouth airflow, blood pressure, snoring, esophageal pH or pressure, etc., American Thoracic Society recommended multi-channel The sleep map is used in the following situations:
(1) Identification of benign or primary snoring (without apnea, hypopnea or cardiovascular, central nervous system manifestations, snoring requiring little treatment).
(2) Evaluation of sleep disorder in children (especially snoring children), excessive sleep during the day, pulmonary heart disease, difficulty in growth, and unexplained erythrocytosis.
(3) Significant airflow obstruction during sleep.
(4) Determine if obstructive breathing requires surgical treatment or if monitoring is needed.
(5) Patients with laryngeal cartilage softening have worsening symptoms or growth difficulties or pulmonary heart disease during sleep.
(6) Obesity patients have unexplained hypercapnia, long-term snoring, high daytime sleepiness, etc.
(7) OSA performance in patients with sickle cell anemia.
(8) Previously diagnosed as OSA with persistent snoring or other related symptoms.
(9) Setting of parameters during continuous positive pressure ventilation.
(10) Monitoring whether weight loss after treatment of obese OSA patients causes an improvement in the severity of OSA.
(11) Patients with severe OSA were followed up after treatment.
(12) Before multiple sleep latency test (MSLT).
2. The automatic continuous positive airway pressure system has two modes of diagnosis and treatment. It does not monitor EEG, electromyography, electromyography, electrocardiogram, only chest and abdomen respiratory movement, nasal flow and oxygen saturation. Degree, can be monitored synchronously to show apnea, snoring, upper airway resistance.
3. Static charge sensitive bed This method is to set an electrostatic load layer and motion sensor under the standard foam mattress. The patient sleeps on the bed, only needs a blood oxygen saturation without any electrodes, and the original motion signal is pre-positioned. After amplification and frequency filtering, the following 3 leads are respectively entered, and OSA patients are divided into 4 kinds of periodic breathing according to the pattern of increased respiratory resistance. Currently, this method is mainly used for primary screening obstructive and central sleep apnea, and Severe snoring with increased upper airway resistance.
4. Other examinations include X-ray of the nasopharyngeal lateral phase, CT and MRI examination, nasopharyngoscopy, etc., which helps to understand the structure of the upper airway, shows the location and extent of stenosis and obstruction, and multiple sleep latency tests. Test, MSLT) helps to judge the degree of daytime sleepiness and the identification of narcolepsy, 50% of obese people, 52% of hypothyroidism, 42.6% of acromegaly may have OSAS, so in diagnosis At the same time as sleep apnea syndrome, attention should also be paid to the diagnosis of other diseases in the body.
Diagnosis
Diagnosis and diagnosis of obstructive sleep apnea in children
diagnosis
The diagnosis of pediatric OSA should be combined with clinical manifestations, physical examination and laboratory examination results. The medical history should pay special attention to the aspects of sleep, such as sleep environment, time, posture, deep sleep state, wakefulness, snoring, wheezing, etc. Craniofacial structure, tongue, position of soft and hard palate, size of uvula, length, adenoid and tonsil hypertrophy, no enlarged lymph nodes in the neck, tumor and comprehensive neurological examination, the treatment is based on the course of the disease, The severity of the symptoms and anatomy, structure, physiological abnormalities and their severity.
The International Classification of Sleep Disorders (ISCD) in 1990 cannot be used in children for the diagnosis of OSAS. The main reason is that children with OSAS do not have excessive daytime sleepiness, and the number of obstructive episodes per hour is not proportional to the severity of OSAS. Therefore, the diagnosis of OSAS in children The standard is revised as follows.
1. Diagnostic criteria for children's OSAS
(1) The caretaker complains that the child has a breathing sound during sleep, and/or an inappropriate daytime sleepiness or behavioral problem.
(2) Complete or partial airway obstruction during sleep.
(3) Accompanying symptoms include:
1 growth barrier.
2 suddenly awakened.
3 gastroesophageal reflux.
4 Nasopharyngeal secretions inhaled.
5 hypoxemia.
6 hypercapnia.
7 behavior disorder.
(4) Detection results of polysomnography:
1 obstructive pulmonary ventilation.
2 One or more obstructive apneas per hour, usually accompanied by one or more of the following manifestations.
A. Arterial oxygen saturation is less than 90% to 92%.
B. Sleep arousal associated with upper airway obstruction.
C. Multiple sleep latency tests show abnormal sleep latency at this age.
(5) Usually accompanied by other diseases, such as proliferative and tonsil hypertrophy.
(6) There may be other manifestations of sleep disorders, such as narcolepsy.
2. Indexing children's OSAS is divided into three degrees according to its severity.
Differential diagnosis
Obstructive sleep apnea should be differentiated from central sleep apnea, which can be seen in a variety of conditions:
1. Neurological diseases such as anterior spinal cord cutting, bilateral anterior spinal cord lesions caused by vascular embolism or degenerative lesions, abnormalities of the cerebrospinal cord, such as occipital macropore developmental malformation, poliomyelitis, lateral medullary syndrome, autonomic nerve Abnormalities: such as familial autonomic abnormalities, insulin-related diabetes, Shy-Drager syndrome, encephalitis, brainstem tumors,
2. Muscle lesions, such as diaphragmatic muscle disease, myotonic dystrophy myopathy, etc.
3. Some obese people, congestive heart failure and so on.
