Obstructive Sleep Apnea

What is obstructive sleep apnea?

Obstructive sleep apnea occurs when a child stops breathing during periods of sleep. The cessation of breathing usually occurs because of a blockage (obstruction) in the airway. Tonsils and adenoids may grow to be large relative to the size of a child's airway (passages through the nose and mouth to the windpipe and lungs). Inflamed and infected glands may grow to be larger than normal, thus causing more blockage. The enlarged tonsils and adenoids block the airway during sleep, for a period of time. The tonsils and adenoids are made of lymph tissue and are located at the back and to the sides of the throat.

During episodes of blockage, the child may look as if he/she is trying to breath (the chest is moving up and down), but no air is being exchanged within the lungs. Often these episodes conclude with a period of awakening and compensation for lack of breathing. Periods of blockage occur regularly throughout the night and result in a poor, interrupted sleep pattern.

Sometimes, the inability to circulate air and oxygen in and out of the lungs results in lowered blood oxygen levels. If this pattern continues, the lungs and heart may suffer permanent damage.

Obstructive sleep apnea is most commonly found in children between 3 to 6 years of age. It occurs more commonly in children with Down syndrome and other congenital conditions affecting the upper airway (i.e., conditions causing large tongue, small jaw, etc.).

What causes obstructive sleep apnea?

In children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids in the upper airway. Infections may cause these glands to enlarge. Large adenoids may completely block the nasal passages and make breathing through the nose difficult or impossible.

There are many muscles in the head and neck that help to keep the airway open. When a person (child or adult) falls asleep, muscle tone tends to decrease, thus, allowing tissues to fold closer together. If the airway is partially closed (by enlarged glands) while awake, falling asleep may result in a completely closed passage.

Obesity may cause obstructive sleep apnea. While a common cause in adults, obesity is a far less common reason for obstructive sleep apnea in children.

A rare cause of obstructive sleep apnea in children is a tumor or growth in the airway. Certain syndromes or birth defects, such as Down syndrome and Pierre-Robin syndrome, can also cause obstructive sleep apnea.

What are the symptoms of obstructive sleep apnea?

The following are the most common symptoms of obstructive sleep apnea. However, each child may experience symptoms differently. Symptoms may include:

• loud snoring or noisy breathing during sleep
  
  
• periods of not breathing - although the chest wall is moving, no air or oxygen is moving through the nose and mouth into the lungs. The duration of these periods is variable and measured in seconds.
  
  
• mouth breathing - the passage to the nose may be completely blocked by enlarged tonsils and adenoids.
  
  
• restlessness during sleep (with or without periods of being awake)
  
  
• excessive daytime sleepiness or irritability (because the quality of sleep is poor, the child may be sleepy or irritable in the daytime)
  
  
• hyperactivity during the day

The symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

How is obstructive sleep apnea diagnosed?

Your child's physician should be consulted if noisy breathing during sleep or snoring becomes noticeable. Your child may be referred to an ear, nose, and throat (ENT) physician (otolaryngologist) for further evaluation.

In addition to a complete medical history and physical examination, diagnostic procedures for obstructive sleep apnea may include:

• sleep history - report from parents or caretaker
  
  
• evaluation of the upper airway
  
  
• sleep study (also called polysomnography) - the best test available for diagnosing obstructive sleep apnea. The test requires a high level of collaboration on the part of the child and may not be possible in younger and/or uncooperative children. Two types of tests are available. In the first type, the child will sleep in a specialized sleep laboratory. In the second type, the child has on similar monitors but sleeps in his/her own bed. During the sleep study a variety of testing occurs to evaluate the following:
  
  
  • brain activity
  • electrical activity of the heart
  • oxygen content in the blood
  • chest and abdominal wall movement
  • muscle activity
  • amount of air flowing through the nose and mouth
    

During the sleep study, episodes of apnea and hypopnea will be recorded:

• apnea - complete airway obstruction.
  
  
• hypopnea - the partial airway obstruction combined with a significant decrease in the oxygen content of the blood.

Based on the laboratory test, sleep apnea is generally considered significant in children if more than 10 apnea episodes occur per night, or one or more occur per hour. Some experts define the problem as significant if a combination of one or more episodes of apnea and/or hypopnea occur per hour of sleep.

Symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Consult your child's physician for more information.

Treatment for obstructive sleep apnea:

Specific treatment for obstructive sleep apnea will be determined by your child's physician based on:

• your child's age, overall health, and medical history
• cause of the condition
• your child's tolerance for specific medications, procedures, or therapies
• expectations for the course of the condition
• your opinion or preference

The treatment for obstructive sleep apnea is based on the cause. Since enlarged tonsils and adenoids are the most common cause of airway blockage in children, the treatment is surgery and removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy). Your child's otolaryngologist will discuss the treatment options, risks, and benefits with you. This surgery requires general anesthesia. Depending on the health of the child, surgery may be performed on an outpatient basis.

If the cause of the disorder is obesity, less invasive treatments may be appropriate, including weight loss and wearing a special mask while sleeping to keep the airway open. This mask delivers continuous positive airway pressure (CPAP). The device itself is often clumsy, and it may be difficult to convince a child to wear such a mask. Surgery may be necessary.

What happens during tonsillectomy and adenoidectomy?

Tonsillectomy and adenoidectomy (T&A) surgery is the second most common major surgery performed on children in the US. About 400,000 surgeries are performed each year. The need for a T&A will be determined by your child's ear, nose, and throat surgeon and discussed with you. Most T&A surgeries are done on an outpatient basis. This means that your child will have surgery and then go home the same day. Some children may be required to stay overnight, such as, but not limited to, children who:

• are not drinking well after surgery.
• have other chronic diseases or problems with seizures.
• have complications after surgery, such as bleeding.
• are younger than 3 years of age.

Before the surgery, you will meet with different members of the healthcare team who are going to be involved with your child's care. These may include:

• day surgery nurses - nurses who prepares your child for surgery. Operating room nurses assist the physicians during surgery. Recovery room (also called the Post Anesthesia Care Unit) nurses care for your child as he/she emerges from general anesthesia.
  
  
• surgeon - a physician who specializes in surgery of the ear, nose, and throat.
  
  
• anesthesiologist - a physician with specialized training in anesthesia. He/she will complete a medical history and physical examination and formulate a plan of anesthesia for your child. The plan will be discussed with you and your questions will be answered. This surgery requires a general anesthesia.

During the surgery, your child will be anesthetized in the operating room. The surgeon will remove your child's tonsils and adenoids through the mouth. There will be no cut on the skin.

In most cases, after the surgery, your child will go to a recovery room where he/she can be monitored closely. After the child is fully awake and doing well, the recovery room nurse will bring the child back to the day surgery area.

At this point, if everything is going well, you and your child will be able to go home. If your child is going to stay the night in the hospital, the child will be brought from the recovery room to his/her room. Usually, the parents are in the room to meet the child.

Bleeding is a complication of this surgery and should be addressed immediately by the surgeon. If the bleeding is severe, the child may return to the operating room.

At home after a T&A:

The following are some of the instructions that may be given to you to help care for your child:

• increased fluid intake
• pain medication, as prescribed
• no heavy or rough play for a duration of time recommended by the surgeon

What are the risks of having a T&A?

Any type of surgery poses a risk to a child. About 4 percent of the children begin bleeding from the surgery within the first two weeks after the surgery, and may require additional blood and/or surgery. Some children may have a change in the sound of their speech due to the surgery. The following are some of the other complications that may occur:

• bleeding (may happen during surgery, immediately after surgery, or at home)
  
  
• dehydration (due to decreased fluid intake; if severe, fluids through an intravenous, or IV, catheter in the hospital may be necessary)
  
  
• fever
  
  
• difficulty breathing (swelling of the area around the surgery; may be life threatening if not treated immediately)

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