Sleep Disordered Breathing

Sleep-disordered breathing is a range of abnormalities in breathing while asleep.

Nadia's Story

Nadia is a 6 year old girl that has been having a hard time in school since she started first grade. Her mom scheduled an appointment with her pediatrician to see if Nadia might have ADHD and to see if she might do better in school if she is treated for this.

Nadia’s teacher has noticed that she seems to “zone out” during class and doesn’t seem to pay attention. Mom will sometimes catch Nadia dozing off in the afternoon when she is doing her homework.

Nadia has no complaints of difficulty falling asleep and sleeps for about 11 hours of sleep per night. She does have occasional headaches. No noted changes in her home or social life.

Expert Insights

BEARS Screening for Sleep Disordered Breathing

Due to the pediatrician's concern for a possible sleep disorder, a BEARS assessment was done. Open the categories below to review some of the history that was obtained from Nadia and her mother.

Bedtime Problems

Nadia falls asleep within 10 minutes at bedtime. Her mother is not worried about this.

Expert Insights

Most children with sleep-disordered breathing do not have any problems at bedtime, and many will fall asleep quickly due to excessive sleepiness.

Excessive Daytime Sleepiness

Nadia seems tired when she wakes in the morning, even if she slept the whole night. Mom usually has a hard time getting her out of bed. Her inattention during school and dozing off while doing homework are also signs that she is sleepy during the day.

Expert Insights

Non-refreshing sleep (awakening feeling tired) is a classic symptom of sleep-disordered breathing.
Excessive sleepiness should prompt further evaluation for sleep-disordered breathing in children.

Awakenings

Nadia will typically sleep through the night. Mom thinks “she is a great sleeper.”

Expert Insights

Nocturnal awakenings may be seen related to sleep-disordered breathing but do not always occur.
Children may report waking up choking or waking up due to problems breathing.

Regularity & Duration

Nadia consistently goes to bed by 8:00 pm and wakes at 7:00 am during the week. Mom has noticed over the past year that she will seem ready for bed earlier than previously. On weekends, she will go to bed at 8:00 pm and wake up around 9:00 am.

Expert Insights

It appears that Nadia is getting enough sleep for her age, as she is sleeping around 10 hours each night.
Although Nadia is going to bed at the same time on weekends, she is sleeping in longer. This can be a sign of insufficient sleep during the weekday. Since Nadia is already sleeping an appropriate amount for her age, this suggests that her sleep quality may be reduced.

Sleep-Disordered Breathing / Snoring

Mom reports that Nadia snores every night, and she sometimes seems to choke and pause breathing in her sleep.

Expert Insights

Snoring, gasping, choking, pauses in breathing (apnea), and struggling to breathe while asleep are all red flags for possible obstructive sleep apnea.
While occasional snoring is common, particularly if children are sick, loud snoring (audible through a closed door) or snoring most nights may be signs of obstructive sleep apnea.
Other signs of possible obstructive sleep apnea can include secondary enuresis (wetting the bed after previously being dry at night), sleeping in unusual positions (such as with the neck hyperextended or sitting up), or morning headaches upon awakening.

Nadia's Evaluation & Diagnosis

What evaluation & diagnostic protocol should Dr. Matthews use to diagnose Nadia?
Check all that apply:

Further determine child's sleep history

Perform physical exam

Order Labs/Other Tests

Complete a Sleep Diary

Order a Sleep Study

Refer to a Specialist

Obtain an Epworth Sleepiness Score

The evaluation protocol strategies we recommend for Nadia's case are:

Further determine child’s sleep history.
Perform a physical examination.
Order a sleep study.
Obtain an Epworth Sleepiness Score.

Elements of Nadia's Sleep History

Sleep History	Case Specific Information	Nadia's Evaluation Results
Determine severity of sleep-disordered breathing symptoms	How loud and frequent is snoring?	Nadia snores nightly, and mom can hear her down the hallway.
	Are there witnessed apneas?	Mom notices her choking most nights, and she does sometimes seem to pause breathing afterwards.
	Have the parents ever had to intervene because the patient wasn’t breathing?	No one has ever had to intervene.
Screen for narcolepsy	Does the patient have a history of feeling weak or have loss of muscle tone during episodes of laughing, crying, or excitement?	Mom has never noticed this.
	Does the patient ever see things that are not present when falling asleep or when first awakening?	Nadia does not report this.
	Does the patient every wake up and feel like they are paralyzed or are not able to move?	Nadia has never had this.
Screen for restless leg syndrome/periodic limb movement disorder	Does the patient seem fidgety at night and have difficulty settling?	Nadia usually falls asleep quickly.
	Does the patient complain of leg discomfort?	Nadia has never complained about this.
	Does the child move their legs when falling asleep?	Mom has not noticed Nadia doing this.
	Does the child kick during sleep?	Nadia will move around in bed, but mom thinks this usually happens after she snorts.
Review medications that the patient is taking	Some medicines such as opiates, sedatives or muscle relaxants may worsen sleep apnea, while others such as nasal steroids or montelukast may help treat obstructive sleep apnea.	Nadia takes loratidine as needed for allergies.
Obtain a family history of sleep disorders	Does anyone else in the family have sleep apnea?	Mom notes that Dad snores, but no one has been diagnosed with sleep apnea.
	Have any siblings had their tonsils removed?	Nadia’s older brother had his tonsils removed when he was 4 years old, “because they were too big.”

Perform a Physical Exam

Information to obtain includes:	Case Evaluation Results
A physical exam should be performed to assess for underlying factors that may contribute to sleep disordered breathing. Vital signs should be reviewed to determine body mass index (BMI) and BMI percentile for age and gender. Additionally, pulse oximetry can be considered. HEENT exam should be performed, with specific focus on the airway. This exam may demonstrate the presence of adenoidal facies, (a sign of enlarged adenoids) or tonsillar hypertrophy. It should also note airway patency. Cardiopulmonary exam should be performed to evaluate for any comorbidities. Neuromuscular exam may demonstrate reduced muscle tone in some patients which may increase the risk of sleep disordered breathing.	Nadia’s BMI is at the 40th percentile. Her ENT exam shows some nasal congestion, adenoid facies, and 4+ (enlarged) tonsils, Her Mallampati score is 2. Cardiac examination reveals no murmurs with a normal S1 and S2. Chest examination reveals bilaterally clear lung fields with no increased work of breathing. Neuro examination: No focal deficits noted with 5/5 bilateral upper and lower extremity strength.

Information to obtain includes:

Case Evaluation Results

A physical exam should be performed to assess for underlying factors that may contribute to sleep disordered breathing.

Vital signs should be reviewed to determine body mass index (BMI) and BMI percentile for age and gender. Additionally, pulse oximetry can be considered.
HEENT exam should be performed, with specific focus on the airway. This exam may demonstrate the presence of adenoidal facies, (a sign of enlarged adenoids) or tonsillar hypertrophy. It should also note airway patency.
Cardiopulmonary exam should be performed to evaluate for any comorbidities.
Neuromuscular exam may demonstrate reduced muscle tone in some patients which may increase the risk of sleep disordered breathing.

Nadia’s BMI is at the 40th percentile. Her ENT exam shows some nasal congestion, adenoid facies, and 4+ (enlarged) tonsils, Her Mallampati score is 2. Cardiac examination reveals no murmurs with a normal S1 and S2. Chest examination reveals bilaterally clear lung fields with no increased work of breathing. Neuro examination: No focal deficits noted with 5/5 bilateral upper and lower extremity strength.

Sleep Study

Information to obtain includes:	Case Evaluation Results
A diagnostic polysomnogram is the gold standard for diagnosing sleep-disordered breathing. During the study, respiratory flow, respiratory effort, end tidal CO2 and oxygen levels will be monitored (in addition to other parameters) to determine the presence of sleep-disordered breathing. The sleep study will report an Apnea-Hypopnea Index (AHI), the number of times per hour that the patient pauses breathing or breathes too shallowly while asleep, which is used to diagnose sleep-disordered breathing. In children, an obstructive AHI >1 event per hour is diagnostic of obstructive sleep apnea. Additionally, if the end tidal CO2 is greater than 50 mmHg for more than 25% of sleep time, this is also considered diagnostic of obstructive sleep apnea. Note that for older children (teenagers), adult scoring criteria may be considered, and an AHI of 5 events per hour may be used as the diagnostic threshold. If possible, the sleep study should be performed at a sleep center with experience managing pediatric patients.	Polysomnogram (PSG) was obtained and demonstrated an AHI of 15, with an obstructive AHI of 14. End tidal CO2 was above 50 mmHg for 30% of the study. Her total sleep time was 369 minutes with a sleep efficiency of 86%. She was noted to have frequent arousals related to respiratory events. Her cardiac and EEG tracings demonstrated no abnormalities. The periodic limb movement index was 2 (normal < 5).

Information to obtain includes:

Case Evaluation Results

A diagnostic polysomnogram is the gold standard for diagnosing sleep-disordered breathing. During the study, respiratory flow, respiratory effort, end tidal CO2 and oxygen levels will be monitored (in addition to other parameters) to determine the presence of sleep-disordered breathing. The sleep study will report an Apnea-Hypopnea Index (AHI), the number of times per hour that the patient pauses breathing or breathes too shallowly while asleep, which is used to diagnose sleep-disordered breathing.
In children, an obstructive AHI >1 event per hour is diagnostic of obstructive sleep apnea. Additionally, if the end tidal CO2 is greater than 50 mmHg for more than 25% of sleep time, this is also considered diagnostic of obstructive sleep apnea.
Note that for older children (teenagers), adult scoring criteria may be considered, and an AHI of 5 events per hour may be used as the diagnostic threshold. If possible, the sleep study should be performed at a sleep center with experience managing pediatric patients.

Polysomnogram (PSG) was obtained and demonstrated an AHI of 15, with an obstructive AHI of 14. End tidal CO2 was above 50 mmHg for 30% of the study. Her total sleep time was 369 minutes with a sleep efficiency of 86%. She was noted to have frequent arousals related to respiratory events. Her cardiac and EEG tracings demonstrated no abnormalities. The periodic limb movement index was 2 (normal < 5).

Obtain an Epworth Sleepiness Scale Score

Information to obtain includes:

Case Evaluation Results

The Epworth Sleepiness Scale is a validated instrument to assess the level of sleepiness. The patient rates themselves from 0 (would never doze) to 3 (high chance of dozing) on their likelihood of falling asleep in eight different situations. A score greater than 10 suggests the presence of excessive sleepiness.

Nadia completed the Epworth Sleepiness Scale. The results are listed below:
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? (0=would never doze off, 1=slight chance of dozing off, 2=moderate chance of dozing off, 3=high chance of dozing off).

Situation	Score
Sitting and reading	1
Watching television	3
Sitting, inactive in a public place (i.e. a theatre or a meeting)	0
As a passenger in a car for an hour without a break	3
Laying down to rest in the afternoon when circumstances permit	3
Sitting and talking to someone	0
Sitting quietly after lunch	1
In a car, while stopped for a few minutes in traffic	2
Total	13

Options that are Not Recommended

Order Labs/Other Diagnostic Tests

Labs and other diagnostic testing is generally not indicated in cases of suspected obstructive sleep apnea.

Complete a sleep diary

A sleep diary can be considered to assess underlying factors such as insufficient sleep that are causing the patient's hypersomnolence, but it is generally not needed to diagnose obstructive sleep apnea.

Refer to a specialist

Referral to a sleep medicine specialist can be considered, but given the high pre-test probability of obstructive sleep apnea, obtaining a sleep study prior to the referral would be preferred; however some sleep specialists see patients before sleep study.

Red Flags

If the patient endorses narcolepsy symptoms such as cataplexy, a referral to sleep medicine should be considered for further evaluation and possible mean sleep latency testing.
Environmental factors like smoke and pet exposure or seasonal exposures can also play a part in snoring history.
Reported cyanosis or apneas requiring parent intervention may require need for further pulmonary evaluation.

Evaluation & Diagnosis

What diagnosis is consistent with Nadia’s daytime sleepiness?
Check all that apply:

Insufficient sleep syndrome

Narcolepsy, type 1

Obstructive sleep apnea

Late-Onset Central Hypoventilation with Hypothalamic Dysfunction

Nadia’s signs and symptoms are consistent with:

Obstructive sleep apnea

Nadia has significant daytime sleepiness, snoring, choking and witnessed apnea at night. These symptoms are all typical for obstructive sleep apnea.

The diagnosis is confirmed by the sleep study that demonstrated an elevated AHI.

In this case, insufficient sleep syndrome, Narcolepsy, and late-onset central hypoventilation are not consistent with the symptoms Nadia demonstrated.

Nadia's Treatment & Referrals

Now it’s time to recommend treatment options for Nadia.
Check all that apply:

Refer to ENT to evaluate for adenotonsillectomy

Start montelukast

Start supplemental oxygen

Start CPAP therapy

Refer to a sleep medicine physician

Start stimulant therapy

The following treatment strategies are recommended for Nadia:

Refer to ENT to evaluate for adenotonsillectomy.
Refer to a sleep medicine physician.

The following treatment strategies are recommended for Nadia:

Adenotonsillectomy

Treatment Strategies for Obstructive sleep apnea

Adenotonsillectomy

Adenotonsillectomy is typically the first line therapy for children with obstructive sleep apnea and enlarged tonsils or adenoids.
In otherwise healthy, non-obese children, adenotonsillectomy is typically curative.

Montelukast

Montelukast has been shown to decrease airway lymphoid tissue size.
This drug may be effective in children with mild sleep apnea.

CPAP

CPAP is a highly effective therapy for obstructive sleep apnea.
It is limited by the need for significant lifestyle changes, including the need to wear a CPAP mask nightly.
CPAP adherence in children is around 50%.
CPAP is typically indicated for obstructive sleep apnea in children who are not candidates for adenotonsillectomy.

Oxygen Therapy

Supplemental oxygen can be used as a second line therapy for children who are not adenotonsillectomy candidates and cannot tolerate CPAP.
It is an inferior therapy to CPAP, as it will reduce oxygen desaturations, but does not improve sleep apnea related sleep fragmentation.

Orthodontic procedures

In select cases, orthodontic procedures such as palate expansion or oral appliances may improve obstructive sleep apnea.
There is limited evidence to support these therapies.

Weight Loss

For obese children, weight loss can improve and sometimes eliminate obstructive sleep apnea.

Watchful Waiting

For children who are found to have mild sleep apnea and no significant daytime impairment (no daytime sleepiness or inattention), watchful waiting can be considered, as many children with mild sleep apnea will outgrow the condition with time.
For children with obstructive sleep apnea related impairment such as daytime sleepiness or school difficulties, treatment is indicated.

When to consult a sleep specalist or refer to another discipline:

Children who may require CPAP therapy should be referred to a sleep specialist.
Children with residual symptoms following adenotonsillectomy should be referred to a sleep specialist, and possibly undergo repeat polysomnogram.

Interdisciplinary Treatment Components

Nadia's Results:

Good news! Nadia’s attention has improved since she underwent an adenotonsillectomy, and she is doing much better in school.

For children who undergo adenotonsillectomy for obstructive sleep apnea, a repeat evaluation for sleep symptoms and daytime sleepiness should be performed around 2-3 months after adenotonsillectomy. If persistent symptoms remain, or if symptoms have not resolved, a repeat sleep study may be indicated to assess for residual obstructive sleep apnea.

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