Patient Presentation
A 6-year-old male came to clinic with rhinitis and coughing with a fever for 2-3 days. The maximum temperature was 101°F. He was not eating as much and was more fatigued. He denied specific pain. His mother was more concerned because he’s “making lots of loud sounds and snoring at night” also. She stated that he always seemed to be a noisy sleeper and his snoring got worse if he had an upper respiratory tract infection. She denied paused breathing but could not further characterize the sounds or snoring. She denied daytime fatigue when he was otherwise well, but was concerned because her husband had recently started to use a breathing machine at night for “his own snoring and stopping breathing.” The past medical history showed a well child who was obese. The family history also showed obesity and lipid abnormalities. The review of systems was otherwise negative.

The pertinent physical exam showed a tired male with normal temperature, respiratory rate of 22/minute, heart rate of 88 beats/minute and a body mass index of 28. HEENT showed clear rhinorrhea, +3 tonsils with a smaller midface/oropharynx without erythema or exudate, and tympanic membranes were normal. His lungs had transmitted upper airway noises but no adventitial breath sounds. The rest of his examination was normal.

The diagnosis of an upper respiratory tract infection was made. After discussing the acute infection, the pediatrician discussed the possibility of obstructive sleep apnea and referred the child to an otolaryngologist. A sleep study was performed showing obstructive sleep apnea and the child underwent tonsillectomy and adenoidectomy with marked improvement in his snoring even during acute illnesses. Life style interventions for obesity were also being worked on by the family.

Discussion
Obstructive sleep apnea syndrome (OSAS) is defined as a “disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns.” It is different than primary snoring which is snoring without apnea, sleep arousals, or problems with gas exchange.
OSAS symptoms include snoring (often with snorts, gasps or pauses), disturbed sleep (often frequent arousals) and daytime neurobehavioral problems. Sleepiness during the day can occur but is less common in children. Risk factors include black race, obesity, adenotonsillar hypertrophy, craniofacial abnormalities, neuromuscular disorders, or family history of disordered breathing.

OSAS occurs in all ages and is most likely under diagnosed with a 2% prevalence rate. Primary snoring has a prevalence of 3-12%. Problems of untreated OSAS include failure to thrive, cor pulmonale including pulmonary and systemic hypertension, and cognitive and behavioral problems. The gold standard for diagnosis is overnight sleep study (polysomnography).

In addition to lifestyle issues such as avoiding tobacco smoke, air pollutants and allergens and treatment of rhinitis and weight loss strategies in some patients, treatment of OSAS for children usually begins with tonsillectomy and/or adenoidectomy. While this can treat many patients, others still will have OSAS. Noninvasive ventilation such as continuous positive airway pressure (CPAP) may be the next step for some children. CPAP devices use a small turbine to create increased pressure that is delivered to the upper airway by a fitted mask. Additional options include other oral-facial surgeries, orthodontic treatments or dental appliances. Drug treatment with nasal steroids and/or montelukast have also been used.

Learning Point
Indications for non-invasive ventilation including CPAP consist of:

• For neonates, infants and pediatric patients
  • Asthma
  • Bronchiolitis
  • Obstructive sleep apnea syndrome
  • Pneumonia
  • Muscle fatigue, impending of respiratory muscles
  • Myopathies
  • Ventilator management
    • Good respiratory drive but still needing minimal respiratory support
    • Weaning
  • Lung collapse prevention
• For adults
  • Obstructive sleep apnea syndrome
  • Chronic obstructive pulmonary disease with exacerbation
  • Acute congestive heart failure with pulmonary edema
  • Acute lung injury
  • Neuromuscular disorders
  • Pneumonia
  • Ventilator weaning

Absolute and relative contraindications include unstable cardiopulmonary status or need for continuous or near continuous ventilator treatment, inability to protect the airway including reduced consciousness or excessive secretions, air trapping or air leak diseases, problems with facial structures including trauma, burns, recent surgery or esophageal or gastric surgery, patients who are very anxious or uncooperative.

Questions for Further Discussion
1. What is the difference between CPAP and BiPAP?
2. What are your local resources for sleep studies?
3. What history and physical examination findings are there for OSAS?

Related Cases

Disease: Sleep Apnea | Snoring | Sleep Disorders

Symptom/Presentation: Cough | Obesity | Rhinitis | Snoring

Specialty: General Pediatrics | Otolaryngology | Allergy / Pulmonary Diseases

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sleep Apnea and Snoring.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Praud JP, Dorion D. Obstructive sleep disordered breathing in children: beyond adenotonsillectomy. Pediatr Pulmonol. 2008 Sep;43(9):837-43.

Marcus CL, Brooks LJ, Draper KA, et.al.; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012 Sep;130(3):576-84.

Sweet DG, Carnielli V, Greisen G, et.al.; European Association of Perinatal Medicine. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants–2013 update. Neonatology. 2013;103(4):353-68.

Gonzalez Mangado N, Troncoso Acevedo MF2, Gomez Garcia T. Home ventilation therapy in obstructive sleep apnea-hypopnea syndrome. Arch Bronconeumol. 2014 Dec;50(12):528-34.

Poobani, SK. Noninvasive Ventilation Procedures. eMedicine. Available from the Internet at:
http://emedicine.medscape.com/article/1417959-overview#a3 (rev. 12/21/2015, cited 4/5/17)

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital