Obstructive Sleep Apnea
What is obstructive sleep apnea?
Obstructive sleep apnea happens when a child stops breathing during periods of sleep. The cessation of breathing usually happens because of a blockage (obstruction) in the airway. Tonsils and adenoids may grow to be large relative to the size of a child's upper airway (passages through the nose and mouth to the windpipe and lungs). Inflamed and infected glands may grow to be larger than normal. This causes 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 or 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 happen 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.
Pediatric obstructive sleep apnea is most commonly found in children between 3 to 6 years of age. It happens more commonly in children with Down syndrome and other congenital conditions affecting the upper airway (for example, conditions causing large tongue or small jaw).
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 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. The child may also speak with a nasal voice.
Restlessness during sleep. This happens with or without periods of being awake.
Excessive daytime sleepiness or irritability. Because the quality of sleep is poor, the child may be sleepy, hard to wake from a nap, or irritable in the daytime.
Hyperactivity during the day. The child may also experience behavioral, school, or social problems.
The symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Always talk with your child's healthcare provider for a diagnosis.
How is obstructive sleep apnea diagnosed?
Your child's healthcare provider should be consulted if noisy breathing during sleep or snoring becomes noticeable. Your child may be referred to an ear, nose, and throat (ENT) specialist (otolaryngologist), or sleep specialist for further evaluation.
In addition to a complete medical history and physical exam, diagnostic procedures for obstructive sleep apnea may include:
Sleep history. A 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 needs 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 lab. In the second type, the child has on similar monitors but sleeps in his or her own bed. Because of only limited medical studies to prove acceptable results in children, home sleep testing is usually not performed.
During the sleep study, a variety of testing evaluates the following:
Electrical activity of the heart
Oxygen, and often carbon dioxide, content in the blood
Chest and abdominal wall movement
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 lab test, sleep apnea is generally considered significant in children if more than 10 apnea episodes happen per night, or one or more happen 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. Talk with your child's healthcare provider for more information.
How is obstructive sleep apnea treated?
Specific treatment for obstructive sleep apnea will be discussed with you by your child's healthcare provider based on:
Your child's age, overall health, and medical history
Cause of the condition
Your child's tolerance for specific medicines, 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 choices, risks, and benefits with you. This surgery needs 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 a common surgery performed on children in the U.S. 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 prepare your child for surgery. Operating room nurses assist the healthcare providers during surgery. Recovery room (also called the Post Anesthesia Care Unit) nurses care for your child as he or she emerges from general anesthesia.
Surgeon. A healthcare provider who specializes in surgery of the ear, nose, and throat.
Anesthesiologist. A healthcare provider with specialized training in anesthesia. He or she will complete a medical history and physical exam 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 or 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 or 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 need to return to the operating room.
How do I care for my child 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 medicine, 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. A child may begin to bleed from the surgery within the first 2 weeks after the surgery, and may need 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 happen:
Bleeding. This may happen during surgery, immediately after surgery, or at home.
Dehydration. This can happen due to decreased fluid intake. If severe, fluids through an intravenous, or IV, catheter in the hospital may be necessary.
Difficulty breathing. If swelling of the area around the surgery happens, it could be life-threatening if not treated immediately.