Sleep Disorders from Pediatrics to Geriatrics

Sandra R. CoulsonMS, ST, Ed, COM

WAKE UP, SNORING IS DANGEROUS!

SLEEP DISORDERS…

• Insomnia: 32 million (unreliable estimate)• Sleep Apnea: estimated 18 million Americans

(NHLBI) • Obstructive sleep apnea: 12 million Americans

Narcolepsy: 200,000 Americans (NHLBI estimate); 50,000 diagnosed.

• Chronic Fatigue Syndrome: 500,000 Americans (CDC/NIAID)

• 2011 Health Grades Inc.

Obstructive Sleep Apnea…

A Common Problem:• Estimated prevalence: 40 MILLION Americans who are undiagnosed (1 in 6) • 50-90% diagnosed are referred for a sleep

evaluation. Most do not follow through.

Myers et al, JAMA, 2013

CENTRAL SLEEP APNEA…

• The sleeper whose problem is central sleep apnea periodically does not breathe at all, or breathes so shallowly that oxygen intake is ineffectual. The brain just seems to shut down. In either type of sleep apnea, obstructive or CENTRAL, the lack of oxygen usually causes the patient to wake, at least briefly. (Hypopneas)

Risk Factors…

• Male gender• Age• Obesity• Neck Circumference > 17.5 inches in men 16 inches in women• Smoking• Craniofacial structures• Smoking• Family History

Risk Factors…

• High blood pressure.• High blood pressure in lungs.• Abnormal heart rhythm, heart failure,

coronary artery disease (CAD), or stroke.• Depression.• Diabetes.

Symptoms of OSA in Children…Restless SleepHeadachesObesityLarge TonsilsNoisy

BreathingAllergic

Shiners Runny NoseFrequent

Upper Airway Infections

EarachesBedwetting

Symptoms of Sleep Apnea in Adultsand Children…

Daytime Symptoms:• Excessive Daytime Sleepiness• Depression / Anxiety / ADHD • Morning Headache• Dry, Irritated Throat & Raspy Voice• Social and Workplace Issues• Short Attention Span, Hot Temper, Impulsive, Memory Problems

Symptoms of Sleep Apnea in Adultsand Children…

Nighttime Symptoms:

• Snoring• Witnessed Breathing Pauses• Frequent Awakenings• Frequent episodes of Bedwetting• Insomnia

Screening Questionnaire…

• Do you snore?• Are you sleepy during the daytime?• Do you have headaches or sore throats in the AM?• Has anyone witnessed apneas or respiratory gasps?• Do you not get ‘enough sleep’ despite adequate time

in bed?• If they answer any affirmatively, use the “EPWORTH

SLEEPINESS SCALE” TO ASSES SEVERITY. We give this to everyone!

Is It a COLD or an ALLERGY?

• Cold: • Runny nose and sneezing last 1-3 days; if cold symptoms persist for more than a

week, see a doctor - you may have complications such • as bronchitis or sinusitis • • Sore throat and / or coughing• • General malaise -fever, muscle aches, chills, sweats, loss of appetite, fatigue -which

indicate an infection • • Burning sensation in nose, often accompanied by nasal/sinus tenderness • • Mucus can become yellow, green, thick, foul-smelling or bloody

• Allergy:

• Persistent watering of nose and eyes lasts anywhere from a few weeks to several months, depending on the allergen

• Itchiness of the nose, eyes and roof of the mouth or back of throat • General feeling of well-being, except for areas experiencing allergic

symptoms; appetite usually is not diminished

• In most cases, sinuses are not painful or tender • Mucus is watery and clear

We Cannot See Adenoids and SeptumsBut We CAN See Tonsils and Tongues

Large Adenoids Deviated Septum

Large tonsils Wide tongue/Long Uvula

Medical Conditions /Sinusitis…

• Diabetes• Gastro esophageal reflux disease• Nasal polyps or septal deviation• Disorders of the immune system (fungal infections are especially risky)• Oral or intravenous steroid treatment• Hypothyroidism -- causes congestion that often clears

up when the condition is treated• Cystic fibrosis -- a genetic disorder in which the mucus is

very thick and builds up

Sleep Disorders Can Cause Other Serious Diseases:

DISEASES… Type II Diabetes• Almost 50% of type 2 diabetes patients have sleep

apnea;1 among obese type 2 diabetes patients, the prevalence of sleep apnea has been estimated at 86%.

AM J RESPIR CRIT CARE MED.2010 Mar 1;181(5):507-13. doi: 10.1164/rccm.200909-1423OC.

Epub 2009 Dec 17.

• 76% Congestive Heart Failure Javaheri S. Sleep-related breathing disorders in heart failure. In: Heart Failure, A Companion to Braunwald’s Heart Disease, edited by Douglas L. Mann. WB Saunders, Philadelphia 2010; 471-487

• 70% Stroke/TIA http://sleepdisorders.about.com/od/sleepandgeneralhealth/f/Sleep_Apnea_Stroke_Risk.htm Mar 4, 2013 ...

Anyone you know???

The reason it is called “Sleep-Disordered Breathing…

Daytime… Nighttime

If you suspect Sleep Apnea…

What do you look for?

Determine Etiological Factors which would prevent the success of a therapy program BY BEING PART OF A team!

1. Deviated Septum 2. Enlarged Turbinates 3. Polyps 4. Enlarged Adenoids and / or Tonsils 5. Allergic Rhinitis and / or Sinusitis 6. Vaulted -Narrow Palatal Arch Formation

REFER! Ask Questions

Questions…

• Neck Size• Morning headaches?• Impaired memory/intellectual

performance• Restless sleep?• Nocturia? (Bedwetting)

Examine the Throat…

Medical History…

• Snores at night/naps• Throat infections• Ear infections• Stops breathing• Has halitosis

ALLERGIC SHINERS…

Long Uvula, Large Tongue=Obstruction…

Neck Size…

Medical problems associated with SLEEP DISORDERD BREATHING…

• Obesity• Excessive sleepiness• Depression• Hypertension• Cardiovascular disease• Diabetes• Stroke• Cognitive impairment• Cerebrovascular disease

CARDIOVASCULARLINKS…

• 5.7 million people in the US have heart failure {American Heart Association Statistics}• 76% of Heart Failure Patients have SDB• Heart Failure is the MOST expensive disorder to treat• Obstructive Sleep Apnea is noted in 49% of atrial

fibrillation patients and 30% of cardiovascular patients

• OSA presents in 70% of heart attack patients

Mortality Links…

• SDB is associated with a 3-fold increase in mortality risk • Severe sleep apnea raises

premature death risk by 46%

Mood Disorder and Apnea…

• 54.1% of Bipolar patients were found to be at risk for OSA• Sleep apnea associated with major depression

(2.4% in men, 5.4% in women)• Treatment of OSA ameliorates symptoms in the short and long term Soreca, Bipolar Disord, 2012

Wheaton, Sleep, 2012 Scjwartz, J Clin Sleep Med, 2007

Restless Legs Syndrome andPeriodic Limb Movements…

• Periodic Leg Movements (PLMD) • Restless Legs Syndrome (RLS) Movement disorder (Rest increases symptoms)• Sensory Motor Syndrome

Cardiovascular Risk and RLS…

• 2 times greater risk of heart and cardiovascular disease

• Women with RLS for 3 years are at greater risk for heart disease• Older Men with RLS are 67% times more likely to have a stroke than those without Li,RCircuLlatioSn,2013

Are pregnant women atrisk for sleep apnea?

Potential risk factors for SDB in pregnancy:

• Nasal congestion and gestational rhinitis (1)• Increased Mallampati scores (2)• Reduction in size of upper airway (3,4)• Weight gain• Reduction in FRC (5) and airway collapsibility (6)• Vacuum effect related to increased ventilator drive (7)

• 1-Young T. J All Clin Immunol 1997; 99: S757-62.• 2- Pilkington S. Br J Anesth 1995; 74:638-42• 3- Iczi B. ERJ 2006; 27:321-7• 4- Iczi B. AJRCCM 2003; 167:137-40• 5- Crapo R. Clin Obstet Gynecol 1995; 39:3-16• 6- White DP. AJRCCM 2005; 172:1363-70• 7- Edwards N. Thorax 2002; 57:555-8

Consequences of Apnea for Pregnant Women…

• Pregnancy associated with lower residual volume and lower functional residual capacity (FRC)• Lower oxygen reserve because of lower FRC and higher oxygen consumption

Preeclampsia…

PEC is an important cause of:• Infant prematurity• Neonatal morbidity• Maternal morbidity and mortality• Maternal ICU admissions• Precursor of cardiovascular disease

Consequences of Apnea on Fetus:

• Concern for fetal wellbeing with recurrent desaturations and possible hypoventilation (Data from high altitude residents strongly suggests risk of growth restriction and PEC with chronic hypoxia) (Doctors in Denver are very aware of the risks!)

Gestational Diabetes…

Diabetes occurring during pregnancy

• 30-50% of women with GDM end up developing DM later in life• GDM is cause for infant morbidity • Other complications

Reflux - Another Issue…

• In a study presented at the 70th Annual Scientific Meeting of the American College of Gastroenterology, 81 patients with documented sleep complaints at least three nights per week underwent polysomnographic sleep evaluations. 26 percent had acid reflux. Of those who suffered with reflux, 94 percent of the recorded reflux events were associated with arousal from sleep or awakening.

Is this a chicken or an egg?

Childhood Obstructive Sleep ApneaOSA

Airway Examination• CT Scan• Lateral Cephalometric Exam

When you see…

• A Narrow, under-developed maxillary arch

Grade 4 Tonsils…

• If the tonsils are not treated or removed, it is certain to be an Orthodontic nightmare and a total relapse case.

Short Lingual Frenulum…

Tongue Thrust = Abnormal Swallow…

Anterior Bite Closed But needs Ortho for Crossbite

•Sleep Studies…

Looks like fun!!!

• Are they accurate?

Sleep Study…

• Typical result…• Time in bed: 9 hours 47 minutes• Time asleep: 6 hours 46 minutes• AWAKE: 3 hours due to Arousals( I did one just to find out what happens. I do not have OSA, but I did not sleep well!)

Treatment Modalities

Tonsillectomy/Adenoidectomy…

• Chronic or recurrent tonsil infections—Tonsillectomy may reduce the number, but will not completely eliminate, these infections.

• Peri-tonsillar abscess (pocket of infection spreading outside the tonsil)

• Enlarged tonsils causing obstruction of the throat• Adenoids blocking the nasal airway

Uvulopalatopharyngoplasty…

Laser-Assisted Uvulopalatoplasty…

• Conservative resection and re-contouring of the soft palate and uvula

• Outpatient procedure• Low morbidity• Success rate: LOW

Somnoplasty…• Radio-frequency generator is used to cause

internal scarring and shrinkage of the soft palate and uvula

• Local Anesthetic• Outpatient• Success: LOW

Uvulopalatopharyngoplasty…

Success: Low

Maxillofacial SURGERY…

• Inferior Sagittal Osteotomy with HYOID suspension

• Ramus osteotomy• Mandibular sub apical osteotomy• Maxillary-mandibular advancement• Tracheostomy Success Rate: Moderate…Very Costly…Often not covered by insurance

Devices…

• Mandibular Repositioners• Tongue Controllers• Nasal/Intra-oral Positive Pressure Devices• Drugstore Appliances (Doctor’s Snore Guard)

Issues with Medications…

• Benzodiazepines, hypnotics, narcotics may relax the airway more in patients who have sleep apnea.• Narcotics can contribute to central sleep apnea.

A GREAT TEAM…

DentistOrthodontistPediatric DentistPediatricianPhysicianBreathing SpecialistOsteopathCranio-Sachral TherapistMyofunctional Therapist

CPAP…• CPAP is still considered the “Gold Standard” by most physicians.

Compliance: Low

Myofunctional Therapy witha TEAM APPROACH

Helps to minimize snoring by training the tongue to rest in a normal posture

Changes head and neck posture which opens the airway

Changes sleep behavior with better sleep rejuvenation

Allows for better nasal breathing (noses are ‘use them or lose them’)

Changes facial esthetics

CHANGES LIVES!

APP for Patient’s MonitoringTheir OWN Snoring…

SNORELAB.COM for IPHONES

Snoreclock.com for DROIDS

SNORELAB.COM…

• This woman snored so loudly that her whole family wore ear plugs to sleep!

• She started the exercise program and went to Seattle to care for her elderly mother.

• She has sent a “SNORE REPORT” every day!

One Week after Starting therapy…

exercises

FACIAL SHAPE CHANGES…

PROFILE CHANGE…

He Stopped Snoring within one week

Airway Examination…• CT Scan• Lateral Cephalometric Head Film

Summary…

• Successful treatment of snoring and sleep apnea is totally dependent upon an accurate diagnosis of the region of obstruction and treatment that is directed at the ETIOLOGY!

Sleep…

“[Sleep is] the golden chain that tieshealth and our bodies together.”

Thomas Dekker (1572-1632)

303-759-2760info@sandracoulson.com