Severe Obstructive Sleep Apnea Sleep Apnea Treatment
Severe Obstructive Sleep ApneaSleep Apnea TreatmentMayo .
Tonsillectomy and Adenoidectomy for OSA Anesthetic Considerations by Denise Chan MD
Tonsillectomy and Adenoidectomy for ObstructiveSleep Apnea: Anesthetic Considerations, by Denise Chan. Hello, my name is Denise Chan, and I'm a pediatricanesthesiologist at Boston Children's . Today, I'll be discussing important aspectsof taking care of children with obstructive sleep apnea syndrome in the perioperativesetting. Introduction. Now, first let's define what is obstructivesleep apnea syndrome. Well, it's a disorder of breathing during sleep, and it's characterizedby a few different things, according to the
American Thoracic Society. First of all, these patients have either prolongedupper airway obstruction, which is known as obstructive hypopnea, or intermittent completeobstruction, known as obstructive sleep apnea. And this occurs with or without snoring. Second, the patient exhibits moderate to severeoxygen desaturation. Third, normal ventilation is disrupted. And fourth, normal sleep patternsare disrupted. So these are the components of obstructive sleep apnea syndrome. Now, in children, obstructive sleep apneasyndrome is oftentimes caused by enlarged
adenoid or tonsillar tissue. And you can seein this illustration that the hypertrophied tonsils really do get in the way of normalairflow. So what do you expect to see in a patientwith this syndromeé First of all, you'll probably see snoring. They'll have difficulty breathingduring sleep, restless sleep, or even nightmares or night terrors. You may see excessive sweating.They may have nocturnal enuresis, or bedwetting, mouth breathing, pauses in breathing, or chronicrhinorrhea. More importantly, though, what is the significanceof having obstructive sleep apnea, and what are the consequences for the patienté Well,there are a number of problems that can occur.
Daytime somnolence patients have fallenasleep while driving older patients, of course and this can lead to motor vehicleaccidents; cognitive dysfunction, which leads to behavioral problems or problems with workor school performance; metabolic effects, such as insulin resistance, type 2 diabetesmellitus, or metabolic syndrome; or other metabolic effects, such as failure to thriveor stunted growth. Or if obstructive sleep apnea is more severeor left untreated, this could lead to cardiovascular morbidity, such as pulmonary or systemic hypertension,cor pulmonale, or stroke. Obstructive sleep apnea syndrome can even lead to death. Andit's been hypothesized to be a factor contributing
to SIDS, or Sudden Infant Death Syndrome.Diagnosis and al Features. In order to diagnose whether or not someonehas obstructive sleep apnea, you must first and foremost perform a thorough history andphysical exam. A sleep history screening for snoring should be a part of every child'sroutine health care visits. It's really unlikely that someone's goingto have obstructive sleep apnea if they don't snore. So if a child does snore, ask the parentsmore details about the sleep history. Does your child have difficulty breathing or stopbreathing during sleepé Or are you worried about their breathing at nighté Does yourchild sweat during sleepé Does your child
have restless sleepé Does he or she breathethrough his mouth while awakeé Has anyone in the family had obstructive sleep apneaor sudden infant death syndromeé Or does your child have behavioral problemsé When you examine the patient, you may noticecertain features that are suggestive of obstructive sleep apnea, such as a small, triangular chin,retrognathia, a high arched palate or a long soft palate, a long oval face, or, of course,large tonsils. There are also certain patients who are athigh risk for having obstructive sleep apnea. And these are patients with obesity; Downsyndrome; PraderWilli syndrome; certain neuromuscular
Intro to the Treatment of Pain with Opioid Medications by Charles Berde for OPENPediatrics
Introduction to Treatment of Pain with OpioidMedication, by Charles Berde. I'm Charles Berde, and I am Director ofthe Division of Pain Medicine at Boston Children's . Overview. In this lecture, we're going to discuss somegeneral considerations regarding al approach to patients with pain, regardingdevelopment of pain perception, and tradeoffs with the use of analgesic medications. A firstpoint is that the experience of pain is protective. It helps us know which factors in the environmentmay be helpful or harmful, and it helps us
to shape learning and behavior. Treating painwith analgesics always reflects a balance between benefits and potential risks, sideeffects, or harm from analgesics. Pain transmission in the fetus develops steadilythrough the second trimester. By full term, human infants show evidence of cortical activationwith noxious stimulation, and they show evidence of degrees of maturation of their pain responses,though pain responses continue to mature during infancy. For human neonates and young infantsundergoing major surgery, pain evokes hormonal, metabolic, and autonomic stress responses.And these stress responses can produce persistent patterns of vigilance and hyper reactivity.
Analgesic medications work at a range of sitesin the periphery, in the spinal cord, and in the brain. Opioid analgesics work, in part,by binding to opioid receptors, which are the targets of endogenous opioid peptides.Opioid receptors are present in the periphery, especially in the gastrointestinal tract,in the spinal cord, in the brain stem, and in forebrain areas that are involved in rewardand affective regulation. Examples of opioid analgesics that are commonlyused include morphine, oxycodone, hydrocodone, hydromorphone, and methadone. Opioid analgesicshave very important roles for treating many types of pain. Some examples include painafter surgery, pain after major injuries,
and pain due to vasoocclusive episodes withsickle cell disease. They have crucial roles in treating pain due to advanced cancer, fortreating dyspnea in endoflife care, and for permitting tolerance of mechanical ventilationduring critical illness. For each of these indications, opioids generally have a veryfavorable balance of benefit versus harm. In other lectures in this series, you willhear about some of the mechanisms that make pain become persistent or chronic. Chronicpain is an extremely common problem in adults and is often associated with disability andimpaired quality of life. Some common types of chronic pain in adults include mechanicallow back pain; neck pain; degenerative arthritis;
widespread musculoskeletal pain, or fibromyalgia;daily headache; irritable bowel syndrome; and pain due to nerve injury or nerve degeneration. Over the past 25 years, there has been a dramaticincrease in prescribing of opioids on a longterm basis for adults who have chronic pain dueto a nonlifelimiting condition. Despite more than tenfold increase in annual prescribingfor these situations in the United States, there's very little evidence that a majorityof people with these types of chronic pain due to nonlifelimiting conditions, receivea good balance of benefit versus harm when they are given opioids on a daily basis. Formost of these patients, in al trials,
they do not show longterm reductions in painscores, and opioids do not seem to make them more active or more able to return to theworkplace. While individual patients do derive longtermbenefit from opioids, it is often hard to determine which those patients are and whowill benefit or who will not. Several factors regarding opioids should make us cautiousin considering longterm opioid prescribing. These include the development of tolerance,opioidinduced hyperalgesia, which we'll define subsequently, and some of the neuropsychologicaland neuroendocrinal effects of opioids. Terminology.