Course 2: New methods in Sleep disordered breathing

Chairs
Pierre-Jean Monteyrol, Christian Guilleminault

Summary
A comprehensive review of key features of pediatric OSA. There is a need to define new understanding in the occurrence of OSA in children, the consequences of the syndrome on the cognitive learning development of children, understand the impact of OSA on functions not often considered as impacted by OSA but that will influence even more negatively learning and cognition .Nasal ventilation may be a must for certain types of sleep-disordered-breathing, but indication , risks and complications must be clearly understood. There is also the need to better understand the risk factors particularly orofacial anatomical that will lead to or worsen sleep-disordered breathing and based on these new findings understand new treatment approaches particularly based on age and demonstration of current outcome. SDB needs a multidisciplinary approach to diagnosis and treatment involving pediatric-sleep specialists, pediatric-pulmonary specialists, pediatric ENT surgeon, pediatric orthodontists using protocols that will aim at eliminating not only SDB but risk of relapse at post pubertal age

Speakers are expected to provide basic and advanced aspects on specific topics that are outlined below.
1) Y-s Huang (Taiwan) Prematurity, sleep-disordered-breathing sleep and cognition
When developing many premature infant do not go back to normal breathing but develop obstructive breathing. Long term follow-up study shows that even if premature infants have different sleep and neuro-cognitive development at early years follow-up compared to full term infants, Post-premature infants with SDB have clearly more cognitive impairment and sleep problems. The persistence of SBD is related to abnormal growth and development of the orofacial structures supporting the upper-airway. More aggressive follow-up and application of reeducation techniques taught to mothers may alleviate some of these negative outcome

2) S Blunden (Australia) Pediatric OSA in school-age children: Behavior and learning
OSA impacts on behavior, and learning as shown by different studies including follow-up studies of treated and untreated individual will be considered…But only preliminary data exist on the potential change of involving the brain

3) CM Hill (UK) Pediatric OSA, cognition and potential contribution of secondary impact of OSA on hearing to worsen cognition impairment
OSA impairs cognition in children, but new data indicates that hearing may also impacted by the syndrome and OSA may impact cognition through a new –rarely considered-pathway

4) R. Amin (Canada) Non-invasive ventilation for the treatment of pediatric sleep disordered breathing in children with comorbidities
There has been a dramatic increase in the past few decades in the number of children with comorbidities receiving non-invasive ventilation at home for sleep disordered breathing. Non-invasive ventilation has been successfully used in children of all ages, from infants to teenagers. Given its rapidly expanding use for all types of sleep disordered breathing, clinicians need to be familiar with the indications, technical and safety considerations as well as potential complications and challenges that may arise when caring for children using non-invasive ventilation.

5) SS. Sullivan (USA) Nasal Involvement in the development of sleep disordered breathing in early life
Coordinated nasal breathing is critical from early life for feeding, sleep, and optimal airway growth. Increased nasal resistance due to developmental, anatomical, or inflammatory sources contributes to sleep disruption, as well as chronic oral breathing. Chronic oral breathing alters patterns of airway growth, which may further predispose to the development of sleep disordered breathing. Treatment for childhood sleep disordered breathing, which often aims to reduce nasal and nasopharyngeal resistance, may not be complete until clinical restoration of nasal breathing is achieved.

6) S.Quo (USA) Pediatric OSA and treatment with orthodontist approach-including Bollard implants-outcome
Extending beyond soft tissue surgical treatments, Stacey Quo will present additional strategies to treat SDB in pre-pubertal and adolescent children. Treatments that target midface deficiencies that result from abnormal breathing will be discussed. Utilizing bimaxillary widening and/or maxillary protraction with bone anchored appliances can be implemented as a stand alone therapy or in combination with other treatments.

7) A. Yoon (USA) Pediatric OSA late teen-agers non compliant with CPAP: What can we offer and outcomes
Consistent CPAP utilization remains a challenge creating significant therapeutic limitations in the late-teenager SDB population. Late-teenager age group is defined as the stage where oro-facial growth has almost reached maximum development and sutural fusion. Dr. Audrey Yoon will discuss novel treatment modalities for modifying orofacial growth and development in late-teenagers using mini-screw assisted palatal expanders in order to achieve maximal increases in nasal and oral cavity volume. Guidelines and examples of Distraction Osteogenesis Maxillary Expansion (DOME), a minimally invasive surgical-orthodontic procedure, will be introduced for more predictable stable management of OSA

8) PJ Monteyrol (France) Surgical Oto-Laryngology and pediatric OSA
Oto-Laryngological surgical treatments are still very much used in pediatric OSA,but have clear limitation, and complications are not unknown

9) C. Guilleminault (USA) How mild changes on Orofacial Development lead to pediatric OSA and what can we do about it
Can we recognize early in life factors that will lead to SDB , how do we understand the cascade of events and can we break the cycle early avoiding pediatric OSA. Which type of treatment can we apply and what are the vulnerable periods in child life

Learning Objectives
Upon completion of this CME activity, participants should be able to:
• Recognize the long term risks that premature infants have to develop OSA that will further impact cognition and sleep and have suggestion on how to approach the post-premature child with OSA
• Recognize the negative impact that OSA has on learning and cognition and sleep development
• Identify secondary problems induced by OSA such as hearing impairment and understand how such problem impact learning and cognition in OSA children
• Understand the indications, technical and safety considerations as well as potential complications and challenges that may arise when caring for children using non-invasive ventilation
• Understand the important role of the nose in development of sleep-disordered-breathing in children
• Understand how specific orthodontic protocols can participate in the resolution of OSA in pediatric cases
• Understand specific orthodontic/oral surgery treatment options that can be offered to late-teen-agers with persistent OSA
• Understand through a short overview the role of ENT in treating pediatric OSA
• Have an evolutionary and developmental view on how mild orofacial impairments leads to OSA, with key clinical findings to look-for and treat aggressively

Target Audience
This course is intended for pediatricians, orthodontists, pediatric surgeons, sleep clinicians, nurses, fellows, and students involved in the diagnosis and management of pediatric sleep-disordered breathing.


Presentations

09:00am – 09:05am Introduction
09:05am – 09:45am Prematurity, sleep-disordered-breathing sleep and cognition, YS. Huang (Taiwan)
09:45am – 10:25am Pediatric OSA in school-age children: Behavior and learning, S. Blunden (Australia)
10:25am – 10:45am Coffee Break
10:45am – 11:25am Pediatric OSA, cognition and potential contribution of secondary impact of OSA on hearing to worsen cognition impairment, CM Hill (UK)
11:25am – 12:05pm Non-invasive ventilation for the treatment of pediatric sleep disordered breathing in children with comorbidities, R. Amin (Canada)
12:05pm – 1:05pm Lunch Break
1:05pm – 1:45pm Nasal Involvement in the development of sleep disordered breathing in early life, SS. Sullivan (USA)
1:45pm – 2:25pm Pediatric OSA and treatment with orthodontist approach-including Bollard implants-outcomes, S. Quo (USA)
2:25pm – 2:45pm Coffee Break
2:45pm – 3:25pm Pediatric OSA late teen-agers non compliant with CPAP: What can we offer and outcomes, A. Yoon (USA)
3:25pm – 3:40pm Surgical Oto-Laryngology and pediatric OSA, PJ Monteyrol (France)
3:40pm – 4:00pm How mild changes on Orofacial Development lead to pediatric OSA and what can we do about it, C. Guilleminault (USA)