The Upper Airway, Asthma and Sleep Disorders in Children

A. Kaditis, MD

Pediatric Pulmonology Unit, Sleep Disorders Laboratory

First Department of Pediatrics

University of Athens School of Medicine

and Aghia Sophia Children’s Hospital

Athens, Greece

Upper Airway, Asthma, Sleep Disorders

SnoringRecurrent Wheezing

Sleep Quality

Upper Airway, Asthma, Sleep Disorders

Pathophysiology of Obstructive Sleep-Disordered Breathing and its

effects on Sleep Quality

Obstructive Sleep-Disordered Breathing

Spectrum of abnormal respiratory patterns during sleep characterized by snoring and increased respiratory effort

� Primary snoring� Upper airway resistance syndrome� Obstructive hypoventilation� Obstructive sleep apnea (OSA)

A Mechanical Model for Obstructive Sleep-Disordered Breathing

Upper Airway Resistance

Katz et al.Genioglossus activity during sleep in normal control subjects and children with OSA. AJRCCM 2004;170:553

Upper Airway Dysfunction and Adenotonsillar Hypertrophy

Conditions affecting Upper Airway Resistance and Pharyngeal Collapsibility

� Septal deviation

� Nasal polyps� Hypertrophied turbinates

� Obesity� Craniofacial abnormalities

� Neuromuscular disorders

OSA symptoms

� Snoring� Reported apneas during sleep� Difficulty breathing during sleep� Restless sleep� Frequent arousals� Daytime sleepiness� Hyperactivity� Decreased cognitive functioning� Learning problems

Allergic Rhinitis and Obstructive Sleep-Disordered Breathing

� McColley et al. High Prevalence of Allergic Sensitization in Children with OSA. Chest 1997;111:170

� Kalra et al. Atopy as a Risk Factor for Habitual Snoring at Age 1 Year. Chest 2006;129:942-6

� 13.7 ± 2.6 months� Independent Risk Factor for habitual snoring

Upper Airway, Asthma, Sleep Disorders

Effects of Recurrent Wheezing on Sleep Quality

Daytime tiredness

Daytime sleepiness

Restless sleep

Difficulty falling asleep

OutcomesOR (95% CI)

<0.015.1(2.2-12.1)

<0.013.8(1.8-8.0)

<0.015.0 (2.2-11.1)

<0.052.0 (1.0-4.0)

pWheezing adjusted for

snoring

Desager et al. Sleep Disturbance and Daytime Symptoms in Wheezing School-Aged Children. J Sleep Res 2005;14:77

Upper Airway, Asthma, Sleep Disorders

Epidemiologic Association between Snoring and Recurrent Wheezing

History of asthma

Cough

Persistent wheeze

Occasional wheeze

Risk factors adjusted for race, obesity

<0.053.83(1.39-10.55)

<0.058.83(2.29-34.05)

<0.057.45 (2.03-27.39)

<0.053.29(1.24-8.94)

pAHI>10

OR (95% CI)

Redline et al. Risk Factors for SDB in Children.AJRCCM 199;159:1527

0.0131.73(1.12-2.67)

History of wheezing

0.5650.88 (0.58-1.35)

PassiveSmoking

0.0411.65 (1.02-2.66)

Obesity

0.0201.67 (1.08-2.58)

Gender

0.1250.95 (0.90-1.01)

Age

pvalue

Dependent variable: snoring

OR (95% CI)

Risk factors

Kaditis et al. Associations of Tonsillar Hypertrophy and Snoring with History of Wheezing in Childhood. Pediatr Pulmonol 2010;45:275

0.0012.23(1.37-3.63)

History of wheezing

0.8510.96 (0.60-1.53)

PassiveSmoking

0.2190.69 (0.38-1.25)

Obesity

0.9061.03 (0.64-1.65)

Gender

0.3210.97 (0.90-1.04)

Age

pvalue

Dependent variable: tonsillar hypertrophy

OR (95% CI)

Risk factors

Kaditis et al. Associations of Tonsillar Hypertrophy and Snoring with History of Wheezing in Childhood. Pediatr Pulmonol 2010;45:275

Wheezing is significantly associated with snoring

In children with tonsillar hypertrophy[OR = 2.76 (1.10-6.93); p=0.031],

But not in children without tonsillar hypertrophy[OR = 1.49 (0.92-2.43); p=0.107].

Tonsillar hypertrophy partially explains the association of snoring with wheezing

Upper Airway, Asthma, Sleep Disorders

Pathogenetic links between Obstructive Sleep-Disordered

Breathing and Recurrent Wheezing

Shibata et al. Increased Leukotriene E4 in the EBC of Children with Mild Asthma. Chest 2006;130:1718

Caballero Balanza et al. Leukotriene B4 and 8-Isoprostane in EBC of Children with Episodic and Persistent Asthma. J Investig Allergol CIin Immunol 2010;20:237

LTB48-

Isoprostane

Goldbart et al. Inflammatory Mediators in EBC of Children with OSAS. Chest 2006;130:143

Biltagi et al. Correlation of 8-isoprostane, IL-6, and cardiac functions in childhood with OSA. Acta Paediatr 2006;97:1397

Kaditis et al. CysLT-Rs in Tonsillar Tissue of Children with OSA. Chest 2008;134:324-31

OSA Recurrent tonsillitis

Goldbart et al. Leukotriene Modifier Therapy for Mild SDB. AJRCCM 2005; 172: 364

OSA Recurrent tonsillitis

Dayyat et al. Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive

sleep apnea. Chest 2009;135:1142

Conclusions

� Obstructive sleep-disordered breathing and recurrent wheezing/asthma: Both result in sleep-disturbance

� Obstructive sleep-disordered breathing is associated with allergic rhinitis and frequently coexists with recurrent wheezing/asthma

� Airway inflammation related to leukotrienes and oxidative stress: Probably participate in the pathogenesis of both snoring and recurrent wheezing