Here are 2 polysomnograms that show obstructive sleep apnea in a child.  I know there's a lot of stuff here, and most of it just looks like a bunch of squiggles (actually, it  is just a bunch of squiggles), but focus on the waveforms marked Thermistor, Chest and Abdomen.  The thermistor is registering breathing, in and out, in undulating fashion, while the other 2 channels are measuring effort at the chest and abdomen.  These are 5 minute blocks of time.  The first one shows normal breathing.  It is regular and uninterupted.



The next one shows obstructive apneas-- they're long, they cause severe desaturations (drops in oxygen level in the SAO2 channel), there's a lot of them and this kid needs to go to surgery.  Notice how that even though there's no airflow in the thermistor for long periods, the child is still struggling to breathe as evidenced by the movement seen in the chest and abdomen channels.

Interestingly, this is the same child, measured during 2 different stages of sleep, delta and REM.  If ever there's any question about sleep apnea in a child, seek qualified medical help, an overnight sleep study is the gold standard in the diagnosis of sleep apnea.



Last edited by sleepydave on Sun Dec 02, 2007 11:19 am; edited 2 times in total

Thanks, Dave.  My child was recently diagnosed with sleep apnea.  13yo, 63" 100lbs., normal size tonsils and adnoids.  Pulmononolgist feels that fixing his nasal septal defect and doing a turbinate shaving will be the cure....I am not so sure.  I have been a respiratory therapist for 20 years.  The past 10 years have been spent doing patient and staff education mainly with asthmatics so I have a tiny bit of knowledge about sleep apnea but need to learn more now.  This looks like a nice forum for me to gather more info.  Currently, he is in his 2nd week of CPAP at home and struggling though keeping the mask on.  As soon as I get my oldest settled in her dorm room in 2 days, I hope to spend a little more time looking at what you have posted vs. his test results.    

Thanks again!

Linda

Linda
Just wondered if you check back -- how is your son doing on CPAP?  OUr daughter, who is 15, is in a similar situation.  When the tonsils are normal size, it is less obvious what can be done for these kids and we have not found anyone even willing to talk surgery (not that we're pushing for it, either) because the tonsils are not enlarged.  Yes, it would be great if we could get her settled happily on CPAP, but she naturally wonders, what will I do when I go to camp?  Sleepovers?  Who will room with me at college if I am on this thing?  I tell her not to borrow trouble from down the road, just concentrate on feeling better now, but that is tough when you are 15 and want to do all those normal teenage things.  

Best wishes -

Hi Williebear,

Thanks for asking.  He is doing much better but to help him keep his mask on, I had to borrow a low pressure alarm from work.  The DME company did swap out our machine and gave us one that has an alarm but it has a very low tone and he simply can turn the alarm off and fall back asleep.  The new alarm I am using is loud and if it's turned off without the proper sequence it continues to alarm.  This allows me to get up and make sure he puts the mask back on.  So far it's only once a night and it's working out well.  I am sleeping much better knowing I will hear the alarm and not have to get up 2 or three times to check.  He is like a new person.  He now wakes up to his alarmclock and gets up himself.  He has always needed so much coaxing to get up to get up in the past and has never been awakend by his alarm clock.  He says he has so much energy and hasn't had a nap in weeks, it's great.  Now I that I know the external alarm works, I need to convince the dme company that we need one.  As far as the slumber parties and spending the nights, I have never allowed my kids to sleep over at a freinds house anyway so that's not an issue.  For slumber parties I will pick them up at midnight and offer to take them back in the morning anytime after 6 am when someone calls from the party.   So far no one has called earlier than 11 am to bring the kid back.     The only thing I have to say about college is that I have been in this field a long time and the first ventilator I used was a huge washing machine and now I use a ventilator that is the size of a toaster.  Technology is always improving and by the time they go to college there will be more attractive options.  If you really think about it I have seen worse looking retainers.

Linda

thanks for the update and the encouragement.  We are still struggling to get L comfortable with the pressure.  She needs BiPAP because her breathing slows down too much as she gets into deeper sleep, and so far she's not been able to sleep past that point where the backup rate kicks in.  But we are still trying.  In a way, it brings back memories of potty training: if you knew how long it was going to take to reach that point of comfort and confidence, you could handle it better and pace yourself a little better.  You'd know how seriously to take your setbacks and how much confidence to put in your successes.  But it's all an unknown still.  We try not to stress ourselves out about it, but I know my daughter and I both think "Maybe tonight will be the night that she finally gets some relief."

WillieBear-

What brand of BiPAP is your daughter using? I have severe, treatment resistant CSA and have been on BiPAP for almost 2 years. In that time I have used 6 different machines- 3-ResMed VPAP II STA, old Respironics BiPAP STD, Quantum PSV, and my primary machine- Respironics Synchrony BiPAP ST. Give me any of the last 3 any night  and I'll be a happy camper...but please don't make me use a VPAP. First night on one and I knew I didn't like it, DME made some adjustments, then the machine literally died during my second night on it with only 12 hours total machine use time. Ended up with another brand new VPAP II STA and even with tons of tweaking I was never happy with it- if I slept all night with it, the next day I felt worse then if I didn't use one at all. Luckily I had my own BiPAP STD I had adquired...it may be old technology but it had less then 20 hours when I got it and its built like a tank- the nights I used it were so much better, as was the next day. We went as far as hanging something in front of the two machines and having my mom randomly switch them out after I fell asleep...without fail I could tell the next day which one I was on by how lousy I felt. Finally after a lot of discussion between my sleep doc, my DME, sales reps from both ResMed & Respironics, and myself we decided to try the Respironics Synchrony which I've been happily using for 18 months. The only thing that could explain my problem was that VPAPs just don't eliminant as many of my centrals as the other machines. At best, BiPAP STs can only reduce my central apneas from 65 per hour to 30+ per hour- about 50% improvement, and after my titration my sleep doctor wasn't even sure that I would see any benefit from using a BiPAP ST (actually had less REM, lower O2 levels, and some other things were worse then my original study). Thankfully my situation is not a common occurance- most people with CSA can get much better results with BiPAP STs.

Last December I ended up in the hospital unexpectedly and you can probably guess...all they had were VPAP II STA's- thankfully I only had to use it one night, my family brought my Synchrony in the next day. The one thing I noticed very clearly with the VPAP was that it did not synchronize with my breathing very well, even when it was in regular mode...when Timed backup kicked in it was even worse. The best way to describe it is that BiPAP should feel like a female dance partener that gracefully follows your lead, gliding from IPAP (inhale) to EPAP (exhale)- which is what all the BiPAPS I've used feel like, except the 3 different VPAPs. The VPAP is more like a dance partener who wants to lead...and when both parteners try to lead you know some toes are going to get stepped on...not a pretty sight. What it comes down to is that VPAPs need to have a lot of tweaking to various 'comfort' (for lack of a better word) settings, like rise time, min & max inhale time, etc. For a lot of people it doesn't seem to matter as much & can use as is; others do very well once they get the comfort settings tweaked just right...the problems is that most DME/RTs don't understand the extra settings. My Respironics Synchrony has additional comfort settings that can be adjusted and when I first got it the Respironics sales rep made sure it was set as closely as he could to the BiPAP STD settings since I had done well with it. I've played around with the additional comfort settings a little and can feel a slight difference but it takes a lot to get the Synchrony to feel out of step with me, like the VPAP seems to be by default. I'm in no way trying to say the VPAP is a bad machine- it just wasn't the right one for me personally. While my experience is very unusual, it might worth it to see if your daughter does better on a different brand of BiPAP or at least have your DME try to adjust the some of the comfort setting to see if it makes a difference for her. Also, what is her backup rate?- sometimes they set it too high so it ends up kicking in so fast that you feel like you're getting out of step and can end up almost hypervenilating trying to catch up. My typical breathing rate at rest is around 12-14 breaths per minute and I do best with a backup rate of 10- it doesn't go too long before trying to get me to breath but it also isn't so fast that I don't have time to take a slightly longer breath cycle.

I know there are not a lot of BiPAP ST users on any of the sleep forums so if you need anything, don't hesitate to ask me. I also went through a lot of health problems as a kid so I understand what your daughter is going through- I really hope she can start seeing some improvement with BiPAP ST soon. It's made a big difference in my life, even though I still have way too many apneas per hour then my doctor & I would like. I couldn't imagine sleeping without it even for a nap now and I really wish it hadn't taken 12+ years for me to be correctly diagnosed & start treatment...I was only 19 when I suddenly started having problems.

Thanks for your reply and for sharing your story.  Our daughter's machine is a brand new Respironics Synchrony, which sounds like the same one you are using.  But I had no idea it had other settings we could adjust, other than the BiPAP pressure and the backup rate.  L's backup rate is 8, which doesn't sound like it would be too intrusive.  Her breathing rate slowed to a low of 4 on her sleep studies in both 2003 and 2005, and both recorded the longest pause at about 25 seconds.  

We will get out the manuals and see what we can learn from those.  I'm still looking forward to the day when my daughter says "I feel really good" and can go all day without falling asleep in class or feeling too tired to function.

You can adjust the Rise time- 1-6- higher means it takes longer to go from EPAP to IPAP so it can feel like an easier transition.  What are her pressure settings? Have they considered trying to see how she does without a back up rate? If I remember she didn't have a lot of centrals so she could be having more disruptions from the backup rate then she would have without it...the treatment could be worse then the problem. Some people with CSA do fine with regular BiPAP with no timed back up rate (some even do well with CPAP but that is not the norm). It would be worth talking to her doctor about trying it if she doesn't see any improvement.

L's pressure settings are the lightest possible -- 8/4.  We will look into adjusting the rise time.  Right now, she has been using the machine for only about 1/2 hour to 90 minutes a night.  She does not remember pulling the mask off (she also must be turning off the machine, since it has a low pressure alarm that we've never heard go off).  Now that you mention it, I don't really know if it's the backup rate that is rousing her -- that's just my guess.  In the morning, she is disappointed to realize she did not sleep all the way through with it, since that of course is the goal.  We'll keep plugging away and see if we can desensitize her some more, so she doesn't pull it off in the night.  Thanks for the advice!

Having the patient disconnect alarm may help, at least for a few nights to let her & maybe you know when she takes off the mask since sounds after 15 or 60 seconds, depending on how its set up. If she wouldn't mind, you could set up a baby monitor in her room just when she is sleeping so you can hear the alarm too. At her age I would definantly want to give her a say in when its on and off for privacy sake...I'm pretty sure when we were her age we wouldn't have been too keen on parents listening in on us,  but when it comes to her health I'm sure she would understand. Patient disconnect alarm may not be something you would want to do long term, though I do find it useful to make sure that I reconnect when I get back from the bathroom in the middle of the night. I went through a period where I would occasionally forget to hook back up after using the bathroom in the middle of the night so I ended up wearing my mask with no air pressure going. After using the alarm for several months, I've found I don't need it any more, but it is a nice option to have when you need it.

As for the low pressure alarm, I've never heard mine go off or seen anything on the alarm chart on the Encore Pro data that I can remember, so I don't think it would go off if she takes off her mask- at least it hasn't on my machine. My understanding is that it is for something related to a machine failure or something...I'm not sure...checked the providers manual (sleepydave- close your eyes...I know patients aren't suppose to have them typically ;) , but it is nice to at least know what each alarm code means, especially when it happens in the middle of the night and such). "Low Pressure alarm" detects when the patient is not receiveing adequate pressure support- pressure below 5cm for 60 continous seconds. Another alarm is "Low Pressure Suport"- it detects when the patient is not receiving adequet pressure therapy- when RxPS-Measured Pressure Support >PSmincm H2O for 60 continous seconds (it gives the definition for each term too, but its still pretty confusing...and giving me flashbacks to high school algerbra). Synchrony can also have an alarm set for apneas- at 10, 20, 30, or 40 seconds, depending on how sensative it needs to be. Since I still have so many apneas even on my BiPAP, I do use this if it seems like I'm having more problems or am starting a new medication that may screw up my breathing even more (we've found muscle relaxers are not a great idea for me- they cause me to have a lot more apneas but that is not typical...just another strange quirk I have). When I use the apnea alarm, I usually have it set for 40 seconds at my doctors recomendation- any lower for me and the alarm would go off way too many times a night....I figure if I haven't taken a breath in 40 seconds that I need to wake up and the machine might as well help me since my brain hasn't figured it out by then.

Like I've said before, I don't recomend making any changes, even to the alarms, without talking to her doctor or her RT at the DME. Of course you actually need access to the clinical menu on the machine to change any of the alarm settings. The only thing you can change from the patient menu is the Rise Time- 3 is the default setting and I usually have mine set at 5 or 6...I can definently tell when its on 1 or 2, and 3 is mildly annoying to me.  Check you PM's (private messages- on the bar near the top of the page, just below the Apnea Support Forum logo)- I mentioned a few things there that might be helpful in a message yesterday.

Hi everybody,

I have a baby girl 1mo. age, and I suspect she has slep apnea... can this be possible for such an early age?


_________________
Eli

Hi Eli:
Sleep apnea can occur at any age.  While breathing can be somewhat disorganized in infants and neonates, especially during REM sleep, this isn't something you want to guess wrong at.  See your pediatrician.
sleepydave

Sorry if this post is addressing issues already discussed, but I'm unable to find such postings. Our 13 yr old son was diagnosed with OSA 1.5 years ago and has been on (unsuccessful) CPAP for nearly 1 year. CPAP has been unsuccessful for 2 reasons; 1. he can't fall asleep with the mask on 2. he repeatedly removes the mask in his sleep and never achieves sufficient therapy time. He is on a reduced schedule at school because it is impossible to wake him. In the a.m. he is either totally non-responsive or he becomes angry and sometimes aggressive then he withdraws for several hours. This was something that occurred just occasionally until 11 months ago when he was diagnosed with mono ... now it is a daily ordeal. His daytime behavior has also worsened. He is often angry and depressed ... once an A-B student and athlete, now struggling in school and unable to participate in sports. His attendance is poor due to frequent illnesses and effects of OSA. He has some other health issues and is under the care of fine doctors, but everything takes so much time ... it is very difficult to go through all this and never see any progress. Are we alone? Anyone have any suggestions for us?

I have a 3.5 year old son diagnosed recently with sleep apnea.  As his tonsils were inlarged we had them removed.  The follow up sleep study reveiled that his apnea had actually gotten worse after the surgery.  So now he is on oxygen at night.  He really needs CPAP but his doctor didn't think that would work since he is a mouth breather.  Also he is autistic so getting his oxygen on at night is a major battle, I pretty much have to sit on him.  I don't know how he will ever be able to do CPAP.  He has an oral aversion and does not like anything around or in his mouth.  I still have to hold him down in order to brush his teeth.

My 18 month old son had a sleep study done on February 23. We just got the test results back today and the doctor suggested that we do an A&T removal. My son has been through so much already in his short lifetime. I am getting a second opinion tomarrow. I just feel so helpless right now. Does anyone have any suggestions?