Take My Breath Away - Carolyn Grad, Mark Washam, & Katie Holtman - APP Conference 2026

Good morning everybody. Thank you for uh attending today. I have some friends on stage with me. I'm Carolyn Grad. I'm the nurse practitioner here in the sleep program at Cincinnati Children's. Um, I have with me Mark Washam, who is also under the pulmonary umbrella with me, um, more from, uh, uh, inpatient side and now outpatient as well, and then Katie Holtman, um, with otolaryngology, um, as well, so. So we are doing um a little 80s theme today to try to keep you moving this morning. It's called Take My Breath Away, Pediatric Sleep Apnea for APPs. And I embraced uh the new AI a little bit and I have a dog wearing a CPAP just to get everybody's attention as well. And our theme. You're gonna hear more of that again, don't worry. Our learning objectives for today, of course, are um identifying the signs and symptoms of sleep apnea. Um, and there are some very common things, very obvious ones, and then a little bit more subtle ones. And then the testing method to diagnose sleep apnea. We're gonna really kind of get into that because that's sort of an involved test. There's a lot of considerations depending on the population that um is, is having that procedure done. And then we're gonna talk about the consequences of not treating sleep apnea and the effects on the child, and then the treatments. And that's partly why we have a couple of folks with us. So, um, certainly we treat it from a pulmonary sleep medicine standpoint, and then ENT is very involved from um a soft tissue surgery perspective. So we're gonna start um also with a poll. Um, so what, what are some signs or symptoms that make you think of pediatric sleep apnea? And we're gonna try to do like a word cloud. So this is just kind of things that come to mind, um, and things that you would think about there. And you have a little music while you're making your decisions. OK. So I'm seeing a lot of um snoring coming in pretty uh in the forefront. And that's what I was talking about with, there's some pretty obvious signs, right? If you're not breathing well at night, you're gonna snore, you're gonna pause or gasp. Um, but I'm also seeing some really Good, um, bigger words as far as daytime sleepiness, fatigue, headaches. Um, there are a lot of things that, that's not the first thing you think of when you think of sleep apnea, um, or at least I think patients and families, that's not necessarily what, what they're thinking of. Um, so that was kind of the take home, um, for that slide. Yes. So this is just kind of summarizing all those things that we were talking about there, um, and, um, some of the answers that we saw, so. I also have a video for you here. This is a, a dog sleeping. And the purpose for this is I actually tried to pick kind of a subtle snore. Not sure if you guys can hear the, the audio to it. Mhm. I also wanted to use this slide because there are actually two types of sleep apnea. So, obstructive sleep apnea is the most common. It accounts for over 95% of sleep apnea, and that is the kind of physi, the physiological obstruction, right? So either the airways obstructing because it's relaxing because of a tone issue, or there's something in there that's obstructing it. Things like tonsils, adenoids, the tongue, the palate. Um, and so you're gonna really hear obstructive sleep apnea, um, the, the snoring, the gasping, choking, um, things like that. And so, with the dog, you heard a little bit of that snore is what I was getting at there. There's also central sleep apnea though, which is much less common, but still certainly a thing. Um, and that's just, just not breathing. It's a, it's a decreased or absent respiratory drive, you're not taking that breath. And you can actually kind of see a little bit of that with the dog as well, right? So. He's pretty quiet and peaceful. Um, if you looked closely though, you could see that little belly was starting to work harder, um, because of that upper obstruction, and then at times even just kind of stopping breathing. Um, so it's kind of trying to encapsulate all of that in that one video. So, how do we treat it? Um, and Mark is gonna get a little bit more into this as well. We certainly use medications for more mild sleep apnea, especially obstructive, um, things that are gonna help open the nose, take down any inflammation, things like that. Um, soft tissue surgery, so again, that, the tonsils and the adenoids, if they're obstructing the airway. Um, breathing machines, I like to say, so CPAP or BiPAP that's gonna put pressure in the airway to help open it up and help to um deal with that obstruction from a collapse standpoint. And then, um, oxygen, which kind of stabilizes the breathing. Newer things are the hypoglossal nerve stimulator, which basically helps to stimulate the tongue and get it out of the airway so that it's not obstructing things. Weight management, there's more pressure on the chest, it's gonna make it harder for you to take a breath. Um, sometimes just how you're positioned to help open that airway. So if you're flat on your back, everything's gonna fall back, but if you're on your side or your belly, you might sound a little bit better. And I included some newer ones. Dental appliances are certainly showing some efficacy, but it's still kind of a, a newer area for treatment. And then I included myofacial therapy because I see this on my Facebook reel all the time, which is like the fancy water bottles and Um, working with like speech therapists to really the, the idea is good of trying to strengthen those muscles in the mouth and in the airway, and well that maybe help treat um obstructive sleep apnea, but that really does not yet have any standardization um or data that's telling us it's, it's effective yet, so. And I really wanted to talk about why do you treat it. So, sleep apnea as a clinician can be very frustrating because going back to that dog video, a lot of parents don't see it. So I like to tell them it's not like asthma where your kid's actively wheezing or coughing in front of you. You may not see it because everybody's sleeping at night. Um, so even though we ask about snoring and all that, sometimes parents are like, I don't know, they go to bed, you know, and we hope for the best and we see them in the morning. So, um, but what's happening is you're not breathing at night, so that seems like a no-brainer to treat it, right? But really, you have to think about it from kind of the tissue or cellular level. So, you're not getting oxygen to the brain and to the body. And that can cause stress, right? So the body knows it's not getting oxygen. It's kind of like low-grade suffocation, right? So you're in that stress state all night instead of sleeping. And then a lot of the times, which is a good thing, the brain says, hey, I'm not breathing like I should, and so it wakes you up to take a better breath, but then you end up with insomnia and very disrupted or poor quality sleep. So this whole list of things on the side can come up. So, and this is often why we get referrals into our sleep clinic is growth and development, you know, a kid who's not growing, um, or there's developmental concerns, heart damage, so that heart is working harder because it's not getting the oxygen that it needs, so it can enlarge, um, and not work as effectively as it should. Metabolic effects. So we all know when you're in that stress state and you're not getting good sleep, you tend to have problems with insulin and metabolism, and you maybe even make poor dietary choices because you're not sleeping well. And then for children, of course, um, school, right, is where we can see a lot of times with how they're doing functionally. So we routinely will see referrals for focus, attention, you know, we're thinking about ADHD but we don't think this kid is sleeping well or the parent mentioned snoring. Um, suddenly, there's been a big change in how they're doing academically, um, you know, what's kind of going on there. Is it because of untreated sleep apnea? Um, so really important to treat it for all these reasons, not just so that you breathe at night. And then how do we find it? So, um, it's a good history, and then as of today, an in-lab sleep study is really the way that you can diagnose sleep apnea. Um, you can look at all the videos, you can hear all the symptoms, but that's really how you're gonna tell, is it there or not and how bad is it. Um, there are home oximetry studies, right? Things that can look at oxygen, um, with a little pulse oximeter on the finger, but that's just gonna tell you your oxygen fluctuation and not what's happening with the airflow, um, through the nose and the mouth, um, or what sleep state you're in or things like that. And in the adult world, um, HSAT or home sleep apnea testing is routinely done. Um, there's many different types of HSATs. New ones seem to come out every day, but the American Academy of Sleep Medicine, again, as of today, does not, um, recommend home sleep testing for children. Just because their sleep is different than adults, it's, it's pretty complex and it does change over um time. So, they really need a little bit more focused assessment. Sometimes we need assistance with putting monitors on them, so having a parent do that by themselves at home can be a little daunting, right? Um, so we still use in lab, um, sleep studies or polysomnography. I did include some other testing, um, when we go back to the effects on the body. So we do look at echocardiograms in sleep clinic. Is there already heart damage? Is there already changes going on there? Um, polycythemia on a CBC can be a sign that the body's trying to compensate for that low grade suffocation I mentioned, um, when you're not getting that good oxygen, is it trying to take care of that on its own? And then brain MRI's, um, sometimes certain, um, brain conditions like Chiari malformations or brain injuries can lead more to that central sleep apnea, where it's that respiratory drive, where it's not telling you to take that breath and things like that. And this leads me into um the next portion of our presentation where Mark's gonna take over. Um, we're gonna talk really a lot about that polysomnography and some special considerations for that, um, as far as finding sleep apnea. Well, there we go. All right, thanks, Carolyn. So I, I also wanted to take another opportunity to really thank the committee that put this together. I think they deserve a round of applause. It's been a great meeting so far, so. Anyway, and, and to check and see if everybody was awake. So polysommography or you typically hear called um a sleep study measures all these different things. Um, if you see the picture of the patient here, he's all hooked up ready for his overnight sleep study. Um, we're looking at not only um uh a kind of a mini EEG, I think there's 5 channels when they're in the sleep lab, but also airflow from the nose. Um, the movement of the jaw and the kind of the facial muscles. He does have a plug or a binky in his mouth. That's not part of the study. That's just to get him to cooperate long enough to hopefully take the picture and put all this stuff on. You see a transcutaneous monitor on there, which is also to measure, um, CO2 at the skin. He's got a band around his chest to, to measure chest movement, moving back and forth, um. And, um, also, um, they pick up sound in the sleep lab room so that they can hear if the patient's making noises, like snoring noises or gasping noises. And then there's also video monitoring so that the person that ultimately has to look at the sleep study will have the opportunity to see what the patient was doing during different phases of the sleep study or when something shows up, um, on one of these channels. The, the study is, is really comprehensive. It's very long. Hats off to our respiratory therapist who helped score the study, and then the pulmonologist actually ends up reading the study at the end. We also use polysommography, um, for patients with mechanical ventilation or patients that were weaning off mechanical ventilation, um, to help us apply therapeutic changes or to evaluate if the patient can be liberated from the ventilator. And if anybody wanted to say awe over this patient in the, in the picture here, it's, it's my, uh, it's my grandson. There we go, thanks. And then I always wondered how do people sleep when they go to the sleep lab. So this is supposed to illustrate that, but you can see you're hooked up with all this stuff. I can't imagine sleeping the night hooked up to this and having folks watch you. Um, an interesting thing happened to me in clinic actually is a, a patient saw the advertisement for this, uh, conference, um, on Facebook, um. And wanted me to tell a joke. So this is, this is my opportunity to tell a dad joke to all of you, and he gave me the joke, so you can groan if you like, but um uh the. The patient asked me. Did you hear the joke about the needle? That's OK, you wouldn't get the point. They And then, some of you didn't get the point. I, I heard the laughter later. Um, Carolyn already mentioned that in laboratory polysommography for children remains the gold standard, uh, for uh diagnosing obstructive sleep apnea or central sleep apnea in both the American Academy of Sleep Medicine, uh, American Academy of Pediatrics, and the American Thoracic Society all endorse that. So who are we gonna do a sleep study with? We already saw in our kind of our word cloud, we named off some things with uh snoring, gasping, um, labored breathing during sleep, um, disturbed sleep patterns, daytime sleepiness, um, inattentional learning problems. The patient has bedwetting, um, they're waking up with a headache every morning. And then we also have some patients who may have high risk conditions that would lead us to think that we wanted to check them with a sleep study as well. And some of those include patients with genetic, uh, chromosomal conditions such as Down syndrome, uh, patients with, uh, Uh, tonsillar hypertrophy, um, patients with midface or mandibular hypoplasias or, um, just facial abnormalities in general. A relative indicator would be patients with big tongues or small tongues or, um, other jaw related issues. Um, Patients with generalized muscular hypotonia or patients with increased obesity risks, such as, um, Prader-Willi syndrome, who have, uh, some, can have complex sleep disordered breathing, um, and we can see central or obstructive components with those patients as well. And then again, I mentioned the craniofacial abnormalities, um. The cleft palate, the high arched palate, or the microtathia. And then other craniofacial mal malformations, including, um, we can see craniofacial malformations in patients that have had traumatic injuries or who have had, uh, burn injuries to the face and then have had, um, to wear, uh, face mask or other, um, Devices to, to their scar area that will um keep their face from growing normally. So then we'll have a, um, uh, again, kind of a mid-face um area that doesn't grow correctly and that may develop sleep syndromes, especially with that. And then our neuromuscular patients, um, kids with muscular dystrophy, um, we're very fortunate to hear that we have a muscular dystrophy clinic, uh, a neuromuscular clinic, and many of those patients are seen in the sleep lab to measure for, um, not only disease progression, but when, to see if these patients need to go on, um, positive pressure ventilation, which I think, um, Carolyn mentioned before as well, and then other neuromuscular conditions, again, that affect the respiratory muscles. So this kind of speaks for itself. Um, we have a very high prevalence of OSA in kids who are overweight. Um, it's only about 9%, it's 9, it's considered to be about 9 to 12% prevalence in healthy weight children, but shoots up to nearly 50% in children with, um, obesity, um, and you can see there's actually a 1 unit increase in risk as the BMI goes up, and then, um. Uh, I'm sorry, uh, 1.9% risk as the, as, uh, as the obesity increases. The, um, research in adults is actually more, um, ominous, I guess is the right word. So heavy kids who may not have sleep apnea or obstructive sleep apnea may develop obstructive sleep apnea as adults, so. Again, importance of counseling and getting these kids in for um weight management is a very important. And then here's some other respiratory conditions that could be diagnosed by a sleep study, including, uh, congenital central alveolar hyperventilation syndrome, also known as Odin's curse. So, this is an example of a central sleep apnea. So, it's not an obstructive event, but it's actually the patient's not generating any, um, effort to, to breathe, um, usually during sleep. Um, again, it's a very rare syndrome, but it, it does occur, and, We see some of these kids as infants who have had, um, events in the nursery or events at home where they've had some cyanosis or oral, um, pharyngeal cyanosis. And then sleep related hyperventilation because of neuromuscular disorders or um the other one I didn't mention before, chest wall deformities. And then primary sleep apnea of infancy, and then central apneas, and again, the congenital central alveolar hyperventilation syndrome is just one form of a central apnea. So how do we diagnose it, so. Uh, the kids get a sleep study in the, in the sleep lab. Um, we look for, um, greater than one obstructive event per hour of sleep, or obstructive hypoventilation, which means they're inital or their transcutaneous CO2 has risen above 50% of, of 50 millimeters of mercury for 25% of the sleep time. Associated with snoring, paradoxical breathing, or flattened nasal airway wave form. And the nasal airway wave form, again, the patient that we showed as an example before had something that looks similar to a nasal cannula. They're actually measuring the amount of gas that's coming in and out at that time, and then graphically displaying it on the total of the sleep study. So, it's for the total period of time the patient's getting the sleep study, usually 7 to 8 hours. And then the abnormal, uh, AHI. So we look at AHI to diagnose the severity of the, um, obstruction. So mild would be 1 to 4 events an hour, moderates that 5 to 9 range, and then severe is considered greater than 10. Um, And again, just to mention, again, we look at this in totality. So the, the sleep study is the way that this is formally diagnosed, but the impact on the patient is the other thing that we're looking at, and Carolyn mentioned some of the, the additional side effects that can occur with that. So, a patient with moderate AHI who's having tremendous events during the day would obviously need a more aggressive approach than maybe somebody. Who's mild and not having any events or moderate and not having any events. So we diagnosed the um. Uh, OSA, and then it depends on what we do then. So, with infants, if they have an HI of less than 10, so that's in that moderate range, we would see if oxygen could blunt the impact of OSA. Um, usually done in the sleep lab, they call it a split study. So, the first night, half of the night is a diagnostic. The second half of the night is actually doing something about the OSA that they discovered. And what we're trying to do with the oxygen, it doesn't cure the OSA. There's no positive pressure, but the oxygen blunts all the desaturations that have gone along with that. So, the patient sleeps better, infants will feed better, um, on oxygen, because as we all remember, they're obligate nosebleed, breathers, so that they're able to get, um, their, uh, feeding in and still be able to breathe during that at the same time. If the AHI is higher, um, especially in an older child, the choice may need to be positive pressure, uh, with CPAP, or if they have a central, um, apneic event or severe OSA, they may need BiPAP. Which, again, uh, just to review, the CPAP is continuous airway pressure. The BiPAP is additional airway pressure on inspiration to kind of open things up, but then they have the continuous all during the whole time that it's applied. And then we talked a little bit about medical management, and I apologize, I've got Flonase on there, um, as a brand name instead of fluticasone, but we typically can use that for mild to moderate OSA to try to open things up. Again, I mentioned the oxygen and the positive pressure. Um, now there's some GLP ones that are available, um, I think just in the adult population right now might be for teens too. That, um, Zebound is approved for, um, use in OSA um for patients that can't tolerate other forms of therapy, and then Katie's gonna talk a little bit more in depth about the surgical management. Here's your ring. Thank you. OK. All right. So, like Mark said, I'm Katie Holtman. I am one of the ENT nurse practitioners here at Cincinnati Children's Hospital. And, um, I do have to say first that it has been such a blessing working with Carolyn and Mark for this presentation because, um, ENT and pulmonary are two sides to the same coin when it comes to obstructive sleep apnea in kids. And, um, I learned a lot from spending time with them over the last few months, and they got to go over these amazing details of obstructive sleep. Sleep apnea, and, um, CPAP and, and some other treatments. And now I'm gonna go over what soft tissue surgeries are the most common and um what we can do to help cure or improve that obstructive sleep apnea in kids. The first piece of the obstructive sleep apnea or obstruction, um, puzzle for children is the adenoids. Adenoid tissue is lymphatic tissue or lymphoid tissue. I explained to families that it's very similar to the tonsils, but just at the back of the nose. They're present at birth, but they don't start to enlarge until 3 to 6 months of age. It's very rare for the adenoids to be significantly enlarged before the age of 1, because they don't truly start to, um, Get a whole lot bigger until after that first year of life. Around age 6 or 7 is when they start to involute on themselves or or start to shrink, start to get smaller. By adulthood, if you take X-ray imaging, you don't see adenoid tissue on an X-ray. Um, I love this picture. I like to use this picture when I'm educating families as well, because you get to see this nice juicy, sorry, if anybody doesn't like that word, nice, um, lumpy, bumpy adenoid tissue here. It's a great example of adenoid hypertrophy. Uh, as you can see, it doesn't take a lot of skill to see that there's a lot of obstruction with that adenoid tissue right there. So hypertrophy is what Causes the obstruction and where the adenoids sit are very important because it's at the back of the nose, right where the nasal airway and oral airway meet, and also where the eustachian tubes drain out from the ears. So that's often why we will see patients in for, um, not just the adenoids being enlarged, but, um, chronic nasal congestion, or postnasal drip, uh, chronic fluid behind the ears, chronic sinusitis. Um, most often in kids, um, school-age children, chronic sinusitis is actually a chronic adenoid problem. Uh, the first step that you take in children who are school age, when they're having chronic sinus issues is addressing the adenoids. I tell families that the adenoids act like a dirty sponge, and it. Picture kind of fits that. So it soaks in all of these, um, particles and, and things that kids breathe in all day and seeps it into the tissues. So that's either going down the back of their throat, coming out of their nose in that chronic rhinorrhea, or feeding fluid and infection behind the tympanic membrane. Adenoid hypertrophy, like I said before, doesn't usually start to occur until 1 to 2 years of age. The signs and symptoms, nasal obstruction, snoring, mouth breathing, um, families will often describe the Darth Vader effect that can happen with nasal obstruction, where they will think a child is snoring and asleep, but they look over and they're awake, and you can all hear that sound in your head, the Sounding like Darth Vader bringing, breathing through his mask, um, which is a, a great sign, uh, we hear often from families about that nasal obstruction. And then another grouping of, of symptoms is this adenoid faces. So you can get what's called Denny's lines, which are creases right underneath the eye that you can see, um, and also allergic shiners, which is the dark circles that patients will come in having under their eyes. Um, I tell families, we as adults, um, particularly as moms, have other reasons for having the dark circles under our eyes that kids don't have. Um, but the reason these kids have them is because when there's chronic nasal obstruction, you have chronic nasal congestion, there is a pooling of the blood and the blood supply at the back of the nose from all of the increased pressure, which then leads to pooling of the blood, which can give them that dark color. It also causes much muscle twitching, which is what gives you those Denny's lines. Um, this is an adenoid picture. Let's see if I can get the pointer to work. Kind of sort of. Uh, OK, so. You can see. Sorry, I can't see very well. And here Yeah, it's not working. Um, there is the adenoid tissue. That is right here, right in this area. And you can see that that airway is more narrow, and you can see it opens up, um, beyond that kind of uh adenoid hypertrophy. The best way and only ways really to assess adenoid tissue from a clinical perspective is either with a nasopharyngeal X-ray, or with um a scope in clinic. You can't actually see the adenoids on physical exam. Um, so we get referrals over for adenoid evaluation, obviously for sleep disordered breathing symptoms or obstructive sleep apnea concerns. Um, the other reasons that we will get referrals over for that nasal obstruction, again, chronic otitis media because of the location of the adenoids and the recurrent sinusitis. I love this image too, so this is a great pre-op and post-op, um. View of an adenoidectomy. On the left side there, you can see the lumpy, bumpy adenoid tissue at the back of the nose, and then see how much improvement on the postoperative side there is in that airflow there. You can imagine how much of a difference getting that bit of tissue out can do for a patient. Uh, post-op phase. Compared to tonsillectomy, adenoidectomy, uh, is much easier. Um, we tell families that the patient will likely wake up from surgery, um, eat or drink something, go home. They are good to go to school post-op day one. If patients need any pain management, it's Tylenol and ibuprofen. Um, I also like to warn families that their child will have very funky breath for 1 to 2 weeks. Um, it is something that we will get calls from families thinking that something is wrong or they're infected because there's such a foul odor. We'll also have patients, I will frequently see them in clinic complaining of referred ear pain. Um, which makes sense because as you take those tissues out, they go in through the mouth and burn off the adenoids at the back of the nose. A lot of swelling happens, um, as they're healing and the tissues are healing at the back, um, which can lead to some of that eustachian tube pressure and referred pain. Um, and patients will also complain about a foul taste in their mouth, which I think is just the breath smelling so bad. Um, complications, bleeding risk. One that we talked to families about is velopharyngeal insufficiency, fancy term for too much air going into the nose, um, which can lead to a really breathy voice or, um, issues with food going up the nose when they're swallowing instead of all going down the way it's supposed to. Um, this is something that's rare, but when it does happen, we can treat that with, um, speech therapy, and, um, most often resolves. The second piece to the obstruction puzzle for pediatrics is, um, tonsils. Tonsils are one of the top two common reasons or concerns that that families come in when they're, um, coming to ENT for an evaluation. So we grade our tonsils on a scale of 1 to 4. I like to show families this image, but I also like to make sure they understand that we don't care so much about the size of the tonsil as we do the size of the symptom. Because if I have a patient who has large adenoids, tonsils that are maybe 2 or 3, but isn't having a ton of symptoms at nighttime, not having daytime symptoms, not affected, um, But I have a patient who has, you know, 2+ tonsils, and they are snoring every night. We have an obstructive index of 4, and they're having difficulty staying awake. I'm going to care more about the patient who's having, maybe has a little bit smaller tonsils, but is having more of the obstructive issues in their life. So enlarged tonsils, and both Carolyn and Mark touched on a lot of this, so I won't spend a whole, whole lot of time. The symptoms we ask about are, are both daytime and nighttime, snoring, pausing in the breathing, gasping and choking, restless sleep, bedwetting, um, sleeping with the neck hyperextended, mouth breathing, uh, difficulty waking up in the morning. Not all teenagers are difficult to wake up just because they're teenagers. Sometimes it's because they get really poor sleep. Um, but one thing I definitely want to touch on is aneuresis or, or bedwetting. When we are looking at this as a symptom of obstructive sleep apnea, it's not the child who has never been able to really stay dry at nighttime, as much as it is the patient that had spent several months or years dry at nighttime and then suddenly are having issues wetting the bed. That's more indicative to us that there is something going on with sleep. And again, sleep study is the gold standard. Um, we get referrals over for tonsils for the sleep concerns, the sleep disorder, breathing, um, recurrent infections, asymmetric tonsils, um, but the, the biggest of them for us is chronic tonsillitis and concerns for obstructive sleep apnea. So, when does a patient go from big tonsils and sleep symptoms to surgery? So, if I have a patient who's coming in with sleep disordered breathing symptoms, they need to have one of these kind of three adjunctive, um, issues. Whether that's hypertrophy of the tonsils, uh, failure to thrive, or a sleep study that documents obstructive sleep apnea. Um, with the hypertrophy of the tonsils, there needs to be some sort of Daytime symptom that we can reasonably expect to improve with removal of the tonsils and adenoids in order to take them out. Um. I have families all the time that will say, it's just happened yesterday. Um, I'll say, I don't think we need to worry about taking the tonsils out. And they say, You mean if I want the tonsils out, you won't just take them out. And I have to say no, no to that. And I think it's because there was a time when, um, tonsils and adenoids were taken out pretty frequently, and families know that this is a common surgery, and that's true. And it is very common. There are a lot of people who have had this done, but it's still a surgery. It's still, um, there's, you know, risks that we're going to talk about and complications. And, you know, we have to make sure we're making the best. Call in case for the patient. And, um, sometimes it's not cutting. Sometimes there's other things we can do like the fluticasone or, you know, other sorts of treatments. Um, But yes, they, they have to have some other component, um, other than just sleep disorder breathing symptom symptoms or just enlarged tonsils. Here's another fun pre and post-op view, um. Again, you can see that lumpy, bumpy tonsil tissue there on the left, uh, with the uvula, and then on the right, I do tell families that if you are squeamish, do not look back at the back of your child's throat in the post-op period for at least the 1st 2 weeks, because it is very ugly, it's very gross. Um, but from a breathing perspective, it's beautiful, um, because that is a nice open airway compared to what it was before. The post-op period, and there's another great image of it. Um, post-op period, we do scheduled, um, pain management with Tylenol and ibuprofen. We tell families every 3 hours scheduled medication. Including through the night for the 1st 7 to 10 days minimum. Um, I don't want patients to have pain. You know, we all know that it's, once your pain gets high, it's so much harder when you have to chase it. And so we like to do this scheduled treatment and give, um, families all the education about the importance of that. They'll also get a couple of doses of Decadron to help with swelling. And then kids who are 6 and older will get a little bit of extra pain medicine. Um, for some breakthrough pain, and, um, we no longer do the Tylenol with codeine because of, um, a black box FDA warning. Complications. This is a big soapbox I get on with families. And this is why I push the Tylenol and ibuprofen being scheduled, um. So significantly, because, and, and wanting to make the right choice for the patient when it comes to surgery is, yes, it's a common procedure, but there are risks with every procedure. There are risks taking the tonsils and adenoids out. Um, from a tonsil standpoint, I, um, always tell families that about 2% of patients, 2 to 4% of patients, um, will have issues with bleeding after surgery. That's typically because they stop drinking, they get dehydrated, and then those scabs at the back of the throat dry out and fall off too soon. And that is the tonsil hemorrhage. And for those of you who have seen that, I know it's burned into your brain. Um, that is a medical emergency. We have them come down to our main campus emergency room for treatment. Um, it is rarer or more rare, um, but it doesn't sound like a big number, 2 or 3 out of 100, but it's a big number when that's your child. Um. So, I tell families, when you're going home, your job is to hydrate, hydrate, hydrate, ice cream, slushies, smoothies, popsicles, water, juice, Gatorade. This is about when I get a big smile from a patient when they hear that. Um, they get as much of that as they want for two weeks. Um. This helps to, this with the scheduled treatment of the ibuprofen and Tylenol really helps to mitigate our risks from surgery because it keeps them hydrated, keeps their pain under control. Um, and, you know, the more hydrated they are, the less pain they're going to have, the better they're going to feel. And, you know, the, the more common post-op course they can have. So special considerations, um, and you know, you know, Mark has touched on this as well. Um, there are a lot of special considerations when it comes to adenotonsillectomy, um, in, in patients. We have a, um, large population in both of our divisions of patients with Down syndrome. Um, the patients with Down syndrome often have multi-levels of obstruction. So it's less likely that taking out the tonsils and adenoids is going to completely cure their obstructive sleep. And that doesn't mean we don't do it. Um, even in cases where there's multi-levels of obstruction, we're still going to do what we can to help improve that. Uh, we have an ENT Down syndrome clinic, um, and we also have a complex obstructive sleep apnea clinic that we do in conjunction with, um, pulmonary for some of our patients who have Down syndrome and then craniofacial abnormalities. We talked about, um, the velopharyngeal insufficiency, but our patients with craniofacial abnormalities, um, particularly cleft lip and cleft palate, have a much higher incidence or risk for that VPI. Uh, we do things intraoperatively to try and mitigate that risk. Patients that we are concerned about a submucosal cleft or a cleft palate or our craniofacial kids that may have more of a risk of VPI will do something called, um, a superior half adenoidectomy. So, um, they won't remove the whole adenoid tissue, but they will remove enough to increase airflow, but to keep it from being too open. Um, and then obesity-wise, Mark touched on this as well, weight management versus GLP1s versus bariatric surgery. It will be great once we can get some, um, data and testing and approval on younger, you know, younger patients, not just adults with GLP1 treatment. Um, but it's made a big difference in the adult world and, you know, we have options here for kids as well. Um, now, this is a population that's very close to my heart. Um, I run a sensory-friendly clinic, an ENT. Um, we have our sensory superheroes that I feel like don't get a nod all the time, um, when it comes to these day in and day out, normal type procedures that we have. Um, sleep studies we talked about are the gold standard. Sleep studies are a time cost, and they're a financial cost. So for our neurotypical families, even, if I have a patient who has Enlarged tonsils and very obvious obstructive symptoms, I don't need that sleep study to say, all right, it would be beneficial to take the tonsils and adenoids out. Um, it's something that I like to think about for my patients who have sensory difficulties, who have autism, who, um, are just what I like to call neuro-spicy, um, because It's daunting as a parent to think of your neurotypical child having to go to a sleep study and have all of these monitors put on, and not being in their own environment. It's very, very intimidating and nearly impossible for some of our families to even grasp the idea of their, you know, um, neurodivergent kid going in and having a sleep study. Um, I like to lean on the families a lot when it comes to that, even when it comes to surgery. Um, there are When I first started talking to families about it, because I, I talk about sleep and sensory friendly clinic a lot. Uh, if they're going to be coming in for an adenotonsillectomy, I want to ask the family what they think about the post-op period. Do you think it would be better to go home, uh, or do you think it would be better to come into the hospital? And one family may say, oh no, I'm going to need help getting medicine in. I'm going to need help making sure fluids are getting in. I want to stay overnight. I want to have all the help that I can get. Um, and the next parent might come in and say, absolutely not. I will do so much better having them at home in their own environment with their own things. Um, and that's going to be best for my child. And we know that, you know, they can have an increased risk for complications, um. And clearly, the idea of CPAP, uh, I think, and correct me if I'm wrong, the adult compliancy rate of CPAP, I believe is 53%. And so if grown adults have trouble being compliant every night, um, uh, you can imagine neurotypical and neuroatypical kids would have a very hard time being compliant. Does anyone have any questions for us? And on and online too. Thank you guys. I have a question from the online audience. In pediatric patients with severe sleep apnea who are planning for bariatric surgery, how important is initiating CPAP treatment before surgery? Many of our patients and families refuse CPAP treatment thinking the weight loss post-surgery will immediately solve the issue. Yeah, so that's a great question. Um, unfortunately, most of the data to answer that is, is for adults, but, um, I think the physiology is still applicable for, for pediatrics. Um, they have shown that when you go into surgery with the best oxygenation and kind of going back to that discussion of what is sleep apnea doing to the tissues in the body and to the heart. So if you're going into a procedure with, without those reserves, with that stress on the body, they do, they have a pretty good study in the adult population that shows that there are poorer surgical outcomes, um, following bariatric surgery when there's untreated sleep apnea going into that. Surgery. So in my sleep clinic, I do get quite a bit of bariatric surgery referrals, um, with that thought of, yeah, we're gonna have weight loss and that's gonna treat the sleep apnea and that's very likely true. It is very effective for that, um, but we do need to treat it before you have surgery. Thank you. I have two additional questions. Um, one is just out of curiosity for the picture that Mark put up with the baby that had the pacifier and all of the things on. Um, do you guys recommend like if someone is having sleep apnea symptoms, if they have a pacifier, you would recommend like getting rid of that prior to doing the sleep study or it's beneficial to have one, or? Not. That is a great question that I have never been asked in my over a decade of being in sleep clinics. Um, so, we, I usually lean towards let the child do what they want to do when they're sleeping, right? Our brains are very smart and they tend to, um, to appreciate even that sleep apnea happening. Now, it can make it more challenging for a sleep study, right? If you're having that, um, airway occluded, and then we're trying to do some nasal breathing, and that's where the cannula is too. So for a sleep study, I would lean towards trying to get that pacifier out before you come to the lab so we can get a better assessment that there's some practical considerations there because we want the patient to sleep. And if that's the only way they're gonna sleep, the pacifier should go in. I mean, there's some real challenges. They're already hooked up with all this stuff. They're already in a strange place. So it, it becomes an issue, but it's a great question. And just to follow up on that for all of the community, uh, providers out there. So if you have a patient that is exhibiting these symptoms, what is, you know, I'm sure as all of the Cincinnati Children's specialties, that there's a long waitlist to get into the sleep clinic. So what do you. What do you recommend for us to give to patients while they're like awaiting to get in if their child is having episodes overnight, um, that are, of course, concerning as a parent, um, what would you recommend while they're awaiting to get in to get their sleep study? That's a great question. So I think everybody in this room knows that as Cincinnati Children's being where we are, we are actually servicing an entire tri-state area in one facility. I feel like a lot of the time, and our, our wait times can sometimes be on the longer end. Um, that's actually why I have all these folks up here. With me is sometimes we have to kind of do everything at the same time. So, send them to ENT if they have big tonsils or risk factors there, let's get that ball rolling and see how they feel as far as symptoms and things like that, um, you know, from a pulmonary side, if there's other considerations or things that we're gonna do treating them there, um. There's not really a great answer to that as far as what can you do at home, right? I, I encourage positioning. So if you're more upright, that's gonna help open your airway and help you breathe better. So things like wedge pillows, getting kids on their side. Um, I think all of us up here are very big fans of fluticasone and things that are gonna help open your nose and help you breathe a little bit better. It's not 100%, certainly not for severe apnea, but that can help a little bit as well. Um, but, um, yes, that is certainly a challenge and just a little soapbox on that. That's why we kept bringing up the sleep study in lab as the gold standard. There is a panel right now with the American Academy of Sleep Medicine that is trying to figure out how else can we assess sleep apnea in children, because the idea that you can get everybody to come into a sleep lab at night and for that cost and that tolerance factor is just really not realistic and then it delays that care. So I just wanna add something too just from a community perspective, if you have patients that you're gonna send um with sleep concerns. Have them take videos. Uh, videos are a big, big help. Um, there was a study that was done with providers who are sleep trained or familiar with sleep issues, looking at videos of kids sleeping, who then had sleep studies and how often were the providers correct about their diagnosis, and it was a very, very high percentage. So, um, I love having videos and I think parents like to have something to do in the meantime as well. Um, so that would be my, my two cents for that. And my other plug for that is we are doing better about getting kids in. So thanks guys. Uh, one more question from online from Jessica. If a patient has sensory needs with concerns for sleep apnea, is it better to refer them to sleep clinic or to ENT sensory clinic? And how does one refer to sensory clinic? That is a great question, um. Um, so for me, if there are. Was the first part of that question again? Sorry, my ADHD kicked in. If they have sensory issues, should you refer to, uh, ENT sensory clinic or sleep clinic? Yes, so, uh, one of the things that we're really blessed with here is we have, um, several physicians in ENT who are double boarded in sleep and otolaryngology. Um, so, if there's a concern and you have a patient who has sensory needs or concerns, and you're not quite sure if a sleep study is going to be the right route, I would, uh, just refer over to ENT. You can refer over to both at the same time, like Carolyn said, we can kind of do things at the same time, likely get in with us a little bit quicker. Um. But referrals, if you refer over to ENT you can just put sensory-friendly clinic on there or feel free to email or or Epic message if there's a particular patient. Um, it's, it's me and, and my schedulers who take care of that. And will the scheduling center know if they ask? No, so the scheduling center is not aware. These are patients that we are trying to make sure really need the appointments and really need the service that we provide. So it would have to be direct referral to ENT and it has to be, it has to state on the referral sensory friendly clinic. Thank you. So for our outpatient folks, there, um, there are some screening tools available, and I use one in a research study that I'm doing with asthma kids looking at comorbidities called stop bang. How like that factors in neck circumference and BMI and, and blood pressure, like how accurate are screening tools? Like you get a kid who comes in and has snoring, like. Other than a history, obviously, are any of these screening tools readily used? Should we be? I don't, yeah. Yeah, that's a great question. The stop bang, I feel like is a little bit more applicable to the adult world because of that neck circumference piece. They do actually measure adults' necks in sleep apnea clinics, and that there's a direct correlation with degree with sleep apnea and degree of sleep apnea. Um, there's a Michigan breathing score that that we use in sleep clinic that's pretty quick and it asks about like snoring and pausing. Um, and that has been, um, you know, validified, and I think that's a good screening tool, but long and short of it, there are multiple screening tools for, um, sleep apnea. We also use the PESs quality of life, which, um, sometimes that in conjunction with the Michigan breathing can tell you how much is this affecting them functionally and what are you hearing symptom wise. So I think that's. That's another great, yeah, like, because you sometimes you'll hear, well, they snore, but only when they're congested or yeah, you know, and so then you're like, well, do I need to send you to the sleep clinic, right. So yeah, I think when if those numbers are high, like the the Michigan breathing really breaks down a lot of um the snoring, the pausing, that you have to answer a lot of yeses on that for it to be like, yeah, this is sleep apnea. So I think that's a great screener. Yeah you ever use that. So, and yeah, we, well, we use, so we use the upward sleepiness score in sleep clinic, that's just more specific to daytime sleepiness, and they now have one that is specific to children because it used to talk about like when you're driving in a car, how likely are you to fall asleep. We're not gonna ask our six year olds that, um, but that can also tell you how sleepy is this kid, because that's another thing too, where some parents, it's like, well, they nap after school sometimes, you know. So, um, that's another good screener for sleepiness. It's Epworth sleepiness score ESS, and now it's ESS Chad is the one for, for kids. I'm gonna chime in real quick too. Something that I don't know if you guys have seen yet, um, just from a community perspective, I'll have families come in more recently after having seen the dentist or the orthodontist with their in-office fancy CTs, I think they are, and they're giving airway scores to families and we'll tell them. That they have a narrow airway. Um, so we'll get that a lot in. I'll get a lot of families coming in. We said we have a narrow airway, we need to get our tonsils and adenoids out. Uh, and there's not a lot of great data on the correlation with that and actual tonsil adenoid, um, obstructive apnea issues. Um, so if you get a family that comes in and asks about that, it's not something to panic about. Um, it does not mean that they have airway obstruction and they need to be seen right away. Uh, and, and just another point too. If you're considering if there's sleep issues and deciding who, who to refer to first, one of the benefits of referring to both at the same time is that if there are obvious physical reasons for having obstruction and symptoms, we can clearly take care of that, and then they maybe not, don't have to see the sleep clinic. But on the flip side, side, if there isn't obvious physical reasons, we get a sleep study, we have that information already done. We have the hardest part taken care of. And then by the time they're seeing the sleep clinic, they're already set up with all the information and all the other boxes have been checked. So it sets the family and the patient up for the most. Um, streamlined care. Thank you guys.