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Pneumonia AspirasiPneumonia Aspirasi
pada Anakpada Anak
Divisi Respirologi AnakDivisi Respirologi Anak
Ilmu Kesehatan Anak FK Unand-RS Dr. M.Ilmu Kesehatan Anak FK Unand-RS Dr. M.
DjamilDjamil
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SejarahSejarah
400 thn SM : Hippocrates400 thn SM : Hippocrates bahayabahaya
aspirasiaspirasi
Mendelson th 1946 :Mendelson th 1946 : aspiration lungaspiration lung
injury injury
Sampai 50 thn terakhir masih menjadiSampai 50 thn terakhir masih menjadi
tantangan pada anak dan dewasatantangan pada anak dan dewasa
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DefinisiDefinisi
ne!monia aspirasi : istilah !m!mne!monia aspirasi : istilah !m!m!nt!k beberapa sindrom klinik!nt!k beberapa sindrom klinik
"ejala klinik tergant!ng material"ejala klinik tergant!ng materialyang teraspirasiyang teraspirasi
#ipikal : berisi makanan $ cairan#ipikal : berisi makanan $ cairanberasal dari lamb!ngberasal dari lamb!ng
%isa j!ga &at lain seperti minyak%isa j!ga &at lain seperti minyaktanah' benda asingtanah' benda asing
(omplikasi : in)eksi(omplikasi : in)eksi
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KlasifikasiKlasifikasi
Men!r!t wakt! kejadian :Men!r!t wakt! kejadian :
* ak!t* ak!t
* silent* silent Men!r!t j!mlah materi :Men!r!t j!mlah materi :
* sedikit* sedikit
* masi) * masi)
Men!r!t jenis material :Men!r!t jenis material :padatpadatcairancairan
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KlasifikasiKlasifikasi
Acute,
large-volume aspiration
Recurrent, small-volume
aspiration and GER
oreign !odies
"ear dro#ning
$%drocar!on &kerosene'
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(onditions Predisposing to(onditions Predisposing to
aspiration )ung *njur%aspiration )ung *njur%+natomic and+natomic and
mechanicalmechanical,e!rom!sc!lar,e!rom!sc!lar Miscellane!sMiscellane!s
,asogastric,asogastric
t!bet!be-aryngeal cle)t-aryngeal cle)t remat!rityremat!rity oor or oraloor or oral
hygienehygiene
tracheostomytracheostomy .le)t palate.le)t palate .erebral palsy.erebral palsy
/##/## "/"/ Hydrocephal!sHydrocephal!s
MicrognathiaMicrognathia M!sc!larM!sc!lardistrophydistrophy
MacroglosiaMacroglosia
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+ Pneumonia Aspirasi akutmasiv+ Pneumonia Aspirasi akutmasiv
#ipikal : mengand!ng makanan#ipikal : mengand!ng makanan $cairan dari lamb!ng $cairan dari lamb!ng
Mengakibatkan per!bahan patologiMengakibatkan per!bahan patologi
dan )isiologi' tgtg pH dan j!mlahdan )isiologi' tgtg pH dan j!mlahmaterialmaterial
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)argesmall particle
Acidneutral li.uid Aspiration
Refle/ air#a%
clossure
Air#a% o!struction
Severe h%poventilation
Pulmonar% edema
$emorrhagic pneumonitis
Destruction and
dilution of surfactant
AtelectasisHypoxemia
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Patholog%cal changesPatholog%cal changes
#ime a)ter aspiration e2ent3#ime a)ter aspiration e2ent3 athologic changesathologic changes
+ )ew min!tes acid asp3+ )ew min!tes acid asp3 +telectasis local+telectasis local
%e)ore 4 ho!rs%e)ore 4 ho!rs /pithelial degeneration o) bronch!s'/pithelial degeneration o) bronch!s'
!lmonary edema' hemorrhagic with!lmonary edema' hemorrhagic with
necrosis type 1 al2eolar cells'necrosis type 1 al2eolar cells'
in)iltrations and )ibrins in al2eolarin)iltrations and )ibrins in al2eolar
spacesspaces
,et 4*76 ho!rs,et 4*76 ho!rs +l2eolar consolidation' m!cosal+l2eolar consolidation' m!cosal
slo!ghingslo!ghing
+)ter 48 jam+)ter 48 jam Hyaline membran may be seenHyaline membran may be seen
%y ho!rs%y ho!rs egeneration o) bronchial epitheli!m'egeneration o) bronchial epitheli!m'
proli)eration o) )ibroblast' decreaseproli)eration o) )ibroblast' decrease
ac!t in)lammationac!t in)lammation
+)ter *7 weeks+)ter *7 weeks arenchymal scarring' bronchiolitisarenchymal scarring' bronchiolitis
obliteransobliterans
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(linical 0anifestations(linical 0anifestations
n2ol2ed witnessed inhalation o)n2ol2ed witnessed inhalation o)
2omit or tracheal s!ctioning o)2omit or tracheal s!ctioning o)
gastric contentsgastric contents
Ha2e se2eral risk )or aspirationHa2e se2eral risk )or aspiration
Mild or se2ere respiratory distressMild or se2ere respiratory distress
.lassic Mendelson syndrome :.lassic Mendelson syndrome :asthma like reactionasthma like reaction whee&ing'whee&ing'
hypoemia' hypercapniahypoemia' hypercapnia
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(linical manifestations(linical manifestations
;e2er' co!ghing and whee&ing;e2er' co!ghing and whee&ing
-ab )inding : le!kocytosis-ab )inding : le!kocytosisin)ection <3in)ection <3
adiological : in)iltrates' esp rightadiological : in)iltrates' esp right
!pper lobes!pper lobes
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0anagement0anagement
S!pporti2e : oygen therapy' mechanicalS!pporti2e : oygen therapy' mechanical2entilation with //2entilation with //
%ronchoscopy and la2age )or large particle%ronchoscopy and la2age )or large particle
,o 2al!e to la2age )or ne!trali&ed acid,o 2al!e to la2age )or ne!trali&ed acidaspiratedaspirated
Maintained intra2asc!lar 2ol!meMaintained intra2asc!lar 2ol!me .orticosteroid : still contro2ersial' !se)!ll.orticosteroid : still contro2ersial' !se)!ll
when gi2ed close to the time o) massi2ewhen gi2ed close to the time o) massi2easpiration' =aspiration' =
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1utcomes1utcomes
Mortality : 40 > 80 ?Mortality : 40 > 80 ?
n)ectio!s complications : 50?n)ectio!s complications : 50?
+ntibiotic )or initial therapy :+ntibiotic )or initial therapy :penicillin' ampicillin' clindamycinpenicillin' ampicillin' clindamycin
.hest perc!ssi2e therapy.hest perc!ssi2e therapy
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(onditions Predisposing to infectious(onditions Predisposing to infectious
complications of Aspirationcomplications of Aspiration
"ingi2itis"ingi2itis
@ecayed teeth@ecayed teeth
"astric o!tlet or intestinal obstr!ction"astric o!tlet or intestinal obstr!ction /nteral t!be )eeding/nteral t!be )eeding
rolonged hospitali&ationrolonged hospitali&ation
/nditracheal int!bation/nditracheal int!bation Ase o) antacid$H blockersAse o) antacid$H blockers
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2 Recurrent, small-volume2 Recurrent, small-volume
aspiration and GERaspiration and GER
Microaspiration or silent aspirationMicroaspiration or silent aspiration
Small aspiration into the l!ngSmall aspiration into the l!ng
"/ : "astro /osophagal e)l!"/ : "astro /osophagal e)l! #here is a relationship among#here is a relationship among
rec!rrent aspiration' "/ andrec!rrent aspiration' "/ and
respiratory diseaserespiratory disease
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Mechanisms or the association oMechanisms or the association o
!"R and Respirator# disease!"R and Respirator# disease
!"R$ causing respirator# disease!"R$ causing respirator# disease
AspirationAspiration
Direct eect % &ronchitis$ tracheitis$ pneumonia$ atelectasisDirect eect % &ronchitis$ tracheitis$ pneumonia$ atelectasis
Rele' rom irritation o trachea or upper air(a#$Rele' rom irritation o trachea or upper air(a#$
lar#ngospasm$ &ronchospasmlar#ngospasm$ &ronchospasm
Indirect eect % inlammator# or another alterationIndirect eect % inlammator# or another alteration
predisposising to air(a# h#perreactivit#predisposising to air(a# h#perreactivit#
"sophageal % air(a# rele' (iout aspiration"sophageal % air(a# rele' (iout aspiration
Respirator# disease causing !"R Respirator# disease causing !"R
diaphragma lattening and changes o intraa&dominal pressurediaphragma lattening and changes o intraa&dominal pressure
gradientgradient
"ect o medication causing decreased lo(er esophageal sphincter"ect o medication causing decreased lo(er esophageal sphincter
pressurepressure
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Disorders associated #ith GERDisorders associated #ith GER
+sthma+sthma %ronchiolitis%ronchiolitis
obliteransobliterans
.hronic co!gh or.hronic co!gh or
whee&ingwhee&ing
+pnea' bradycardia+pnea' bradycardia
+telectases+telectases +c!te li)e threating+c!te li)e threating
e2entse2ents
%ronchiectasis%ronchiectasis StridorStridor!lmonary )ibrosis!lmonary )ibrosis HoarsnessHoarsness
ne!monia'ne!monia'
bronchitisbronchitis
-aryngomalacia-aryngomalacia
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3 oreign !od% aspiration3 oreign !od% aspiration
Brganic or anorganic materialBrganic or anorganic material
nitially placing objects in the mo!thnitially placing objects in the mo!th
#here is three distinct clinical phase#here is three distinct clinical phase
* period immediately a)ter the aspiration:* period immediately a)ter the aspiration: co!ghing' gagging' chokin' stridor' whee&ing'co!ghing' gagging' chokin' stridor' whee&ing'
cyanoticcyanotic
* min!tes to month : asymtomatic phase* min!tes to month : asymtomatic phase
* renewed symtomatic period : o!gh' sp!t!m* renewed symtomatic period : o!gh' sp!t!mprod!ction' )e2er' whee&ing' hemoptysisprod!ction' )e2er' whee&ing' hemoptysis
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Supporting 0anagementSupporting 0anagement
o chest + and -ateralo chest + and -ateral
May be radiol!scentMay be radiol!scent
o epiration and inspirationso epiration and inspirations %ronchoscopy ' %ronchography%ronchoscopy ' %ronchography
+c!te aspiration : Heimlich+c!te aspiration : Heimlich
mane!2ermane!2er %lind )inger sweeping is%lind )inger sweeping is
contraindicated in in)antcontraindicated in in)ant
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(omplications after air#a% foreign(omplications after air#a% foreign
!ad% removal!ad% removal+c!te airway+c!te airway
obstr!ctionobstr!ction-aringeal laceration-aringeal laceration
ne!momediastin!mne!momediastin!m %ronchial stenosis%ronchial stenosis
ne!mothorane!mothora #racheoseophageal#racheoseophageal
)ist!la)ist!la
Massi2e hempotysisMassi2e hempotysis @istal bronchiectasis@istal bronchiectasis
-aringeal edema-aringeal edema
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4 "ear dro#ning4 "ear dro#ning
Most likely in children !nder 5 yearsMost likely in children !nder 5 years -!ng inj!ry ind!ced hypoia to the l!ng-!ng inj!ry ind!ced hypoia to the l!ng
parenchyma as well as aspiration o) water'parenchyma as well as aspiration o) water'
debris' gastric contents' or bacteriadebris' gastric contents' or bacteria n )resh water aspiration : p!lmonaryn )resh water aspiration : p!lmonary
s!r)actant is washed o!t and dil!teds!r)actant is washed o!t and dil!ted atelectasisatelectasis
n saltwater aspiration : osmotic shi)t o)n saltwater aspiration : osmotic shi)t o)protein*rich )l!id )rom the capillary intoprotein*rich )l!id )rom the capillary intothe al2eolithe al2eoli p!lmonary edemap!lmonary edema
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5 $%drocar!on aspiration5 $%drocar!on aspiration
isk )actor : preschool age' mental retardation'isk )actor : preschool age' mental retardation'
etcetc
(erosene : most commonly(erosene : most commonly
Sign and symptom : choking' co!ghing' gaggingSign and symptom : choking' co!ghing' gagging ;e2er' cyanosis' se2ere respiratory distress;e2er' cyanosis' se2ere respiratory distress
o changes : appear a)ter 70 min!tes a)ter ingesto changes : appear a)ter 70 min!tes a)ter ingest
hydrocarbon' most commonly in 1 ho!rshydrocarbon' most commonly in 1 ho!rs
@econtamination like : ind!ction o) 2omiting'@econtamination like : ind!ction o) 2omiting'nasogastric la2age' are contraindicatednasogastric la2age' are contraindicated
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OSASOSAS::(Obstructive sleep(Obstructive sleep
apnea syndrome)apnea syndrome)
aaconsequenceconsequence
of childhoodof childhood
obesitobesit
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*ntroduction*ntroduction
ObstructiveObstructive sleep apnea syndromesleep apnea syndrome
(OSAS)(OSAS)
is ais a disorder of breathingdisorder of breathing during sleepduring sleepthat disrupts normal ventilation as wellthat disrupts normal ventilation as well
as sleep pattern and associated withas sleep pattern and associated with
symptoms including habitualsymptoms including habitual snoring,snoring,sleep diculties, and/or daytimesleep diculties, and/or daytime
neurobehavioral problemsneurobehavioral problems
Pediatrics !!"#!$#%!Pediatrics !!"#!$#%!
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……IntroductionIntroduction
Prevalence of OSAS in &S$ #%#!'Prevalence of OSAS in &S$ #%#!' he most common symptom of OSAS he most common symptom of OSAS
in children isin children is snoringsnoring is* factors$is* factors$
+ adenotonsillar hypertrophyadenotonsillar hypertrophy+ obesityobesity
+ craniofacial anomaliescraniofacial anomalies+ neuromuscular disorderneuromuscular disorder
Am am Physician !!-".$##-0%1-Am am Physician !!-".$##-0%1-
Pediatrics !!"#!$0!-%#Pediatrics !!"#!$0!-%#
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onsilloadenoidectomy onsilloadenoidectomy (A) is the(A) is the2rst line therapy2rst line therapy
3linical s4uealae$3linical s4uealae$
+neurobehavioral problemsneurobehavioral problems
+cardiovascular problemscardiovascular problems
+failure to thrivefailure to thrive
+mortalitymortality
Sleep 5edicine eview !!6"0$.#%7!Sleep 5edicine eview !!6"0$.#%7!
Am am Physician !!-".$##-0%1-Am am Physician !!-".$##-0%1-
……IntroductionIntroduction
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DefinitionDefinition
1SAS is during 6 hours of nocturnal sleep,1SAS is during 6 hours of nocturnal sleep,
at least 37 apneic episodesat least 37 apneic episodes
Apnea #as defined as cessation of Apnea #as defined as cessation of
respirator% flo# for at least +7 secondsrespirator% flo# for at least +7 seconds
A$* A$*8 the ratio of the total num!er of8 the ratio of the total num!er of
apneas and h%popneas o!served to theapneas and h%popneas o!served to the
total sleep time in hourtotal sleep time in hourPediatrics 1976; 58:23-31.
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8e2nition8e2nition
8isorder of breathing during sleep8isorder of breathing during sleep
Prolonged partial upper airwayProlonged partial upper airway
obstruction 9/ intermittent completeobstruction 9/ intermittent complete
obstructionobstruction
8isrupt normal ventilation during sleep8isrupt normal ventilation during sleep
9 normal sleep pattern9 normal sleep pattern
Symptoms$ snoring, sleep diculties, 9/Symptoms$ snoring, sleep diculties, 9/
daytime neurobehavioral problemsdaytime neurobehavioral problems
Pediatrics !!"#!$#%!Pediatrics !!"#!$#%!
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is! factorsis! factors
Enlarge tonsils and or adenoidsEnlarge tonsils and or adenoids Craniofacial abnormalitiesCraniofacial abnormalities
AgeAge Sex: Adult Male>>>Sex: Adult Male>>> ObesityObesity
)"RS Monograph *++,%-/01)"RS Monograph *++,%-/01
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3linical manifestation3linical manifestation
SnoringSnoring
Sleep disorder breathingSleep disorder breathing
Apnea episodesApnea episodes
5outh breathing5outh breathing
re4uent awa*eningre4uent awa*ening
8iaphoresis8iaphoresis
:;cessive daytime somnolent:;cessive daytime somnolent :nuresis:nuresis
e;tboo* of pediatrics< #0 e;tboo* of pediatrics< #0thth edision< !!-$#60%7.edision< !!-$#60%7.
Am am Phisician !-".$##-0%1-Am am Phisician !-".$##-0%1-
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3linical manifestation3linical manifestation
8uring wa*efulness are often normal8uring wa*efulness are often normal
Adenotonsillar hypertrophy$ mouthAdenotonsillar hypertrophy$ mouth
breathing, nasal obstruction duringbreathing, nasal obstruction during
wa*efulness, adenoidal facies 9 hyponasalwa*efulness, adenoidal facies 9 hyponasal
speechspeech
3omplications$ systemic hypertension,3omplications$ systemic hypertension,
pulmonary hypertension 9 poor growthpulmonary hypertension 9 poor growth
Pediatrics !!"#!$0!-%#Pediatrics !!"#!$0!-%#
Am am Phisician !-".$##-0%1-Am am Phisician !-".$##-0%1-
"#A#"#A#
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"#A#"#A#Ad$%t &'i%dren
Snoring With pauses ContinuousGender M:!"#$%:$ M:!$:$
Enlarged &#A 'ncommon Most common
Obesity Major MinorComplications cardiopulmona
ry
Gro(th)
beha*ior)
de*elopmentalSurgical minority Most cases
C+A+ Most common Selected
cases
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Pat'op'ysio%o(yPat'op'ysio%o(y
,ncreased,ncreased fat depositionfat deposition in thein thepharyngeal (allspharyngeal (alls
External compressionExternal compression
by superficiallyby superficially
located fat masseslocated fat masses ,ncreased,ncreased neck circumferenceneck circumference
Deegan PC et al. ERS Monograph 1998: 28-62
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8iagnosis8iagnosis
=old standard$ polysomnography (PS=)=old standard$ polysomnography (PS=)
Pediatrics !!6"##$70!%0Pediatrics !!6"##$70!%0
>ead and nec* surgery%otolaryngology" #7< h< 0!0%>ead and nec* surgery%otolaryngology" #7< h< 0!0%
8? SaO
5ild 1%! @71
5oderate #%-! .1%7-
Severe @-! .1
able #< 3lassi2cation of OSAS
Severity
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Screening testScreening test
3linical score3linical score
Pulse o;ymetryPulse o;ymetry BideotapingBideotaping
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3linical score3linical score
hree 4uestions hree 4uestions
+ >ow often would you say your child has>ow often would you say your child has
diculty breathing when he or she isdiculty breathing when he or she is
sleepingCsleepingC(!Dnever, #Doccasionaly, Dfre4uently, 6Dconstantly)(!Dnever, #Doccasionaly, Dfre4uently, 6Dconstantly)
+ 8oes your child stop breathing when he8oes your child stop breathing when he
or she is asleepCor she is asleepC
(!Dno, #Dyes)(!Dno, #Dyes)
+ >ow often would you say your child>ow often would you say your child
snoresCsnoresC (!Dnever, #Doccasinaly,Dfre4uently,(!Dnever, #Doccasinaly,Dfre4uently,
6Dconstantly)6Dconstantly)
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OSAS scoreDOSAS scoreD
#,-(a) E #,-#(b) E !,0#(c) % 6,06#,-(a) E #,-#(b) E !,0#(c) % 6,06
Frouillette classi2cation$Frouillette classi2cation$
+%#D OSAS (%)%#D OSAS (%)
+ %# G 6,1D doubtfull%# G 6,1D doubtfull
+@6,1D OSAS (E)@6,1D OSAS (E)
HH3linical score3linical score
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5anagement5anagement
Surgical$Surgical$
+ onsilloadenoidectomy onsilloadenoidectomy
+&vulopalatoplasty&vulopalatoplasty
+3raniofacial correction3raniofacial correction
+ racheostomy racheostomy
Am am Phisician !!-".$##-0%1-Am am Phisician !!-".$##-0%1-
Sleep 5edicine eview !!6"0$.#%7!Peditrics !!"#!$0!-%#Sleep 5edicine eview !!6"0$.#%7!Peditrics !!"#!$0!-%#
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HH5anagement5anagement
Ion surgicalIon surgical
+educing body weighteducing body weight
+3ontinuous positive airway3ontinuous positive airwaypressurepressure (3PAP)(3PAP)
+3anule o;ygen3anule o;ygen
+3orticosteroid3orticosteroid Am am Phisician !!-".$##-0%1-Am am Phisician !!-".$##-0%1-
Sleep 5edicine eview !!6"0$.#%7!Sleep 5edicine eview !!6"0$.#%7!
Peditrics !!"#!$0!-%#Peditrics !!"#!$0!-%#
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Other testsOther tests Polysomnography (PS=)$ severe OSASPolysomnography (PS=)$ severe OSAS
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")ese - "#A#")ese - "#A#
Obese children (ith breathingObese children (ith breathingdifficulties: -. / 012 OSASdifficulties: -. / 012 OSAS
Obese children (ith 3asymptomatic4:Obese children (ith 3asymptomatic4:$.)"2 OSAS$.)"2 OSAS
Obese ,5WObese ,5W >> $"%2 OSAS more$"%2 OSAS morepre*alencepre*alence
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")esity")esity
#he pre2alence o) obesity: increase#he pre2alence o) obesity: increase)Am 2 3lin 4utr 5667//%5+-1)Am 2 3lin 4utr 5667//%5+-1
Anderdiagnose .linical diagnosis CsAnderdiagnose .linical diagnosis Cs
%M3%M3D hysician: 46?hysician: 46?
D ,!rse: 77?,!rse: 77?
D esident: 1 ?esident: 1 ? )2 Am 8oard Fam 9ract 5667*%*0-5*1)2 Am 8oard Fam 9ract 5667*%*0-5*1
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*ana(ement*ana(ement
6epair craniofacial abnormalities6epair craniofacial abnormalities &onsiloadenoidectomy&onsiloadenoidectomy
C+A+C+A+ &opical steroid&opical steroid 7iet7iet
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epair craniofacia%epair craniofacia%
n yo!ng childrenn yo!ng children
@epend on anatomical abnormalities@epend on anatomical abnormalities
D ,asal s!rgery,asal s!rgery
D etroling!al operationsetroling!al operations
D Maillo)acial s!rgeryMaillo)acial s!rgery
Levy P et al. ERS Monograph 1998;205-26
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+onsi%oadenoidectomy+onsi%oadenoidectomy
/))ecti2ity : 5*100?/))ecti2ity : 5*100? (Schechter MS. Pediatrics(Schechter MS. Pediatrics
2002; 109:1-20)2002; 109:1-20)
+ssociated with: increased gain in+ssociated with: increased gain in
height' weight' %Mheight' weight' %M (Arch Pediatr Adolesc Med(Arch Pediatr Adolesc Med
1999;153:33-7)1999;153:33-7)
mpro2e a)ter tonsiloadenoidectomy'mpro2e a)ter tonsiloadenoidectomy'
b!t se2ere @ o)ten had manyb!t se2ere @ o)ten had manyrespiratory problemsrespiratory problems (Arch Otolaryngol Head Neck(Arch Otolaryngol Head Neck
Surg 1995; 121:525!"#Surg 1995; 121:525!"#
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&PAP&PAP
*ndication8 e/cessive da%time sleepiness*ndication8 e/cessive da%time sleepiness *mprovement in*mprovement in
9 SleepinessSleepiness
9 (ognitive function score(ognitive function score
9 :lood pressure:lood pressure
9 ,,$a%ity of %ife$a%ity of %ife
Enle!an "M. A! # res$ir %rit %are Med 2002;&5:7'3-'Enle!an "M. A! # res$ir %rit %are Med 2002;&5:7'3-'
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+opica% steroid+opica% steroid
%eclomethasone 4 weeks3 can%eclomethasone 4 weeks3 can
red!ce adenoid hypertrophy andred!ce adenoid hypertrophy and
nasal airway obstr!ctionnasal airway obstr!ction
.ontro2ersial.ontro2ersial
Deman !" et al.Pe#atr$% 1995&95&'55-6(
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ei('t %ossei('t %oss
%eha2io!r modi)ication%eha2io!r modi)icationD +nalysis o) eating+nalysis o) eatingD ;ood related beha2io!r;ood related beha2io!r
@iet therapy@iet therapyD /d!cation/d!cationD oor adherenceoor adherence
/ercise/erciseD eg!larlyeg!larly
"astric s!rgery"astric s!rgeryD "astric 2ol!me limited"astric 2ol!me limited
Mont%errat !M et al. ERS Monograph1998&1((-)8..
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&omp%ications&omp%ications
8eurobeha*ioral changes8eurobeha*ioral changes ailure to thri*eailure to thri*e
EnuresisEnuresis
6espiratory tract diseases6espiratory tract diseases +oor Academic performances+oor Academic performances
9 Mathematics O6 -;<= $;-#$%;$) science O6 ?;-= $;-#Mathematics O6 -;<= $;-#$%;$) science O6 ?;-= $;-#
$?;<) spelling O6 -;0= $;-#$%;-$?;<) spelling O6 -;0= $;-#$%;- Cardio*asculer abnormalities: corpulmonaleCardio*asculer abnormalities: corpulmonale
*r%$ht+ MS et al. ,m ! Re%pr rt are Me# 200';168&(6(-8
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&onc%$sions&onc%$sions
BS+S: disease on 1BS+S: disease on 1stst cent!rycent!ry
Bbese is a risk )actors o) BS+SBbese is a risk )actors o) BS+S
Eeight red!ction is key managementEeight red!ction is key managemento) BS+S with obese childhoodo) BS+S with obese childhood
beside tonsiloadenoidectomybeside tonsiloadenoidectomy
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