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Pediatric Sleep Apnea Treatment: Managing Complex Cases

Author Melissa Malena covers Pediatric Sleep Apnea Treatment: Managing Complex Cases on BackTable ENT

Melissa Malena • Aug 17, 2023 • 40 hits

Children with complex and multifaceted health issues such as Down syndrome or cerebral palsy may still experience severe sleep apnea after adenoid and tonsil removal. Being overweight can be a significant risk factor for these children, yet weight loss is not a simple ask for patients and their families. Management of the overall wellbeing of these patients must be multidisciplinary and case based, due to the unique circumstances of each child. Given this approach, expert pediatric otolaryngologist Dr. Javan Nation implements a decisional framework before submitting patients for sleep studies and trialing CPAP as a potential solution. This article features excerpts from the BackTable ENT podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• Many children with complex disorders have residual sleep apnea, even after a tonsillectomy and adenoidectomy (TNA). Some require earlier interventions, and specialists must often navigate a lack of standardized treatment due to the unique nature of each child's condition.

• BMI, weight gain velocity, and overall weight play vital roles in determining the severity of sleep apnea in children. Rapid weight gain and obesity can exacerbate the condition, while even minor weight loss can be beneficial.

• Dr. Nation utilizes a "three strikes" framework, assessing nighttime symptoms (snoring, pausing, gasping), daytime symptoms (tiredness, irritability), and physical indicators (enlarged tonsils/adenoids) to determine the need for a sleep study or intervention.

• The technical criteria for a successful CPAP trial involve wearing the device 50% to 80% of the night for five nights a week. Beyond technical success, the real-world implementation of CPAP must consider the impact on the family. Caregivers' well-being and the child's ability to adapt to the therapy are key to determining if CPAP is the right solution.

Managing Pediatric Sleep Apnea

Table of Contents

(1) Multidisciplinary Care in Pediatric Sleep Apnea Treatment

(2) Weight Management as a Pediatric Sleep Apnea Treatment

(3) The Role of Sleep Studies in Pediatric Sleep Apnea Treatment

(4) Pediatric Sleep Apnea Treatment with CPAP: What Defines Success

Multidisciplinary Care in Pediatric Sleep Apnea Treatment

Treating sleep apnea creates unique challenges in children with special needs and different conditions such as Down syndrome, craniofacial disorders, Achondroplasia, and cerebral palsy. Dr. Nation introduces a specialized clinic in San Diego that focuses on a multidisciplinary approach, including ENT, pulmonary, orthodontics, craniofacial surgery, and genetics. This approach has evolved to be more efficient and patient-centered, involving shared decision-making with families. The collaboration among specialists helps to tailor treatment for each child's unique needs, avoiding redundant or conflicting measures, and it also facilitates continuous learning among the practitioners.

[Dr. Gopi Shah]
That's great. Let's get into y'all's practice then because that sounds like a very rich background and training for it. Now, here we are 10 years later and we can go into it. You briefly mentioned some of these children with complex sleep, we talked about comorbidities. We've talked about the kids who may have had TNA and they still have sleep apnea. Let's get a little bit more specific about who these kids are and how they present for you. What are their risk factors? What do you normally see?

[Dr. Javan Nation]
A lot of times these are patients I'll see in my general ENT clinic and it's really nice to have a place to send these patients. It's nice for the parents as well and for the hospital, in general. You come across a patient who-- Let's put some examples out there. Let's say I see a patient with Down syndrome who's already had their tonsils and adenoids out. For all these patients, we're going to get a postoperative sleep study and if they're still symptomatic and they still have sleep apnea, it can be very challenging to decide what to do next.

In the past, you would send them to pulmonology and say, "Go see the pulmonologist. They're going to talk to you about CPAP." Then the pulmonologist would see them and say, "Maybe there's some adenoid regrowth or something." They'd have a question so they'd send them back to see us. These families are getting bounced back and forth between the specialists. Now, you see these patients in your general practice and you refer them into the complex sleep clinic. It's our home. It's our catchment area for these patients. If there's questions, you'd not have for pulmonology or for craniofacial surgery or for orthodontics we can handle it then. We'd refer them into that clinic.

Generally, we self-refer in this clinic. We've talked about opening it up and having pediatricians and other people refer into it, but we've found that it's actually more high yield if the specialists only are referring to it. They're all coming from ENT, they're all coming from pulmonary, they're all coming from craniofacial surgery as well as genetics and sometimes neurology. It's that I'll come to an elite bunch where you're by yourself in clinic and you're like, "Wow, this patient's complicated. What should we do next?"

After I see them, but then most of the time when we're thinking about these patients. We're in the group multidisciplinary setting of all the specialists together in one room speaking with the family and trying to figure out what to do.

[Dr. Gopi Shah]
That's basically the child sees all of you guys then in one setting or how does the patient visit go in the multidisciplinary complex sleep clinic?

[Dr. Javan Nation]
It's a great question.

[Dr. Gopi Shah]
Or you'll pre-round on these patients and just decide who each kid needs to see or how do y'all just have rounds at the table at the end of a certain afternoon and have a list of patients? Tell me how it actually works.

[Dr. Javan Nation]
Great question. First, we'll sit down before the clinic starts and we'll go through all the patients. We have our amazing PA, Anita Lazar, who will put all the patients together.

[Dr. Gopi Shah]
I know Anita, shout out to Anita. I've worked with her. She's so bright.

[Dr. Javan Nation]
She's the best. We're so lucky to have her in San Diego.

[Dr. Gopi Shah]
Absolutely.

[Dr. Javan Nation]
She'll put them all together and we'll sit down for about 30 minutes before and go through all the patients as a group and say, "Here's who's coming? Here's their medical background," and we can review the sleep study together and just prepare for the patient. Then we all go see the patient together. This is something that's evolved over time. We used to see the patients separately. I'd go in by myself and talk to the family and then pulmonary would come in and talk to the family and we'd all have separate visits, but what we find works better is doing it all together at the same time. The reason why is the patients don't have or the families don't have to say the same thing over and over again.

It works for the families but it also works for us because what I've really enjoyed is listening to the history that the plastic surgeons are getting or the pulmonologists are getting. I'm learning a lot from them as well and they're learning from me because we're all coming at this from a slightly different angle. Then really what it comes down to is working through our treatment algorithm together is the best way because there's really no right or wrong answer for what to do. In many cases, it's a conversation with the family, and having that conversation together is the best way to go about it because we can say, "Let's talk about orthodontics. What are the options here?"

We say, "What did the soft tissue look like?" Then if the plastic surgeon's say, "We can talk about orthodontic surgery," or whatnot. Having that conversation together with the family, I think is more valuable than talking about it afterwards, and then calling the family with what we decided because it's really a shared decision.

[Dr. Gopi Shah]
The thought process for everybody is happening at the same time and then you can actually discuss it together at that moment and then talk and bring the family in at the same time. That sounds pretty awesome.

[Dr. Javan Nation]
Exactly. Right. Because the family's input is just as important as anybody's because it's a shared decision with them. Right? In some cases, the idea of going through orthognathic surgery doesn't sound so bad to them. Other times they hear that and they're like, "No, let's think about something different."

[Dr. Gopi Shah]
We've talked about the kids who are going to be the ones that had the TNA and we still have some sleep apnea. A lot of our children with Down syndrome, who will have residual sleep apnea, sometimes our kids that are obese who maybe have had TNA are still having symptoms. We've talked about craniofacial kids or kids with hypotonia, syndromic, other syndromic kids. Achondroplasia, I'm sure, will come in as well. Those are tough, that's a tough group.
And am I assuming correctly in saying most of these kids have had a TNA or because we also find that there's a handful, especially the young kids who haven't had TNA yet? I think of my Achondroplasia babies, a lot of them will get these sleep studies when they're like three to four months because they want to, maybe we're looking at some concern at the foramen magnum and is there any concern of sleep apnea? Now we have the sleep study and maybe the central component looks fine, but now we have this obstructive component, but there are four months.

Do you have kids like that too? There's definitely, not most of them, but there's these, I feel like we're seeing more and more of even some of the kids, post TNA, that haven't gotten better, that maybe we haven't done the TNA on, or super tin or-- Tell me in your experience.

[Dr. Javan Nation]
That's exactly right. Yes, we have a handful of Achondroplasia patients. Yes. Just like you said, we see them at a younger age because, yes, we're getting a sleep study before the age of one. Yes, sure enough, they don't have big tonsils and hardly anybody's going to do a tonsillectomy on anybody under one, especially if they're not enlarged. Right?

[Dr. Gopi Shah]
Right.

[Dr. Javan Nation]
Yes. That's a very challenging patient population as well. We see a lot of cerebral palsy patients.

[Dr. Gopi Shah]
Yes. The hypotonia. Right? Those are always difficult as well.

[Dr. Javan Nation]
Yes. You mentioned craniofacial patients. A lot of patients with cleft palates, any craniofacial disorder, if their skeleton is small, their airway is going to be small and they're at high risk for sleep apnea. We see a lot of craniofacial patients who have already had a distraction maybe when they're younger. Because, generally if they have craniofacial deformities and they have sleep apnea, when they're an infant, they're going to start with a distraction.

A lot of these patients will come back when they're five and they've already had a distraction and now they have very severe sleep apnea and they're not tolerating a CPAP. Yes, it's a very diverse patient population and it really helps to have all the specialists there together to figure out the best options.

Listen to the Full Podcast

Children with Complex Sleep Apnea with Dr. Javan Nation on the BackTable ENT Podcast)
Ep 119 Children with Complex Sleep Apnea with Dr. Javan Nation
00:00 / 01:04

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Weight Management as a Pediatric Sleep Apnea Treatment

Weight, BMI, and weight gain velocity implements a significant influence on childhood sleep apnea. Dr. Nation emphasizes the importance of sleep studies, even in severe cases, to ensure proper care management and mitigate risks. Weight loss methods, including medication like Ozempic, have the potential to play a role in managing sleep apnea. Weight management in children is a definite challenge and requires multidisciplinary approaches, although there are potential upcoming advancements in treatment.

[Dr. Gopi Shah]
Do you look at, in terms of other data you might have in front of you at the time of that clinic visit, do you look at weight, BMI, or growth over time? What about some of that information? Does that come into any of your decision-making?

[Dr. Javan Nation]
For sure. Yes. If this is a patient who comes in with sleep-disordered breathing with big tonsils and we're thinking about doing surgery, I, for sure, look at the weight. The BMI for each percentile is what I care about. I'm going to always get a sleep study for these patients. I know it's not realistic everywhere for places that don't have that resource. We've grown as an institution a lot where we went from like having two beds per night to like 14.

It's really nice. You get a lot of sleep studies. We know what's going on with these patients beforehand, but for me, it's a safety thing. I recently had a patient sent to me that had Down Syndrome and was two-year-old and somebody else had ordered the sleep study but it took a little bit longer than he wanted to get it.

It was mentioned by another otolaryngologist to say, "Hey, what's the point of waiting for the sleep study?" The parents hear this kid obstructing at night. He's got huge tonsils. He's got Down Syndrome. There's no question he's got sleep apnea. What's the point? Maybe just admit him afterwards if you don't have that information.

Fortunately, we did wait a little bit longer to get that sleep study. I'm so glad we did because the AHI came out at 115. It's very, very severe. What's the difference? I'm going to put that kid in the ICU overnight versus putting him on the floor where he can have a one-on-one nurse who's going to be at his bedside versus a nurse who's sharing him with five to seven other patients. I know it can be inconvenient and, in many places, it can be a hard resource to get access to, but in my opinion, I think it's extremely important.

[Dr. Gopi Shah]
Yes. Definitely. We have a history of Down Syndrome or morbid obesity or anything, and even especially when they all come together, each little thing is just going to exponentially make that sleep apnea worse and worse and that perioperative management more and more challenging.

You're right. The sleep apnea didn't happen overnight, so taking the extra month or two that it might take to get the data you need so that it's set up right. The care, pre-op, post-op, peri-op, everybody's on the same page with where this kid is at, I think, is very important. I've had similar situations, frustrated parents, but for some of those kids were if that gut feeling doesn't feel right and that's that clinical art of medicine. I'm not saying everything's anecdotal practice, but you start developing that gut feeling, I think, go with that.

[Dr. Javan Nation]
Yes. For sure.

[Dr. Gopi Shah]
Yes. Things happen easily in terms of when I started looking-- so I look at BMI percentile for age. I started looking at weight because one of my fellowship director, Romaine Johnson, looked at weight gain velocity in some of these kids, and found that kids that had rapid weight gain, for example, over a year or two, versus kids that were already "heavyset" but stayed in that same chart. The kids that had the greater change in weight had higher sleep apnea on their PSGs.

Sometimes, I'll look at that, and on the flip side, I've found some kids, and this was a family, a child, a teenager, a child with Down Syndrome, who actually lost 7 to 10 pounds. We're talking about all kinds of secondary sleep surgeries at the time and it cut it down. Then, it's like, "Well, okay. Let's reevaluate and see." You know what I mean? Do you look at any of those trends?

[Dr. Javan Nation]
I don't. I've never heard of that weight gain velocity before. That's really interesting. I wonder why. I wonder if it has to do with the tone or with their natural tone being set at a certain area and all that.

[Dr. Gopi Shah]
Yes. Then, all of a sudden, you have all that weight on top. Yes. Maybe it's what you're used to. I have seen the flip side with weight loss. It's not everybody that can do that, but if that-- and it's not a ton. Over time, it can be a couple of pounds. It doesn't have to be like, "Oh, I don't know if we're going to lose the 20 whatever." It's even simple, just a little bit can go a long way. Is weight management, nutrition, or any of that part of the clinic? Those are hard clinics to get into.

[Dr. Javan Nation]
Absolutely. Yes. It's not. We don't have a nutritionist. We don't have a bariatric surgeon. Those are dreams to maybe one day have that. I would absolutely love that. I've talked about it with the hospital administration. We're just not there yet.

There are places that have bariatric surgeons, but I got to say one of the things I'm excited about is for all these patients, we have them see the endocrinologist if they're obese. We'll loop in nutrition, but as far as weight management, it's usually disappointing. You tell them, you advise them on how to eat better, and spend more time outside, and cut out the snacks, and these types of things. It's just hard.

It's hard for these kids to lose weight. Sitting around for six months or a year and seeing if people lose weight, I generally find them disappointed, but I got to say, the thing I'm excited about is our endocrinologists have recently started giving these kids Ozempic, the weight loss medication.

This is brand new for some of these really obese kids that have severe sleep apnea who use CPAP and do okay. They don't have great complaints, but maybe they do okay. We're starting some of these kids on Ozempic. I'm actually very excited to see how this changes our management options for these patients.

[Dr. Gopi Shah]
That's cool because even, again, a few pounds might make a difference in terms of setting and use. That's pretty exciting.

[Dr. Javan Nation]
Yes. For sure.

The Role of Sleep Studies in Pediatric Sleep Apnea Treatment

Sleep studies are a vital tool in sleep apnea treatment and physicians must consider not only the AHI (Apnea Hypopnea Index) but also individual symptoms, behaviors, and gas exchange patterns. Dr. Nation explains his "three strikes" approach to assessment, looking at nighttime and daytime symptoms along with enlarged tonsils or adenoids. The severity of sleep apnea does not always correlate with symptoms. Physicians must consider multiple factors in treatment, such as gas exchange, arousal threshold, and individual patient differences. Sleep study graphs are also an important tool and apnea specialists work closely with pulmonologists to gain comprehensive insights.

[Dr. Gopi Shah]
In terms of some of the more "objective data" we have, we have sleep studies. Can we talk a little bit about what are the data points that you like to look at starting with just-- How do you go through it? What do you look at? What stands out to you? What are the things that you take into consideration?

[Dr. Javan Nation]
A lot of times it depends who the patient is. Let's talk about a seven-year-old that comes to see me in general ENT clinic because they're having a lot of behavioral issues. Parents say, "Sometimes they snore, sometimes they don't. It's not clear. I don't hear any pausing or gasping." The framework I use when I approach these kids is, I like the one, two, three strikes you're out. Are you familiar with this one? No? Okay. This is how I approach it with the family.

First strike I'm looking at is nighttime symptoms. Are they snoring, pausing, gasping, bedwetting, tossing, turning? They check that box, then move on to the daytime symptoms. Are they waking up tired? Are they irritable? Are they disruptive in the classroom? Having a hard time staying on task? Emotional ability, things like that. If that's present, then they check that daytime box.

Then the third box is enlarged tonsils and/or adenoids. If they match all three of these and they don't have any other high-risk symptoms, you don't actually really need to get a sleep study. Often, they'll check maybe two out of three boxes. They'll maybe have some snoring but daytime symptoms aren't so bad or they'll have bad daytime symptoms and then nighttime symptoms aren't so bad. In those patients, I'll get a sleep study.

Sometimes, I'm looking for different things. One of the interesting things about a sleep study is that you can't just pay attention to the AHI, or the abstract of AHI, and say, "Oh, this kid, the OHI is 2.5. It's not that bad, you're fine." Because what we actually find is, a lot of these really high-functioning kids, they're actually more symptomatic when they have mild sleep apnea than some of the kids that have severe sleep apnea.

Because what we know is that a lot of kids, especially these high-functioning kids with mild sleep apnea are more symptomatic than other patients who have severe sleep apnea. These are kids that are going to have a lot of daytime symptoms. You can't just say, "Oh, your sleep apnea is not that bad. It's not a big deal," because it's a syndrome. It's the way these nighttime events are affecting you in the daytime.

When I think about why we care about sleep apnea for kids, it's not so much that it's going to lead to congestive heart failure and whatnot, as it might, we just don't know, we don't have those longitudinal studies, but really what we're looking at is, we're looking at how this issue is affecting their development and their ability to learn and keep up with other kids and develop. Those really symptomatic ones, a lot of times won't have high AHIs, but intervening and doing something for them can make a huge difference.

For that particular patient, I'm looking at, is there any sleep apnea or not? Because if there's just no sleep apnea, then I'm not sure that-- If they're not even snoring during the sleep study, I'm not sure that addressing that is the right thing for the patient, and I think we need to look elsewhere. If we're looking for complex patients, yes. If we're looking at our Down Syndrome patient who's in our complex sleep clinic who has a very high AHI of 20, what I care more about is the gas exchange, especially if we're going to consider intervening for this patient.

As an ENT, probably the most common reason we get a sleep study for patients with comorbidities is to assess the severity because we want to see, is this a patient that I have to be really concerned about after surgery. You know from the history the kid's going to have sleep apnea. An obese kid with 4-plus tonsils, why do we get a sleep study? It's not because we're questioning if they need the surgery or not, we just want to know how bad it is.

This is one of those interesting areas too. I'd like to get your take on it as, at what point do you put them in the ICU? Nobody knows the answer to that. I know some places have a very low threshold to put them in the ICU. We're still trying to figure ours out. We actually just came with some criteria in the last couple of weeks as a group for who should go to the ICU.

I did a study, recently published in IGPL looking at predictors of overnight events. What was really interesting about that was, it's not the AHI that was a predictor. A lot of kids would have an AHI of 100 and have no events overnight, what we found were the predictors was the gas exchange and specifically the oxygen. We found that having 0.5% of the night below 90% for their oxygen was a predictor of an overnight airway event as well as having a nadir below 80%, which makes sense.

Because if you think about these patients, some of these patients have a very low threshold of arousal, and so they're going to have a small little obstructive event, and they're going to wake up right away. That's not the kid that's going to have a respiratory complication after surgery. They're protecting their airway just fine. In fact, they're protecting their airway so well that their brain can't rest, and so they're having a lot of daytime behavioral issues.

It's the kid who's not protecting the airway who has a very high threshold arousal. Those are the ones who are going to have respiratory complications that are dangerous. Those are the kids that their brains can allow them to get down into the 80s or spend a lot of time below 90%. For these patients, that's what I'm looking at, it's the gas exchange.

[Dr. Gopi Shah]
I think that's a great point. Like you said, I don't have a specific AHi cut-off because you're right, some of the kids that will come in with a sleep study of an AHI of 50 or 60 an hour and we put them in ICU do fine. They're not the ones that if they're eight years old and whatnot, they're not the ones that are always having trouble. I think you're right, it's looking at all the things that come into play, alternators inputting, and how long.

This was actually more when the anesthesiologist, I remember like, "Look at their Co2, look how much they're holding on. They're not ventilating. They're holding onto that CO2." I started paying attention more to not just how high it gets, but how long do they hold on to that. A lot of how induction goes and how extubation goes will clue you in and how, a lot of times you have to reserve that ICU bed pre-op and that's probably the better way to do it.

You have to start thinking about it because in terms of your induction, extubation, you're part of that care and talking the anesthesia and everybody being on the same page. Age, and then, obviously, we've talked about comorbidities, which these kids, whether it's poor tone hypotonia, young age, craniofacial, difficult airway, all that comes into play. You're right, it's not just AHI of 50 an hour.

Those are going to make you think but there's a lot that has to come into play as well so we don't miss an AHI of 20 that then really has a peak CO2 in the 60s for however long or 75 whatever, uncertain. Are you looking at the graphs or do you just look at the typed-out report?

[Dr. Javan Nation]
I go through the graph. For the most part, I work really close with their pulmonologist and so we're on the same page. What they put in the report is mostly what I care about but I do look through the graph. The main reason is, you get a better sense of how that night went. A really good study, you can see the patient fall asleep, and you're going to see them go from mild, moderate, to deep sleep, and then, they're going to have their first REM episode around midnight. Then, it's going to happen again, and the REM episode will happen again, and they get longer and longer and longer.

The REM episodes increase into the morning hours and they get longer. I can see how that sleep study went. Was it a good night's sleep? If this is a patient where they're in that mild range, it's an AHI of 2.5. Did we underestimate what's going on? Did they get enough REM sleep?

Looking at the graph, you can quickly see how much time they were in deep sleep, how much REM they had, and give you a good sense. Is this a kid that was in the sleep lab, he was uncomfortable, he never really could get comfortable, he just couldn't fall asleep, or dad was laying next to him snoring? Some other circumstance affected the quality of the sleep study and looking at that graph can clue you into what's going on.

We, as otolaryngologists, don't watch the videos like the pulmonary doctors do. We talk to these guys. They look at the video. They're looking at the kid moving back and forth, so they're getting that information, which we don't have, but we can get similar information looking at that graph.

Pediatric Sleep Apnea Treatment with CPAP: What Defines Success

The criteria for a successful trial of CPAP (Continuous Positive Airway Pressure) in children with sleep apnea requires CPAP to be worn 50% to 80% of the night for five nights a week. However, Dr. Nation emphasizes the importance of considering the family's wellbeing. Success with CPAP may vary significantly between children, particularly in cases involving Down Syndrome or autism. For some families, CPAP may technically be working, but if it is causing strain and exhaustion for caregivers, alternatives might be sought.

[Dr. Gopi Shah]
Then you touched on CPAP. I think I like the idea of-- because it's how we used to practice in Dallas as well, is the trial of a good CPAP trial. My question for you is what defines a good trial of CPAP and what is considered success? Is it wearing 50% of the night for 5 days over 4 months successful, is there a certain criteria that you guys have?

[Dr. Javan Nation]
Right. That's the technical criteria, 50% to 80% of the night for 5 nights a week, but when you really sit down, and you talk to these families, it goes beyond that. For a lot of these families, they might be doing that. The kid might be a seven-year-old kid with Down Syndrome, and we pull up the data, and we see, "Oh, he's doing a good job wearing a CPAP," but then, you actually sit down, and you talk to the family, and mom will tell you, "She hasn't slept in seven months." She's waking up three or four times a night because she hears a mask leak, and she has to go in the room, and put it back on.

Mom's exhausted. The family is affected by what's going on. Is that realistic? Maybe technically it's working, but is that really working for the family? I'd say, "No." You really have to get into this, like how is this CPAP affecting the family? Sometimes, some of these Down's kids absolutely love it, so they won't go to bed until they have their CPAP on, and they'll remind the parents to put it on.

If they wake up and they feel a mask leak, they adjust it themselves, and they're just rock stars. We don't have to worry about them. They're going to do great. There's other ones who-- especially if they have autism, they just don't accept it, and you have these great moms who will give everything they have to keep the CPAP on, but mom's not doing well, or dad's not doing well. In a situation like that, we might be more prone to try some other option besides CPAP.

Podcast Contributors

Dr. Javan Nation discusses Children with Complex Sleep Apnea on the BackTable 119 Podcast

Dr. Javan Nation

Dr. Javan Nation is a pediatric otolaryngologist with Rady's Children Hospital in San Diego, California.

Dr. Gopi Shah discusses Children with Complex Sleep Apnea on the BackTable 119 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, July 11). Ep. 119 – Children with Complex Sleep Apnea [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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