# Obstructive Sleep Apnea — GCMD Library living collection

Everything in the library about obstructive sleep apnea — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 136 cited statements

## Episodes
### Medical Management
- [Postoperative Pediatric Pain Practice Post the Codeine Era: Peri-Operative...](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912) — video · 1:01:18 · [machine version](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912.md)

### Case-Based Learning
- [PDC 2020 Practice Gaps](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998) — video · 1:23:26 · [machine version](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998.md)

### In-Depth Reviews
- [Take My Breath Away - Carolyn Grad, Mark Washam, & Katie Holtman - APP Conference 2026](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089) — video · 58:54 · [machine version](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=0) Historical context and pediatric physiological differences (Ep 1)
- [8:28](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=508) Pain assessment tools and preemptive analgesia principles (Ep 1)
- [14:26](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=866) Ketorolac dosing, codeine pharmacogenetics, and opioid alternatives (Ep 1)
- [29:08](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1748) Practical opioid selection and PCA management (Ep 1)
- [39:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2370) Combination analgesics and acetaminophen toxicity prevention (Ep 1)
- [48:26](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2906) Adjunctive agents: dexamethasone, IV lidocaine, and acetaminophen dosing updates (Ep 1)
- [0:12](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=12) Introduction and Obstructive Sleep Apnea in Obese Surgical Patients (Ep 2)
- [7:54](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=474) Long-term Surveillance After Esophageal Atresia Repair (Ep 2)
- [13:22](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=802) Gas Embolism During Neonatal Laparoscopy (Ep 2)
- [24:24](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=1464) Thromboelastography in Pediatric Trauma (Ep 2)
- [29:00](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=1740) CDH Readiness Criteria and Pulmonary Hypertension Management (Ep 2)
- [41:00](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=2460) Conservative Management of Spontaneous Pneumothorax (Ep 2)
- [51:38](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3098) Balanced Resuscitation in Pediatric Trauma (Ep 2)
- [60:01](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3601) Peritoneal Dialysis Catheter Placement Guidelines (Ep 2)
- [68:21](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4101) Hemodialysis Access: Fistula versus Catheter (Ep 2)
- [75:42](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4542) Newer Biologic Agents for Inflammatory Bowel Disease and Androgen Insensitivity Management (Ep 2)
- [0:26](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=26) Introduction and OSA Overview: Signs, Symptoms, and Pathophysiology (Ep 3)
- [12:02](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=722) Polysomnography and Diagnostic Criteria for Pediatric Sleep Apnea (Ep 3)
- [24:58](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1498) Surgical Management: Adenoidectomy and Tonsillectomy (Ep 3)
- [46:59](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2819) Audience Q&A: Clinical Scenarios and Referral Pathways (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "In the last 40 years, the prevalence of obesity has gone to over 18% of children worldwide" — Liz Byerly (epidemiological) [Ep 2 · 6:39](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=399)
- "Kids who are obese and receiving therapy for DVT require closer monitoring of their enoxaparin levels because they can have altered drug metabolism due to obesity" — Liz Byerly (clinical) [Ep 2 · 7:24](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=444)
- "NASPGHAN and European counterparts recommend screening endoscopy at 10 years of age for esophageal atresia patients, whether or not they're on anti-reflux medications" — Liz Byerly (host_summary) [Ep 2 · 10:38](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=638)
- "NASPGHAN guidelines recommend screening endoscopy in early adulthood for esophageal atresia patients, and then every 5 to 10 years for adults" — Liz Byerly (host_summary) [Ep 2 · 11:10](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=670)
- "A significant number of children with repaired esophageal atresia will have esophageal metaplasia or Barrett's esophagus, and symptoms often do not correlate with pathology" — Liz Byerly (clinical) [Ep 2 · 11:22](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=682)
- "Studies from the Netherlands and Finland showed an increased risk of esophageal carcinoma in patients with repaired esophageal atresia" — Liz Byerly (host_summary) [Ep 2 · 12:00](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=720)
- "The most likely cause of cardiac arrest during laparoscopy in neonates is pneumopericardium from extraperitoneal insufflation" — Liz Byerly (clinical) [Ep 2 · 16:22](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=982)
- "A survey of pediatric surgeons in the United States found that 28% had experienced gas embolism during neonatal laparoscopy" — Liz Byerly (host_summary) [Ep 2 · 16:44](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=1004)
- "The problem occurs because insufflation tubing contains air with nitrogen, which is not soluble in blood, unlike carbon dioxide. It's like the baby gets the bends when you insufflate all that air" — Liz Byerly (clinical) [Ep 2 · 17:52](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=1072)
- "End-tidal CO2 is the most sensitive detector of a gas embolism during laparoscopic surgery" — Liz Byerly (clinical) [Ep 2 · 17:14](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=1034)
- "Prevention strategies include turning gas on and flushing tubing of air before connecting it to the patient, which decreases the amount of nitrogen and air delivered" — Liz Byerly (clinical) [Ep 2 · 19:09](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=1149)
- "On thromboelastography, if R time is abnormal, the patient needs FFP. If alpha angle is abnormal, administer cryoprecipitate. If maximum amplitude is abnormal, give platelets. If LY30 shows excessive fibrinolysis, give aminocaproic acid or tranexamic acid" — Liz Byerly (clinical) [Ep 2 · 27:03](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=1623)
- "Canadian CDH Collaborative readiness criteria for surgery include normal blood pressure for age, urine output >1cc/kg/hr, serum lactate <3, FiO2 <50%, preductal saturation around 90%, and pulmonary artery pressures less than systemic" — Eric Skarsgard (host_summary) [Ep 2 · 37:49](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=2269)
- "Surgery is a stressor on the pulmonary vascular bed in CDH patients, so we want to see pulmonary artery pressures trending down and less than systemic pressures before operating" — Eric Skarsgard (clinical) [Ep 2 · 38:20](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=2300)
- "For CDH patients with predominantly right ventricular dysfunction on echo, treatment options are nitric oxide, sildenafil, and increasingly PGE1, which maintains the ductus open and allows a pop-off vent for the right ventricle" — Eric Skarsgard (clinical) [Ep 2 · 39:47](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=2387)
- "A randomized trial of spontaneous pneumothorax showed roughly equivalent lung re-expansion by 8 weeks (high 90%) between conservative management and intervention groups" — Eric Skarsgard (host_summary) [Ep 2 · 50:13](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3013)
- "The spontaneous pneumothorax trial showed a threefold increase in adverse events in the interventional group, including bleeding, need for catheter repositioning, and continuing air leaks" — Eric Skarsgard (host_summary) [Ep 2 · 50:22](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3022)
- "The spontaneous pneumothorax trial showed a twofold increase in twelve-month recurrence rates for patients who received intervention versus conservative management" — Eric Skarsgard (host_summary) [Ep 2 · 50:50](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3050)
- "ATLS 10th edition guidelines recommend limiting crystalloid to not more than 20cc per kilogram in pediatric trauma resuscitation" — Eric Skarsgard (host_summary) [Ep 2 · 56:18](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3378)
- "Giving excessive crystalloid worsens dilutional coagulopathy and increases metabolic acidosis in trauma patients" — Eric Skarsgard (clinical) [Ep 2 · 56:37](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3397)
- "Military data from Afghanistan and Iraq showed that increased use of massive transfusion protocols in pediatric trauma patients correlated with decreased mortality between 2001 and 2013" — Eric Skarsgard (host_summary) [Ep 2 · 57:18](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3438)
- "Early balanced blood product resuscitation (red cells, platelets, and plasma) results in using less blood products overall and significantly improved mortality and morbidity outcomes" — Eric Skarsgard (host_summary) [Ep 2 · 57:58](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3478)
- "Military studies clearly show a survival advantage from use of tranexamic acid in trauma patients" — Eric Skarsgard (host_summary) [Ep 2 · 58:32](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3512)
- "There is no evidence supporting intentional hypotensive resuscitation as a strategy in pediatric trauma" — Eric Skarsgard (opinion) [Ep 2 · 58:51](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3531)
- "SCOPE Collaborative guidelines for peritoneal dialysis catheter placement include preoperative antibiotic with gram-positive coverage, downward or lateral exit site placement, and no suture at the exit site" — Todd Ponsky (host_summary) [Ep 2 · 60:21](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3621)
- "Failure rates for dialysis access are quite high: 45% within two months for hemodialysis catheters and 30 to 50% for peritoneal dialysis catheters" — Todd Ponsky (host_summary) [Ep 2 · 63:07](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=3787)
- "Analysis of a large international registry shows over 70% of children have a hemodialysis catheter placed and only 26% receive an AV fistula" — Todd Ponsky (host_summary) [Ep 2 · 67:22](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4042)
- "Multiple studies show superior primary and secondary patency rates for AV fistulas compared to catheters in pediatric patients" — Todd Ponsky (host_summary) [Ep 2 · 67:34](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4054)
- "Organizations have recommended considering AV fistula use in children over 20 kg who will require at least 12 months of hemodialysis" — Todd Ponsky (host_summary) [Ep 2 · 68:04](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4084)
- "Half-life of even a living donor kidney is only about 23-24 years, so a 5-year-old receiving a transplant will face retransplant at age 27-28" — Eric Skarsgard (clinical) [Ep 2 · 69:16](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4156)
- "Entyvio (vedolizumab) is a monoclonal antibody targeted at the gut epithelium with a great safety profile in adult studies" — Todd Ponsky (host_summary) [Ep 2 · 73:55](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4435)
- "In a 2017 review of 64 children who had failed anti-TNF therapy, 25 reached steroid-free remission with Entyvio" — Todd Ponsky (host_summary) [Ep 2 · 74:16](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4456)
- "The risk of cancer in complete androgen insensitivity is probably lower than previously thought, closer to 1 to 2% rather than 2 to 5%" — Todd Ponsky (host_summary) [Ep 2 · 78:55](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4735)
- "Patients with androgen insensitivity report feeling abnormal after gonadectomy even when given estrogens, because the testes are a source of estrogen as well as testosterone that is converted peripherally" — Todd Ponsky (host_summary) [Ep 2 · 79:12](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4752)
- "Women on estrogens for prolonged periods after gonadectomy have increased cardiovascular risk" — Todd Ponsky (host_summary) [Ep 2 · 79:36](https://library.globalcastmd.com/watch/pdc-2020-practice-gaps-2998?t=4776)
- "In 1968, Swafford and Allen reported that only 2 out of 60 children (3%) required pain medication following general surgery, stating pediatric patients seldom need medication for pain relief." — Fareed (host_summary) [Ep 1 · 1:19](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=79)
- "The real revolution in pediatric pain management started in the 1990s." — Fareed (opinion) [Ep 1 · 1:35](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=95)
- "The blood-brain barrier in neonates and infants is immature and reaches relative maturity at approximately 9 months of age; full barrier function comparable to adults is achieved around 2 years." — Fareed (clinical) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=180)
- "Fentanyl, being highly lipophilic, crosses the blood-brain barrier equally in adults and pediatric patients regardless of barrier maturity." — Fareed (clinical) [Ep 1 · 3:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=200)
- "Morphine dosing (0.1 mg/kg) is calculated based on the blood-brain barrier preventing some morphine from reaching the brain; in neonates with immature barriers, more morphine crosses, requiring dose adjustment." — Fareed (clinical) [Ep 1 · 3:35](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=215)
- "Pharmaceutically, 100 mcg of fentanyl is equivalent to 10 mg of morphine because fentanyl is 100 times more potent than morphine, but this equivalence does not apply in the first year of life due to immature blood-brain barrier." — Fareed (clinical) [Ep 1 · 4:05](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=245)
- "Hepatic metabolism in neonates is immature and cannot adequately handle phase 1 and phase 2 drug metabolism; liver function matures by approximately one year of age." — Fareed (clinical) [Ep 1 · 4:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=270)
- "Protein binding is reduced in neonates due to insufficient albumin and alpha-1 acid glycoprotein production; the unbound (free) portion of drugs is responsible for pharmacodynamic effects." — Fareed (clinical) [Ep 1 · 4:45](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=285)
- "Renal function in neonates is immature until approximately one year of age; kidneys cannot concentrate urine, handle protein load, or manage sodium load effectively." — Fareed (clinical) [Ep 1 · 5:10](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=310)
- "Volume of distribution differs significantly in neonates compared to adults: neonates are 'born bags of water' with higher total body water, affecting hydrophilic drug distribution, while adults have higher fat content affecting lipophilic drugs." — Fareed (clinical) [Ep 1 · 5:25](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=325)
- "Preemptive analgesia, including regional blocks, reduces pain signals reaching the CNS and also reduces the stress response (aldosterone, epinephrine, norepinephrine, glucagon, neuropeptide Y), which can later act as pain modulators." — Fareed (clinical) [Ep 1 · 10:55](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=655)
- "NSAIDs exhibit a ceiling effect: increasing the dose beyond a certain point does not increase analgesic efficacy but does increase side effects." — Fareed (clinical) [Ep 1 · 12:10](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=730)
- "The recommended dose of ketorolac in pediatrics is 0.2 to 0.3 mg/kg per dose, maximum 15 mg per dose, given no more frequently than every 8 hours." — Fareed (guideline) [Ep 1 · 12:25](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=745)
- "Studies have shown that ketorolac doses exceeding 15 mg per dose or more than 3 doses per day result in increased side effects without additional analgesic benefit." — Fareed (clinical) [Ep 1 · 12:45](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=765)
- "Ketorolac-induced kidney damage can be both cumulative and idiosyncratic; at Akron Children's Hospital, one case of kidney damage occurred after a single high dose." — Fareed (clinical) [Ep 1 · 13:05](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=785)
- "At Akron Children's Hospital, IV ketorolac is limited to a maximum of 15 mg every 8 hours for no more than 2 days; a third day requires clinical reassessment." — Fareed (guideline) [Ep 1 · 13:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=810)
- "The FDA black box warning for ketorolac recommends no more than 15 mg as a single dose in children under age 13." — Todd Ponsky (host_summary) [Ep 1 · 14:28](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=868)
- "Dr. Joshi's practice uses ketorolac 15 mg three times daily, combined with 1 g acetaminophen three to four times daily, which decreases opioid consumption by approximately 50%." — Joshi (clinical) [Ep 1 · 15:07](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=907)
- "For adult patients, Dr. Joshi loads with 30 mg ketorolac intraoperatively, then continues 15 mg every 8 hours postoperatively." — Joshi (clinical) [Ep 1 · 16:04](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=964)
- "Tramadol is a weak mu-opioid receptor agonist and a weak norepinephrine and serotonin reuptake inhibitor, providing an alternative mechanism of action when opioid receptors show resistance." — Fareed (clinical) [Ep 1 · 17:04](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1024)
- "Tramadol is particularly effective for muscular pain, making it an excellent choice for patients with congenital scoliosis and similar conditions." — Fareed (opinion) [Ep 1 · 17:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1050)
- "Tramadol is classified as a Schedule 4 drug in the US (as of the recording date), though it is considered an opioid elsewhere; it has addiction potential." — Fareed (clinical) [Ep 1 · 17:45](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1065)
- "Codeine has an unfavorable side effect profile with high incidence of nausea, vomiting, and constipation—more than stronger narcotics like hydrocodone or oxycodone." — Fareed (clinical) [Ep 1 · 18:15](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1095)
- "Codeine is not a preferred drug of addiction due to unfavorable side effects, minimal tolerance development (especially to constipation), and less euphoria compared to other opioids." — Fareed (clinical) [Ep 1 · 18:35](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1115)
- "Codeine conversion to morphine occurs in the liver via the cytochrome P450 enzyme CYP2D6; approximately 10% of Caucasians lack this enzyme and are poor metabolizers." — Fareed (clinical) [Ep 1 · 19:05](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1145)
- "10 to 29% of North African and Ethiopian populations have multiple copies of the CYP2D6 gene, making them ultra-rapid metabolizers who convert codeine to extremely high serum levels of morphine after normal codeine doses." — Fareed (clinical) [Ep 1 · 19:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1170)
- "Codeine dosing is 10 times the morphine dose (e.g., 1 mg/kg codeine vs. 0.1 mg/kg morphine) because only a small portion converts to morphine; ultra-rapid metabolizers effectively receive 10 times the intended morphine dose." — Fareed (clinical) [Ep 1 · 20:00](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1200)
- "CYP2D6 polymorphism has been implicated in neonatal toxicity and death when codeine is administered to lactating mothers, particularly those with increased CYP2D6 activity; two infant deaths have been reported." — Fareed (clinical) [Ep 1 · 20:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1230)
- "The FDA reviewed reports of children aged 2 to 5 who developed serious adverse effects or died after taking codeine for pain relief following tonsillectomy/adenoidectomy for obstructive sleep apnea; three pediatric deaths and one life-threatening respiratory depression case were documented." — Fareed (host_summary) [Ep 1 · 20:55](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1255)
- "All children who died or had life-threatening events from codeine had evidence of inherited ability to convert codeine to fatal amounts of morphine and received doses within the typical therapeutic range." — Fareed (host_summary) [Ep 1 · 21:35](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1295)
- "FDA recommendations for codeine prescribing include: use the lowest effective dose for the shortest period, do not administer more than 6 doses per day, counsel caregivers on toxicity signs, and consider prescribing alternatives." — Fareed (host_summary) [Ep 1 · 22:40](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1360)
- "90% of pediatric hospitals surveyed across the US have already removed codeine from their formularies." — Fareed (epidemiological) [Ep 1 · 23:40](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1420)
- "As of November 1st (year of recording), Akron Children's Hospital removed all codeine formulations from the pharmacy and order sets." — Fareed (guideline) [Ep 1 · 23:55](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1435)
- "Oxycodone is 10 times more potent than codeine and is dosed at 0.05 to 0.1 mg/kg, which can be problematic for very small children requiring precise measurement with TB syringes." — Fareed (clinical) [Ep 1 · 24:50](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1490)
- "Boston Children's Hospital discharges mothers with pre-filled TB syringes of oxycodone (6–10 syringes for 2 days, every 4–6 hours) to avoid dosing errors." — Fareed (clinical) [Ep 1 · 25:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1520)
- "No hydrocodone preparation exists without acetaminophen in the US; Lortab elixir (hydrocodone with acetaminophen) is widely available." — Fareed (clinical) [Ep 1 · 25:55](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1555)
- "Hydromorphone is 7 to 8 times more potent than morphine and is recommended for resistant severe pain or when patients have multiple allergies or side effects to other narcotics." — Fareed (clinical) [Ep 1 · 26:40](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1600)
- "Hydromorphone has a much better overall side effect profile than morphine and is the first choice for PCAs at Akron Children's Hospital; approximately 950 of 1000 annual PCAs use hydromorphone." — Fareed (clinical) [Ep 1 · 27:05](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1625)
- "Ibuprofen 10 mg/kg every 6 to 8 hours has been shown in multiple studies to be equivalent or equipotent to codeine for mild to moderate pain." — Fareed (clinical) [Ep 1 · 28:00](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1680)
- "The FDA is moving the maximum daily dose of acetaminophen in adults from 4 g per day down to 3 g per day." — Fareed (host_summary) [Ep 1 · 28:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1710)
- "After giving 1 g IV acetaminophen intraoperatively, only 2 g remains available for that day under the new 3 g/day maximum." — Fareed (clinical) [Ep 1 · 28:45](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1725)
- "In children, the maximum acetaminophen dose has been reduced from 100 mg/kg/day to 60 mg/kg/day for infants and young children up to age 2; for children over age 2, the maximum is 90 mg/kg/day." — Fareed (guideline) [Ep 1 · 43:00](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2580)
- "Acetaminophen and NSAID dosing must be calculated based on lean body weight, not actual or ideal body weight, especially in the 40% of US pediatric population that is obese; failure to do so can result in mortality." — Fareed (clinical) [Ep 1 · 43:35](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2615)
- "Hydrocodone is the recommended first-choice opioid alternative to codeine for pain rated 7 or above (or lower if not controlled by acetaminophen, NSAIDs, or tramadol)." — Fareed (opinion) [Ep 1 · 30:10](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1810)
- "Lortab (hydrocodone 7.5 mg in 15 mL, or 0.5 mg/mL) has a better side effect profile than codeine and is dosed like morphine (0.1 mg/kg)." — Fareed (clinical) [Ep 1 · 30:35](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1835)
- "Hydrocodone requires CYP2D6 to convert to hydromorphone, but because the dose is 1/10 that of codeine, even ultra-rapid metabolizers remain within a safe therapeutic range." — Fareed (clinical) [Ep 1 · 31:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=1880)
- "At Akron Children's Hospital, PCA lockout intervals are: hydromorphone every 20 minutes, morphine every 10 minutes, fentanyl every 6 minutes." — Fareed (guideline) [Ep 1 · 41:33](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2493)
- "Dr. Joshi's practice for opioid-naive adults: morphine 1 mg every 5–6 minutes or 2 mg every 10 minutes; hydromorphone 0.2 mg every 10 minutes." — Joshi (clinical) [Ep 1 · 45:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2730)
- "For opioid-tolerant patients, give at least half of their daily opioid dose preoperatively and consider adding a background infusion early, though not initially." — Joshi (clinical) [Ep 1 · 45:55](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2755)
- "Hydromorphone achieves peak CSF levels faster than morphine; when optimal pain control is achieved in the recovery room with morphine, peak CSF levels occur later on the floor, increasing side effect risk including respiratory depression." — Joshi (clinical) [Ep 1 · 35:19](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2119)
- "At Parkland Hospital (Dallas), hydromorphone is preferred over morphine due to better pharmacokinetics and because many patients (diabetics, Hispanics, African Americans) have renal dysfunction." — Joshi (opinion) [Ep 1 · 36:00](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2160)
- "Fentanyl PCAs are used for patients with morphine or hydromorphone intolerance, for trauma patients with severe pain in the first 24 hours (to assess usage before converting to longer-acting agents), and for movement-related pain when patients are otherwise comfortable at rest." — Melanie (clinical) [Ep 1 · 36:29](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2189)
- "For chronic opioid therapy patients, larger PCA doses with longer lockout intervals (e.g., 3–4 mg morphine every 20 minutes) reduce anxiety and provide better analgesia than frequent small doses." — Melanie (clinical) [Ep 1 · 38:00](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2280)
- "PCA demand dose must always be equal to or greater than the continuous infusion rate to ensure patients feel the bolus effect." — Melanie (guideline) [Ep 1 · 39:10](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2350)
- "Prescribing combination opioid-acetaminophen products (e.g., hydrocodone/acetaminophen) alongside separate acetaminophen creates high risk of acetaminophen overdose; instead, prescribe single-agent opioids (oxycodone or hydromorphone elixir) with scheduled ibuprofen." — Fareed (clinical) [Ep 1 · 39:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2370)
- "At least three large studies (≥1000 patients each), including one from Cleveland Clinic, demonstrated efficacy and safety of NSAIDs (including ketorolac) after tonsillectomy without increased bleeding risk." — Fareed (clinical) [Ep 1 · 45:50](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2750)
- "Similar literature from prostatectomy studies shows NSAIDs (ketorolac) do not increase bleeding risk in bloody surgical procedures." — Fareed (clinical) [Ep 1 · 46:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2780)
- "A single dose of dexamethasone 4 to 8 mg given after induction of anesthesia provides significant antiemetic prophylaxis and postoperative pain relief and should be used in most patients unless contraindicated." — Joshi (guideline) [Ep 1 · 48:26](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2906)
- "Dexamethasone 4 mg does increase blood sugar levels in diabetics but does not exceed treatment thresholds (140–180 mg/dL per American Diabetes Association and American College of Endocrinologists); it is safe in well-controlled diabetics." — Joshi (clinical) [Ep 1 · 49:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2970)
- "The PROSPECT group reviewed data showing single-dose dexamethasone does not increase perioperative infection risk in high-risk patients." — Joshi (clinical) [Ep 1 · 50:10](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3010)
- "Dexamethasone benefits are greater for outpatient procedures due to high incidence of postoperative nausea/vomiting and home opioid use." — Joshi (opinion) [Ep 1 · 51:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3080)
- "MD Anderson Cancer Center routinely gives every surgical patient dexamethasone with induction." (clinical) [Ep 1 · 51:53](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3113)
- "Dexamethasone dosing varies by indication: 0.15 mg/kg for nausea/vomiting, 0.1 mg/kg for pain, 0.5 mg/kg (maximum 8 mg) for anti-inflammatory effect (airway edema)." — Fareed (guideline) [Ep 1 · 53:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3200)
- "IV lidocaine infusion (1 mg/kg bolus, then 1–2 mg/kg/hr) is called 'poor man's epidural analgesia' and has been compared to epidural analgesia in abdominal surgery, showing significant benefit for pain relief, return of bowel function, ambulation, and hospital stay." — Joshi (clinical) [Ep 1 · 54:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3260)
- "The PROSPECT group recommends IV lidocaine infusion as second-line therapy (not first-line) when thoracic epidural is contraindicated or failed, or when NSAIDs/COX-2 inhibitors and acetaminophen are contraindicated due to renal or hepatic issues." — Joshi (guideline) [Ep 1 · 55:00](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3300)
- "IV lidocaine dosing remains controversial with significant variability across studies, preventing consensus; the recommendation is a balance between dosing extremes." — Joshi (opinion) [Ep 1 · 55:40](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3340)
- "IV lidocaine has anti-inflammatory properties in addition to analgesic effects." — Joshi (clinical) [Ep 1 · 56:05](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3365)
- "Approximately 35,000 cases per year in the US involve liver damage from acetaminophen toxicity." — Fareed (epidemiological) [Ep 1 · 57:35](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3455)
- "The FDA's Anesthetic and Analgesic Drug Products Advisory Committee (AADPAC) is addressing acetaminophen toxicity, codeine enzyme issues, and hydrocodone addiction." — Fareed (host_summary) [Ep 1 · 57:50](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3470)
- "Expected FDA changes by early 2014 include: universal 3 g/day acetaminophen maximum, pediatric dosing of 60–90 mg/kg/day, and maximum 325 mg acetaminophen per combination pill (Percocet, Vicodin, etc.)." — Fareed (host_summary) [Ep 1 · 59:55](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3595)
- "Johnson & Johnson requested the FDA change Tylenol package insert to 3 g/day maximum; the FDA granted this for Tylenol brand only, not for all acetaminophen products or IV formulations." — Joshi (guideline) [Ep 1 · 57:38](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3458)
- "IV acetaminophen package insert still states 1 g four times daily (4 g/day total); the FDA has not mandated the 3 g/day limit for IV formulations." — Joshi (guideline) [Ep 1 · 58:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3500)
- "Acetaminophen has a ceiling effect: no more than 1 g per dose provides additional efficacy, but higher doses increase side effects." — Joshi (clinical) [Ep 1 · 58:50](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3530)
- "Combination opioid-acetaminophen drugs have caused the most harm because patients do not understand they are exceeding 4 g/day acetaminophen." — Joshi (clinical) [Ep 1 · 60:30](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=3630)
- "Oxycodone has very high 'likability' among drug addicts and is strongly euphoria-inducing; it is probably the worst choice of opioids for patients with previous opioid addiction or alcoholism, worse than morphine or hydromorphone." — Alan (opinion) [Ep 1 · 43:20](https://library.globalcastmd.com/watch/postoperative-pediatric-pain-practice-post-the-codeine-era-peri-operative-912?t=2600)
- "Obstructive sleep apnea accounts for over 95% of pediatric sleep apnea cases." — Carolyn Grad (epidemiological) [Ep 3 · 3:58](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=238)
- "Central sleep apnea is characterized by decreased or absent respiratory drive rather than physical airway obstruction." — Carolyn Grad (clinical) [Ep 3 · 4:10](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=250)
- "Untreated sleep apnea causes low-grade suffocation at the tissue and cellular level, preventing oxygen delivery to brain and body." — Carolyn Grad (clinical) [Ep 3 · 8:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=520)
- "The brain wakes the patient to restore breathing during apneic events, resulting in fragmented sleep and insomnia." — Carolyn Grad (clinical) [Ep 3 · 9:05](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=545)
- "Untreated OSA can cause cardiac enlargement and dysfunction because the heart works harder without adequate oxygen." — Carolyn Grad (clinical) [Ep 3 · 9:35](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=575)
- "Sleep deprivation from OSA leads to insulin resistance, metabolic dysfunction, and poor dietary choices." — Carolyn Grad (clinical) [Ep 3 · 9:50](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=590)
- "OSA commonly presents with school difficulties including attention problems, focus issues, and academic decline that may be mistaken for ADHD." — Carolyn Grad (clinical) [Ep 3 · 10:05](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=605)
- "In-laboratory polysomnography is the gold standard for diagnosing pediatric sleep apnea as of today." — Carolyn Grad (guideline) [Ep 3 · 10:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=640)
- "Home oximetry studies show oxygen fluctuation but cannot assess airflow, sleep state, or definitively diagnose OSA." — Carolyn Grad (clinical) [Ep 3 · 10:55](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=655)
- "The American Academy of Sleep Medicine does not recommend home sleep apnea testing for children because pediatric sleep is more complex than adult sleep and changes over time." — Carolyn Grad (guideline) [Ep 3 · 11:15](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=675)
- "Polycythemia on CBC can indicate the body is compensating for chronic hypoxia from untreated sleep apnea." — Carolyn Grad (clinical) [Ep 3 · 11:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=700)
- "Brain conditions like Chiari malformations or brain injuries can cause central sleep apnea by affecting respiratory drive." — Carolyn Grad (clinical) [Ep 3 · 11:50](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=710)
- "Polysomnography measures EEG, nasal airflow, jaw and facial muscle movement, chest wall motion, transcutaneous CO2, and includes audio and video recording." — Mark Washam (clinical) [Ep 3 · 12:02](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=722)
- "The American Academy of Sleep Medicine, American Academy of Pediatrics, and American Thoracic Society all endorse in-laboratory polysomnography as the gold standard for diagnosing pediatric sleep apnea." — Mark Washam (guideline) [Ep 3 · 14:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=880)
- "High-risk conditions for sleep apnea include Down syndrome, tonsillar hypertrophy, midface or mandibular hypoplasia, macroglossia, generalized muscular hypotonia, obesity syndromes like Prader-Willi, and craniofacial abnormalities including cleft palate." — Mark Washam (clinical) [Ep 3 · 15:20](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=920)
- "Patients with burn injuries to the face who wear scar-management masks can develop abnormal facial growth leading to sleep apnea." — Mark Washam (clinical) [Ep 3 · 16:15](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=975)
- "OSA prevalence is 9-12% in healthy-weight children but increases to nearly 50% in children with obesity." — Mark Washam (epidemiological) [Ep 3 · 17:00](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1020)
- "Each unit increase in BMI carries a 1.9% increased risk for obstructive sleep apnea." — Mark Washam (epidemiological) [Ep 3 · 17:20](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1040)
- "Children with obesity who do not have OSA may develop it as adults, making weight management counseling important." — Mark Washam (clinical) [Ep 3 · 17:30](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1050)
- "Congenital central alveolar hypoventilation syndrome (Ondine's curse) is a rare form of central sleep apnea where patients do not generate respiratory effort during sleep." — Mark Washam (clinical) [Ep 3 · 17:55](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1075)
- "OSA is diagnosed when there is greater than one obstructive event per hour of sleep, or obstructive hypoventilation with transcutaneous CO2 above 50 mmHg for 25% of sleep time, associated with snoring, paradoxical breathing, or flattened nasal airflow waveform." — Mark Washam (clinical) [Ep 3 · 19:00](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1140)
- "OSA severity is graded by apnea-hypopnea index (AHI): mild 1-4 events/hour, moderate 5-9 events/hour, severe greater than 10 events/hour." — Mark Washam (clinical) [Ep 3 · 19:45](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1185)
- "Treatment decisions consider both AHI severity and daytime functional impact; a patient with moderate AHI and severe daytime symptoms requires more aggressive treatment than someone with similar AHI but no symptoms." — Mark Washam (clinical) [Ep 3 · 20:10](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1210)
- "For infants with AHI less than 10, oxygen therapy can blunt OSA impact by preventing desaturations, though it does not cure the obstruction." — Mark Washam (clinical) [Ep 3 · 20:50](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1250)
- "Infants on oxygen for OSA feed better because they are obligate nose breathers and can maintain oxygenation while feeding." — Mark Washam (clinical) [Ep 3 · 21:15](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1275)
- "Split-night sleep studies perform diagnostic assessment in the first half and therapeutic intervention (such as oxygen or CPAP titration) in the second half." — Mark Washam (clinical) [Ep 3 · 21:00](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1260)
- "CPAP provides continuous positive airway pressure; BiPAP provides additional inspiratory pressure and is used for central apnea or severe OSA." — Mark Washam (clinical) [Ep 3 · 22:00](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1320)
- "Intranasal fluticasone can be used for mild to moderate OSA to reduce nasal inflammation and improve airflow." — Mark Washam (clinical) [Ep 3 · 22:30](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1350)
- "Tirzepatide (Zepbound) is FDA-approved for OSA in adults who cannot tolerate other therapies; approval for teens may be forthcoming." — Mark Washam (clinical) [Ep 3 · 23:00](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1380)
- "Adenoid tissue is lymphoid tissue similar to tonsils, located at the back of the nose, present at birth but not significantly enlarged until 3-6 months of age." — Katie Holtman (clinical) [Ep 3 · 25:10](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1510)
- "Adenoids begin to involute around age 6-7 and are typically not visible on X-ray imaging by adulthood." — Katie Holtman (clinical) [Ep 3 · 25:35](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1535)
- "Adenoid hypertrophy causes obstruction at the junction of the nasal and oral airways and at the eustachian tube openings, leading to nasal congestion, postnasal drip, chronic otitis media, and chronic sinusitis." — Katie Holtman (clinical) [Ep 3 · 26:20](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1580)
- "In school-age children with chronic sinusitis, the first treatment step is addressing adenoid hypertrophy rather than sinus-directed therapy." — Katie Holtman (clinical) [Ep 3 · 26:55](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1615)
- "Adenoids act like a dirty sponge, trapping particles and seeding infection into the throat, nose, and middle ear." — Katie Holtman (clinical) [Ep 3 · 27:15](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1635)
- "Adenoid facies includes Dennie's lines (creases under the eyes) and allergic shiners (dark circles) caused by chronic nasal congestion leading to venous pooling and muscle twitching." — Katie Holtman (clinical) [Ep 3 · 28:30](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1710)
- "Adenoid tissue cannot be assessed on physical exam; evaluation requires nasopharyngeal X-ray or nasal endoscopy." — Katie Holtman (clinical) [Ep 3 · 29:30](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1770)
- "Adenoidectomy recovery is easier than tonsillectomy; patients typically eat or drink immediately post-op, return to school on post-op day one, and require only acetaminophen and ibuprofen for pain." — Katie Holtman (clinical) [Ep 3 · 30:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1840)
- "Post-adenoidectomy patients have foul breath for 1-2 weeks and may experience referred ear pain from eustachian tube swelling during healing." — Katie Holtman (clinical) [Ep 3 · 31:10](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1870)
- "Velopharyngeal insufficiency (excessive nasal airflow causing breathy voice or nasal regurgitation) is a rare adenoidectomy complication that usually resolves with speech therapy." — Katie Holtman (clinical) [Ep 3 · 31:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1900)
- "Tonsil size is graded 1-4, but symptom severity matters more than tonsil size; a patient with grade 2 tonsils and severe symptoms may need surgery more than a patient with grade 3 tonsils and minimal symptoms." — Katie Holtman (clinical) [Ep 3 · 32:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=1960)
- "New-onset enuresis (bedwetting after a dry period) is more indicative of OSA than lifelong enuresis." — Katie Holtman (clinical) [Ep 3 · 34:30](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2070)
- "Tonsillectomy is indicated for sleep-disordered breathing when there is tonsillar hypertrophy, failure to thrive, or polysomnography-documented OSA, plus a daytime symptom reasonably expected to improve with surgery." — Katie Holtman (guideline) [Ep 3 · 35:20](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2120)
- "Post-tonsillectomy pain management requires scheduled acetaminophen and ibuprofen every 3 hours including overnight for the first 7-10 days minimum." — Katie Holtman (clinical) [Ep 3 · 37:10](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2230)
- "Children 6 and older receive additional breakthrough pain medication post-tonsillectomy; codeine is no longer used due to FDA black box warning." — Katie Holtman (clinical) [Ep 3 · 37:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2260)
- "Post-tonsillectomy hemorrhage occurs in 2-4% of patients, typically from dehydration causing premature scab detachment, and is a medical emergency requiring emergency department evaluation." — Katie Holtman (clinical) [Ep 3 · 38:20](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2300)
- "Aggressive hydration with ice cream, slushies, smoothies, popsicles, water, juice, and Gatorade for two weeks post-tonsillectomy reduces hemorrhage risk and pain." — Katie Holtman (clinical) [Ep 3 · 39:00](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2340)
- "Children with Down syndrome often have multi-level airway obstruction; adenotonsillectomy may improve but not cure their OSA." — Katie Holtman (clinical) [Ep 3 · 39:50](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2390)
- "Patients with cleft palate or craniofacial abnormalities have higher velopharyngeal insufficiency risk; superior half adenoidectomy (partial removal) increases airflow while reducing VPI risk." — Katie Holtman (clinical) [Ep 3 · 40:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2440)
- "Sleep studies are particularly challenging for neurodivergent children; when obvious physical obstruction and symptoms exist, surgery can proceed without polysomnography." — Katie Holtman (clinical) [Ep 3 · 42:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2560)
- "For neurodivergent patients undergoing adenotonsillectomy, families should decide whether overnight hospital observation or home recovery better suits their child's needs." — Katie Holtman (clinical) [Ep 3 · 44:10](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2650)
- "Adult CPAP compliance is approximately 53%, suggesting pediatric compliance (especially in neurodivergent children) would be even more challenging." — Katie Holtman (epidemiological) [Ep 3 · 46:30](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2790)
- "Adult studies show poorer surgical outcomes following bariatric surgery when OSA is untreated pre-operatively, likely due to reduced tissue oxygenation and cardiac stress." — Carolyn Grad (host_summary) [Ep 3 · 47:50](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=2870)
- "While awaiting sleep clinic appointments, interim management includes positioning (upright, side-lying), intranasal fluticasone, and home video documentation of sleep." — Carolyn Grad (clinical) [Ep 3 · 50:50](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=3050)
- "A study showed sleep-trained providers viewing home videos of children sleeping had very high diagnostic accuracy compared to subsequent polysomnography results." — Mark Washam (host_summary) [Ep 3 · 52:00](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=3120)
- "The American Academy of Sleep Medicine has a panel currently evaluating alternative methods to assess pediatric sleep apnea beyond in-laboratory polysomnography due to access, cost, and tolerance barriers." — Carolyn Grad (clinical) [Ep 3 · 52:35](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=3155)
- "The Michigan breathing score and pediatric sleep quality of life questionnaire are validated screening tools for pediatric OSA." — Mark Washam (clinical) [Ep 3 · 55:30](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=3330)
- "The Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD) assesses daytime sleepiness in age-appropriate scenarios." — Carolyn Grad (clinical) [Ep 3 · 56:40](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=3400)
- "Orthodontic or dental office airway scoring from cone-beam CT imaging lacks strong correlation with clinically significant OSA and should not trigger urgent referrals." — Katie Holtman (clinical) [Ep 3 · 57:20](https://library.globalcastmd.com/watch/take-my-breath-away-carolyn-grad-mark-washam-katie-holtman-app-conference-2026-12089?t=3440)

## Changelog
- Sep 25: 3 items added automatically

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