Anesthetic management of children undergoing drug-induced sleep endoscopy: A retrospective review

Bispectral Index versus the University of Michigan Sedation Scale in assessing sedation depth during pediatric drug-induced sleep endoscopy

BACKGROUND AND PURPOSE

Bispectral Index (BIS) and University of Michigan Sedation Scale (UMSS) were two commonly used methods of monitoring the sedation depth, but their correlation was not clear. The purpose of this study is to ascertain if BIS correlates with UMSS in determining the sedation level during pediatric drug-induced sleep endoscopy (DISE).

METHODS

One-hundred children, aged 36-143 months, with ASA I~II grade, were enrolled. They were subject to general anesthesia for an elective adenotonsillectomy. Two drug regimens were used. After UMSS ≥ 3, the sites of airway obstructions were located by checking the supraglottic airway structures with a fibrous laryngoscope. UMSS scores, BIS values, electromyography (EMG), and signal quality indices (SQIs) were recorded at the pre-medication and pre-DISE baseline (T0), 5 min subsequent to medication administration but prior to DISE initiation (T1), 1 min after DISE was initiated (T2), 1 min after DISE was completed (T3), 1 min subsequent to tracheal intubation (T4), 1 min following extubation (T5), and 30 min past extubation (T6).

RESULTS

There were strong correlations between BIS monitor readings and UMSS scores for total and two regimens. Kappa values revealed moderate agreement between BIS and UMSS for total and two regimens. The agreement rates were 67.47% for the total, 61.43% for Regimen 1, and 73.42% for Regimen 2, respectively.

CONCLUSION

BIS correlates with UMSS in determining the sedation level during pediatric DISE for two regimens. BIS might serve as an appropriate indicator of sedation intensity when UMSS could not be used.

Effects of drug-induced sleep endoscopy in children with conventional obstructive sleep apnea-hypopnea syndrome: a systematic review and meta-analysis

PURPOSE

This study aimed to conduct a meta-analysis and systematic review of drug-induced sleep endoscopy (DISE) in pediatric conventional obstructive sleep apnea-hypopnea syndrome (OSAHS) without previous upper airway surgery, or comorbidity, to evaluate the change in treatment strategies and to identify obstructive sites observed during DISE. This study aimed to explore the role of DISE in the management of pediatric conventional OSAHS.

METHODS

A comprehensive search was conducted using both computerized and manual methods to retrieve relevant case studies on DISE-guided treatment of pediatric conventional OSAHS from databases including PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, WF, and VIP database. The search period extended from database inception to January 2023. Strict inclusion and exclusion criteria were applied to select relevant literature, and data extraction was performed accordingly. Meta-analysis was conducted using the Stata 16.0 software.

RESULTS

A total of 761 patients from four studies were included in the meta-analysis. All pediatric patients had no history of upper airway surgery, craniofacial abnormalities, or syndromes other than OSAHS. The quality assessment revealed that the included studies were of low methodological quality and consisted of non-randomized case studies. Meta-analysis results indicated that in pediatric patients with OSAHS, the obstruction rates observed during DISE were as follows: nasopharyngeal (adenoid) obstruction 93%, soft palate obstruction 35%, oropharyngeal (tonsil) obstruction 76%, tongue base obstruction 32%, supraglottic obstruction 31%, and multi-level obstruction 60%. DISE led to a change in the conventional surgical approach in 45% (95% CI: 29-60%) of patients with OSAHS, providing individualized treatment plans. Postoperative symptoms and sleep-related parameters improved significantly compared to preoperative values, with DISE findings possibly enhancing surgical success rates and potentially avoiding unnecessary procedures.

CONCLUSION

In some cases, DISE may potentially lead to alterations in conventional surgical approaches for children with OSAHS who had no history of upper airway surgery, craniofacial abnormalities, or other syndromes.. The results of our meta-analysis were in favor of DISE-directed approach for pediatric conventional OSAHS. However, further high-quality randomized controlled trials (RCTs) are warranted in future research to investigate the role of DISE in the management of pediatric OSAHS.

Clinical Application of Pediatric Sleep Endoscopy: An International Survey

OBJECTIVES

To investigate through an international survey the actual clinical application of drug-induced sleep endoscopy (DISE) in pediatric patients with obstructive sleep apnea (OSA) and to clarify the use, application, clinical indications, and protocol of pediatric DISE.

METHODS

A specific survey about pediatric DISE was initially developed by five international otolaryngologists with expertise in pediatric sleep apnea and drug-induced sleep endoscopy and was later spread to experts in the field of sleep apnea, members of different OSA-related associations.

RESULTS

A total of 101 participants who answered all the survey questions were considered in the study. Sixty-four sleep apnea experts, equivalent to 63.4% of interviewed experts, declared they would perform DISE in pediatric OSA patients. A total of 81.9% of responders agreed to consider the DISE as the first diagnostic step in children with persistent OSA after adenotonsillectomy surgery, whereas 55.4% disagreed with performing DISE at the same time of scheduled adenotonsillectomy surgery to identify other possible sites of collapse. In the case of young patients with residual OSA and only pharyngeal collapse during DISE, 51.8% of experts agreed with performing a velopharyngeal surgery. In this case, 27.7% disagreed and 21.4% were neutral.

CONCLUSION

Pediatric DISE is internationally considered to be a safe and effective procedure for identifying sites of obstruction and collapse after adenotonsillectomy in children with residual OSA. This is also useful in cases of patients with craniofacial malformations, small tonsils, laryngomalacia or Down syndrome to identify the actual site(s) of collapse. Despite this evidence, our survey highlighted that pediatric DISE is not used in different sleep centers.

Efficacy of high-flow nasal oxygen during drug-induced sleep endoscopy in patients with obstructive sleep apnea

PURPOSE

High-flow nasal oxygenation (HFNO) can provide a low level of continuous positive airway pressure and alveolar recruitment. We aimed to compare the efficacy of pre-oxygenation with HFNO and low-flow nasal oxygenation (LFNO) during drug-induced sleep endoscopy (DISE).

METHODS

In the LFNO group, preoxygenation was performed for 10 min at 3 L·min-1. In the HFNO group, preoxygenation was performed for 10 min at 30 L·min-1 at a fraction of inspired oxygen of 100% using the Optiflow device. From the start of sedative administration to the end of DISE, vital signs were monitored continuously. The primary outcome was the lowest oxygen saturation (SpO2) during DISE.

RESULTS

Of 24 patients enrolled, 12 were randomly assigned to the LFNO and 12 to the HFNO groups. The prevalence of hypoxia events was 75% in the LFNO group and 58% in the HFNO group. The difference in lowest oxygen saturation between the two groups was not significant between the two groups (P=0.665). The lowest SpO2 during all procedures was comparable between the two groups (86.8 ± 6.5% in the LFNO group and 87.2 ± 8.0% in the HFNO group; P=0.912).

CONCLUSIONS

The findings suggest that HFNO may not be superior to LFNO as a preoxygenation tool to prevent hypoxia during DISE.

Comparison of the Effect of Adding Low-dose Ketamine to Dexmedetomidine and Propofol on the Quality of Sedation and Hemodynamic Response in Children During Upper Gastrointestinal Endoscopy: A Double-blind Randomized Clinical Trial

Background: As endoscopy is an invasive and painful procedure, it is necessary to use a suitable sedative with a minimum dose, especially in children. Objectives: This study aimed to compare the effect of adding low-dose ketamine to dexmedetomidine and propofol on the quality of sedation and hemodynamic response in children during upper gastrointestinal endoscopy. Methods: This double-blind, randomized clinical trial was conducted on 52 children who were candidates for endoscopy in 2 groups, each consisting of 26 patients. In the first group (Ketadex group), infusion of dexmedetomidine (0.7 - 1 μg/kg) for 10 minutes and ketamine bolus (0.4 mg/kg) for anesthesia induction was prescribed. In the second group (Ketofol group), infusion of propofol (50 - 100 μg/kg) for 10 minutes and ketamine bolus (0.4 mg/kg) for anesthesia induction was prescribed. Results: The mean blood pressure of children decreased slightly during and after the endoscopic procedure in the Ketadex group than in the Ketofol group (P < 0.05). The recovery time was significantly less in the Ketofol group (41.85 ± 7.03 minutes) than in the Ketadex group (55.12 ± 7.55 minutes; P < 0.001). Conclusions: The addition of the low-dose ketamine to propofol and dexmedetomidine did not result in any significant changes in the level of sedation, the incidence of adverse effects, and the endoscopist’s satisfaction; however, the recovery time was shorter in the propofol-ketamine combination than in the dexmedetomidine-ketamine combination.

The safety and efficacy of esketamine in comparison to dexmedetomidine during drug-induced sleep endoscopy in children with obstructive sleep apnea hypopnea syndrome: A randomized, controlled and prospective clinical trial

Background and Purpose: Data and high-quality studies of anesthetic methods for children with obstructive sleep apnea hypopnea syndrome (OSAHS) who undergo drug-induced sleep endoscopy (DISE) are limited. Research on pediatric DISE using esketamine has never been reported before. To test the safety and efficacy of esketamine during DISE in children with OSAHS, we compare esketamine (Group K) with dexmedetomidine (Group D) in this study. Methods: 100 children with ASA Ⅰ∼Ⅱ grade, prepared for an elective adenotonsillectomy under general anesthesia, were enrolled in this study and randomized into two groups. Midazolam 0.1 mg/kg was administered intravenously for both groups. In Group D a 1 μg/kg bolus of dexmedetomidine was given over 10 min followed by the infusion rate 1 μg/kg/hr to the end of DISE. Group K received a 1.0 mg/kg IV bolus of esketamine over 10 s followed by the infusion rate 1 mg/kg/hr to the end of DISE. Results: Group K had a higher percentage of success than Group D (p = 0.008). The onset time of Group K was shorter than that of Group D (p = 0.000). The University of Michigan Sedation Scale (UMSS) score of Group K was higher than that of Group D (p = 0.005). The risk of adverse effects (AEs) was lower in Group K (p = 0.000). In Group D, systolic and diastolic blood pressure (SBP and DBP) and heart rate (HR) all decreased, while in Group K, SBP, DBP, and HR hardly changed. Conclusion: Esketamine in comparison to dexmedetomidine provides more effective and safer depth of anesthesia for OSAHS pediatric DISE by ensuring short onset time, deep sedation, and few AEs. Clinical Trial Registration: ClincalTrials.gov, identifier NCT04877639.

Association between sleep quality and general anesthesia in teenager under elective surgery: a prospective study

OBJECTIVE

Anesthesia was reported to be associated with lowered postoperative sleep quality in adults, but its effect on teenager was less understood. This study was conducted to explore the association between postoperative sleep quality and general anesthesia in teenagers.

METHODS

A prospective study was conducted. Teenagers aged from 12 to 16 years who were treated with general anesthesia and under urologic or otolaryngologic surgery were recruited. Healthy teenagers matched by sex and age (± 3 years) with the specific case were recruited as the controls. The Sleep Habits Questionnaire was applied to assess the sleep quality of the teenagers. We applied a logistic regression analysis to evaluate the association between general anesthesia in teenagers under elective surgery and poor sleep quality. Risk ratio (RR) and its corresponding 95% confidence interval (CI) were computed.

RESULTS

A total of 212 teenagers were included comprising 106 patients with general anesthesia who underwent urologic or otolaryngologic surgery and 106 healthy controls. The male participants were accounting for 47.2% (100/212). Anesthesia duration and surgery duration in the patients were 103.7 ± 14.4 min and 162.1 ± 17.0 min, respectively. Positive associations between general anesthesia and poor sleep quality in the 1st, 3rd, and 7th postoperative days were found, and RRs and their corresponding 95%CIs were 4.87 (1.72-13.79), 3.33 (1.22-9.1), and 3.26 (1.07-9.93), respectively. However, there was a lack of statistical associations before surgery and after 14 postoperative days.

CONCLUSIONS

Teenagers who were treated with general anesthesia and under urologic or otolaryngologic surgery might have poor sleep quality within 7 postoperative days.

Pediatric drug-induced sleep endoscopy: An updated review of the literature

The field of drug-induced sleep endoscopy (DISE) has grown considerably over the last 10∼15 years, to now include its use in pediatric patients. In this review article, we outline our approach to the use of this technology in Children with Airway Obstruction, most specifically in the management of children with airway obstruction and known or suspected adenotonsillar enlargement.

The Quest for a DISE Protocol

OBJECTIVE

The objective of this quality initiative project was to modify our existing institutional drug-induced sleep endoscopy (DISE) protocol so that the surgeon could consistently determine obstructive breathing patterns while minimizing children's discomfort.

METHODS

A quality initiative study utilizing the well-described plan-do-study-act (PDSA) process was conducted at a tertiary hospital for children with polysomnogram-documented obstructive sleep apnea who were undergoing DISE. A 4-point Likert measurement tool was created. Change in each Likert rating with subsequent PDSA cycle was tested with the Wilcoxon rank sum test (Mann-Whitney), and change across all PDSA cycles was tested with the Kruskal-Wallis equality-of-populations rank test.

RESULTS

After a series of 4 PDSA cycles with 81 children, the DISE protocol was streamlined from 14 to 9 steps. There was significant improvement for all aspects of the DISE, with a final overall median rating of 1 (excellent) for intravenous (IV) placement, scope insertion, and anesthesiologist and surgeon satisfaction (P < .01).

DISCUSSION

For sleep surgeons, DISE is quickly becoming what bronchoscopy is to the airway surgeon. Utilizing inhalational agents to obtain IV access and insert the flexible scope in the rapid "on-off" fashion optimizes DISE success regardless of the primary sedation medication and allows ample time for these agents to dissipate.

IMPLICATIONS FOR PRACTICE

Adoption of a DISE protocol that includes nasal premedication and inhalational volatile gases for IV and scope insertion at the onset provides a more predictable level of sedation that is well tolerated by the patient, enabling the otolaryngologist to create an obstructive sleep apnea treatment plan.

Procedural Sedation for Pediatric Upper Gastrointestinal Endoscopy in Korea

BACKGROUND

Sedative upper endoscopy is similar in pediatrics and adults, but it is characteristically more likely to lead to respiratory failure. Although recommended guidelines for pediatric procedural sedation are available within South Korea and internationally, Korean pediatric endoscopists use different drugs, either alone or in combination, in practice. Efforts are being made to minimize the risk of sedation while avoiding procedural challenges. The purpose of this study was to collect and analyze data on the sedation methods used by Korean pediatric endoscopists to help physicians perform pediatric sedative upper endoscopy (PSUE).

METHODS

The PSUE procedures performed in 15 Korean pediatric gastrointestinal endoscopic units within a year were analyzed. Drugs used for sedation were grouped according to the method of use, and the depth of sedation was evaluated based on the Ramsay scores. The procedures and their complications were also assessed.

RESULTS

In total, 734 patients who underwent PSUE were included. Sedation and monitoring were performed by an anesthesiologist at one of the institutions. The sedative procedures were performed by a pediatric endoscopist at the other 14 institutions. Regarding the number of assistants present during the procedures, 36.6% of procedures had one assistant, 38.8% had 2 assistants, and 24.5% had 3 assistants. The average age of the patients was 11.6 years old. Of the patients, 19.8% had underlying diseases, 10.0% were taking medications such as epilepsy drugs, and 1.0% had snoring or sleep apnea history. The average duration of the procedures was 5.2 minutes. The subjects were divided into 5 groups as follows: 1) midazolam + propofol + ketamine (M + P + K): n = 18, average dose of 0.03 + 2.4 + 0.5 mg/kg; 2) M + P: n = 206, average dose of 0.06 + 2.1 mg/kg; 3) M + K: n = 267, average dose of 0.09 + 0.69 mg/kg; 4) continuous P infusion for 20 minutes: n = 15, average dose of 6.6 mg/kg; 5) M: n = 228, average dose of 0.11 mg/kg. The average Ramsay score for the five groups was 3.7, with significant differences between the groups (P < 0.001). Regarding the adverse effects, desaturation and increased oxygen supply were most prevalent in the M + K group. Decreases and increases in blood pressure were most prevalent in the M + P + K group, and bag-mask ventilation was most used in the M + K group. There were no reported incidents of intubation or cardiopulmonary resuscitation. A decrease in oxygen saturation was observed in 37 of 734 patients, and it significantly increased in young patients (P = 0.001) and when ketamine was used (P = 0.014). Oxygen saturation was also correlated with dosage (P = 0.037). The use of ketamine (P < 0.001) and propofol (P < 0.001) were identified as factors affecting the Ramsay score in the logistic regression analysis.

CONCLUSION

Although the drug use by Korean pediatric endoscopists followed the recommended guidelines to an extent, it was apparent that they combined the drugs or reduced the doses depending on the patient characteristics to reduce the likelihood of respiratory failure. Inducing deep sedation facilitates comfort during the procedure, but it also leads to a higher risk of complications.