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

Abstract

Objective

To determine the best anesthetic technique for DISE based on a retrospective review of the current literature and to highlight research gaps that should be addressed in future studies.

Methods

A comprehensive retrospective review of the literature on anesthetic regimens for pediatric DISE through March 2020 was performed. Specific medical subject heading (MesH) terms included: drug-induced sleep endoscopy and anesthesia, DISE, child, obstructive sleep apnea, sleep disordered breathing.

Results

Twelve articles were included. One study was a retrospective comparative study while the remaining 11 were case series. Five studies described anesthetic technique for DISE pre-T&A, two post-T&A, and four both pre- and post-T&A. The heterogeneity of the studies did not allow for a meta-analysis. A total of 1110 children ages 2 months to 19 years were included. Sedation depth and anesthetic outcomes with DISE were infrequently described. Eleven studies used a sevoflurane inhalational induction and mostly transitioned to a total IV anesthetic for maintenance. Propofol was the most commonly used sole anesthetic. A total of three studies used a combination of remifentanil and propofol, one used dexmedetomidine alone, one used sevoflurane alone, and one compared different regimens. Dexmedetomidine and ketamine have the most favorable profile for pediatric DISE but are not universally used. DISE completion, as reported in two studies, was 93% and 100%.

Conclusion

There are several anesthetic regimens for DISE that achieve good sedation and outcomes. The combination of ketamine and dexmedetomidine may be the ideal regimen. Limited data and lack of protocols/high-quality studies exist on anesthetic regimens for pediatric DISE.

Introduction

Pediatric obstructive sleep apnea (OSA) affects 1–4% of children in the US [1]. The most common cause of pediatric OSA is adenotonsillar hypertrophy, for which the first-line surgical therapy is adenotonsillectomy (T&A). Up to 75% of children may have persistent OSA after surgery [2]. Risk factors include severe OSA on initial polysomnography (PSG), obesity, craniofacial anomalies, hypotonia, and Down syndrome [1].

PSG is the criterion standard for diagnosing OSA, but it can be cumbersome, time-consuming, costly, and requires a sleep laboratory. In addition, PSG does not indicate the site of airway obstruction, predict resolution of symptoms, or direct further therapy. Other techniques have been explored to better identify and manage children with OSA. First described by Croft and Pringle in 1991, “drug-induced sleep endoscopy” (DISE) was renamed by Kezirian and Hohenhurst in 2005 to better describe the three key elements of the procedure: “the use of pharmacological agents to achieve sedation, the target depth of sedation as approximating natural sleep as much as possible, and the endoscopic evaluation of the upper airway” [3]. Many indications exist for DISE in children. DISE is commonly used to identify anatomic causes of persistent pediatric OSA after T&A. It can also be used to direct therapy in sleep-dependent laryngomalacia and pre-surgical evaluation for hypoglossal nerve stimulator implantation [1,4].

The anesthetic goals during DISE include utilizing a regimen that quickly and predictably provides a target depth of sedation while allowing tolerance of the procedure, maintenance of cardiorespiratory parameters, avoidance of airway collapse beyond what naturally occurs during sleep, and avoidance of rescue maneuvers or supplemental oxygen. In children, craniofacial syndromes, neurologic impairment, and hypotonia make these challenges even greater. Though upper airway obstruction in children is more common during REM sleep [5], no known anesthetic agent exists that replicates REM sleep. The use of sedation may interfere with natural sleep and the level of sedation required to tolerate DISE may cause excessive airway collapse.

Several studies on indications and outcomes of DISE in children are present in the literature [[6], [7], [8]]. However, scant literature exists regarding anesthetic protocols in pediatric DISE despite unique challenges in children [1]. The primary objective of this study is to review the existing literature regarding anesthetic regimens in children undergoing DISE in order to determine the best anesthetic technique for DISE. The secondary objective is to highlight research gaps that should be addressed in future studies.