Review ArticleAnesthetic management of children undergoing drug-induced sleep endoscopy: A retrospective review
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.
Section snippets
Methods
A literature review using PubMed (www.ncbi.nlm.nih.gov/pubmed), SCOPUS, and Web of Science databases was performed for articles published between January 1, 1990 to January 1, 2020. The following medical subject heading (MesH) terms were used: Drug-induced sleep endoscopy and anesthesia, DISE, child, obstructive sleep apnea, sleep disordered breathing. Article titles and abstracts were reviewed to determine eligibility for inclusion. Bibliographies were also reviewed to identify studies missed
Results
Fig. 1 summarizes the literature search and results. A total of 12 studies were included in the retrospective review and are summarized in Table 1. The total number of children included was 1110. The age ranged from 2 months to 19 years. One study evaluated patients with Prader-Willi syndrome regardless of an OSA diagnosis [13]. All other studies were of children with OSA undergoing DISE for evaluation of the upper airway. Five studies evaluated the airway pre-T&A [[14], [15], [16], [17], [18]
Discussion
This retrospective review illustrates that there are a variety of anesthetic techniques that are used successfully for pediatric DISE. This review also highlights the limitations of existing studies including poor study design, limited data on the effects of anesthetic agents on the upper airway, and lack of consensus on determining sedation depth during DISE. No consensus, or agreed guidelines, exists on the best anesthetic regimens or protocols in pediatric DISE [25,26]. Many studies evaluate
Conclusions
Few studies exist comparing different anesthetic regimens used for pediatric DISE. Medications with minimal effects on respiratory control, such as dexmedetomidine and ketamine, work best for DISE but are not universally used. The combination of ketamine and dexmedetomidine may be the best regimen for pediatric DISE. Premedication, though commonly used in the pediatric population, should be avoided. Inhalational agents and opioids worsen upper airway obstruction and should also be avoided.
Financial disclosure
None.
Declaration of competing interest
None.
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2021, World Journal of Otorhinolaryngology - Head and Neck SurgeryCitation Excerpt :Currently, multiple anesthetic protocols have been proposed (Table 1), but none have been universally accepted. The most common anesthetic agents used in pediatric DISE are propofol, midazolam, dexmedetomidine (DEX), ketamine, and inhalational agents (i.e. sevoflurane).23 For adults, propofol is the anesthetic most frequently used for DISE and is titrated to a bispectral index between 50 and 75.9