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Effectiveness of pediatric drug-induced sleep endoscopy for REM-predominant obstructive sleep apnea

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Abstract

Study objectives

Because dexmedetomidine (DEX)-induced sedation mimics non-rapid eye movement (NREM) sleep, its utility in sedating children with REM-predominant disease is unclear. We sought to determine the effectiveness of pediatric drug-induced sleep endoscopy (DISE) using DEX and ketamine for children with REM-predominant OSA, specifically whether or not at least one site of obstruction could be identified.

Methods

A retrospective case series of children without tonsillar hypertrophy undergoing DISE at a tertiary pediatric hospital from 10/2013 through 9/2015 who underwent subsequent surgery to address OSA with polysomnography (PSG) before and after.

Results

We included 56 children, mean age 5.6±5.4 years, age range 0.1-17.4 years, mean BMI 20.3±7.4 kg/m2 (76±29 percentile). At least one site of obstruction was identified in all patients, regardless of REM- or NREM-predominance. The mean obstructive apnea-hypopnea index (oAHI) improved (12.6 ± 10.7 to 9.0 ± 14.0 events/h) in children with REM-predominant (P = 0.013) and NREM-predominant disease (21.3 ± 18.9 to 10.3 ± 16.2 events/h) (P = 0.008). The proportion of children with a postoperative oAHI < 5 was 53% and 55% for REM- and NREMpredominant OSA, respectively. Unlike children with NREM-predominant disease, children with REM-predominant disease had significant improvement in the mean saturation nadir (P < 0.001), total sleep time (P = 0.006), and sleep efficiency (P = 0.015).

Conclusions

For children with OSA without tonsillar hypertrophy, DISE using DEX/ketamine was useful to predict at least one site of obstruction, even for those with REM-predominant OSA. DISE-directed outcomes resulted in significant improvements in mean oAHI, total sleep time, sleep efficiency, saturation nadir, and the proportion with oAHI < 5, after surgery for some children with REM-predominant disease.

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Abbreviations

AASM:

American academy of sleep medicine

BMI:

Body mass index

CCHMC:

Cincinnati children’s hospital medical center

DEX:

Dexmedetomidine

EEG:

Electroencephalography

ETCO2 :

End-tidal carbon dioxide

kg:

Kilogram

mg:

Milligram

MRI:

Magnetic resonance imaging

NREM:

Non-rapid eye movement

oAHI:

Obstructive apnea hypopnea index

OSA:

Obstructive sleep apnea

O2 :

Oxygen

Pcrit :

Critical closing airway pressure

PSG:

Polysomnography

REM:

Rapid eye movement

SD:

Standard deviation

TST:

Total sleep time

μg:

Microgram

References

  1. Katz ES, D’Ambrosio CM (2008) Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc 5:253–262

    Article  Google Scholar 

  2. Croft CB, Pringle M (1991) Sleep nasoendoscopy: a technique of assessment in snoring and obstructive sleep apnoae. Clin Otolaryngol Allied Sci 16:504–509

    Article  CAS  Google Scholar 

  3. Lin AC, Koltai PJ (2012) Sleep endoscopy in the evaluation of pediatric obstructive sleep apnea. Int J Pediatr 2012:576719

    Article  Google Scholar 

  4. Wootten CT, Chinnadurai S, Goudy SL (2014) Beyond adenotonsillectomy: outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 78:1158–1162

    Article  Google Scholar 

  5. Wilcox LJ, Bergeron M, Reghunathan S, Ishman SL (2017) An updated review of pediatric drug-induced sleep endoscopy. Laryngoscope Investig Otolaryngol 2(6):423–431

    Article  Google Scholar 

  6. He S, Peddireddy NS, Smith DF et al (2017) Outcomes of drug-induced sleep endoscopy-directed surgery for pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg. https://doi.org/10.1177/0194599817740332

  7. Teshome G, Belani K, Braun JL, Constantine DR, Gattu RK, Lichenstein R (2014) Comparison of dexmedetomidine with pentobarbital for pediatric MRI sedation. Hosp Pediatr 4:360–365

    Article  Google Scholar 

  8. Takrouri MS, Seraj MA, Channa AB, el-Dawlatly AA, Thallage A, Riad W, Khalaf M (2002) Dexmedetomidine in intensive care unit: a study of hemodynamic changes. Middle East J Anesthesiol 16:587–595

    PubMed  Google Scholar 

  9. Venn RM, Hell J, Grounds RM (2000) Respiratory effects of dexmedetomidine in the surgical patient requiring intensive care. Crit Care 4:302–308

    Article  CAS  Google Scholar 

  10. Hsu YW, Cortinez LI, Robertson KM, Keifer JC, Sum-Ping ST, Moretti EW, Young CC, Wright DR, Macleod DB, Somma J (2004) Dexmedetomidine pharmacodynamics: part I: cross-over comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers. Anesthesiology 101:1066–1076

    Article  CAS  Google Scholar 

  11. Ehsan Z, Mahmoud M, Shott SR, Amin RS, Ishman SL (2016) The effects of anesthesia and opioids on the upper airway: a systematic review. Laryngoscope 126:270–284

    Article  CAS  Google Scholar 

  12. Green SM, Roback MG, Krauss B (2010) Laryngospasm during emergency department ketamine sedation: a case-control study. Pediatr Emerg Care 26:798–802

    Article  Google Scholar 

  13. Mistry RB, Nahata MC (2005) Ketamine for conscious sedation in pediatric emergency care. Pharmacotherapy 25:1104–1111

    Article  Google Scholar 

  14. Green SM, Krauss B (2004) Clinical practice guidelines for emergency department ketamine dissociative sedation in children. Ann Emerg Med 44:460–471

    Article  Google Scholar 

  15. Mason KP, O’Mahony E, Zurakowski D, Libenson MH (2009) Effect of increasing depth of dexmedetomidine sedation on the EEG in children. Paediatr Anaesth 19:1175–1183

    Article  Google Scholar 

  16. Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM, American Academy of Sleep Medicine (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. J Clin Sleep Med 8(5):597–619

    Article  Google Scholar 

  17. Schwengel DA, Sterni LM, Tunkel DE, Keitmiller ES (2009) Perioperative management of children with obstructive sleep apnea. Anesth Analg 1091:60–75

    Article  Google Scholar 

  18. McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM (1992) Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1189:940–943

    Article  Google Scholar 

  19. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K (2002) Can assessment for obstructive sleep apnea help predict post adenotonsillectomy respiratory complications. Anesthesiology 962:313–322

    Article  Google Scholar 

  20. Koo BB, Dostal J, Ioachimescu O, Budur K (2008) The effects of gender and age on REM-related sleep-disordered breathing. Sleep Breath 12:259–264

    Article  Google Scholar 

  21. Koo BB, Patel SR, Strohl K, Hoffstein V (2008) Rapid eye movement-related sleep-disordered breathing: influence of age and gender. Chest 134:1156–1161

    Article  Google Scholar 

  22. Haba-Rubio J, Janssens JP, Rochat T, Sforza E (2005) Rapid eye movement-related disordered breathing: clinical and polysomnographic features. Chest 128:3350–3357

    Article  Google Scholar 

  23. Mason KP, O'Mahony E, Zurakowski D, Libenson MH (2009) Effects of dexmedetomidine sedation on the EEG in children. Paediatr Anaesth 19(12):1175–1183

    Article  Google Scholar 

  24. Huupponen E, Maksimow A, Lapinlampi P, Särkelä M, Saastamoinen A, Snapir A, Scheinin H, Scheinin M, Meriläinen P, Himanen SL, Jääskeläinen S (2008) Electroencephalogram spindle activity during dexmedetomidine sedation and physiological sleep. Acta Anaesthesiol Scand 52(2):289–294

    Article  CAS  Google Scholar 

  25. Mahmoud M, Ishman SL, McConnell K et al (2017) Upper airway reflexes are preserved during dexmedetomidine sedation in children with down syndrome and obstructive sleep apnea. J Clin Sleep Med 13(5):721–727

    Article  Google Scholar 

  26. Bhana N, Goa KL, McClellan KJ (2000) Dexmedetomidine. Drugs 59:263–268

    Article  CAS  Google Scholar 

  27. Shelly MP (2001) Dexmedetomidine: a real innovation or more of the same? Br J Anaesth 87:677–678

    Article  CAS  Google Scholar 

  28. Koroglu A, Demirbilek S, Teksan H, Sagir O, But AK, Ersoy MO (2005) Sedative, haemodynamic and respiratory effects of dexmedetomidine in children undergoing magnetic resonance imaging examination: preliminary results. Br J Anaesth 94:821–824

    Article  CAS  Google Scholar 

  29. Boudewyns A, Verhulst S, Maris M, Saldien V, Van de Heyning P (2014) Drug-induced sedation endoscopy in pediatric obstructive sleep apnea syndrome. Sleep Med 15:1526–1531

    Article  CAS  Google Scholar 

  30. Mokhlesi B, Punjabi NM (2012) “REM-related” obstructive sleep apnea: an epiphenomenon or a clinically-important entity? Sleep 35(1):5–7

    Article  Google Scholar 

  31. Goh DY, Galster P, Marcus CL (2000) Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am J Respir Crit Care Med 162:682–686

    Article  CAS  Google Scholar 

  32. Chami HA, Baldwin CM, Silverman A, Zhang Y, Rapoport D, Punjabi NM, Gottlieb DJ (2010) Sleepiness, quality of life, and sleep maintenance in REM versus non-REM sleep-disordered breathing. Am J Respir Crit Care Med 181:997–1002

    Article  Google Scholar 

  33. Marcus CL, Moore RH, Rosen CL et al (2013) A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 368:2366–2376

    Article  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA

    David F. Smith, Shan He, Nithin S. Peddireddy, Christine H. Heubi, Sally R. Shott, Aliza P. Cohen & Stacey L. Ishman

  2. Division of Pulmonary and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA

    David F. Smith, Christine H. Heubi & Stacey L. Ishman

  3. Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    David F. Smith, Christine H. Heubi, Sally R. Shott & Stacey L. Ishman

  4. Department of Otolaryngology, Shanghai Children’s Hospital Affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China

    Shan He

  5. Department of Otolaryngology–Head and Neck Surgery, Geisinger Medical Center, Danville, PA, USA

    P. Vairavan Manickam

Authors
  1. David F. Smith
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  2. Shan He
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  3. Nithin S. Peddireddy
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  8. Stacey L. Ishman
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Corresponding author

Correspondence to Stacey L. Ishman.

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The authors’ declare that they have no conflict of interest.

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No off-label or investigational use of drugs/materials. The authors have no other disclosures to report.

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This article does not contain any studies with human participants performed by any of the authors.

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Institution where work was performed: Cincinnati Children’s Hospital Medical Center

This abstract was presented as an oral presentation at the Triological Society Combined Sections Meeting on January 20, 2017.

Current Knowledge / Study Rationale: Drug-induced sleep endoscopy (DISE) is performed for infant obstructive sleep apnea (OSA) or children with persistent OSA after adenotonsillectomy. However, results of DISE-directed surgery have not been compared between those with REM- versus non-REM (NREM)-predominant OSA. Given the effects of certain anesthetics, it is important to determine the utility of DISE for children with rapid eye movement (REM)-predominant OSA.

Study Impact: While dexmedetomidine and ketamine induce NREM-like sleep, identification of a site of obstruction was possible for all of the children with REM-predominant OSA and some had significant improvement in their postoperative oAHI, saturation nadir, total sleep time, and sleep efficiency. This group also had surgical success rates similar to children with NREM-predominant OSA. Here, we demonstrate that DISE using dexmedetomidine and ketamine is useful to evaluate airway obstruction in some children with REM-predominant OSA. Larger studies are needed to better understand more about the specific patients that would be best served by DISE evaluation.

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Smith, D.F., He, S., Peddireddy, N.S. et al. Effectiveness of pediatric drug-induced sleep endoscopy for REM-predominant obstructive sleep apnea. Sleep Breath 24, 1705–1713 (2020). https://doi.org/10.1007/s11325-020-02056-7

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  • DOI: https://doi.org/10.1007/s11325-020-02056-7

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