Management of obstructive sleep apnea in children: A Canada-wide survey

Abstract

Background Obstructive sleep apnea frequently persists in children following adenotonsillectomy, which is the first-line treatment recommended for obstructive sleep apnea with adenotonsillar hypertrophy. Drug-induced sleep endoscopy (DISE) is a diagnostic tool increasingly used to assess pediatric obstructive sleep apnea, but its use has not been standardized. The overarching goal of this study was to document the current practice of Canadian otolaryngologists managing this population. Methods A nation-wide online cross-sectional survey of Canadian otolaryngologist members of the Canadian Society of Otolaryngology – Head and Neck Surgery and the Association d’otorhinolaryngologie et chirurgie cervico-faciale du Québec. The 58-question electronic survey was developed based on a validated survey redaction guide with the aim to assess management and treatment of pediatric obstructive sleep apnea, as well as indications and performance of DISE. Consensus on practice items was defined by a minimum of 75% similar answers. Results One hundred and nine Canadian otolaryngologists completed the survey on management of pediatric obstructive sleep apnea, among which 12 of them completed the questions on DISE. Overall, there was a poor rate of agreement of 55% among the respondents for the 58 questions altogether. There was a consensus to assess pediatric obstructive sleep apnea clinically ± with videos (82.6%), to assess adenotonsillar hypertrophy clinically (93.6%) and with flexible scope in the office (80.7%), as well as for the airway sites examined endoscopically during DISE. However, there was no consensus regarding anesthetic protocol and scoring system. DISE was mostly performed in cases of persistent obstructive sleep apnea after adenotonsillectomy rather than before performing any surgical procedure. There was no difference in the management of obstructive sleep apnea between otolaryngologists who perform DISE and those who do not. The only difference between otolaryngologists who practice in community centers versus in tertiary care centers was the more frequently use of the Brodsky tonsil scale by the latter ones. Conclusion This Canadian-wide survey highlighted a lack of consensus in the management of pediatric obstructive sleep apnea and DISE. Certain aspects regarding DISE remain unclear, including establishment of its ideal timing in order to eventually avoid unnecessary tonsillectomies.

Recent advances in paediatric sleep disordered breathing

“…There is a flourishing literature in relation to drug-induced sleep endoscopy (DISE) as a tool for evaluating the anatomical site of airway obstruction. A survey by COUSINEAU et al [43] of practice in Canada identified wide variation, with DISE rarely performed before AT or PSG. It was felt to be helpful in the absence of adenotonsillar hypertrophy or where there was a discrepancy between the clinical findings and severity of sleep apnoea.…”

Considerations in Surgical Management of Pediatric Obstructive Sleep Apnea: Tonsillectomy and Beyond

“…It should reproduce the various stages of sleep including rapid eye movement, preserve brainstem reflexes, maintain respiratory rhythm and upper airway muscle activity, yet be relatively short with amnestic properties [13]. Most experts agree that either propofol or dexmedetomidine are preferrable in achieving this [59], although debate continues for the role of other agents [13,63,64].…”

“…This technique has increasingly been applied to pediatric OSA in the last decade; however, the evidence for its use is still evolving. Controversy still exists in the appropriate indications, sedation regimen, endoscopy protocol, and interpretation of DISE results [13,59,63]. There is strong consensus that a PSG confirming OSA should be completed prior to considering DISE [59,64].…”

“…There is strong consensus that a PSG confirming OSA should be completed prior to considering DISE [59,64]. It is generally recommended that DISE is used when there is persistent PSG-proven OSA post adenotonsillectomy [29,59,63,64] as DISE was not found to change the plan for adenotonsillectomy in >95% of surgically naïve children with OSA [59].…”

“…Of these, only 0.3% required additional intervention for the lower airway findings [59]. Debate continues, however, on the best method of scoring DISE findings with a goal of predicting surgical outcomes [59,63,64]. Potential complications of DISE include laryngospasm, bronchospasm, oversedation, hypotension, bradycardia, and respiratory depression.…”