The effects of Anesthesia and opioids on the upper airway: A systematic review

Efficacy of nonopioid analgesics and adjuvants in multimodal analgesia for reducing postoperative opioid consumption and complications in obesity: a systematic review and network meta-analysis

BACKGROUND

Managing postoperative pain in patients with obesity is challenging. Although multimodal analgesia has proved effective for pain relief, the specific impacts of different nonopioid i.v. analgesics and adjuvants on these patients are not well-defined. This study aims to assess the effectiveness of nonsteroidal antiinflammatory drugs, paracetamol, ketamine, α-2 adrenergic receptor agonists, lidocaine, magnesium, and oral gabapentinoids in reducing perioperative opioid consumption and, secondarily, in mitigating the occurrence of general and postoperative pulmonary complications (POPCs), nausea, vomiting, PACU length of stay (LOS), and hospital LOS among surgical patients with obesity.

METHODS

A systematic review and network meta-analysis was performed. PubMed, Scopus, Web of Science, CINAHL, and EMBASE were searched. Only English-language RCTs investigating the use of nonopioid analgesics and adjuvants in adult surgical patients with obesity were included. The quality of evidence and certainty were assessed using the RoB 2 tool and GRADE framework, respectively.

RESULTS

In total, 37 RCTs involving 3602 patients were included in the quantitative analysis. Compared with placebo/no intervention or a comparator, dexmedetomidine, ketamine, lidocaine, magnesium, and gabapentin significantly reduced postoperative opioid consumption after surgery. Ketamine/esketamine also significantly reduced POPCs. Ibuprofen, dexmedetomidine, and lidocaine significantly reduced postoperative nausea, whereas dexmedetomidine, either alone or combined with pregabalin, and lidocaine reduced postoperative vomiting. Dexmedetomidine significantly reduced PACU LOS, whereas both paracetamol and lidocaine reduced hospital LOS.

CONCLUSIONS

Intravenous nonopioid analgesics and adjuvants are crucial in multimodal anaesthesia, reducing opioid consumption and enhancing postoperative care in adult surgical patients with obesity.

SYSTEMATIC REVIEW PROTOCOL

CRD42023399373 (PROSPERO).

Adverse events in patients with obstructive sleep apnea undergoing procedural sedation in ambulatory settings: An updated systematic review and meta-analysis

OBJECTIVE

Patients with obstructive sleep apnea (OSA) may be at increased risk for adverse events during procedural sedation, however, there remains a gap in the literature quantifying these risks. This systematic review and meta-analysis aimed to evaluate the risk of peri-procedural adverse events in OSA patients undergoing procedural sedation in ambulatory settings, compared to those without OSA.

METHODS

Four databases were systematically searched for studies published from January 1, 2011 to January 4, 2024. The inclusion criteria were: adult patients with OSA undergoing procedural sedation in ambulatory settings, peri-procedural adverse events reported, and control group included. The primary outcome was the incidence of peri-procedural adverse events amongst patients with vs without OSA.

RESULTS

Nineteen studies (27,973 patients) were included. The odds of respiratory adverse events were significantly increased for patients with OSA (OR 1.65, 95 % CI 1.03-2.66, P = 0.04). Furthermore, the odds of requiring an airway maneuver/intervention were significantly greater for patients with OSA (OR 3.28, 95 % CI 1.43-7.51, P = 0.005). The odds of cardiovascular adverse events were not significantly increased for patients with OSA.

CONCLUSION

Patients with OSA undergoing procedural sedation in ambulatory settings had 1.7-fold greater odds of respiratory adverse events and 3.3-fold greater odds of requiring airway maneuvers/interventions.

Incidences of Rocuronium Use during Anesthetic Induction in Adult Patients Undergoing Orthopedic Surgery Using Supraglottic Airway Devices: A Retrospective Analysis

Background/Objectives: Neuromuscular blocking agents (NMBAs) are not usually necessary during the induction of general anesthesia in patients using supraglottic airway (SGA) devices. In this study, we assessed the incidences of rocuronium use in adult patients undergoing general anesthesia using SGA devices. Methods: From September 2022 to August 2023, the medical records of adult patients (≥19 years) who underwent orthopedic surgery using SGA devices were retrospectively investigated. The incidences of rocuronium use during anesthetic induction were analyzed according to the anesthetic induction drug. The association of rocuronium use during anesthesia was analyzed in terms of demographic (age, sex, height, and weight), surgical (surgical time), and anesthetic factors (premedication, anesthetic agent, anesthetic time). Results: In total, 321 patients were enrolled. The incidence rate of rocuronium use during anesthetic induction was 28.3%. In the subgroup analysis, patients receiving total intravenous anesthesia (TIVA) with propofol (PPF) and remifentanil showed a markedly lower incidence (14.4%) than the other anesthetic groups. Premedication or short anesthetic duration was associated with lower incidences of rocuronium use. Demographic and other anesthetic factors did not seem to affect the incidences of rocuronium use during anesthesia. Conclusions: The incidence of rocuronium use during anesthetic induction with SGA devices was significantly lower with the PPF-TIVA compared to that using remimazolam-TIVA or inhalational anesthesia. Premedication with midazolam and shorter operation times were associated with a significantly lower incidence of rocuronium use.

Identifying the pathophysiological traits of obstructive sleep apnea during dexmedetomidine sedation

Dexmedetomidine (DEX) has been described as a safe sedative in clinical practice, but its effects on the pathophysiological traits of obstructive sleep apnea (OSA) are unclear. We estimated the effects of DEX sedation on the four key pathophysiological traits of OSA (pharyngeal collapsibility, dilator muscle function, arousal threshold, and loop gain) in adult patients with OSA by conducting a secondary analysis of a prospective diagnostic trial. Pathophysiological traits estimated from polysomnography and the respiratory parameters under natural sleep and DEX-induced sleep were compared. Bivariate and multivariate linear regression analyses were used to estimate the relationship between pathophysiological traits and OSA severity for both sleep states. Adult patients with OSA had a significantly higher pharyngeal collapsibility (Vpassive: 44.9 [15.7 to 53.8] vs. 53.3 [34.2 to 66.3] %eupnea, p < 0.001), arousal threshold (178.5 [132.5 to 234.6] vs. 140.5 [123.2 to 192.3] %eupnea, p < 0.001), and loop gain (LG1: 0.74 ± 0.25 vs. 0.60 ± 0.17, p < 0.001; LGn: 0.52 ± 0.12 vs. 0.44 ± 0.08, p < 0.001) during DEX-induced sleep compared with natural sleep. There was no significant difference in dilator muscle function or PSG respiratory parameters between natural versus DEX-induced sleep states. Bivariate regression analysis showed varying degrees of correlation between OSA traits and severity. Multiple regression analysis indicated that collapsibility was the strongest predictor of the apnea-hypopnea index for both sleep states. Dexmedetomidine sedation in patients with OSA increased the pharyngeal collapsibility without impairing dilator muscle function, while elevating arousal threshold and increasing loop gain.

Advanced Diagnostic Techniques in Obstructive Sleep Apnea

Optimal surgical and medical management of obstructive sleep apnea requires clinically reliable identification of patterns and sites of upper airway obstruction. A wide variety of modalities have been used to evaluate upper airway obstruction. Drug-induced sleep endoscopy (DISE) and cine MRI are increasingly used to identify upper airway obstruction sites, to characterize airway obstruction patterns, to determine optimum medical and surgical treatment, and to plan individualized surgical management. Here, we provide an overview of the applications of DISE and cine MRI in assessing upper airway obstruction in children and adults with obstructive sleep apnea.

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.

Obstructive Sleep Apnea and Risk of Postoperative Complications after Non-Cardiac Surgery

Obstructive sleep apnea (OSA), a common sleep disorder, poses significant challenges in perioperative management due to its complexity and multifactorial nature. With a global prevalence of approximately 22.6%, OSA often remains undiagnosed, and increases the risk of cardiac and respiratory postoperative complications. Preoperative screening has become essential in many institutions to identify patients at increased risk, and experts recommend proceeding with surgery in the absence of severe symptoms, albeit with heightened postoperative monitoring. Anesthetic and sedative agents exacerbate upper airway collapsibility and depress central respiratory activity, complicating intraoperative management, especially with neuromuscular blockade use. Additionally, OSA patients are particularly prone to opioid-induced respiratory depression, given their increased sensitivity to opioids and heightened pain perception. Thus, regional anesthesia and multimodal analgesia are strongly advocated to reduce perioperative complication risks. Postoperative care for OSA patients necessitates vigilant monitoring and tailored management strategies, such as supplemental oxygen and Positive Airway Pressure therapy, to minimize cardiorespiratory complications. Health care institutions are increasingly focusing on enhanced monitoring and resource allocation for patient safety. However, the rising prevalence of OSA, heterogeneity in disease severity, and lack of evidence for the efficacy of costly perioperative measures pose challenges. The development of effective screening and monitoring algorithms, alongside reliable risk predictors, is crucial for identifying OSA patients needing extended postoperative care. This review emphasizes a multidimensional approach in managing OSA patients throughout the perioperative period, aiming to optimize patient outcomes and minimize adverse outcomes.

Advanced Diagnostic Techniques in Obstructive Sleep Apnea

Optimal surgical and medical management of obstructive sleep apnea (OSA) requires clinically reliable identification of patterns and sites of upper airway obstruction. A wide variety of modalities has been used to evaluate upper airway obstruction. Drug-induced sleep endoscopy (DISE) and cine MRI are increasingly used to identify upper airway obstruction sites, to characterize airway obstruction patterns, to determine optimum medical and surgical treatment, and to plan individualized surgical management. Here, the authors provide an overview of the applications of DISE and cine MRI in assessing upper airway obstruction in children and adults with OSA.

Characteristics and Mechanism of Upper Airway Collapse Revealed by Dynamic MRI During Natural Sleep in Patients with Severe Obstructive Sleep Apnea

Purpose

Upper airway collapse during sleep in patients with obstructive sleep apnea (OSA) is a complex and dynamic phenomenon. By observing and analyzing the dynamic changes in the upper airway and its surrounding tissues during airway obstruction, we aim to reveal dynamic characteristics in different obstruction patterns, and the relationship between anatomical features during normal breathing and dynamic characteristics of airway obstruction.

Patients and Methods

Dynamic MRI was performed in 23 male patients (age range 26-63) with severe OSA diagnosed by overnight polysomnography, and obstruction events were identified from their images. Dynamic changes in parameters of the upper airway and surrounding tissues were measured to assess the key characteristics in different obstruction patterns.

Results

We categorized airway obstruction into four types based on the obstruction location and motion characteristics of tissues during collapse, and detailed the alterations in the airway and surrounding tissues under each obstruction pattern. In all 112 obstruction events extracted from the dynamic images of 23 patients, type A (retropalatal obstruction caused by the soft palate separated from the tongue), BI, BII (both retropalatal obstructions caused by the soft palate attached to the tongue, and C (retropalatal and retroglossal obstruction caused by the soft palate and the tongue), accounted for 28.6%, 44.6%, 12.5%, and 14.3% respectively. In severe OSA patients with tongue and palatal obstruction related to type B or C, the more posterior hyoid position, shorter distance between tongue and uvula, and wider retropalatal space, the larger the tongue displacement and deformation during collapse, and the greater the reduction in airway space.

Conclusion

There are multiple airway obstruction patterns, each with its own anatomical characteristics and behaviors during collapse. Hyoid position, tongue and uvula distance, and retropalatal space play an important role in airway collapse and should be paid more attention in the treatment of OSA.

The Application of Ultrasound to Quantify Hyoid Motion During Drug-Induced Sleep Endoscopy

INTRODUCTION

The significance of hyoid dynamics in OSA pathophysiology remains unclear. Drug-induced sleep endoscopy (DISE) is often used for evaluating patients intolerant to positive airway pressure (PAP) therapy. We performed DISE with concurrent hyoid-focused ultrasonography to quantify hyoid dynamics during obstructive and non-obstructive breathing.

METHODS

A cross-sectional analysis from a prospective cohort of patients undergoing DISE with PAP titration (DISE-PAP) and hyoid-focused ultrasound was conducted. Hyoid ultrasound was performed during obstructive breathing, and non-obstructive breathing after PAP administration. Motion was quantified by generating displacement curves based on echo-tracking hyoid movement. The image analysis protocol for quantifying hyoid displacement was performed independently by two researchers, and reliability of measures was assessed. Univariate and multivariate regressions were performed for various clinical data and hyoid displacement during obstructive breathing.

RESULTS

Twenty patients met inclusion criteria. On average, the cohort was male (75%), elderly (65.9 ± 10 years), overweight (29.3 ± 3.99 kg/m2 ), and with moderate-to-severe OSA (29.3 ± 12.5 events/h). Mean hyoid displacement during obstructive breathing was 5.81 mm (±3.48). In all patients, hyoid displacement decreased after PAP administration (-3.94 mm [95% CI: -5.10, -2.78]; p < 0.0001). Inter-rater reliability for measures of hyoid displacement was excellent. After multivariate regression, hyoid displacement at baseline was associated with higher AHI (β [95% CI] = 0.18 [0.03, 0.33], p = 0.020).

CONCLUSION

During DISE, hyoid displacement is greater during obstructive breathing with significant variability amongst patients. Further, these ultrasonographic measurements had excellent intra- and inter-rater reliability. Additional, larger studies are needed to understand contributors to hyoid mobility.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:3221-3227, 2023.

Preoperative risk evaluation and perioperative management of patients with obstructive sleep apnea: a narrative review

Obstructive sleep apnea (OSA) is a common sleep-breathing disorder associated with significant comorbidities and perioperative complications. This narrative review is aimed at comprehensively overviewing preoperative risk evaluation and perioperative management strategies for patients with OSA. OSA is characterized by recurrent episodes of upper airway obstruction during sleep leading to hypoxemia and arousal. Anatomical features, such as upper airway narrowing and obesity, contribute to the development of OSA. OSA can be diagnosed based on polysomnography findings, and positive airway pressure therapy is the mainstay of treatment. However, alternative therapies, such as oral appliances or upper airway surgery, can be considered for patients with intolerance. Patients with OSA face perioperative challenges due to difficult airway management, comorbidities, and effects of sedatives and analgesics. Anatomical changes, reduced upper airway muscle tone, and obesity increase the risks of airway obstruction, and difficulties in intubation and mask ventilation. OSA-related comorbidities, such as cardiovascular and respiratory disorders, further increase perioperative risks. Sedatives and opioids can exacerbate respiratory depression and compromise airway patency. Therefore, careful consideration of alternative pain management options is necessary. Although the association between OSA and postoperative mortality remains controversial, concerns exist regarding adverse outcomes in patients with OSA. Understanding the pathophysiology of OSA, implementing appropriate preoperative evaluations, and tailoring perioperative management strategies are vital to ensure patient safety and optimize surgical outcomes.

Influence of glutamatergic and GABAergic neurotransmission on obstructive sleep apnea

Glutamate and γ-aminobutyric acid (GABA) are the two main neurotransmitters in the human brain. The balance between their excitatory and inhibitory functions is crucial for maintaining the brain's physiological functions. Disturbance of glutamatergic or GABAergic neurotransmission leads to serious health problems including neurodegeneration, affective and sleep disorders. Both GABA and glutamate are involved in the control of the sleep-wake cycle. The disturbances in their function may cause sleep and sleep-related disorders. Obstructive sleep apnea (OSA) is the most common sleep respiratory disorder and is characterized by repetitive collapse of the upper airway resulting in intermittent hypoxia and sleep fragmentation. The complex pathophysiology of OSA is the basis of the development of numerous comorbid diseases. There is emerging evidence that GABA and glutamate disturbances may be involved in the pathogenesis of OSA, as well as its comorbidities. Additionally, the GABA/glutamate targeted pharmacotherapy may also influence the course of OSA, which is important in the implementation of wildly used drugs including benzodiazepines, anesthetics, and gabapentinoids. In this review, we summarize current knowledge on the influence of disturbances in glutamatergic and GABAergic neurotransmission on obstructive sleep apnea.

Objective Pharyngeal Phenotyping in Obstructive Sleep Apnea With High-Resolution Manometry

OBJECTIVE

Drug-induced sleep endoscopy (DISE) is a commonly used diagnostic tool for surgical procedural selection in obstructive sleep apnea (OSA), but it is expensive, subjective, and requires sedation. Here we present an initial investigation of high-resolution pharyngeal manometry (HRM) for upper airway phenotyping in OSA, developing a software system that reliably predicts pharyngeal sites of collapse based solely on manometric recordings.

STUDY DESIGN

Prospective cross-sectional study.

SETTING

An academic sleep medicine and surgery practice.

METHODS

Forty participants underwent simultaneous HRM and DISE. A machine learning algorithm was constructed to estimate pharyngeal level-specific severity of collapse, as determined by an expert DISE reviewer. The primary outcome metrics for each level were model accuracy and F1-score, which balances model precision against recall.

RESULTS

During model training, the average F1-score across all categories was 0.86, with an average weighted accuracy of 0.91. Using a holdout test set of 9 participants, a K-nearest neighbor model trained on 31 participants attained an average F1-score of 0.96 and an average accuracy of 0.97. The F1-score for prediction of complete concentric palatal collapse was 0.86.

CONCLUSION

Our findings suggest that HRM may enable objective and dynamic mapping of the pharynx, opening new pathways toward reliable and reproducible assessment of this complex anatomy in sleep.

Efficacy and safety comparison of esketamine-propofol with nalbuphine-propofol for upper gastrointestinal endoscopy in children: a multi-center randomized controlled trial

Background and Aims

Anesthetics such as propofol, esketamine and nalbuphine are used during the upper gastrointestinal endoscopy to achieve and maintain the desired sedation level. The aim of the study was to evaluate the effectiveness and safety of propofol-nalbuphine and propofol-esketamine in children.

Methods

A multi-centered study was performed at three tertiary class-A hospitals. Children between 3 and 12 years old undergoing diagnostic painless upper gastrointestinal endoscopy were included and randomly divided into esketamine or nalbuphine group to estimate the primary outcome of successful endoscope insertion. The patients were given esketamine 0.5 mg/kg and propofol 2 mg/kg intravenously in esketamine group, with nalbuphine 0.2 mg/kg and propofol 2 mg/kg in the nalbuphine group. The primary outcome was success rate for the first attempt of endoscope insertion in each group. Secondary outcomes included the safety of both anesthesia regimens and gastroenterologist's satisfaction. We used the Face, Leg, Activity, Cry and Consolability (FLACC) scale to evaluate the level of pain before and during the procedure and the Pediatric Anesthesia Emergence Delirium (PAED) scale to assess the level of agitation and delirium after awakening from anesthesia.

Results

Among 246 patients, 200 were randomly included in the final intention-to-treat analysis, with 100 patients in each group. The success rate for the first attempt of endoscope insertion in the esketamine group was higher than the nalbuphine group (97% vs. 66%; P < 0.01). The heart rate and mean arterial pressure after intraoperative administration in the esketamine group were higher than those in the nalbuphine group, while the delirium incidence during awakening was higher in esketamine group (all P < 0.05).

Conclusion

The success rate for the first attempt of endoscope insertion of children undergoing upper gastrointestinal endoscopy in the esketamine group was higher than the nalbuphine group, propofol-related hemodynamic changes were reduced accordingly, while the incidence of esketamine-related adverse effects could be high.

Clinical Trial Registration

Chinese Clinical Trial Registry: ChiCTR2000040500.

Spontaneous Ventilation With High-Flow Nasal Oxygen for Elective Suspension Microlaryngoscopy

Objective

Spontaneous ventilation under intravenous anesthesia allows the surgeon to work without interruption or obstruction of the operating field during suspension microlaryngoscopy (SML). High-flow nasal oxygen therapy (HFNO) is increasingly used in anesthesia. We hypothesized that its use during SML would increase patient safety even in situations where the airway is compromised by tumor or stenosis.

Study Design

Retrospective observational study.

Setting

University Hospital of Lausanne, Switzerland.

Methods

Adults patients who were scheduled for elective microlaryngeal surgery and managed with HFNO in spontaneous ventilation under general anesthesia between October 2020 and December 2021.

Results

Twenty-seven patients for a total of 32 surgical procedures were performed under HFNO with spontaneous ventilation. Seventy-five percent of the patients had respiratory symptoms. Twelve patients (42.9%) were planned for the treatment of subglottic or tracheal stenosis and 5 patients were managed for vocal cord cancer (18.5%). Out of 32 surgeries, 4 cases of saturation < 92% occurred, 3 of them during the decrease of the fraction of inspired oxygen to 30% for the use of the laser. In 3 cases, the patients were intubated to correct the hypoxemia.

Conclusion

Spontaneous respiration using intravenous anesthesia and high-flow nasal oxygen is a modern technique that increases patient safety while allowing the surgeon to work without interruption or imputation of the operative field during SML. This approach is particularly promising for the management of airways compromised by tumors or laryngotracheal stenosis.

The Effect of Tonsillectomy and Adenoidectomy on Upper Airway Obstruction Patterns in Children with Obstructive Sleep Apnea

Introduction  Alterations in upper airway flow dynamics and sites of airway obstruction immediately after tonsillectomy and adenoidectomy (TA) have not been assessed. Identification of the changes in airway obstruction patterns after TA potentially improves the surgical management of children with obstructive sleep apnea (OSA). Objective  To evaluate the effect of TA on upper airway obstruction patterns detected with drug-induced sleep endoscopy (DISE). Methods  The medical records of patients who underwent pre-TA DISE during the induction of anesthesia and post-TA DISE at the end of TA were reviewed. Data pertaining to polysomnography and DISE findings were analyzed. Results  Twenty-seven patients (15 male and 12 females aged between 2 and 18 years old) were identified. All patients had obstruction at multiple sites of the upper airway. Prior to TA, airway obstruction was at the level of the velum in 27 patients, of the oropharynx/lateral walls in 27, of the tongue in 7, and of the epiglottis in 4. After TA, airway obstruction was at the level of the velum in 24 patients, of the oropharynx/lateral walls in 16, of the tongue in 6, and of the epiglottis in 4. The degree of obstruction at the levels of the velum and oropharynx/lateral walls after TA was significantly decreased. Conclusions  Drug-induced sleep endoscopy performed prior to TA revealed that most of the sites of airway obstruction persisted after TA in OSA children with multiple sites of airway obstruction. Further studies in larger group of children with OSA are needed to establish the value of DISE findings in predicting residual OSA after TA, surgical planning, determining the need for post TA sleep study, and counseling caregivers.

A Protocol for Propofol-Infusion Drug-Induced Sleep Endoscopy

OBJECTIVE

The objective of this study was to outline a protocol utilizing propofol infusion without an initial bolus during drug-induced sleep endoscopy (DISE). We define normative values for final propofol infusion rate (P^final ) during DISE and sedation depth values at P^final .

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic hospital.

METHODS

A review of patients with obstructive sleep apnea who underwent DISE between 2016 and 2020 was performed. The following patient data were recorded: demographics; DISE procedure details, including P^final , time to P^final , frequency and cadence of infusion rate changes, depth of sedation as measured by Bispectral Index and SedLine values, and hemodynamics; and polysomnography details including apnea-hypopnea index severity and minimum oxygen saturation. A mixed linear model adjusted for age and body mass index was performed for the analysis of effects on P^final . Pearson correlation coefficients determined the strength of association between depth of sedation measured and pattern of collapse on DISE and P^final .

RESULTS

There were 246 patients who met inclusion criteria. P^final resembled a normal distribution (mean ± SD, 156.44 ± 26.69 mcg/kg/min; median, 150 mcg/kg/min). Analysis demonstrated that P^final was influenced by male sex, current smoker status, time to P^final , and number of propofol dose changes (P < .05). Depth of sedation categories measured differently between Bispectral Index and SedLine (55-65 vs 45-55, P < .001). The pattern including severity of collapse on DISE was not associated with P^final (P > .05). No patients required intra- or postoperative respiratory support beyond oxygen via nasal canula.

CONCLUSION

We describe a propofol slow-infusion DISE protocol that demonstrates safe and reproducible outcomes.

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.

High-flow nasal oxygenation during gastrointestinal endoscopy. Systematic review and meta-analysis

Background

The use of high-flow nasal oxygen (HFNO) has the potential to improve patient safety by limiting hypoxaemia during gastrointestinal endoscopy. The degree of benefit is not adequately established.

Methods

English language literature searches of PubMed, Scopus, Web of Science, and Cochrane Library electronic databases were performed to identify randomised controlled trials comparing HFNO and conventional oxygen therapy (COT) for patients undergoing gastrointestinal endoscopy under deep sedation. The primary endpoint was the incidence of hypoxic events observed during endoscopic procedures. The secondary endpoints were the incidence of recourse to rescue manoeuvres, procedure interruption, and adverse events. A meta-analysis and a post hoc trial sequence analysis were performed.

Results

A total of 2867 patients from six randomised controlled trials were considered. Desaturation was observed in 5.2% and 27.2% of patients receiving HFNO and COT, respectively. Desaturation <90% was observed in 1.8% and 12.6% of the patients receiving HFNO and COT, respectively. In the subgroup analysis, desaturation occurrence was lower during HFNO than during COT in non-obese patients (2.2% vs 25.2%) and obese patients (22.9% vs 43.3%). Desaturation occurrence was lower during maximum (3.6% vs 26.9%) and minimum (15.9% vs 29.8%) HFNO therapy than during COT. HFNO showed a lower recurrence to rescue manoeuvres rate (4.7% vs 34.3%), a lower procedure interruption rate (0.4% vs 6.7%), and a lower adverse events rate (18.7% vs 21%) than COT. A high level of heterogeneity between the studies precluded confidence in drawing inference from the meta-analysis.

Conclusions

The evidence reviewed suggests that compared with COT, HFNO has fewer hypoxaemic events during gastrointestinal endoscopy, but this may not apply to all patients and clinical scenarios.

Effects of propofol combined with lidocaine on hemodynamics, serum adrenocorticotropic hormone, interleukin-6, and cortisol in children

BACKGROUND

Children are a unique patient population. Anesthesia for pediatric abdominal surgery has long been achieved mainly with intravenous amiodarone and propofol alone or combined with other anesthetics. The incidence of complications and postoperative adverse reactions is relatively high owing to the imperfect development of various protocols for children. Choosing the most appropriate anesthesia program is an important means of reducing adverse reactions.

AIM

To explore the clinical value of propofol combined with lidocaine-assisted anesthesia in pediatric surgery.

METHODS

A total of 120 children who underwent abdominal surgery at our hospital from January 2016 to March 2018 were selected and divided into groups A and B using the random number table method, with 60 patients in each group. Group B received ketamine for anesthesia, while group A received ketamine, propofol, and lidocaine. The pre- and postoperative heart rate (HR); mean arterial pressure (MAP); arterial oxygen saturation (SpO₂); serum adrenocorticotropic hormone (ACTH), interleukin-6 (IL-6), and cortisol (Cor) levels; restlessness score during the recovery period [Paediatric Anesthesia Emergence Delirium Scale (PAED)]; and adverse reactions were compared between the two groups.

RESULTS

The HR, MAP, and SpO₂ Level at five minutes before initiating anesthesia were compared between groups A and B, and the difference was not statistically significant (P > 0.05). At 10 and 20 minutes after anesthesia initiation, the HR and MAP were lower in group A compared with group B (P < 0.05). The differences in preoperative serum ACTH, IL-6, and Cor levels between groups A and B were not statistically significant (P > 0.05); however, the postoperative serum ACTH, IL-6, and Cor levels in group A were lower compared with group B (P < 0.05). Furthermore, the visual analog scale scores of group A at 2 h and 8 h postoperative were lower than those in group B, and the differences were statistically significant (P < 0.05). The mean PAED score in group A was lower than that in group B (P < 0.05), and the incidence of restlessness in group A was 23.33% lower than that in group B (36.67 %) (P < 0.05). The incidence of adverse reactions was lower in group A than in group B (6.25% vs 16.25%).

CONCLUSION

The anesthetic effect of propofol combined with lidocaine and ketamine in pediatric surgery was better than that of ketamine alone, and had less influence on hemodynamics and pediatric stress response indices, lower incidence of restlessness in the recovery period, and lower incidence of adverse reactions.

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS.

Methods

To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus.

Results

Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items).

Conclusions

ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

Outcome of CPAP Titration for Moderate-to-Severe OSA Under Drug-Induced Sleep Endoscopy: A Randomized Controlled Crossover Trial

Background

The titration pressure of continuous positive airway pressure (CPAP) is important in patients with obstructive sleep apnea (OSA). This study aimed to understand the difference between drug-induced sleep endoscopy (DISE)-guided CPAP titration and conventional sleep center (CSC) CPAP titration in patients with OSA.

Methods

In this randomized, controlled, and single-blind crossover trial, we compared the effects of 1-month CPAP treatment in patients with OSA with either DISE-guided CPAP titration or CSC CPAP titration. Twenty-four patients with OSA were recruited for the study. All patients underwent polysomnography, DISE-guided CPAP titration, and accommodation. Initially, patients were randomly assigned to receive either DISE-guided CPAP titration or CSC CPAP treatment for the first month. They were then switched to other treatments in the second month. The Epworth sleepiness scale (ESS) score was recorded at baseline, 1 and 2 months.

Results

The upper limit of the pressure of DISE-guided titration and CSC CPAP titration was not significantly different (13.9 ± 0.7 vs. 13.5 ± 0.5 cm H₂O; P = 0.92). The residual apnea-hypopnea index and compliance were also not significantly different between the groups. ESS score significantly improved from baseline to 1 month after CPAP treatment in both groups. Both epiglottis (anterior-posterior collapse) and tongue base collapse were significantly associated with 95% CPAP pressure (P = 0.031 and 0.038, respectively). After multivariate regression analyses, the epiglottis (anterior-posterior collapse) was an independent factor for 95% CPAP pressure. The incidence rate of bradycardia was 58.3%, which is a safety concern for DISE. Despite the high incidence of bradycardia, all patients with bradycardia recovered with proper management.

Conclusion

Both modalities were comparable in terms of establishing the pressure settings required to treat patients. Further large-scale studies are required to confirm these results.

Trial registration

https://clinicaltrials.gov/, NCT03523013.

Postoperative respiratory complications in children with obstructive sleep apnoea syndrome

Objective

We aimed to prospectively assess the effect of comorbidities on the occurrence of postoperative respiratory complications (PoRCs) after adenotonsillectomy in children with obstructive sleep apnoea syndrome (OSA) and whether otherwise healthy children need a higher level of postoperative monitoring.

Methods

577 children who had OSA and underwent adenotonsillectomy were enrolled. The effects of demographics, comorbidities and OSA on PoRCs were investigated with logistic regression analysis.

Results

The PoRC rate was 4.3%. Postoperative oxygen desaturations were more marked in patients with comorbidities (p = 0.005). The presence of comorbidity increased the risk of PoRCs (odds ratio 4.234/3.226-5.241, 95% confidence intervals, p < 0.001). There was no difference in apnoea-hypopnoea index (AHI) values between comorbid patients with and without PoRCs [8.2 (3.8-50.2) vs 14.3 (11.7-23.3)]. (p = 0.37). In the group of patients without comorbidities, PoRCs were associated with a higher AHI [14.7 (3.4-51.3) vs 3.9 (2.0-8.0), p < 0.001].

Conclusions

Comorbidities are more closely linked with PoRCs than OSA severity. In patients without comorbidity, PoRCs are associated with OSA severity and usually occur within the first 2 hours after the intervention.

Cost of Total Intravenous Anesthesia Versus Inhalation Anesthesia in Obstructive Sleep Apnea Surgery

OBJECTIVES

To compare cost and time spent in surgical and postoperative courses in patients with obstructive sleep apnea (OSA) undergoing surgery with either total intravenous anesthesia (TIVA) or inhalational anesthesia.

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective review on patients undergoing surgery for OSA under general anesthesia from January 2019 to October 2020. Cost per service was acquired for the day of surgery.

RESULTS

A total of 230 patients were included: 95 received TIVA; 135 received inhalation anesthesia. Total cost was significantly higher in the TIVA nasal surgery group by $286 (P = .035). TIVA produced significantly higher pharmacy and operating room costs across all surgeries and OSA severities. These increased costs were offset by significantly lower supply costs in upper airway stimulator (UAS, -$419.50; P = .007) and uvulopalatopharyngoplasty (UPPP, -$115.16; P = .015) patients receiving TIVA. In the TIVA cohort, there was a trend toward lower recovery room costs after UAS (-$111.09; P = .063) and nasal surgery (-$64.45; P = .096) and anesthesia costs after nasal surgery (-$36.67; P = .054). Total recovery time was reduced by 18 minutes (P = .004) for nasal surgery, 25 minutes (P = .043) for UAS, and 27 minutes (P = .147) for UPPP patients receiving TIVA.

CONCLUSION

When used in an outpatient setting for patients with OSA, TIVA adds to pharmacy and operating room costs, but this is usually offset by lower supply, anesthesia, and recovery room costs. We found decreased recovery times in the TIVA cohort. TIVA has proven benefits in patient outcomes and can be cost-effective in OSA surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Opioids and obstructive sleep apnea

Opioids are widely prescribed for pain management, and it is estimated that 40% of adults in the United States use prescription opioids every year. Opioid misuse leads to high mortality, with respiratory depression as the main cause of death. Animal and human studies indicate that opioid use may lead to sleep-disordered breathing. Opioids affect control of breathing and impair upper airway function, causing central apneas, upper airway obstruction, and hypoxemia during sleep. The presence of obstructive sleep apnea (OSA) increases the risk of opioid-induced respiratory depression. However, even if the relationship between opioids and central sleep apnea is firmly established, the question of whether opioids can aggravate OSA remains unanswered. While several reports have shown a high prevalence of OSA and nocturnal hypoxemia in patients receiving a high dose of opioids, other studies did not find a correlation between opioid use and obstructive events. These differences can be attributed to considerable interindividual variability, divergent effects of opioids on different phenotypic traits of OSA, and wide-ranging methodology. This review will discuss mechanistic insights into the effects of opioids on the upper airway and hypoglossal motor activity and the association of opioid use and obstructive sleep apnea.

CITATION

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

[Features of sleependoscopy in children]

OBJECTIVE

To describe the technique and determine the indications for sleep endoscopy in children.

MATERIAL AND METHODS

This study included 35 children, the average age of 5 years 1 month ± 3 years 4 months (from 1 year 6 months to 14 years 5 months). All children underwent standard polysomnography and sleep endoscopy.

RESULTS

According to polysomnography, severe obstructive sleep apnea (OSA) was diagnosed in 21 children, moderate - in 8 children and mild - in 6 children. Sleep endoscopy revealed that in most cases in unoperated children (about 70%), adenoids and palatine tonsils were the cause of obstruction. In the group of children, who previously underwent surgery for OSA, the causes of residual apnea more often were soft palate and palatine tonsils. In 5 of 8 children, tonsils pharyngoscopy size did not exceed the 1st degree. In 1 child after adenotonsillectomy, the hypertrophic tori tubarii were the cause of obstruction. Another rare cause of upper airway obstruction, lingual tonsil hypertrophy, was found in 2 primary patients.

CONCLUSION

Sleep endoscopy is a safe and useful method that makes it possible to determine the level of obstruction in children and to plan the optimal amount of surgical treatment.

Continuous positive airway pressure to reduce the risk of early peripheral oxygen desaturation after onset of apnoea in children: A double-blind randomised controlled trial

Continuous positive airway pressure (CPAP) during anaesthesia induction improves oxygen saturation (SpO₂) outcomes in adults subjected to airway manipulation, and could similarly support oxygenation in children. We evaluated whether CPAP ventilation and passive CPAP oxygenation in children would defer a SpO₂ decrease to 95% after apnoea onset compared to the regular technique in which no positive airway pressure is applied. In this double-blind, parallel, randomised controlled clinical trial, 68 children aged 2–6 years with ASA I–II who underwent surgery under general anaesthesia were divided into CPAP and control groups (n = 34 in each group). The intervention was CPAP ventilation and passive CPAP oxygenation using an anaesthesia workstation. The primary outcome was the elapsed time until SpO₂ decreased to 95% during a follow-up period of 300 s from apnoea onset (T1). We also recorded the time required to regain baseline levels from an SpO₂ of 95% aided by positive pressure ventilation (T2). The median T1 was 278 s (95% confidence interval [CI]: 188–368) in the CPAP group and 124 s (95% CI: 92–157) in the control group (median difference: 154 s; 95% CI: 58–249; p = 0.002). There were 17 (50%) and 32 (94.1%) primary events in the CPAP and control groups, respectively. The hazard ratio was 0.26 (95% CI: 0.14–0.48; p<0.001). The median for T2 was 21 s (95% CI: 13–29) and 29 s (95% CI: 22–36) in the CPAP and control groups, respectively (median difference: 8 s; 95% CI: -3 to 19; p = 0.142). SpO₂ was significantly higher in the CPAP group than in the control group throughout the consecutive measures between 60 and 210 s (with p ranging from 0.047 to <0.001). Thus, in the age groups examined, CPAP ventilation and passive CPAP oxygenation deferred SpO₂ decrease after apnoea onset compared to the regular technique with no positive airway pressure.

Sleep Endoscopy Findings in Children With Obstructive Sleep Apnea and Small Tonsils

OBJECTIVE

Obstructive Sleep Apnea (OSA) in children is treated primarily with adenotonsillectomy (AT). When clinical exam demonstrates small tonsils, the success of AT in resolving OSA is uncertain. The purpose of this study is to determine the utility of Drug induced Sleep Endoscopy (DISE) for children with OSA and small tonsils (Brodsky scale 1+) and to identify what obstructive trends exist in this subset of patients and to determine the utility of DISE-directed surgical intervention in patients with small tonsils.

METHODS

A retrospective chart review was performed for patients who underwent DISE at a tertiary care center over a 2-year period. Inclusion criteria were 1+ tonsils and a positive sleep study. Data collected included DISE findings, BMI, comorbid conditions, and pre-op PSG data.

RESULTS

Forty children were included with a mean age of 5.0 years (range 8 months-16 years). Mean preoperative AHI was 5.46 and mean oxygen saturation nadir was 87.1%. The most common contributor to airway obstruction was the adenoid (29 patients, 72.5%), followed by the tongue base or lingual tonsil (21 patients, 52.5%). The palatine tonsils (10 patients, 25.0%), epiglottis (10.0%), or obstruction intrinsic to the larynx (10.0%) were significantly less frequently identified as contributors to OSA when compared to the adenoid (P < .001). The majority of patients had multilevel obstruction (25 patients, 62.5%). Adenoidectomy (27 patients, 67.5%) was the most commonly performed procedure, followed by tonsillectomy (10 patients, 25.0%, P < .001) and tongue base surgery (9 patient 22.5%, P < .001).

CONCLUSION

In this group, small palatine tonsils were infrequently identified as a contributor to airway obstruction and tonsillectomy was avoided in most cases. This study illustrates the utility of DISE as a tool to personalize the surgical management of pediatric patients with OSA and small tonsils on physical exam.

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

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.

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.

Pediatric Airway Endoscopy: Recommendations of the Society for Pediatric Pneumology

For many decades, pediatric bronchoscopy has been an integral part of the diagnosis and treatment of acute and chronic pulmonary diseases in children. Rapid technical advances have continuously influenced the performance of the procedure. Over the years, the application of pediatric bronchoscopy has considerably expanded to a broad range of indications. In this comprehensive and up-to-date guideline, the Special Interest Group of the Society for Pediatric Pneumology reviewed the most recent literature on pediatric bronchoscopy and reached a consensus on a safe technical performance of the procedure.

A Nationwide Analysis of Cleft Palate Repair: Impact of Local Anesthesia on Operative Outcomes and Hospital Cost

BACKGROUND

This study investigates the associations between local anesthesia practice and perioperative complication, length of stay, and hospital cost for palatoplasty in the United States.

METHODS

Patients undergoing cleft palate repair between 2004 and 2015 were abstracted from the Pediatric Health Information System database. Perioperative complication, length of stay, and hospital cost were compared by local anesthesia status. Multiple logistic regressions controlled for patient demographics, comorbidities, and hospital characteristics.

RESULTS

Of 17,888 patients from 49 institutions who met selection criteria, 8631 (48 percent), 4447 (25 percent), and 2149 (12 percent) received epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone, respectively. The use of epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with decreased perioperative complication [adjusted OR, 0.75 (95 percent CI, 0.61 to 0.91) and 0.63 (95 percent CI, 0.47 to 0.83); p = 0.004 and p = 0.001, respectively]. Only bupivacaine- or ropivacaine-alone recipients experienced a significantly reduced risk of prolonged length of stay on adjusted analysis [adjusted OR, 0.71 (95 percent CI, 0.55 to 0.90); p = 0.005]. Risk of increased cost was reduced in users of any local anesthetic (p < 0.001 for all).

CONCLUSIONS

Epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with reduced perioperative complication following palatoplasty, while only the latter predicted a decreased postoperative length of stay. Uses of epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone were all associated with decreased hospital costs. Future prospective studies are warranted to further delineate the role of local anesthesia in palatal surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison of Jaw Elevation Device vs. Conventional Airway Assist during Sedation in Chronic Kidney Diseases Undergoing Arteriovenous Fistula Surgery: A Randomized Controlled Trial

Patients with chronic renal failure (CRF) are likely to have obstructive sleep apnea (OSA) underdiagnosed, and maintaining airway patency is important during sedation. This study compared Jaw elevation device (JED) with conventional airway interventions (head lateral rotation, neck extension, oral or nasal airway insertion, and jaw thrust maneuver) during sedation and hypothesized that JED may be effective to open the airway. A total of 73 patients were allocated to a conventional group (n = 39) and a JED group (n = 34). The number of additional airway interventions was the primary outcome. Percentage of patients with no need of additional interventions and apnea-hypopnea index (AHI) were secondary outcomes. The number of additional interventions was significantly less in the JED group compared to the conventional group (0 (0–0) vs. 1 (0–2); p = 0.002). The percentage of patients with no requirement for additional interventions was significantly higher in the JED group compared to the conventional group (76.5% vs. 43.6%; p = 0.004). AHI was significantly lower in the JED group compared to the conventional group (4.5 (1.5–11.9) vs. 9.3 (3.8–21.9), p = 0.015). In conclusion, JED seems to be effective in opening the airway patency during sedation in CRF patients.

Polysomnography parameters as predictors of respiratory adverse events following adenotonsillectomy in children

STUDY OBJECTIVES

The first line treatment of obstructive sleep apnea syndrome in children is adenotonsillectomy but this may result in perioperative respiratory adverse events (PRAEs). The primary aim of this study is to examine whether the McGill oximetry score (MOS) and other polysomnography parameters can predict major PRAEs following adenotonsillectomy. We secondarily evaluated the MOS inter-rater reliability and correlation with other polysomnography parameters.

METHODS

This retrospective study included all children aged 0-18 years who underwent preoperative polysomnography between June 2010 and January 2016 prior to adenotonsillectomy at a tertiary pediatric institution. Oximetries from polysomnograms were assigned a MOS. Univariable and multivariable models for prediction of major PRAEs were constructed. MOS was correlated with polysomnography parameters and inter-rater reliability was evaluated.

RESULTS

This study included 106 children; 15 had a major PRAE. A multivariable prediction model that combined MOS and age showed evidence for the ability to predict major PRAEs with an area under the receiver operating characteristic curve of 0.68 (95% confidence interval 0.52, 0.84), whereby increased MOS and younger age were associated with PRAEs, but apnea-hypopnea index was not. MOS had excellent inter-rater reliability (Kappa=0.95) and was highly correlated with oxygen saturation nadir and cumulative time percentage with oxygen saturation less than 90%.

CONCLUSIONS

A prediction model including MOS and age may predict PRAEs following adenotonsillectomy. This suggests that nocturnal oximetry provides the most essential information of polysomnography measures to direct postoperative monitoring following adenotonsillectomy.

Perioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review

The prevalence of obstructive sleep apnea (OSA) has reached 1 billion people worldwide, implying significant risk for the perioperative setting as patients are vulnerable to cardiopulmonary complications, critical care requirement, and unexpected death. This review summarizes main aspects and considerations for the perioperative management of OSA, a condition of public health concern. Critical determinants of perioperative risk include OSA-related changes in upper airway anatomy with augmented collapsibility, diminished capability of upper airway dilator muscles to respond to airway obstruction, disparities in hypoxemia and hypercarbia arousal thresholds, and instability of ventilatory control. Preoperative OSA screening to identify patients at increased risk has therefore been implemented in many institutions. Experts recommend that in the absence of severe symptoms or additional compounding health risks, patients may nevertheless proceed to surgery, while heightened awareness and the adjustment of postoperative care is required. Perioperative caregivers should anticipate difficult airway management in OSA and be prepared for airway complications. Anesthetic and sedative drug agents worsen upper airway collapsibility and depress central respiratory activity, while the risk for postoperative respiratory compromise is further increased with the utilization of neuromuscular blockade. Consistently, opioid analgesia has proven to be complex in OSA, as patients are particularly prone to opioid-induced respiratory depression. Moreover, basic features of OSA, including intermittent hypoxemia and repetitive sleep fragmentation, gradually precipitate a higher sensitivity to opioid analgesic potency along with an increased perception of pain. Hence, regional anesthesia by blockade of neural pathways directly at the site of surgical trauma as well as multimodal analgesia by facilitating additive and synergistic analgesic effects are both strongly supported in the literature as interventions that may reduce perioperative complication risk. Health care institutions are increasingly allocating resources, including those of postoperative enhanced monitoring, in an effort to increase patient safety. The implementation of evidence-based perioperative management strategies is however burdened by the rising prevalence of OSA, the large heterogeneity in disease severity, and the lack of evidence on the efficacy of costly perioperative measures. Screening and monitoring algorithms, as well as reliable risk predictors, are urgently needed to identify OSA patients that are truly in need of extended postoperative surveillance and care. The perioperative community is therefore challenged to develop feasible pathways and measures that can confer increased patient safety and prevent complications in patients with OSA.

Sufentanil EC50 for endotracheal intubation with aerosol inhalation of carbonated lidocaine by ultrasonic atomizer

BACKGROUND

Nebulized lidocaine reduced stress response for endotracheal intubation. However, the impact of novel lidocaine aerosol inhalation for intubation by ultrasonic atomizer was unclear. Hence, we designed aerosol inhalation of lidocaine by ultrasonic atomizer, to seek whether the dosage of sufentanil for intubation could be less or not.

METHODS

Intravenous injection of sufentanil started at 0.5 μg/kg, and sufentanil dosage was increased/decreased (step-size 0.05 μg/kg for sufentanil) using Dixon's up and down method. The observation was terminated after 8 reflexes.

RESULTS

The EC50 and EC95 of sufentanil with lidocaine by ultrasonic atomizer for intubation were found to be 0.232 μg/kg (95% CI: 0.187-0.270 μg/kg) and 0.447 μg/kg (95% CI: 0.364-0.703 μg/kg). 55.88% out of 34 patients showed hemodynamic index change < 20% of baseline during intubation.

CONCLUSION

Aerosol inhalation of lidocaine by ultrasonic atomizer reduced the dosage of sufentanil for endotracheal intubation. Lidocaine inhalation by ultrasonic atomizer for airway anesthesia with minimal dosage of sufentanil could be recommended, particularly in patients who need more stable hemodynamic changes or spontaneous respiration.

TRIAL REGISTRATION

Chinese Registry of Central Trial, ChiCTR-IOR-17014198 . Registered 28 December 2017.

Neuronal mechanisms underlying opioid-induced respiratory depression: our current understanding

Opioid-induced respiratory depression (OIRD) represents the primary cause of death associated with therapeutic and recreational opioid use. Within the United States, the rate of death from opioid abuse since the early 1990s has grown disproportionally, prompting the classification as a nationwide "epidemic." Since this time, we have begun to unravel many fundamental cellular and systems-level mechanisms associated with opioid-related death. However, factors such as individual vulnerability, neuromodulatory compensation, and redundancy of opioid effects across central and peripheral nervous systems have created a barrier to a concise, integrative view of OIRD. Within this review, we bring together multiple perspectives in the field of OIRD to create an overarching viewpoint of what we know, and where we view this essential topic of research going forward into the future.

Diagnosis of Retrolingual Obstruction during Drug-Induced Sleep Endoscopy versus Polysomnography with Nasopharyngeal Tube in Patients with Obstructive Sleep Apnea

OBJECTIVE

To compare the retrolingual obstruction during drug-induced sleep endoscopy (DISE) with the retrolingual obstruction during polysomnography with nasopharyngeal tube (NPT-PSG).

METHODS

A cross-sectional study of 77 consecutive patients with moderate and severe obstructive sleep apnea (OSA) was conducted. After 15 patients were excluded from the study for not completing DISE or NPT-PSG successfully, 62 patients were included in this study. Retrolingual sites of obstruction grade 2 determined by DISE according to the VOTE (velum, oropharynx lateral wall, tongue base, and epiglottis) classification were considered as retrolingual obstruction, while apnea-hypopnea index (AHI) ≥ 15 events/hour determined by NPT-PSG was considered as retrolingual obstruction. The extent of agreement between DISE and NPT-PSG findings was evaluated using unweighted Cohen's kappa test.

RESULTS

The 62 study participants (11 moderate OSA, 51 severe OSA) had a mean (SD) age of 39.8 (9.9) years, and 58 (94%) were men. No statistically significant differences between included and excluded patients were observed in patient characteristics. The extent of agreement in retrolingual obstruction between DISE and NPT-PSG was 80.6% (Cohen k = 0.612; 95% CI, 0.415-0.807).

CONCLUSION

Retrolingual obstruction requiring treatment showed good agreement between DISE and NPT-PSG, suggesting that NPT-PSG may also be a reliable method to assess the retrolingual obstruction.

Dexmedetomidine sedation for endobronchial ultrasound-guided transbronchial needle aspiration, a randomised controlled trial

Background and aim

Appropriate sedation is important to the success of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Dexmedetomidine is a sedative agent that operates via the α2 adrenergic agonist, which provides sleep-like sedation with little respiratory suppression. This study compared the efficacy and safety of dexmedetomidine sedation with propofol in cases of EBUS-TBNA.

Methods

Patients requiring EBUS-TBNA were randomly assigned dexmedetomidine sedation (D, n=25) or propofol sedation (P, n=25). Vital signs, diagnostic yield and the bispectral index (BIS) were recorded throughout the bronchoscopic procedure and recovery period. The tolerance and cooperation of the patients were evaluated using questionnaires.

Measurements and results

The lowest mean arterial blood pressure in group D (79.2±9.9 versus 72.5±12.9 mmHg, p=0.049) exceeded that in group P, the lowest heart rate was lower (60.9±10.2 versus 71.4±11.8 beats·min⁻¹, p=0.006) and the mean BIS during sedation was significantly higher (84.1±8.3 versus 73.6±5.7, p<0.001). Patients in group D were more likely to report perceiving procedure-related symptoms and express an unwillingness to undergo the bronchoscopy again, if indicated (41.1 versus 83.3%, p=0.007). One subject in group D aborted EBUS-TBNA due to intolerance. Many of the variables in the two groups were similar, including the proportion of hypoxaemic events, recovery times, patient cooperation and diagnostic yield.

Conclusions

The effects of dexmedetomidine on haemodynamics were in line with its pharmacodynamic features. Patients who received dexmedetomidine were more likely than those who received propofol to perceive the procedures. Overall, dexmedetomidine did not prove inferior to propofol sedation in terms of patient cooperation or diagnostic yield.

Compared to propofol sedation for EBUS-TBNA, dexmedetomidine provided patients lighter sedation with lower heart rates and less decrease in blood pressure. The recovery times, hypoxaemia, cooperation and diagnostic yield in the two groups were similar.https://bit.ly/33qgEj3

Effects of Premedication With Midazolam on Recovery and Discharge Times After Tonsillectomy and Adenoidectomy

Background

Midazolam is commonly used preoperatively for anxiety. Adverse effects data in pediatric patients with obstructive sleep apnea (OSA) undergoing tonsillectomy and adenoidectomy (T&A) is limited.

Aims

We hypothesized that preoperative midazolam increases the time to emergence from anesthesia and postoperative discharge. Secondary objectives assessed if patients receiving midazolam experienced increased side effects or complications from treatment.

Methods

This study was a retrospective chart review of patients undergoing T&A from July 2014 to December 2015. Midazolam receiving patients (midazolam group: MG) were compared to patients who did not (non-midazolam group: NMG). Multivariable analyses were performed and adjusted for predefined potential cofounder variables.

Results

Emergence and discharge times were 5.2 minutes (95% CI [-7.1, 17.4]; p=0.41) and 10.1 minutes (95% CI [-6.7, 26.8]; p=0.24) longer in MG. These results were not statistically significant. Comparing by OSA status, there was no statistical difference in emergence and discharge times between mild, moderate and severe OSA groups or between MG and NMG within each OSA group. Emergence and discharge times in moderate OSA was 6.1 minutes (95% CI [-17.6, 29.8]; p=0.61) and 18.8 minutes (95% CI [-16.4, 53.9]; p=0.29) longer than mild OSA, and in the severe OSA group, 2.6 minutes (95% CI [-19.9, 25.1]; p=0.82) shorter and 2.8 minutes (95% CI [-30.3, 35.9]; p=0.87) longer. The incidence of postoperative complications was comparable between MG and NMG groups.

Conclusions

Premedication with midazolam was not associated with prolonged emergence or discharge time or higher incidence of complications after anesthesia for T&A in patients with OSA.

Dexmedetomidine-induced polysomnography as a diagnostic method in obstructive sleep apnea: a reliable alternative method?

BACKGROUND

Under-diagnosis of obstructive sleep apnea (OSA) is common because of the demanding and time-consuming nature of polysomnography (PSG). Herein, we assessed the utility of a short daytime dexmedetomidine-induced PSG for diagnosis of OSA in adults.

METHODS

This was a single-center, prospective, diagnostic trial. We evaluated 86 patients using a full overnight PSG and a short diurnal drug-induced PSG (DIPSG). DIPSG was induced by continuous intravenous dexmedetomidine infusion. Sedation depth was monitored and maintained using the Narcotrend index (50-70). Diagnostic performance for DIPSG with different apnea-hypopnea index (AHI) cut-off values were calculated. Bland-Altman plots used for analysis. Sleep architecture and position were compared.

RESULTS

We studied 47 OSA patients and 39 healthy volunteers. Sensitivity and specificity for detection of OSA by DIPSG were 92% and 79%, respectively, for an AHI cut-off value of 5, 90% and 77%, respectively, for an AHI cut-off value of 15, and 95% and 85%, respectively, for an AHI cut-off value of 30. The DIPSG bias was -5 (-25; 15) for AHI and -3 (-13; 7) for minimal oxygen saturation. N2 sleep was increased (32.9% vs. 50.75%, respectively; p < 0.01) and REM sleep was decreased (21.35% vs. 1.24%, respectively; p < 0.01) during DIPSG. Twenty-eight (33%) participants had postural shifts during DIPSG. No significant adverse events were observed during DIPSG.

CONCLUSIONS

Dexmedetomidine-induced PSG had a good sensitivity and specificity, and can be used as a screening tool for diagnosis of OSA in adults.

CHINESE CLINICAL TRIAL REGISTRATION

ChiCTR1900024044.

Expert Consensus Statement: Pediatric Drug-Induced Sleep Endoscopy

OBJECTIVE

To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep.

METHODS

Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized.

RESULTS

The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research.

CONCLUSION

Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.

[German S1 guideline: obstructive sleep apnea in the context of tonsil surgery with or without adenoidectomy in children-perioperative management]

Otolaryngologic surgery is one of the most frequent operative interventions performed in children. Tonsil surgery with or without adenoidectomy due to hyperplasia of the tonsils and adenoids with obstruction of the upper airways with or without tympanic ventilation disorder is the most common of these procedures. Children with a history of sleep apnoea (OSA) suffer from a significantly increased risk of perioperative respiratory complications. Cases of death and severe permanent neurologic damage have been reported due to apnoea and increased opioid sensitivity. The current guideline represents a pragmatic risk-adjusted approach. Patients with confirmed or suspected OSA should be treated perioperatively according to their individual risks and requirements, in order to avoid severe permanent damage.