Dexmedetomidine versus propofol during drug-induced sleep endoscopy and sedation: a systematic review

Dexmedetomidine-Oxycodone combination for conscious sedation during colonoscopy in obese patients: A randomized controlled trial

Background

Obesity is a risk factor for sedation-related respiratory depression during colonoscopy. In a colonoscopy, propofol is frequently used because of its strong sedative and hypnotic properties. However, propofol is associated with marked respiratory depression. The objective of this trial was to investigate the effectiveness and safety of dexmedetomidine plus oxycodone for conscious sedation during colonoscopy in obese patients.

Methods

A total of 120 patients had colonoscopies, and they were divided into two groups at random: Dexmedetomidine and oxycodone were used to sedate group Dex + oxy; while group Pro + oxy received anesthesia with propofol plus oxycodone. Parameters including blood pressure, heart rate, respiration, blood oxygen saturation, injection pain, and recovery time were recorded for both groups.

Results

The incidence of hypoxemia was significantly reduced in group Dex + oxy compared with group Pro + oxy (4.9% vs 20.3%, P = 0.011). Blood pressure was lower, and heart rate was higher in group Pro + oxy compared with group Dex + oxy (P < 0.05). In addition, group Dex + oxy showed a significantly shorter caecal insertion time, recovery time to orientation, and recovery time to walking than group Pro + oxy (P < 0.05). Endoscopist satisfaction scores were significantly higher in group Dex + oxy compared with group Pro + oxy (P = 0.042).

Conclusion

For obese patients, dexmedetomidine plus oxycodone effectively sedate them with few adverse effects, while also reducing colonoscopy operation difficulty by allowing obese patients to reposition. Thus, dexmedetomidine plus oxycodone could be used safely as a conscious sedation method for colonoscopy in obese patients.

Trial registration

The protocol was registered at www.chictr.org.cn (ChiCTR1800017283, July 21, 2018).

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.

Dexmedetomidine Sedation Combined With Remifentanil in MitraClip Procedures is Feasible and Improves Hemodynamics

OBJECTIVES

The objective of the study was to compare the overall feasibility, respiratory and hemodynamic stability, as well as process times of a dexmedetomidine-based sedative regimen compared with general anesthesia among patients undergoing MitraClip procedures.

DESIGN

A retrospective cohort study.

SETTING

A single tertiary care university center.

PARTICIPANTS

The study included 79 patients.

INTERVENTIONS

Dexmedetomidine sedation versus general anesthesia.

MEASUREMENTS AND MAIN RESULTS

Seventy-nine MitraClip procedures in dexmedetomidine/remifentanil conscious sedation (DCS, n = 26) or general anesthesia (GA, n = 53), performed between 2018 and 2020 at Charité - Universitätsmedizin Berlin, were analyzed retrospectively. Patients' median age was 81 years in both groups without differences in preinterventional EuroScore I (DCS 6 [5; 8], GA 7 [6; 8]) or systolic function (left ventricular ejection fraction: DCS 50% [32; 60] v. GA 50% [36; 60]; tricuspid annular plane systolic excursion: DCS 19 mm [16; 22] v GA 19 mm [15; 22]). During MitraClip procedures, respiratory parameters revealed no differences between groups, whereas patients under DCS showed higher mean arterial pressures (DCS 64 mmHg [59; 74] v GA 58 mmHg [53; 66]) and needed less norepinephrine (DCS 0.0µg/kg/min [0.0; 0.2] v GA 0.08 µg/kg/min [0.05; 0.15]). Emergence from both anesthesia regimens to readiness for intensive care unit transfer was faster in DCS (8 min [4; 18] v GA 16 min [11; 23]); however, total process time was comparable between groups (DCS 128 min [104; 155] v GA 142 min [117; 190]). Two patients required a switch from DCS to GA due to oral bleeding or prolonged procedure time. Both were excluded from the analysis. There was no switch to open surgery and no differences in postoperative complications between DCS and GA.

CONCLUSION

Dexmedetomidine/remifentanil sedation appears to be feasible and a safe option for MitraClip procedures, and provides better hemodynamic stability with faster emergence times compared with general anesthesia.

Evaluation of patient state index, bispectral index, and entropy during drug induced sleep endoscopy with dexmedetomidine

Multiple electroencephalographic (EEG) monitors and their associated EEG markers have been developed to aid in assessing the level of sedation in the operating room. While many studies have assessed the response of these markers to propofol sedation and anesthetic gases, few studies have compared these markers when using dexmedetomidine, an alpha-2 agonist. Fifty-one patients underwent drug induced sleep endoscopy with dexmedetomidine sedation. Continuous EEG was captured using SedLine (Masimo, Inc), and a playback system was used to extract the bispectral index (BIS) (Medtronic Inc), the patient state index (PSI) (Masimo, Inc), the state and response Entropy (GE Healthcare), and calculate the spectral edge frequency 95% (SEF95). Richmond Agitation-Sedation Scale (RASS) scores were assessed continually throughout the procedure and in recovery. We assessed the correlation between EEG markers and constructed ordinal logistic regression models to predict the RASS score and compare EEG markers. All three commercial EEG metrics were significantly associated with the RASS score (p < 0.001 for all metrics) whereas SEF95 alone was insufficient at characterizing dexmedetomidine sedation. PSI and Entropy achieved higher accuracy at predicing deeper levels of sedation as compared to BIS (PSI: 58.3%, Entropy: 58.3%, BIS: 44.4%). Lightening secondary to RASS score assessment is significantly captured by all three commercial EEG metrics (p < 0.001). Commercial EEG monitors can capture changes in the brain state associated with the RASS score during dexmedetomidine sedation. PSI and Entropy were highly correlated and may be better suited for assessing deeper levels of sedation.

Ketamine and dexmedetomidine (Keto-dex) or ketamine and propofol (Keto-fol) for procedural sedation during endoscopic retrograde cholangiopancreatography: Which is safer? A randomized clinical trial

BACKGROUND

Optimum procedural sedation is very essential for conducting non-operating room procedures such as endoscopic retrograde cholangiopancreatography (ERCP). The combination of ketamine and dexmedetomidine (KD) is expected to balance out the undesirable effects of either drug and provide smooth sedation. Together ketamine and propofol (KP) also provide synergistic sedation with stable hemodynamics. This prospective, single-blinded randomized study aimed to compare the effect of both the combinations during ERCP in terms of oxygen desaturation, respiratory depression, hemodynamic parameters, analgesia, recovery time, and ease with which the endoscopist could perform the endoscopy.

METHODS

This prospective, single-blinded randomized study (CTRI/2019/08/020625) was conducted on 84, ASA (American Society of Anesthesiologists) physical status I or II patients, of age 18-65 years presenting for ERCP in a tertiary care center. They were randomized to receive either KD (n=42) or KP (n=42) combination during ERCP. Mean SPO₂ at the end of the procedure was compared between the groups. Apart from these periprocedural hemodynamic and respiratory parameters, pain scores on arrival in the recovery room (t0), 15 minutes (t15), and 30 minutes (t30), recovery time, and endoscopist's satisfaction as per a Likert's scale were recorded.

RESULTS

The mean SpO₂ (SpO₂ recorded every minute during the procedure and averaged over procedure time in minutes) in group KP (97.7 [96.1-98.6]) was significantly lower than group KD (98.5 [98.1-98.8]) (p=0.005). The post-procedure pain scores measured at t0 and t15 were higher in group KP (p<0.001 and p=0.043), and comparable at t30 in both the groups (p=0.711). The time to achieve Modified Aldrete score (MAS) ≥ 9 was significantly more in group KD (p<0.001). The lowest mean arterial pressure and heart rate in group KD were significantly lower than in group KP (p<0.001, p=0.006, respectively). The overall endoscopist satisfaction was better in group KP compared to group KD (p= 0.011).

CONCLUSIONS

The combination of ketamine-dexmedetomidine for procedural sedation during ERCP is a safe alternative to ketamine-propofol with a better respiratory profile.

CLINICAL TRIAL NUMBER AND REGISTRY URL

CTRI/2019/08/020625 ( www.ctri.nic.in ).

The clinical application progress and potential of drug-induced sleep endoscopy in obstructive sleep apnea

Background and Objective: Obstructive sleep apnoea (OSA) is characterized by nocturnal repetitive upper airway (UA) collapse. For sleep physicians, the recognition of UA collapse characteristics is critical for understanding OSA mechanisms and developing individualized treatment plans. Drug-induced sleep endoscopy (DISE) is an exam during simulated sleep that allows the dynamic assessment of the UA of individuals with OSA. The initial recognition of DISE was to locate the sites of UA obstruction and direct the surgical selection of OSA since it was introduced in the 1990s. After approximately 30 years of studies, based on advances in endoscopic operative techniques and innovative treatments of OSA, DISE had been performed to explore mechanisms and comprehensive treatments related to UA collapse. Methods: This article reviewed contemporary DISE advances, including indications and contraindications, technique of induced sleep, endoscopic operation, UA characteristics classification.Results and Conclusions: Precise selection based on the association between collapse patterns and treatment modalities, such as continuous positive airway pressure, oral appliance, positional therapy, robotic surgery and neurostimulator implanting, is the future research prospect based on DISE.Key messagesDISE provides sleep physicians with valuable information about the upper airway collapse characteristics and dynamic changes during sleep.The studies based on DISE findings improve the selectivity and efficiency of treatment modalities, including classical therapies such as continuous positive airway pressure, oral appliance, positional therapy, and innovative therapies such as neurostimulator implanting and robotic surgery, promote the advancement of OSA precision medicine.

Effects of Dexmedetomidine on Postoperative Pain and Recovery Time in Obese Patients

Objective

The objective of this study is to investigate the effect of dexmedetomidine on postoperative pain and recovery time in obese patients.

Methods

A total of 100 obese patients with body mass index (BMI) ≥ 30 kg/m² who underwent laparoscopic sleeve gastrectomy under general anesthesia in our hospital from January 2019 to December 2021 were included and assigned into DEX group (dexmedetomidine group) and NS group (normal saline group). The bariatric surgery patients who were given normal saline pump were the NS group (n = 50), and the bariatric surgery patients who were given the dexmedetomidine pump were the DEX group (n = 50). The patients in the DEX group were given continuous intravenous infusion of dexmedetomidine before, during, and after induction of anesthesia at a dose of 0.4 μg. kg-1. h-1, 0.4 μg·kg-1. h-1, 0.2 μg·kg-1. h-1, respectively. The NS group was infused with the same volume of normal saline for the same time. The two groups of patients were treated with the same anesthesia induction and maintenance program. By comparing the operation, anesthesia, postoperative extubation, and recovery time of the two groups of patients, the effect of dexmedetomidine on the postoperative recovery time of obese patients was analyzed. Visual analogue scale (VAS) and adverse reactions were compared to analyze the effect of dexmedetomidine on postoperative pain in obese patients.

Results

The operation, anesthesia, postoperative extubation, and recovery time of the DEX group were significantly lower than those of the NS group, whereas the VAS and adverse reactions were significantly lower than those in the NS group (P < 0.05).

Conclusion

An appropriate dose of dexmedetomidine in bariatric surgery for morbidly obese patients can effectively shorten the recovery time and extubation time of patients, reduce postoperative pain and the incidence of adverse reactions, and is worthy of clinical application. Dexmedetomidine 2 μg/kg has promising anesthesia benefits in bariatric surgery of obese patients, can provide favorable analgesia and quality of recovery, help reduce the degree of stress response of patients, and does not increase the risk of adverse events. However, this study has certain limitations, so physicians should tailor the dosage according to the patient's physical condition in clinical practice.

Predicting upper airway collapse sites found in drug-induced sleep endoscopy from clinical data and snoring sounds in patients with obstructive sleep apnea: a prospective clinical study

STUDY OBJECTIVES

The primary aim was to predict upper airway collapse sites found in drug-induced sleep endoscopy (DISE) from demographic, anthropometric, clinical examination, sleep study, and snoring sound parameters in patients with obstructive sleep apnea (OSA). The secondary aim was to identify the above-mentioned parameters that are associated with complete concentric collapse of the soft palate.

METHODS

All patients with OSA who underwent DISE and simultaneous snoring sound recording were enrolled in this study. Demographic, anthropometric, clinical examination (viz., modified Mallampati classification and Friedman tonsil classification), and sleep study parameters were extracted from the polysomnography and DISE reports. Snoring sound parameters during DISE were calculated.

RESULTS

One hundred and nineteen patients with OSA (79.8% men; age = 48.1 ± 12.4 years) were included. Increased body mass index was found to be associated with higher probability of oropharyngeal collapse (P < .01; odds ratio = 1.29). Patients with a high Friedman tonsil score were less likely to have tongue base collapse (P < .01; odd ratio = 0.12) and epiglottic collapse (P = .01; odds ratio = 0.20) than those with a low score. A longer duration of snoring events (P = .05; odds ratio = 2.99) was associated with a higher probability of complete concentric collapse of the soft palate.

CONCLUSIONS

Within the current patient profile and approach, given that only a limited number of predictors were identified, it does not seem feasible to predict upper airway collapse sites found in DISE from demographic, anthropometric, clinical examination, sleep study, and snoring sound parameters in patients with OSA.

CITATION

Huang Z, Bosschieter PFN, Aarab G, et al. Predicting upper airway collapse sites found in drug-induced sleep endoscopy from clinical data and snoring sounds in obstructive sleep apnea patients: a prospective clinical study. J Clin Sleep Med. 2022;18(9):2119-2131.

Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome

OBJECTIVES

To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome.

DESIGN

A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data.

METHODS

The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results.

RESULTS

Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion.

CONCLUSION

Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.

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.

Efficacy of dexmedetomidine on postoperative pain in patients undergoing gastric and esophageal endoscopic submucosal dissection: a study protocol for a randomized controlled prospective trial

BACKGROUND

Endoscopic submucosal dissection (ESD) is widely used as an effective treatment of early gastric and esophageal tumors, as it is minimally invasive, safe, and convenient. Epigastric pain is a common complication of ESD. In the traditional cognition, the postoperative pain of ESD is not serious and does not attach too much attention. However, previous studies found that the incidence of moderate to severe pain after ESD can be as high as 44.9~62.8%. At present, there is no unified understanding of how to carry out good postoperative analgesia in patients undergoing ESD of stomach and esophagus. The purpose of present study is to investigate the efficacy of intraoperative dexmedetomidine (DEX) using on postoperative pain though observing the postoperative visual analog scale (VAS) score within 48 h after ESD surgery, so as to explore an effective analgesia and anesthetic method in patients undergoing gastric and esophagus ESD.

METHODS/DESIGN

This study is a prospective, single-center, two-arm, randomized control trail. In total, 120 patients undergoing endoscopic submucosal dissection were stratified by type of surgery (i.e., gastric or esophagus ESD) and randomized into two treatment groups, DEX group (group D, n = 60) and control group (group C, n = 60). Patients in the experimental group (DEX group) will be administrated a loading dose of DEX at 1 μg/kg for 15 min and a continuous infusion at 0.6 μg/kg/h until 30 min before the end of operation. In control group, the same volume of normal saline was infused. The primary outcome is VAS at 2 h after ESD surgery. The secondary outcome will be VAS at 1 h, 4 h, 6 h,18 h, 24 h, and 48 h, the status of perioperative hemodynamics, the use of remedial analgesics, sedation score, shivering, postoperative nausea and vomiting (PONV), and satisfaction scores of patient and complication of ESD (such as bleeding, perforation, aspiration pneumonia).

DISCUSSION

The results of this study will demonstrate that intraoperative application of DEX is beneficial for postoperative pain treatment in patients undergoing ESD. This study will not only confirm that postoperative pain treatment is necessary for patients undergoing ESD but also provides an effective anesthesia method for postoperative analgesia.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR2100043837 , registered on March 4, 2021, http://www.chictr.org.cn .

Impact of Upper Airway Characteristics on Disease Severity and CPAP Therapy in Chinese Patients With OSA: An Observational Retrospective Study

Objective

The characteristics of the upper airway (UA) are important for the evaluation and treatment of obstructive sleep apnea (OSA). This study aimed to investigate the association of UA characteristics with OSA severity, titration pressure, and initiation of and 3-month compliance with continuous positive airway pressure (CPAP).

Methods

This retrospective study included consecutive patients examined using a semi-quantitative UA evaluation system (combination with physical examination and awake endoscopy) during 2008–2018 at the Department of Respiratory and Critical Care Medicine, Peking University First Hospital. First, the differences in UA characteristics were compared between patients with simple snorers and mild OSA and those with moderate-to-severe OSA. Then, the effect of UA characteristics on the initiation to CPAP therapy and 3-month adherence to CPAP was conducted.

Results

Overall, 1,002 patients were included, including 276 simple snorers and patients in the mild OSA group [apnea-hypopnea index (AHI) <15] and 726 patients in the moderate-to-severe OSA group (AHI ≥15). Tongue base hypertrophy, tonsillar hypertrophy, mandibular recession, neck circumstance, and body mass index (BMI) were independent risk factors for moderate-to-severe OSA. Among those patients, 119 patients underwent CPAP titration in the sleep lab. The CPAP pressures in patients with thick and long uvulas, tonsillar hypertrophy, lateral pharyngeal wall stenosis, and tongue hypertrophy were higher than those of the control group (P < 0.05, respectively). The logistic regression analysis showed that nasal turbinate hypertrophy, mandibular retrusion, and positive Müller maneuver in the retropalate and retroglottal regions were independent predictors for the initiation of home CPAP treatment.

Conclusion

Multisite narrowing and function collapse of the UA are important factors affecting OSA severity, CPAP titration pressure, and the initiation of home CPAP therapy. Clinical evaluation with awake endoscopy is a safe and effective way for the assessment of patients with OSA in internal medicine.

Combination of Dexmedetomidine and Butorphanol Optimized Sedation in Drug-Induced Sleep Endoscopy: A Randomized, Double-Blind Trial

OBJECTIVE

Drug-induced sleep endoscopy (DISE) allows for the evaluation of dynamic airway collapse in patients with obstructive sleep apnea. However, a standardized sedation regimen for DISE is not yet available. This study aimed to investigate the safety profiles and efficacies of dexmedetomidine combined with butorphanol for DISE.

METHODS

Sixty patients with obstructive sleep apnea scheduled to undergo DISE were randomly divided into Group D and Group DB. All recipients were initially given intravenous butorphanol (1 mg) (Group DB) or saline (Group D). Subsequently, both groups were sedated using a loading dose of 1.0 µg/kg/h of dexmedetomidine. Hemodynamic and respiratory parameters, the time to attain sufficient sedation, wakeup time, and adverse events during DISE were recorded.

RESULTS

Compared with Group D, the time until sufficient sedation and wakeup time in Group DB were significantly reduced. A higher performer satisfaction level was achieved in Group DB. Patients in Group DB showed a higher incidence of bradycardia compared with Group D. However, the bradycardia resolved spontaneously in both groups without any treatment. There was no instance of cough, hypotension, arrhythmia, nausea or vomiting in either group.

CONCLUSION

Compared to dexmedetomidine alone, a small dose of butorphanol infusion (1 mg) as an adjunct treatment to dexmedetomidine during DISE can reduce the dosage of dexmedetomidine, shorten the time until sufficient sedation and enhance the performer satisfaction level. This synergistic combination could be a promising sedation regimen for DISE in terms of procedural convenience and patient safety.

Outcomes of dexmedetomidine sedation for drug-induced sleep ciné magnetic resonance imaging studies in pediatric obstructive sleep apnea patients

BACKGROUND

Dexmedetomidine is utilized as a sedative agent for drug-induced sleep cine magnetic resonance imaging studies due to its ability to mimic natural sleep and lack of respiratory depressant effects. The outcomes of dexmedetomidine sedation such as respiratory complications and unplanned admissions in obstructive sleep apnea patients undergoing these studies are currently unknown.

AIM

To describe the outcomes of dexmedetomidine sedation for outpatient drug-induced sleep magnetic resonance imaging in pediatric patients with obstructive sleep apnea.

METHODS

This is a retrospective chart review conducted in pediatric patients with obstructive sleep apnea undergoing outpatient drug-induced sleep ciné magnetic resonance imaging studies with dexmedetomidine sedation. Demographics, comorbidities, polysomnography study results, vital signs, respiratory complications, airway interventions, successful completion of the scan, and unplanned hospital admissions were measured.

MAIN RESULTS

We analyzed 337 patients aged 2-18 years (median age of 11 years). The imaging was completed with dexmedetomidine as the sole sedative agent in 61% (N = 207) patients. Ketamine was administered as additional sedative agent in 36% (N = 122) of the patients. There was no difference in sedation-related adverse events and respiratory complications with regard to the severity of sleep apnea with the exception of mild desaturation episodes (SpO2 85%-90%). Patients who received additional sedative agents had significantly longer recovery room stay (71.5 [44] vs 55 [39] minutes; 95% CI of difference [9 to 23 min], p < 0.001) and total periprocedural stay (164.5 [52] vs 138 [64] minutes; 95% CI of difference [17 to 35 min], p < .001).

CONCLUSIONS

Dexmedetomidine alone or along with ketamine provided acceptable sedation in majority of the patients with obstructive sleep apnea undergoing outpatient diagnostic sleep magnetic resonance imaging studies without significant respiratory adverse events regardless of the severity of sleep apnea. Sedation failure and unplanned admissions are rare, and routine planned admission may not be required for this patient population.

Prediction of the obstruction sites in the upper airway in sleep-disordered breathing based on snoring sound parameters: a systematic review

BACKGROUND

Identification of the obstruction site in the upper airway may help in treatment selection for patients with sleep-disordered breathing. Because of limitations of existing techniques, there is a continuous search for more feasible methods. Snoring sound parameters were hypothesized to be potential predictors of the obstruction site. Therefore, this review aims to i) investigate the association between snoring sound parameters and the obstruction sites; and ii) analyze the methodology of reported prediction models of the obstruction sites.

METHODS

The literature search was conducted in PubMed, Embase.com, CENTRAL, Web of Science, and Scopus in collaboration with a medical librarian. Studies were eligible if they investigated the associations between snoring sound parameters and the obstruction sites, and/or reported prediction models of the obstruction sites based on snoring sound.

RESULTS

Of the 1016 retrieved references, 28 eligible studies were included. It was found that the characteristic frequency components generated from lower-level obstructions of the upper airway were higher than those generated from upper-level obstructions. Prediction models were built mainly based on snoring sound parameters in frequency domain. The reported accuracies ranged from 60.4% to 92.2%.

CONCLUSIONS

Available evidence points toward associations between the snoring sound parameters in the frequency domain and the obstruction sites in the upper airway. It is promising to build a prediction model of the obstruction sites based on snoring sound parameters and participant characteristics, but so far snoring sound analysis does not seem to be a viable diagnostic modality for treatment selection.

Analgesia and patient comfort after enhanced recovery after surgery in uvulopalatopharyngoplasty: a randomised controlled pilot study

Background

Uvulopalatopharyngoplasty(UPPP) is the most prevalent surgical treatment of obstructive sleep apnea, but postoperative pharyngeal pain may affect patient comfort. The enhanced recovery after surgery pathway has been proved beneficial to many types of surgery but not to UPPP yet. The aim of this pilot study was to preliminarily standrize an enhanced recovery after surgery protocol for UPPP, to assess whether it has positive effects on reducing postoperative pharyngeal pain and improving patient comfort, and to test its feasibility for an international multicentre study.

Methods

This randomised controlled study analysed 116 patients with obstructive sleep apnoea (OSA) who were undergoing UPPP in a single tertiary care hospital. They were randomly divided according to treatment: the ERAS group (those who received ERAS treatment) and the control group (those who received traditional treatment). Ninety-five patients completed the assessment (ERAS group, 59 patients; control group, 36 patients). Pharyngeal pain and patient comfort were evaluated using a visual analogue scale (VAS) at 30 min and at 6, 12, 24 and 48 h after UPPP. Complications, hospitalisation duration, and hospital cost were recorded.

Results

The VAS scores for resting pain and swallowing pain were significantly lower in the ERAS group than those in the control group at 30 min and at 6, 12, 24 and 48 h after surgery. Patient comfort was improved in the ERAS group. The hospitalisation duration and cost were comparable between the groups. The incidence of complications showed an increasing trend in the ERAS group.

Conclusion

The ERAS protocol significantly relieved pharyngeal pain after UPPP and improved comfort in patients with OSA, which showed the prospect for an larger study. Meanwhile a potential increase of post-operative complications in the ERAS group should be noticed.

Trial registration

Chinese Clinical Trial Registry (23/09/2018, ChiCTR1800018537)

The correlation between the STOP-Bang score and oxygen saturation during spinal anesthesia with dexmedetomidine sedation

BACKGROUND

The STOP-Bang questionnaire is a simple screening tool with high sensitivity for the detection of severe obstructive sleep apnea. Predicting airway obstruction would allow the safe management of sedative patients to prevent intraoperative hypoxia. This study was designed to check the correlation between the STOP-Bang score and oxygen saturation (SpO2) during sedation and confirm the availability of the STOP-Bang questionnaire as a preoperative exam for predicting the incidence of hypoxia in sedative patient management.

METHODS

This study included 56 patients who received spinal anesthesia. The pre-anesthesia evaluation was conducted using the STOP-Bang questionnaire. The patients were under spinal anesthesia with an average block level of T10. Dexmedetomidine was infused with a loading dose of 1 μg/kg over 10 min and a maintenance dose of 0.5 μg/kg/h until the end of the procedure. The SpO2 of the patients was recorded every 5 min.

RESULTS

The STOP-Bang score was negatively correlated with the lowest SpO2 (coefficient = -0.774, 95% confidence interval [CI]: -0.855 to -0.649, standard error [SE] = 0.054, P < 0.001). The item of "observed apnea" was the most correlated one with hypoxic events (odds ratio = 6.00, 95% CI: 1.086 to 33.145).

CONCLUSIONS

The STOP-BANG score was significantly correlated with the lowest SpO2 during spinal anesthesia, which enabled the prediction of meaningful hypoxia before it occurred in the sedated patients.

The Use of Propofol versus Dexmedetomidine for Patients Receiving Drug-Induced Sleep Endoscopy: A Meta-Analysis of Randomized Controlled Trials

The sedation outcomes associated with dexmedetomidine compared with those of propofol during drug-induced sleep endoscopy (DISE) remains unclear. Electronic databases (i.e., the Cochrane controlled trials register, Embase, Medline, and Scopus) were searched from inception to 25 December 2020 for randomized controlled trials (RCTs) that evaluated the sedation outcomes with dexmedetomidine or propofol in adult patients diagnosed with obstructive sleep apnea (OSA) receiving DISE. The primary outcome was the difference in minimum oxygen saturation (mSaO2). Five RCTs (270 participants) published between 2015 and 2020 were included for analysis. Compared with dexmedetomidine, propofol was associated with lower levels of mSaO2 (mean difference (MD) = -7.24, 95% confidence interval (CI) -12.04 to -2.44; 230 participants) and satisfaction among endoscopic performers (standardized MD = -2.43, 95% CI -3.61 to -1.26; 128 participants) as well as a higher risk of hypoxemia (relative ratios = 1.82, 95% CI 1.2 to 2.76; 82 participants). However, propofol provided a shorter time to fall asleep and a lower risk of failed sedation compared with dexmedetomidine. No significant difference was found in other outcomes. Compared with propofol, dexmedetomidine exhibited fewer adverse effects on respiratory function and provided a higher level of satisfaction among endoscopic performers but was associated with an elevated risk of failed sedation.

Guidelines for sedation in gastroenterological endoscopy (second edition)

Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release up-to-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.

Comparison of dexmedetomidine-propofol and ketamine-propofol administration during sedation-guided upper gastrointestinal system endoscopy

BACKGROUND

Dexmedetomidine and ketamine popular sedative agents that result in minimal respiratory depression and the presence of analgesic activity. We aimed to compare the effectiveness and safety of a dexmedetomidine-propofol combination and a ketamine-propofol combination during upper gastrointestinal system endoscopy.

METHODS

The study commenced after receiving approval from the local ethics committee. Patients between 18 and 60 years in the American Society of Anesthesiologists (ASA) I and II groups were included. Patients who had severe organ disease, who had allergies to the study drugs, and who refused to participate were excluded. Cases were randomized into a dexmedetomidine-propofol group (Group D, n = 30) and a ketamine-propofol group (Group K, n = 30). Cardiac monitoring, peripheral oxygen saturation, and bispectral index (BIS) monitoring were performed. Group D received 1 mg/kg dexmedetomidine + 0.5 mg/kg propofol intravenous (IV) bolus, 0.5 μg/kg/h dexmedetomidine + 0.5 mg/kg/h propfol infusion. Group K received 1 mg/kg ketamine + 0.125 mL/kg propofol iv bolus, 0.25 mg/kg/h ketamine + 0.125 mL/kg/h propfol infusion. Patients were followed up with a Ramsay Sedation Scale (RSS) of ≥4. Means, standard deviations, lowest and highest frequency values, and ratio values were used for descriptive statistics, and the SPSS 22.0 program was used for statistical analyses.

RESULTS

In Group K, recovery time and mean blood pressure (MBP) values were significantly shorter. Furthermore, coughing rate, pulse, and BIS values were higher than in Group D (P < .05). Although there were no significant differences between the groups in terms of endoscopic tolerance and endoscopist satisfaction, we observed that the dexmedetomidine group experienced more comfortable levels of sedation.

CONCLUSION

Dexmedetomidine-propofol and ketamine-propofol combinations may be suitable and safe for endoscopy sedation due to their different properties. It was observed that the dexmedetomidine-propfol combination was superior in terms of sedation depth and that the ketamine-propofol combination was superior in terms of early recovery. As a result, we suggest the dexmedetomidine-propofol combination for upper gastrointestinal system endoscopy sedation due to hemodynamic stability and minimal adverse effects.

Propofol versus dexmedetomidine during drug-induced sleep endoscopy (DISE) for pediatric obstructive sleep apnea

PURPOSE

To test for differences in DISE findings in children sedated with propofol versus dexmedetomidine. We hypothesized that the frequency of ≥ 50% obstruction would be higher for the propofol than dexmedetomidine group at the dynamic levels of the airway (velum, lateral walls, tongue base, and supraglottis) but not at the more static adenoid level.

METHODS

A single-center retrospective review was performed on children age 1-18 years with a diagnosis of sleep disordered breathing or obstructive sleep apnea (OSA) who underwent DISE from July 2014 to Feb 2019 scored by the Chan-Parikh scale sedated with either propofol or dexmedetomidine (with or without ketamine). Logistic regression was used to test for a difference in the odds of ≥ 50% obstruction (Chan-Parikh score ≥ 2) at each airway level with the use of dexmedetomidine vs. propofol, adjusted for age, sex, previous tonsillectomy, surgeon, positional OSA, and ketamine co-administration.

RESULTS

Of 117 subjects, 57% were sedated with propofol and 43% with dexmedetomidine. Subjects were 60% male, 66% Caucasian, 31% obese, 38% syndromic, and on average 6.5 years old. Thirty-three percent had severe OSA and 41% had previous tonsillectomy. There was no statistically significant difference in the odds of ≥ 50% obstruction between the two anesthetic groups at any level of the airway with or without adjustment for potential confounders.

CONCLUSION

We did not find a significant difference in the degree of upper airway obstruction on DISE in children sedated with propofol versus dexmedetomidine. Prospective, randomized studies would be an important next step to confirm these findings.

Dexmedetomidine: What's New for Pediatrics? A Narrative Review

Over the past few years, despite the lack of approved pediatric labelling, dexmedetomidine’s (DEX) use has become more prevalent in pediatric clinical practice as well as in research trials. Its respiratory-sparing effects and bioavailability by various routes are only some of the valued features of DEX. In recent years the potential organ-protective effects of DEX, with the possibility for preserving neurocognitive function, has put it in the forefront of clinical and bench research. This comprehensive review focused on the pediatric literature but presents relevant, supporting adult and animal studies in order to detail the recent growing body of literature around the pharmacology, end-organ effects, organ-protective effects, alternative routes of administration, synergetic effects, and clinical applications, with considerations for the future.

Comparison of Findings between Clinical Examinations and Drug-Induced Sleep Endoscopy in Patients with Obstructive Sleep Apnea Syndrome

The Velum, Oropharynx, Tongue base and Epiglottis (VOTE) classification on drug-induced sleep endoscopy (DISE) is used widely for obstructive sleep apnea (OSA) syndrome, though research into comparative physical examinations with VOTE on DISE is still limited. The aim of this study was to evaluate the relationship between the findings of physical examinations and DISE in patients with OSA. Fifty-five patients with OSA were enrolled in this retrospective study. All of the patients received clinical explorations including a Brodsky classification, a modified Mallampati score (MMS), a modified Friedman’s staging system, and a Muller’s test. Drug-induced sleep endoscopy was further evaluated in the operating room. There were significant relationships between Brodsky classification, modified Friedman’s staging system, Muller’s test and oropharynx collapse during DISE (p < 0.05). Brodsky classification, MMS, modified Friedman’s staging system and retropalatal lateral-to-lateral (L–L) collapse of Muller’s test were significantly correlated with VOTE count (p < 0.05). The concordance between VOTE under DISE and Brodsky classification or modified Friedman’s staging system was moderate. In contrast, the concordance between VOTE under DISE and MMS or Muller’s test was slight. The study revealed that Brodsky classification and Friedman staging had a significant relationship with DISE on the velum and oropharynx, but the level of tongue base is uncertain between DISE and MMS. Correlation of awake evaluation of tongue base is still not correlated to the DISE findings. Pre-treatment evaluation of DISE is still warranted.

Use of Dexmedetomidine in Transfemoral Transcatheter Aortic Valve Implantation (tf-TAVI) Procedures

INTRODUCTION

Dexmedetomidine is a highly selective alpha-2 adrenoreceptor agonist without any effect on the GABA receptor. Its sedative, anxiolytic, analgesic, and sympatholytic activities together with opioid-sparing effects make it suitable for short- and long-term sedation in the intensive care setting. We report our experience with dexmedetomidine use during transfemoral transcatheter aortic valve implantation (TAVI) procedure as an alternative to general anesthesia.

METHODS

This is a retrospective analysis of high-risk patients undergoing dexmedetomidine infusion for the transfemoral TAVI procedure between July 2017 and October 2019. The primary outcome parameters were hemodynamic: heart rate (HR), mean arterial pressure (MAP); respiratory oxygen saturation (SpO₂), pH, partial pressure of arterial oxygen (PaO₂), partial pressure of arterial carbon dioxide (PaCO₂), and sedation level (Richmond Agitation-Sedation Scale, RASS). The frequency of conversion to general anesthesia and the need for sedative "rescue therapy" were secondary endpoints. We also reported the overall anesthetic management and the incidence of intra- and postoperative complications.

RESULTS

Eighty-five patients were evaluated (age 81.58 ± 5.23 years, 36.5% men, 63.5% women). High comorbidity, according to the Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM). The patients' hemodynamic functions were kept normal. Complications such as cardiac arrest occurred in four patients; orotracheal intubation and cardiopulmonary resuscitation were necessary. Atrioventricular block occurred in nine patients. Respiratory parameters were maintained stable. Complications such as apnea, hypoventilation, and hypoxemia did not occur. All patients had RASS scores above or equal to 0 and - 1. No patient required rescue midazolam or fentanyl. No conversion to general anesthesia in patients sedated with dexmedetomidine was observed in the absence of hemodynamic complications caused by the surgical technique.

CONCLUSION

In this series, sedation with dexmedetomidine for TAVI procedures with femoral access was proven effective and safe. Dexmedetomidine may be a valid alternative to general anesthesia in high-risk older patients undergoing transfemoral TAVI.

Upper Airway Collapsibility during Dexmedetomidine and Propofol Sedation in Healthy Volunteers: A Nonblinded Randomized Crossover Study

BACKGROUND

Dexmedetomidine is a sedative promoted as having minimal impact on ventilatory drive or upper airway muscle activity. However, a trial recently demonstrated impaired ventilatory drive and induction of apneas in sedated volunteers. The present study measured upper airway collapsibility during dexmedetomidine sedation and related it to propofol.

METHODS

Twelve volunteers (seven female) entered this nonblinded, randomized crossover study. Upper airway collapsibility (pharyngeal critical pressure) was measured during low and moderate infusion rates of propofol or dexmedetomidine. A bolus dose was followed by low (0.5 μg · kg · h or 42 μg · kg · min) and moderate (1.5 μg · kg · h or 83 μg · kg · min) rates of infusion of dexmedetomidine and propofol, respectively.

RESULTS

Complete data sets were obtained from nine volunteers (median age [range], 46 [23 to 66] yr; body mass index, 25.4 [20.3 to 32.4] kg/m). The Bispectral Index score at time of pharyngeal critical pressure measurements was 74 ± 10 and 65 ± 13 (mean difference, 9; 95% CI, 3 to 16; P = 0.011) during low infusion rates versus 57 ± 16 and 39 ± 12 (mean difference, 18; 95% CI, 8 to 28; P = 0.003) during moderate infusion rates of dexmedetomidine and propofol, respectively. A difference in pharyngeal critical pressure during sedation with dexmedetomidine or propofol could not be shown at either the low or moderate infusion rate. Median (interquartile range) pharyngeal critical pressure was -2.0 (less than -15 to 2.3) and 0.9 (less than -15 to 1.5) cm H2O (mean difference, 0.9; 95% CI, -4.7 to 3.1) during low infusion rates (P = 0. 595) versus 0.3 (-9.2 to 1.4) and -0.6 (-7.7 to 1.3) cm H2O (mean difference, 0.0; 95% CI, -2.1 to 2.1; P = 0.980) during moderate infusion of dexmedetomidine and propofol, respectively. A strong linear relationship between pharyngeal critical pressure during dexmedetomidine and propofol sedation was evident at low (r = 0.82; P = 0.007) and moderate (r = 0.90; P < 0.001) infusion rates.

CONCLUSIONS

These observations suggest that dexmedetomidine sedation does not inherently protect against upper airway obstruction.

Updates on management of pediatric obstructive sleep apnea

Obstructive sleep apnea (OSA) affects about 1%-5% of the pediatric population. The consequences of untreated OSA in children include neurocognitive deficits, behavioral problems, poor school performance as well as systemic and pulmonary hypertension. The treatment options for pediatric OSA are numerous with a variety of surgical and non-surgical interventions. As our understanding of the complexities of OSA grows, the options for management have continued to expand as well. The objectives of this review are to describe the commonly prescribed treatments for pediatric OSA including adenotonsillectomy as well as use of positive airway pressure. We also highlight other surgical and non-surgical interventions available. In addition, we provide updates on current research focusing on newer diagnostic and experimental treatment modalities.

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

Obesity and Obstructive Sleep Apnea in the Ambulatory Patient

Obesity and obstructive sleep apnea (OSA) are often associated with increased perioperative risks and challenges for the anesthesiologist. This article addresses the current controversies surrounding perioperative care of morbidly obese patients with or without OSA scheduled for ambulatory surgery, particularly in a free-standing ambulatory center. Topics discussed include preoperative selection of obese and OSA patients for ambulatory surgeries, intraoperative methods to reduce perioperative risk, and appropriate postoperative care.

Dexmedetomidine versus propofol at different sedation depths during drug-induced sleep endoscopy: A randomized trial

OBJECTIVES/HYPOTHESIS

The aim of this study was to compare the effect of dexmedetomidine and propofol on airway dynamics, cardiorespiratory system, and emergence following drug-induced sleep endoscopy (DISE).

STUDY DESIGN

Prospective, randomized, single-blinded study.

METHODS

Sixty patients age 18 to 65 years in American Society of Anesthesiologists physical status groups 1 and 2 scheduled to undergo DISE were randomly allocated to either Group P (N = 30; receiving propofol infusion at 50-150 μg/kg/min) or Group D (N = 30; receiving dexmedetomidine bolus of 1 μg/kg followed by infusion at 0.5-1.0 μg/kg/hr). DISE was done at light sleep and deep sleep. Airway obstruction at tongue base was recorded as primary outcome. Airway obstruction at velum, oropharyngeal lateral wall, and epiglottis level during light and deep sedation, hemodynamic and respiratory parameters, time to attain sufficient sedation, time for emergence from sedation, and any adverse events during DISE with the two study drugs were recorded as secondary outcomes.

RESULTS

There was a greater degree of obstruction at the tongue base level (P = 0.001) and Oropharynx level (P = 0.017) in Group P compared with Group D during deep sedation. Increase in airway obstruction from light to deep sleep was seen with propofol at the oropharynx (P = 0.0185) and tongue base (P = 0.0108) levels. Two patients (6.6%) in Group D and 10 patients (33.3%) in Group P showed oxygen saturation below the minimum oxygen saturation recorded during polysomnography. Time to open eyes to call after stopping sedation was significantly less in Group P (P = 0.005).

CONCLUSIONS

Dexmedetomidine shows a lesser degree of airway collapse and higher oxygen saturation levels at greater sedation depth during DISE. Propofol has a faster onset and emergence from sedation.

LEVEL OF EVIDENCE

1b Laryngoscope, 130:257-262, 2020.

Drug-Induced Sleep Endoscopy in Treatment Options Selection

Drug-induced sleep endoscopy is a safe and practical technique to evaluate the dynamic upper airway collapse during sleep. We review drug-induced sleep endoscopy in adults, including its indications, technique, evaluation of upper airway collapse, and clinical application. Drug-induced sleep endoscopy is useful to improve treatment options selection for patients with obstructive sleep apnea, especially for those who are unable to accept or tolerate continuous positive airway pressure therapy. Owing to a lack of standardization for drug-induced sleep endoscopy, it is difficult to compare the published literature from different sleep centers across the world.

Drug-induced sleep endoscopy: from obscure technique to diagnostic tool for assessment of obstructive sleep apnea for surgical interventions

PURPOSE OF REVIEW

Provide a practical update on drug-induced sleep endoscopy (DISE) for anesthesia providers, which can also serve as a reference for those preparing to establish a DISE program.

RECENT FINDINGS

New developments in surgical approaches to OSA and the growing global incidence of the condition have stimulated increased interest and demand for drug-induced sleep endoscopy. New techniques include transoral robotic surgery and hypoglossal nerve stimulation. Recent DISE literature has sought to address numerous debates including relevance of DISE findings to those during physiologic sleep and the most appropriate depth and type of sedation for DISE. Propofol and dexmedetomidine have supplanted midazolam as the drugs of choice for DISE. Techniques based on pharmacokinetic models of propofol are superior to empiric dosing with regard to risk of respiratory compromise and the reliability of dexmedetomidine to achieve adequate conditions for a complete DISE exam is questionable.

SUMMARY

The role of DISE in surgical evaluation and planning for treatment of OSA continues to develop. Numerous questions as to the optimal anesthetic approach remain unanswered. Multicenter studies that employ a standardized approach using EEG assessment, pharmacokinetic-pharmacodynamic modelling, and objectively defined clinical endpoints will be helpful. There may be benefit to undertaking DISE studies in non-OSA patients.

Controversies in Obstructive Sleep Apnea Surgery

Obstructive sleep apnea (OSA) is a common chronic disease characterized by repetitive pharyngeal collapse during sleep. OSA is associated with cardiovascular disease and increased mortality, among other issues. Continuous positive airway pressure (CPAP) is considered first line therapy for OSA, but is not always tolerated. Both non-surgical and surgical alternative management strategies are available for the CPAP intolerant patient. This article explores controversies surrounding airway evaluation, definition of successful treatment, and surgical management of the CPAP intolerant patient with moderate to severe OSA. Controversies specific to maxillomandibular advancement (MMA) are also discussed.

A case-control study of Drug-Induced Sleep Endoscopy (DISE) in pediatric population: A proposal for indications

OBJECTIVE

To evaluate whether and when Drug-Induced Sleep Endoscopy (DISE) changes diagnosis and treatment plan in pediatric Obstructive Sleep Apnoea Syndrome (OSAS) with the aim to identify specific subgroups of patients for whom DISE should be especially considered.

METHODS

A case-control study of DISE in 150 children with OSAS. Pre-operative OSA were assessed through detailed history, Chervin questionnaire, physical examination and overnight polysomnography. The group of study was divided into three subgroups according to clinical and polysomnographyc criteria: conventional OSAS, disproportional OSAS and persistent OSAS. Endoscopic evaluation of the upper airway during DISE was scored using Chan classification. Surgical treatment was tailored individually upon the basis of sleep endoscopy findings: performance of any surgery other than tonsillectomy and adenoidectomy (T&A) was considered as a change of the treatment plan. Cases and controls were compared considering presence and absence of DISE-directed extra surgery, respectively.

RESULTS

150 patients with mean age (SD) 56.09 (23.94) months and mean apnoea-hypopnea index (AHI) of 5.79 (6.52) underwent DISE. The conventional subgroup represented the 58.67% of the sample (n = 88), while the disproportional one counted for the 26.67% (n = 40), and the persistent one for 14.66% (n = 22) of the population. Sleep endoscopy changed the surgical plan in 4.5% of conventional OSAS, 17.5% of disproportional OSAS and 72.7% of persistent OSAS (p < 0.005). Overall, a change of the treatment plan operated by DISE was associated with a non-conventional OSAS status (OR = 6; 95% CI = 1.6-26.4).

CONCLUSIONS

DISE is a safe procedure in children suffering from OSAS, and, despite being unnecessary in conventional cases of OSA, DISE should be considered not only in syndromic children, as previously demonstrated, but also in the general non-syndromic pediatric population, in the case of non-conventional OSA patients, and in children with persistent OSAS.

Sleep endoscopy findings in children with persistent obstructive sleep apnea after adenotonsillectomy

OBJECTIVES

Describe the patterns of obstruction in persistent pediatric OSA and their relationship with patient weight.

STUDY DESIGN

Retrospective review.

METHODS

All pediatric DISE procedures performed at a tertiary care hospital between October 2010 and October 2015 were reviewed. Patients had polysomnography after adenotonsillectomy that confirmed persistent obstructive sleep apnea (OSA). Variables included age, gender, co-morbidities, and AHI. DISE findings focused on inferior turbinates, adenoid, tongue base, epiglottis, aryepiglottic (AE) folds, arytenoids, lingual tonsil and their contributions to obstruction.

RESULTS

34 patients were included with mean age of 7.85 (2-16) years, mean BMI of 23.15 (13.6-44.8) and mean AHI of 6.34 (1.5-25.2) events per hour. Obstruction occurred at the level of the epiglottis in 97%, with retropositioning by tongue base (73.6%) or lingual tonsil enlargement (70.5%). Obstruction occurred at the inferior turbinates in 76.5%, the adenoid in 64.7% and the palate in 58.8%. Shortened AE folds were less often identified (15%). Multiple sites of partial or complete obstruction were found in 97% of patients. Overweight or obese patients had a mean of 3 sites of complete obstruction and 4.69 sites of partial or complete obstruction as compared to 2.33 and 4.52 in underweight or normal weight children. Overweight or obese children were more likely to have obstruction at the lingual tonsil or adenoid than normal/underweight children.

CONCLUSION

Multiple sites of obstruction in persistent pediatric OSA were found. Children with higher BMIs had slightly different findings, suggesting that attention to adenoid regrowth and lingual tonsil hypertrophy is important.

A review on drug-induced sedation endoscopy - Technique, grading systems and controversies

Sleep disordered breathing (SDB) comprises a spectrum of disorders, ranging from simple snoring to severe obstructive sleep apnoea (OSA), with a significant burden to health care systems in high income countries. If left untreated, OSA has significant cumulative, long-term health consequences. In the 1990s drug induced sedation endoscopy (DISE) has been developed to become a primary tool in the diagnosis and management of OSA. It allows meticulous endoscopic evaluation of the airway and identifies areas of collapse, thereby informing both on the selection of surgical techniques, where efficacy depends entirely on success at relieving obstruction at a certain level and on the usefulness of conservative measures, such as mandibular advancement splints. This article provides a review of the literature on DISE, covering different grading systems and techniques, explaining different rationales and discussing controversies.

Effect of dexmedetomidine in the prophylactic endoscopic injection sclerotherapy for oesophageal varices: a study protocol for prospective interventional study

Background

Dexmedetomidine (DEX) is a novel, highly selective α2-adrenoceptor agonist that elicits sedative, amnestic, sympatholytic and analgesic effects in patients. Several Japanese investigators have reported the clinical usefulness of DEX for sedation in endoscopic therapies for gastrointestinal malignancies; however, there have been limited data regarding the usefulness and safety of DEX for sedation during endoscopic procedures for oesophageal varices (OVs), such as endoscopic injection sclerotherapy (EIS). In this prospective, single-arm interventional study, we aimed to elucidate these issues.

Methods

Patients who require two or more sessions of prophylactic EIS for the treatment of OVs will be enrolled in this prospective interventional study. EIS procedures include two methods: (1) sedation during endoscopic procedures will be performed using conventional methods (pentazocine (PNZ) and midazolam (MDZ)), and (2) sedation during endoscopic procedures will be performed using PNZ, low-dose MDZ and DEX. These two methods were randomly assigned in the first and second EIS. The effect and safety of these two procedures with respect to patient sedation are to be compared with the degree of sedation evaluated using the Bispectral Index monitoring system (Aspect Medical Systems, Norwood, Massachusetts, USA).

Ethics and dissemination

This study received approval from the Institutional Review Board at Hyogo College of Medicine (approval no. 2324). The authors are committed to publishing the study results as widely as possible in peer-reviewed journals, and to ensuring that appropriate recognition is provided to everyone who is working on this study.

Trial registration number

UMIN000026688; Pre-results.