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.

Quality of life and self-image in patients undergoing tracheostomy

OBJECTIVES

The objective of this study is to understand trends in the Quality of Life and Self Image in patients undergoing an elective tracheostomy for non-malignant laryngeotracheal pathologies. We will also discuss the relationship between quality of life and patient demographics.

STUDY DESIGN

A prospective, IRB approved cohort study was conducted in a tertiary referral center. The SF-12, was used to assess the mental and physical health of patients. The 12 questions on this tool were scored to generate a Physical Composite Score(PCS) and a Mental Composite Score (MCS). A higher score indicates better health.

METHODS

The retrospective arm of the study included patients who presented to the senior author and had a trachesotomy for greater than 6 months. For the prospective arm of the study patients were recruited when they were to undergo an elective tracheostomy. Patients were recruited over a 12 month period. In the prospective arm the questionnaire was administered one to seven days pre-operatively and one to three weeks postoperatively. Variables analyzed included age, gender, marital status, education, occupation and other co-morbidities.

RESULTS

In the prospective group, Mean PCS scores were higher in the post-trach period (38.2 ± 6.9) compared to the pre-trach period (35.4 ± 11.5). However, there is a decline in the MCS score in the post-trach period (49 ± 8.5) compared to the pre-trach period (55.4 ± 7.3). In the retrospective group, Mean PCS scores in this group was 28.5 ± 12.3 while the mean MCS score was 40.5 ± 18.3.

CONCLUSION

Planned tracheostomy is a beneficial intervention for patients with benign airway pathologies, since they experience an improvement in their physical health and the ability to perform activities of daily living. There is a decline in mental health postoperatively, which we attribute to worsening self esteem. Patients who did not undergo planned tracheostomy as seen in the retrospective group, experienced a decline in their physical and mental functioning. This can be attributed to the lack of understanding of the benefit of the procedure and poor preoperative counseling. We recommend perioperative psychological assessment to improve mental health in patients undergoing elective trachesotomies.

Role of cardiac troponin T in the long-term risk stratification of patients undergoing percutaneous coronary intervention

AIMS

To investigate the long-term prognostic significance of pre- and post-procedure troponin T (TnT) elevations in patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

TnT and CK-MB were measured pre- and post-procedure in 212 patients undergoing PCI. Major adverse events (composite of death, myocardial infarction and revascularization) were ascertained 6 years later. Pre-procedural TnT was a significant independent predictor of time to major events (hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.16-2.64) and death or myocardial infarction. Post-procedural TnT elevation above normal was the only independent predictor of the primary end-point at 1 year (HR 2.39, 95% CI 1.09-5.26) but was not significantly related to event-free survival throughout follow-up. Post-PCI elevation of TnT 5x above normal, however, did significantly predict time to events during the entirety of follow-up. By contrast, CK-MB was not an independent predictor in any of the analyses.

CONCLUSIONS

Our study confirms the long-term prognostic value of pre-procedural TnT elevation in patients undergoing PCI, and demonstrates the superior predictive ability of a post-procedural increase in TnT 5x normal for long-term adverse events. Whether the prognostic significance of smaller post-procedural TnT elevations extends beyond the intermediate-term awaits further investigation.