Journal club
Dr Dhanoush
Moderator - Dr G K Behera
Article
E ects of drug‐induced sleep endoscopy in children with
conventional obstructive sleep apnea–hypopnea syndrome: a
systematic review and meta‐analysis
Xin Wang · Yong‐chao Chen · Lan Li · Hong‐guang Pan · Yi‐shu Teng
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Published on 2 November 2023
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Introduction
Pediatric obstructive sleep apnea–hypopnea syndrome (OSAHS), which is a common condition in
children, a ecting between 1.2% and 5.7% of the population.
The condition is characterized by recurrent partial or complete upper airway obstruction, leading to
hypoventilation and pauses in breathing during sleep. This can result in adverse health e ects,
including behavioral and neurocognitive problems, cardiovascular issues, and impaired growth and
development.
The most common cause of pediatric OSAHS in otherwise healthy children is adenotonsillar
hypertrophy, and adenotonsillectomy is recommended as the rst-line treatment by the American
Academy of Pediatrics.
However, it is noted that many children experience persistent OSAHS even after surgery, with up to
33.7% of children continuing to have sleep-disordered breathing post-operatively.
Multi-level airway obstruction is considered a key factor in treatment-resistant cases.
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Introduction
To improve treatment outcomes, drug-induced sleep endoscopy (DISE) has been
introduced as a tool to assess airway obstructions during sleep, which may be missed in
awake examinations.
DISE provides a more accurate assessment of the obstruction sites and can lead to more
targeted treatments. However, the use of DISE in pediatric OSAHS, especially in patients
without previous surgery or underlying syndromes, has been debated.
Some studies argue that DISE should not be widely used in children without prior surgery
or comorbidities, while others suggest it can be bene cial in guiding treatment decisions.
The paper aims to systematically review the available literature to determine the role of
DISE in pediatric OSAHS without previous upper airway surgeries or other signi cant
conditions, focusing on its impact on treatment strategies and surgical outcomes.
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Drug induced sleep endoscopy
• OSAHS is characterized by intermittent episodes of complete or partial upper
airway obstruction during sleep due to:
a) Pharyngeal muscles hypotonia
b) Increased intracavitary negative pressure during inspiration associated
with the supine position.
• This leads to pharyngeal walls collapse and a patency reduction of retro
palatal and/or retro lingual region with an increase in air ow resistance.
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Drug induced sleep endoscopy
• Although CPAP is considered to be the best non surgical treatment modality,
however Compliance is a big issue .
• For other surgical modality (Except Bimax advancement, rarely
tracheostomy), they requires precise location of the obstruction.
• Classically, indications are founded on clinical examination with exible
endoscopy; other methods(Cephalometry, CT, MRI) are also available, but all
have the drawback of being performed with the patient awake
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Drug induced sleep endoscopy
• Ideal evaluation technique would be
an assessment of breathing, sleeping
patients, as this would provide a real-
time, dynamic assessment.
• However, these e orts are generally
abandoned due to the discomfort
experience by patients, particularly
with movement of the endoscope to
view multiple areas of the pharyngeal
airway
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Drug induced sleep endoscopy
Croft and Pingle in 1991
Drug-induced sleep endoscopy (DISE) is an upper airway evaluation technique
with 3 key features:
• Use of pharmacologic agents to achieve sedation,
• Target depth of sedation as approximating natural sleep as much as
possible, and
• Endoscopic evaluation of the upper airway
Drug induced sleep endoscopy
Subjects
• A ected by socially disturbing snoring and OSAHS, in whom non-CPAP
therapy is considered .
• Failed CPAP therapy or who encounter di culties in tolerating CPAP, as
reasons for failure or di culty in tolerating CPAP could be potentially
highlighted.
• Fatients in whom previous surgery has failed and may allow the clinician to
recommend either OAT or further surgical intervention addressing anatomical
segment that may be causing residual symptom
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Drug induced sleep endoscopy
• DISE can be performed in any safe clinical setting such as:
1. Operating theatre
2. Endoscopy room
3. Clinical room
• Set up with standard anaesthetic equipment (basic monitoring and resuscitation kits in
case of emergency), and where relevant ambience such as silence and darkness is
available.
• DISE can usually be performed as a day-case while, in rare cases, overnight stay may be
necessary depending on the patient's general condition and if surgical therapy has been
concurrently performed.
Surgical options available
1. Uvulopalatopharyngoplasty (UPPP)
2. Adenotonsillectomy
3. Genioglossus Advancement (GA)
4. Maxillomandibular Advancement (MMA)
5. Tongue Base Reduction
6. Hypoglossal Nerve Stimulation (Inspire Therapy)
7. Septoplasty and Turbinate Reduction
8. Bariatric Surgery
9. Pillar Procedure
10. Tracheostomy
[Link]
Uvulopalatoplasty
Genioglossus advancement
Maxillomandibular advancement
Hypoglossal nerve stimulation
Pillar proceedure
Supraglottoplasty
Drug induced sleep endoscopy
• Studies reported that propofol did not change the respiratory pattern nor
signi cantly in uence the apnea-hypopnea index (AHI),but did interfere with
the sleep architecture, speci cally a reduction in rapid eye movement (REM)
sleep.
• Bispectral index (BIS) score may provide additional monitoring of sedation. It
provides direct information on the e ects of anesthetics and sedatives on the
brain by placing a sensor on a patient's forehead.
• The pursuited value during DISE ranges from 50 to 70.
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Aims and Objectives
• To evaluate the role of drug-induced sleep endoscopy (DISE) in the management of pediatric population
without any history of surgery.
• The study focuses on assessing how DISE in uences treatment strategies and identifying the obstructive sites
in the airway during DISE.
• The objectives of the study are:
1. To identify the obstructive sites observed during DISE in pediatric patients with conventional OSAHS.
2. To evaluate how often DISE results in modi cations to the conventional surgical approach in pediatric
OSAHS cases.
3. To assess the e ectiveness of DISE in improving postoperative outcomes, such as symptom relief and
sleep-related parameters.
4. To provide evidence on whether DISE enhances surgical success rates and helps avoid unnecessary
procedures in children with OSAHS.
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Study design
Inclusion criteria
1. Pediatric participants diagnosed with obstructive sleep apnea–hypopnea syndrome (OSAHS), with no
restrictions on gender, ethnicity, geographic origin, disease severity, or duration.
2. Children undergoing DISE prior to their rst-line treatment for OSAHS, where DISE was used to guide
treatment decisions.
3. The primary outcome being assessed was the frequency of treatment plan modi cations after DISE.
Secondary outcomes included identi cation of obstructive sites during DISE and details related to the
treatment.
Exclusion criteria
1. Studies with unclear diagnostic criteria, a history of upper airway surgeries (e.g., adenotonsillectomy),
or the presence of comorbidities such as Down syndrome, severe craniofacial anomalies, or
neuromuscular diseases.
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Results
The meta-analysis results for the obstructed sites identi ed during DISE in pediatric
conventional OSAHS show the following:
• Nasopharyngeal (adenoid) obstruction was identi ed in 93% of cases (95% CI:
85–100%).
• Soft palate obstruction occurred in 35% of cases (95% CI: 14–55%).
• Oropharyngeal (tonsil) obstruction was found in 76% of cases (95% CI: 54–98%).
• Tongue base obstruction was present in 32% of cases (95% CI: 3–61%).
• Supraglottic obstruction was observed in 31% of cases (95% CI: 5–56%).
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Results
• Regarding multi-level obstruction (adenoid and tonsils), two studies
reported on this, with obstruction rate of 60% (95% CI: 49–71%).
• For the rate of treatment modi cation, DISE led to changes in treatment
strategy in 45% of cases (95% CI: 29–60%).
• In terms of treatment received post-DISE, adenoidectomy and tonsillectomy
were the primary interventions. However, DISE also revealed the need for
tongue base surgery and supraglottic surgery in some cases.
• These ndings highlight the role of DISE in providing more personalized and
e ective treatment strategie
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Results
Rate of treatment modi cation
• DISE resulted in a change in the treatment plan for 45% of the patients (95% CI: 29%–60%).
• Factors such as sample size and the use of di erent medications during DISE did not in uence
the heterogeneity or alter the rate of treatment modi cation.
• The results remained consistent even after excluding individual studies, indicating the robustness
of the ndings.
Details of Treatment Modi cation:
• In most cases, adenoidectomy and tonsillectomy remained the primary treatments for pediatric
OSAHS.
• Additional surgical interventions: Based on DISE ndings, some patients were also indicated for
tongue base surgery and supraglottic surgery, which would not have been considered in a
conventional treatment plan without DISE.
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Discussion
• The discussion emphasizes the growing role of drug-induced sleep endoscopy (DISE) in pediatric
obstructive sleep apnea–hypopnea syndrome (OSAHS), particularly for cases without prior surgery or
comorbidities.
• DISE allows for the identi cation of multiple obstruction sites that might be missed during routine
exams, leading to more tailored and effective treatments.
• The meta-analysis found that DISE modi ed treatment plans in 45% of cases, signi cantly improving
outcomes like symptom relief and sleep parameters. Despite the promising results, the study
acknowledges limitations, including the lack of randomized controlled trials and methodological
weaknesses.
• While DISE is valuable for individualized treatment, more high-quality research is needed to con rm its
role in pediatric OSAHS management.
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Thank you