Expert Consensus Statement: Pediatric Drug‐Induced Sleep Endoscopy

Abstract

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.

Debates in pediatric obstructive sleep apnea treatment

“…Drug-induced sleep endoscopy (DISE) and airway reconstruction via imaging is indicated for children with OSA who have small tonsils, as well as for those with persistent OSA. 7 Such patients may also benefit considerably from multidisciplinary consultation.…”

“… 10 Factors associated with non-resolution of OSA with watchful waiting include obesity, 11 progressive tonsillar hypertrophy, 11 male sex, 11 low socioeconomic status, 53 asthma, 54 African American ethnicity, 55 and moderate to severe OSA. 7 Watchful waiting is, therefore, an acceptable option in patients with mild OSA who have no significant risk factors for progression.…”

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

“…Recognized risk factors for persistent OSA post-tonsillectomy include children with asthma, allergic rhinitis, age > 7 years, black ethnicity, obesity, syndromic features, or severe pre-operative OSA [14,18,20,28,59]. The severity of the pre-operative OSA is a clinical predictor for residual OSA, with severe OSA defined as an AHI > 4.7 [18,28].…”

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

“…Drug-induced sleep endoscopy is the flexible endoscopic evaluation of the airway from the nose to hypopharynx in a sleeping patient. This procedure was initially described in 1991 and has been widely adopted in adults to assess the soft palate, oropharynx, tongue base, and epiglottis in sleep [59]. This technique has increasingly been applied to pediatric OSA in the last decade; however, the evidence for its use is still evolving.…”