The Daily Dose • Thursday, May 20, 2021

Strategies Against Pediatric Sleep Breathing Disorders

Hana Nadeem

Four panelists discussed pediatric sleep breathing disorders, the techniques and outcomes of tonsillectomy during the Society of Anesthesia and Sleep Medicine panel, “Pediatric Tonsillectomy: To Breathe or Not to Breathe, that is the Painful Question” on May 15 at IARS 2021 Annual Meeting.

Obstructive Sleep Apnea: From Metabolomics to “Humanomics” and Back

In the recent years, more studies have been published on sleep breathing disorders, especially obstructive sleep apnea (OSA). It is increasingly prevalent but mostly underdiagnosed clinically, according to the first speaker, Olubukola Nafiu, MD, FRCA, MS, from Nationwide Children’s Hospital. To diagnose such a condition, the gold-standard test was to perform an intrusive technique called polysomnography. Due to a high variability in diagnostic precision of sleep studies, and the absence of clear lab markers, Dr. Nafiu presented an interesting approach of diagnosis, connecting the metabolomics to humanomics. “Can the ‘omics’ bridge the gap?” Dr. Nafiu asked. This question was followed by explaining the role of metabolomic profiling in OSA by studying and identifying metabolites (sugars, nucleotides, amino acids, lipids) within cell, tissues and organs that could be related to this sleep disorder and connecting this aspect to the “humanomics.” Even though this approach is still being studied in the research field, Dr. Nafiu indicated that it is a promising tool to use for diagnosing and managing patients with OSA.

Opioid Sparing Techniques for Tonsillectomy

“Is there an opioid free option for tonsillectomy?” Raj Subramanyam, MBBS, MD, MS, Children’s Hospital of Philadelphia, the next speaker,  discussed the increased rate in malpractice claims when it comes to tonsillectomy procedures. After presenting multiple studies and articles, he reviewed the multiple side effects associated with the use of opioids, ranging from respiratory complications and constipation to persistent new opioid use and overdose. Stating that “not using opioids doesn’t mean no analgesia, it means analgesic using opioid alternative,” it has been demonstrated that the use of NSAID (e.g., ibuprofen) was an equivalent analgesic with no effect on bleeding risk and was concomitant with a decrease in postoperative unexpected admissions and rate of nausea/vomiting posttonsillectomy. Dr. Subramanyam briefly mentioned the American Academy of Otolaryngology Head & Neck surgery guidelines and recommended potentially avoiding the use of postoperative opioids and switching to NSAIDs due to its better outcomes.

Based on evidence in the literature, Dr. Subramanyam ended his presentation with two takeaway points on the role of opioid-sparing techniques for tonsillectomy: either provide intraoperative opioids and none postoperatively, or avoid intraoperative opioids and titrate postoperative opioids as rescue for breakthrough pain.

Postoperative Respiratory Complications following a T&A: Predictive Factors in Those Children with and without Prior Sleep Study

Lisa Elden, MD, FRCPC, from Children’s Hospital of Philadelphia, discussed a prestigious childhood adrenal tonsillectomy study, also known as the CHAT trial, and published in The New England Journal of Medicine, evaluating the impact of obstructive sleep apnea syndrome in children with abnormal sleep studies. She outlined the different factors related to developing postoperative respiratory complications following a tonsillectomy and adenoidectomy (T&A).

Knowing that T&A is a first-line treatment for OSA in children, Dr. Elden established that the CHAT randomized clinical trial demonstrated how effective surgery is for children with OSA. It compared children who underwent T&A within a month of diagnosis to those who were monitored for 7 months and results showed improvement of respiratory indices on polysomnography (CO2 and arousal), behavior scores, quality of life and sleepiness scores. However, no difference in neurocognitive tests was observed and less vigorous improvements were detected in Black and obese patients. Dr. Elden stated that her study helped confirm some findings from retrospective studies regarding postoperative complications, which were 7% clinically impactful. Dehydration, fever and hemorrhage were among the most significant complications, but more clinically important complications were noted due to death: bleeding, aspiration, laryngospasm and pulmonary edema.

There is an inconsistent correlation with severity scores of polysomnograms (PSG) and clinical/postoperative outcomes or response to treatment. Dr. Elden presented another study, “Predictors of perioperative complications in higher risk children after adenotonsillectomy for obstructive sleep apnea: a prospective study,” highlighting the following elements as predictive factors for respiratory complications following T&A: preoperative PSG SpO2 nadir <80% and peak CO2 >60 mmHg. She also mentions that obesity, history of OSA and use of postoperative opioids increase risk of postoperative respiratory events. Accordingly, it is better to evaluate these risks factors, perform a postoperative follow-up and monitor at-risk children. She mentioned at the end of her presentation the caveat to consider admitting at-risk patients younger than three years with craniofacial syndrome, PSG scores in the severe ranges as mentioned above and for those with comorbid conditions and subgroups with high risk (obesity, black race).

Measures to Improve Perioperative Airway Management in Obstructive Sleep Apnea Patients

“What are the factors to consider when managing a pediatric OSA airway?” Kimmo Murto, MD, FRCPC, from CHEO Hospital, Ottawa, listed multiple elements involved in airway collapse in children with OSA and how to properly manage the airway perioperatively. These were the main takeaway points from his presentation.

  1. Obesity and small bony enclosure lead to an excess of soft material. The soft tissue and bone imbalance predispose to pharyngeal airway collapse and needs to be considered prior to airway management.
  2. In pediatric OSA, there is a dysfunction in the neuro-motor control of the upper airway muscles. In the awake cycle, a high genioglossus electromyography (EMG) muscle activity was observed vs in the asleep cycle, this effect is altered, and a lower genioglossus EMG activity is noted. This result represents a high risk of airway collapse and should be managed appropriately.
  3. OSA is known as a chronic low-grade systemic inflammatory disease. Dr. Murto presented a study, “Inhibition of α5 γ-Aminobutyric Acid Type A Receptors Restores Recognition Memory After General Anesthesia,” indicating that in presence of proinflammatory IL-1 cytokine, there was an augmentation in GABA-A 5 receptor inhibitory activity by anesthetic agents. Influencing GABA-A receptor mediated drug effect, this effect should be taken into consideration when choosing an anesthetic.
  4. Some of the nondepolarizing muscle relaxants promote upper airway collapse, e.g., sevoflurane, desflurane, propofol, opioids and midazolam. These agents may predispose to unintended airway-related complications including decreased ventilatory drive. It is ultimately important to choose wisely when it comes to picking a NMDR.
  5. Neostigmine increases upper airway collapsibility by decreasing genioglossus muscle activity in response to negative pharyngeal pressure. Therefore, considering suggamadex over neostigmine for amino-steroid muscle relaxant reversal may improve airway management.
  6. Utilize airway maneuvers to enhance longitudinal traction when managing OSA airway in children to improve airway patency.