2017 Sec 1 Green Book

A 2014 study by Vroegop et al retrospectively examined

a case series of 1249 adult patients who underwent both

PSG and DISE.

This study found a statistically significant

association between AHI and airway obstruction at the level

of the epiglottis. DeCorso et al prospectively evaluated the

relationship between PSG parameters and airway obstruc-

tion on DISE in a cohort of 138 adult patients with OSA.

This study utilized the VOTE system to grade the anatomic

obstruction on DISE, and the authors found a statistically

significant association between AHI and the severity of ana-

tomic obstruction on DISE. While both these studies found

a correlation between anatomic obstruction on DISE and

pre-DISE PSG parameters, they included only adult

patients; the management of pediatric OSA patients is very

different from that of adults, and these results may not be

applicable to children.

While the above studies represent significant contribu-

tions to the DISE literature, data derived from adult OSA

patients will not necessarily have a direct correlation with

pediatric OSA patients. There are a number of important

differences to point out regarding the etiology and manage-

ment of pediatric and adult OSA: the obvious physiologic

differences (eg, airway size and compliance), the presence

of medical comorbidities associated with the aging process,

the differences in neuromuscular control, the prevalence of

morbid obesity, and the potential for growth and continued

development that likely differentiate pediatric from adult

OSA. In adults, surgical intervention is considered only

after an appropriate trial of continuous positive airway pres-

sure (CPAP) treatment. In children, surgery is often the

first-line therapy; the clinical expertise necessary to manage

CPAP in children is scarce.

In addition, CPAP is not Food

and Drug Administration approved for outpatient use in

patients

40 kg, and industry support in terms of providing

appropriate equipment for pediatric CPAP is limited. Such

differences highlight the need for continued research into

pediatric DISE as well as the development of DISE-directed

surgical procedures.

Given the weak to moderate correlation coefficients obtained

from our statistical analysis, there are other factors not con-

trolled for in the present study that influenced the relationship

between the level of anatomic obstruction observed on DISE

and the severity of pediatric OSA in this study. First, the sur-

geons performing DISE were not blinded to the preendoscopy

PSG parameters; this introduces bias that we were not able to

control for using the outlined statistical methods. Given the ret-

rospective nature of the present study, it was not feasible to

blind the surgeons from the PSG data, as such data were used

to determine each patient’s candidacy to undergo DISE and

DISE-directed surgery for OSA. However, these correlations

still provide the needed foundational data to build further pro-

spective investigations performed in a blinded manner similar to

the methods described in our initial work.

For the present

study, we chose to include all children who presented to our

institutions with a PSG and met the criteria for undergoing

DISE, regardless of age, severity of OSA, and medical com-

plexity. This ‘‘real world’’ strategy, when coupled with basic

PSG results, provides a broad illustration of these early correla-

tions, again helping to set the stage for further studies that will

ideally focus on both typically developing and medically com-

plex populations.

In addition, the present study included data from DISE

performed by 8 attending surgeons and PSGs performed at

multiple sleep laboratories; the differences in surgical tech-

nique and PSG interpretation introduce variability that

cannot be controlled for in our statistical model. There was

also no documentation of the anesthetic technique used for

the DISE procedures included in this study. The specific

doses and durations of the anesthesia administered during

DISE or variations from the institutional protocols for DISE

anesthesia were not collected as part of the study and there-

fore could not be included in our analysis.

Moving forward, we propose to use the results from the

present study as a basis for a multicenter prospective study

evaluating the association between PSG parameters and the

level of anatomic obstruction on pediatric DISE. Expanding

the breadth and depth of investigations via PSG parameters,

surgical and anesthetic techniques, and patient-reported out-

comes (including quality of life) and focusing on specific

patient populations will further guide research studies that

will undoubtedly help to shape the clinical practice of treat-

ing the many facets of pediatric OSA. To do so, we will need

to follow patients undergoing DISE-directed surgery longi-

tudinally and collect data from postintervention PSGs to

determine the impact of such procedures on PSG parameters

and quality-of-life measures. In addition, with a larger cohort

of patients, we will be able to look at specific sites of ana-

tomic obstruction, as defined by the C-P score, to character-

ize the impact of that site or a procedure directed at that

anatomic location in the pathophysiology and treatment of

pediatric OSA. Such an approach should also allow us to

examine the incidence and treatment of pediatric OSA

caused by multiple sites of airway obstruction.

Author Contributions

John P. Dahl

, conception and design, data acquisition, analysis,

and interpretation, drafting the work, critical revisions, final

approval and accountability for entire product;

Craig Miller

, data

acquisition and interpretation, critical revisions, final approval and

accountability for entire product;

Patricia L. Purcell

, conception

and design, data acquisition, analysis, and interpretation, drafting

the work, critical revisions, final approval and accountability for

entire product;

David A. Zopf

, data acquisition and interpretation,

critical revisions, final approval and accountability for entire prod-

uct;

Kaalan Johnson

, data acquisition and interpretation, critical

revisions, final approval and accountability for entire product;

David L. Horn

, data acquisition and interpretation, critical revi-

sions, final approval and accountability for entire product;

Maida

L. Chen

, data acquisition and interpretation, critical revisions,

final approval and accountability for entire product;

Dylan K.

Chan

, data acquisition and interpretation, critical revisions, final

approval and accountability for entire product;

Sanjay R. Parikh

conception and design, data acquisition, analysis, and interpreta-

tion, drafting the work, critical revisions, final approval and

accountability for entire product.

Dahl et al