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Triological Society: Combined Sections Meeting
Studies of anesthesia’s effect on upper airway are limited
CORONADO, CALIF. – Studies of the most appropriate anesthetic agents for drug-induced sleep endoscopy are limited, but according to the best available evidence, local anesthetics appear to affect airway reflexes while inhalation anesthetics and opioids exaggerate dynamic airway collapse, so they may not be ideal.
Those are key conclusions from a systematic review of literature on the effects of commonly used anesthetic agents and opioids on the upper airway presented at the Triological Society’s Combined Sections meeting. Drug-induced sleep endoscopy (DISE) “is a great tool to assess upper airway dynamics in order to determine optimal surgical therapy for obstructive sleep apnea,” said Dr. Zarmina Ehsan, a pediatric pulmonary medicine fellow at Cincinnati Children’s Hospital Medical Center. “There’s a lack of understanding regarding how upper airway dynamics are altered by anesthetic agents, compared with normal sleep. This is important because this hinders the development of universal guidelines and protocols for the use of DISE.”
Using PubMed, EMBASE, and other sources, she and her associates conducted a qualitative systematic review of studies related to common anesthetic agents and opioids in the medical literature through September 2014. To be eligible for inclusion, a study must have evaluated the agent’s effect on the upper airway, must have contained an abstract, and must have been published in English. Studies with fewer than seven subjects, no original data, review articles, and those involving animals were excluded. The researchers reviewed 180 abstracts and included 56 full text articles in the final analysis, for a total study population of 8,540 patients. At the meeting Dr. Ehsan summarized the following findings by agent:
• Lidocaine. This agent is safe for topical use, has a rapid onset of action, and an intermediate duration of efficacy. Lidocaine acts on muscles “which are potent dilators and tensors of the pharyngeal and laryngeal structures,” she said. Of 10 studies included in the analysis, 7 assessed the impact of lidocaine on upper airway obstruction. Of these, three showed increased airway obstruction while four showed no significant effects. There were two studies on sleep parameters with conflicting results: One showed an increase in mean apnea duration with lidocaine use while the other did not. From this the researchers concluded that lidocaine does affect upper airway dynamics.
• Propofol. This lipophilic intravenous agent has a quick onset of action and acts by global central nervous system depression. Of 12 studies included in the analysis, 4 examined dose-response characteristics and showed a dose-dependent decrease in airway cross-sectional area with increased dosing of propofol. “So increasing your dose makes airway obstruction more likely,” Dr. Ehsan said. “The levels of obstruction were greatest at the base of tongue, and the closure was primarily in the anterior-posterior direction.” Three studies found that propofol caused a decrease in genioglossus electromyogram activity, while the remaining five studies assessed heterogeneous outcomes. “Overall, the studies showed that propofol had a dose-dependent effect on the upper airway with increasing doses making airway obstruction more likely,” she said.
• Dexmedetomidine (DEX). This agent is an alpha-2 adrenergic agonist with sedative, anxiolytic, and analgesic effects. It’s typically given as a 10-minute loading dose followed by a continuous infusion, and is recommended when you want to preserve spontaneous respiration. Of the four DEX-related studies that were included in the analysis, all demonstrated a minimal effect on upper airway cross-sectional area. “One of the studies looked at sleep parameters and concluded that DEX does approximate non-REM sleep without causing respiratory depression,” Dr. Ehsan added. “So overall, DEX was less likely to result in upper airway obstruction, compared with propofol.”
• Midazolam. This agent is commonly used for procedural sedation, with an onset of action within 1-3 minutes and a duration of 15-60 minutes. Of the six studies involving midazolam, two evaluated sleep staging. One reported lack of REM sleep and increased duration of stage N3 sleep, while the other study found that all sleep stages were observed at a lower dosage. The remaining four studies had heterogeneous outcomes. This led the researchers to conclude that midazolam “may lead to upper airway obstruction,” Dr. Ehsan said. “It’s unclear if this is dose dependent.”
• Pentobarbital. Of the two studies involving this short-acting barbiturate, one showed no effect on pharyngeal critical pressure or respiratory muscle function, while the other found that pentobarbital can increase the upper airway cross-sectional area. “So the effect of pentobarbital is unclear,” she said.
• Ketamine. This N-methyl-D-aspartate receptor has a rapid onset and a minimal effect on the central respiratory drive. Of the three studies involving ketamine, one found a 10% incidence of transient laryngospasm, one found that the incidence of transient laryngospasm was higher when it was delivered intramuscularly vs. intravenously, and one found that ketamine was safe in infants undergoing upper airway endoscopy. The researchers concluded that overall, ketamine “could be useful during DISE.”
• Inhalation anesthetics. There were 11 studies of these agents. Of these, six found that inhalation anesthetics caused upper airway collapse while five had heterogeneous outcomes. “Overall, a majority of studies found that inhalation anesthetics exaggerate dynamic airway collapse,” Dr. Ehsan said.
• Opioids. Of the nine studies involving these agents, six found that opioids caused upper airway obstruction; two found that they caused depression of upper airway reflexes, and one found that they caused a decrease in respiratory compliance. “Overall, opioids increase upper airway obstruction,” she said.
Dr. Ehsan acknowledged certain limitations of the analysis, including the fact that there was little information on sleep state approximated by many of these agents, “which makes it difficult to determine the ideal anesthetic protocol. There was substantial heterogeneity in outcomes, and few prospective studies comparing the ability of anesthetics to approximate natural sleep.” She recommended that future efforts focus on comparative effectiveness studies between the agents, as well as evaluate the impact of combining anesthetic agents. “This is important, because most DISE protocols use a combination of agents,” she said.
The meeting was jointly sponsored by the Triological Society and the American College of Surgeons
Dr. Ehsan reported having no relevant financial conflicts.
On Twitter @dougbrunk
CORONADO, CALIF. – Studies of the most appropriate anesthetic agents for drug-induced sleep endoscopy are limited, but according to the best available evidence, local anesthetics appear to affect airway reflexes while inhalation anesthetics and opioids exaggerate dynamic airway collapse, so they may not be ideal.
Those are key conclusions from a systematic review of literature on the effects of commonly used anesthetic agents and opioids on the upper airway presented at the Triological Society’s Combined Sections meeting. Drug-induced sleep endoscopy (DISE) “is a great tool to assess upper airway dynamics in order to determine optimal surgical therapy for obstructive sleep apnea,” said Dr. Zarmina Ehsan, a pediatric pulmonary medicine fellow at Cincinnati Children’s Hospital Medical Center. “There’s a lack of understanding regarding how upper airway dynamics are altered by anesthetic agents, compared with normal sleep. This is important because this hinders the development of universal guidelines and protocols for the use of DISE.”
Using PubMed, EMBASE, and other sources, she and her associates conducted a qualitative systematic review of studies related to common anesthetic agents and opioids in the medical literature through September 2014. To be eligible for inclusion, a study must have evaluated the agent’s effect on the upper airway, must have contained an abstract, and must have been published in English. Studies with fewer than seven subjects, no original data, review articles, and those involving animals were excluded. The researchers reviewed 180 abstracts and included 56 full text articles in the final analysis, for a total study population of 8,540 patients. At the meeting Dr. Ehsan summarized the following findings by agent:
• Lidocaine. This agent is safe for topical use, has a rapid onset of action, and an intermediate duration of efficacy. Lidocaine acts on muscles “which are potent dilators and tensors of the pharyngeal and laryngeal structures,” she said. Of 10 studies included in the analysis, 7 assessed the impact of lidocaine on upper airway obstruction. Of these, three showed increased airway obstruction while four showed no significant effects. There were two studies on sleep parameters with conflicting results: One showed an increase in mean apnea duration with lidocaine use while the other did not. From this the researchers concluded that lidocaine does affect upper airway dynamics.
• Propofol. This lipophilic intravenous agent has a quick onset of action and acts by global central nervous system depression. Of 12 studies included in the analysis, 4 examined dose-response characteristics and showed a dose-dependent decrease in airway cross-sectional area with increased dosing of propofol. “So increasing your dose makes airway obstruction more likely,” Dr. Ehsan said. “The levels of obstruction were greatest at the base of tongue, and the closure was primarily in the anterior-posterior direction.” Three studies found that propofol caused a decrease in genioglossus electromyogram activity, while the remaining five studies assessed heterogeneous outcomes. “Overall, the studies showed that propofol had a dose-dependent effect on the upper airway with increasing doses making airway obstruction more likely,” she said.
• Dexmedetomidine (DEX). This agent is an alpha-2 adrenergic agonist with sedative, anxiolytic, and analgesic effects. It’s typically given as a 10-minute loading dose followed by a continuous infusion, and is recommended when you want to preserve spontaneous respiration. Of the four DEX-related studies that were included in the analysis, all demonstrated a minimal effect on upper airway cross-sectional area. “One of the studies looked at sleep parameters and concluded that DEX does approximate non-REM sleep without causing respiratory depression,” Dr. Ehsan added. “So overall, DEX was less likely to result in upper airway obstruction, compared with propofol.”
• Midazolam. This agent is commonly used for procedural sedation, with an onset of action within 1-3 minutes and a duration of 15-60 minutes. Of the six studies involving midazolam, two evaluated sleep staging. One reported lack of REM sleep and increased duration of stage N3 sleep, while the other study found that all sleep stages were observed at a lower dosage. The remaining four studies had heterogeneous outcomes. This led the researchers to conclude that midazolam “may lead to upper airway obstruction,” Dr. Ehsan said. “It’s unclear if this is dose dependent.”
• Pentobarbital. Of the two studies involving this short-acting barbiturate, one showed no effect on pharyngeal critical pressure or respiratory muscle function, while the other found that pentobarbital can increase the upper airway cross-sectional area. “So the effect of pentobarbital is unclear,” she said.
• Ketamine. This N-methyl-D-aspartate receptor has a rapid onset and a minimal effect on the central respiratory drive. Of the three studies involving ketamine, one found a 10% incidence of transient laryngospasm, one found that the incidence of transient laryngospasm was higher when it was delivered intramuscularly vs. intravenously, and one found that ketamine was safe in infants undergoing upper airway endoscopy. The researchers concluded that overall, ketamine “could be useful during DISE.”
• Inhalation anesthetics. There were 11 studies of these agents. Of these, six found that inhalation anesthetics caused upper airway collapse while five had heterogeneous outcomes. “Overall, a majority of studies found that inhalation anesthetics exaggerate dynamic airway collapse,” Dr. Ehsan said.
• Opioids. Of the nine studies involving these agents, six found that opioids caused upper airway obstruction; two found that they caused depression of upper airway reflexes, and one found that they caused a decrease in respiratory compliance. “Overall, opioids increase upper airway obstruction,” she said.
Dr. Ehsan acknowledged certain limitations of the analysis, including the fact that there was little information on sleep state approximated by many of these agents, “which makes it difficult to determine the ideal anesthetic protocol. There was substantial heterogeneity in outcomes, and few prospective studies comparing the ability of anesthetics to approximate natural sleep.” She recommended that future efforts focus on comparative effectiveness studies between the agents, as well as evaluate the impact of combining anesthetic agents. “This is important, because most DISE protocols use a combination of agents,” she said.
The meeting was jointly sponsored by the Triological Society and the American College of Surgeons
Dr. Ehsan reported having no relevant financial conflicts.
On Twitter @dougbrunk
CORONADO, CALIF. – Studies of the most appropriate anesthetic agents for drug-induced sleep endoscopy are limited, but according to the best available evidence, local anesthetics appear to affect airway reflexes while inhalation anesthetics and opioids exaggerate dynamic airway collapse, so they may not be ideal.
Those are key conclusions from a systematic review of literature on the effects of commonly used anesthetic agents and opioids on the upper airway presented at the Triological Society’s Combined Sections meeting. Drug-induced sleep endoscopy (DISE) “is a great tool to assess upper airway dynamics in order to determine optimal surgical therapy for obstructive sleep apnea,” said Dr. Zarmina Ehsan, a pediatric pulmonary medicine fellow at Cincinnati Children’s Hospital Medical Center. “There’s a lack of understanding regarding how upper airway dynamics are altered by anesthetic agents, compared with normal sleep. This is important because this hinders the development of universal guidelines and protocols for the use of DISE.”
Using PubMed, EMBASE, and other sources, she and her associates conducted a qualitative systematic review of studies related to common anesthetic agents and opioids in the medical literature through September 2014. To be eligible for inclusion, a study must have evaluated the agent’s effect on the upper airway, must have contained an abstract, and must have been published in English. Studies with fewer than seven subjects, no original data, review articles, and those involving animals were excluded. The researchers reviewed 180 abstracts and included 56 full text articles in the final analysis, for a total study population of 8,540 patients. At the meeting Dr. Ehsan summarized the following findings by agent:
• Lidocaine. This agent is safe for topical use, has a rapid onset of action, and an intermediate duration of efficacy. Lidocaine acts on muscles “which are potent dilators and tensors of the pharyngeal and laryngeal structures,” she said. Of 10 studies included in the analysis, 7 assessed the impact of lidocaine on upper airway obstruction. Of these, three showed increased airway obstruction while four showed no significant effects. There were two studies on sleep parameters with conflicting results: One showed an increase in mean apnea duration with lidocaine use while the other did not. From this the researchers concluded that lidocaine does affect upper airway dynamics.
• Propofol. This lipophilic intravenous agent has a quick onset of action and acts by global central nervous system depression. Of 12 studies included in the analysis, 4 examined dose-response characteristics and showed a dose-dependent decrease in airway cross-sectional area with increased dosing of propofol. “So increasing your dose makes airway obstruction more likely,” Dr. Ehsan said. “The levels of obstruction were greatest at the base of tongue, and the closure was primarily in the anterior-posterior direction.” Three studies found that propofol caused a decrease in genioglossus electromyogram activity, while the remaining five studies assessed heterogeneous outcomes. “Overall, the studies showed that propofol had a dose-dependent effect on the upper airway with increasing doses making airway obstruction more likely,” she said.
• Dexmedetomidine (DEX). This agent is an alpha-2 adrenergic agonist with sedative, anxiolytic, and analgesic effects. It’s typically given as a 10-minute loading dose followed by a continuous infusion, and is recommended when you want to preserve spontaneous respiration. Of the four DEX-related studies that were included in the analysis, all demonstrated a minimal effect on upper airway cross-sectional area. “One of the studies looked at sleep parameters and concluded that DEX does approximate non-REM sleep without causing respiratory depression,” Dr. Ehsan added. “So overall, DEX was less likely to result in upper airway obstruction, compared with propofol.”
• Midazolam. This agent is commonly used for procedural sedation, with an onset of action within 1-3 minutes and a duration of 15-60 minutes. Of the six studies involving midazolam, two evaluated sleep staging. One reported lack of REM sleep and increased duration of stage N3 sleep, while the other study found that all sleep stages were observed at a lower dosage. The remaining four studies had heterogeneous outcomes. This led the researchers to conclude that midazolam “may lead to upper airway obstruction,” Dr. Ehsan said. “It’s unclear if this is dose dependent.”
• Pentobarbital. Of the two studies involving this short-acting barbiturate, one showed no effect on pharyngeal critical pressure or respiratory muscle function, while the other found that pentobarbital can increase the upper airway cross-sectional area. “So the effect of pentobarbital is unclear,” she said.
• Ketamine. This N-methyl-D-aspartate receptor has a rapid onset and a minimal effect on the central respiratory drive. Of the three studies involving ketamine, one found a 10% incidence of transient laryngospasm, one found that the incidence of transient laryngospasm was higher when it was delivered intramuscularly vs. intravenously, and one found that ketamine was safe in infants undergoing upper airway endoscopy. The researchers concluded that overall, ketamine “could be useful during DISE.”
• Inhalation anesthetics. There were 11 studies of these agents. Of these, six found that inhalation anesthetics caused upper airway collapse while five had heterogeneous outcomes. “Overall, a majority of studies found that inhalation anesthetics exaggerate dynamic airway collapse,” Dr. Ehsan said.
• Opioids. Of the nine studies involving these agents, six found that opioids caused upper airway obstruction; two found that they caused depression of upper airway reflexes, and one found that they caused a decrease in respiratory compliance. “Overall, opioids increase upper airway obstruction,” she said.
Dr. Ehsan acknowledged certain limitations of the analysis, including the fact that there was little information on sleep state approximated by many of these agents, “which makes it difficult to determine the ideal anesthetic protocol. There was substantial heterogeneity in outcomes, and few prospective studies comparing the ability of anesthetics to approximate natural sleep.” She recommended that future efforts focus on comparative effectiveness studies between the agents, as well as evaluate the impact of combining anesthetic agents. “This is important, because most DISE protocols use a combination of agents,” she said.
The meeting was jointly sponsored by the Triological Society and the American College of Surgeons
Dr. Ehsan reported having no relevant financial conflicts.
On Twitter @dougbrunk
AT THE COMBINED SECTIONS WINTER MEETING
Key clinical point: Choice of an appropriate anesthetic protocol for drug-induced sleep endoscopy must be based on a limited number of comparative studies.
Major finding: Local anesthetics appear to affect upper airway reflexes while inhalation anesthetics and opioids exaggerate dynamic airway collapse.
Data source: A qualitative systematic review of 56 studies related to common anesthetic agents and opioids published in the medical literature through September 2014.
Disclosures: Dr. Ehsan reported having no financial disclosures.
Upper airway stimulation an option in some patients
CORONADO, CALIF. – Some patients with treatment-refractory obstructive sleep apnea may be candidates for upper airway stimulation, though those with complete concentric palatal collapse may not respond, according to Dr. Marion Boyd Gillespie.
“There’s been sound research showing that patients with obstructive sleep apnea have reduced neural tone, so it may not be due to fat in the tongue; some of it may have to do with reduced neural tone,” Dr. Gillespie, who directs the snoring clinics at the Medical University of South Carolina, Charleston, said at the Triological Society’s Combined Sections Meeting. “During these apneic events, there’s a reduction in the neural tone of the genioglossus muscle, which is the main dilator of the upper airway. With upper airway stimulation, we’re trying to account for that loss of neural tone by providing more neural impulse to these muscle groups that perform the dilator functions.”
In 2014 the Food and Drug Administration cleared an upper airway stimulation system manufactured by Inspire Medical Systems, a pacemakerlike device that’s implanted in the subclavicular space. The system features a stimulator lead that attaches to the right hypoglossal nerve and a sensing lead that goes between the external and internal intercostal muscles to detect breathing. “That allows the device to know when in the phase of respiration to fire,” said Dr. Gillespie, professor of otolaryngology–head and neck surgery at the university. “The sensing lead detects the respiratory wave, and the stimulatory lead starts stimulation at the end of expiration, because that’s when the airway is in its most collapsible state. It continues about two-thirds of the way through the inspiratory cycle to keep the airway open.”
Titration of the device is very similar to continuous positive airway pressure, he continued. Once implanted, the patient “will go back to the sleep lab where a tech who’s trained in the device will ramp up stimulation until observed apneas and hypopneas are adequately reduced. You would think that isolated stimulation of the hypoglossal nerve would only open up the airway at the level of the tongue. However, our initial investigation showed that there is dilation at the velopharynx as well,” Dr. Gillespie said. By moving the tongue out of the posterior airway, “you’re moving the dorsum of the tongue away from the velopharynx. You’re also getting active traction on the palatoglossal fold,” he added.
Results of the initial trial of the system in 126 patients with a mean body mass index of 28.4 kg/m2 were published last year (N. Engl. J. Med. 2014;370:139-49). At 12 months of follow-up, patients experienced a 68% overall reduction in their apnea-hypopnea index (AHI) score, from a preoperative mean of 29 to a postoperative mean of 9. In addition, patients had a 70% overall reduction in their oxygen desaturation index (ODI). The researchers also observed normalization of patient-based outcomes, with improvement in the Functional Outcomes of Sleep Questionnaire score and reduction of the Epworth Sleepiness Scale score to a level of 10 on average. “We also saw a reduction of snoring,” said Dr. Gillespie, who was a member of the research team. “Snoring went from 72% of patients having severe, annoying snoring to the point where a bed partner leaves the room, to 15% postoperatively.” Even so, 96% of patients who had a previous history of uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP) still had tongue-based collapse after 12 months of follow-up. “But we found that their response to this therapy was just as good as people who had never had a UPPP or LAUP,” Dr. Gillespie said at the meeting, jointly sponsored by the Triological Society and the American College of Surgeons. “So it seems like patients who have failed UPPP are still good candidates for upper airway stimulation therapy.”
Dr. Gillespie noted that selection criteria for the trial were limited to patients with a BMI of less than 32 kg/m2 and to those who did not have complete circumferential collapse at the level of the soft palate on preoperative drug-induced endoscopy. These criteria were based on an earlier pilot study that showed that patients with complete circumferential collapse at the level of the soft palate did not respond to upper airway stimulation (J. Clin. Sleep Med. 2013;9:433-8).
Dr. Gillespie disclosed that he has received research support from Inspire Medical Systems, Olympus, and Surgical Specialties. He is also a consultant for those companies as well as for Medtronic.
On Twitter @dougbrunk
Dr. David Schulman, FCCP, comments: The data presented by Dr. Gillespie add to the growing body of literature showing the benefits of stimulation of the upper airway muscles during sleep in a selected subgroup of obstructive sleep apnea (OSA) patients, demonstrating improvements in both physiologic and functional parameters. Given the well-described issues with continuous positive airway pressure (CPAP) adherence and the lesser efficacy of currently available CPAP alternatives, patients with obstructive sleep apnea and their providers have long awaited access to hypoglossal nerve stimulators to add to the armamentarium of options for management of the disorder.
While early data continue to show promise for this treatment, a number of physiologic and anatomic characteristics serve as relative contraindications, limiting the generalizability of study results to some patient populations (such as those with body mass index greater than 32 kg/m2 or those with concentric collapse of the soft palate). While upper airway stimulation is not likely to be the first-line OSA treatment for the majority of patients, it is an important step forward for those unwilling or unable to use CPAP.
Dr. David Schulman, FCCP, comments: The data presented by Dr. Gillespie add to the growing body of literature showing the benefits of stimulation of the upper airway muscles during sleep in a selected subgroup of obstructive sleep apnea (OSA) patients, demonstrating improvements in both physiologic and functional parameters. Given the well-described issues with continuous positive airway pressure (CPAP) adherence and the lesser efficacy of currently available CPAP alternatives, patients with obstructive sleep apnea and their providers have long awaited access to hypoglossal nerve stimulators to add to the armamentarium of options for management of the disorder.
While early data continue to show promise for this treatment, a number of physiologic and anatomic characteristics serve as relative contraindications, limiting the generalizability of study results to some patient populations (such as those with body mass index greater than 32 kg/m2 or those with concentric collapse of the soft palate). While upper airway stimulation is not likely to be the first-line OSA treatment for the majority of patients, it is an important step forward for those unwilling or unable to use CPAP.
Dr. David Schulman, FCCP, comments: The data presented by Dr. Gillespie add to the growing body of literature showing the benefits of stimulation of the upper airway muscles during sleep in a selected subgroup of obstructive sleep apnea (OSA) patients, demonstrating improvements in both physiologic and functional parameters. Given the well-described issues with continuous positive airway pressure (CPAP) adherence and the lesser efficacy of currently available CPAP alternatives, patients with obstructive sleep apnea and their providers have long awaited access to hypoglossal nerve stimulators to add to the armamentarium of options for management of the disorder.
While early data continue to show promise for this treatment, a number of physiologic and anatomic characteristics serve as relative contraindications, limiting the generalizability of study results to some patient populations (such as those with body mass index greater than 32 kg/m2 or those with concentric collapse of the soft palate). While upper airway stimulation is not likely to be the first-line OSA treatment for the majority of patients, it is an important step forward for those unwilling or unable to use CPAP.
CORONADO, CALIF. – Some patients with treatment-refractory obstructive sleep apnea may be candidates for upper airway stimulation, though those with complete concentric palatal collapse may not respond, according to Dr. Marion Boyd Gillespie.
“There’s been sound research showing that patients with obstructive sleep apnea have reduced neural tone, so it may not be due to fat in the tongue; some of it may have to do with reduced neural tone,” Dr. Gillespie, who directs the snoring clinics at the Medical University of South Carolina, Charleston, said at the Triological Society’s Combined Sections Meeting. “During these apneic events, there’s a reduction in the neural tone of the genioglossus muscle, which is the main dilator of the upper airway. With upper airway stimulation, we’re trying to account for that loss of neural tone by providing more neural impulse to these muscle groups that perform the dilator functions.”
In 2014 the Food and Drug Administration cleared an upper airway stimulation system manufactured by Inspire Medical Systems, a pacemakerlike device that’s implanted in the subclavicular space. The system features a stimulator lead that attaches to the right hypoglossal nerve and a sensing lead that goes between the external and internal intercostal muscles to detect breathing. “That allows the device to know when in the phase of respiration to fire,” said Dr. Gillespie, professor of otolaryngology–head and neck surgery at the university. “The sensing lead detects the respiratory wave, and the stimulatory lead starts stimulation at the end of expiration, because that’s when the airway is in its most collapsible state. It continues about two-thirds of the way through the inspiratory cycle to keep the airway open.”
Titration of the device is very similar to continuous positive airway pressure, he continued. Once implanted, the patient “will go back to the sleep lab where a tech who’s trained in the device will ramp up stimulation until observed apneas and hypopneas are adequately reduced. You would think that isolated stimulation of the hypoglossal nerve would only open up the airway at the level of the tongue. However, our initial investigation showed that there is dilation at the velopharynx as well,” Dr. Gillespie said. By moving the tongue out of the posterior airway, “you’re moving the dorsum of the tongue away from the velopharynx. You’re also getting active traction on the palatoglossal fold,” he added.
Results of the initial trial of the system in 126 patients with a mean body mass index of 28.4 kg/m2 were published last year (N. Engl. J. Med. 2014;370:139-49). At 12 months of follow-up, patients experienced a 68% overall reduction in their apnea-hypopnea index (AHI) score, from a preoperative mean of 29 to a postoperative mean of 9. In addition, patients had a 70% overall reduction in their oxygen desaturation index (ODI). The researchers also observed normalization of patient-based outcomes, with improvement in the Functional Outcomes of Sleep Questionnaire score and reduction of the Epworth Sleepiness Scale score to a level of 10 on average. “We also saw a reduction of snoring,” said Dr. Gillespie, who was a member of the research team. “Snoring went from 72% of patients having severe, annoying snoring to the point where a bed partner leaves the room, to 15% postoperatively.” Even so, 96% of patients who had a previous history of uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP) still had tongue-based collapse after 12 months of follow-up. “But we found that their response to this therapy was just as good as people who had never had a UPPP or LAUP,” Dr. Gillespie said at the meeting, jointly sponsored by the Triological Society and the American College of Surgeons. “So it seems like patients who have failed UPPP are still good candidates for upper airway stimulation therapy.”
Dr. Gillespie noted that selection criteria for the trial were limited to patients with a BMI of less than 32 kg/m2 and to those who did not have complete circumferential collapse at the level of the soft palate on preoperative drug-induced endoscopy. These criteria were based on an earlier pilot study that showed that patients with complete circumferential collapse at the level of the soft palate did not respond to upper airway stimulation (J. Clin. Sleep Med. 2013;9:433-8).
Dr. Gillespie disclosed that he has received research support from Inspire Medical Systems, Olympus, and Surgical Specialties. He is also a consultant for those companies as well as for Medtronic.
On Twitter @dougbrunk
CORONADO, CALIF. – Some patients with treatment-refractory obstructive sleep apnea may be candidates for upper airway stimulation, though those with complete concentric palatal collapse may not respond, according to Dr. Marion Boyd Gillespie.
“There’s been sound research showing that patients with obstructive sleep apnea have reduced neural tone, so it may not be due to fat in the tongue; some of it may have to do with reduced neural tone,” Dr. Gillespie, who directs the snoring clinics at the Medical University of South Carolina, Charleston, said at the Triological Society’s Combined Sections Meeting. “During these apneic events, there’s a reduction in the neural tone of the genioglossus muscle, which is the main dilator of the upper airway. With upper airway stimulation, we’re trying to account for that loss of neural tone by providing more neural impulse to these muscle groups that perform the dilator functions.”
In 2014 the Food and Drug Administration cleared an upper airway stimulation system manufactured by Inspire Medical Systems, a pacemakerlike device that’s implanted in the subclavicular space. The system features a stimulator lead that attaches to the right hypoglossal nerve and a sensing lead that goes between the external and internal intercostal muscles to detect breathing. “That allows the device to know when in the phase of respiration to fire,” said Dr. Gillespie, professor of otolaryngology–head and neck surgery at the university. “The sensing lead detects the respiratory wave, and the stimulatory lead starts stimulation at the end of expiration, because that’s when the airway is in its most collapsible state. It continues about two-thirds of the way through the inspiratory cycle to keep the airway open.”
Titration of the device is very similar to continuous positive airway pressure, he continued. Once implanted, the patient “will go back to the sleep lab where a tech who’s trained in the device will ramp up stimulation until observed apneas and hypopneas are adequately reduced. You would think that isolated stimulation of the hypoglossal nerve would only open up the airway at the level of the tongue. However, our initial investigation showed that there is dilation at the velopharynx as well,” Dr. Gillespie said. By moving the tongue out of the posterior airway, “you’re moving the dorsum of the tongue away from the velopharynx. You’re also getting active traction on the palatoglossal fold,” he added.
Results of the initial trial of the system in 126 patients with a mean body mass index of 28.4 kg/m2 were published last year (N. Engl. J. Med. 2014;370:139-49). At 12 months of follow-up, patients experienced a 68% overall reduction in their apnea-hypopnea index (AHI) score, from a preoperative mean of 29 to a postoperative mean of 9. In addition, patients had a 70% overall reduction in their oxygen desaturation index (ODI). The researchers also observed normalization of patient-based outcomes, with improvement in the Functional Outcomes of Sleep Questionnaire score and reduction of the Epworth Sleepiness Scale score to a level of 10 on average. “We also saw a reduction of snoring,” said Dr. Gillespie, who was a member of the research team. “Snoring went from 72% of patients having severe, annoying snoring to the point where a bed partner leaves the room, to 15% postoperatively.” Even so, 96% of patients who had a previous history of uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP) still had tongue-based collapse after 12 months of follow-up. “But we found that their response to this therapy was just as good as people who had never had a UPPP or LAUP,” Dr. Gillespie said at the meeting, jointly sponsored by the Triological Society and the American College of Surgeons. “So it seems like patients who have failed UPPP are still good candidates for upper airway stimulation therapy.”
Dr. Gillespie noted that selection criteria for the trial were limited to patients with a BMI of less than 32 kg/m2 and to those who did not have complete circumferential collapse at the level of the soft palate on preoperative drug-induced endoscopy. These criteria were based on an earlier pilot study that showed that patients with complete circumferential collapse at the level of the soft palate did not respond to upper airway stimulation (J. Clin. Sleep Med. 2013;9:433-8).
Dr. Gillespie disclosed that he has received research support from Inspire Medical Systems, Olympus, and Surgical Specialties. He is also a consultant for those companies as well as for Medtronic.
On Twitter @dougbrunk
EXPERT ANALYSIS AT THE COMBINED SECTIONS WINTER MEETING
Half of patients elect head and neck surgery before meeting surgeon
CORONADO, CALIF. – About half of patients decide to undergo head and neck surgery even before meeting their surgeon, and concerns about cost of the procedure weigh heavily on their minds, results from a pilot study demonstrated.
In an effort to determine which factors influence patient decision making about elective surgery in otolaryngology, lead study author Dr. Maya G. Sardesai and her associates surveyed 48 consecutive adults who underwent head and neck surgery performed by one of six surgeons at Harborview Medical Center, Seattle, between March and September 2014.
The effort “rose from an observation in her clinical practice that, despite similar degrees of disease burden and similar counseling, patients sometimes show widely divergent degrees of enthusiasm for elective procedures,” Dr. Sardesai of the department of otolaryngology-head and neck surgery at the medical center said at the Triological Society’s Combined Sections Meeting. “This prompted the question: What information influences decision making in this setting?”
Current guidelines emphasize discussing the risks and benefits of surgery in the informed consent process, she continued, “but some studies of decision making in this setting have suggested that other factors might also influence decisions, such as family advice, social perception, and cost. There’s limited data in the otolaryngology literature about this, even though there’s a preponderance of quality-of-life surgery with low but potentially significant risks.”
With input from patients and surgeons, the researchers created a 35-question survey and administered it in the surgeon’s office, with questions that centered around the timing of the procedure, advice of others, sources of information, and their approach to decision making. More than half of patients (56%) were undergoing tonsillectomy, followed by a nasal procedure (48%), palate procedure (44%), midline glossectomy (35%), hyoid suspension (4%), genioglossus advancement (4%), laryngeal procedure (2%), and other (6%). (The numbers exceeded 100% because some patients underwent more than one procedure.)
Nearly half of subjects (49%) reported making their decision to pursue surgery even before their surgical consultation or meeting their surgeon. The researchers then divided the cohort into patients who had decided to pursue surgery before or after meeting their surgeon. Among those who made the decision before meeting the surgeon, 64% rated information they received from their primary care provider as very important, while 100% rated information they received from the surgeon as very important. These percentages were similar among patients who made the decision after meeting the surgeon (43% and 96%, respectively).
Patients who made their decision to pursue surgery after meeting their surgeon also were more likely to weigh information received from the Internet as more important, compared with patients who made their decision before meeting their surgeon (38% vs. 20%). “This difference was not statistically significant,” Dr. Sardesai said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “All patients felt that Internet information seemed important.”
Patients in both groups weighed concerns about symptoms as very important (in the range of 83%), which rated “highly if not more than concerns about the risks with or without surgery (70%).” Finally, she and her associates found that 49% of patients in both groups considered the cost of medical bills as very important, “which is an interesting finding, because our current consent process doesn’t include much discussion about monetary costs of treatment.”
Overall, the findings suggest that otolaryngologists and head and neck surgeons should reach out to referring providers “to ensure that they are well informed about the indications, benefits, limitation, and risks of head and neck surgeries,” Dr. Sardesai concluded. “This may also enhance opportunities for shared and collaborative decision making. If decisions are being made prior to consultation, it begs the question about whether there are potential surgery candidates who defer surgical consultation altogether, and thus may be missing opportunities for better care. As otolaryngologists, we should also take an active role in providing and curating information from the Internet, since this is currently likely an increasingly important source of information for patients.”
She acknowledged certain limitations of the study, including its small sample size and the potential for recall bias. In addition, the survey “was administered in a surgeon’s office, which might bias patients to overemphasize the role of the surgeon,” she said. “Our future plans are to administer an enhanced version of the survey to broader [practice settings] to better understand these differences.”
Dr. Sardesai reported having no relevant financial conflicts.
On Twitter @dougbrunk
CORONADO, CALIF. – About half of patients decide to undergo head and neck surgery even before meeting their surgeon, and concerns about cost of the procedure weigh heavily on their minds, results from a pilot study demonstrated.
In an effort to determine which factors influence patient decision making about elective surgery in otolaryngology, lead study author Dr. Maya G. Sardesai and her associates surveyed 48 consecutive adults who underwent head and neck surgery performed by one of six surgeons at Harborview Medical Center, Seattle, between March and September 2014.
The effort “rose from an observation in her clinical practice that, despite similar degrees of disease burden and similar counseling, patients sometimes show widely divergent degrees of enthusiasm for elective procedures,” Dr. Sardesai of the department of otolaryngology-head and neck surgery at the medical center said at the Triological Society’s Combined Sections Meeting. “This prompted the question: What information influences decision making in this setting?”
Current guidelines emphasize discussing the risks and benefits of surgery in the informed consent process, she continued, “but some studies of decision making in this setting have suggested that other factors might also influence decisions, such as family advice, social perception, and cost. There’s limited data in the otolaryngology literature about this, even though there’s a preponderance of quality-of-life surgery with low but potentially significant risks.”
With input from patients and surgeons, the researchers created a 35-question survey and administered it in the surgeon’s office, with questions that centered around the timing of the procedure, advice of others, sources of information, and their approach to decision making. More than half of patients (56%) were undergoing tonsillectomy, followed by a nasal procedure (48%), palate procedure (44%), midline glossectomy (35%), hyoid suspension (4%), genioglossus advancement (4%), laryngeal procedure (2%), and other (6%). (The numbers exceeded 100% because some patients underwent more than one procedure.)
Nearly half of subjects (49%) reported making their decision to pursue surgery even before their surgical consultation or meeting their surgeon. The researchers then divided the cohort into patients who had decided to pursue surgery before or after meeting their surgeon. Among those who made the decision before meeting the surgeon, 64% rated information they received from their primary care provider as very important, while 100% rated information they received from the surgeon as very important. These percentages were similar among patients who made the decision after meeting the surgeon (43% and 96%, respectively).
Patients who made their decision to pursue surgery after meeting their surgeon also were more likely to weigh information received from the Internet as more important, compared with patients who made their decision before meeting their surgeon (38% vs. 20%). “This difference was not statistically significant,” Dr. Sardesai said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “All patients felt that Internet information seemed important.”
Patients in both groups weighed concerns about symptoms as very important (in the range of 83%), which rated “highly if not more than concerns about the risks with or without surgery (70%).” Finally, she and her associates found that 49% of patients in both groups considered the cost of medical bills as very important, “which is an interesting finding, because our current consent process doesn’t include much discussion about monetary costs of treatment.”
Overall, the findings suggest that otolaryngologists and head and neck surgeons should reach out to referring providers “to ensure that they are well informed about the indications, benefits, limitation, and risks of head and neck surgeries,” Dr. Sardesai concluded. “This may also enhance opportunities for shared and collaborative decision making. If decisions are being made prior to consultation, it begs the question about whether there are potential surgery candidates who defer surgical consultation altogether, and thus may be missing opportunities for better care. As otolaryngologists, we should also take an active role in providing and curating information from the Internet, since this is currently likely an increasingly important source of information for patients.”
She acknowledged certain limitations of the study, including its small sample size and the potential for recall bias. In addition, the survey “was administered in a surgeon’s office, which might bias patients to overemphasize the role of the surgeon,” she said. “Our future plans are to administer an enhanced version of the survey to broader [practice settings] to better understand these differences.”
Dr. Sardesai reported having no relevant financial conflicts.
On Twitter @dougbrunk
CORONADO, CALIF. – About half of patients decide to undergo head and neck surgery even before meeting their surgeon, and concerns about cost of the procedure weigh heavily on their minds, results from a pilot study demonstrated.
In an effort to determine which factors influence patient decision making about elective surgery in otolaryngology, lead study author Dr. Maya G. Sardesai and her associates surveyed 48 consecutive adults who underwent head and neck surgery performed by one of six surgeons at Harborview Medical Center, Seattle, between March and September 2014.
The effort “rose from an observation in her clinical practice that, despite similar degrees of disease burden and similar counseling, patients sometimes show widely divergent degrees of enthusiasm for elective procedures,” Dr. Sardesai of the department of otolaryngology-head and neck surgery at the medical center said at the Triological Society’s Combined Sections Meeting. “This prompted the question: What information influences decision making in this setting?”
Current guidelines emphasize discussing the risks and benefits of surgery in the informed consent process, she continued, “but some studies of decision making in this setting have suggested that other factors might also influence decisions, such as family advice, social perception, and cost. There’s limited data in the otolaryngology literature about this, even though there’s a preponderance of quality-of-life surgery with low but potentially significant risks.”
With input from patients and surgeons, the researchers created a 35-question survey and administered it in the surgeon’s office, with questions that centered around the timing of the procedure, advice of others, sources of information, and their approach to decision making. More than half of patients (56%) were undergoing tonsillectomy, followed by a nasal procedure (48%), palate procedure (44%), midline glossectomy (35%), hyoid suspension (4%), genioglossus advancement (4%), laryngeal procedure (2%), and other (6%). (The numbers exceeded 100% because some patients underwent more than one procedure.)
Nearly half of subjects (49%) reported making their decision to pursue surgery even before their surgical consultation or meeting their surgeon. The researchers then divided the cohort into patients who had decided to pursue surgery before or after meeting their surgeon. Among those who made the decision before meeting the surgeon, 64% rated information they received from their primary care provider as very important, while 100% rated information they received from the surgeon as very important. These percentages were similar among patients who made the decision after meeting the surgeon (43% and 96%, respectively).
Patients who made their decision to pursue surgery after meeting their surgeon also were more likely to weigh information received from the Internet as more important, compared with patients who made their decision before meeting their surgeon (38% vs. 20%). “This difference was not statistically significant,” Dr. Sardesai said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “All patients felt that Internet information seemed important.”
Patients in both groups weighed concerns about symptoms as very important (in the range of 83%), which rated “highly if not more than concerns about the risks with or without surgery (70%).” Finally, she and her associates found that 49% of patients in both groups considered the cost of medical bills as very important, “which is an interesting finding, because our current consent process doesn’t include much discussion about monetary costs of treatment.”
Overall, the findings suggest that otolaryngologists and head and neck surgeons should reach out to referring providers “to ensure that they are well informed about the indications, benefits, limitation, and risks of head and neck surgeries,” Dr. Sardesai concluded. “This may also enhance opportunities for shared and collaborative decision making. If decisions are being made prior to consultation, it begs the question about whether there are potential surgery candidates who defer surgical consultation altogether, and thus may be missing opportunities for better care. As otolaryngologists, we should also take an active role in providing and curating information from the Internet, since this is currently likely an increasingly important source of information for patients.”
She acknowledged certain limitations of the study, including its small sample size and the potential for recall bias. In addition, the survey “was administered in a surgeon’s office, which might bias patients to overemphasize the role of the surgeon,” she said. “Our future plans are to administer an enhanced version of the survey to broader [practice settings] to better understand these differences.”
Dr. Sardesai reported having no relevant financial conflicts.
On Twitter @dougbrunk
AT THE COMBINED SECTIONS WINTER MEETING
Key clinical point: Otolaryngologists and head and neck surgeons should ensure that primary and referring providers are well educated about elective head and neck procedures.
Major finding: Nearly half of patients opted for elective head and neck surgery even before meeting their surgeon.
Data source: A survey of 48 consecutive adults who underwent elective head and neck surgery between March and September 2014.
Disclosures: Dr. Sardesai reported having no financial disclosures.
NMBAs not linked to longer LOS after pediatric tracheostomy
CORONADO, CALIF. – The use of neuromuscular blockade agents in pediatric patients after tracheostomy was not an independent predictor of longer hospital length of stay, results from a 3-year, single-center study suggest. Factors which portended a longer length of stay including having a longer preoperative length of stay and being cared for in the neonatal intensive care unit.
“Across the country there are widespread initiatives to improve quality of care,” study coauthor Eric Bauer said at the Triological Society’s Combined Sections Meeting.
“Tracheostomy has been identified as a contributor to prolonged length of stay. Additionally, it’s a procedure associated with increased rates of pediatric otolaryngology infections and major adverse events including accidental decannulation. However, the factors which increase prolonged hospital stay have not been determined.”
Mr. Bauer, a fourth-year medical student at the Ohio State University, Columbus, noted that some published studies in the medical literature that focus on the use of neuromuscular blockade agents (NMBAs) following pediatric single-stage laryngeal or tracheal reconstruction suggest that these medications may prolong hospital stay and increase complication risk. “Therefore, the goal of our study was to determine if the use of NMBAs in pediatric patients following tracheostomy is associated with a prolonged length of stay,” he said at the meeting jointly sponsored by the Triological Society and the American College of Surgeons..
Mr. Bauer and his fellow researchers performed a retrospective chart review from 2010 to 2013 for all tracheostomies performed and cared for in the neonatal and pediatric intensive care units of Nationwide Children’s Hospital, Columbus. In all, 114 patients were included, 26 of whom received neuromuscular blockade agents in the postoperative period. Patients cared for in the cardiothoracic ICU were excluded from the analysis.
After collecting demographic, clinical, and 30-day outcome characteristics for all patients, the researchers observed no significant differences between those who received NMBAs and those who did not with respect to patient median age, gender, and baseline medical condition differences. “Patients who received NMBAs did have more cardiac illness (50% vs. 22% among those who did not receive NMBAs; P = .005), while patients who did not receive NMBAs had more neurologic disease (81% vs. 54%; P = .006),” Mr. Bauer said. “Overall, it was a medically complex patient group with a vast array of illnesses.”
Upper-airway obstruction was the most common indication for surgery, followed by cardiopulmonary and neurologic conditions. The researchers found that patients who did not receive NMBAs had more neurologic indications for tracheostomy, compared with their counterparts who did receive the agents (38% vs. 8%; P = .003), while patients who ultimately received NMBA had more cardiopulmonary indications for surgery (54% vs. 18%; P< .001).
In an analysis of preoperative factors, patients who ultimately received NMBA, compared with those who did not, had longer preoperative length of stay (LOS) (28-93 days vs. 59-224 days; P = .002), more respiratory failure 3 days prior to surgery (96% vs. 74%; P = .014), and prolonged intubation periods prior to surgery (0-24 days vs. 6-45 days; P = .009). However, location of care (NICU vs. PICU) was similar throughout. In addition, the physiologic status on the day of surgery as indicated by the Pediatric Risk of Mortality score was similar in both groups.
Mr. Bauer went on to report that preoperative interventions including 30-day use of glucocorticoids, inotropes, and aminoglycosides were similar between the two groups, as was the use of blood transfusions 48 hours prior to surgery. As for postoperative sedation, opioid use and pediatric daily dosing was similar between groups. However, the rate of dexmedetomidine use was twice as high in patients who ultimately received NMBAs, compared with those who did not (46% vs. 26%; P = .026).
In terms of outcomes, the rate of pressure ulcers, pneumonia, urinary tract infections, and other complications did not differ between the two groups, while the rate of mortality at the time of data collection was also similar (12% among those who received NMBAs and 15% among those who did not). This “mirrors the national average of 13%-20%,” Mr. Bauer said. “In addition, there were no mortalities related to the procedure itself.”
On univariate analysis, postoperative LOS was a median of 10 days longer in patients who received NMBAs, compared with those who did not (23 vs. 33 days, respectively; P = .043). After multivariate analysis, however, that association was no longer significant (P = .91). Multivariable analysis also found that patients with traumatic indications for tracheostomy placement had a 44% shorter LOS (P = .002), while those with upper-airway obstruction indications for tracheostomy placement had a 27% shorter LOS (P = .02). A similar association was observed in patients who tolerated oral nutrition prior to surgery, as compared with enteral nutrition (a 48% reduction in LOS; P< .001).
Factors which portended a longer postoperative LOS were preoperative lengths of stay that lasted 10 days or more (P less than .001) and being cared for in the neonatal vs. the pediatric ICU (P = .002).
“The use of paralytic agents in this complex cohort was not an independent predictor of longer LOS,” Mr. Bauer concluded. “Instead, factors such as preoperative LOS along with [certain] indications ultimately affected the LOS. Finally, the ideal sedative protocol following tracheostomy has not been determined and requires additional investigation.”
Mr. Bauer reported that neither he nor his associates had relevant financial conflicts to disclose.
On Twitter @dougbrunk
CORONADO, CALIF. – The use of neuromuscular blockade agents in pediatric patients after tracheostomy was not an independent predictor of longer hospital length of stay, results from a 3-year, single-center study suggest. Factors which portended a longer length of stay including having a longer preoperative length of stay and being cared for in the neonatal intensive care unit.
“Across the country there are widespread initiatives to improve quality of care,” study coauthor Eric Bauer said at the Triological Society’s Combined Sections Meeting.
“Tracheostomy has been identified as a contributor to prolonged length of stay. Additionally, it’s a procedure associated with increased rates of pediatric otolaryngology infections and major adverse events including accidental decannulation. However, the factors which increase prolonged hospital stay have not been determined.”
Mr. Bauer, a fourth-year medical student at the Ohio State University, Columbus, noted that some published studies in the medical literature that focus on the use of neuromuscular blockade agents (NMBAs) following pediatric single-stage laryngeal or tracheal reconstruction suggest that these medications may prolong hospital stay and increase complication risk. “Therefore, the goal of our study was to determine if the use of NMBAs in pediatric patients following tracheostomy is associated with a prolonged length of stay,” he said at the meeting jointly sponsored by the Triological Society and the American College of Surgeons..
Mr. Bauer and his fellow researchers performed a retrospective chart review from 2010 to 2013 for all tracheostomies performed and cared for in the neonatal and pediatric intensive care units of Nationwide Children’s Hospital, Columbus. In all, 114 patients were included, 26 of whom received neuromuscular blockade agents in the postoperative period. Patients cared for in the cardiothoracic ICU were excluded from the analysis.
After collecting demographic, clinical, and 30-day outcome characteristics for all patients, the researchers observed no significant differences between those who received NMBAs and those who did not with respect to patient median age, gender, and baseline medical condition differences. “Patients who received NMBAs did have more cardiac illness (50% vs. 22% among those who did not receive NMBAs; P = .005), while patients who did not receive NMBAs had more neurologic disease (81% vs. 54%; P = .006),” Mr. Bauer said. “Overall, it was a medically complex patient group with a vast array of illnesses.”
Upper-airway obstruction was the most common indication for surgery, followed by cardiopulmonary and neurologic conditions. The researchers found that patients who did not receive NMBAs had more neurologic indications for tracheostomy, compared with their counterparts who did receive the agents (38% vs. 8%; P = .003), while patients who ultimately received NMBA had more cardiopulmonary indications for surgery (54% vs. 18%; P< .001).
In an analysis of preoperative factors, patients who ultimately received NMBA, compared with those who did not, had longer preoperative length of stay (LOS) (28-93 days vs. 59-224 days; P = .002), more respiratory failure 3 days prior to surgery (96% vs. 74%; P = .014), and prolonged intubation periods prior to surgery (0-24 days vs. 6-45 days; P = .009). However, location of care (NICU vs. PICU) was similar throughout. In addition, the physiologic status on the day of surgery as indicated by the Pediatric Risk of Mortality score was similar in both groups.
Mr. Bauer went on to report that preoperative interventions including 30-day use of glucocorticoids, inotropes, and aminoglycosides were similar between the two groups, as was the use of blood transfusions 48 hours prior to surgery. As for postoperative sedation, opioid use and pediatric daily dosing was similar between groups. However, the rate of dexmedetomidine use was twice as high in patients who ultimately received NMBAs, compared with those who did not (46% vs. 26%; P = .026).
In terms of outcomes, the rate of pressure ulcers, pneumonia, urinary tract infections, and other complications did not differ between the two groups, while the rate of mortality at the time of data collection was also similar (12% among those who received NMBAs and 15% among those who did not). This “mirrors the national average of 13%-20%,” Mr. Bauer said. “In addition, there were no mortalities related to the procedure itself.”
On univariate analysis, postoperative LOS was a median of 10 days longer in patients who received NMBAs, compared with those who did not (23 vs. 33 days, respectively; P = .043). After multivariate analysis, however, that association was no longer significant (P = .91). Multivariable analysis also found that patients with traumatic indications for tracheostomy placement had a 44% shorter LOS (P = .002), while those with upper-airway obstruction indications for tracheostomy placement had a 27% shorter LOS (P = .02). A similar association was observed in patients who tolerated oral nutrition prior to surgery, as compared with enteral nutrition (a 48% reduction in LOS; P< .001).
Factors which portended a longer postoperative LOS were preoperative lengths of stay that lasted 10 days or more (P less than .001) and being cared for in the neonatal vs. the pediatric ICU (P = .002).
“The use of paralytic agents in this complex cohort was not an independent predictor of longer LOS,” Mr. Bauer concluded. “Instead, factors such as preoperative LOS along with [certain] indications ultimately affected the LOS. Finally, the ideal sedative protocol following tracheostomy has not been determined and requires additional investigation.”
Mr. Bauer reported that neither he nor his associates had relevant financial conflicts to disclose.
On Twitter @dougbrunk
CORONADO, CALIF. – The use of neuromuscular blockade agents in pediatric patients after tracheostomy was not an independent predictor of longer hospital length of stay, results from a 3-year, single-center study suggest. Factors which portended a longer length of stay including having a longer preoperative length of stay and being cared for in the neonatal intensive care unit.
“Across the country there are widespread initiatives to improve quality of care,” study coauthor Eric Bauer said at the Triological Society’s Combined Sections Meeting.
“Tracheostomy has been identified as a contributor to prolonged length of stay. Additionally, it’s a procedure associated with increased rates of pediatric otolaryngology infections and major adverse events including accidental decannulation. However, the factors which increase prolonged hospital stay have not been determined.”
Mr. Bauer, a fourth-year medical student at the Ohio State University, Columbus, noted that some published studies in the medical literature that focus on the use of neuromuscular blockade agents (NMBAs) following pediatric single-stage laryngeal or tracheal reconstruction suggest that these medications may prolong hospital stay and increase complication risk. “Therefore, the goal of our study was to determine if the use of NMBAs in pediatric patients following tracheostomy is associated with a prolonged length of stay,” he said at the meeting jointly sponsored by the Triological Society and the American College of Surgeons..
Mr. Bauer and his fellow researchers performed a retrospective chart review from 2010 to 2013 for all tracheostomies performed and cared for in the neonatal and pediatric intensive care units of Nationwide Children’s Hospital, Columbus. In all, 114 patients were included, 26 of whom received neuromuscular blockade agents in the postoperative period. Patients cared for in the cardiothoracic ICU were excluded from the analysis.
After collecting demographic, clinical, and 30-day outcome characteristics for all patients, the researchers observed no significant differences between those who received NMBAs and those who did not with respect to patient median age, gender, and baseline medical condition differences. “Patients who received NMBAs did have more cardiac illness (50% vs. 22% among those who did not receive NMBAs; P = .005), while patients who did not receive NMBAs had more neurologic disease (81% vs. 54%; P = .006),” Mr. Bauer said. “Overall, it was a medically complex patient group with a vast array of illnesses.”
Upper-airway obstruction was the most common indication for surgery, followed by cardiopulmonary and neurologic conditions. The researchers found that patients who did not receive NMBAs had more neurologic indications for tracheostomy, compared with their counterparts who did receive the agents (38% vs. 8%; P = .003), while patients who ultimately received NMBA had more cardiopulmonary indications for surgery (54% vs. 18%; P< .001).
In an analysis of preoperative factors, patients who ultimately received NMBA, compared with those who did not, had longer preoperative length of stay (LOS) (28-93 days vs. 59-224 days; P = .002), more respiratory failure 3 days prior to surgery (96% vs. 74%; P = .014), and prolonged intubation periods prior to surgery (0-24 days vs. 6-45 days; P = .009). However, location of care (NICU vs. PICU) was similar throughout. In addition, the physiologic status on the day of surgery as indicated by the Pediatric Risk of Mortality score was similar in both groups.
Mr. Bauer went on to report that preoperative interventions including 30-day use of glucocorticoids, inotropes, and aminoglycosides were similar between the two groups, as was the use of blood transfusions 48 hours prior to surgery. As for postoperative sedation, opioid use and pediatric daily dosing was similar between groups. However, the rate of dexmedetomidine use was twice as high in patients who ultimately received NMBAs, compared with those who did not (46% vs. 26%; P = .026).
In terms of outcomes, the rate of pressure ulcers, pneumonia, urinary tract infections, and other complications did not differ between the two groups, while the rate of mortality at the time of data collection was also similar (12% among those who received NMBAs and 15% among those who did not). This “mirrors the national average of 13%-20%,” Mr. Bauer said. “In addition, there were no mortalities related to the procedure itself.”
On univariate analysis, postoperative LOS was a median of 10 days longer in patients who received NMBAs, compared with those who did not (23 vs. 33 days, respectively; P = .043). After multivariate analysis, however, that association was no longer significant (P = .91). Multivariable analysis also found that patients with traumatic indications for tracheostomy placement had a 44% shorter LOS (P = .002), while those with upper-airway obstruction indications for tracheostomy placement had a 27% shorter LOS (P = .02). A similar association was observed in patients who tolerated oral nutrition prior to surgery, as compared with enteral nutrition (a 48% reduction in LOS; P< .001).
Factors which portended a longer postoperative LOS were preoperative lengths of stay that lasted 10 days or more (P less than .001) and being cared for in the neonatal vs. the pediatric ICU (P = .002).
“The use of paralytic agents in this complex cohort was not an independent predictor of longer LOS,” Mr. Bauer concluded. “Instead, factors such as preoperative LOS along with [certain] indications ultimately affected the LOS. Finally, the ideal sedative protocol following tracheostomy has not been determined and requires additional investigation.”
Mr. Bauer reported that neither he nor his associates had relevant financial conflicts to disclose.
On Twitter @dougbrunk
AT THE COMBINED SECTIONS WINTER MEETING
Key clinical point: The use of paralytic agents in pediatric patients after undergoing tracheostomy was not an independent predictor of longer postoperative hospital length of stay.
Major finding: Patients who ultimately received neuromuscular blockade agents, compared with those who did not, had longer preoperative LOS (28-93 days vs. 59-224 days; P = .002) and more respiratory failure three days prior to surgery (96% vs. 74%; P = .014).
Data source: A retrospective chart review of 114 tracheostomies performed and cared for in the neonatal and pediatric intensive care units of Nationwide Children’s Hospital from 2010 to 2013.
Disclosures: Mr. Bauer reported that neither he nor his associates had relevant financial conflicts to disclose.
Analysis examines glossectomy as solo treatment for sleep apnea
CORONADO, CALIF. – Results from a new meta-analysis suggest that glossectomy significantly improves sleep outcomes when performed as part of a multi-level surgery for adults with obstructive sleep apnea.
However, “there is insufficient evidence to analyze the role of glossectomy as a stand-alone procedure for the treatment of sleep apnea,” lead study author Dr. Alexander W. Murphey said in an interview in advance of The Triological Society’s Combined Sections meeting, where the work was presented. “The lack of available data for glossectomy as a single treatment was disappointing, and points to the need for further studies in this population.”
Glossectomy for OSA was first reported in 1991 as a salvage surgery after uvulopalatopharyngoplasty, said Dr. Murphey, who is completing a clinical research fellowship in the department of otolaryngology-head and neck surgery at Medical University of South Carolina, Charleston, under the mentoring of Dr. Marion B. Gillespie and Dr. Shaun A. Nguyen. Since that time, “many modifications have been made regarding technique and instrumentation with recent focus on minimally invasive techniques aimed at maximizing tissue reduction while limiting the inherent morbidity associated with glossectomy,” he said. “The aim of our study was to review and analyze all of the available literature on partial glossectomy for OSA in one study. Overall, there is a significant lack of research into glossectomy, and what literature is available include small, case-series that analyze glossectomy as part of complex, multi-level surgeries. This study represents the first large scale meta-analysis on the role of glossectomy, and attempts to determine the role of glossectomy both as part of multi-level surgery, and as a single, stand-alone sleep apnea treatment.”
Dr. Murphey used the PubMed-NCBI literature database to identify studies with 10 or more patients and reported preoperative and postoperative apnea-hypopnea index (AHI) scores. The primary endpoint was change in AHI while secondary endpoints included predefined surgical success rates, and changes in additional reported sleep outcomes such as Epworth Sleep Scores (ESS), Lowest Oxygen Saturation (LSAT), and snoring visual analog scale (VAS). The researchers reported results from 15 articles with 442 patients treated with three glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision (SMILE). In pooled analyses that compared baseline vs. post-surgery, investigators observed significant reductions in AHI (from 48 to 20); ESS (from 12 to 5), and VAS (from 9 to 3; all with a P of less than .0001). In addition, they observed a significant increase in LSAT (from 77% to 84%; P less than .0001), according to the findings, presented at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.
Surgical success, which was defined as an AHI less than 20 and a greater than 50% reduction in AHI, was achieved in 56% of cases, while complications occurred in 18% of patients. Only 24 patients (5%) were treated with glossectomy as sole therapy for OSA. Among these 24 patients, significant reductions occurred in AHI (from 42 to 25; P=.0345) and ESS (from 12 to 7; P less than .0001).
Dr. Murphey acknowledged certain limitations of the analysis, including “a lack of quality research involving glossectomy, with the majority of available published data drawn from small, case-series without control arms,” he said. “Additionally, studies varied in surgical approach, inclusion criteria, and accompanying procedures in multi-level treatment. This makes it extremely difficult to truly compare treatments.”
The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
CORONADO, CALIF. – Results from a new meta-analysis suggest that glossectomy significantly improves sleep outcomes when performed as part of a multi-level surgery for adults with obstructive sleep apnea.
However, “there is insufficient evidence to analyze the role of glossectomy as a stand-alone procedure for the treatment of sleep apnea,” lead study author Dr. Alexander W. Murphey said in an interview in advance of The Triological Society’s Combined Sections meeting, where the work was presented. “The lack of available data for glossectomy as a single treatment was disappointing, and points to the need for further studies in this population.”
Glossectomy for OSA was first reported in 1991 as a salvage surgery after uvulopalatopharyngoplasty, said Dr. Murphey, who is completing a clinical research fellowship in the department of otolaryngology-head and neck surgery at Medical University of South Carolina, Charleston, under the mentoring of Dr. Marion B. Gillespie and Dr. Shaun A. Nguyen. Since that time, “many modifications have been made regarding technique and instrumentation with recent focus on minimally invasive techniques aimed at maximizing tissue reduction while limiting the inherent morbidity associated with glossectomy,” he said. “The aim of our study was to review and analyze all of the available literature on partial glossectomy for OSA in one study. Overall, there is a significant lack of research into glossectomy, and what literature is available include small, case-series that analyze glossectomy as part of complex, multi-level surgeries. This study represents the first large scale meta-analysis on the role of glossectomy, and attempts to determine the role of glossectomy both as part of multi-level surgery, and as a single, stand-alone sleep apnea treatment.”
Dr. Murphey used the PubMed-NCBI literature database to identify studies with 10 or more patients and reported preoperative and postoperative apnea-hypopnea index (AHI) scores. The primary endpoint was change in AHI while secondary endpoints included predefined surgical success rates, and changes in additional reported sleep outcomes such as Epworth Sleep Scores (ESS), Lowest Oxygen Saturation (LSAT), and snoring visual analog scale (VAS). The researchers reported results from 15 articles with 442 patients treated with three glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision (SMILE). In pooled analyses that compared baseline vs. post-surgery, investigators observed significant reductions in AHI (from 48 to 20); ESS (from 12 to 5), and VAS (from 9 to 3; all with a P of less than .0001). In addition, they observed a significant increase in LSAT (from 77% to 84%; P less than .0001), according to the findings, presented at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.
Surgical success, which was defined as an AHI less than 20 and a greater than 50% reduction in AHI, was achieved in 56% of cases, while complications occurred in 18% of patients. Only 24 patients (5%) were treated with glossectomy as sole therapy for OSA. Among these 24 patients, significant reductions occurred in AHI (from 42 to 25; P=.0345) and ESS (from 12 to 7; P less than .0001).
Dr. Murphey acknowledged certain limitations of the analysis, including “a lack of quality research involving glossectomy, with the majority of available published data drawn from small, case-series without control arms,” he said. “Additionally, studies varied in surgical approach, inclusion criteria, and accompanying procedures in multi-level treatment. This makes it extremely difficult to truly compare treatments.”
The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
CORONADO, CALIF. – Results from a new meta-analysis suggest that glossectomy significantly improves sleep outcomes when performed as part of a multi-level surgery for adults with obstructive sleep apnea.
However, “there is insufficient evidence to analyze the role of glossectomy as a stand-alone procedure for the treatment of sleep apnea,” lead study author Dr. Alexander W. Murphey said in an interview in advance of The Triological Society’s Combined Sections meeting, where the work was presented. “The lack of available data for glossectomy as a single treatment was disappointing, and points to the need for further studies in this population.”
Glossectomy for OSA was first reported in 1991 as a salvage surgery after uvulopalatopharyngoplasty, said Dr. Murphey, who is completing a clinical research fellowship in the department of otolaryngology-head and neck surgery at Medical University of South Carolina, Charleston, under the mentoring of Dr. Marion B. Gillespie and Dr. Shaun A. Nguyen. Since that time, “many modifications have been made regarding technique and instrumentation with recent focus on minimally invasive techniques aimed at maximizing tissue reduction while limiting the inherent morbidity associated with glossectomy,” he said. “The aim of our study was to review and analyze all of the available literature on partial glossectomy for OSA in one study. Overall, there is a significant lack of research into glossectomy, and what literature is available include small, case-series that analyze glossectomy as part of complex, multi-level surgeries. This study represents the first large scale meta-analysis on the role of glossectomy, and attempts to determine the role of glossectomy both as part of multi-level surgery, and as a single, stand-alone sleep apnea treatment.”
Dr. Murphey used the PubMed-NCBI literature database to identify studies with 10 or more patients and reported preoperative and postoperative apnea-hypopnea index (AHI) scores. The primary endpoint was change in AHI while secondary endpoints included predefined surgical success rates, and changes in additional reported sleep outcomes such as Epworth Sleep Scores (ESS), Lowest Oxygen Saturation (LSAT), and snoring visual analog scale (VAS). The researchers reported results from 15 articles with 442 patients treated with three glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision (SMILE). In pooled analyses that compared baseline vs. post-surgery, investigators observed significant reductions in AHI (from 48 to 20); ESS (from 12 to 5), and VAS (from 9 to 3; all with a P of less than .0001). In addition, they observed a significant increase in LSAT (from 77% to 84%; P less than .0001), according to the findings, presented at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.
Surgical success, which was defined as an AHI less than 20 and a greater than 50% reduction in AHI, was achieved in 56% of cases, while complications occurred in 18% of patients. Only 24 patients (5%) were treated with glossectomy as sole therapy for OSA. Among these 24 patients, significant reductions occurred in AHI (from 42 to 25; P=.0345) and ESS (from 12 to 7; P less than .0001).
Dr. Murphey acknowledged certain limitations of the analysis, including “a lack of quality research involving glossectomy, with the majority of available published data drawn from small, case-series without control arms,” he said. “Additionally, studies varied in surgical approach, inclusion criteria, and accompanying procedures in multi-level treatment. This makes it extremely difficult to truly compare treatments.”
The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
AT THE COMBINED SECTIONS WINTER MEETING
Key clinical point: Among adults with obstructive sleep apnea, glossectomy significantly improved sleep outcomes when performed as part of a multi-level surgery, though evidence is sparse.
Major finding: There are no available data on the role of glossectomy as a stand-alone procedure for the treatment of OSA.
Data source: A meta-analysis of 15 articles concerning 442 patients treated with three glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision.
Disclosures: The researchers reported having no financial disclosures.
