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1 All authors: Department of Radiology, Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039.
Received February 14, 2001;
accepted after revision May 1, 2001.
Presented at the annual meeting of the American Roentgen Ray Society,
Seattle, April-May 2001.
Abstract
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MATERIALS AND METHODS. Eighty consecutive dynamic sleep fluoroscopic studies were evaluated. The type of sedation used, success rate, complications related to the sedation, and characteristics of the children studied were reviewed. Patients were sedated in accordance with our departmental sedation program guidelines. Findings on fluoroscopy were correlated with episodes of oxygen desaturation or noisy breathing.
RESULTS. In all 80 cases, dynamic sleep fluoroscopy was successfully performed. Seventy-two studies were performed, with sedation supervised by the radiologist. Four patients fell asleep without sedation. In four patients, sedation was performed by an anesthesiologist (preprocedural decision). Sixty-four children (80%) had complex medical problems, and 39 (49%) had a history of previous airway surgery. All studies were considered successful. Specific diagnoses were identified in 66 children (83%). No children suffered complications or required tracheal intubation.
CONCLUSION. Children with airway compromise who are being evaluated for obstructive sleep apnea can be successfully and safely sedated for dynamic sleep fluoroscopy when a structured sedation program is used.
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All studies were performed and monitored by a pediatric radiologist. A
structured sedation program that defined protocols such as criteria that
physicians and nurses must meet to be eligible to perform sedation, a
restricted list of drugs used for sedation, guidelines for patient monitoring
during the procedure and recovery, and discharge criteria was used
[4,
5]. Patients were prepared for
the procedure according to our departmental sedation program guidelines
[4], which meet the guidelines
of the American Academy of Pediatrics
[5]. Informed consent was
obtained for sedation from the child's parents or legal guardians. The
sedation nurse and pediatric radiologist obtained a history and physical
examination immediately before each sedation. During the procedure, a
radiologist, radiology technologist, and radiology nurse were present. Food
and drink were withheld for 4-8 hr before the examination to decrease the risk
of aspiration. Patients were sedated with either oral chloral hydrate (70-100
mg/kg) or IV pentobarbital (3 mg/kg, with repeated dosing if the patient
remained awake, up to a total of 7 mg/kg). Drug choice was based on patient
age (guideline: chloral hydrate for age 
1 year, pentobarbital for age
1 year).
During the entire procedure and sedation recovery, respiratory rate, heart rate and rhythm, and blood oxygen saturation were monitored, using transcutaneous pulse oximetry. The child's parents were encouraged to attend the procedure to reduce the child's anxiety and to verify that the sleep patterns observed were typical of those that occurred at home. If the radiologist performing the procedure or the referring physician considered the child to be at excessive risk for conscious sedation, an anesthesiologist was scheduled to be present and provide the sedation. This decision was made at the discretion of the involved physicians. There were not strict criteria for this decision. The number of patients for whom an anesthesiologist was consulted to provide sedation was recorded.
All studies were performed in a room equipped with lateral fluoroscopy (Fig. 1A,1B). The children were imaged in the supine position with lateral fluoroscopy. Fluoroscopic findings were correlated with episodes of oxygen desaturation or noisy breathing. Oxygen desaturations were typically similar to those recorded at home by parents when patients were sleeping in natural conditions. Many patients received supplemental oxygen by nasal cannula or face mask, but this was not administered until after the imaging portion of the study was complete to avoid masking diagnostic information. Physical observations that were noted and correlated with fluoroscopic findings included respiratory effort, thoracic wall motions, and episodes of apnea. Fluoroscopic evaluation was performed for approximately 10-20 sec at areas of anatomic interest when signs of airway occlusion occurred. The percentage of patients with an observed abnormal finding and the type of abnormal finding detected were recorded. Specific diagnoses such as adenoid enlargement, glossoptosis, pharyngeal collapse (Fig. 1A,1B), laryngomalacia, and tracheomalacia were made using previously published criteria for these diagnoses on dynamic sleep studies [1,2,3, 6,7,8].
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Short-term levels of desaturation and noisy breathing are an expected part of abnormal findings on a dynamic fluoroscopic sleep study [1,2,3]. Complications were defined in relation to airway compromise, which is the major safety issue separating sedation of children with obstructive sleep apnea from sedation of other children. Complications from sedation were considered present if the patient had respiratory distress to the extent that the patient required bag mask ventilation or tracheal intubation, other physicians were called to the site of the sleep study to help treat the degree of respiratory distress, or the patient required hospitalization related to the performance of sedation. More minor complications (vomiting, agitation) not related to airway status were also recorded.
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Concerning the underlying condition of the patients and risks for sedation other than the history of the airway abnormality in question, 64 children (80%) had complex medical problems, which included syndromes or multiple congenital anomalies in 35 (44%) and neuromuscular compromise, such as cerebral palsy, in 19 patients (24%). Only 16 patients (20%) had no underlying abnormal findings. Thirty-nine (49%) patients had a history of previous airway-related surgery.
As we expected, patients did have limited episodes of oxygen desaturation and noisy breathing during the study. However, no children suffered complications. None required tracheal intubation, developed respiratory distress requiring the aid of other physicians, or required hospitalization related to sedation for the dynamic sleep fluoroscopy study. None had minor complications.
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In children with obstructive sleep apnea in whom there is a complicated medical history or persistent sleep apnea after a surgical procedure performed to treat sleep apnea, dynamic sleep fluoroscopy with sedation has been shown to be a useful adjunct to endoscopy, affecting treatment decisions in more than 50% of children [1]. Dynamic sleep fluoroscopy is particularly helpful in identifying dynamic abnormalities of the airway, such as functional collapse, compared with static, fixed obstructions. The first line of treatment for many of these dynamic causes of obstructive sleep apnea is the use of positive pressure airway devices during sleep [18]. Some types of obstructive sleep apnea will decrease with age. Therefore, if positive pressure ventilation can relieve the symptoms, it may be the only necessary therapy until the child outgrows the condition. Knowledge of the specific abnormal finding is important because the odds of positive pressure therapy being helpful and of the child's outgrowing the condition are different for each specific entity. Therefore, the length of trial for conservative therapy may be influenced. In addition, when conservative treatment fails, the specific types of surgery that can be performed differ for each type of airway obstruction.
One of the most serious complications of sedation is airway obstruction and apnea [19]. Therefore, airway compromise is considered a risk factor for both general anesthesia and conscious sedation [5, 20, 21]. Many institutions do not perform sedation in children with documented or suspected airway compromise. We often encounter resistance from our sedation nurses when they are preparing for the sedation of a child for a dynamic fluoroscopic sleep study. In contrast to the sedation of children for all other imaging procedures, the goal of sedation for a dynamic sleep study is to reproduce the conditions of sleep that often lead to some degree of airway compromise and hypoxia in patients with obstructive sleep apnea. It is the information gained from the imaging appearance of the airway during this state that is helpful to the clinicians caring for these patients. These children experience similar episodes of hypoxia and noisy breathing each night at home when sleeping.
Two issues concern the use of sedation in the evaluation of obstructive sleep apnea. The first, and the issue primarily addressed in this study, is safety. The second issue is whether the physiologic state induced by sedation is reflective of the physiologic state that occurs when the patient is naturally asleep. There is some debate concerning this issue. Our referring otolaryngologists and pulmonologists rely on the information provided by the dynamic sleep fluoroscopic studies performed with sedation and believe that those studies provide accurate information that improves the care of patients with obstructive sleep apnea. Many centers use sleep deprivation, rather than sedation, to perform polysomnography. Most sleep laboratories are constructed to be conducive to sleep (i.e., with a conformable bed). Our dynamic sleep fluoroscopic studies are performed in our interventional radiology suite, which is not designed to be conducive to sleep. These examinations must be scheduled among the many other activities occurring in this suite. Early in our experience, we tried sleep deprivation but did not have much success because of the room construction and time restraints. Four patients in this study did spontaneously fall asleep and were examined successfully without sedation.
Much attention has been given in the literature to the importance of using a structured sedation program [4, 5, 22,23,24]. In 1992, the Committee on Drugs of the American Academy of Pediatrics published guidelines for nonanesthesiologists performing conscious sedation [5]. These guidelines set standards for patient selection, monitoring, and discharge. Since the publication of these guidelines, a number of publications have stressed the safety and success of sedation in imaging departments that use structured sedation programs complying with the American Academy of Pediatrics guidelines [4, 22,23,24]. However, to our knowledge, there has not been a report describing the safety and success of a structured sedation program specifically used in children with obstructive sleep apnea.
In our study, no complications were seen in children who underwent sedation for dynamic fluoroscopic sleep studies. No patients required tracheal intubation or hospitalization. Because our institution may have one of the greatest experiences with dynamic sleep fluoroscopy in children with obstructive sleep apnea, we reviewed our experience with the use of sedation for a number of reasons: to share this experience with others, to document that we are providing optimal care for our patients, and to serve as a template for possible improvement as we continue to image children with obstructive sleep apnea. The importance of safety and sedation in children with obstructive sleep apnea has been intensified by the increasing use of MR cine techniques to provide more anatomically detailed images of these patients during sleep. In such cases, access to the patient is limited as a result of the MR gantry.
Our study was limited by a number of factors. First, although we may have one of the greatest experiences with dynamic sleep fluoroscopy in children, the study population was relatively small, with 80 patients. Second, this was a retrospective review of our experience, rather than a prospective trial. Finally, safety in a tertiary pediatric center with a large experience in both imaging patients with obstructive sleep apnea and in sedation of children for imaging may not be transferable to other institutions.
In our study, no child experienced a complication related to sedation for a dynamic sleep fluoroscopy study. Although the potential of airway compromise should be considered in patients being evaluated for sedation, a history of obstructive sleep apnea in itself is not a contraindication to conscious sedation in the appropriate setting. The use of a structured sedation program, appropriately equipped facilities, experienced personnel, and adequate backup physician support are emphasized. We conclude that children with obstructive sleep apnea can be safely sedated for the purpose of dynamic sleep fluoroscopy when a structured sedation program is used.
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