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Research Needs Assessment for Children With Obstructive Sleep Apnea Undergoing Diagnostic or Surgical Procedures

Murto, Kimmo T. MD, FRCPC*,†; Chen, Wesley BScH; Katz, Sherri L. MD, MSc, CM, FRCPC§; Schwengel, Deborah A. MD, MEHP; Elden, Lisa M. MD, MSc, FRCSC, FAAP; Belani, Kumar G. MBBS, MS#; Gozal, David MD, MBA**

doi: 10.1213/ANE.0000000000003309
Respiration and Sleep Medicine
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Recent concerns have been raised about the quality and safety of adenotonsillectomy, a common surgery performed to treat obstructive sleep apnea (OSA) in children. OSA is a risk factor for opioid-related perioperative respiratory complications including those associated with anoxic brain injury or death. Our objective was to identify controversial issues related to the care of children with OSA. A standardized Delphi consensus technique involving an interdisciplinary group of 24 pediatric OSA experts identified 3 key issues: “postoperative disposition, preoperative screening, and pain management.” These topics are prime candidates for future systematic reviews and will guide Society of Anesthesia and Sleep Medicine–related research endeavors.

From the *Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada

Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada

§Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Department of Pediatric Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania

#Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota

**Department of Pediatrics, University of Chicago, Chicago, Illinois.

Published ahead of print February 23, 2018.

Accepted for publication December 19, 2017.

Funding: Institutional and/or departmental.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Kimmo T. Murto, MD, FRCPC, Department of Anesthesiology and Pain Medicine, Children’s Hospital of Eastern Ontario-Ottawa Children's Treatment Center, University of Ottawa, 401 Smyth Rd, Ottawa, ON K1H 8L1, Canada. Address e-mail to kmurto@cheo.on.ca.

The Society for Anesthesia and Sleep Medicine (SASM) Pediatric Committee conducted a study to identify controversial issues related to the care of children at risk for obstructive sleep apnea (OSA). Such study was deemed important because of recent concerns raised around the quality and safety of adenotonsillectomy (AT)1,2 performed in children. Currently, AT is the first-line treatment for OSA and is one of the most common pediatric surgeries in North America. Moderate to severe pain is common after this surgery, with opioids being considered a cornerstone of pain management. However, OSA may increase the perioperative risk for opioid-related respiratory complications, including those associated with anoxic brain injury or death.3–6 Furthermore, only a small proportion of the children undergoing AT have an OSA diagnosis confirmed by sleep study,5 which limits risk stratification and ability to determine appropriate pain management and postoperative disposition. As a result, perioperative care for this surgical population is highly variable and uses excessive postoperative health care service resources.2,7 Further, OSA may also be underappreciated in children undergoing non-AT surgeries or diagnostic procedures, potentially subjecting them to an increased risk for a serious adverse event. This study used a standardized interdisciplinary Delphi technique8 to identify the top 3 controversial issues related to the care of children at risk for OSA undergoing sedation or general anesthesia for a diagnostic or therapeutic procedure. This technique was used to ensure the inclusion of a large number of geographically dispersed pediatric OSA experts while minimizing cost and maximizing participant anonymity.

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METHODS

This study adheres to the applicable “Conducting and REporting DElphi Studies”9 recommendations, and it received local research ethics board approval (protocol 15/29X). During a 4-month period beginning in October 2015, a 2-round Delphi consensus technique was used to obtain feedback from an interdisciplinary panel of North American and European pediatric OSA experts. Seventeen committee and resource members of the SASM Pediatric Committee identified 25 colleagues considered experts in the care of children with OSA (42 potential study participants in total). Specialty representation included anesthesiology, otolaryngology, pulmonology, and sleep medicine. No preliminary reading material was provided to the participants because their OSA expertise was implicit, with the majority having published in peer-reviewed literature on related material. Participants were surveyed using Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, TN) technology. Each participant anonymously provided his or her demographic details and top 3 controversial topics of interest in rank order in response to a single pilot-tested open-ended question: “In your practice involved with the management of children at risk for OSA and undergoing sedation/general anesthesia for a diagnostic/therapeutic procedure, what are the top three issues you find to be controversial and in need of further research and/or consensus?” Round 1 free-text responses were initially collated by W.C. (an objective subject matter novice) and further categorized in collaboration with K.T.M. (a subject matter expert) before being presented in descending rank order of topic category of interest (determined by the number of associated topics generated) and rated by the same clinicians during the second round. Topic category of interest rating was based on a 5-point Likert scale (1 = no importance, 2 = minimal importance, 3 = moderate importance, 4 = major importance, and 5 = greatest importance). The participants were informed of which topic category of interest their own 3 controversial topics were assigned, and therefore they had the choice to either maintain their own rankings or be influenced by the group. Consensus was predetermined as ≥75% of participants selecting a value ≥4 (major importance) for a topic category of interest. Nonresponders were contacted twice in round 1 and ≤4 times in round 2 before the survey was closed. Participant sample size was based on a convenience sample because Delphi-related literature indicates that there is no standard methodology to calculate panel size.8,10 However, appreciating 12–15 participants have been recommended in this literature; this established our lower sample size threshold with the understanding that larger panels have been used. Data are presented as medians or proportions.

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RESULTS

Table 1.

Table 1.

Table 2.

Table 2.

In the first Delphi round, 39 participants were contacted (3 participants were excluded because an e-mail address was not provided) and 24 of 39 clinicians (62%) responded: anesthesiologists (n = 12), otolaryngologists (n = 4), pulmonologists (n = 4), and sleep medicine specialists (n = 4) (Table 1). The median range of number of years in practice after residency was 11–15 years (range, 0–30 years), 22 of 24 (92%) had completed pediatric subspecialty training, 14 of 24 (58%) practiced in the United States, and 18 of 24 (75%) practiced in an academic pediatric hospital care setting. Seven topic categories of interest were identified and ranked based on related topic generation frequency (Supplemental Digital Content, Table 1, http://links.lww.com/AA/C281) and respondent ranking in rounds 1 and 2, respectively (Table 2). These topics were rated by 23 of 24 (96%) of the same clinicians during the second round. Two topics met the criteria for consensus. The majority (96%) of respondents selected “postoperative disposition” as a controversial topic in need of further research. In addition, 83% also selected “preoperative screening” as a consensus for a second topic. Although “pain management” did not achieve a consensus (74%), it was considered to be the third most controversial topic due to its consistent top 3 rank order in each round.

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DISCUSSION

The results of this study identified important topics of interest to an interdisciplinary panel of pediatric experts regarding the care of children at risk for OSA. In descending order of importance, the 3 most controversial topics and their associated issues are as follows:

  1. “Postoperative disposition” related to risk assessment for respiratory complications and need for additional monitoring after sedation or general anesthesia. While OSA appears to increase the risk for respiratory complications after AT in children, it currently remains unclear what aspect(s) of OSA predicts this risk (eg, OSA severity based on the apnea–hypopnea index versus gas exchange abnormalities versus associated pathophysiology including obesity).11 Also, it is unclear whether this risk varies by surgical or diagnostic procedure and what is considered to be appropriate postoperative monitoring. Current monitoring guidelines12,13 defer to local standards of practice, which may explain, in part, the high degree of variation in care. Tools to predict perioperative respiratory adverse events in children are being developed.14–16
  2. “Preoperative screening” related to identifying alternative means to polysomnography (PSG) for OSA diagnoses. For various reasons including cost and limited accessibility, <12% of children undergo PSG before AT,4,17 and there is no pediatric version of the adult OSA questionnaire (snore, tired, observed pauses, pressure elevation, body mass index, age, neck circumference, and gender [STOP-BANG]).18 In contrast to the American Academy of Pediatric (2012)13 guidelines, current surgery (American Academy of Otolaryngology-Head and Neck Surgery 2011)19 and anesthesia (American Society of Anesthesiologists 2014)12 guidelines do not recognize alternatives to PSG to screen for OSA in children. However, work related to pediatric OSA questionnaire development,20,21 overnight pulse oximetry,22 home-based sleep studies,17 and biological markers show promise and should be considered in future guidelines.13
  3. “Pain management” related to prescribing analgesics including opioids to children with OSA undergoing AT or other surgical procedures. An underlying sensitivity to the respiratory depressant effect of opioids has been demonstrated in children undergoing AT, and measures to reduce opioid dose has resulted in a 50% reduction in postoperative desaturations.23 The role of nonopioid analgesics (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], steroids, and α-2 agonists), modified opioids (eg, tapentadol), opioid-sparing protocols, and other means to safely manage pain and provide sedation in this patient population need to be determined.

The strengths of our study include participant specialty diversity and geographic dispersity considered ideal to maximize topic relevance and favor international collaborative research opportunities. However, our study has several limitations. First, our number of participants would appear to be small, but our number is consistent with previous publications.8,10 Arguably, our panel’s diversity of viewpoints and expertise counter concerns related to sample size. Second, we do not know what proportion of the total number of academically active pediatric OSA experts our panel size represents. However, of the study participants contacted, we achieved a respectable 62% (24/39) response rate, of which 96% (23/24) completed the study. Inviting additional participants may have increased expertise at the risk of diminishing returns. Third, specialist diversity was limited to 4 specialties, with anesthesiologists accounting for 50% of participants, which may have influenced topic selection. However, nonanesthesiologists had the option to avoid being influenced by topics chosen by other panel members. Finally, panel representation by other groups including funders, policymakers, and patients/families is ideal, but it would have been prohibitively complex and expensive to execute. To conclude, these 3 topics are prime candidates for future systematic review and will guide SASM-related research endeavors.

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ACKNOWLEDGMENTS

We thank our nonauthor contributors who participated in the study design and/or interpretation of the work and are represented by the following current and former members of the Society of Anesthesia and Sleep Medicine (SASM) Pediatric Committee: Nicholas M. Dalesio, MD, Assistant Professor, Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Children’s Hospital, Baltimore, Maryland; Stacey L. Ishman, MD, MPH, Professor, University of Cincinnati School of Medicine, Department of Otolaryngology, Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; Sapna R. Kudchadkar, MD, Assistant Professor, Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care, Johns Hopkins Children’s Hospital, Baltimore, Maryland; Jerrold Lerman, MD, BASc, FRCPC, FANZCA, Clinical Professor of Anesthesiology, Jacobs School of Medicine and Biomedical Sciences, Department of Anesthesiology, Women and Children’s Hospital of Buffalo, Buffalo, New York; Conor McDonnell, MD, MB, Associate Professor, University of Toronto, Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Olubukola O. Nafiu, MD, Associate Professor, University of Michigan, Department of Anesthesiology, C.S. Mott Children’s Hospital, Ann Arbor, Michigan; Vidya T. Raman, MD, FAAP, Associate Professor, University of Ohio, Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio; and Rajeev Subramanyam, MD, MS, Associate Professor, University of Cincinnati School of Medicine, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. We thank Johanna Spaans for reviewing and editing the manuscript.

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DISCLOSURES

Name: Kimmo T. Murto, MD, FRCPC.

Contribution: This author helped in initial conception and design of the study; assisted in data acquisition, analysis, and interpretation; cowrote the first draft of the manuscript and was involved with subsequent revisions; has approved the final version of the manuscript; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Name: Wesley Chen, BScH.

Contribution: This author assisted in study design; helped in data acquisition, analysis, and interpretation; cowrote the first draft of the manuscript and was involved with subsequent revisions; has approved the final version of the manuscript; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Name: Sherri L. Katz, MD, MSc, CM, FRCPC.

Contribution: This author assisted in the conception of the study; helped in data interpretation and subsequent manuscript revisions; has approved the final version of the manuscript; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Name: Deborah A. Schwengel, MD, MEHP.

Contribution: This author assisted in the conception of the study and subsequent manuscript revisions; has approved the final version of the manuscript; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Name: Lisa M. Elden, MD, MSc, FRCSC, FAAP.

Contribution: This author assisted in the conception of the study and subsequent manuscript revisions; has approved the final version of the manuscript; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Name: Kumar G. Belani, MBBS, MS.

Contribution: This author assisted in the conception of the study and subsequent manuscript revisions; has approved the final version of the manuscript; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Name: David Gozal, MD, MBA.

Contribution: This author helped in initial conception of the study and subsequent manuscript revisions; has approved the final version of the manuscript; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

This manuscript was handled by: David Hillman, MD.

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