Drug-induced sleep endoscopy-continuous positive airway pressure (DISE-CPAP), a newer modality to choose the right candidates for CPAP

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is recommended for moderate-to-severe obstructive sleep apnea (OSA). We aimed to investigate whether or not combining drug-induced sleep endoscopy (DISE) with CPAP titration may inform more appropriate pressure settings.

MATERIALS AND METHODS

A sleep CPAP titration study and DISE-CPAP treatment were performed on consecutive subjects with moderate-to-severe OSA under controlled sedation using bispectral monitoring. Video recordings of dynamic changes in UA with CPAP pressure ranges of 5 to 25 cm were assessed in accordance with the VOTE classification. The 95th percentile (95th PC) pressure of the CPAP titration trial was compared to optimal pressure for alleviating UA blockage.

RESULTS

We included 30 subjects (mean age 37.5, 17% women). All showed UA collapse at more than one level, with more than 80% of them collapsing completely at the levels of the velum and oropharynx. At the velum, 90% of subjects experienced improvement with CPAP. At the oropharynx, 75% of subjects experienced improvement with CPAP. The mean pressure and standard deviation (SD) of the 95th PC of the CPAP titration was 14.3 (3.5) cmH2O, while the pressure required to partially or fully open the airway (best possible pressure) was 16.1 (3.9) cmH2O; mean (SD) difference, 1.9 (2.2); P ≤ 0.001. The limits of agreement between the CPAP 95th pressure and the ideal pressure were - 6.32 to + 2.52.

CONCLUSIONS

The palate and lateral pharynx were more affected by CPAP than the hypopharynx. Most of the time, the mean 95th PC CPAP titration pressure was lower than the mean optimal pressure needed to alleviate the collapse.

Sleep Endoscopy with Positive Airway Pressure: A Method for Better Compliance and Individualized Treatment of Patients with Obstructive Sleep Apnea

In this study, we aimed to observe the effects of positive airway pressure (PAP) on individual levels of obstruction during drug-induced sleep endoscopy (DISE) of the upper airways (UA), to evaluate at which pressures the obstruction disappeared or worsened, and to identify cases in which PAP was ineffective. This prospective study was conducted from June 2018 to June 2022. PAP testing was performed during DISE in patients with moderate and severe OSA. The pressure was gradually increased over the range from 6.0 to 18.0 hPa. Our findings were evaluated using the VOTE classification. The examination was performed in 56 patients, with a median apnea-hypopnea index (AHI) of 26.4. Complete obstruction of the soft palate was observed in 51/56 patients (91%), oropharyngeal obstruction in 15/56 patients (27%), tongue base obstruction in 23/56 patients (41%), and epiglottic collapse in 16/56 patients (29%). PAP was most effective in cases of complete oropharyngeal obstruction, and least effective in cases of epiglottic collapse, where it was ineffective in 11/16 patients. DISE with PAP is a simple diagnostic method that can be helpful for identifying anatomic and dynamic reasons for PAP intolerance. The main indication is ineffective PAP treatment.

The clinical application progress and potential of drug-induced sleep endoscopy in obstructive sleep apnea

Background and Objective: Obstructive sleep apnoea (OSA) is characterized by nocturnal repetitive upper airway (UA) collapse. For sleep physicians, the recognition of UA collapse characteristics is critical for understanding OSA mechanisms and developing individualized treatment plans. Drug-induced sleep endoscopy (DISE) is an exam during simulated sleep that allows the dynamic assessment of the UA of individuals with OSA. The initial recognition of DISE was to locate the sites of UA obstruction and direct the surgical selection of OSA since it was introduced in the 1990s. After approximately 30 years of studies, based on advances in endoscopic operative techniques and innovative treatments of OSA, DISE had been performed to explore mechanisms and comprehensive treatments related to UA collapse. Methods: This article reviewed contemporary DISE advances, including indications and contraindications, technique of induced sleep, endoscopic operation, UA characteristics classification.Results and Conclusions: Precise selection based on the association between collapse patterns and treatment modalities, such as continuous positive airway pressure, oral appliance, positional therapy, robotic surgery and neurostimulator implanting, is the future research prospect based on DISE.Key messagesDISE provides sleep physicians with valuable information about the upper airway collapse characteristics and dynamic changes during sleep.The studies based on DISE findings improve the selectivity and efficiency of treatment modalities, including classical therapies such as continuous positive airway pressure, oral appliance, positional therapy, and innovative therapies such as neurostimulator implanting and robotic surgery, promote the advancement of OSA precision medicine.

Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome

OBJECTIVES

To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome.

DESIGN

A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data.

METHODS

The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results.

RESULTS

Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion.

CONCLUSION

Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.

Practical Implementation of Sleep Endoscopy with Positive Airway Pressure in Clinical Practice

Drug-induced sleep endoscopy with positive airway pressure (DISE-PAP) is a new technique that allows for both the visualization of upper airway collapse as well as to evaluate the degree of airway collapsibility. This DISE-PAP protocol provides an affordable and clinically efficient manner in which to immediately implement this technique in clinical practice. Laryngoscope, 2022.

Outcome of CPAP Titration for Moderate-to-Severe OSA Under Drug-Induced Sleep Endoscopy: A Randomized Controlled Crossover Trial

Background

The titration pressure of continuous positive airway pressure (CPAP) is important in patients with obstructive sleep apnea (OSA). This study aimed to understand the difference between drug-induced sleep endoscopy (DISE)-guided CPAP titration and conventional sleep center (CSC) CPAP titration in patients with OSA.

Methods

In this randomized, controlled, and single-blind crossover trial, we compared the effects of 1-month CPAP treatment in patients with OSA with either DISE-guided CPAP titration or CSC CPAP titration. Twenty-four patients with OSA were recruited for the study. All patients underwent polysomnography, DISE-guided CPAP titration, and accommodation. Initially, patients were randomly assigned to receive either DISE-guided CPAP titration or CSC CPAP treatment for the first month. They were then switched to other treatments in the second month. The Epworth sleepiness scale (ESS) score was recorded at baseline, 1 and 2 months.

Results

The upper limit of the pressure of DISE-guided titration and CSC CPAP titration was not significantly different (13.9 ± 0.7 vs. 13.5 ± 0.5 cm H₂O; P = 0.92). The residual apnea-hypopnea index and compliance were also not significantly different between the groups. ESS score significantly improved from baseline to 1 month after CPAP treatment in both groups. Both epiglottis (anterior-posterior collapse) and tongue base collapse were significantly associated with 95% CPAP pressure (P = 0.031 and 0.038, respectively). After multivariate regression analyses, the epiglottis (anterior-posterior collapse) was an independent factor for 95% CPAP pressure. The incidence rate of bradycardia was 58.3%, which is a safety concern for DISE. Despite the high incidence of bradycardia, all patients with bradycardia recovered with proper management.

Conclusion

Both modalities were comparable in terms of establishing the pressure settings required to treat patients. Further large-scale studies are required to confirm these results.

Trial registration

https://clinicaltrials.gov/, NCT03523013.

Evaluation of Therapeutic Positive Airway Pressure as a Hypoglossal Nerve Stimulation Predictor in Patients With Obstructive Sleep Apnea

Importance

Recent retrospective hypoglossal nerve stimulation (HGNS) outcomes data suggest that patients with low therapeutic positive airway pressure (PAP) levels achieve greater success than patients with high therapeutic PAP levels.

Objective

To examine the use of therapeutic nasal PAP levels at the soft palate in predicting the outcomes of HGNS for patients with obstructive sleep apnea.

Design, Setting, and Participants

This prospective cohort study used drug-induced sleep endoscopy (DISE) to evaluate the predictive capacity of therapeutic PAP levels in HGNS outcomes. In an academic sleep surgery center, 27 consecutive patients with obstructive sleep apnea who underwent DISE before implantation of an HGNS device were evaluated. The study was conducted from May 1, 2018, to June 26, 2019.

Exposures

Positive airway pressure delivered through a nasal mask during DISE.

Main Outcomes and Measures

Improvement in apnea-hypopnea index as measured from full-night preoperative and postoperative efficacy studies.

Results

Twenty-seven patients met all inclusion criteria. The mean (SD) age was 62.0 (14.4) years, 14 participants were men (51.9%), and mean body mass index was 28.1 (4.0). Responders to HGNS therapy (n = 18) had significantly lower mean (SD) palatal opening pressure compared with nonresponders (n = 9) (5.0 [2.8] vs 9.2 [3.7] cm H2O, respectively; mean difference, -4.2; 95% CI, -6.8 to -1.6 cm H2O). After adjusting for age, sex, and body mass index, the mean palatal opening pressure value for the responders remained 3.5 cm H2O lower (95% CI, -6.7 to -0.4 cm H2O) than that of nonresponders. A palatal opening pressure cutoff level less than 8 cm H2O demonstrated a positive predictive value of 82.4%; sensitivity, 77.8%; and specificity, 66.7%.

Conclusions and Relevance

In this small prospective cohort study, therapeutic nasal PAP levels during DISE differed significantly between responder and nonresponders to HGNS. Because DISE represents a mandatory, relatively standardized diagnostic tool for HGNS candidacy, the use of therapeutic nasal PAP through DISE can be broadly implemented and studied across multiple centers to possibly improve patient selection for HGNS.

Therapeutic Positive Airway Pressure Level Predicts Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

STUDY OBJECTIVES

To determine whether therapeutic positive airway pressure (PAP) level predicts response to hypoglossal nerve stimulation (HGNS) for obstructive sleep apnea using the coprimary outcomes of apnea-hypopnea index (AHI) and 4% oxygen desaturation index.

METHODS

Combined cohort study from two US sleep otolaryngology training programs. Subjects were adults with AHI > 15 events/h who underwent HGNS. Eligible subjects had diagnostic preoperative sleep studies, full-night efficacy postoperative studies and therapeutic PAP levels available for analysis. Low and high PAP groups were compared using the t test for continuous variables and chi-square test for categorical variables.

RESULTS

Fifty-six patients met all inclusion criteria. On average, patients were male, Caucasian, middle-aged, and overweight. Thirteen patients were in the low PAP group (< 8 cm H₂O) and 43 patients in the high PAP group (≥ 8 cm H₂O). Although both groups experienced improvement of polysomnographic measures with HGNS, the low PAP group achieved a significantly larger mean AHI reduction (36.7 ± 22.7 versus 18.4 ± 23.4, P = .02). Additionally, the low PAP group had a greater response rate (defined as AHI < 20 events/h and > 50% reduction of AHI) than the high PAP group (92% versus 44%, P < .01).

CONCLUSIONS

Therapeutic PAP level may aid in the discernment of candidacy for HGNS, with a strong positive predictive value for PAP levels < 8 cm H₂O. A larger prospective study is needed to confirm these findings.

CITATION

Lee CH, Seay EG, Walters BK, Scalzitti NJ, Dedhia RC. Therapeutic positive airway pressure level predicts response to hypoglossal nerve stimulation for obstructive sleep apnea. J Clin Sleep Med. 2019;15(8):1165-1172.

Drug-induced sleep endoscopy while administering CPAP therapy in patients with CPAP failure

Study objectives

To study the pattern of upper airway collapse in patients with CPAP failure by performing DISE while administering CPAP therapy and to determine the reason for CPAP failure accordingly.

Methods

This observational retrospective study comprised 30 patients diagnosed with OSA and CPAP failure, who underwent DISE while administering CPAP therapy. During DISE, the upper airway was assessed with and without CPAP therapy using the VOTE classification. Additionally, a jaw thrust maneuver was performed, in order to mimic the effect of an additional mandibular advancement device (MAD) in combination with CPAP therapy. Consequently, the outcome of DISE was translated into a clinically relevant categorization.

Results

Eleven patients (37%) had a persistent anteroposterior (AP) collapse, including a collapse at velum, tongue base, or epiglottis level and multilevel collapse. Eight patients (27%) had a floppy epiglottis. Five patients (17%) had a persistent complete concentric collapse (CCC) and three patients had a persistent laryngeal collapse (10%). In three patients (10%), no airway collapse was found after CPAP administration.

Conclusions

Based on the results of the reported study, in most cases, the potential cause of CPAP failure can be determined by this new diagnostic method. Consequently, suggestions can be made for additional therapy.

Drug-Induced Sleep Endoscopy: Evaluation of a Selection Tool for Treatment Modalities for Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a very common disorder with important day and nighttime symptoms and long-term effects on health. Different treatment modalities such as positive airway pressure (PAP), oral appliance therapy using custom-made, titratable mandibular advancement devices (MAD), different types of surgery and positional therapy have been introduced over the years, with patient preference and adherence to therapy being key elements in improving treatment outcomes. Several patient selection tools to improve treatment outcomes have been introduced and evaluated over the years. Drug-induced sleep endoscopy (DISE) is a procedure that provides real-time upper airway evaluation of the sites of flutter and upper airway collapse. This review focuses on the indications and contraindications for DISE, methods of sedation and evaluation, add-on maneuvers, and the results on patient selection and treatment outcomes. A PICO approach was used to clarify the aims of this review. DISE has the advantage of being easily accessible in most ENT practices and being 3-dimensional, dynamic, site specific, safe and it is valuable in selecting patients for upper airway surgery and oral appliance therapy. There is a strong interest for further standardization and exploration of the predictive value of this evolving technique.

Nasal vs. oronasal mask during PAP treatment: a comparative DISE study

PURPOSE

The present study evaluated the upper airway pattern of obstruction in individuals undergoing drug-induced sleep endoscopy (DISE) exam with positive airway pressure (PAP), and compared this effect through a nasal or oronasal mask.

METHODS

Prospective study. Patients requiring PAP due to obstructive sleep apnea (OSA) were evaluated through DISE at three different moments: (1) a baseline condition (without PAP); (2) PAP treatment with a nasal mask; and (3) PAP with an oronasal mask at the same pressure. The conditions were compared intra-individually, following VOTE classification. A TOTAL VOTE score (the sum of VOTE scores observed for each anatomical site) was also applied to compare intra-individual results.

RESULTS

Thirteen patients were enrolled in the study. All patients presented multi-level pharyngeal obstruction at baseline condition. In six patients, the pattern of obstruction differed according to the mask. Nasal mask significantly decreased the obstruction score when compared with baseline condition both in velum (P value < 0.05) and oropharynx regions (P value < 0.005). TOTAL VOTE score was also significantly lower during nasal mask evaluation when compared with basal condition (P value < 0.005). Remarkably, oronasal mask with the same pressure was not as effective as nasal masks. Obstruction levels observed at the tongue base or epiglottis levels were more resistant to PAP treatment.

CONCLUSIONS

Collapse in velum and oropharyngeal sites is more compliant to PAP than obstruction at lower levels of the pharynx, either with nasal or oronasal masks. Nasal mask is superior to prevent pharyngeal collapse than oronasal devices under the same pressure.

Remotely controlled mandibular positioning of oral appliance therapy during polysomnography and drug-induced sleep endoscopy compared with conventional subjective titration in patients with obstructive sleep apnea: protocol for a randomized crossover trial

BACKGROUND

The amount of mandibular protrusion is a key factor in optimizing the efficacy of mandibular advancement device (MAD) therapy in an individual patient diagnosed with obstructive sleep apnea. This process is called titration and is generally based on resolution of subjective symptoms like snoring and/or daytime sleepiness as a function of protrusion. An objective approach uses a remotely controlled mandibular positioner (RCMP) during a full-night polysomnography (PSG), in analogy with continuous positive airway pressure (CPAP) titration. More recently, the feasibility of RCMP use during drug-induced sleep endoscopy (DISE) titration was reported.

METHODS

This randomized crossover trial will compare DISE-assisted titration to PSG-guided titration, as well as with the conventional subjective titration method. The primary outcome is the actual mandibular protrusive position found to be the most optimal for each tested titration procedure. Furthermore, the therapeutic efficacy will be compared among the different titration modalities using level 1 sleep studies.

DISCUSSION

Currently, the optimal titration of MAD therapy is most often based on 'trial and error'. The conventional method relies on subjective improvement in symptoms, although this may not provide the most accurate indicator for efficient titration. Therefore, relying on objective criteria in the titration process should be advantageous. In analogy with CPAP, titration of the most optimal mandibular protrusion could be performed using RCMP during an overnight titration PSG. Recently, it was shown that titration under direct visualization of upper airway patency and collapsibility is feasible using the RCMP during DISE. However, no clinical results for such a procedure are as yet available. This study is the first to compare the most optimal mandibular protrusive position according to three titration procedures, as well as to compare the therapeutic efficacy of these titration methods.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03716648 . Registered on 23 October 2018.

IMAGES: Drug-Induced Sleep Endoscopy: An Investigative Tool for Mechanisms of PAP Failure

ABSTRACT

This is a case report of a 60-year-old female with mild obstructive sleep apnea (OSA) who presented to CPAP Alternatives clinic following multiple failed attempts at positive airway pressure (PAP) therapy. She underwent drug-induced sleep endoscopy (DISE) with the concurrent application of PAP via two different mask types. Application of the oronasal mask at low pressures demonstrated soft palate collapse, while high pressures resulted in posterior tongue collapse. In contrast, application of the nasal mask eliminated palatal and tongue obstruction at low pressures, despite mask leak at higher pressures. She was recommended a trial of nasal autoPAP, which with the use of a chinstrap, resulted in both subjective and objective improvement of her OSA.

European position paper on drug-induced sleep endoscopy: 2017 Update

BACKGROUND

The first edition of the European position paper (EPP) on drug-induced sleep endoscopy (DISE) was published in 2014 with the aim to standardise the procedure, to provide an in-depth insight into the main aspects of this technique and to have a basis for future research. Since 2014, new studies have been published concerning new sedative agents or new insights into the pattern/levels of the obstruction depending on the depth of sedation. Therefore, an enlarged group of European experts in the field of sleep breathing disorders (SBD), including the most of the first DISE EPP main authors, has decided to publish an update of the European position paper on DISE, in order to include new evidence and to find a common language useful for reporting the findings of this endoscopic evaluation in adult population affected by SBD.

METHODS

The authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centres in order to provide an update regarding the standardisation of the DISE procedure and an in-depth insight into the main aspects of this technique.

RESULTS

After the first European Position Consensus Meeting on DISE and its update, consensus was confirmed for indications, required preliminary examinations, where to perform DISE, technical equipment required, staffing, local anaesthesia, nasal decongestion, other medications, patient positioning, basics and special diagnostic manoeuvres, drugs and observation windows. So far, no consensus could be reached on a scoring and classification system. However, regarding this aim, the idea of an essential classification, such as VOTE with the possibility of its graded implementation of information and descriptions, seems to be the best way to reach a universal consensus on DISE classification at this stage. A common DISE language is mandatory, and attempts to come to a generally accepted system should be pursued.

Remotely Controlled Mandibular Positioning During Drug-Induced Sleep Endoscopy Toward Mandibular Advancement Device Therapy: Feasibility and Protocol

STUDY OBJECTIVES

The potential of a remotely controlled mandibular positioner (RCMP) during sleep studies in individual patients suffering from obstructive sleep apnea (OSA) for the determination of the effective target protrusive position (ETPP) of the mandible has been demonstrated. The research goal of this study was to assess the feasibility of the application of RCMP during drug-induced sleep endoscopy (DISE) for the determination of ETPP.

METHODS

Ten patients in whom OSA was diagnosed (50% male; age 54 ± 9.5 years; body mass index 26.9 ± 2.1 kg/m²; apnea-hypopnea index 28.4 ± 13.2 events/h) were enrolled prospectively. Dental RCMP trays were fitted during wakefulness. Maximal protrusion and edge-to-edge positions were measured. Upper airway collapsibility was scored during DISE, including full-range mandibular RCMP titration within 45 minutes. ETPP was defined as the mandibular threshold protrusion yielding a stable upper airway in the absence of snoring, oxygen desaturation and apneas.

RESULTS

RCMP trays were retentive and no adverse reactions occurred. RCMP was fitted intraorally prior to sedation with maxillary and mandibular trays in edge-to-edge position. Upon sedation, progressive protrusion was performed followed by reversed titration until ETPP was noted. In one patient ETPP was not within the mandibular range of motion. In one patient RCMP needed to be removed because of clenching.

CONCLUSIONS

The results of this study illustrate that it is feasible to use RCMP during DISE and to determine ETPP within 45 minutes. Comparative research with polysomnography would be useful to further validate the therapy outcome upon use of RCMP during DISE.

A review on drug-induced sedation endoscopy - Technique, grading systems and controversies

Sleep disordered breathing (SDB) comprises a spectrum of disorders, ranging from simple snoring to severe obstructive sleep apnoea (OSA), with a significant burden to health care systems in high income countries. If left untreated, OSA has significant cumulative, long-term health consequences. In the 1990s drug induced sedation endoscopy (DISE) has been developed to become a primary tool in the diagnosis and management of OSA. It allows meticulous endoscopic evaluation of the airway and identifies areas of collapse, thereby informing both on the selection of surgical techniques, where efficacy depends entirely on success at relieving obstruction at a certain level and on the usefulness of conservative measures, such as mandibular advancement splints. This article provides a review of the literature on DISE, covering different grading systems and techniques, explaining different rationales and discussing controversies.

Drug-Induced Sleep Endoscopy as a Selection Tool for Surgical Management of Obstructive Sleep Apnoea Syndrome: Our Personal Experience

The role of Drug-induced sleep endoscopy as a selection tool for surgical management of obstructive sleep apnoea syndrome.

SOURCE OF DATA

Polysomnography proved OSA patients, who are planned for surgery in dept. of ENT AND HEAD& NECK, JSS Hospital, Mysore.

STUDY DESIGN

A prospective clinical study.

METHOD

30 Polysomnography proved OSA patients, age between 20 and 60 years have been selected for Drug Induced Sleep Endoscopy (DISE) after taking informed consent for proposed surgery. Inj propofol infusion given throughout the DISE procedure and upper airway nasal endoscopy performed for assessment of site of collapse (Retropalatal, Retrolingual, Hypopharyngral), type of collapse (circumferential, lateral) and severity of obstruction, Lowest SpO₂, apnoeic episodes and DISE findings were recorded. Out of these thirty patients 90% were male and 10% were female, observed that 66.7% of males and 40.7% of females belonged to 31-40 age group, and BMI of 63.3% of patient population were overweight, 20% were obese and 5% were normal. Mean fall in SpO₂ was 90.20 ± 2.77 in normal subjects, 83.05 ± 5.14 in overweight subjects and 68.83 ± 9.11 in obese subjects. Normal subjects had 0.4 ± 0.9 apnoeic episodes, overweight subjects had 0.9 ± 1.6 episodes and obese subjects had 4.0 ± 2 apnoeic episodes. We observed that 40% had retropalatal airway collapse, 23.3% had airway obstruction at the base of the tongue, 20% had airway obstruction with floppy epiglottis, 12% multiple level collapse, 6.7% of patient population had grade 4 enlarged tonsils, 3.3% had lateral pharyngeal wall collapse, and 0% hypopharyngeal collapse. Out of 30, 29 Patients underwent surgery (Expansion sphincter pharyngo plasty-14, Hyoid advancement-4, Uuvulopalatoplasty-10, Epiglottic surgery-6, Zeta pharyngoplasty-2, midline glossectomy-3, Endoscopic septoplasty-5, Inferio turbinoplasty-2, LASSER Assisted lingual tonsillectomy-1), All these 29 patient were followed for 3 months, at the end of 3rd month again Each subject was evaluated with a baseline Epworth Sleepiness Scale and LEVEL-3 PSG, the results were impressive with statistically significant. DISE is a dynamic, safe, and easy-to-perform technique that visualizes, the anatomical sites of snoring or apneas for assessment site of collapse (Retropalatal, Retrolingual, Hypopharyngral), type of collapse (Circumferential, Lateral) and severity of obstruction and guides the design of a tailor-made treatment plan for a OSA SURGEON in individual cases, which will improves perioperative outcome.

Impact of continuous positive airway pressure in patients with obstructive sleep apnea during drug-induced sleep endoscopy

OBJECTIVES

The primary objective of the study was to understand the differential impact of continuous positive airway pressure (CPAP) on the location, degree and pattern of airway collapse in obstructive sleep apnea (OSA) patients utilizing drug-induced sleep endoscopy (DISE).

STUDY DESIGN

Non-randomized trial.

SETTING

University Medical Center.

PARTICIPANTS

Fifteen consecutive OSA patients undergoing DISE.

MAIN OUTCOMES AND MEASURES

The patterns of airway collapse were videorecorded at baseline and under differential application of nasal CPAP (nCPAP) at 5, 10 and 15 cm H₂ O. For each modality, the pattern and degree of airway collapse were analyzed by three independent observers using the velum, oropharynx, tongue base, epiglottis (VOTE) classification system.

RESULTS

The modest nCPAP pressures (10 cm H₂ O) had the greatest impact on the lateral walls of the pharynx, followed by the palatal region. The collapsibility of the tongue base and epiglottis demonstrated significant resistance to nCPAP application, which was overcome by increasing nCPAP to 15 cm H₂ O. Compared to 5 cm H₂ O, nCPAP pressures of 10 and 15 cm H₂ O improved complete collapse at least at one level of the upper airway (P=.016 and .001, respectively). Increased nCPAP pressures also led to changes in the configuration of airway collapse at the level of the velum.

CONCLUSIONS

The differential nCPAP effects observed in this study may help to understand some of the mechanisms responsible for inadequate patient response and poor nCPAP compliance. The use of DISE in combination with CPAP may serve as a first step in optimizing patients that failed to adapt to treatment with CPAP. This approach can help the physician identify patterns of airway collapse that may require varying pressures different from the one the patient is using, as well as anatomical factors that may be corrected to help with compliance.

[Drug-induced sedation endoscopy-quo vadis? : Review and outlook]

BACKGROUND

Drug-induced sedation endoscopy (DISE) is a diagnostic procedure which allows evaluation of the collapsibility of the upper airway. According to expert opinion, it is possible to imitate nocturnal collapsibility and perform a realistic investigation of the site of obstruction and vibration. This should enable sufficient and precise therapeutic advice to be given solely on the basis of clinical assessment.

OBJECTIVE

The current publication critically evaluates the present state of development of DISE and its potential indications.

MATERIALS AND METHODS

A PubMed literature research was performed using "sleep" and "endoscopy" or "DISE" as keywords. Relevant publications were evaluated.

RESULTS

The present publication provides a historical summary of the available publications and relates these to other methods for examining obstructive sleep apnea. The present state of DISE in terms of drugs applied, grading systems, and validity is evaluated. Indications for DISE are described and critically discussed on the basis of literature data.

CONCLUSION

DISE provides deep insights into the genesis of obstructions of the upper airway and snoring. Although its value for diagnosis and treatment of sleep-disordered breathing could not yet be demonstrated for all non-CPAP (continuous positive airway pressure) therapies, DISE could identify predictive parameters some methods. Further potential indications for DISE might be predictive examinations for mandibular advancement devices and respiration-synchronous neurostimulation of the hypoglossal nerve. DISE will thus remain a valuable diagnostic tool for obstructive sleep apnea and rhonchopathy.

Drug-Induced Sleep Endoscopy Changes the Treatment Concept in Patients with Obstructive Sleep Apnoea

The present study evaluated whether drug-induced sleep endoscopy (DISE) helps identify the site of obstruction in patients with obstructive sleep apnoea (OSA). A total of 51 consecutive patients with polysomnography-confirmed OSA were enrolled in this prospective study. The presumed site of obstruction was determined according to history, otorhinolaryngologic examination, and polysomnography and a therapeutic plan designed before DISE. In 11 patients with severe OSA and/or previously failed continuous positive airway pressure (CPAP) treatment, DISE with simultaneous CPAP was performed. Multilevel collapse was noted in 49 patients (96.1%). The most frequent multilevel collapse was palatal, oropharyngeal, and tongue base collapse (n = 17, 33.3%), followed by palatal and oropharyngeal collapse (n = 12, 23.5%). Pathology of the larynx (epiglottis) was observed in 16 patients (31.4%). The laryngeal obstruction as a reason for intolerance of CPAP was observed in 3/11 (27.3%) patients. After DISE, the surgical plan was changed in 31 patients (60.8%). The results indicate that DISE helps identify the site of obstruction in the upper airways in patients with OSA more accurately and that the larynx plays an important role in OSA.

The Use of Remotely Controlled Mandibular Positioner as a Predictive Screening Tool for Mandibular Advancement Device Therapy in Patients with Obstructive Sleep Apnea through Single-Night Progressive Titration of the Mandible: A Systematic Review

STUDY OBJECTIVES

To perform a review of the current evidence regarding the use of a remotely controlled mandibular positioner (RCMP) and to analyze the efficacy of RCMP as a predictive selection tool in the treatment of obstructive sleep apnea (OSA) with oral appliances that protrude the mandible (OAm), exclusively relying on single-night RCMP titration.

METHODS

An extensive literature search is performed through PubMed.com, Thecochranelibrary.com (CENTRAL only), Embase.com, and recent conference meeting abstracts in the field.

RESULTS

A total of 254 OSA patients from four full-text articles and 5 conference meeting abstracts contribute data to the review. Criteria for successful RCMP test and success with OAm differed between studies. Study populations were not fully comparable due to range-difference in baseline apneahypopnea index (AHI). However, in all studies elimination of airway obstruction events during sleep by RCMP titration predicted OAm therapy success by the determination of the most effective target protrusive position (ETPP). A statistically significant association is found between mean AHI predicted outcome with RCMP and treatment outcome with OAm on polysomnographic or portable sleep monitoring evaluation (p < 0.05).

CONCLUSIONS

The existing evidence regarding the use of RCMP in patients with OSA indicates that it might be possible to protrude the mandible progressively during sleep under poly(somno)graphic observation by RCMP until respiratory events are eliminated without disturbing sleep or arousing the patient. ETPP as measured by the use of RCMP was significantly associated with success of OAm therapy in the reported studies. RCMP might be a promising instrument for predicting OAm treatment outcome and targeting the degree of mandibular advancement needed.

Upper airway structural changes induced by CPAP in OSAS patients: a study using drug-induced sleep endoscopy

We studied upper airway structural changes induced by continuous positive airway pressure (CPAP) in obstructive sleep apnea syndrome (OSAS) patients using drug-induced sleep endoscopy (DISE). This prospective study was conducted at an academic secondary referral center. In total, 28 male OSAS patients (mean age 41.1 years) with only retropalatal level obstructions were enrolled. Measurements of the obstruction site were obtained in two steps: first a measurement was taken of the obstruction site in accordance with sleep apnea, then, a measurement was taken of the obstruction site in accordance with DISE-assisted CPAP titration, including quantitative changes in the occlusion site before and after CPAP in pixel format using an area calculation program. There was a tendency for persistent closing in cases of antero-posterior (AP) obstruction versus cases of lateral (Lat) obstruction in the CPAP titration. Lat obstructions showed a tendency to be wider than AP obstructions in the quantitative analysis. These results show that the pattern and degree of airway expansion after CPAP differ in accordance with the obstruction site.

European position paper on drug-induced sedation endoscopy (DISE)

BACKGROUND

Although drug-induced sedation endoscopy (DISE) represents the most widespread diagnostic tool for upper airway endoscopic evaluation of snoring and obstructive sleep apnea hypopnea syndrome (OSAHS), many controversies exist about how to perform the sedation, the indications for DISE, and how to report DISE findings. The present position paper reports on a consensus as proposed by a group of European experts in the field of DISE after discussion during a recent dedicated meeting.

METHODS

The authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centers in order to provide a standardization of the DISE procedure and an in-depth insight in the main aspects of this technique.

RESULTS

A proposal of the DISE procedure standardization has been achieved with a general agreement concerning the terminology, indications, contraindications, required preliminary examinations, setting, technical equipment required, staffing, local anesthesia and nasal decongestion, patient positioning, basis and special diagnostic maneuvers, and the applied sedation drugs and observation windows. Otherwise, no consensus has been reached on a scoring and classification system.

CONCLUSIONS

Although consensus has been reached on several aspects of the DISE procedure, some topics remain open to future research, such as a better analysis of the importance of positional aspects during DISE and a further comparison of the differences in degree, level and pattern of upper airway collapse observed during DISE versus during natural sleep and awake endoscopy. Finally, a universally accepted scoring and classification system is lacking.

[Drug-induced sleep videoendoscopy: clinical usefulness and literature review]

Fiberoptic examination of the pharynx under drug-induced sleep is a test that helps to detect the areas of vibration and collapse in patients with sleep-disordered breathing. This article is a review of the available literature on the subject, aimed at helping otolaryngologists to understand the procedure and to resolve some controversies surrounding it.