Drug-induced sleep endoscopy: a two drug comparison and simultaneous polysomnography

Efficacy of high-flow nasal oxygen during drug-induced sleep endoscopy in patients with obstructive sleep apnea

PURPOSE

High-flow nasal oxygenation (HFNO) can provide a low level of continuous positive airway pressure and alveolar recruitment. We aimed to compare the efficacy of pre-oxygenation with HFNO and low-flow nasal oxygenation (LFNO) during drug-induced sleep endoscopy (DISE).

METHODS

In the LFNO group, preoxygenation was performed for 10 min at 3 L·min-1. In the HFNO group, preoxygenation was performed for 10 min at 30 L·min-1 at a fraction of inspired oxygen of 100% using the Optiflow device. From the start of sedative administration to the end of DISE, vital signs were monitored continuously. The primary outcome was the lowest oxygen saturation (SpO2) during DISE.

RESULTS

Of 24 patients enrolled, 12 were randomly assigned to the LFNO and 12 to the HFNO groups. The prevalence of hypoxia events was 75% in the LFNO group and 58% in the HFNO group. The difference in lowest oxygen saturation between the two groups was not significant between the two groups (P=0.665). The lowest SpO2 during all procedures was comparable between the two groups (86.8 ± 6.5% in the LFNO group and 87.2 ± 8.0% in the HFNO group; P=0.912).

CONCLUSIONS

The findings suggest that HFNO may not be superior to LFNO as a preoxygenation tool to prevent hypoxia during DISE.

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.

Treatment of primary epiglottis collapse in OSA in adults with glossoepiglottopexy: a 5-year experience

Objective

To review our 5-year experience with a modified version of glossoepiglottopexy for treatment of obstructive sleep apnoea syndrome (OSA) in two hospitals.

Methods

A retrospective analysis was carried out on a cohort of adult patients affected by OSA suffering from primary collapse of the epiglottis who underwent a modified glossoepiglottopexy. All patients underwent drug-induced sleep endoscopy, polysomnographic and swallowing evaluation, and assessment with the Epworth Sleepiness Scale (ESS).

Results

Forty-nine patients were retrospectively evaluated. Both the apnoea-hypopnoea index (AHI) (median AHI_post-AHI_pre = -22.4 events/h; p < 0.001) and oxygen desaturation index (ODI) showed a significant postoperative decrease (median ODI_post-ODI_pre = -18 events/h; p < 0.001), as did hypoxaemia index (median T_{90% post}-T_{90% pre} = -5%; p < 0.001). The ESS questionnaire revealed a significant decrease in postoperative scores (median ESS_post-ESS_pre =- 9; p < 0.001). None of the patients developed postoperative dysphagia.

Conclusions

Our 5-year experience demonstrates that modified glossoepiglottopexy is a safe and reliable surgical technique for treatment of primary epiglottic collapse in OSA patients.

The Use of Middle Latency Auditory Evoked Potentials (MLAEP) as Methodology for Evaluating Sedation Level in Propofol-Drug Induced Sleep Endoscopy (DISE) Procedure

To analyze the middle latency auditory evoked potential index (MLAEPi), compared to the standard bispectral index (BIS), as a method for evaluating the sedation level in drug-induced sleep endoscopy (DISE). In this controlled clinical study on a sample of 99 obstructive sleep apnea (OSA) or snoring patients, we compared the MLAEPi with the BIS after propofol infusion during the standard DISE technique in order to define the MLAEPi values within the observational window of the procedure. The DISE procedure was divided into eight steps, and we collected both MLAEPi and BIS data values from the same patient in every step. The MLAEPi showed a faster response than the BIS after propofol infusion during DISE. Therefore, the clinical use of the MLAEPi in evaluating the sedation level seems to be a good alternative to the current technological standards.

Oxygen desaturation during flexible bronchoscopy with propofol sedation is associated with sleep apnea: the PROSA-Study

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial obstruction of the upper airways during sleep. Conscious sedation for flexible bronchoscopy (FB) places patients in a sleep-like condition. We hypothesize that oxygen desaturation during flexible bronchoscopy may help to detect undiagnosed sleep apnea.

METHODS

Single-centre, investigator-initiated and driven study including consecutive patients undergoing FB for clinical indication. Patients completed the Epworth Sleepiness Scale (ESS), Lausanne NoSAS score, STOP-BANG questionnaire and the Berlin questionnaire and underwent polygraphy within 7 days of FB. FB was performed under conscious sedation with propofol. Oxygen desaturation during bronchoscopy was measured with continuous monitoring of peripheral oxygen saturation with ixTrend (ixellence GmbH, Germany).

RESULTS

145 patients were included in the study, 62% were male, and the average age was 65.8 ± 1.1 years. The vast majority of patients (n = 131, 90%) proved to fulfill OSA criteria based on polygraphy results: 52/131 patients (40%) had mild sleep apnea, 49/131 patients (37%) moderate sleep apnea and 30/131 patients (23%) severe sleep apnea. Patients with no oxygen desaturation had a significantly lower apnea-hypopnea index than patients with oxygen desaturation during bronchoscopy (AHI 11.94/h vs 21.02/h, p = 0.011). This association remained significant when adjusting for the duration of bronchoscopy and propofol dose (p = 0.023; 95% CI 1.382; 18.243) but did not hold when also adjusting for age and BMI.

CONCLUSION

The severity of sleep apnea was associated to oxygen desaturation during flexible bronchoscopy under conscious sedation. Patients with oxygen desaturation during bronchoscopy might be considered for sleep apnea screening.

TRIAL REGISTRATION

The Study was approved by the Ethics Committee northwest/central Switzerland, EKNZ (EK 16/13) and was carried out according to the Declaration of Helsinki and Good Clinical Practice guidelines. Due to its observational character, the study did not require registration at a clinical trial registry.

Drug-induced sleep endoscopy: techniques, interpretation and implications

PURPOSE OF REVIEW

The purpose of this article is to highlight recent advances in the burgeoning field of drug-induced sleep endoscopy (DISE).

RECENT FINDINGS

One of the first studies to investigate the correlation of DISE findings and natural sleep endoscopy found good agreement in clinically significant obstruction. Previous studies have shown good agreement of DISE findings with the use of different sedative agents implying that the choice of sedative may not be crucial. However, recent studies show variable patterns of collapse, especially at the tongue base, with the use of different sedative agents. A universally accepted classification scheme for drug-induced sleep endoscopy is lacking. A new DISE classification system, termed Palate, Tonsils, Lateral pharyngeal wall, Tongue base, Epiglottis, was introduced this year with the noted advantage of being able to better differentiate between clinically relevant tonsillar and lateral pharyngeal wall collapse. Despite recent advances in the field, there remains no general consensus that DISE findings predict surgical success but may aid in the identification of patients who will respond well to oral appliance therapy.

SUMMARY

Drug-induced sleep endoscopy is a structure-based evaluation of the upper airway that more closely resembles the natural sleep state compared with awake evaluation.

A New Technological Advancement of the Drug-Induced Sleep Endoscopy (DISE) Procedure: The "All in One Glance" Strategy

To illustrate a new technological advance in the standard drug-induced sleep endoscopy (DISE) model, a new machine was used, the Experimental 5 Video Stream System (5VsEs), which is capable of simultaneously visualizing all the decisional parameters on a single monitor, and recording and storing them in a single uneditable video. The DISE procedure was performed on 48 obstructive sleep apnea (OSA) or snoring patients. The parameters simultaneously recorded on a single monitor are (1) the pharmacokinetics and pharmacodynamics of propofol (through the target controlled infusion (TCI) pump monitor), (2) the endoscopic upper airway view, (3) the polygraphic pattern, and (4) the level of sedation (through the bispectral index (BIS) value). In parallel to the BIS recording, the middle latency auditory evoked potential (MLAEP) was also recorded and provided. Recorded videos from the 5VsEs machine were re-evaluated six months later by the same clinician and a second clinician to evaluate the concordance of the therapeutic indications between the two. After the six-month period, the same operator confirmed all their clinical decisions for 45 out of 48 videos. Three videos were no longer evaluable for technical reasons, so were excluded from further analysis. The comparison between the two operators showed a complete adherence in 98% of cases. The 5VsEs machine provides a multiparametric evaluation setting, defined as an “all in one glance” strategy, which allows a faster and more effective interpretation of all the simultaneous parameters during the DISE procedure, improving the diagnostic accuracy, and providing a more accurate post-analysis, as well as legal and research advantages.

The anesthesia airway evaluation: Correlation with sleep endoscopy findings

PURPOSE

Drug-induced sleep endoscopy (DISE) is a cost-effective, safe, and reliable tool to evaluate obstructive sleep apnea (OSA) patients by revealing upper airway sites, patterns, and severity of obstruction. DISE provides valuable data because reliable evaluation of the OSA airway while awake has remained elusive. Few studies (with mixed results) have analyzed the correlation between pre-operation, awake airway assessments routinely performed by anesthesia and DISE results.

METHODS

Preoperative anesthesia evaluation records and subsequent DISE reports were obtained for 99 adult patients undergoing DISE between 2016 and 2018. All patients carried the diagnosis of OSA, based on polysomnography. Anesthesia-collected variables were compared with DISE findings in an effort to determine if commonly-utilized physical exam findings correlated to patterns of upper airway collapse observed on sleep endoscopy.

RESULTS

Most anesthesia preoperative evaluation variables were not found to be predictive of any identifiable patterns of collapse on DISE, including Mallampati score, ability to prognath, and overall airway assessment score. Obesity did not correlate with circumferential collapse at the velopharynx, or to multi-level collapse. Thyromental distance <6.5 cm was found to be statistically correlated to total epiglottic collapse (E = 2+). Friedman tongue position scores were found to be correlated to velopharyngeal collapse (p < 0.05).

CONCLUSIONS

Anesthesia airway assessment algorithms and physical exam findings do not correlate well with findings on sleep endoscopy. DISE remains the gold standard for evaluating levels of collapse and operative planning in the OSA population.

Test-retest reliability of drug-induced sleep endoscopy using midazolam

STUDY OBJECTIVES

Drug-induced sleep endoscopy (DISE) has been suggested to be a valuable method for determining the obstruction patterns causing sleep-disordered breathing. However, since DISE is not performed throughout the duration of sleep but for less than 1 hour, the reproducibility and reliability of DISE are questionable. Therefore, we aimed to determine the test-retest reliability of DISE using midazolam.

METHODS

Thirty-four patients diagnosed with obstructive sleep apnea were prospectively included in this study. The patients underwent 2 separate DISE examinations that were performed at different days using the same drug and technique. For a more accurate comparison, the depth of sleep and examination time were identically controlled. VOTE classification was used to classify the obstruction findings, and the findings of upper airway obstruction were compared between the 2 tests.

RESULTS

There were 30 men and four women; the mean age was 45.4 ± 13.1 years. The mean apnea-hypopnea index was 38.3 ± 22.6, and the lowest oxygen saturation was 77.5% ± 12.4%. The lateral wall of the oropharynx, tongue base, and epiglottis showed very good agreement, and the velum showed good agreement between the first and second DISE examinations.

CONCLUSIONS

The reliability of DISE is debatable because it observes only a small portion of the total sleep, but this study suggests that DISE is a reliable test because the findings of 2 separate DISE examinations on different days showed a high concordance rate.

Pediatric Drug Induced Sleep Endoscopy: A Simple Sedation Recipe

Objective:

To describe a minimalist approach to sedating children for DISE procedures.

Methods:

We searched existing literature and derived and tested our algorithm on patients using evidence-based studies.

Results:

We were able to successfully sedate, without airway intervention, 15 highly complex children with a variety of comorbidities for DISE procedures.

Conclusion:

We describe a minimalistic sedation approach for DISE procedures in highly complex children. Further studies are required to compare this regimen to natural sleep states.

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

Obstruction Patterns During Drug-Induced Sleep Endoscopy vs Natural Sleep Endoscopy in Patients With Obstructive Sleep Apnea

Importance

Drug-induced sleep endoscopy (DISE) has been suggested to be a valuable technique for identifying the obstruction site associated with sleep-disordered breathing. However, the reliability of DISE findings is controversial because the procedure uses sedative drugs, which may have implications for the obstruction patterns observed on DISE.

Objective

To compare the obstruction patterns during DISE with the obstruction patterns during natural sleep endoscopy (NSE).

Design, Setting, and Participants

This prospective cohort study was conducted between June 2013 and May 2018 in Kyungpook National University Chilgok Hospital in Daegu, South Korea. All analysis took place from June 1 to July 31, 2018. Participants had an obstructive sleep apnea diagnosis, were older than 18 years, and had an apnea hypopnea index higher than 5 on type I polysomnography. The patients initially enrolled were excluded from the study for not reaching adequate sleep depth and waking up during insertion of the nasopharyngoscope.

Intervention

Patients underwent DISE using midazolam and NSE without sedatives on 2 different days.

Main Outcomes and Measures

Obstruction findings were observed only in the same range (65-75) of the bispectral index on both days. Obstruction findings were classified according to the VOTE (velum, oropharynx lateral wall, tongue base, and epiglottis) classification. The extent of agreement between DISE and NSE findings was evaluated using Cohen weighted κ value.

Results

The study included 26 patients with snoring or obstructive sleep apnea (mean [SD] age, 44.7 [10.3] years; predominantly male [22 (85%)]). The mean (SD) apnea hypopnea index was 41.9 (17.2) and the lowest mean (SD) oxygen saturation was 79.8% (12.2%). The degree of agreement in upper-airway obstruction between DISE and NSE was 76.9% (Cohen weighted κ = 0.42; 95% CI, 0.02-0.83) in the velum, 88.5% (Cohen weighted κ = 0.84; 95% CI, 0.67-1.01) in the oropharynx lateral wall, 69.2% (Cohen weighted κ = 0.66; 95% CI, 0.46-0.86) in the tongue base, and 92.3% (Cohen weighted κ = 0.67; 95% CI, 0.24-1.11) in the epiglottis. Agreement of configuration of the velum was 88.5% (Cohen weighted κ = 0.50; 95% CI, -0.03 to 1.03) and the epiglottis was 92.3% (Cohen weighted κ = 0.67; 95% CI, 0.24-1.11).

Conclusions and Relevance

Obstruction patterns of the upper airway appeared to be in agreement between DISE and NSE, suggesting that DISE may be a reliable test; future studies of multiple positions and sleep stages with larger sample sizes may confirm these results.

Drug-Induced Sleep Endoscopy: Technique, Indications, Tips and Pitfalls

Drug-induced sleep endoscopy (DISE) is a diagnostic tool to assess the upper airway of snorers and obstructive sleep apnea patients in conditions that mimic natural sleep. Although DISE appears simple and similar to awake endoscopy, there are many aspects that need to be standardized in order to obtain reliable and reproducible information. In this article, we will recommend how to reliably perform DISE, its indications, and how to obtain and interpret the information of the upper airway.

Dexmedetomidine versus propofol at different sedation depths during drug-induced sleep endoscopy: A randomized trial

OBJECTIVES/HYPOTHESIS

The aim of this study was to compare the effect of dexmedetomidine and propofol on airway dynamics, cardiorespiratory system, and emergence following drug-induced sleep endoscopy (DISE).

STUDY DESIGN

Prospective, randomized, single-blinded study.

METHODS

Sixty patients age 18 to 65 years in American Society of Anesthesiologists physical status groups 1 and 2 scheduled to undergo DISE were randomly allocated to either Group P (N = 30; receiving propofol infusion at 50-150 μg/kg/min) or Group D (N = 30; receiving dexmedetomidine bolus of 1 μg/kg followed by infusion at 0.5-1.0 μg/kg/hr). DISE was done at light sleep and deep sleep. Airway obstruction at tongue base was recorded as primary outcome. Airway obstruction at velum, oropharyngeal lateral wall, and epiglottis level during light and deep sedation, hemodynamic and respiratory parameters, time to attain sufficient sedation, time for emergence from sedation, and any adverse events during DISE with the two study drugs were recorded as secondary outcomes.

RESULTS

There was a greater degree of obstruction at the tongue base level (P = 0.001) and Oropharynx level (P = 0.017) in Group P compared with Group D during deep sedation. Increase in airway obstruction from light to deep sleep was seen with propofol at the oropharynx (P = 0.0185) and tongue base (P = 0.0108) levels. Two patients (6.6%) in Group D and 10 patients (33.3%) in Group P showed oxygen saturation below the minimum oxygen saturation recorded during polysomnography. Time to open eyes to call after stopping sedation was significantly less in Group P (P = 0.005).

CONCLUSIONS

Dexmedetomidine shows a lesser degree of airway collapse and higher oxygen saturation levels at greater sedation depth during DISE. Propofol has a faster onset and emergence from sedation.

LEVEL OF EVIDENCE

1b Laryngoscope, 130:257-262, 2020.

Is epiglottis surgery necessary for obstructive sleep apnea patients with epiglottis obstruction?

OBJECTIVES/HYPOTHESIS

To examine the effect of epiglottis obstruction during drug-induced sleep endoscopy (DISE) on the surgical results of multilevel sleep surgery without epiglottic intervention.

STUDY DESIGN

Cross-sectional study.

METHODS

This investigation involved patients diagnosed with severe obstructive sleep apnea (OSA) based on preoperative polysomnography (PSG), who underwent DISE followed by multilevel OSA surgery without epiglottic intervention at Kyung Hee Medical Center (Seoul, South Korea) between March 2013 and July 2016. During DISE, obstruction patterns of the upper airway were evaluated using the velum, oropharynx, tongue base, epiglottis classification method. Follow-up PSG was performed 3 months after surgery to determine the success rate of multilevel surgery without epiglottic intervention. A comparison was done between the group with epiglottis obstruction and the group without epiglottis obstruction.

RESULTS

Epiglottis obstruction was observed during DISE in 43.7% of patients. After application of exclusion criteria, 54 subjects were included (27 with and 27 without epiglottis obstruction). DISE revealed an association between epiglottis obstruction and tongue base collapse (P = .02). Comparing pre- and postoperative PSG findings, both groups exhibited improvement postoperatively. The success rate was 44.4% in the epiglottis obstruction group and 40.7% in the non-epiglottis obstruction group (P = .80). There was no difference in surgical success rates between the two groups.

CONCLUSIONS

The prevalence of epiglottis obstruction requiring epiglottic surgery was lower than what was found during DISE. Sleep surgeons may consider staged epiglottic surgery in patients with epiglottis obstruction.

LEVEL OF EVIDENCE

3b Laryngoscope, 129:2658-2662, 2019.

Effect of remifentanil during drug-induced sleep endoscopy in patients with obstructive sleep apnea

PURPOSE

During drug-induced sleep endoscopy (DISE) in patients with obstructive sleep apnea, the increased depth of propofol anesthesia is related to the increased collapsibility of the upper airway with dose-dependent. We examined the effect of remifentanil on propofol concentration during DISE.

METHODS

In a prospective randomized trial, 56 adult patients were divided into remifentanil-propofol (n = 28) and propofol alone (n = 28) groups. Anesthesia was administered using a target-controlled infusion system. In the remifentanil-propofol group, 0.5 ng/ml remifentanil was administered prior to propofol infusion and its concentration maintained; thereafter, in the propofol alone group, normal saline was injected instead of remifentanil. Propofol was infused at a concentration of 1.5 μg/ml after the target concentration of remifentanil was reached. In both groups, the concentration of propofol was increased by 0.5 μg/ml if the degree of sedation was not sufficient. The sedation level was targeted at observer's assessment of alertness/sedation (OAA/S) scale 3.

RESULTS

The mean propofol concentration was 2.87 ± 0.60 μg/ml in the remifentanil-propofol group, which was lower than that in the propofol alone group (3.38 ± 0.72 μg/ml, P < 0.001). The time until sufficient sedation to perform DISE was shorter in the remifentanil-propofol group (P < 0.001). Apnea-hypopnea index and the lowest peripheral capillary oxygen saturation (SpO₂) during polysomnography showed no statistical difference between groups (P > 0.05). The lowest SpO₂ and VOTE classification during DISE were also not statistically different (P > 0.05).

CONCLUSIONS

Use of remifentanil during DISE reduces the target concentration of propofol required for patient sedation to perform DISE without respiratory depression.

The Effect of Sedating Agents on Drug-Induced Sleep Endoscopy Findings

OBJECTIVE

Drug-induced sleep endoscopy (DISE) has gained interest for upper airway evaluation in patients with snoring and obstructive sleep apnea (OSA), and different drugs have been used to induce sedation. Nevertheless, all drugs have presented specific advantages and disadvantages with differential effects on respiratory physiology. This study evaluated and compared the effects of midazolam, propofol and dexmedetomidine on DISE findings, O₂ nadir, and bispectral index (BIS) in the same sample of patients.

STUDY DESIGN

Case series prospective study.

METHODS

Consecutive patients who elected to undergo surgery for OSA treatment and were intolerant to conservative therapies underwent DISE with propofol, dexmedetomidine, and midazolam between July 2015 and July 2016.

RESULTS

Fifty-two patients were analyzed, and 43 (82.7%) were men. Agreement among drugs for both degree and patterns of obstruction was excellent at all sites (velum, oropharynx, and epiglottis) except for the tongue base. Dexmedetomidine had the least complete collapse sites and highest O₂ nadir and was the only drug for which apnea severity and obstruction levels (upper, lower, or combined) were correlated. The variability among drug treatments for the BIS index was considerable, and propofol had the lowest variability and average value.

CONCLUSION

Drug selection had a relevant influence in DISE findings. Compared with dexmedetomidine, midazolam and propofol presented higher incidence of tongue base collapse, lower O₂ levels, and lower BIS index values. Propofol resulted in an O₂ nadir that most resembled that observed during polysomnography. The BIS index variability differed among drugs, and its use was considered relevant for sedation orientation.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:506-513, 2019.

Sleep endoscopy findings in children with persistent obstructive sleep apnea after adenotonsillectomy

OBJECTIVES

Describe the patterns of obstruction in persistent pediatric OSA and their relationship with patient weight.

STUDY DESIGN

Retrospective review.

METHODS

All pediatric DISE procedures performed at a tertiary care hospital between October 2010 and October 2015 were reviewed. Patients had polysomnography after adenotonsillectomy that confirmed persistent obstructive sleep apnea (OSA). Variables included age, gender, co-morbidities, and AHI. DISE findings focused on inferior turbinates, adenoid, tongue base, epiglottis, aryepiglottic (AE) folds, arytenoids, lingual tonsil and their contributions to obstruction.

RESULTS

34 patients were included with mean age of 7.85 (2-16) years, mean BMI of 23.15 (13.6-44.8) and mean AHI of 6.34 (1.5-25.2) events per hour. Obstruction occurred at the level of the epiglottis in 97%, with retropositioning by tongue base (73.6%) or lingual tonsil enlargement (70.5%). Obstruction occurred at the inferior turbinates in 76.5%, the adenoid in 64.7% and the palate in 58.8%. Shortened AE folds were less often identified (15%). Multiple sites of partial or complete obstruction were found in 97% of patients. Overweight or obese patients had a mean of 3 sites of complete obstruction and 4.69 sites of partial or complete obstruction as compared to 2.33 and 4.52 in underweight or normal weight children. Overweight or obese children were more likely to have obstruction at the lingual tonsil or adenoid than normal/underweight children.

CONCLUSION

Multiple sites of obstruction in persistent pediatric OSA were found. Children with higher BMIs had slightly different findings, suggesting that attention to adenoid regrowth and lingual tonsil hypertrophy is important.

The use of drug-induced sleep endoscopy in England and Belgium

Purpose

The purpose of this international survey is to ascertain the current practice of drug-induced sleep endoscopy (DISE) for patients with sleep-disordered breathing (SDB) by Otolaryngologists in the United Kingdom and Belgium. We compare the results with recommendations from the European Position Paper on drug-induced sleep endoscopy.

Methods

An online questionnaire was circulated to Consultant Otolaryngologists, independent practitioners, and trainees across the two countries. Eleven questions were used in total.

Results

181 responses from the UK and 117 responses from Belgium were received, mostly from consultants and independent practitioners. SDB was a common presentation to ENT practice, seen by over 90% of clinicians. The use of DISE varied greatly between the two countries (72.9% Belgium, 26.1% UK). 54.1% of Belgian respondents use DISE on over 50% of their patients, compared to only 32.4% of British clinicians. Attitudes of surgeons towards the diagnostic value of DISE varied; in Belgium, the majority (54%) gave a rating of 3 or more (1 = useless to 5 = essential), with no respondents giving a score of 0 (useless). In the UK only 16% of respondents felt DISE had useful clinical value, with 25 respondents deeming it ’useless’. The majority opt for DISE when non-surgical therapies fail (51.4% UK, 61.3% Belgium). The majority of participants do not use objective measures for depth of sedation (75.7% UK, 66.7% Belgium), with a marked variation on anaesthetic methods. 62.2% of UK clinicians do not use a classification system, whereas in Belgium the majority of clinicians (60.8%) use the VOTE grading system.

Conclusions

Clinicians in Belgium were more favourable to using DISE than in the UK. Differences in its clinical effectiveness were apparent between the two countries. A consensus on patient selection, method of sedation and an effective classification system seemed to be lacking from both countries. Further education is required to raise awareness for the use of 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.

Diagnosing Tongue Base Obstruction in Pierre Robin Sequence Infants

Objective:

To investigate whether awake endoscopy can diagnose base-of-tongue obstruction as reliably as sleep endoscopy in infants with Pierre Robin sequence (PRS).

Design:

The study was retrospective with the clinicians blinded to patient identity. Endoscopy findings were assessed and measured by the performing pediatric otolaryngologist.

Setting:

Tertiary care children’s hospital.

Patients:

All infants with PRS managed between January 2005 and July 2015 were included. There were 141 patients, of which 35 underwent both awake endoscopy (AE) and drug-induced sleep endoscopy (DISE).

Interventions:

Bedside AE and DISE in the operating room.

Main Outcome Measures:

Presence of moderate or severe base-of-tongue collapse was assessed. Sensitivity, specificity, and positive likelihood ratio of AE findings as well as intertest differences between AE and DISE were calculated.

Results:

AE had 50.0% sensitivity (95% confidence interval [CI] 27.2%-72.8%) and 86.7% specificity (95% CI 59.5%-98.3%) for detecting base-of-tongue obstruction compared to DISE; false negative rate was 50.0% (n = 10). Positive likelihood ratio was 3.75 (CI 0.96-14.65). Compared to AE, DISE demonstrated significantly more cases of base-of-tongue obstruction ( P = .039).

Conclusions:

Bedside AE has low sensitivity for detecting base-of-tongue collapse in infants with PRS. Because of the substantial false negative rate, AE may not be a reliable diagnostic modality for ruling out base-of-tongue obstruction in this susceptible population. DISE may be indicated in high-risk patients to avoid underdiagnosing upper airway obstruction.

Drug induced sleep endoscopy: its role in evaluation of the upper airway obstruction and patient selection for surgical and non-surgical treatment

Sleep related breathing disorders cause obstruction of the upper airway which can be alleviated by continuous positive airway pressure (CPAP) therapy, oral devices or surgical intervention. Non-surgical treatment modalities are not always accepted by patients and in order to attain successful surgical outcomes, evaluation of the upper airway is necessary to carefully select the patients who would benefit from surgery. There are numerous techniques available to assess the upper airway obstruction and these include imaging, acoustic analysis, pressure transducer recording and endoscopic evaluation. It is essential to note that the nocturnal obstructive upper airway has limited muscle control compared to the tone of the upper airway lumen during wakefulness. Thus, if one were to attempt to identify the anatomical segments contributing to upper airway obstruction in sleep related breathing disorders; it must be borne in mind that evaluation of the airway must be performed if possible when the patient is awake and asleep albeit during drug induced sleep. This fact as such limits the use of imaging techniques for the purpose. Drug induced sleep endoscopy (DISE) was pioneered at Royal National Throat, Nose and Ear Hospital, London in 1990 and initially introduced as sleep nasendoscopy. The nomenclature and the technique has been modified by various Institutions but the core value of this evaluation technique remains similar and extremely useful for identifying the anatomical segment responsible for obstructing the upper airway during sleep in patients with sleep related breathing disorders. There have been numerous controversies that have surrounded this technique but over the last two decades most of these have been addressed and it now remains in the forefront of methods of evaluating the upper airway obstruction. A variety of sedative agents and different grading systems have been described and efforts to unify various aspects of the technique have been made. This article will look at its usefulness and advantages and will discuss some important contributions made to the field of evaluation of the upper airway using DISE.

Drug-induced sedation endoscopy (DISE) classification systems: a systematic review and meta-analysis

PURPOSE

Drug-induced sedation endoscopy (DISE) classification systems have been used to assess anatomical findings on upper airway obstruction, and decide and plan surgical treatments and act as a predictor for surgical treatment outcome for obstructive sleep apnoea management. The first objective is to identify if there is a universally accepted DISE grading and classification system for analysing DISE findings. The second objective is to identify if there is one DISE grading and classification treatment planning framework for deciding appropriate surgical treatment for obstructive sleep apnoea (OSA). The third objective is to identify if there is one DISE grading and classification treatment outcome framework for determining the likelihood of success for a given OSA surgical intervention.

METHODS

A systematic review was performed to identify new and significantly modified DISE classification systems: concept, advantages and disadvantages.

RESULTS

Fourteen studies proposing a new DISE classification system and three studies proposing a significantly modified DISE classification were identified. None of the studies were based on randomised control trials.

CONCLUSION

DISE is an objective method for visualising upper airway obstruction. The classification and assessment of clinical findings based on DISE is highly subjective due to the increasing number of DISE classification systems. Hence, this creates a growing divergence in surgical treatment planning and treatment outcome. Further research on a universally accepted objective DISE assessment is critically needed.

Drug-Induced Sedation Endoscopy (DISE) DATA FUSION system: clinical feasibility study

Drug-induced sleep endoscopy (DISE) is a diagnostic technique for 3D dynamic anatomical visualisation of upper airway obstruction during sedated sleep. There is a lack of standardised procedure and objective measurement associated with information capture, information management, evaluation of DISE findings, treatment planning, and treatment outcomes. The objective of this study is to present clinical feasibility results using a DISE DATA FUSION system for capturing, merging, displaying and storing anatomical data from an endoscopic imaging system and cardiorespiratory data from an anaesthesiological monitoring system simultaneously in real-time during DISE. This prospective cohort study included 20 patients presenting with symptoms of sleep related breathing disorders undergoing drug-induced sedation endoscopy and had volunteered for DISE DATA FUSION system to be used during their DISE assessment. The DISE DATA FUSION system was used to capture, merge, display, and store anatomical changes from an endoscopic imaging system and cardiorespiratory changes from an anaesthesiological monitoring system simultaneously in real time during drug-induced sedation endoscopy assessment. In all 20 patients, anatomical obstructions at different levels of the pharyngeal lumen (soft palate, velum, tonsils, oropharynx lateral wall, base of tongue, and epiglottis) with a different obstruction configuration and severity were captured simultaneously in real time with its associated cardiorespiratory parameters. Furthermore, a composite video consisting of an anatomical image, blood oxygen level, pulse rate, blood pressure, and timestamp was created for every obstructive event. Our system provides a useful and better way of capturing, merging, visualising, and storing anatomical data/physiological data simultaneously during DISE in real time. Furthermore, it enhances the understanding of the impact of the anatomical severity due to the simultaneous display of the cardiovascular parameters at that specific time of anatomical obstruction for optimising surgical decision based on DISE.

Insights since FDA Approval of Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea

Purpose

The literature on hypoglossal nerve stimulation (HNS) for the treatment of moderate-to-severe obstructive sleep apnea (OSA) was reviewed from 2014, the time of FDA approval for the Inspire Systems device, to 2017 for themes that might be useful conceptually and practically in the consideration of this new non-anatomic surgical therapy.

Recent Findings

there are now further follow-up articles since the 12-month results for Apnea Reduction (STAR) trial of the Inspire device, and post-approval publications which report similar and/0r improved AHI outcomes. Other emerging themes include drug-induced sedation endoscopy (DISE) as a tool in assessment of eligibility and a more detailed understanding of mechanisms for an HNS effects.

Summary

The post-STAR literature provides guidelines for an integrated coordination of medicine and surgery to appropriately screen and manage patients.

Fibronasolaringoscopia en el diagnóstico de síndrome de apnea-hipopnea obstructiva del sueño (SAHOS)

En los pacientes con diagnóstico de trastornos respiratorios del sueño (TRS) no se ha podido asociar ningún hallazgo anatómico a la severidad de la patología que el paciente presenta o a su éxito quirúrgico. Los avances actuales en la tecnología de video han permitido evaluar de manera más fidedigna las medidas de la vía aérea (VA) y trazar un mapa más exacto del sitio específico de obstrucción. La fibronasolaringoscopia es una técnica accesible y económica para la evaluación de la VA en múltiples posiciones en períodos de sueño y vigilia; esta requiere un amplio conocimiento por parte del examinador de la anatomía y fisiología de la vía aérea superior para determinar los sitios exactos de obstrucción y los patrones de colapso que podrían determinar la posibilidad del manejo quirúrgico o no, haciendo de este examen diagnóstico parte fundamental en el estudio de los pacientes con TRS.

uDISE model: a universal drug-induced sedation endoscopy classification system-part 1

Drug-induced sedation endoscopy (DISE) classification systems play a significant role in clinical analysis based on DISE findings, treatment decision process, treatment planning process and fundamentally in treatment outcomes. However, there is a major problem: there is no universally agreed DISE classification system. Hence, for the same DISE examination different DISE classification systems can be used to: assess anatomic findings, decide and plan different treatments. Hence, this leads to different treatment outcomes. The key objective of this study is to propose uDISE model: universal drug-induced sedation endoscopy (DISE) classification system. Set theory and relational mapping was used to develop a DISE classification system based on anatomical structures/level; degree of severity; and configuration of obstruction and its relationship with existing DISE classification systems. uDISE model consists of seven anatomical sites (nose, velum, tonsils, lateral pharyngeal wall/oropharynx, tongue base, epiglottis and larynx), three degrees of obstructive severity (none, partial and complete), three configurations of obstruction (anteroposterior, lateral and circumferential) and a severity index. uDISE model was mapped to four existing DISE classification systems: Pringle and Croft grading system, VOTE, NOHL and P-T-L-Tb-E. uDISE model provides a methodology for mapping different DISE findings based on different classification systems into one common DISE assessments format. This provides a framework for comparing different DISE assessments, treatment plan and treatment outcome irrespective of DISE classification system used. Further research is required to establish a complete relational mapping between uDISE model and other existing DISE classification systems.

Drug-induced sleep endoscopy with target-controlled infusion using propofol and monitored depth of sedation to determine treatment strategies in obstructive sleep apnea

BACKGROUND

Drug-induced sleep endoscopy (DISE) has become an important diagnostic examination tool in the treatment decision process for surgical therapies in the treatment of obstructive sleep apnea (OSA). Currently, there is a variety of regimes for the performance of DISE, which renders comparison and assessment across results difficult. It remains unclear how the different regimes influence the findings of the examination and the resulting conclusions and treatment recommendations. This study aimed to investigate the correlation between increasing levels of sedation (i.e., light, medium, and deep) induced by propofol using a target-controlled infusion (TCI) pump, with the obstruction patterns at the levels of the velum, oropharynx, tongue base, and epiglottis (i.e., VOTE classification). A second goal was the establishment of a sufficient sedation level to enable a reliable decision regarding treatment recommendations.

MATERIAL AND METHODS

Forty-three patients with OSA underwent a DISE procedure using propofol TCI. Three levels of sedation were defined, depending on entropy levels and assessment of sedation: light sedation, medium sedation, and deep sedation. The evaluation of the upper airway at each level, with increasing sedation, was documented using the VOTE classification. The elapsed time at which each assessment was performed was recorded.

RESULTS

Upper airway changes occurred and were measured throughout the DISE procedure. Clinically useful determinations of airway closure occurred at medium sedation; this level of sedation was most probably achieved with a blood propofol concentration of 3.2 μg/ml. In all 43 patients, definite treatment decisions could be made at medium sedation level. Increasing sedation did not result in changes in the treatment decision.

CONCLUSIONS

Changes in upper airway collapse during DISE with propofol TCI occur at levels of medium sedation. Decisions regarding surgical treatment could be made at this level of sedation.

CLINICAL TRIAL NAME

Upper Airway Collapse in Patients with Obstructive Sleep Apnea Syndrome by Drug Induced Sleep Endoscopy (URL: https://clinicaltrials.gov/ct2/results?term=NCT02588300&Search=Search ) REGISTRATION NUMBER: NCT02588300.

[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.

Novel Surgical Approaches for the Treatment of Obstructive Sleep Apnea

Novel approaches to upper airway anatomic phenotyping, more reconstructive upper airway surgical techniques, and new implantable hypoglossal neurostimulation technology have very favorable potential to improve symptoms and quality-of-life measures, to reduce obstructive sleep apnea (OSA) disease severity and associated cardiovascular risk, and to serve as an adjunct to continuous positive airway pressure, oral appliances, and other forms of OSA medical therapy. Successful surgical therapy depends critically on accurate diagnosis, skillful knowledge and examination of the upper airway anatomy, proper procedure selection, and proficient technical application.

Variable Findings for Drug-Induced Sleep Endoscopy in Obstructive Sleep Apnea with Propofol versus Dexmedetomidine

OBJECTIVE

To compare VOTE classification findings (velum, oropharyngeal-lateral walls, tongue base, and epiglottis) for drug-induced sleep endoscopy (DISE) among patients with obstructive sleep apnea (OSA) using 2 sedation protocols.

STUDY DESIGN

Case series with chart review.

SETTING

Single tertiary institution.

SUBJECTS

Patients with OSA who underwent DISE.

METHODS

A total of 216 patients underwent DISE between November 23, 2011, and May 1, 2015. DISE findings based on VOTE classification were compared between patients receiving the propofol- and dexmedetomidine-based sedation protocols.

RESULTS

Patients with OSA (N = 216; age, 44.3 ± 11.7 years; body mass index, 27.9 ± 4.8 kg/m(2)) underwent DISE with intravenous administration of propofol (n = 52) or dexmedetomidine (n = 164). There were no statistically significant differences between the 2 groups in baseline apnea-hypopnea index, oxygen desaturation index, Mallampati score, tonsil size, Epworth Sleepiness Scale score, peripheral oxygen saturation nadir, age, sex, or body mass index. Patients in the propofol group had a significantly increased likelihood of demonstrating complete tongue base obstruction (75%, 39 of 52) versus partial or no obstruction (25%, 13 of 52) in the anterior-posterior dimension, as compared with the dexmedetomidine group (complete obstruction: 42.7%, 70 of 164; partial or no obstruction: 57.3%, 94 of 164; odds ratio: 4.0; 95% confidence interval: 2.0-8.1; P = .0001). Obstruction of other airway subsites was not significantly different.

CONCLUSION

Use of propofol versus dexmedetomidine to induce sedation may have a significant effect on the pattern of upper airway obstruction observed during DISE. Randomized prospective studies are indicated to confirm these initial findings.

Association between Drug-Induced Sleep Endoscopy and Measures of Sleep Apnea Burden

OBJECTIVE

To test the following associations: (1) complete obstruction on drug-induced sleep endoscopy (DISE) and polysomnographic and subjective measures of obstructive sleep apnea; (2) tongue base/epiglottic obstruction and apnea index.

STUDY DESIGN

Retrospective cohort.

SETTING

Academic medical center.

SUBJECTS AND METHODS

Subjects included surgically naïve adult patients with DISE. Chart extraction included demographics, polysomnography, and Epworth Sleepiness Scale and SNORE25 (Symptoms of Nocturnal Obstruction and Related Events 25) scores. Each DISE video was examined for complete obstruction at velum, oropharynx, tongue, epiglottis (VOTE system). Student's t test, correlation, and multivariate linear regression were performed.

RESULTS

Among 65 subjects, complete obstruction was observed at 0 (3%), 1 (46%), 2 (48%), and 3 (3%) subsites, respectively. Subjects with 0-1 subsites vs 2-4 subsites of complete obstruction had similar apnea indexes (13 ± 24 vs 12 ± 17, P = .78, 83% power to detect difference of 15), apnea-hypopnea indexes (30 ± 25 vs 31 ± 28, P = .96, 54% power to detect difference of 15), Epworth Sleepiness Scale scores (11 ± 7 vs 12 ± 5, P = .34, 91% power to detect difference of 5), and SNORE25 scores (2.0 ± 1.1 vs 1.9 ± 1.0, P = .70, 96% power to detect difference of 1.0), with similar results after adjusting for age, sex, body mass index, and tonsil status. Neither tongue base nor epiglottic obstruction was associated with apnea index.

CONCLUSION

The number of subsites with complete obstruction on DISE was not associated with polysomnographic, subjective sleepiness, and quality-of-life measures. Tongue base and epiglottic obstruction were not associated with apnea index. Larger detailed analyses are needed to determine the importance of each site and degree of obstruction seen on DISE.

Comparison of three sedation regimens for drug-induced sleep endoscopy

PURPOSE

Drug-induced sleep endoscopy (DISE) allows for direct airway observation in patients with obstructive sleep apnea. This study compared the safety profiles and efficacies of three regimens for DISE.

METHODS

Sixty-six patients were randomly assigned to receive propofol alone (n = 22), a propofol-remifentanil combination (n = 22), or a dexmedetomidine-remifentanil combination (n = 22). Remifentanil was infused at a concentration of 1.5 ng·ml(-1) in the propofol-remifentanil and dexmedetomidine-remifentanil groups, whereas saline was infused in the propofol group. The propofol and propofol-remifentanil groups received propofol at a starting concentration of 1.0 μg·ml(-1), then 0.1 μg·ml(-1) increments at 5 min intervals. The dexmedetomidine-remifentanil group received 1.0 μg·kg(-1) loading dose of dexmedetomidine for 10 min and then 0.2 μg·kg(-1)·h(-1) increments at 5 min intervals.

RESULTS

The incidence of oxygen desaturation was significantly higher in the propofol-remifentanil group compared with that of the dexmedetomidine-remifentanil group (77 vs. 45%, respectively, P = 0.024). Even with a maximum dose of dexmedetomidine (1.4 μg·kg(-1)·h(-1)), 50% of the dexmedetomidine-remifentanil group did not reach sufficient sedation and required additional propofol. Cough reflex occurred in five patients of propofol group and in neither of the other groups (P = 0.004).

CONCLUSIONS

The propofol-remifentanil combination was associated with a higher incidence of desaturation. The dexmedetomidine-remifentanil combination was associated with inadequate sedation in one half of the patients, even though it produced less respiratory depression. Addition of remifentanil reduced the cough reflex.

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.