Sneezing during drug-induced sedation endoscopy

Bilateral Postprocedural Rhinitis After Intravenous Sedation With Supplemental Nasal Oxygen (PRAISE SNOG) After Cataract Surgery

Rhinitis is classified as allergic or nonallergic. It presents with nasal congestion, nasal pruritus, posterior nasal drainage, rhinorrhea, and/or sneezing. During short procedures, nasal cannula administration of supplemental oxygen may be utilized to prevent hypoxia. Postprocedural rhinitis after intravenous sedation with supplemental nasal oxygen (PRAISE SNOG) - a noninflammatory variant of nonallergic rhinitis - has been observed in colonoscopy patients. Symptoms (sneezing and/or rhinorrhea with or without tearing) typically begin during emergence from sedation and persist for hours to days before resolving. A 66-year-old woman developed bilateral PRAISE SNOG following cataract extraction; her bilateral symptoms of nasal pruritus, rhinorrhea, and sneezing began immediately after awakening from sedation and spontaneously resolved within 24 hours. Mucosal irritation by the nasal cannula prongs that deliver the oxygen is a postulated pathogenesis for postprocedural rhinitis. Modification of the nasal prong composition (by using a soft silicon-based material), placement (by insertion prior to the induction of sedation and by not impinging on the nasal mucosa), and length (by trimming from 10 to two millimeters) are possible actions that might be initiated in order to prevent PRAISE SNOG.

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.

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.