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

The effect of drug-induced sleep endoscopy on surgical outcomes for obstructive sleep apnea: a systematic review

PURPOSE

Drug-induced sleep endoscopy (DISE) is the most widespread diagnostic tool for upper-airway endoscopic evaluation of snoring and obstructive sleep apnea (OSA). However, a consensus on the effectiveness of DISE on surgical outcomes is still lacking. This study aimed to quantify the effect of DISE on surgical outcomes and to compare DISE with awake examination using the Müller Maneuver (MM).

METHODS

This systematic review was performed according to the PRISMA guidelines. Published studies from the last 30 years were retrieved from the Cochrane Library, MEDLINE, SCOPUS, and PubMed databases. Studies comparing DISE with awake examination, or MM were included. Surgical success rate was defined according to Sher's criteria, achieving a postoperative apnoea-hypopnea index (AHI) value < 20 events per hour and a 50% improvement from preoperative AHI. Outcomes are presented in terms of surgical success, pre- and postoperative AHI, Epworth sleepiness score (ESS), oxygen desaturation index (ODI) and lowest oxygen saturation (LOS).

RESULTS

This review included 8 studies comprising 880 patients. DISE group showed a higher LOS increase, ODI decrease, ESS decrease than non-DISE group (6.83 ± 3.7 versus 3.68 ± 2.9, p<0.001; 19.6 ± 11.2 versus 12.6 ± 10.4, p<0.001; 6.72 ± 4.1 versus 3.69 ± 3.1, p<0.001). Differences in surgical success rate were significant only between DISE and MM (64.04% versus 52.48%, p = 0.016). AHI decrease resulted higher in non-DISE than in DISE group (39.92 ± 24.7 versus 30.53 ± 21.7, p<0.001).

CONCLUSION

Results of this systematic review suggest that the evidence is mixed regarding a positive effect of DISE on surgical outcomes.

Airway Collapsibility during Drug-Induced Sleep Endoscopy Relates with Clinical Features of Obstructive Sleep Apnea

INTRODUCTION

Increased pharyngeal collapsibility leads to obstructive sleep apnea (OSA). Positive airway pressure titration during drug-induced sleep endoscopy (DISE-PAP) provides objective collapsibility metrics, the pharyngeal opening pressure (PhOP), and active pharyngeal critical pressure (PcritA ). We examined the interrelationships between risk factors of OSA, airway collapsibility measures, and clinical manifestations of the disease.

METHODS

This is a cross-sectional analysis of consecutive OSA patients undergoing DISE-PAP. Nasal PAP was increased stepwise until inspiratory flow limitation was abolished, signifying PhOP. PcritA was derived from the resulting titration pressure-flow relationships. Clinical data including demographics, anthropometrics, sleep studies, and patient-symptom questionnaires were obtained from the electronic medical record. Multivariate regression was used to evaluate the relationship between risk factors, airway collapsibility, and clinical data.

RESULTS

On average, the 164 patients meeting inclusion criteria were middle-aged (54.2 ± 14.7 years), overweight/obese (BMI 29.9 ± 4.5 kg/m2 ), male (72.6%), White (79.3%) and had severe OSA (AHI 32.0 ± 20.5 events/hour). Mean PhOP was 7.5 ± 3.3 cm H2 O and mean PcritA was 0.80 ± 3.70 cm H2 O. Younger age (Standardized β = -0.191, p = 0.015) and higher BMI (Standardized β = 0.176, p = 0.028) were associated with higher PhOP, but not PcritA . PhOP and PcritA were both associated with AHI, supine AHI, and SpO2 nadir. Higher PhOP was associated with higher snoring scores (Standardized β = 0.246, p = 0.008), but not other patient-reported outcomes.

CONCLUSION

Objective assessment of passive and active airway mechanics during DISE relates with clinical risk factors for OSA. Quantitative measures of collapsibility provide accessible and meaningful data, enhancing the standard sleep surgery evaluation.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1978-1985, 2024.

A Critical Analysis of Pharyngeal Patterns of Collapse in Obstructive Sleep Apnea: Beyond the Endoscopic Classification Systems

(1) Background: Drug-Induced Sleep Endoscopy (DISE) enables the three-dimensional and dynamic visualization of the upper airway (UA) during sleep, which is useful in selecting the best treatment option for obstructive sleep apnea (OSA) patients, particularly for surgical procedures. Despite international consensus statements or position papers, a universally accepted DISE methodology and classification system remain a controversial open question. (2) Methods: A review of the English scientific literature on DISE related to endoscopic classification systems and surgical outcome predictors (3) Results: Of the 105 articles, 47 were included in the analysis based on their content's relevance to the searched keywords. (4) Conclusions: A final report and scoring classification system is not universally accepted; the most internationally applied endoscopic classification system during DISE does not cover all patterns of events that occur simultaneously during the endoscopic examination, highlighting that several configurations of collapse and obstruction at different UA levels could be observed during DISE, which should be described in detail if DISE has to be considered in the decision-making process for the UA surgical treatment in OSA patients and if DISE has to have a role as a predictive factor for surgical outcomes analysis.

The prognostic role of ultrasound and magnetic resonance imaging in obstructive sleep apnoea based on lateral oropharyngeal wall obstruction

PURPOSE

This study examined the prognostic value of the lateral pharyngeal wall (LPW)-based obstruction and obstructive sleep apnoea (OSA) prediction using ultrasound (US) and MRI (magnetic resonance imaging).

METHODS

One hundred patients with and without OSA were enrolled, according to overnight polysomnography. The LPW thickness (LPWT) was measured using a Philips Ingenia 1.5 T MRI device, and US measurements were carried out at rest and during Müller's manoeuvre (MM) with a Samsung RS85 device. The obstruction was localised under drug-induced sleep endoscopy.

RESULTS

Significantly greater LPWT using MRI was observed in the OSA group compared to the control group, while US results showed a significant difference only in the case of LPWT during MM on the left side. Obese patients presented significantly higher LPWT values. A significant correlation between BMI and LPWT was observed. Men presented significantly higher LPWT MRI values and left-sided LPWT using US compared to women. LPWT and AHI parameters were significantly correlated. The severity of LPW obstruction correlated with LPWT, while the LPW collapse significantly correlated with AHI. The severity of LPW collapse differed depending on the AHI values. Using US LPWT values and anthropometric parameters, a 93% effectiveness in OSA prognostication and 89% in LPWT-based obstruction were detected. MRI detected OSA in 90% and LPW-based obstruction in 84%. US successfully detected LPW-based collapse severity in 67%.

CONCLUSION

US LPWT measurements were helpful in detecting OSA and LPWT-based obstruction. These examinations may be useful for surgical planning.

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.

Determining the Site of Upper Airway Narrowing in Snorers Using a Noninvasive Technique

Background

In this study, we aimed to determine the site of obstruction if surgical treatment is considered. Flexible nasopharyngoscopy is an invasive procedure currently used for the assessment of snoring and the level of obstruction. Here, we examine the role of Somnoscreen™ plus, a noninvasive cardiorespiratory polysomnographic device, in identifying the site of obstruction in patients presenting with snoring.

Methodology

This cross-sectional study was conducted in the Sleep Research Center at King Abdulaziz University Hospital. Polysomnography was conducted using Somnoscreen™ plus. All participants underwent flexible nasopharyngoscopy after polysomnography.

Results

Nasopharyngoscopy revealed that the most common site of obstruction was the nose and the soft palate (35.4%), followed by the soft palate alone (25%). Somnoscreen revealed that the site of obstruction was the nose and the soft palate in 18 (37.5%) patients and the nose alone in 16 (33.3%) patients. However, distal obstructions were not detected using Somnoscreen. The concordance of nasopharyngoscopy and Somnoscreen was 52.9%. However, it showed a discrepancy in identifying distal obstructions, which Somnoscreen™ plus failed to detect.

Conclusions

Somnoscreen appears to be sensitive for identifying proximal airway obstructions. The audio signal recordings can potentially be used as a tool to detect the site of airway obstruction in snoring; however, further studies are needed.

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.

Hypoglossal Nerve Stimulation Therapy

Hypoglossal nerve stimulation (HNS) has been shown to be a safe alternative in the treatment of moderate-to-severe obstructive sleep apnea (OSA). A recent meta-analysis of 12 studies by Costantino et al. indicated the surgical success rates at 55-75%, a reduction of the apnea hypopnea index (AHI) of 18 events/h, and a reduction of the Epworth Sleepiness Scale (ESS) of 2.9-5.3. After animal studies in the 1970s, the first trial on humans to decrease upper airway resistance by transcutaneous electrical stimulation of the genioglossus was reported in 1989. A separate stimulation of protruding and retracting muscles was realized in 1995 by fine-wire electrodes that were placed into the tongue transoral. Over the next years, several companies developed implantable devices for hypoglossal stimulation in OSA. Initially, devices were developed that used unilateral stimulation of the hypoglossal nerve. In 2014, a device for unilateral respiratory frequency-controlled hypoglossal stimulation finally received FDA approval after a successful phase III trial. In recent years, a device for bilateral breath rate-independent stimulation of the hypoglossal nerve has been added to these approaches as a new development. Accordingly, hypoglossal nerve stimulation, on the one hand, is now an established tool for patients with OSA when standard treatments are not satisfactory. Beyond that, hypoglossal stimulation is undergoing a continuous and impressive development like hardly any other field of surgical therapy for OSA.

Diagnosis of upper airways collapse in moderate-to-severe OSAHS patients: a comparison between drug-induced sleep endoscopy and the awake examination

PURPOSE

Compare awake evaluation (modified Mallampati score-MMs, Müller maneuver-MM) to drug-induced sleep endoscopy (DISE) findings according to NOHL (nose-oropharynx-hypopharynx-larynx) classification in moderate-to-severe OSAHS patients.

METHODS

43 moderate-to-severe OSAHS patients referred to our ENT department were enrolled over a 2-year period. In this observational prospective study, each patient was evaluated by the same ENT team both in wakefulness and during pharmacologically induced sleep. Level and severity of the obstruction were described.

RESULTS

The comparison of degree of collapsibility was statistically significative only at hypopharyngeal level: 41.8% of the patients showed a hypopharyngeal obstruction in wakefulness whereas 88.3% in DISE (p = 0.000). Laryngeal level was found in 18.6% patients during awake examination, conversely DISE demonstrated laryngeal obstruction in 4.6%. DISE identified significantly higher incidence of multilevel collapses (p = 0.001). However, the incidence of oropharyngeal obstruction in patients classified as MMs I and II was significantly higher in DISE compared to MM (p = 0.021).

CONCLUSION

DISE is the best predictor of hypopharyngeal obstruction, whereas MM underestimates the severity of the collapse at this level. DISE is more reliable than MM to identify the obstruction in patients with MMs score I and II.

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.

Role of transpalatal advancement pharyngoplasty in management of lateral pharyngeal wall collapse in OSA

INTRODUCTION

Non-response to palatal surgery for OSA is a problem. Residual lateral wall hypopharyngeal collapse is the proposed mechanism of failure.

OBJECTIVE

This study aims to evaluate the role of transpalatal advancement pharyngoplasty in non-responders to primary palatal surgery with residual lateral wall hypopharyngeal collapse.

METHODS

This is a retrospective study that was conducted on patients who underwent transpalatal advancement pharyngoplasty for residual lateral wall hypopharyngeal. Inclusion criteria were age greater than 18-years, OSA proved by the polysomnography with apnea hypopnea index >15, lateral wall collapse at the level of hypopharynx as proved by drug-induced sleep endoscopy and had a previous tonsillectomy or previous palatal surgery for OSA. Exclusion criteria were those with no history of tonsillectomy or any other surgery for OSA and those with a missed followup. Data of included patients were collected and included gender, age, polysomnographic data like the apnea hypopnea index, oxygen desaturation and the calculated preoperative Epworth sleepiness scale. The early outcome included symptom improvement as measured by Epworth sleepiness scale score and lateral pharyngeal wall evaluation by nasopharyngoscopic examination in the first postoperative month. Late outcome measurement was performed by the 6-month postoperative polysomnography. Data were analyzed using SPSS program.

RESULTS

The study included 37 patients with a mean age of (40.43 ± 6.51). The study included 26 men and 11 women. There was a statistically significant improvement of apnea hypopnea index from 37.8 ± 9.93 to 9.9 ± 2.55. In addition, a statistically significant improvement of lowest oxygen saturation from 78.9 ± 3.39 to 83.3 ± 3.31 was encountered. The patients improved clinically, and this improvement was measured by statistically significant improvement of Epworth sleepiness scale score and snoring visual analogue scale.

CONCLUSION

Transpalatal advancement pharyngoplasty widens the retropalatal airway and has a great role in the management of the vertical palate phenotype. In addition, it can have a role in the management of lateral walls, especially lateral wall hypopharyngeal collapse.

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.

The Emerging Role of Drug-Induced Sleep Endoscopy in the Management of Obstructive Sleep Apnea

Obstructive sleep apnea is a prevalent sleep disorder characterized by partial or complete obstruction of the upper airway. Continuous positive airway pressure is the first-line therapy for most patients, but adherence is often poor. Alternative treatment options such as mandibular advancement devices, positional therapy, and surgical interventions including upper airway stimulation target different levels and patterns of obstruction with varying degrees of success. Drug-induced sleep endoscopy enables the visualization of upper airway obstruction under conditions mimicking sleep. In the era of precision medicine, this additional information may facilitate better decision-making when prescribing alternative treatment modalities, with the hope of achieving better adherence and/or success rates. This review discusses the current knowledge and evidence on the role of drug-induced sleep endoscopy in the non-positive airway pressure management of obstructive sleep apnea.

Computer-Assisted Quantitative Analysis of Drug-Induced Sleep Endoscopy for Obstructive Sleep Apnea/Hypopnea Syndrome

OBJECTIVES

To use computer-assisted quantitative measurements of upper airway changes during drug-induced sleep endoscopy (DISE) and to correlate these parameters with disease severities and physiologic changes in patients with obstructive sleep apnea/hypopnea syndrome (OSA).

DESIGN

A retrospective study.

SETTING

Tertiary academic medical center.

PATIENTS AND METHODS

A total of 170 patients who failed continuous positive airway pressure therapy and then underwent upper airway surgery were enrolled. All patients received polysomnography and DISE preoperatively. We used ImageJ 1.48v to obtain maximal and minimal measurements, including cross-sectional areas and anterior-posterior and lateral diameters at 4 anatomic levels (retropalatal, oropharyngeal, retroglossal, and retroepiglottic) under DISE, and then computed the percentage changes. We analyzed the clinical values of DISE changes by computer-assisted analysis in patients with OSA and any correlations between these changes and polysomnography parameters.

RESULTS

The percentage changes of upper airway showed significant collapses at all 4 anatomic levels (all P < .0001). We also found that the changes at retropalatal levels were significantly greater and that retroglossal levels were significantly smaller, while the changes of anterior-posterior diameters at retroglossal levels showed a significant positive association with apnea-hypopnea index and desaturation index. However, there were no statistically significant correlations between upper airway changes and obesity.

CONCLUSION

Computer-assisted quantitative analysis could evaluate upper airway changes of OSA in an objective way and may help identify the sites of obstruction during DISE more accurately. Upper airway showed multilevel collapse with independent significant changes in patients with OSA, with the retropalatal and retroglossal levels playing important roles in particular.

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.

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.

The Impact of Drug-induced Sleep Endoscopy on Therapeutic Decisions in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

Objective The aim of this study was to assess the ability of drug-induced sleep endoscopy (DISE) to change therapeutic decisions through the identification of obstruction sites in patients with obstructive sleep apnea (OSA). Materials and methods A systematic review and meta-analysis were conducted concerning studies that reported the impact of DISE on therapeutic recommendations. The percentage of change was collected for each study and per site of the collapse. The pooled rate of change and the respective 95% confidence interval (CI) were computed. Subgroup analysis was performed based on patients' age, sample size, the applied DISE protocol, and the originally used diagnostic modality before DISE. Results In a total of nine studies, 1247 patients were included (69.2% males, 59.7% children, 78.04% with a multilevel collapse). Therapeutic decisions changed in 43.69% of patients (CI, 33.84 to 53.54). The change rates were significantly higher in adults (54.0% versus 25.9% in children, P = 0.001), midazolam-based DISE protocols (78.4% versus 48.45% for midazolam plus propofol and 33.9% for propofol, P < 0.001), and after awake endoscopy (62.2% as compared to 44.6% after clinical basic examination [CBE], 40.1% after CBE, lateral cephalometry, and Müller maneuver, P = 0.02). Changes at uvular and palatal sites were more frequent in adults and at the tonsils in children. Conclusion The DISE approach can be promoted via implementing unified classification systems of obstruction sites; the widescale application of target-controlled infusion and its therapeutic benefits can be explored in well-designed randomized studies that compare its efficacy with other diagnostic modalities.

Drug-induced sleep endoscopy-directed adenotonsillectomy in pediatric obstructive sleep apnea with small tonsils

The study aims to examine drug-induced sleep endoscopy (DISE) in the decision-making process of pediatric obstructive sleep apnea (OSA) patients with small tonsils. This was a retrospective study of children who underwent awake flexible endoscopy, DISE, and adenoidectomy with/without tonsillectomy at the Shanghai Children’s Medical Center between 03/2015 and 12/2016. Tonsillectomy was performed for tonsillar obstruction found by DISE. Adenoidectomy was performed for all children. Cardio-pulmonary coupling (CPC) and oximetry were observed before/after surgery. The study included 126 children: 56 (44.4%) with grade 2 tonsils and 70 (55.6%) with grade 1. Mean age was 5.7±3.2 (range, 2.8–10.4) years and mean BMI of 15.7±5.5 kg/m². Unexpectedly, DISE showed tonsillar obstruction in 57 (45.2%) children, including 44 (78.6%) with grade 2 tonsils and 13 (18.6%) with grade 1. Therefore, DISE-directed tonsillectomy was performed for 57 patients. There was an improvement in respiratory disturbance index (RDI) and oxygen saturation nadir in the DISE (P = 0.0007, P = 0.037) and control (P = 0.001, P = 0.023) groups 6 months after surgery, but RDI improvement was better in the DISE group compared with controls 1 year after surgery (P = 0.042). DISE is a good way to determine the necessity of tonsillectomy in pediatric OSA patients with small tonsils.

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.

Qualitative assessment of awake nasopharyngoscopy for prediction of oral appliance treatment response in obstructive sleep apnoea

PURPOSE

Clinical methods to identify responders to oral appliance (OA) therapy for obstructive sleep apnoea (OSA) are needed. Awake nasopharyngoscopy during mandibular advancement, with image capture and subsequent processing and analysis, may predict treatment response. A qualitative assessment of awake nasopharyngoscopy would be simpler for clinical practice. We aimed to determine if a qualitative classification system of nasopharyngoscopic observations reflects treatment response.

METHODS

OSA patients were recruited for treatment with a customised two-piece OA. A custom scoring sheet was used to record observations of the pharyngeal airway (velopharynx, oropharynx, hypopharynx) during supine nasopharyngoscopy in response to mandibular advancement and performance of the Müller manoeuvre. Qualitative scores for degree (< 25%, 25-50%, 50-75%, > 75%), collapse pattern (concentric, anteroposterior, lateral) and diameter change (uniform, anteroposterior, lateral) were recorded. Treatment outcome was confirmed by polysomnography after a titration period of 14.6 ± 9.8 weeks. Treatment response was defined as (1) Treatment AHI < 5, (2) Treatment AHI < 10 plus > 50% AHI reduction and (3) > 50% AHI reduction.

RESULTS

Eighty OSA patients (53.8% male) underwent nasopharyngoscopy. The most common naspharyngoscopic observation with mandibular advancement was a small (< 50%) increase in velopharyngeal lateral diameter (37.5%). The majority of subjects (72.5%) were recorded as having > 75% velopharyngeal collapse on performance of the Müller manoeuvre. Mandibular advancement reduced the observed level of pharyngeal collapse at all three pharyngeal regions (p < 0.001). None of the nasopharyngoscopic qualitative scores differed between responder and non-responder groups.

CONCLUSION

Qualitative assessment of awake nasopharyngoscopy appears useful for assessing the effect of mandibular advancement on upper airway collapsibility. However, it is not sensitive enough to predict oral appliance treatment outcome.

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) 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.