Drug-induced sleep endoscopy: the effect of different passive maneuvers on the distribution of collapse patterns of the upper airway in obstructive sleep apnea patients

Modifications in Upper Airway Collapsibility during Sleep Endoscopy with a Mandibular Positioner: Study in Snorers and Obstructive Sleep Apnea Patients

BACKGROUND

Mandibular advancement devices (MADs) are an effective treatment for patients with sleep-related breathing disorders, with variable response. Increasingly more research points to the predictive value of Drug-Induced Sleep Endoscopy (DISE) in patient selection. This study aims to analyze the changes in upper airway collapsibility using a titratable MAD simulator during DISE.

METHODS

This study included 104 patients with simple snoring and obstructive sleep apnea (OSA). The VOTE scale was used to assess the presence of collapses during the DISE both without and with the MAD simulator.

RESULTS

In snorers, there was a decrease in collapses at the level of the soft palate and oropharynx when the advancement was achieved. Patients with mild OSA also showed a decrease in collapses at the base of the tongue. Patients with moderate/severe OSA exhibited significant amelioration at all levels. The levels at which there were residual collapses despite the maneuver were, in order, the velopharynx, oropharynx, epiglottis, and tongue.

CONCLUSIONS

The MAD simulator reduces collapsibility at all levels and in all severity groups. Residual collapses suitable for combined treatments were able to be identified. This highlights the need for individualized patient selection, as upper airway collapsibility exhibits variable improvement or worsening with the MAD simulator regardless of the severity of the condition.

Upper Airway Surgery or Weight Control? Modified Drug-Induced Sleep Endoscopy for Obstructive Sleep Apnea

OBJECTIVE

To identify the value of head rotation in the supine position and oral appliance (OA) use in drug-induced sleep endoscopy (DISE).

STUDY DESIGN

Eighty-three sleep apnea adults undergoing target-controlled infusion-DISE (TCI-DISE) were recruited from a tertiary academic medical center.

SETTING

During DISE, 4 positions were utilized: supine position (position 1), head rotation (position 2), mandibular advancement using an OA (position 3), and head rotation with an OA (position 4).

METHODS

Polysomnography (PSG) data and anthropometric variables during DISE were analyzed.

RESULTS

Eighty-three patients (65 men and 18 women; mean [standard deviation, SD], 48.5 [11.0] years) who underwent PSG and TCI-DISE were included. The mean (SD) apnea-hypopnea index (AHI) was 35.5 (22.4) events/h. Twenty-three patients had persistent complete concentric velopharyngeal collapse in the supine position, even with concurrent head rotation and OA (position 4). Their mean (SD) AHI was 54.7 (24.6) events/h, significantly higher than that of the 60 patients without such collapse in position 4 (p < .001). Their mean (SD) body mass index (BMI) was 29.0 (4.1) kg/m2 , also significantly higher (p = .005). After adjustment for age, BMI, tonsil size, and tongue position, the degree of velum and tongue base obstruction was significantly associated with sleep apnea severity in positions 2, 3, and 4.

CONCLUSION

We showed the feasibility, safety, and usefulness of using simple edge-to-edge, reusable OA in DISE. Patients who are not responsive to head rotation and OA during TCI-DISE may need upper airway surgery and/or weight control.

Palatal Coupling Maneuvers Do Not Predict Hypoglossal Nerve Stimulator Treatment Efficacy

OBJECTIVE(S)

Maneuvers during drug-induced sleep endoscopy (DISE), for patients with obstructive sleep apnea (OSA), have been used as predictors for success with oral appliances. Hypoglossal nerve stimulation (HGNS) promotes opening at the velum through palatoglossus coupling. In this study, we evaluate maneuvers during DISE as predictors for HGNS treatment efficacy.

METHODS

We evaluated patients undergoing HGNS between November, 2014 and February, 2021. We assessed maneuvers including jaw thrust and chin lift during preoperative DISE. The impact of tongue base and palatal opening during these maneuvers were rated from 1 to 4 (1: no improvement, 2: mild improvement, 3: moderate improvement, 4: significant improvement). Patients were grouped by a score of 1-2 (weak response) or 3-4 (strong response). Apnea hypopnea index (AHI) change was calculated from the difference between preoperative and postoperative sleep study.

RESULTS

One hundred and seventy one patients were included. With jaw thrust, there was no significant difference in AHI change between patients with weak or strong response at the palate (n = 68 vs. 94, 9.5 vs. 13.6, p = 0.21) or tongue base (n = 24 vs. 138, 16.6 vs. 11.3, p = 0.24). On chin lift, there was no significant difference at the palate (n = 82 vs. 18, 13.9 vs. 11.4, p = 0.63) or tongue base (n = 92 vs. 72, 10.8 vs. 14.6, p = 0.24). On multiple linear regression analysis, lower body mass index, higher preoperative AHI, and higher preoperative oxygen nadir were associated with a larger AHI change.

CONCLUSION

Palatal coupling maneuvers during DISE are not predictive of AHI change with HGNS. Findings using these maneuvers should not preclude HGNS candidacy.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:431-436, 2023.

The predictive value of drug-induced sleep endoscopy for treatment success with a mandibular advancement device or positional therapy for patients with obstructive sleep apnea

PURPOSE

As drug-induced sleep endoscopy (DISE) can provide additional diagnostic information on collapse patterns of the upper-airway, it is widely used in patients with obstructive sleep apnea (OSA). Although more controversial, DISE may also predict the success of treatment with a mandibular advancement device (MAD) and/or positional therapy (PT). In 2018, we proposed a prediction model to investigate the predictive value of passive maneuvers during DISE - such as jaw thrust and changes in body position - on upper-airway patency. Based on the outcomes of various studies, we then adjusted our DISE protocol to better mimic the effect of a MAD, PT, or a combination of both. The aim of this study was to verify whether or not our adjustments would increase the value of DISE as a selection tool.

METHODS

This single-center retrospective cohort study involved a consecutive series of patients with OSA. Patients were included if a DISE had been performed in supine and non-supine sleeping position and with and without a boil-and-bite MAD in situ between December 2018 and February 2020. The VOTE scoring system was used to evaluate the obstruction at four levels of the upper-airway.

RESULTS

Among 94 patients included. the median apnea-hypopnea index (AHI) was 16.2 (events/h). As a temporary MAD during DISE reduced obstruction by 54% and jaw thrust by 57%, both mimicked the effect of the custom-made MADs referred to in the literature, which reduces the AHI by 60%. Head-and-trunk rotation reduced obstruction by 55% and thus mimicked the effect of PT, which is known to reduce the AHI by 50%.

CONCLUSION

A jaw thrust, a temporary MAD, and head-and-trunk rotation during DISE all seem to mimic the treatment effects of MAD and PT. These findings may be of added value when choosing OSA treatment. To prove the predictive value of these maneuvers during DISE, a prospective study should be performed.

Novel Intraoral Negative Airway Pressure in Drug-Induced Sleep Endoscopy with Target-Controlled Infusion

BACKGROUND

In intermittent negative airway pressure (iNAP) therapy, soft tissues are reshaped into a forward-resting position, thus reducing airway obstruction during sleep. This study investigated the effect of iNAP therapy that was administered during drug-induced sleep endoscopy with target-controlled infusion (TCI-DISE) in patients with obstructive sleep apnea (OSA) intolerant of continuous positive airway pressure (CPAP) therapy.

METHODS

This prospective case series study included 92 patients with polysomnography (PSG)-confirmed OSA who underwent TCI-DISE with iNAP from January 2018 to February 2020 at a tertiary referral hospital. Upper airway obstruction was evaluated and scored using the velum, oropharynx, tongue base, and epiglottis (VOTE) classification. Obstruction severity was assessed multiple times with the patient in the supine position with or without lateral rotation of the head and the application of iNAP therapy, respectively.

RESULTS

After the application of iNAP therapy in the supine position, obstruction severity decreased significantly: from complete or partial obstruction to partial or no obstruction in 37, 12, and 36 patients (40.2%, 13%, and 39%, respectively) with velar obstruction, oropharyngeal, and tongue base obstruction, respectively. After simultaneously applying iNAP therapy with head rotation, obstruction severity decreased in 47, 43, and 19 patients (51%, 47%, and 21%, respectively) with velar, tongue base, and epiglottic obstruction, respectively.

CONCLUSION

In TCI-DISE, we found that iNAP therapy relieved velar, oropharyngeal, and tongue base obstruction in the supine position in some patients. Moreover, iNAP therapy can be combined with positional therapy to alleviate velar, tongue base, and epiglottic obstruction in some patients. TCI-DISE can also be used to screen the possible responders for iNAP therapy because it is less time consuming than PSG.

The clinical characteristics of patients with an isolate epiglottic collapse

OBJECTIVE

We analyzed the clinical characteristics of patients with isolated epiglottic collapse (IEC) who had an epiglottic anteroposterior (AP) collapse as the only cause of snoring during drug-induced sleep endoscopy (DISE).

METHODS

A retrospective analysis of 334 consecutive DISE examinations was performed. Patients who had only epiglottic AP collapse were designated as the IEC group. There were four age- and sex-matched controls for each case, and these patients were designated as the control group. Demographic factors, polysomnography findings, cephalometry, and awake nasopharyngoscopic findings were analyzed.

RESULTS

A total of 11 IEC cases and 44 controls were included. The IEC group had a significantly lower apnea-hypopnea index, higher minimum oxygen saturation level, lower body mass index, and shorter mandible plane to hyoid distance than the controls. However, there were no differences in epiglottic shape or curvature between the two groups. In addition, no IEC was noted during awake endoscopy. Nine (81.8%) epiglottic collapses were resolved with the mouth open and jaw thrust maneuver, which simulated the use of an oral appliance. Six (54.4%) were resolved with head turning, mimicking the lateral sleep position.

CONCLUSION

The clinical characteristics of IEC patients differed from the control group, and IEC could not be identified during awake endoscopy. Therefore, patients with severe snoring but AHI < 5 or mild sleep apnea on polysomnographic findings and DISE, should be considered likely to have IEC. In addition, use of an oral appliance is recommended as an effective treatment for IEC.

The Effect of the Modified Jaw-Thrust Maneuver on the Depth of Sedation During Drug-Induced Sleep Endoscopy

STUDY OBJECTIVES

The modified jaw-thrust maneuver (MJTM) during drug-induced sleep endoscopy (DISE) is known to predict the treatment effect of mandibular advancement devices. However, its effect on the depth of sedation and potential to provoke arousal by awakening patients during the maneuver has not been studied so far. This study investigated the effect of the MJTM on the depth of sedation during DISE.

METHODS

Forty patients on whom the MJTM was performed during DISE were included. The effect of the maneuver was evaluated at the levels of the velum, lateral wall of the oropharynx, base of the tongue, and epiglottis. Obstruction was defined as the collapse of the upper airway exceeding 75%, and improvement with the MJTM was defined as the widening of the upper airway by more than 50% during the maneuver. A bolus injection of midazolam was used to induce sedation and control the depth of sedation (bispectral index value of 60 to 80).

RESULTS

Obstructions were present in the velum of all patients, lateral wall of the oropharynx of 13 patients, base of the tongue of 28 patients, and epiglottis of 6 patients. After the MJTM, improvement of the obstruction was observed in 57.5%, 61.5%, 82%, and 66.7% of patients with velum, lateral wall of the oropharynx, base of the tongue, and epiglottis obstructions, respectively. An increase in the bispectral index value of more than 20 was observed in 8 patients. Four patients awakened during the procedure.

CONCLUSIONS

The MJTM significantly relieved obstruction during DISE, especially at the base of the tongue. However, this might have been caused by an increase in the degree of awakening during the maneuver. Therefore, MJTM's effect on the depth of sedation may help in improving the degree of airway obstruction.