Drug-induced Sedation Endoscopy Research Articles

Incidence and risk factors of nocturnal penetrations and aspirations in patients with obstructive sleep apnea during drug-induced sedation endoscopy.

Obstructive sleep apnea has been linked to an increased risk of pneumonia, possibly due to higher rates of nighttime aspirations. Few studies have directly investigated such aspirations in individuals with sleep apnea. This retrospective study included 142 adult patients with obstructive sleep apnea who underwent drug-induced sedation endoscopy between 2017 and 2020. The incidence of penetrations and aspirations during the procedure was assessed, along with potential associated factors. The results showed that 28.1% of the patients experienced penetrations, 48.5% had aspirations, and 23.2% had neither. Male gender and epiglottic collapse were significantly associated with both penetrations and aspirations, while oropharyngeal collapse was more common in those without these events. This study highlights a high rate of aspirations during the procedure in individuals with sleep apnea, with epiglottic collapse and male gender identified as potential risk factors. These findings underscore the need for further research to understand the mechanisms of nighttime aspirations in sleep apnea and to develop targeted strategies to reduce pneumonia risk in this population.

Inter-observer and intra-observer agreement in drug-induced sedation endoscopy \u2014 a systematic approach

ObjectiveTo evaluate the feasibility of systematic observer training in drug-induced sedation endoscopy (DISE) interpretation.MethodsFifty DISE videos were randomly selected from a group of 200 videos of cohort of patients with OSA and/or snoring. The videos were assessed blindly and independently using a modified VOTE classification by an expert observer and by two novice observers starting their training. A systematic approach was initiated. Clusters of 10 videos were scored individually by each observer and then re-evaluated as the expert observer clarified the decision-making in plenum. Kappa coefficient (κ) was calculated as a measure of agreement.ResultsThe intra-observer variation for the total agreement and kappa values for the expert observer ranged between moderate to substantial agreement in VOTE classification, whereas the novices varied between “less than chance agreement” to “moderate agreement.” The inter-observer variation showed increased agreement and kappa values from day 1 to day 2 for both novice observers except at the velum level for observer C. The total agreement and kappa values for each site also improved compared to results of day 1, except at velum for observer C. The velum site seemed to be more difficult to evaluate. The learning curve varied during the study course for each site of the upper airways.ConclusionThis study shows that systematic intensive training is feasible, although expert level is not acquired after 100 evaluations. The learning curve for the expert observer showed “moderate to substantial agreement” but differed between the trainees.Level of evidence2

Comparative Efficacy of Patients with OSA Undergoing Multi-level Surgery followed by Upper Airway Stimulation vs. Isolated Upper Airway Stimulation

PurposeUpper airway stimulation (UAS) via hypoglossal nerve stimulation is a viable management option for patients with obstructive sleep apnea (OSA). Important exclusion criteria for the current UAS protocol include AHI above 65 events per hour or concentric collapse of the velum seen on drug-induced sedation endoscopy (DISE). The authors describe the treatment efficacy of a cohort of UAS patients who were initially ineligible, but who were implanted following multilevel surgery that reversed the exclusion criteria. MethodsThe design in a single-center, retrospective study. Data collection included demographics, body-mass index (BMI), apnea-hypopnea index (AHI) titration results, oxygen desaturation index (ODI), Drug Induced Sedation Endoscopy (DISE) results, Epworth sleepiness score (ESS), and Fatigue Severity Score (FSS). ResultsThirty-six subjects underwent UAS implantation (Inspire system, MN, USA) from 2016 to 2019. Eighteen subjects who were initially ineligible for UAS first underwent multi-level surgery, including uvulopalatopharyngoplasty (UPPP), genioglossus advancement (GGA), distraction osteogenesis maxillary expansion (DOME), or maxillomandibular advancement (MMA). Mean subject age was 62.3±9 years with 28% being female. Mean subject BMI was 29±4kg/m2. Seventeen subjects met the criteria for UAS and underwent surgery. Mean subject age was 62.9±14 years with 12% being female. Mean subject BMI was 26.7±4kg/m2. Mean pre-treatment AHI for 2-staged patients was 49±29 events per hour, which was reduced to 3.6±5 events per hour with an average voltage of 1.8V±0.9. Mean pre-treatment AHI for UAS-only cohort was reduced from 33±14 events per hour to 5.3±6 events per hour with an average voltage of 1.9V±0.3. ConclusionFor patients who are ineligible for UAS due to severity of OSA or concentric collapse of the velum, multilevel surgery including UPPP, GGA, DOME, or MMA followed by UAS confers reliable, effective, and equitable post-treatment results.

Depth of sedation during drug induced sedation endoscopy monitored by BiSpectral Index® and Cerebral State Index®.

Drug induced sedation endoscopy (DISE) is performed to investigate patterns and sites of obstruction in patients with sleep-disordered breathing (SDB). During DISE the patients are sedated to obtain a muscular relaxation of the upper airway which mimics the relaxation during natural sleep. Different sleep stages are intended to be simulated by drug induced sedation, and it is helpful to measure the depth of sedation. The BiSpectral Index® (BIS) is often used for this procedure. Besides the BIS, other means of sedation depth monitoring exist in anaesthesiology but have not yet been investigated with respect to DISE. Monitoring of the Cerebral State Index® (CSI) is one of these methods. The aim of the study was to compare the BIS and CSI for sedation depth monitoring during DISE. Sixty patients underwent DISE monitored by the BIS and CSI in parallel. The BIS and CSI values were compared using the Bland-Altman analysis. The BIS and CSI values differed during the course of sedation during DISE by a mean of - 6.07. At light sedation (BIS 60-80), lower values by 10 scale points of CSI compared with BIS were detectable. At deeper sedation levels (BIS 40-50), the CSI turned to present equal and even higher values compared with the BIS. Sedation depth measurement during DISE can be performed by the BIS or CSI, but the differences should be interpreted carefully as comparable data for sleep stages in natural sleep are available only for BIS.

Transoral Endoscopic Coblation Tongue Base Surgery in Obstructive Sleep Apnea: Resection versus Ablation

Background: A new transoral tongue base surgical procedure for the treatment of snoring and obstructive sleep apnea (OSA) is described. It is named “Robo-Cob” technique because it is similar to transoral robotic surgery (TORS) but it is performed by means of coblation technology in order to resect the tongue base in countries where TORS is not an available option for such benign conditions. Methods: In this prospective, randomized, controlled trial, the new Robo-Cob technique was carried out in 25 adult OSA patients with confirmed tongue base hypertrophy at preoperative drug-induced sedation endoscopy. The results of this procedure were compared with the coblation endoscopic lingual lightening (CELL) technique used to ablate (or minimally resect) the central part of the tongue base, in another 25 adult OSA patients with similar characteristics (age, sex, preoperative body mass index and Apnea-Hypopnea Index, AHI). The base of tongue surgery was part of multilevel surgery including also septoturbinoplasty and barbed reposition pharyngoplasty (with/without tonsillectomy). Results: In this study, the Robo-Cob technique is proved to be feasible and effective in all cases either alone or when combined with other procedures in multilevel surgical settings. No/minimal intraoperative or postoperative complications were observed. Postoperative pain as measured by visual analog scale ranged from 3 to 7. No tracheostomy was done in any patient. Objective clinical improvement was confirmed by a level 3 polygraphy performed 6 months after surgery. There was significant difference in operative time at the level of the tongue base between Robo-Cob and CELL techniques, with shorter times observed within the Robo-Cob group. Moreover, the Robo-Cob technique provided tongue base tissue specimens that allowed measurement of the volume that ranged from 5 to 17 cm³ (mean 11.64 ± 3.49 cm³). It was found that resection of at least 10 cm³ of tongue base tissue was associated with better outcomes in terms of postoperative AHI reduction. Conclusion: In this study, the added values of using coblation for resection and not ablation appear to be the short surgical time, the low postoperative tissue edema, and the possibility of providing tissue specimens to measure resected volumes.

A feasibility study in the treatment of obstructive sleep apnea syndrome and snoring: Nasopharyngeal stent.

The objective of this study is to create a new choice of treatment with nasopharyngeal stent in isolated retro palatal obstruction and snoring for the treatment of obstructive sleep apnea syndrome (OSAS). The study included five patients with mild OSAS and snoring. Nasopharyngeal stents were applied in these patients with drug-induced sedation endoscopy. With the nasopharyngeal stents, we aimed to prevent the soft palate to fall backwards while sleeping, especially at supine position in order to prevent the occurrence of apnea and hypopnea, providing a way for the airway to remain open as well as a support behind the soft palate and thus prevent snoring based on the vibration created by draught. We suggest a new alternative treatment approach to devices that need to be continuously used such as CPAP or intraoral devices or surgical methods that have many unwanted discomforts for the patients.

Adult sleep apnea and tonsil hypertrophy: should pharyngoplasty be associated with tonsillectomy?

Velopharyngoplasty and palatine tonsillectomy are at the very heart of the surgical treatment of obstructive sleep apnea syndrome (OSAS) care. In cases of major tonsil hypertrophy, we evaluated the relevance of associating soft palate surgery with palatine tonsillectomy, independent of the soft palate length. We conducted a retrospective single-center study in OSAS patients with grade III or IV tonsils treated with tonsillectomy. Preoperative assessment included an upper airway examination performed while the patient was awake, a polysomnography and a drug-induced sedation endoscopy (DISE). Surgical efficacy was assessed on postoperative polysomnography. Success was considered when the postoperative apnea-hypopnea index (AHI) was less than 20 events/h with a 50% reduction. We compared palatine tonsillectomy efficacy alone (group A) and associated with soft palate surgery (group B). We analyzed 33 patients who had undergone surgery between December 2006 and May 2018. Their preoperative mean BMI and mean AHI were 27.3 ± 7.5kg/m2 and 38.6 ± 21.4 events/h, respectively. The two groups (A, n = 18 and B, n = 15) were clinically comparable. The success rate was 72.2% in group A and 60% in group B. There was no statistically significant difference between the two groups (p > 0.1). According to this study, in our institution, in cases of major tonsillar hypertrophy, simultaneous soft palate surgery had no significant impact on the success rate, regardless of soft palate length. Associating soft palate surgery with palatine tonsillectomy does not seem mandatory to increase the success rate. III. Retrospective comparative study.

Obstructive sleep apnea syndrome in the pediatric age: the role of the otorhinolaryngologist.

Obstructive sleep apnea (OSA) is the primary indication for tonsillectomy, one of the most common pediatric surgical procedures, commonly performed in association with adenoidectomy. The objective of this review article is to evaluate the role of the otorhinolaryngologist in pediatric OSA. A literature review has been performed on the following topics: peculiarities of sleep-disordered breathing in pediatric age; discrimination of sleep disorders; adenotonsillar hypertrophy; surgical techniques; adjuvant surgical procedures. The role of the otorhinolaryngologist in pediatric OSA is important for the evaluation of the upper airways and of essential biometric and polysomnographic data and for indication and execution of appropriate surgical treatment. In the majority of healthy children, adenotonsillectomy for OSA results in a dramatic improvement in respiratory parameters as measured by polysomnography. When post-surgical residual OSA occurs, it is essential to monitor patients by means of drug-induced sleep endoscopy (DISE). Otolaryngologic assessment is of paramount importance to correctly classify a child with OSA. Correct inspection of the upper airway and quantification of the quality of sleep through polysomnography lead to the right therapeutic choice. Knowledge of different surgical techniques helps to deal with residual OSA after studying the obstruction sites by drug-induced sedation endoscopy.

Propofol sedation in Drug Induced Sedation Endoscopy without an anaesthesiologist – a study of safety and feasibility

Propofol sedation in Drug Induced Sedation Endoscopy (DISE) of the upper airway of patients with obstructive sleep apnea (OSA) without the presence of anesthesiologist has not been done before. Propofol sedation is normally administered by an anesthesiologist. This is the first study of this new method. Based on the positive experience with Nurse-administered Propofol Sedation (NAPS) for endoscopic procedures in the departments of gastroenterology we wanted to test the set-up as method of propofol sedation for DISE procedures in our Otorhinolaryngology (ORL) department. The ORL specialists and staff nurses that carry out DISE procedures all underwent a formalized education in Nurse-administered Propofol Sedation before the study. We included 200 patients with severe snoring and / or obstructive sleep apnea. They were referred for DISE examination prior to possible targeted surgery based on the findings. In our study the aforementioned ORL team successfully cared out propofol sedation without the presence of an anesthesiologist. All examinations were carried out according to plan. There were no adverse events during the procedures or in the following observational period. The NAPS method of sedation for DISE seems safe and feasible when performed by trained staff in a hospital setting.

Effect of Drug-Induced Sedation Endoscopy on the Decision of Treatment Plan in Patients with Obstructive Sleep Apnea

Effect of Drug-Induced Sedation Endoscopy on the Decision of Treatment Plan in Patients with Obstructive Sleep Apnea

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

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. 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. 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. 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.

Drug-induced sedation endoscopy in surgically naïve infants and children with obstructive sleep apnea: impact on treatment decision and outcome.

Adenotonsillectomy (AT) is the first-line treatment for obstructive sleep apnea (OSA) in children irrespective of clinical upper airway (UA) findings. We aimed to investigate whether drug-induced sedation endoscopy (DISE) changes treatment decision and outcome in otherwise healthy children and infants with OSA. Retrospective analysis of prospectively collected data on polysomnography, DISE, and treatment in surgically naïve, otherwise healthy infants (n=34) and children (n=75) with OSA. Treatment success is defined as post-treatment obstructive apnea/hypopnea index (oAHI) <5h-5-1, and cure is defined as oAHI <2h-1. Based upon UA findings during DISE, AT was performed in 22 infants and 57 children. oAHI improved from 16.5h-1 (8.1-28.3) to 0.8h-1 (0.3-4.2) (p=0.01) in infants and from 28.6h-1 (23.4-34.9) to 0.7h-1 (0.4-1.8) (p<0.001) in children. AT was successful in 84.2% of infants and 91.4% of children. A cure was obtained in 68.4% of infants and 78.7% of children. DISE changed the treatment decision in 1/3rd of infants and 1/4th of children, and they did not undergo AT. In the non-AT group, isolated adenoidectomy/tonsillectomy or non-surgical treatment was successful in 86.6% of children and in 100% of infants. Cure was achieved in 66.6% of children and 75% of infants. DISE performed in otherwise healthy and surgically naïve infants and children with OSA altered the therapeutic decision making in up to 1/3rd to 1/4th of the cases and resulted in comparable treatment outcomes as standard treatment by AT. The present data suggest that DISE may provide individually tailored treatment of OSA in otherwise healthy infants and children.

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.

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

Are Drug‐Induced Sedation Endoscopy–Based Predictors Better Predictors of Uvulopalatopharyngoplasty Outcomes?

Otolaryngology–Head and Neck SurgeryVolume 157, Issue 1 p. 167-167 Letter to the Editor Are Drug-Induced Sedation Endoscopy–Based Predictors Better Predictors of Uvulopalatopharyngoplasty Outcomes? Esuabom Dijemeni MSc, Esuabom Dijemeni MScSearch for more papers by this authorGabriele D’Amone, Gabriele D’AmoneSearch for more papers by this authorIsrael Gbati, Israel GbatiSearch for more papers by this author Esuabom Dijemeni MSc, Esuabom Dijemeni MScSearch for more papers by this authorGabriele D’Amone, Gabriele D’AmoneSearch for more papers by this authorIsrael Gbati, Israel GbatiSearch for more papers by this author First published: 03 July 2017 https://doi.org/10.1177/0194599817710442 No sponsorships or competing interests have been disclosed for this article. Read the full textAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume157, Issue1July 2017Pages 167-167 RelatedInformation

UDISE model: a universal drug-induced sedation endoscopy classification system\u2014part 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.

0635 FEASIBILITY OF DRUG INDUCED SEDATION ENDOSCOPY IN THE BRONCHOSCOPY SUITE

Patients with obstructive sleep apnea (OSA) commonly experience difficulty tolerating positive airway pressure (PAP) therapy. Drug Induced Sedation Endoscopy (DISE) assesses airway characteristics while the patient is sedated and may help guide alternative interventions for OSA. Since DISE is performed in the operating room, its cost is high and its availability limited to the surgeon’s busy schedule. Performing DISE in the bronchoscopy suite may reduce cost and improve access to care while maintaining a low risk for complications. Following training by an ENT physician, a sleep boarded pulmonologist performed DISE in the bronchoscopy suite. Patients with OSA and difficulty tolerating PAP therapy were evaluated for alternative interventions via DISE. A propofol infusion was administered by an anesthesiologist trained on performing DISE and sedation level was tracked via Bispectral IndexTM for a target level of 60–75. Videos of the DISE were recorded for multidisciplinary conference review with ENT and to track patient outcomes following interventions. Baseline polysomnography prior to DISE was reviewed to classify severity of OSA. Complication rates were tracked. Facility costs of DISE in the bronchoscopy suite were compared to those of the operating room. The sleep trained pulmonologist performed 21 DISE procedures in the bronchoscopy suite over a period of ten months. Review of polysomnography prior to DISE demonstrated an average AHI of 34.3+/-15.9 and an average SpO2 nadir 78 +/- 8.3%. No complications were observed during DISE. The facility fee for performing DISE procedures in the operating room was twice as much as the facility fee for performing DISE in the bronchoscopy suite while the operator charges were the same. Based on these findings, performance of DISE in the bronchoscopy suite appears feasible, safe and cost effective. Its performance by the sleep trained pulmonologist may improve access to care and may help identify successful alternative treatments for patients with PAP intolerance. Further studies are needed to identify the training necessary for pulmonary based sleep specialists to become proficient in the procedure. None

Drug-induced sedation endoscopy in children

Few data are available about the pattern of upper airway (UA) obstruction in children <2years with obstructive sleep apnea syndrome (OSAS). Also, the role of adenoidectomy versus adenotonsillectomy (AT) is poorly defined in this age group. We performed drug-induced sedation endoscopy(DISE) in young OSAS children to investigate the pattern of UA obstruction and the value of DISE in therapeutic decision making. Retrospective analysis of ≤2-year-old children undergoing DISE-directed UA surgery. OSAS severity and the treatment outcomes were documented by polysomnography. Data are available for 28 patients, age 1.5years (1.3-1.8), BMI-z score 0.5 (-0.7to1.3) with severe OSAS, obstructive apnea/hypopnea index (oAHI) 13.8/hr (7.5-28.3). All but 3 had (>50%) obstruction at the level of the adenoids, and all but 5 had (>50%) tonsillar obstruction. DISE-directed treatment consisted of adenoidectomy (n = 4), tonsillectomy (n = 1), and AT (n = 23). There was a significant improvement in respiratory parameters. Twenty children (71.4%) had a postoperative oAHI <2/hr. None had palatal or tongue base obstruction. Five children had a circumferential UA narrowing (hypotonia), 2 of them had residual OSAS. DISE showed a collapse of the epiglottis in 6 and late-onset laryngomalacia in 4. These findings did not affect surgical outcome. Adenotonsillar hypertrophy is the major cause of UA obstruction, and DISE-directed UA surgery was curative in 71,4% of children ≤2years. We suggest that DISE may be helpful in surgical decision making. Circumferential UA narrowing may result in less favorable surgical outcomes.

The importance of drug-induced sedation endoscopy (D.I.S.E.) techniques in surgical decision making: conventional versus target controlled infusion techniques-a prospective randomized controlled study and a retrospective surgical outcomes analysis.

Drug-Induced Sedation Endoscopy (DISE) consists of the direct observation of the upper airways during sedative-induced sleep, allowing the identification of the sites of pharyngeal collapse, which is the main pathological event in Obstructive Sleep Apnea (OSA). The Authors have compared Target Controlled Infusion (TCI) sedation endoscopy (TCI-DISE) technique to conventional DISE (CDISE), performed by a manual bolus injection of sedative agent, to recreate accurately and safely snoring and apnea patterns comparable to natural sleep. The authors conducted a prospective, randomized, long-term study and a retrospective analysis of surgical outcomes. The apnea-event observation and its correlation with pharyngeal collapse patterns is the primary endpoint; secondary endpoints are defined as stability and safety of sedation plan of DISE-TCI technique. From January 2009 to January 2011, OSA patients were included in the study and randomly allocated into two groups: the bolus injection conventional DISE group and the TCI-DISE group. Third endpoint is to compare the surgical outcomes enrolling OSA patients from January 2009 to June 2015. We recorded the complete apnea-event at oropharynx and hypopharynx levels in 15/50 pts in conventional DISE group (30%) and in 99/123 pts in TCI-DISE group (81%) (p < 0.0001). Four pts needed oxygen in conventional DISE group because a severe desaturation occurred during the first bolus of propofol (1mg/kg) (p = 0.4872ns). We recorded instability of the sedation plan in 13 patients of conventional DISE group (65%) and 1 patient of the TCI-DISE group (5%) (p = 0.0001). In 37 TCI-DISE group surgical patients we reported a significant reduction of postoperative AHI (from 42.7 ± 20.2 to 11.4 ± 10.3) in comparison with postoperative AHI in 15C-DISE group surgical patients (from 41.3 ± 23.4 to 20.4 ± 15.5) (p = 0.05). Our results suggest the DISE-TCI technique as first choice in performing sleep-endoscopy because of its increased accuracy, stability and safety. However, it is mandatory an accurate assessment of PSG/PM, which allows us to differentiate OSA patients in whom UA anatomical abnormalities are predominant in comparison with not-anatomical pathophysiologic factors, achieving good surgical patient's selection and outcomes as a consequence.

Reliability of drug-induced sedation endoscopy: interobserver agreement.

Several studies have demonstrated the validity, reliability, and safety of drug-induced sedation endoscopy (DISE) in assessing the collapse of the upper airway (UA) in patients with obstructive sleep apnea hypoapnea syndrome (OSAHS). The aim of this study was to assess the interobserver agreement on DISE and on therapeutic decision between an expert observer and an observer in training. This was a cross-sectional study. Thirty-one DISE videos performed in our service were randomly selected. Videos belonged to patients with OSAHS who wanted alternative treatments to CPAP. The videos were reviewed by an ENT experienced on DISE and a second observer in formation. Each observer independently assessed the presence of collapse of the UA according to a modified VOTE classification and proposed an alternative treatment to CPAP. Interobserver agreement kappa values were calculated. In assessing the presence of collapse at different levels of the upper airway, the percentage of agreement was 80% at the level of the soft palate (kappa=0.1667), 89.29% in the oropharynx (k=0.7742), 80.65% at the tongue base (k=0.5571), and 74.17% at the epiglottis (k=0.4768). When degree and configuration of the collapse was evaluated, the interrater agreement was moderate to good, except at the level of the tongue base where the agreement was weak for both degree and configuration of collapse (k=0.34 and 0.38, respectively). Interobserver agreement was moderate when the indication of alternative treatments to CPAP is valued based on the findings of DISE. Overall, DISE is a reliable technique even when assessing interobserver agreement between an experienced observer and one in training; however, tongue base is the level of the upper airway that presents the greatest difficulties when assessing the collapse with DISE. Therefore, it is important to develop learning curves for this technique in order to obtain more reliable results.