Drug-induced Sleep Endoscopy In Patients Research Articles

Surgical failure guided by DISE in patients with obstructive sleep apnea: a systematic review and meta-analysis.

The failure rate and risk factors of upper airway surgery with drug induced sleep endoscopy (DISE) remain unknown in the treatment of obstructive sleep apnea (OSA). This review aims to analyze the failure rate of upper airway surgery with DISE and identify obstruction sites for surgical failure. A systematic review was conducted using PubMed, Embase, Web of Science, and Google Scholar until May 20th, 2023. We included studies that used DISE to assess obstructive sites before upper airway surgery and reported surgical failure rates and outcomes in patients with OSA. 25 studies with a total of 1522 patients were included in the systematic review and meta-analysis. Upper airway surgery guided by DISE had a relatively low failure rate of 37% (95% CI 0.31-0.44) in the random effects model (I2 = 85.97%, P < 0.001). According to the velum, oropharynx, tongue base, and epiglottis (VOTE) scoring system, major risk factors for surgical failure included circumferential collapse at the velum, lateral wall collapse and small tonsils at the oropharynx, anterior-posterior lingual collapse and complete collapse at the tongue base. High body mass index and large preoperative apnea hypopnea index were also risk factors for OSA surgical failure. Upper airway surgery guided by DISE in patients with OSA had a low failure rate of 37%. DISE can identify obstruction sites associated with surgical failure and guide single-level and multi-level surgeries.

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

High-flow nasal oxygenation (HFNO) can provide a low level of continuous positive airway pressure and alveolar recruitment. We aimed to compare the efficacy of pre-oxygenation with HFNO and low-flow nasal oxygenation (LFNO) during drug-induced sleep endoscopy (DISE). In the LFNO group, preoxygenation was performed for 10 min at 3 L·min-1. In the HFNO group, preoxygenation was performed for 10 min at 30 L·min-1 at a fraction of inspired oxygen of 100% using the Optiflow device. From the start of sedative administration to the end of DISE, vital signs were monitored continuously. The primary outcome was the lowest oxygen saturation (SpO2) during DISE. Of 24 patients enrolled, 12 were randomly assigned to the LFNO and 12 to the HFNO groups. Theprevalence of hypoxia events was 75% in the LFNO group and 58% in the HFNO group. The difference in lowest oxygen saturation between the two groups was not significant between the two groups (P=0.665). The lowest SpO2 during all procedures was comparable between the two groups (86.8 ± 6.5% in the LFNO group and 87.2 ± 8.0% in the HFNO group; P=0.912). The findings suggest thatHFNO may not be superior to LFNO as a preoxygenation tool to prevent hypoxia during DISE.

Effect of Body Mass Index on Upper Airway Obstruction as Revealed by Drug-Induced Sleep Endoscopy in Patients With Sleep-Disordered Breathing

Background and Objectives Drug-induced sleep endoscopy (DISE) usefully determines the sites of airway obstruction in patients with sleep-disordered breathing. It is widely accepted that obesity increases obstructive sleep apnea. However, no study has explored how and where obesity causes obstructions. In this study, we described the patterns of upper airway obstruction revealed by DISE in patients of various body mass indices (BMIs) with sleep-disordered breathing.Subjects and Method All subjects had sleep-disordered breathing and underwent DISE. Endoscopic findings at the retropalatal (upper lateral, upper anteroposterior [AP]) and retrolingual (lower lateral, lower AP) levels were graded; obstruction was complete (2), partial (1), or none (0). Subjects with BMI &lt;25 (&lt;25 group), 25≤BMI&lt;30 (25&lt;30 group), and ≥30 kg/m&lt;sup&gt;2&lt;/sup&gt; (&gt;30 group) were compared using a dummy variable; to this end, we employed R ver. 4.0.5.Results For the total of 153 patients reviewed, the mean age was 43.1±12.2 years and the mean BMI was 26.0±3.4 kg/m&lt;sup&gt;2&lt;/sup&gt;. At the retropalatal AP level, the DISE grade was significantly higher in the 25&lt;30 group than in the &lt;25 group (&lt;i&gt;p&lt;/i&gt;=0.029) but not in the &gt;30 group (&lt;i&gt;p&lt;/i&gt;=0.248). At the retropalatal lateral level, significant increases were evident in both of the higher BMI groups (&lt;i&gt;p&lt;/i&gt;=0.06 and &lt;i&gt;p&lt;/i&gt;=0.024, respectively). No significant relationship was found at the retrolingual level.Conclusion In terms of the retropalatal AP and lateral diameters, a higher BMI is associated with a greater incidence of more severe obstruction.

Correlation between the transverse dimension of the maxilla, upper airway obstructive site, and OSA severity.

Acquiring a better comprehension of obstructive sleep apnea physiopathology can contribute to improving patient selection for surgical treatments. We hypothesize that maxillary transverse deficiency restricts the space available for the tongue, leading to upper airway obstruction during sleep. Our primary hypothesis was that maxillary transverse deficiency increases the prevalence of tongue collapse during drug-induced sleep endoscopy (DISE). The secondary hypothesis was that maxillary transverse deficiency will also increase the prevalence of circumferential collapse at the velopharynx. The exploratory hypothesis was that maxillary transverse deficiency is associated with increased obstructive sleep apnea severity. The objectives of this study were to correlate maxillary morphometric measurements with (1) the anatomic level of obstruction during DISE and (2) the apnea-hypopnea index on polysomnography. We made a cross-sectional analysis of patients with obstructive sleep apnea undergoing DISE in search of positive airway pressure alternative treatment. Maxillary measurements were collected from a computed tomography scan (interpremolar distance, intermolar distance [IMD] and sella-nasion A point angle), findings from DISE, and sleep study variables from polysomnography. Correlation between computed tomography, DISE, and polysomnography data was assessed using Pearson's correlation, and receiver operating characteristic curves were determined for each facial measurement. Sixty-nine patients were included in the study. The group with velopharyngeal circumferential collapse had mean IMD = 26.30 mm (25.5-31.45), and the group with anteroposterior collapse had mean IMD = 29.20 mm (26.8-33.10; P = .040). The group with complete tongue-base obstruction had mean interpremolar distance = 26.40 mm (25.1-28) and IMD = 26.30 mm (25.6-28.4), and the group without obstruction had mean interpremolar distance = 28.7 mm (27.2-30; P = .003) and IMD = 34.06 mm (32.1-37; P < .001). The receiver operating characteristic curve determined an IMD cutoff of 29.8 mm for predicting tongue-base obstruction. The maxillary transverse deficiency, identified by reduction in interpremolar distance and IMD, predicted the occurrence of complete tongue-base obstruction, complete concentric collapse at the velopharynx, and multilevel obstruction during DISE. We did not find an association between the maxillary measurements and obstructive sleep apnea severity. These associations hold some promise in ultimately supplanting insights previously available only through DISE.

Comparison of Findings between Clinical Examinations and Drug-Induced Sleep Endoscopy in Patients with Obstructive Sleep Apnea Syndrome.

The Velum, Oropharynx, Tongue base and Epiglottis (VOTE) classification on drug-induced sleep endoscopy (DISE) is used widely for obstructive sleep apnea (OSA) syndrome, though research into comparative physical examinations with VOTE on DISE is still limited. The aim of this study was to evaluate the relationship between the findings of physical examinations and DISE in patients with OSA. Fifty-five patients with OSA were enrolled in this retrospective study. All of the patients received clinical explorations including a Brodsky classification, a modified Mallampati score (MMS), a modified Friedman’s staging system, and a Muller’s test. Drug-induced sleep endoscopy was further evaluated in the operating room. There were significant relationships between Brodsky classification, modified Friedman’s staging system, Muller’s test and oropharynx collapse during DISE (p < 0.05). Brodsky classification, MMS, modified Friedman’s staging system and retropalatal lateral-to-lateral (L–L) collapse of Muller’s test were significantly correlated with VOTE count (p < 0.05). The concordance between VOTE under DISE and Brodsky classification or modified Friedman’s staging system was moderate. In contrast, the concordance between VOTE under DISE and MMS or Muller’s test was slight. The study revealed that Brodsky classification and Friedman staging had a significant relationship with DISE on the velum and oropharynx, but the level of tongue base is uncertain between DISE and MMS. Correlation of awake evaluation of tongue base is still not correlated to the DISE findings. Pre-treatment evaluation of DISE is still warranted.

Nasal Surgery May Improve Upper Airway Collapse in Patients With Obstructive Sleep Apnea: A Drug-Induced Sleep Endoscopy Study.

The aim of this study is to evaluate the effects of nasal surgery in the upper airway (UA) collapse using drug induced sleep endoscopy (DISE) in a group of patients with obstructive sleep apnea hypopnea syndrome (OSAHS). Prospective cohort of patients treated with nasal surgery between 2015 and 2016. All patients were diagnosed with mild to severe OSAHS. The inclusion criteria were age between 18 and 70 years, apnea-hypopnea index (AHI) higher than 15, and septal deviation. All patients had a DISE performed before surgery and 3 months after. The DISE findings were evaluated through the NOHL scale. Thirty-four patients were included. Surgical success with subjective and objective improvement in nasal obstructions was achieved in all cases. The pattern of UA obstruction did change significantly following nasal surgery (P < 0.05). Before nasal surgery, 74% of the patients demonstrated multilevel obstruction. After nasal surgery, only 50% patients showed multilevel collapse (P < 0.05). Among patients with single-level collapse, the oropharynx was the most common location of obstruction. It became more frequent after nasal surgery was done (41% vs 21%, P < 0.05). Significant improvement was shown in hypopharyngeal collapse. Postoperative AHI decreased from a mean of 26.7 to 19 events/h, but this change was not significant. Nasal surgery may improve hypopharyngeal collapses observed during DISE in patients with OSAHS. Thus, an improvement in nasal obstruction may also modify the surgical plan based on UA functional findings in OSAHS patients.

Analyzed the related factors of VOTE score for drug-induced sleep endoscopy in patients with obstructive sleep apnea

Objective:To analyze the related factors of VOTE score for drug-induced endoscopy（DISE） in patients with obstructive sleep apnea （OSA）. Method:Fifty-four OSA patients, diagnosed by polysomnograph, underwent surgical treatment from Nov 2014 to Dec 2016 in our hospital. All patients underwent drug induced sleep endoscope, and then the collapse of pharyngeal space was evaluated. We analyzed the related factors with VOTE score. Result:The occlusion rates were significant statistical different in different spaces of 54 OSA patients undergoing DISE（P=0.000, velum 98.15%, oropharynx 81.48%, tongue base 40.47%, and epiglottis 11.11% respectively）. The rateand of tongue base collapsing was related with Mallampatis（P<0.05） and Friedman stage（P<0.05）. The VOTE score was weakly related with Friedman stage（r=0.297, P<0.05）, medium related with BMI（r=0.376, P<0.05）, AHI（r=0.312, P<0.05） and lowest SpO2（r=0.376, P<0.01）. Conclusion:In the VOTE scoring system for DISE, the rate of collapse in tongue base was related with Mallampatis and Friedman stage. The VOTE score was medium related with BMI, AHI and Lowest SpO2, mild related with Friedman stage.

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

During drug-induced sleep endoscopy (DISE) in patients with obstructive sleep apnea, the increased depth of propofol anesthesia is related to the increased collapsibility of the upper airway with dose-dependent. We examined the effect of remifentanil on propofol concentration during DISE. In a prospective randomized trial, 56 adult patients were divided into remifentanil-propofol (n = 28) and propofol alone (n = 28) groups. Anesthesia was administered using a target-controlled infusion system. In the remifentanil-propofol group, 0.5ng/ml remifentanil was administered prior to propofol infusion and its concentration maintained; thereafter, in the propofol alone group, normal saline was injected instead of remifentanil. Propofol was infused at a concentration of 1.5μg/ml after the target concentration of remifentanil was reached. In both groups, the concentration of propofol was increased by 0.5μg/ml if the degree of sedation was not sufficient. The sedation level was targeted at observer's assessment of alertness/sedation (OAA/S) scale 3. The mean propofol concentration was 2.87 ± 0.60μg/ml in the remifentanil-propofol group, which was lower than that in the propofol alone group (3.38 ± 0.72μg/ml, P < 0.001). The time until sufficient sedation to perform DISE was shorter in the remifentanil-propofol group (P < 0.001). Apnea-hypopnea index and the lowest peripheral capillary oxygen saturation (SpO2) during polysomnography showed no statistical difference between groups (P > 0.05). The lowest SpO2 and VOTE classification during DISE were also not statistically different (P > 0.05). Use of remifentanil during DISE reduces the target concentration of propofol required for patient sedation to perform DISE without respiratory depression.

Meta-Analysis of Obstruction Site Observed With Drug-Induced Sleep Endoscopy in Patients With Obstructive Sleep Apnea.

To perform a meta-analysis on the distribution and characteristics of the obstructive site in patients with obstructive sleep apnea (OSA) using data from a variety of published studies that evaluated the obstruction with drug-induced sleep endoscopy (DISE). A literature search was performed to identify studies in which DISE was used to identify the obstruction site in adult patients with OSA, and the obstruction site was described in sufficient detail. Four items were evaluated in the meta-analysis: the obstruction site, closing direction of the soft palate, degree of closure, and percentage of single-level obstructions. A total of 2,950 patients from 19 studies were included. In the two-level classification system, the rate of obstruction was 91.6% for the soft palate and 58.0% for the tongue base. In the four-level classification system, the rate of obstruction was 84.1% for soft palate, 32.8% for the tonsil, 51.6% for the tongue base, and 34.3% for the epiglottis. The soft palate closed in the anteroposterior direction at a rate of 44.4% and in the concentric direction at a rate of 46.5%. The rate of a closure of 75% or more was 69.3% for the soft palate and 56.8% for the hypopharynx. The percentage of single-level obstructions was 42.5%. The soft palate is obstructed in most patients with OSA, and the tongue base is obstructed in half of the patients. In addition, multilevel obstructions including the tonsil, lateral pharyngeal wall, or epiglottis are common; thus, these areas must be checked carefully. NA Laryngoscope, 129:1235-1243, 2019.

Patterns of Upper Airway Obstruction on Drug-Induced Sleep Endoscopy in Patients with Sleep-Disordered Breathing with AHI

ObjectiveTo describe the patterns of upper airway obstruction in patients with sleep-disordered breathing with apnea-hypopnea index (AHI) <5 using drug-induced sleep endoscopy (DISE).Study DesignRetrospective study.SettingTertiary care center.Subjects and MethodsInclusion of patients with sleep-disordered breathing with AHI <5 on polysomnography who underwent DISE. Patients <18 years of age were excluded. DISE findings were reported with the VOTEL classification system: the level of collapse was described as occurring at the velum, oropharynx, tongue base, epiglottis, and the lingual tonsils. The degree of collapse was reported as complete, partial, or none. The pattern of the obstruction was described as anteroposterior, lateral, or concentric when applicable.ResultsA total of 54 patients with sleep-disordered breathing with AHI <5 underwent DISE. Ages ranged from 19 to 65 years. DISE was performed alone in 7% (n = 4) of patients and in conjunction with surgery in 93% (n = 50) of patients. The velum was the most frequent site of upper airway obstruction (85%, n = 46), followed by base of tongue (63%, n = 34), epiglottis (39%, n = 21), lingual tonsils (35%, n = 19), and oropharynx (31%, n = 17). Eighty-three percent (n = 45) of patients had multiple levels of upper airway obstruction, and 15% (n = 8) had a single level of upper airway obstruction.ConclusionPatients with sleep-disordered breathing with AHI <5 have significant upper airway obstruction as seen on DISE. DISE findings indicate that a majority of these patients have multiple levels of upper airway obstruction, which can lead to significant symptoms.

Efficacy of different doses of dexmedetomidine combined with propofol for drug-induced sleep endoscopy in patients with snoring

Objective To evaluate the efficacy of different doses of dexmedetomidine combined with propofol for drug-induced sleep endoscopy(DISE)in the patients with snoring. Methods Sixty patients with snoring, aged 24-62 yr, with body mass index of 24-37 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective DISE, were randomly divided into either group Ⅰor groupⅡ, with 30 patients in each group.In Ⅰ and Ⅱ groups, dexmedetomidine was infused over 10 min in a loading dose of 0.4 and 0.8 μg/kg, respectively, followed by an infusion of 0.4 μg·kg-1·h-1.At 15 min of dexmedetomidine infusion, propofol was given by target-controlled infusion with the initial target plasma concentration(Cp)of 1.0 μg/ml.At 2 min after the target effect-site and plasma concentrations were balanced, the Cp of propofol was increased/decreased by 0.2 μg/ml to maintain the Cp of propofol stable during DISE.Bispectral index(BIS)value was recorded before anesthesia(T1), at 10 and 15 min of dexmedetomidine infusion(T2, 3), at 2 min after the target effect-site and plasma concentrations were balanced(T4), at the beginning of DISE(T5), when the fiberoptic laryngoscope was placed at the site of oropharynx(T6), at the end of DISE(T7), at emergence(T8), and while discharge from the examination room(T9). Richmond Agitation Sedation Scale(RASS)scores were recorded at T1-4.Sleep was recorded within 15 min of dexmedetomidine infusion.The emergence time, discharge time, and anesthetics-related adverse events were recorded. Results All the patients completed DISE successfully.BIS values were maintained at 75-90, and RASS scores ≤ 4 during dexmedetomidine infusion.BIS values were maintained at 65-75 during DISE.Compared with groupⅠ, BIS values were significantly decreased at T4, and RASS scores were significantly increased at T2-4, the sleep rate was significantly increased within 15 min of dexmedetomidine infusion, the Cp of propofol was significantly decreased during DISE, the emergence time was significantly prolonged(P 0.05). Conclusion Dexmedetomidine infused at 0.4 μg·kg-1·h-1 after infusion of a loading dose of 0.8 μg/kg combined with propofol provides better efficacy for DISE in the patients with snoring. Key words: Dexmedetomidine; Propofol; Snoring; Endoscopy; Sleep

Analysis of the influence of head rotation during drug-induced sleep endoscopy in obstructive sleep apnea

Currently, drug-induced sleep endoscopy (DISE) in obstructive sleep apnea (OSA) is predominantly performed in supine position. When positional therapy (avoidance of supine sleeping position in positional OSA (POSA) is implemented as (part of the) treatment, one should assess levels of obstruction in the other sleeping positions. Therefore, the current study examined the influence of difference head positions during DISE in patients with OSA and POSA. Consecutive prospective study. DISE was performed in patients with an apnea hypopnea index at baseline polysomnography greater than 5 events/h. The upper airway was assessed at velum, oropharynx, tongue base, and epiglottis level in supine position. The patients head were then tilted to the left and the right side and the DISE findings were recorded. One hundred consecutive patients were included. In positional apneics (n = 67), lateral position was associated with decreased frequency of complete anteroposterior collapse at velum (P < 0.01), tongue base (P < 0.01), and epiglottis (P < 0.01) level-and increased frequency of partial anteroposterior collapse at velum (P < 0.01), tongue base (P < 0.01), and epiglottis (P <0.05) level in comparison with supine position. DISE findings showed no difference between the right and left position, whereas findings after head rotation were significantly different in comparison with the supine position. Head rotation improves upper airway collapse during DISE in supine position. This improvement of upper airway patency is more predominant in POSA patients.

Sleep endoscopy with simulation bite for prediction of oral appliance treatment outcome

The aim of this study was to assess the value of drug-induced sleep endoscopy (DISE) using a custom-made simulation bite in maximal comfortable protrusion (MCP) of the mandible, in the prediction of treatment outcome for obstructive sleep apnea (OSA) with a mandibular advancement device (MAD). Two hundred patients (74% male; age 46±9years; apnea-hypopnea index [AHI] 19±13h(-1) sleep; body mass index [BMI] 27±4kgm(-2) ) with sleep-disordered breathing underwent DISE with a simulation bite in MCP. One hundred and thirty-five patients with an established diagnosis of OSA commenced MAD treatment. The associations between the findings during DISE with simulation bite and treatment outcome were evaluated. Treatment response was defined as a reduction in AHI following MAD treatment of≥50% compared to baseline. Overall MAD treatment response in the studied population was 69%. The results of this study demonstrated a statistically significant association between a positive effect of the simulation bite on the upper airway patency during DISE and treatment response with MAD (P<0.01). The results of this study suggest that the use of a simulation bite in maximal comfortable protrusion (MCP) of the mandible, as used during DISE in patients with OSA, tends to be effective in predicting treatment response of MAD treatment.

Drug-induced sleep endoscopy in adults with sleep-disordered breathing: Technique and the VOTE Classification system

Drug-induced sleep endoscopy (DISE) offers an unique evaluation of the upper airway. After pharmacologic induction of unconscious sedation, it is possible to evaluate endoscopically the structures contributing to upper airway obstruction in sleep disordered breathing. The authors describe DISE techniques and the VOTE classification system for reporting of DISE findings. The VOTE classification focuses on the primary structures that contribute to upper airway obstruction and represents a common language to describe the patterns of obstruction during DISE. The latter can facilitate the scientific evaluation of DISE, including its role in directing treatment.