An updated review of pediatric drug-induced sleep endoscopy.
ABSTRACT: Drug-induced sleep endoscopy (DISE) involves assessment of the upper airway using a flexible endoscope while patients are in a pharmacologically-induced sleep-like state. The aim of this article is to review the current literature regarding the role of DISE in children with obstructive sleep apnea (OSA). The indications, typical anesthetic protocol, comparison to other diagnostic modalities, scoring systems, and outcomes are discussed.A comprehensive review of literature regarding pediatric DISE up through May 2017 was performed.DISE provides a thorough evaluation of sites of obstruction during sedation. It is typically indicated for children with persistent OSA after tonsillectomy, those with OSA without tonsillar hypertrophy, children with risk factors predisposing then to multiple sites of obstruction, or when sleep-state dependent laryngomalacia is suspected. The dexmedotomidine and ketamine protocol, which replicates non-REM sleep, appears to be safe and is often used for pediatric DISE, although propofol is the most commonly employed agent for DISE in adults. Six different scoring systems (VOTE, SERS, Chan, Bachar, Fishman, Boudewyns) have been used to report pediatric DISE findings, but none is universally accepted.DISE is a safe and useful technique to assess levels of obstruction in children. There is currently no universally-accepted anesthetic protocol or scoring system for pediatric DISE, but both will be necessary in order to provide a consistent method to report findings, enhance communication among providers and optimize surgical outcomes.N/A.
Project description:Objective:To describe a series of pediatric cases of obstructive sleep apnea (OSA) with paradoxical vocal cord movement noted on drug-induced sleep endoscopy (DISE). Materials and Methods:Case series and chart review of children who had undergone DISE for OSA that showed PVCM. Results:Three cases where paradoxical vocal cord motion (PVCM) was noted during DISE are described. Two had an enlarged adenoid, and one had no other site of obstruction. Two were treated with adenoidectomy and antireflux medications. One received proton pump inhibitors alone. In all 3 cases, OSA symptoms resolved. Conclusion:This case series of documented obstructive sleep apnea related to paradoxical vocal cord movement suggests that this entity occurs during sleep with airway obstruction. Further clarification of etiology of PVCM during OSA and its management is needed.
Project description: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.
Project description:The aim of this study was to establish a standardized protocol for drug-induced sleep endoscopy (DISE) to differentiate obstruction patterns in obstructive sleep apnea (OSA). Target-controlled infusion (TCI) of the sedative propofol was combined with real-time monitoring of the depth of sedation using bispectral analysis. In an observational study 57 patients (mean age 44.8 years, ± SD 10.5; mean apnea hypopnea Index (AHI) 30.8/hr, ± SD 21.6, mean BMI 28.2 kg/m2, ± SD 5.3) underwent cardiorespiratory polysomnography followed by DISE with TCI and bispectral analysis. Sleep was induced solely by the intravenous infusion of propofol with a TCI-pump, with an initial target plasma level of 2.0 µg/ml. Under continuous monitoring of the patient's respiration, state of consciousness and value of the bispectral analysis, the target plasma propofol level was raised in steps of 0.2 µg/ml/2 min until the desired depth of sedation was reached. The mean value of the bispectral analysis at the target depth of sedation was determined and the obstruction patterns during DISE-TCI-bispectral analysis then classified according to the VOTE-system. Subsequently the results were analyzed according to polysomnographic and anthropometric data. The occurrence of multilevel obstruction sites across all degrees of severity of OSA clarifies the need for sleep endoscopy prior to upper airway surgery. The advantage of this technique is the reproducibility of the protocol even for heterogeneous groups of patients. In addition, the gradual controlled and standardized increase of the plasma level of propofol with real-time control of the bispectral index leads to a precisely controllable depth of sedation. The DISE-TCI-bispectral analysis procedure is a step towards a required reproducible protocol of sleep endoscopy - capable of standardization. However it is not yet known whether these observed obstruction patterns also correspond to findings in natural sleep.
Project description:<h4>Objective</h4>To demonstrate lateral pharyngeal wall collapse and increased apnea-hypopnea index in a child posttonsillectomy.<h4>Background</h4>Some children have worsening of their sleep symptoms after tonsillectomy for obstructive sleep apnea. This case report demonstrates an open airway on drug-induced sleep endoscopy (DISE) in a child with tonsillar hypertrophy followed by more pronounced airway obstruction related to lateral pharyngeal wall collapse after tonsillectomy.<h4>Case presentation</h4>A 7-year-old boy presented with obstructive sleep apnea and underwent workup with DISE. Following adenotonsillectomy and subsequent lingual tonsillectomy with epiglottopexy, the patient's sleep apnea symptoms and polysomnogram results worsened. Subsequent DISE showed a more narrowed oropharyngeal airway space as compared to his preoperative DISE.<h4>Discussion</h4>Palatine tonsillar tissue may splint open the airway and prevent airway obstruction in a subset of pediatric patients. Further clinical studies are necessary to determine which children experience this phenomenon. Clinical examination using DISE can be useful in making clinical decisions prior to tonsillectomy.
Project description:To evaluate the effect of sedation depth on drug-induced sleep endoscopy (DISE).Ninety patients with obstructive sleep apnea (OSA) and 18 snorers underwent polysomnography and DISE under bispectral index (BIS)-guided propofol infusion at two different sedation levels: BIS 65-75 (light sedation) and 50-60 (deep sedation).For the patients with OSA, the percentages of velopharynx, oropharynx, hypopharynx, and larynx obstructions under light sedation were 77.8%, 63.3%, 30%, and 33.3%, respectively. Sedation depth was associated with the severity of velopharynx and oropharynx obstruction, oropharynx obstruction pattern, tongue base obstruction, epiglottis anteroposterior prolapse and folding, and arytenoid prolapse. In comparison, OSA severity was associated with the severity of velopharynx obstruction, severity of oropharynx obstruction, and arytenoid prolapse (odds ratio (95% confidence interval); 14.3 (4.7-43.4), 11.7 (4.2-32.9), and 13.2 (2.8-62.3), respectively). A good agreement was noted between similar DISE findings at different times and different observers (kappa value 0.6 to 1, respectively). A high percentage of arytenoid prolapse (46.7% among the patients with OSA under light sedation) was noted.Greater sedative depth increased upper airway collapsibility under DISE assessment. DISE under BIS-guided propofol infusion, and especially a level of 65-75, offers an objective and reproducible method to evaluate upper airway collapsibility. Some findings were induced by drug sedation and need careful interpretation. Specific arytenoid prolapse patterns were noted for which further investigations are warranted.http://www.clinicaltrials.gov, identifier: NCT01100554.A commentary on this article appears in this issue on page 965.
Project description:One of the challenges of surgery for obstructive sleep apnea (OSA) is identifying the correct surgical site for each patient. The objective of this study was to use drug-induced sleep endoscopy (DISE) and nasopharyngeal tube (NPT) placement to determine the effect of eliminating palatal collapse on the obstruction seen on other segments of the upper airway.Forty-one OSA patients were enrolled in this prospective study. All patients had a polysomnogram followed by DISE. DISE findings were recorded and compared with and without placement of a NPT. Obstruction was graded with a scale that incorporates location, severity, and interval of obstruction.Most patients (83%) demonstrated multilevel obstruction on initial DISE. With the nasopharyngeal airway in place, many patients with multilevel obstruction had at least a partial improvement (74%) and some a complete resolution (35%) of collapse (p < 0.05). Reduction in collapse was observed at the lateral walls (86%), epiglottis (55%), and tongue base (50%). NPT placement did not significantly alter upper airway morphology of patients with incomplete palatal obstruction or mild OSA.To our knowledge, this is the first study to evaluate the effect of soft palatal stenting on downstream pharyngeal obstruction during DISE. Our study provides evidence that reducing soft palatal collapse can reduce negative pharyngeal pressure and thereby alleviate other sites of upper airway obstruction. Taken together, these findings provide a means to identify appropriate candidates for isolated palatal surgery and better direct a minimally invasive approach to the surgical management of OSA.
Project description:Background:The Friedman staging is a classic system to predict outcomes of obstructive sleep apnea (OSA) surgery. Increasing stage indicates more severe upper airway (UA) obstruction and worse surgical successful rate. In previous studies, the UA obstruction between stages were usually assessed based on awake examination. Drug-induced sleep endoscopy (DISE) is a new method that can evaluate airway collapse characteristics during sleep. Therefore, we planned to compare Friedman staging and DISE findings and fulfill the knowledge gap on the correlation between awake and sedated UA examination. Methods:Retrospective case series study that assessed patients with OSA who underwent DISE. Subjects were classified to stage II and stage III groups based on Friedman staging system. UA collapse characteristics based on velum, oropharynx, tongue base, epiglottis (VOTE) classification, including single/multiple obstruction sites, single/combined upper and lower obstruction levels, collapse degree and patterns in different sites, and surgical results among the groups were analyzed. Results:A total of 175 cases were analyzed. No significant differences were found in baseline measurements between groups. Stage III patients (n=102) had a higher proportion (74.5%) with 3 or 4 obstruction sites than stage II (57.5%, n=73). Velum (V) + oropharynx (O) + tongue base (T) was the most common multi-sites combined obstruction pattern with 33% in stage II and 37% in stage III, isolated lower level obstruction was the least with 6% and 4%, respectively. No significant differences were found in obstruction sites and levels. 106 patients underwent surgeries and 33 had post-surgical sleep study, 73.7% and 63.6% response rate were found in stage II and III with no significant difference. Conclusions:Upper and lower combined obstruction was the main pattern of collapse in both, Friedman stage II and III patients. Patients with OSA and Friedman stage III had more than 2 sites of obstruction than stage II patients.
Project description:Importance:The anatomic mechanisms underlying positional vs nonpositional obstructive sleep apnea (OSA) are poorly understood and may inform treatment decisions. Objective:To examine drug-induced sleep endoscopy (DISE) findings in the supine vs nonsupine body positions in positional and nonpositional obstructive sleep apnea. Design, Setting, and Participants:A cross-sectional study of 65 consecutive eligible adults with OSA undergoing DISE without marked tonsillar hypertrophy, including 39 with positional OSA (POSA) and 26 with nonpositional OSA (N-POSA) was conducted in a sleep surgery practice at a tertiary academic medical center. Exposures:Drug-induced sleep endoscopy performed in the supine vs nonsupine body position. Main Outcomes and Measures:Drug-induced sleep endoscopy findings were scored separately for the supine and lateral body positions using the VOTE classification (velum, oroparyngeal lateral walls, tongue, epiglotis) and with identification of a single primary structure contributing to airway obstruction. Velum-related obstruction was separated into anteroposterior and lateral components. Results:The 65 study participants had a mean (SD) age of 52.4 (11.7) years, and 55 (84.6) were men. Mean (SD) body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) was 27.2 (3.1), with only 9 (14%) of 65 participants having a BMI greater than 30. The supine body position was associated with greater odds of anteroposterior velum- (odds ratio [OR], 7.28; 95% CI, 3.53-15.01), tongue- (OR, 29.4; 95% CI, 12.1-71.5), and epiglottis-related (OR, 11.0; 95% CI, 1.3-92.7) obstruction in the entire cohort, with similar findings in the POSA and N-POSA subgroups. The supine body position was associated with a lower odds of oropharyngeal lateral wall-related (OR, 0.22; 95% CI, 0.07-0.70) obstruction in the N-POSA subgroup, whereas there was no increase in the overall sample or the POSA subgroup. The oropharyngeal lateral walls were a common primary structure causing obstruction, especially in the lateral body position. Conclusions and Relevance:In a study population of primarily nonobese adults, DISE findings differed based on body position, generally corresponding to gravitational factors. Treatments that address velum- and tongue-related obstruction successfully may be more effective in the POSA population.
Project description:Drug-induced sleep endoscopy is a diagnostic technique that allows dynamic evaluation of the upper airway during artificial sleep. The lack of a standardized procedure and the difficulties associated with direct visual detection of obstructive events result in poor intraobserver and interobserver reliability, especially when otolaryngology surgeons not experienced in the technique are involved.To describe a drug-induced sleep endoscopy technique implemented with simultaneous polygraphic monitoring of cardiorespiratory parameters (DISE-PG) in patients with a diagnosis of obstructive sleep apnea syndrome and discuss the technique's possible advantages compared with the standard procedure.This prospective cohort study included 50 consecutive patients with obstructive sleep apnea syndrome who underwent DISE-PG from March 1, 2013, to June 30, 2014. A standard protocol was adopted, and all the procedures were carried out in an operation room by an experienced otolaryngology surgeon under the supervision of an anesthesiologist. Endoscopic and polygraphic obstructive respiratory events were analyzed offline in a double-blind setting and randomized order.The feasibility and safety of the DISE-PG technique, as well as its sensitivity in detecting respiratory events compared with that of the standard drug-induced sleep endoscopy procedure.All 50 patients (43 men and 7 women; mean [SD] age, 51.1 [12.1] years) underwent DISE-PG without technical problems or patient difficulties regarding the procedure. As expected, polygraphic scoring was more sensitive than endoscopic scoring in identifying obstructive events (mean [SD] total events, 13.3 [6.8] vs 5.3 [3.6]; mean [SD] difference, 8.8 [5.6]; 95% CI, 7.3 to 10.4; Cohen d, -1.5). This difference was most pronounced in patients with a higher apnea-hypopnea index (AHI) at baseline (mean [SD] difference for AHI >30, 27.1% [31.0%]; 95% CI, -36.2% to 90.4%; Cohen d, 0.2; for AH I >40, 76.0% [35.5%]; 95% CI, 4.6% to 147.4%; Cohen d, 0.5; for AHI >50, 92.2% [37.2%]; 95% CI, 17.3% to 167.1%; Cohen d, 0.6) and a high percentage of hypopneas (?75% of all obstructive events) at baseline (mean [SD] difference, 20.2% [5.4%]; 95% CI, 9.2% to 31.3%; Cohen d, 1.1). No other anthropomorphic or polygraphic features at baseline were associated with the differences between the DISE-PG and baseline home sleep apnea test.The DISE-PG technique is feasible, safe, and more sensitive at detecting an obstructed breathing pattern than is drug-induced sleep endoscopy alone. The DISE-PG technique could be helpful for accurate comprehension of upper airway obstructive dynamics (ie, degree of obstruction and multilevel pattern) and a nonobstructive breathing pattern (ie, central apneas).
Project description:ABSTRACT:This is a case report of a 60-year-old female with mild obstructive sleep apnea (OSA) who presented to CPAP Alternatives clinic following multiple failed attempts at positive airway pressure (PAP) therapy. She underwent drug-induced sleep endoscopy (DISE) with the concurrent application of PAP via two different mask types. Application of the oronasal mask at low pressures demonstrated soft palate collapse, while high pressures resulted in posterior tongue collapse. In contrast, application of the nasal mask eliminated palatal and tongue obstruction at low pressures, despite mask leak at higher pressures. She was recommended a trial of nasal autoPAP, which with the use of a chinstrap, resulted in both subjective and objective improvement of her OSA.