Beyond VOTE: The New Frontier of Drug-Induced Sleep Endoscopy

Abstract

Alternatives to positive airway pressure therapy, including surgery, represent an important area of research. Specifically, predictors of response to surgical therapy remain underdeveloped. Drug-induced sleep endoscopy (DISE) holds promise as a diagnostic tool to identify patient-specific causes of airway collapse. Herein, we present a novel, standardized approach which combines anatomic and physiologic measurements during DISE. Our DISE platform measures airflow, airway compliance, airway collapsibility, and structural drivers of collapse. Taken together, these inputs provide a comprehensive framework to further inform the surgeon in providing personalized care of the patient with obstructive sleep apnea.

Practical Implementation of Sleep Endoscopy with Positive Airway Pressure in Clinical Practice

“…The pressure needed to resolve obstruction and snoring at the level of the lateral walls (lateral wall opening pressure or “LOP”), tongue base opening pressure (“TOP”), and epiglottis opening pressure (“EOP”) were also determined. The overall pressure needed to resolve complete upper airway obstruction and snoring was deemed the pharyngeal opening pressure (“PhOP”) 5 . Upon completion of the sleep endoscopy, the flexible nasopharyngoscope is removed from the patient's naris.…”

“…The overall pressure needed to resolve complete upper airway obstruction and snoring was deemed the pharyngeal opening pressure ("PhOP"). 5 Upon completion of the sleep endoscopy, the flexible nasopharyngoscope is removed from the patient's naris. The mask is then removed and the patient is returned to anesthesia.…”

“…4 Dedhia et al recently published their updated DISE-CAD protocol (drug-induced sleep endoscopy-characterization of airway dynamics) in which they extracted relevant anatomic and physiologic parameters of each patient's upper airway during sleep endoscopy. 5 Multiple major academic centers across the country are currently evaluating the benefits of using PAP during DISE. While there appears to be an abundance of information that can be gleaned from determining the opening pressures of the airway-and sleep surgeons across the country are interested in implementing the protocol-it has previously been relegated primarily to research settings and has had limited practical application in the clinical setting due to barriers of cost and efficiency.…”

“…They noted that a POP level less than 8 cmH 2 0 correlated with a positive predictive value of 82.4% surgical success for HGNS as defined by a 50% reduction in the apnea‐hypopnea index 4 . Dedhia et al recently published their updated DISE‐CAD protocol (drug‐induced sleep endoscopy‐characterization of airway dynamics) in which they extracted relevant anatomic and physiologic parameters of each patient's upper airway during sleep endoscopy 5 . Multiple major academic centers across the country are currently evaluating the benefits of using PAP during DISE.…”

Enhanced drug‐induced sleep endoscopy: Distinguishing central from obstructive apnea

“…His past medical history was notable for rhinitis, cardiomyopathy, atrial fibrillation, and congestive heart failure with preserved ejection fraction (55%), all treated medically. DISE was performed using the Drug‐Induced Sleep Endoscopy with Characterization of Airway Dynamics (DISE‐CAD) protocol (UPenn IRB, IRB#833511), which acquires real‐time respiratory airflow and airway pressure signals alongside endoscopic image capture, enabling simultaneous anatomical and physiological assessment 1 . CPAP was also titrated after baseline observation during DISE‐CAD to quantify upper airway collapsibility 2 …”