Drug Selection Influences Drug-Induced Sleep Endoscopy Findings

How do the effects of midazolam, propofol, and dexmedetomidine compare on drug-induced sleep endoscopy (DISE) findings, O₂ nadir, and bispectral index (BIS) in the same sample of patients with snoring and obstructive sleep apnea (OSA)?

Bottom Line
Compared with dexmedetomidine, midazolam and propofol presented higher incidence of tongue base collapse, lower O₂ levels, and lower BIS index values. Propofol resulted in an O₂ nadir that most resembled that observed during polysomnography.

Background: DISE has gained interest for upper airway (UA) evaluation in patients with snoring and OSA because UA evaluation in awake OSA patients may be insufficient to evaluate UA collapse during sleep. Different drugs have been used to induce sedation during DISE, and each presents specific advantages and disadvantages with differential effects on respiratory physiology.

Study design: Case series prospective study of 52 consecutive OSA patients who underwent DISE with propofol, dexmedetomidine, and midazolam between July 2015 and July 2016.

Setting: Federal University of the State of Rio de Janeiro, Brazil.

Synopsis: Considering the velum, oropharynx, tongue base, and epiglottis (VOTE) classification, agreement among drugs was excellent for the degree and pattern at all obstruction sites except the tongue base, for which agreement ranged from fair to moderate. Dexmedetomidine resulted in the fewest cases of complete collapse at the tongue base; however, all patients who presented complete collapse at the tongue base site during the DISE with dexmedetomidine also presented tongue base collapse with the other drugs. Regardless of sedative, the most frequent finding was patients with two obstruction sites. Combined obstruction levels were significantly higher with midazolam. It was not possible to establish a correlation between apnea-hypopnea index (AHI) and the number of sites with complete collapse. DISE findings with dexmedetomidine indicated an association between patients with severe apnea and their obstruction levels. During DISE, the mean O₂ nadir was 78.26% ± 9.0% with midazolam, 78.76% ± 8.4% with propofol, and 90.32% ± 4.7% with dexmedetomidine. The O₂ nadir with dexmedetomidine was significantly higher than with midazolam and propofol and during polysomnography. Variability among drugs related to the BIS index was considerable, with propofol having the lowest variability and average value. No significant adverse effects were observed. Limitations included lack of a general population sample with OSA and performance of propofol and dexmedetomidine tests on the same day.

Citation: Viana A, Zhao C, Rosa T, et al. The effect of sedating agents on drug-induced sleep endoscopy findings. Laryngoscope. 2019;129:506–513