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

INTRODUCTION

Drug-induced sleep endoscopy (DISE) as a means of upper airway diagnostics was first introduced by Croft and Pringle in 1991 with the use of midazolam sedation (Clin Otolaryngol Allied Sci. 1991;16:504-509). Since then, there have been a variety of medications and techniques introduced to modify and improve the ability to evaluate sites of upper airway collapse in a drug-induced “sleep” state. However, our current methods of DISE provide only a qualitative visualization of upper airway collapse and do not provide any quantitative information regarding the degree or severity of upper airway collapsibility. 

The use of continuous positive airway pressure (CPAP) during drug-induced sleep endoscopy has been previously described as a diagnostic tool to assess upper airway collapse. Civelek and colleagues performed a double-blind study of 16 patients and reported that CPAP titration pressures during sleep endoscopy under propofol sedation approximated pressures obtained during an in-laboratory titration within natural sleep (Laryngoscope. 2012;122:691-695). In 2019, Lee and colleagues demonstrated that a preoperative therapeutic positive airway pressure (PAP) level less than 8 cm H₂O had a 92% positive predictive value for surgical success in hypoglossal nerve stimulator implantation (HGNS) as compared to only 44% in patients with PAP levels greater than or equal to 8 cm H₂O (J Clin Sleep Med. 2019;15:1165-1172). A follow-up study by the same group used therapeutic nasal PAP during DISE to examine the palatal opening pressure of the airway (POP). They noted that a POP level less than 8 cm H₂O correlated with a positive predictive value of 82.4% surgical success for HGNS as defined by a 50% reduction in the apnea-hypopnea index (JAMA Otolaryngol Head Neck Surg. 2020;146:691-698). Dedhia and colleagues 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 (ORL J Otorhinolaryngol Relat Spec. 2021;1-6).

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.

Herein, we describe a novel method to implement drug-induced sleep endoscopy with positive airway pressure (DISE-PAP) in a cost-effective and highly clinically efficient manner, allowing it to be immediately introduced in both clinical and research settings.