Drug-Induced Sleep Endoscopy (DISE) with Target Controlled Infusion (TCI) and Bispectral Analysis in Obstructive Sleep Apnea

Abstract

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/m, ± 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.

Obstructive sleep apnea and rhonchopathy are associated with downregulation of trefoil factor family peptide 3 (TFF3)—Implications of changes in oral mucus composition

“…After polysomnography had confirmed OSA, patients underwent sleep endoscopy to determine the elegibility factor of velar/oropharyngeal obstruction. A standardized propofol-based drug-induced sleep endoscopy (DISE) with TCI and BIS™ (DISE-TCI-BIS) was performed as described previously [ 23 ].…”

The Impact of Drug-induced Sleep Endoscopy on Therapeutic Decisions in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

“…The TCI system ensures a pharmacokinetic simulation pattern that prevents the loss of upper airway neuromuscular tone. Moreover, sedation depth could be controlled using a bispectral index (BIS) monitor [27].…”

Anesthetic management for simultaneous drug-induced sleep endoscopy and maxillomandibular advancement in a patient with obstructive sleep apnea

“…The onset of dexmedetomidine takes approximately 5 minutes, and it takes time to control the concentration [ 6 13 ]. Propofol has the advantage of rapid onset, easy concentration control using TCI [ 14 ], and sedation depth control using a BIS monitor; it is therefore recommended as a primary drug for DISE [ 7 ].…”

“…Dexmedetomidine has a lower rate of respiratory depression than propofol, is hemodynamically stable, and can induce sleep that resembles normal sleep [ 4 5 ]; therefore, it is reported to be more appropriate for DISE [ 6 ]. However, propofol has the advantages of rapid onset, maintenance of blood drug concentration through target-controlled infusion (TCI), and sedation depth control using a bispectral index (BIS) monitor, and is therefore recommended for DISE use [ 7 ]. In this study, we report a patient who underwent simultaneous successful DISE using propofol, followed by successful MMA surgery.…”