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

Abstract

ObjectiveThe aim of this study was to assess the ability of drug-induced sleep endoscopy (DISE) to change therapeutic decisions through the identification of obstruction sites in patients with obstructive sleep apnea (OSA).Materials and methodsA systematic review and meta-analysis were conducted concerning studies that reported the impact of DISE on therapeutic recommendations. The percentage of change was collected for each study and per site of the collapse. The pooled rate of change and the respective 95% confidence interval (CI) were computed. Subgroup analysis was performed based on patients’ age, sample size, the applied DISE protocol, and the originally used diagnostic modality before DISE.ResultsIn a total of nine studies, 1247 patients were included (69.2% males, 59.7% children, 78.04% with a multilevel collapse). Therapeutic decisions changed in 43.69% of patients (CI, 33.84 to 53.54). The change rates were significantly higher in adults (54.0% versus 25.9% in children, P = 0.001), midazolam-based DISE protocols (78.4% versus 48.45% for midazolam plus propofol and 33.9% for propofol, P < 0.001), and after awake endoscopy (62.2% as compared to 44.6% after clinical basic examination [CBE], 40.1% after CBE, lateral cephalometry, and Müller maneuver, P = 0.02). Changes at uvular and palatal sites were more frequent in adults and at the tonsils in children.ConclusionThe DISE approach can be promoted via implementing unified classification systems of obstruction sites; the widescale application of target-controlled infusion and its therapeutic benefits can be explored in well-designed randomized studies that compare its efficacy with other diagnostic modalities.

Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision

“…DISE enables direct visualization of dynamic airway changes and, therefore, permits delineation of the site of obstruction and subsequent treatment planning [104]. As mentioned, DISE has rapidly gained momentum and the indications and guidelines for the use of this technique will likely emerge in the upcoming years [105][106][107][108][109][110]. At this point, it is routine clinical practice in children with residual OSA after T&A to initially offer PAP therapy and medical therapy, and when patients are either unable, unsuccessful, or unwilling to adopt such options, then use of DISE-directed surgical therapies seems a logical and reasonable step, notwithstanding its limitations [111,112].…”

A Critical Analysis of Pharyngeal Patterns of Collapse in Obstructive Sleep Apnea: Beyond the Endoscopic Classification Systems

“…Interestingly, Albdah et al [ 38 ] in a systematic review and meta-analysis observed that DISE plays a significant role in changing the initial treatment surgical options in about fifty percent of OSA patients, particularly for epiglottis involvement and soft palate surgical procedures. The change in surgical treatment was more significant when midazolam was applied during DISE compared to other sedation protocols.…”

A single-center pilot study comparing dexmedetomidine continuous infusion versus propofol TCI for drug-induced sleep endoscopy (DISE)

“…The present pilot study offers a small-scale but clinically interesting opportunity to evaluate the efficacy of dexmedetomidine in a real-life scenario, highlighting some of the strengths and shortcomings of a drug that has received attention in several settings (operative sedations, intraoperative use, critical care): in the context of DISE, dexmedetomidine continues to attract some interest, especially by nonexperts, as an agent hypothetically preventing deeper and longer desaturations. Therefore, we aimed to assess whether dexmedetomidine, in light of its pharmacodynamic properties, could replace propofol for DISE if needed or preferred, and with the main purpose to assess the timing and quality of peripheral oxygen desaturations, in respect of the procedure goals, that is the reproduction of airway obstruction patterns for the identification of the ideal surgical intervention [9,10] . Propofol has consistently established itself as the gold standard for sedation in this setting as it combines overall safety and time effectiveness.…”