Research on drug-induced sleep endoscopy's effect on treatment approaches for obstructive breathing while sleeping

doi: 10.56294/saludcyt2024.930

ORIGINAL

Research on drug-induced sleep endoscopy’s effect on treatment approaches for obstructive breathing while sleeping

Investigación sobre el efecto de la endoscopia del sueño inducida por fármacos en los enfoques de tratamiento de la respiración obstructiva durante el sueño

A Govindarajan¹ *, Nibedita Mohanty² *, T.M.J. Santhoshakumari³ *, Pradeep. S⁴ *, Pavas Saini⁵ *, Ashmeet Kaur⁶ *

¹Sri Balaji Vidyapeeth, (deemed to be university), Department of otorhinolaryngology. Puducherry, India.

²Kalinga Institute of nursing sciences, Department of Medical surgical Nursing. Bengaluru, India.

³Sri Balaji Vidyapeeth University, Department of Biochemistry, Puducherry, India.

⁴JSS Dental College and Hospital, Department of Orthodontics, Mysore, India.

⁵Chitkara University, Centre of Research Impact and Outcome, Punjab, India.

⁶Chitkara University, Centre for Research and Development, Himachal Pradesh, India.

Cite as: Govindarajan A, Mohanty N, Santhoshakumari T, S P, Saini P, Kaur A. Research on drug-induced sleep endoscopy’s effect on treatment approaches for obstructive breathing while sleeping. Salud, Ciencia y Tecnología. 2024; 4:.930. https://doi.org/10.56294/saludcyt2024.930

Submitted: 29-12-2023 Revised: 22-04-2024 Accepted: 23-08-2024 Published: 24-08-2024

Editor: Dr. William Castillo-González

ABSTRACT

The research aims to investigate how various medications for obstructive breaths during sleep (OBS) are affected by drug-induced sleep endoscopy (DISE). A thorough examination of the literature revealed that treatment suggestions impacted by DISE had been implemented. The percentage change for every research and collapse location was noted. The cumulative level of modifications and related 94 % confidence interval (CI) were estimated. According to the patient’s age, the sample size, the DISE method, and the major diagnostic modality used prior to DISE, analysis of subgroups were conducted. These 1 246 patients (68,1 % men, 58,6 % kids, and 77,03 % with a multilevel collapse) were involved in nine trials in all. In 42,69 % of patients (CI, 32,74 to 52,53), the course of treatment altered. The variation in rates increased following awake endoscopy (61,1 % opposed to 43,5 percent following clinical basic examination (CBE) and 40,1 percent opposed to Muller man oeuvre, P = 0,02), CBE, and lateral cephalometry and midazolam-based DISE procedures. Target-controlled infusion is widely used, and randomized studies that compared its efficacy with different methods of diagnosis can be used to examine its therapeutic benefits. The DISE approach can be encouraged by introducing uniform categorization systems of blockage locations.

Keywords: Obstructed Breathing While Sleeping (OBS); Clinical Basic Examination (CBE); Patients; Confidence Interval (CI).

RESUMEN

El objetivo de esta investigación es estudiar cómo se ven afectados diversos medicamentos para la respiración obstructiva durante el sueño (OBS) por la endoscopia del sueño inducida por fármacos (DISE). Se anotó el porcentaje de cambio para cada investigación y lugar de colapso. Se estimó el nivel acumulativo de modificaciones y el intervalo de confianza (IC) del 94 % relacionado. Se realizaron análisis de subgrupos en función de la edad del paciente, el tamaño de la muestra, el método de DISE y la principal modalidad diagnóstica utilizada antes de la DISE. Estos 1 246 pacientes (68,1 % hombres, 58,6 % niños y 77,03 % con un colapso multinivel) participaron en nueve ensayos en total. En el 42,69 % de los pacientes (IC, 32,74 a 52,53) se alteró el curso del tratamiento. La variación de las tasas aumentó tras la endoscopia despierta (61,1 % frente a 43,5 % tras el examen clínico básico (ECB) y 40,1 % frente al Muller man oeuvre, p = 0,02), el ECB y la cefalometría lateral y los procedimientos de DISE basados en midazolam. La infusión controlada por objetivo se utiliza ampliamente, y los estudios aleatorizados que compararon su eficacia con diferentes métodos de diagnóstico pueden utilizarse para examinar sus beneficios terapéuticos. El enfoque DISE puede fomentarse mediante la introducción de sistemas uniformes de categorización de las localizaciones de obstrucción.

Palabras clave: Respiración Obstruida Mientras Duerme (OBS); Examen Clínico Básico (ECB); Pacientes; Intervalo de Confianza (IC).

INTRODUCTION

Drug-induced sleep endoscopy (DISE) is a medical method that is increasingly being used to diagnose and treat obstructive sleep apnea (OSA). Studies have shown the validity of DISE. It gives clinical information that is not accessible by simple clinical examination alone.⁽¹⁾ Although a sleep endoscopy performed during a patient’s natural sleep is the perfect test, it is not a realistic diagnostic tool since it must be done overnight and the instrument used may wake the patient.⁽²⁾ OBS is defined by a recurrence of respiratory problem episodes linked to lower oxygen saturation and sleep awakenings that have an impact on the heart, the workplace, and the brain while also increasing morbidity and death.⁽³⁾ In the 1990s, DISE began to take shape due to the need for accurately assessing collapse in people with OBS and improving surgical outcomes.^(4,5) Fundamentally speaking, therapy continues to be the ideal benchmark for cautious leadership of OBS.⁽⁶⁾ The certain instances, of DISE may also assist in the identification of individuals that are not appropriate candidates for particular therapies.⁽⁷⁾

The purpose of this research is to evaluate the influence that DISE has on the different treatment options that are currently accessible for OBS patients. Paper⁽⁸⁾ was conducted to determine the possibility that our modifications will result in an enhancement in the usefulness of DISE as a specific tool. The obstruction evaluation for each of the Upper Airway’s four segments was conducted using the VOTE score technique. Research⁽⁹⁾ investigated the possibility that obstructive sleep apnea patients’ oral appliance treatment outcomes predicted by drug-induced sleep endoscopic characteristics. Study⁽¹⁰⁾ intended to better understand the collapse patterns in OBS patients with low DISE. Patients with a history of OBS who underwent DISE were included. The patients were divided into four categories. Study⁽¹¹⁾developed a classification method that enhances the reliability of the classification while assessing the appropriateness of lateral hedgeoperation, was created. Study⁽¹²⁾ examined every facet of DISE, including the procedure, the many assessment techniques, and the practical use of the approach. DISE was developed as a helpful approach to discovering dynamic upper airway collapse during sedation that mimics the state of natural sleep.

METHOD

Research that demonstrated that DISE altered therapeutic recommendations was subjected to an extensive evaluation and a meta-analysis that was carried out. A target-controlled infusion may be compared to other diagnostic approaches in meticulously planned controlled experiments to better understand its potential utility and therapeutic benefits.

Study selection and search strategy

The suggestions made by the PRISMA included adhered to ensure that the main plan and methodology of the present inquiry were executed correctly. Google Scholar, Embase,Web of Science, PubMed,and others were all exhaustively searched for relevant papers. The search was limited to papers published between 2000 and 2019. The most recent query to any of the databases was executed on the 18th of August 2019.

Primary and secondary outcomes

The main result was the proportion of patients that originally prescribed OBS treatment was altered after receiving DISE. The collapse sites that DISE could best identify were among the additional results. The Epworth sleepiness scale (ESS), that evaluate modifications to sleeping parameters after therapy is driven through both modalities, were also recorded every time it was practical.

Eligibility criteria

The possible impact of DISE usage on altering treatment choices in OBS patients was reported in both retrospective and prospective cohort research. All instances with OBS that had their diagnosis verified, regardless of age, are included. The sample has to include at least 24 patients. Studies that provided inadequate information on the main results were disregarded.

Data extraction

The extraction of data was placed using particular spreadsheets set up in Microsoft Excel. The subsequent information was gathered for each research that was evaluated: research-related information, such as the initial the author’s last name, samples size, the nation of the publication’s release, and the research’s design; demographics about the patients, such as distribution of genders, average age, and means BMI; diagnostic methods, such as the drugs employed in DISE, the number of collapse sites found, and others; the degree of concordance among DISE and other methods; post-therapeutic sleep metrics like AHI and ESS.

Quality assessment

The Newcastle-Ottawa quality evaluation scale, a particular measure for non-randomized research, was used to evaluate the quality of the research. Each research was evaluated on an average of nine factors across three primary categories, involving comparable, selecting, and results. The Newcastle-Ottawa score (NOS) ranged from 0 (poor) to 9 (outstanding), as well as research was deemed to be of good quality when it had a NOS of at least6.

Statistical analysis

The density of altered choices is divided by the total number of patients multiplied by 100 to get a percent of the change in treatment decisions. Utilizing Microsoft Excel, the proportion of improvement at every site of collapses was shown and evaluated as additional, decreased, or unaltered treatment choices. The change in the percentage of each trial along with the SE was entered using the RevMan software compute the pooling percent variation of all studies and the corresponding 95 % CI. The statistical heterogeneity across research was evaluated using an I2 test, and a model with random effects was utilized that there was indeed considerable heterogeneity. In cases of considerable heterogeneity, analysis of the subgroups was carried out according to the age of the patients, sample size (greater than 100 or less than 100), the DISE procedure that was followed, and the initial diagnosis method.

RESULTS

Results of the search process

At the outset, 320 entries were retrieved from several databases; further analysis revealed 17 records to be duplicates that were subsequently deleted. A search on Google found a total of two records. As a result, 305 different titles were evaluated in their entirety. The full-text versions of 8 different articles were evaluated to determine whether or not to include them. One study was disregarded because it did not provide a report on the main outcome, and another was disregarded because it was written. In the end, seven researchers fulfilled the requirements to be considered eligible figure 1.

Figure 1. An illustration of the research procedure performed in the current investigation using PRISMA

Characteristics of the included studies

The research was contained and released between 2009 and 2018. The others were prospective cohort investigations, while one was a case-control study and another a retrospective examination of patient data to look into the results. The number of samples varied from 37 to 558. There were 1 247 patients overall (69,21 % men).

DISE-related findings

CBE alone, as well as results of CBE,Müller maneuver, and the lateral cephalometrywas the original bases for treatment recommendations that were revised by DISE in table 1.

Table 1. Properties of the researches that were incorporated in the analysis
Reference	Study Design	Mean age	Single orMulti-level collapse	MeanBMI (kg/m2)	Medication(s)used in DISE
⁽¹³⁾	Prospective	45,3 ±1 1,24	10/27	33,0 ±7,25	glycopyrrolate (0,4±0,3 mg) & Midazolam (0,7±0,7mg) while CBE, then propofol (192±59mg) during DISE
⁽¹⁴⁾	Retroactive	6,1 ±2,7	Not Applicable	Not Applicable	propofol (200- 350mcg/kg/min) & Remifentanil (2-2,5mcg/ml)
⁽¹⁵⁾	Case-control	4,64 ±1,89	Not Applicable	Not Applicable	Sedatives such for the induction process, accompanied by propranolol.
⁽¹⁶⁾	Prospective	4,06 ±0,9	16/20	14,7 ±0,19	Propofol (6-10mg/kg/h continuous infusion, then1-2 mg initial bolus)
⁽¹⁷⁾	Prospective	45,0 ±11,41	13/45	28,57 ±4,38	firstly, propofol by TCI, then1 mg midazolam in bolus
⁽¹⁸⁾	Prospective	44,5 ±11,3	2/48	30,2 ±4,0	Propofol (1mg/kg initially, then boluses of 10-20 mg every 3-5 minutes)
⁽¹⁹⁾	Prospective	45,3 ±6,4	46/115	27,1 ±3,2	Propofol (via TCI)

Changes in therapeutic decisions

Propofol studies alone contributed to the observed heterogeneity, according to subgroup analysis in table 2, patients’ ages.

Table 2. DISE-directed subgroups study of treatment choice modifications depending on pattern amount, the DISE method in utilize, and the comparison
Field	Research	Representative (I2 %)	Development amount (95 percent CI)	P
Pattern amount
<100	5	R(98)	30,92(17,39 44,44)	0,07
>100	2	R(90)	52,07(36,26 67,86)
DISE versus other modalities
CBE	5	R(96)	62,16(42,13 82,15)	0,03
AE	2	NA	44,63(27,89 61,37)
CBE, LC, and MM	2	NA	35,13(32,21 38,04)
DISE method
Midazolam	2	NA	48,45(39,76 57,12)	<0,001
Propofol	5	R(96)	3 3,99(23,09,44,82)
Propofol and Midazolam	4	F(30)	7 8,35(62,75 9 3,96)

While comparing the effects of midazolam-based DISE approaches to those of midazolam and propofol combined (48,45 %) and propofol alone (33,99 %), P> 0,001 revealed a considerably greater rate of change in treatment choices (78,35 %). The variation in percentages were significantly higher in comparison to awake endoscopic (62,16 %) CBE even (44,63 %), and the Müller maneuver (40,12 %), CBE coupled with lateral cephalometry in Table 2.

In five investigations including 231 patients, descriptions of the alterations at surgical sites in adults were in-depth. Epiglottis (42,9 %) with delicate palates (39,8 %) was often subjects of DISE’s revised recommendations. DISE, mandibular advancement devices (MADs) were the usually extra assistance (28,1 %), followed by soft palate (19,9 %) and epiglottis (26 %) operations. soft palate surgeries (19,9 %) and surgical procedures for the tonsils, epiglottis, and base of the tongue (16,9 % for each) were most frequently decreased operations figure 2 and table 3.

Table 3. Adults DISE surgery procedures in comparison with various methods of diagnosis
	No change	Added	Reduced
Soft palate	100	0	0
Tonsils	11,7	26,9	61,4
Epiglottis	100	0	0
Tongue base	93,7	6,3	0
Tongue	100	0	0
Nose	96,9	3,1	0
Osteotomies	100	0	0
MAD	100	0	0

Figure 2. Adults DISE surgery procedures in comparison with various methods of diagnosis

The altered locations of airway collapse in children were identified by two investigations. With an 88,3 % modification rate, tonoplast was the most often modified procedure. Less common (6,3 % and 3,1 %, respectively, (figure 3 and table 4) were the procedures on the tongue base and the nose.

Table 4. Children DISE surgery procedures in comparison with various methods of diagnosis
	No change	Added	Reduced
Soft palate	60,2	19,9	19,9
Tonsils	74,5	8,7	16,9
Epiglottis	57,1	26	16,9
Tongue base	74	9,1	16,9
Tongue	91,4	8,6	0
Nose	99,1	0,9	0
Osteotomies	99,1	0,9	0
MAD	62,3	28,1	9,5

Figure 3. Children DISE surgery procedures in comparison with various methods of diagnosis

Post-Therapeutic outcomes after DISE recommendations

AHI and DISE’s recommendations for changing surgical plans were not shown to be significantly correlated. In a case-control study, it was also discovered that there were no significant differences between patients whose procedures were guided by DISE and those whose treatments were guided by CBE in the several the patients having an AHI of >10 preference sleeping based on the contents.

DISCUSSION

The purpose of directing future treatment methods and the identification of blockage locations in OBS patients is of the utmost significance. A patient’s chance of having a successful operation during sleep surgery may depend on the areas of collapse that are chosen. The majority of changes to uvular and palatal locations were expected given that most studies updated their treatment recommendations for individuals undergoing UPPP and RFP procedures. This is because waking procedures did not mimic the dynamic behavior of collapsible elements if a person is sleeping. Rapid induction has sometimes been used to show central apnea. The degrees of blockage at the velum, oropharynx, and base of the tongue varied significantly across groups, according to the authors, leading to either an under of airway obstruction.

CONCLUSIONS

A majority of OBS patients that utilized the DISE technique changed their treatment plans, with around half of them. The epiglottis and the soft palate were changed surgically at a greater frequency than those of various sites of blockage, and the alterations’ values are considerably greater versus in youngsters and adults employing midazolam-based DISE as opposed to additional techniques. Regarding blockage locations discovered by DISE, a standardized categorization method is required. Future research should also look at the efficacy, security, and dependability of DISE-driven methods.

REFERENCES

1. Zhou, Ning, et al. “Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement.” Journal of clinical sleep medicine 18.4 (2022): 1073-1081.

2. Chiu, Feng-Hsiang, et al. “Effect of modified uvulopalatopharyngoplasty without tonsillectomy on obstructive sleep apnea: polysomnographic outcome and correlation with drug-induced sleep endoscopy.” Nature and Science of Sleep (2021): 11-19.

3. Vroegop, Anneclaire V., Olivier M. Vanderveken, and Johan A. Verbraecken. “Drug-induced sleep endoscopy: evaluation of a selection tool for treatment modalities for obstructive sleep apnea.” Respiration 99.5 (2020): 451-457.

4. Vonk, P. E., et al. “Floppy epiglottis during drug-induced sleep endoscopy: an almost complete resolution by adopting the lateral posture.” Sleep and Breathing 24 (2020): 103-109.

5. Viana, Alonço, Débora Estevão, and Chen Zhao. “The clinical application progress and potential of drug-induced sleep endoscopy in obstructive sleep apnea.” Annals of Medicine 54.1 (2022): 2908-2919.

6. Kirkham, Erin M., et al. “Drug-induced sleep endoscopy in children with positional obstructive sleep apnea.” Otolaryngology–Head and Neck Surgery 164.1 (2021): 191-198.

7. Lin, Huan-Yu, et al. “Comparison of findings between clinical examinations and drug-induced sleep endoscopy in patients with obstructive sleep apnea syndrome.” International journal of environmental research and public health 17.17 (2020): 6041.

8. Bosschieter, P. F. N., P. E. Vonk, and N. De Vries. “The predictive value of drug-induced sleep endoscopy for treatment success with a mandibular advancement device or positional therapy for patients with obstructive sleep apnea.” Sleep and Breathing (2021): 1-8.

9. Koutsourelakis, Ioannis, et al. “The role of sleep endoscopy in oral appliance therapy for obstructive sleep apnea.” Auris Nasus Larynx 48.2 (2021): 255-260.

10. Woo, Hyun-Jae, et al. “Characteristics of obstructive sleep apnea patients with a low body mass index: emphasis on the obstruction site determined by drug-induced sleep endoscopy.” Clinical and experimental otorhinolaryngology 13.4 (2020): 415-421.

11. Dedhia, Raj C., Everett G. Seay, and Alan R. Schwartz. “Beyond VOTE: the new frontier of drug-induced sleep endoscopy.” ORL 84.4 (2022): 296-301.

12. Yui, Mariane S., et al. “Can drug-induced sleep endoscopy (DISE) predict compliance with positive airway pressure therapy? A pilot study.” Sleep and Breathing (2022): 1-8.

13. Gillespie, M. Boyd, et al. “A trial of drug‐induced sleep endoscopy in the surgical management of sleep‐disordered breathing.” The Laryngoscope 123.1 (2013): 277-282.

14. Gazzaz, Malak Jamal, et al. “Does drug-induced sleep endoscopy change the surgical decision in surgically naïve non-syndromic children with snoring/sleep disordered breathing from the standard adenotonsillectomy? A retrospective cohort study.” Journal of Otolaryngology-Head & Neck Surgery 46.1 (2017): 12.

15. Collu, Maria Antonietta, et al. “A case-control study of Drug-Induced Sleep Endoscopy (DISE) in pediatric population: A proposal for indications.” International journal of pediatric otorhinolaryngology 108 (2018): 113-119.

16. Boudewyns, A., et al. “Drug-induced sedation endoscopy in pediatric obstructive sleep apnea syndrome.” Sleep medicine 15.12 (2014): 1526-1531.

17. Pilaete, Karen, Joris De Medts, and Kathelijne Godelieve Delsupehe. “Drug-induced sleep endoscopy changes snoring management plan very significantly compared to standard clinical evaluation.” European Archives of Oto-Rhino-Laryngology 271 (2014): 1311-1319.

18. Hybášková, Jaroslava, et al. “Drug‐induced sleep endoscopy changes the treatment concept in patients with obstructive sleep apnoea.” BioMed Research International 2016.1 (2016): 6583216.

19. Fernández‐Julián, Enrique, et al. “Surgical planning after sleep versus awake techniques in patients with obstructive sleep apnea.” The Laryngoscope 124.8 (2014): 1970-1974.

FINANCING

None.

CONFLICT OF INTEREST

None.

AUTHORSHIP CONTRIBUTION

Conceptualization: A Govindarajan, Nibedita Mohanty, T.M.J. Santhoshakumari, Pradeep. S, Pavas Saini, Ashmeet Kaur.

Data curation: A Govindarajan, Nibedita Mohanty, T.M.J. Santhoshakumari, Pradeep. S, Pavas Saini, Ashmeet Kaur.

Formal analysis: A Govindarajan, Nibedita Mohanty, T.M.J. Santhoshakumari, Pradeep. S, Pavas Saini, Ashmeet Kaur.

Drafting - original draft: A Govindarajan, Nibedita Mohanty, T.M.J. Santhoshakumari, Pradeep. S, Pavas Saini, Ashmeet Kaur.

Writing - proofreading and editing: A Govindarajan, Nibedita Mohanty, T.M.J. Santhoshakumari, Pradeep. S, Pavas Saini, Ashmeet Kaur.