Drug-induced sleep endoscopy in the identification of obstruction sites in patients with obstructive sleep apnea: a systematic review

Viana Jr., Alonço da Cunha; Thuler, Luiz Claudio Santos; Araújo-Melo, Maria Helena de

doi:10.1016/j.bjorl.2015.01.007

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Brazilian Journal of Otorhinolaryngology

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Review Article • Braz. j. otorhinolaryngol. 81 (4) • Jul-Aug 2015 • https://doi.org/10.1016/j.bjorl.2015.01.007 copy

Drug-induced sleep endoscopy in the identification of obstruction sites in patients with obstructive sleep apnea: a systematic review^☆ ☆ Please cite this article as: Viana Jr. AC, Thuler LCS, Araújo-Melo MH. Drug-induced sleep endoscopy in the identification of obstruction sites in patients with obstructive sleep apnea. Braz J Otorhinolaryngol. 2015;81:439-46. ^☆☆ ☆☆ Institution: Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

INTRODUCTION:

Obstructive sleep apnea syndrome has multifactorial causes. Although indications for surgery are evaluated by well-known diagnostic tests in the awake state, these do not always correlate with satisfactory surgical results.

OBJECTIVE:

To undertake a systematic review on endoscopy during sleep, as one element of the diagnosis routine, aiming to identify upper airway obstruction sites in adult patients with OSAS.

METHODS:

By means of electronic databases, a systematic review was performed of studies using drug-induced sleep endoscopy to identify obstruction sites in patients with OSAS.

RESULTS:

Ten articles were selected that demonstrated the importance of identifying multilevel obstruction, especially in relation to retrolingual and laryngeal collapse in OSAS.

CONCLUSION:

DISE is an additional method to reveal obstruction sites that have not been detected in awake patients.

Obstructive sleep apnea; Sleep disorders; Sleep; Sleep medicine specialty; Snoring; Endoscopy

STROBE articles		Gregório et al.⁹	Rodriguez-Bruno et al.¹⁶	Kezirian et al.¹⁷	Hamans et al.¹⁸	Campanini et al.¹⁴	Ravesloot and Vries¹⁰	Rabelo et al.¹¹	Salamanca et al.¹³	Soares et al.¹⁵	Gillespie et al.¹²
Items	N°
Title and abstract	1	+	+	+	+	+	+	+	+	+	+
Introduction
Context	2	+	+	+	+	+	+	+	+	+	+
Objectives	3	+	+	+	+	+	+	+	+	+	+
Method
Design	4	+	+	+	+	+	+	?	+	+	+
Context	5	+	+	?	+	+	+	+	+	+	+
Participants	6	+	+	+	+	+	+	+	+	+	+
Variables	7	+	+	+	+	+	+	+	+	+	+
Sources of data/measurement	8	+	+	+	+	+	+	+	+	+	+
Bias	9	?	+	+	?	?	?	+	?	+	?
Study size	10	+	+	+	+	+	+	+	+	+	+
Quantitative variables	11	+	+	+	+	?	?	+	?	+	?
Statistical methods	12	+	+	+	+	+	+	+	?	+	+
Results
Participants	13	?	+	+	?	?	+	+	+	+	?
Descriptive data	14	+	+	+	+	+	+	+	+	+	+
Outcome	15	+	+	+	+	+	+	+	+	+	+
Main results	16	+	+	+	+	+	+	+	?	+	+
Other analyses	17	?	?	?	?	?	+	?	?	+	?
Discussion
Main results	18	+	+	+	+	+	+	+	+	+	?
Limitations	19	?	+	+	?	?	+	?	?	+	?
Interpretation	20	+	+	+	+	+	+	+	+	+	+
Generalization	21	?	+	+	?	+	?	?	?	?	?
Other information
Funding	22	N	+	+	?	+	?	?	?	+	?
Total		16	21	19	16	17	18	17	14	21	14
Level of evidence		3B	1B	1B	2B	2B	2B	2B	2B	2B	2B
Grade of recommendation		B	A	A	B	B	B	B	B	B	B

Reference	Site/year	Study design	Population^a	Assessed groups	Inducing drug	Classification system
Gregório et al.⁹	São Paulo, SP, Brazil, 2007	Series of cases, prospective	8 (3 M: 37.5%) (5 F: 62.5%)	Awake (dorsal decubitus) vs. induced sleep	Midazolam	DISE^b
Rodriguez-Bruno et al.¹⁶	San Francisco, California, USA, 2009	Prospective cohort	32 (29 M: 90.6%) (3 F: 9.4%)	Induced sleep	Propofol	DISE^b
Kezirian et al.¹⁷	San Francisco, California, USA, 2010	Prospective cohort	108 (94 M: 87.03%) (14 F: 12.97%)	Induced sleep	Propofol	DISE^b
Hamans et al.¹⁸	Edegem, Belgium, 2010	Retrospective analysis	70	Induced sleep	Propofol and midazolam	FUJITA
Campanini et al.¹⁴	Pisa, Italy, 2010	Retrospective analysis	250 (225 M: 90%) (25 F: 10%)	Awake vs. induced sleep	Propofol	NOHL^c
Ravesloot and Vries¹⁰	Amsterdam, The Netherlands, 2011	Prospective observational	100 (20 M: 20%) (80 F: 80%)	Induced sleep	Propofol (56%) or midazolam (44%)	VOTE^d
Rabelo et al.¹¹	São Paulo, SP, Brazil, 2013	Cohort	46 (34 M: 73.9%) (12 F: 26.1%)	Awake vs. induced sleep	Propofol	Fujita
Salamanca et al.¹³	Milan, Italy, 2013	Retrospective analysis	614 (497 M: 80.9%) (117 F: 19.1%)	Induced sleep	Propofol	NOHL^c
Soares et al.¹⁵	Detroit, Michigan, USA, 2013	Series of cases	53 (40 M: 75.5%) (13 F: 24.5%)	Awake vs. induced sleep	Propofol	DISE^b
Gillespie et al.¹²	Hempstead, NY, USA, 2013	Prospective clinical trial	38 (22 M: 57.9%) (16 F: 42.1%)	Awake × induced sleep	Propofol	NOHL^c + VOTE^d

Reference	Outcome	Results	Conclusions
Gregório et al.⁹	Pharyngeal obstruction sites.	Retropalatal collapse similar to during MM^aand induced sleep. In contrast, retrolingual obstruction was significantly lower during MM.^a	DISE^b is safe with emphasis on retrolingual obstruction. The estimate of the obstruction level by DISE^b was higher than MM.^a
Rodriguez-Bruno et al.¹⁶	Pharyngeal obstruction sites at the examination retest assessed by two surgeons.	Most showed palatal and hypopharynx collapse. Diverse obstruction patterns.	Method reliability is good, especially for evaluation of hypopharynx sites.
Kezirian et al.¹⁷	Pharyngeal obstruction sites and agreement between two surgeons.	Collapse >50% at palatal level in 92–94% and of the hypopharynx in 83–84%.	Inter-examiner reliability is moderate to significant. Concordance is greater in the hypopharynx assessment.
Kezirian et al.¹⁷		Diverse structures contributed to the obstruction.
Hamans et al.¹⁸	Pharyngeal obstruction sites.	Monolevel palatal collapse in 31.9%.	Safe and feasible method if performed by an anesthesiologist and useful to identify the pharyngeal collapse site.
		Monolevel tongue/hypopharynx collapse in 27.8%.
		Multilevel collapse in 31.9% of patients.
		Absence of collapse in 5.6% of patients.
Campanini et al.¹⁴	Pharyngeal obstruction sites.	Similar results in only 24%.	Additional useful method for detecting collapse of hypopharyngeal and laryngeal sites. It is not the only one, but should be considered an additional specific tool in OSAS.^c
		Discordance in the oropharynx of 32% and in the hypopharynx of 59%.
		Laryngeal involvement in 30% during sedation.
Ravesloot and Vries¹⁰	Pharyngeal obstruction sites.	Palatal collapse in 83%, base of tongue in 56%, epiglottis in 38%, oropharynx in 7%.	Concordance between the severity of the obstruction sites and the severity of AHI.^dReports the importance of DISE^b in the surgical conduct.
		Multilevel collapse in 76% of patients.
		AHI^d is higher in patients with multilevel obstruction.
Rabelo et al.¹¹	Pharyngeal obstruction sites.	At DISE^b collapse was observed as follows: velopharyngeal in 78%, oropharyngeal in 34%, hypopharyngeal in 54%. Collapse at single level in 47% and multilevel in 52%	Absence concordance between the findings of patient while awake and under sedation.
Salamanca et al.¹³	Sites and pattern of pharyngeal obstruction in two groups (AHI >15 and ≤15)^d	AHI^d ≤15 with monolevel collapse in 61% and multilevel in 28%.	DISE^b is considered safe, easily feasible, valid, reliable, and essential in selecting treatment.
		AHI^d >15 with monolevel collapse in 46% and multilevel in 53%.
		The larynx is affected in 22.5% of cases with AHI^d >15
Soares et al.¹⁵	Pharyngeal obstruction sites.	Severe retropalatal collapse with MM,^a 90%, and by DISE,^b 98%.	Statistical differences in the identification of retrolingual collapse.
		Severe retrolingual collapse with MM,^a 35%, and by DISE,^b 84%.	In-depth analysis of technique, training, and interpretation is required.
		Twice the probability of severe retrolingual collapse by DISE.^b
Gillespie et al.¹²	Pharyngeal obstruction sites analyzed by three examiners.	DISE^b with more severe collapse than awake.	Method with more information on pharyngeal function and collapse assisting in the surgical conduct.
		Multi-segmental collapse in 73%.
		Monolevel palatal collapse, 16%, and in base of tongue, 11%.	Standardization of technique, training and interpretation is required.
		The surgical plan was changed in 62% of cases.
		Good results in intraand inter-examiner reliability. Correlation between DISE^b and AHI severity and age.

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
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[1] * Corresponding author at: Rua Senador Dantas, 20/708, Centro, 20031-204, Rio de Janeiro, RJ. E-mail: aloncovianajr@gmail.com (A.C. Viana Jr).