In this study, we aimed to observe the effects of positive airway pressure (PAP) on individual levels of obstruction during drug-induced sleep endoscopy (DISE) of the upper airways (UA), to evaluate at which pressures the obstruction disappeared or worsened, and to identify cases in which PAP was ineffective. This prospective study was conducted from June 2018 to June 2022. PAP testing was performed during DISE in patients with moderate and severe OSA. The pressure was gradually increased over the range from 6.0 to 18.0 hPa. Our findings were evaluated using the VOTE classification. The examination was performed in 56 patients, with a median apnea-hypopnea index (AHI) of 26.4. Complete obstruction of the soft palate was observed in 51/56 patients (91%), oropharyngeal obstruction in 15/56 patients (27%), tongue base obstruction in 23/56 patients (41%), and epiglottic collapse in 16/56 patients (29%). PAP was most effective in cases of complete oropharyngeal obstruction, and least effective in cases of epiglottic collapse, where it was ineffective in 11/16 patients. DISE with PAP is a simple diagnostic method that can be helpful for identifying anatomic and dynamic reasons for PAP intolerance. The main indication is ineffective PAP treatment.

Department of Anesthesiology Resuscitation and Intensive Medicine University Hospital Ostrava 708 52 Ostrava Czech Republic

Department of Applied Mathematics Faculty of Electrical Engineering and Computer Science VSB Technical University of Ostrava 708 00 Ostrava Czech Republic

Department of Otorhinolaryngology and Head and Neck Surgery University Hospital Ostrava 708 52 Ostrava Czech Republic

Department of Otorhinolaryngology Faculty of Medicine in Pilsen University Hospital in Pilsen Charles University 305 99 Pilsen Czech Republic

Department of Pediatric Neurology University Hospital Ostrava 708 52 Ostrava Czech Republic

Faculty of Medicine University of Ostrava 703 00 Ostrava Czech Republic

Zobrazit více v PubMed

Pavwoski P., Shelgikar A.V. Treatment options for obstructive sleep apnea. Neurol. Clin. Pract. 2016;7:77–85. doi: 10.1212/CPJ.0000000000000320. PubMed DOI PMC

Waters T. Alternative interventions for obstructive sleep apnea. Clevel. Clin. J. Med. 2019;86:34–41. doi: 10.3949/ccjm.86.s1.06. PubMed DOI

Weaver T.E., Grunstein R.R. Adherence to continuous positive airway pressure therapy: The challenge to effective treatment. Proc. Am. Thorac. Soc. 2008;5:173–178. doi: 10.1513/pats.200708-119MG. PubMed DOI PMC

Freiser M.E., Schell A.E., Soose R.J. DISE-PAP: A method for troubleshooting residual AHI elevation despite positive pressure therapy. J. Clin. Sleep Med. 2020;16:631–633. doi: 10.5664/jcsm.8240. PubMed DOI PMC

Torre C., Liu S.Y., Kushida C.A., Nekhendzy V., Huon L.K., Capasso R. Impact of continuous positive airway pressure in patients with obstructive sleep apnea during drug-induced sleep endoscopy. Clin. Otolaryngol. 2017;42:1218–1223. doi: 10.1111/coa.12851. PubMed DOI

Cavaliere M., Russo F., Iemma M. Awake versus druginduced sleep endoscopy: Evaluation of airway obstruction in obstructive sleep apnea/hypopnoea syndrome. Laryngoscope. 2013;123:2315–2318. doi: 10.1002/lary.23881. PubMed DOI

Hybášková J., Jor O., Novák V., Matoušek P., Komínek P. Možné využití spánkové endoskopie pro zvýšení efektivity léčby (operační i neoperační) u pacientů s obstrukční spánkovou apnoí. Cesk Slov Neurol N. 2017;80/113:428–433. doi: 10.14735/amcsnn2017428. DOI

Certal V.F., Pratas R., Guimaraes L., Lugo R., Tsou Y., Camacho M., Capasso R. Awake examination versus DISE for surgical decision making in patients with OSA: A systematic rewiew. Laryngoscope. 2016;126:768–774. doi: 10.1002/lary.25722. PubMed DOI

Civelek S., Emre I.E., Dizdar D., Cuhadaroglu C., Eksioglu B.K., Eraslan A.K., Turgut S. Comparison of conventional continuous positive airway pressure to continuous positive airway pressure titration performed with sleep endoscopy. Laryngoscope. 2012;122:691–695. doi: 10.1002/lary.22494. PubMed DOI

Jung S.H., Koo S.K., Choi J.W., Moon J.S., Lee S.H. Upper airway structural changes induced by CPAP in OSAS patients: A study using drug-induced sleep endoscopy. Eur. Arch. Otorhinolaryngol. 2017;274:247–252. doi: 10.1007/s00405-016-4233-9. PubMed DOI

Lan M.C., Hsu Y.B., Lan M.Y., Huang Y.C., Kao M.C., Huang T.T., Chiu T.J., Yang M.C. The predictive value of drug-induced sleep endoscopy for CPAP titration in OSA patients. Sleep Breath. 2018;22:949–954. doi: 10.1007/s11325-017-1600-8. PubMed DOI

Kezirian E.J., Hussey H.M., Brietzke S.E., Cohen S.M., Davis G.E., Shin J.J., Weinberger D.G., Cabana M.D. Hypopharyngeal surgery in obstructive sleep apnea: Practice patterns, perceptions, and attitudes. Otolaryngol. Head Neck Surg. 2012;147:964–971. doi: 10.1177/0194599812453000. PubMed DOI

De Vito A., Carrasco L.M., Vanni A., Bosi M., Braghiroli A., Campanini A., De Vries N., Hamans E., Hohenhorst W., Kotecha B.T., et al. European position paper on drug-induced sedation endoscopy (DISE) Sleep Breath. 2014;18:453–465. doi: 10.1007/s11325-014-0989-6. PubMed DOI

Croft C.B., Pringle M. Sleep nasendoscopy: A technique of assessment in snoring and obstructive sleep apnea. Clin. Otolaryngol. Allied Sci. 1991;16:504509. doi: 10.1111/j.1365-2273.1991.tb01050.x. PubMed DOI

Veer V., Zhang H., Mandavia R., Mehta N. Introducing a new classification for drug-induced sleep endoscopy (DISE): The PTLTbE system. Sleep Breath. 2020;24:1685–1693. doi: 10.1007/s11325-020-02035-y. PubMed DOI

De Corso E., Fiorita A., Rizzotto G., Mennuni G.F., Meucci D., Giuliani M., Marchese M.R., Levantesi L., Marca G.D., Paludetti G., et al. The role of drug-induced sleep endoscopy in the diagnosis and management of obstructive sleep apnoea syndrome: Our personal experience. Acta Otorhinolaryngol. Ital. 2013;33:405–413. doi: 10.1007/s12070-017-1113-6. PubMed DOI PMC

Bachar G., Nageris B., Feinmesser R., Hadar T., Yaniv E., Shpitzer T., Eidelman L. Novel grading system for quantifying upper-airway obstruction on sleep endoscopy. Lung. 2012;190:313–318. doi: 10.1007/s00408-011-9367-3. PubMed DOI

Cho J.S., Soh S., Kim E.J., Cho H.J., Shin S., Kim H.J., Koo B.N. Comparison of three sedation regimens for drug-induced sleep endoscopy. Sleep Breath. 2015;19:711–717. doi: 10.1007/s11325-015-1127-9. PubMed DOI

Hybášková J., Babiarová V., Jor O., Novák V., Matoušek P., Komínek P. Flexibilní endoskopie horních dýchacích cest v léky navozeném spánku. Otorinolaryngol. Foniatr. 2016;65:30–34.

Atkins J.H., Mandel J.E. Drug-induced sleep endoscopy: From obscure technique to diagnostic tool for assessment of obstructive sleep apnea for surgical interventions. Curr. Opin. Anaesthesiol. 2018;31:120–126. doi: 10.1097/ACO.0000000000000543. PubMed DOI

Pépin J.L., Krieger J., Rodenstein D., Cornette A., Sforza E., Delguste P., Deschaux C., Grillier V., Lévy P. Effective Compliance during the First 3 Months of Continuous Positive Airway Pressure A European Prospective Study of 121 Patients. Am. J. Respir. Crit. Care Med. 1999;160:1124–1129. doi: 10.1164/ajrccm.160.4.9802027. PubMed DOI

Sabil A., le Vaillant M., Stitt C., Goupil F., Pigeanne T., Leclair-Visonneau L., Masson P., Bizieux-Thaminy A., Humeau M.-P., Meslier N., et al. A CPAP Data–Based Algorithm for Automatic Early Prediction of Therapy Adherence. Sleep Breath. 2021;25:957–962. doi: 10.1007/s11325-020-02186-y. PubMed DOI

Schwab R.J., Pack A.I., Gupta K.B., Metzger L.J., Oh E., Getsy J.E., Hoffman E.A., Gefter W.B. Upper airway and soft tissue structural changes incuded by CPAP in normal subjects. Am. J. Respir. Crit. Care Med. 1996;154:1106–1116. doi: 10.1164/ajrccm.154.4.8887615. PubMed DOI

Lai C.C., Friedman M., Lin H.C., Wang P.C., Hwang M.S., Hsu C.M., Lin M.C., Chin C.H. Clinical predictors of effectivecontinuous positive airway pressure in patients with obstructive sleep apnea/hypopnea syndrome. Laryngoscope. 2015;125:1983–1987. doi: 10.1002/lary.25125. PubMed DOI

Torre C., Camacho M., Liu S.Y., Huon L.K., Capasso R. Epiglottis collapse in adult obstructive sleep apnea: A systematic review. Laryngoscope. 2016;126:515–523. doi: 10.1002/lary.25589. PubMed DOI

Dedhia E.C., Rosen C.A., Soose R.J. What is the role of the larynx in adult obstructive sleep apnea? Laryngoscope. 2014;124:1029–1034. doi: 10.1002/lary.24494. PubMed DOI

Verse T., Pirsig W. Age-related changes in the epiglottis causing failure of nasal continuous positive airway pressure therapy. J. Laryngol. Otol. 1999;113:1022–1025. doi: 10.1017/S0022215100145888. PubMed DOI

Kwon E.O., Jung S.Y., Al-Dilaijan K., Min J.Y., Lee K.H., Kim S.W. Is Epiglottis Surgery Necessary for Obstructive Sleep Apnea Patients With Epiglottis Obstruction? Laryngoscope. 2019;129:2658–2662. doi: 10.1002/lary.27808. PubMed DOI

Roustan V., Barbieri M., Incandela F., Missale F., Camera H., Braido F., Mora R., Peretti G. Transoral glossoepiglottopexy in the treatment of adult obstructive sleep apnoea: A surgical approach. Acta Otorhinolaryngol. Ital. 2018;38:38–44. doi: 10.14639/0392-100X-1857. PubMed DOI PMC

Betka J., Kubíčková J., Klozar J., Šonka K. Poruchy Dýchání ve Spánku. 1st ed. Tobiáš; Hradec Králové, Czech Republic: 2019. pp. 106–113.

Mickelson S.A., Rosenthal L. Midline glossectomy and epiglottidectomy for obstructive sleep apnea syndrome. Laryngoscope. 1997;107:614–619. doi: 10.1097/00005537-199705000-00011. PubMed DOI

Cassano M. Endoscopic coblator-assisted epiglottoplasty in “obstructive sleep apnoea syndrome” patients. Clin. Otolaryngol. 2017;42:1112–1114. doi: 10.1111/coa.12536. PubMed DOI

Oluwasanmi A.F., Mal R.K. Diathermy epiglottectomy: Endoscopic technique. J. Laryngol. Otol. 2001;115:289–292. doi: 10.1258/0022215011907479. PubMed DOI

Catalfumo F.J., Golz A., Westerman S.T., Gilbert L.M., Joachims H.Z., Goldenberg D. The epiglottis and obstructive sleep apnoea syndrome. J. Laryngol. Otol. 1998;112:940–943. doi: 10.1017/S0022215100142136. PubMed DOI

Gobbi R., Baiardi S., Mondini S., Cerritelli L., Piccin O., Scaramuzzino G., Milano F., Melotti M.R., Mordini F., Pirodda A., et al. Technique and Preliminary Analysis of Drug-Induced Sleep Endoscopy With Online Polygraphic Cardiorespiratory Monitoring in Patients With Obstructive Sleep Apnea Syndrome. JAMA Otolaryngol. Head Neck Surg. 2017;143:459–465. doi: 10.1001/jamaoto.2016.3964. PubMed DOI PMC

Ebben M.R., Narizhnaya M., Segal A.Z., Barone D., Krieger A.C. A randomised controlled trial on the effect of mask choice on residual respiratory events with continuous positive airway pressure treatment. Sleep Med. 2014;15:619–624. doi: 10.1016/j.sleep.2014.01.011. PubMed DOI