Name: drug-induced sleep endoscopy (dise) with target controlled infusion (tci) and bispectral analysis in obstructive sleep apnea
Uploaded: 2016-12-06T12:30:00
Description: Watch this Scientific Journal Video about Drug-Induced Sleep Endoscopy DISE with Target Controlled Infusion TCI and Bispectral Analysis in Obstructive Sleep Apnea at JoVE.com

The authors are grateful to Philipp Grundtner for his help with the statistical analyses.

The protocol follows the guidelines of the local ethics committee of the Friedrich-Alexander University Erlangen-N&#252;rnberg (FAU).
1. DISE-TCI-Bispectral Analysis Procedure
<ol>
	<li>Perform venipuncture and place an IV catheter in the patients left back of the hand or median cubital vein to obtain intravenous access to administer the sedative.</li>
	<li>Carry out the investigation at room temperature (22 &#176;C).</li>
	<li>Bring the awake patient into the operating theater. Place the patient in the supine p...

<ol>
	<li>Punjabi, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+epidemiology+of+adult+obstructive+sleep+apnea.">The epidemiology of adult obstructive sleep apnea.</a> Proc Am Thorac Soc. 5 (2), 136-143 (2008).</li><li>Giles, L. T., Lasserson, T. J., Smith, B., White, J., Wright, J. J., Cates, C. 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B., Pringle, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sleep+nasendoscopy:+a+technique+of+assessment+in+snoring+and+obstructive+sleep+apnoea.">Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea.</a> Clin Otolaryngol Allied Sci. 16 (5), 504-509 (1991).</li><li>De Vito, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Drug-induced+sleep+endoscopy:+conventional+versus+target+controlled+infusion+techniques--a+randomized+controlled+study.">Drug-induced sleep endoscopy: conventional versus target controlled infusion techniques--a randomized controlled study.</a> Eur Arch Otorhinolaryngol. 268 (3), 457-462 (2011).</li><li>Kezirian, E. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interrater+reliability+of+drug-induced+sleep+endoscopy.">Interrater reliability of drug-induced sleep endoscopy.</a> Arch Otolaryngol Head Neck Surg. 136 (4), 393-397 (2010).</li><li>Rodriguez-Bruno, K., Goldberg, A. N., McCulloch, C. E., Kezirian, E. 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The Report of an American Academy of Sleep Medicine Task Force.</a> Sleep. 22 (5), 667-689 (1999).</li><li>Iber, C., Ancoli-Israel, S., Chesson, A., Quan, S. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. 1st ed. , (2007).</li><li>Berry, R. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rules+for+scoring+respiratory+events+in+sleep:+update+of+the+2007+AASM+Manual+for+the+Scoring+of+Sleep+and+Associated+Events.+Deliberations+of+the+Sleep+Apnea+Definitions+Task+Force+of+the+American+Academy+of+Sleep+Medicine.">Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine.</a> J Clin Sleep Med. 8 (5), 597-619 (2012).</li><li>Kezirian, E. J., Hohenhorst, W., de Vries, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Drug-induced+sleep+endoscopy:+the+VOTE+classification.">Drug-induced sleep endoscopy: the VOTE classification.</a> Eur Arch Otorhinolaryngol. 268 (8), 1233-1236 (2011).</li><li>Ihmsen, H., Schraag, S., Kreuer, S., Bruhn, J., Albrecht, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Target-controlled+infusion.+Clinical+relevance+and+special+features+when+using+pharmacokinetic+models.">Target-controlled infusion. Clinical relevance and special features when using pharmacokinetic models.</a> Anaesthesist. 58 (7), 708-715 (2009).</li><li>Marsh, B., White, M., Morton, N., Kenny, G. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pharmacokinetic+model+driven+infusion+of+propofol+in+children.">Pharmacokinetic model driven infusion of propofol in children.</a> Brit J Anaesth. 67 (1), 41-48 (1991).</li><li>Schnider, T. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+influence+of+method+of+administration+and+covariates+on+the+pharmacokinetics+of+propofol+in+adult+volunteers.">The influence of method of administration and covariates on the pharmacokinetics of propofol in adult volunteers.</a> Anesthesiology. 88 (5), 1170-1182 (1998).</li><li>Sigl, J. C., Chamoun, N. 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D., Rakoff, S., Imperato, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fibro-optic+study+of+pharyngeal+airway+during+sleep+in+patients+with+hypersomnia+obstructive+sleep-apnea+syndrome.">Fibro-optic study of pharyngeal airway during sleep in patients with hypersomnia obstructive sleep-apnea syndrome.</a> Laryngoscope. 88 (8), 1310-1313 (1978).</li><li>Fujita, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+the+effectiveness+of+uvulopalatopharyngoplasty.">Evaluation of the effectiveness of uvulopalatopharyngoplasty.</a> Laryngoscope. 95 (1), 70-74 (1985).</li><li>Zerpa Zerpa, ., Carrasco Llatas, M., Agostini Porras, G., Dalmau Galofre, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Drug-induced+sedation+endoscopy+versus+clinical+exploration+for+the+diagnosis+of+severe+upper+airway+obstruction+in+OSAHS+patients.">Drug-induced sedation endoscopy versus clinical exploration for the diagnosis of severe upper airway obstruction in OSAHS patients.</a> Sleep Breath. 19 (4), 1367-1372 (2015).</li><li>Fernandez-Julian, E., Garcia-Perez, M. A., Garcia-Callejo, J., Ferrer, F., Marti, F., Marco, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+planning+after+sleep+versus+awake+techniques+in+patients+with+obstructive+sleep+apnea.">Surgical planning after sleep versus awake techniques in patients with obstructive sleep apnea.</a> Laryngoscope. 124 (8), 1970-1974 (2014).</li><li>Vroegop, A. V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Drug-induced+sleep+endoscopy+in+sleep-disordered+breathing:+report+on+1,249+cases.">Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases.</a> Laryngoscope. 124 (3), 797-802 (2014).</li></ol>

The first experiments using flexible fiber optic rhinopharyngolaryngoscopy during spontaneous sleep to detect the site of obstruction was described as early as the 1970s22. However, the roots of this investigative technique were initially of a purely descriptive pathophysiological nature. During the establishment of surgical techniques to treat OSA, such as uvulopalatopharyngoplasty (UPPP) by Fujita, it was, however, shown that the success of the operation was apparently dependent on a careful preoperative sel...

Obstructive sleep apnea (OSA) is characterized by repetitive phases of complete (apnea) or partial (hypopnea) collapse of the upper airways during sleep. These phases are often associated with arterial oxygen desaturation and a fragmentation of sleep caused by arousals. The reported prevalence of OSA with accompanying daytime symptoms in the general population is 3 - 7% in men and 2 - 5% in women1. The gold standard in the treatment of moderate to severe OSA is nasal continuous positive airway pressure (nCPAP), for which compliance is internationally reported as about 40 - 60%2. This treatment is used by 29 - 83% of OSA patients on a regular basis for less than 4 hr3. Both positive and negative predictors regarding long-term compliance of CPAP-use are well known nowadays4. In addition, emotional and clinical side effects often considerably reduce compliance. Alternative treatment options such as upper airway surgery therefore play an important role in OSA therapy. However, the fact that the success rate of surgery (responder rate) is relatively low in comparison with ventilation therapy is problematic 5,6.
It was hoped that the introduction of sleep endoscopy by Croft and Pringle in 1991 would not only provide further insights into the pathophysiology of OSA but also might improve the responder rate through individualized surgical treatment7. As early as 2011, studies by De Vito et al. demonstrated the advantage of using investigative techniques based on target-controlled infusion (TCI) and bispectral analysis with respect to safety, stability and accuracy8. In the meantime, the validity and reliability of sleep endoscopy have been established and, ever since the 2014 European Position Paper, it is on the road to standardization9-11. The aim of the present study is to establish a standardized protocol for sleep endoscopy by target-controlled infusion of the sedative propofol, combined with real-time monitoring of the depth of sedation using bispectral analysis, in order to differentiate obstruction patterns according to OSA-severity.
CASE PRESENTATION:
Study Design:
The retrospective study was conducted in the Department of Otorhinolaryngology, Head &#38; Neck Surgery of the Friedrich-Alexander University Erlangen-N&#252;rnberg between September 2012 and November 2014, following approval by the local Ethics Committee. All 57 participating patients, aged 20 to 73 years, were recruited by the Department of Otorhinolaryngology, Head and Neck Surgery. 52 patients were men and 5 women. In addition to a standardized interview, they were examined by an otorhinolaryngologist and underwent an awake endoscopy to assess the upper airways. Cardiorespiratory polysomnography was then undertaken in the Department&#39;s sleep laboratory to enable an exact classification of their sleep-related breathing disorder. The OSA severity was classified as mild (AHI 5 - 15/hr), moderate (AHI &#62; 15 &#60; 30/hr) or severe (AHI &#62; 30/hr), according to the criteria of the American Academy of Sleep Medicine Task Force12. The indication for sleep endoscopy was established in the context of a planned surgical intervention of the upper airways (primary indication) or in the case of nCPAP non-compliance (secondary or adjuvant indication).
Inclusion criteria for this study were men and women aged 18 - 75 years with mild, moderate or severe OSA diagnosed by polysomnography. Exclusion criteria were an American Society of Anesthesiologists Classification (ASA) IV/V, central sleep apnea, positive history of misuse of sedatives, alcohol or addictive drugs, allergy to propofol, pregnant women.
Diagnosis, Assessment, and Plan:
Cardiorespiratory polysomnography (PSG):
Polysomnography was carried out with a 33-channel cardiorespiratory diagnostic system. The technical procedure for the polysomnographic diagnostics followed the recommendations of the American Academy of Sleep Medicine (AASM) in the standardized technique using an electroencephalogram (EEG; F4-M1, C4-M1, O2-M1), right and left electro-oculogram, electromyogram of the mentalis and tibialis muscles, nasal pressure cannula, thoracic and abdominal respiratory effort sensors (inductive plethysmographs), body position sensors, pulse oximetry, snoring microphone, a one-channel ECG and an infrared video recording13. The evaluation was performed according to the AASM Criteria (Version 2.0, 2012) and was undertaken by an accredited medical sleep specialist of the German Sleep Society (DGSM)13, 14. After polysomnography had confirmed OSA, all 57 patients underwent a standardized propofol-based Drug-Induced Sleep Endoscopy (DISE) with TCI and bispectral analysis (DISE-TCI-bispectral analysis).
Preoperative preparations:
Due to the muscle relaxant effect, no premedication with benzodiazepines was given in the case of sleep endoscopies undertaken solely for diagnostic purposes. If the sleep endoscopy was performed during a planned surgical procedure, clonidine was used for premedication as an alternative for benzodiazepines, taking the corresponding contraindications into account.
Classification of the obstruction:
The VOTE system was used for classification purposes15. The following sites of obstruction were considered: velum, oropharynx (lateral oropharyngeal walls, tonsils), tongue base and epiglottis. Obstruction severity was divided into three grades (no obstruction; partial and complete obstruction). The configuration of the obstruction was divided into anterior-posterior, lateral and concentric.
Target-controlled infusion (TCI):
Target-Controlled Infusion (TCI) describes the infusion of drugs using microchip-controlled infusion pumps to achieve a target concentration in the blood. The aim of this method is the rapid achievement and maintenance of a certain effect (e.g., sedation) based on a specified (defined) plasma level or an effect level in the case of effect-site TCI. Calculation of the plasma level or effect-site level is based on pharmacokinetic 3-compartment models (according to Marsh or Schnider) that use the pharmacological half-life values and distribution coefficients determined in a volunteer population16-18. The infusion rates needed to rapidly achieve and maintain the specified target level of propofol in plasma are then automatically calculated and controlled by the infusion pump. The present study used a system consisting of an infusion pump and a data manager together with the pre-programmed pharmacokinetic model of Marsh. The objective depth of sedation was simultaneously monitored by bispectral analysis.
Bispectral analysis:
The bispectral analysis/index is correlated with electrical activity in the brain. The monitor of bispectral analysis records frontal EEG signals and, with the help of various proprietary algorithms, analyzes the distribution of the EEG power spectrum. The bispectral index is a dimensionless number between 0 and 100 19. In general, a value around 90 reflects a preponderance of high-frequency beta-waves and indicates that the patient is awake. Bispectral analysis values below 10 are indicative of EEG suppression 20, 21. This scale therefore provides an indirect measurement of the effect of sedatives on the brain. In order to maintain an adequate depth of anesthesia and avoid an undesirable intraoperative awakeness of the patient, a bispectral index of &#60; 60 is recommended. On the other hand, values of the bispectral index of &#60; 40 should be avoided, in order to prevent unnecessarily deep anesthesia.
All sleep endoscopies were performed by two experienced otorhinolaryngology consultants with additional qualifications in sleep medicine (T. M. 59.6% (34/57), A. F. 40.4% (23/57).

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			<td height="20" style="height:20px;width:387px;">Cardiorespiratory polysomnography&#160;</td>
			<td style="width:544px;"></td>
			<td style="width:313px;"></td>
			<td style="width:179px;"></td>
		</tr>
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			<td height="20" style="height:20px;">SOMNOscreen&#160;</td>
			<td>SOMNOmedics, Randersacker, Germany</td>
			<td>SBT202</td>
			<td></td>
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			<td></td>
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			<td height="20" style="height:20px;">Sedation</td>
			<td></td>
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			<td height="20" style="height:20px;">Propofol-Lipuro 20 mg/mL; 2,6-diisopropylphenol</td>
			<td>B. Braun Melsungen AG, Melsungen, Germany</td>
			<td></td>
			<td></td>
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			<td height="20" style="height:20px;">Target-controlled infusion (TCI)</td>
			<td></td>
			<td></td>
			<td></td>
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			<td height="20" style="height:20px;">Infusion pump Orchestra Module DPS Visio</td>
			<td>Fresenius Kabi, Germany GmbH&#160;</td>
			<td>Z082420</td>
			<td></td>
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			<td height="20" style="height:20px;">Data manager Orchestra Base Primea</td>
			<td>Fresenius Kabi Germany GmbH</td>
			<td>Z081320</td>
			<td></td>
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			<td height="20" style="height:20px;">Bispectral analysis (BIS)</td>
			<td></td>
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			<td></td>
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			<td height="20" style="height:20px;">BIS single-use electrode BIS Quatro Sensor</td>
			<td>Covidien, Neustadt/Donau, Germany GmbH</td>
			<td>186-0106</td>
			<td></td>
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			<td height="20" style="height:20px;">BIS monitor BIS VISTA</td>
			<td>Covidien, Neustadt/Donau, Germany GmbH</td>
			<td>186-0210</td>
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			<td height="20" style="height:20px;">Endoscope&#160;</td>
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			<td height="20" style="height:20px;">Laryngo fiberscope, length 30 cm, diameter 3.5 mm</td>
			<td>KARL STORZ GmbH &#38; Co. KG, Tuttlingen, Germany</td>
			<td>11101RP</td>
			<td></td>
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			<td height="20" style="height:20px;">Picture Archiving&#160; System&#160;</td>
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			<td></td>
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			<td height="20" style="height:20px;width:387px;">AIDA</td>
			<td>Karl STORZ GmbH &#38; Co. KG, Tuttlingen, Germany</td>
			<td>WD 200-XX</td>
			<td></td>
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			<td height="20" style="height:20px;width:387px;"></td>
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			<td height="20" style="height:20px;width:387px;">Premedication&#160;</td>
			<td></td>
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			<td height="20" style="height:20px;">Catapresan; Clonidin-HCl 0.075 mg/0.15 mg/0.3 mg</td>
			<td>Boehringer Ingelheim Pharma, GmbH &#38; Co. KG, Ingelheim am Rhein, Germany</td>
			<td></td>
			<td></td>
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drug-induced sleep endoscopy (dise) with target controlled infusion (tci) and bispectral analysis in obstructive sleep apnea

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, &#177; SD 10.5; mean apnea hypopnea Index (AHI) 30.8/hr, &#177; SD 21.6, mean BMI 28.2 kg/m2, &#177; 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 &#181;g/ml. Under continuous monitoring of the patient&#39;s respiration, state of consciousness and value of the bispectral analysis, the target plasma propofol level was raised in steps of 0.2 &#181;g/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 &#8212; capable of standardization. However it is not yet known whether these observed obstruction patterns also correspond to findings in natural sleep.

Characteristics of the patients are shown in Table 1. The mean value of the bispectral analysis at the desired depth of sedation was 60 (&#177; SD 10.4, range 35 - 80; 95% confidence interval 42.0 - 47.6). Single or multiple combined sites of obstruction were found across all levels of OSA severity. The identified sites of obstruction, in decreasing order of frequency, were: velar 59.6% (34/57), tongue base 43.9% (25/57), oropharynx 42.1% (24/57) or at the level of the ep...

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

The aim of this study was to establish a standardized protocol for sleep endoscopy to differentiate obstruction patterns in obstructive sleep apnea (OSA). Target-controlled infusion (TCI) of the sedative was combined with real-time monitoring of the depth of sedation using bispectral analysis.

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

The aim of this study was to establish a standardized protocol for drug-induced sleep endoscopy (DISE) to differentiate obstruction patterns in ...

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