the sleep specialist’s role in airway evaluation

The Sleep Specialist’s

Role in Airway Evaluation

Karel Calero, MD Assistant Professor

Pulmonary Critical Care and Sleep Medicine University of South Florida Morsani College of Medicine

Objectives

Physical exam findings complicating

obstructive sleep apnea

Airway changes in specific conditions

Imaging modalities to assess sites of

obstruction in the upper airway

Drug Induced Sleep Endoscopy

Airway Obstruction

General Examination

Respiration. 2012;83(6):559-66. doi: 10.1159/000335839. Epub 2012 Mar 1.

Down’s Syndrome

Narrowed midface/throat

Adenoid & tonsillar

hypertrophy

Macroglossia

Decreased muscle tone

Central apnea

Obesity

Nasal Examination

Nasal Obstruction

Kryger, M.H. Atlas of Clinical Sleep Medicine. ISBN 978-1-4160-4711-7. Pub. 2010.

Nasal Valve Collapse

Nasal Strips

Oropharynx Examination

Airway Classification

Mallampati Friedman

Tonsillar Hypertrophy

UPPP Outcomes

Kryger, M.H. Atlas of Clinical Sleep Medicine. ISBN 978-1-4160-4711-7. Pub. 2010.

Mandibular & Dental Assessment

Kryger, M.H. Atlas of Clinical Sleep Medicine. ISBN 978-1-4160-4711-7. Pub. 2010.

Dental Device Assessment

Kryger, M.H. Atlas of Clinical Sleep Medicine. ISBN 978-1-4160-4711-7. Pub. 2010.

Other Factors Affecting OSA Severity

Sleep position preferences

Neck size

Katz SL, et al. Does neck-to-waist ratio predict obstructive sleep apnea in children?

J Clin Sleep Med. 2014 Dec 15;10(12):1303-8. doi: 10.5664/jcsm.4284.

Condition Specific Airway Changes

Obesity

QJM. 2014 Dec;107(12):949-54. doi: 10.1093/qjmed/hcu029. Epub 2014 Feb 6.

Retropalatal Fat Deposits

Fat

deposit

Weight loss decreases size of fat deposits and increases airway size

Retropalatal

airspace

Horner RL. Respiratory control of the upper airway. In: SRS Basics of Sleep Guide.

Opp MR, et al. Westchester, IL: Sleep Research Society. pp. 91-97, 2005

Head & Neck Cancer

3.5 cm x 3.8 cm x 4 cm mass arising from the tongue base

Barnes, et al. Sleep Med. 2004 Nov;5(6):605-7

Pregnancy

Reduced FRC

Increased Mallampati IV score by 34%

Larger neck circumference

Decreased nasal patency

Lin, et al. Gender differences in obstructive sleep apnea and treatment implications.

Sleep Med Review 2008 Dec;12(6):481-96. doi: 10.1016/j.smrv.2007.11.003. Epub 2008 Oct 31.

Aging

Variation in bony pharynx

Increased soft palate length

Increased pharyngeal fat pads

Decreased genioglossus response

Lin, et al. Gender differences in obstructive sleep apnea and treatment implications.

Sleep Med Review 2008 Dec;12(6):481-96. doi: 10.1016/j.smrv.2007.11.003. Epub 2008 Oct 31.

Gender Specifics

Men

Inferior hyoid

Anterior lower facial

height

Women

Anterior hyoid

Posterior facial height

Rama, et al. Sites of Obstruction in OSA. CHEST 122 (4): 1139-47 Oct 2002

Where is the Obstruction?

Techniques to Assess Sites of

Upper Airway Obstruction

Method Advantages Disadvantages

Endoscopy Direct visualization

+/- PSG

Stenting by scope

Anesthesia

Fluoroscopy Real time imaging

See outside pharyngeal

airway

+/- PSG

Radiation

Two-Dimensional

+/-Sedation

Catheters Full night data

+/- PSG

Stenting by catheter

Precise localization

CT scan Scan entire upper airway

+/-PSG

No anesthesia

Radiation

MRI Real time imaging

Non-invasive

No simultaneous PSG

Need sedation

Who Needs Further Assessment?

CPAP intolerant patients

Pressure out of proportion to airway

anatomy

Choosing modalities other than CPAP and

predicting response to treatment

– Mandibular Advancement Device

Functional Imaging Predicts MAD

Success

PSG

Low radiation dose CT

scan with/without MAD

Change in UA volume/

resistance

De Backer, et al. Functional imaging using computational fluid dynamics to predict treatment success of mandibular

advancement devices in sleep-disordered breathing. J. Biomech 2007;40(16):3708-14. Epub 2007 Jul 30.

Drug Induced Sleep Endoscopy

https://inspiresleep.wistia.com/medias/2m04a

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Drug Induced Sedation Endoscopy

Flexible nasal endoscopy under moderate sedation in the supine position

Total sedation time: 10-15 mins; Evaluation stage: 10 mins; Recovery quick

Performed for decades and safe, >7500 procedures without side effects or

emergency situations1

1.Hohenhorst et al Oper Tech Otolaryngol 2012; 2. Kezirian et al Eur Arch Otorhinolaryngol 2011

* Airway Level

Direction

Anterior-

Posterior

Lateral Concentric

Velopharynx (Soft Palate)

Oropharynx

Tongue Base

Epiglottis

Degree: None – (no to little obstruction, 0-25%)

Partial – (vibration, 25-75%)

Complete - (collapsed, >75%)

VOTE Method1,2 – Level, Degree, Direction

DISE

Concentric Collapse

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AP Collapse

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Incidence of Severe Airway Collapse

DISE vs Clinical Examination

Zerpa et al. Drug-induced sedation endoscopy versus clinical exploration for the diagnosis of severe

upper airway obstruction in OSAHS patients. Sleep Breath. 2015 Dec;19(4):1367-72. doi:

10.1007/s11325-015-1266-z. Epub 2015 Oct 8.

Propofol Induced Sleep Endoscopy

PSG with and without DISE

Rabelo, et al. Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep

disorders and controls. Laryngoscope. 2013 Sep;123(9):2300-5. doi: 10.1002/lary.23664. Epub 2013 Jun 25.

N3 sleep observed. REM sleep was absent.

Surgical Planning

Identify areas of obstruction

Predict surgical failure:

– severe lateral oropharyngeal wall collapse

(73.3% vs. 36.8%, P = .037)

– severe supraglottic collapse (93.3% vs. 63.2%,

P = .046)

Soares et al. Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea

surgery. Laryngoscope. 2012 Feb;122(2):473-9. doi: 10.1002/lary.22474. Epub 2012 Jan 17.

Eichler et al. Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and

obstructive sleep apnea? Sleep Breath. 2013 Mar;17(1):63-8. doi: 10.1007/s11325-012-0647-9. Epub 2012 Jan 22.

Mandibular Advancement Device Evaluation

Prediction of treatment response – Not good for treatment failure prediction

Sites of treatment failure

Vroeqop et al. Sleep endoscopy with simulation bite for

prediction of oral appliance treatment outcome. J Sleep Res.

2013 Jun;22(3):348-55. doi: 10.1111/jsr.12008. Epub 2012

Dec 4.

Kent et al. Drug-Induced Sedation Endoscopy in the Evaluation of

OSA Patients with Incomplete Oral Appliance Therapy Response.

Otolaryngol Head Neck Surg. 2015 Aug;153(2):302-7.

doi: 10.1177/0194599815586978. Epub 2015 Jun 4.

Hypoglossal Nerve Stimulator

Stimulator Off

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Stimulator On

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Future Directions

Longitudinal evaluation of DISE in the

bronchoscopy room

Evaluation of multiple sedation modalities

during DISE

Conclusions

Airway structure and function changes

during sleep

Identification of the site of airway

obstruction may improve treatment

outcomes