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Is There a Perfect Drug for Sedation in DISE?

  • SLEEP MEDICINE: Sleep Apnea (K Pang, Section Editor)
  • Published:
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Abstract

Purpose of Review

Drug-induced sleep endoscopy (DISE) provides additional information about upper airway sites and patterns of narrowing in obstructive sleep apnea. There is a great variability on drugs chosen for DISE in the literature. In this systematic review, we looked for differences in obstruction patterns, as well as cardiovascular, neurological, or respiratory differences between the different drugs.

Recent Findings

All drugs reproduced a similar upper airway collapse on DISE. Propofol and midazolam showed a higher rate of respiratory depression; however, propofol has better pharmacokinetic properties. Dexmedetomidine has a safer respiratory profile and diminishes nausea, cough, sneeze reflexes, and saliva secretion, but holds a lower cardiovascular security.

Summary

The ideal drug for DISE has not been found yet; each of these existing drugs has its advantages and disadvantages. The right drug should be chosen by the surgeon and/or the anesthetists’ preferences and the patient’s condition.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Kezirian EJ. Drug-induced sleep endoscopy. Oper Tech Otolaryngol Head Neck Surg. 2006;17:230–2. https://doi.org/10.1016/j.otot.2006.10.005.

    Article  Google Scholar 

  2. • Ehsan Z, Mahmoud M, Shott SR, et al. The effects of anesthesia and opioids on the upper airway: a systematic review. Laryngoscope. 2016;126:270–84. https://doi.org/10.1002/lary.25399Systematic review of the cardiac and UA effects of multiple drugs used for sedation in DISE. Propofol produces a collapse of the UA that is dose dependent; dexmedetomidine has the lowest inhibitory effect on the respiratory center.

    Article  CAS  PubMed  Google Scholar 

  3. • Shteamer JW, Dedhia RC. Sedative choice in drug-induced sleep endoscopy: a neuropharmacology-based review. Laryngoscope. 2017;127:273–9. https://doi.org/10.1002/lary.26132Systematic review of the articles published before 2016. Even though neither of the drugs could reproduce the exact respiration of natural sleep, dexmedetomidine has a neuropharmacological profile promising to reproduce natural sleep.

    Article  PubMed  Google Scholar 

  4. Liu L, Wu AP, Yang Y, Liu SQ, Huang YZ, Xie JF, et al. Effects of propofol on respiratory drive and patient-ventilator synchrony during pressure support ventilation in postoperative patients: a prospective study. Chin Med J. 2017;130:1155–60. https://doi.org/10.4103/0366-6999.205864.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Genta PR, Eckert DJ, Gregorio MG, Danzi NJ, Moriya HT, Malhotra A, et al. Critical closing pressure during midazolam-induced sleep. J Appl Physiol. 2011;111:1315–22. https://doi.org/10.1152/japplphysiol.00508.2011.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. De Vito A, Carrasco Llatas M, Ravesloot MJ, et al. European position paper on drug-induced sleep endoscopy: 2017 Update. 2018.

  7. Cho JS, Soh S, Kim EJ, Cho HJ, Shin S, Kim HJ, et al. Comparison of three sedation regimens for drug-induced sleep endoscopy. Sleep Breath. 2015;19:711–7. https://doi.org/10.1007/s11325-015-1127-9.

    Article  PubMed  Google Scholar 

  8. •• Chang ET, Certal V, Song SA, et al. Dexmedetomidine versus propofol during drug-induced sleep endoscopy and sedation: a systematic review. Sleep Breath. 2017;21:727–35. https://doi.org/10.1007/s11325-017-1465-xSystematic review of the articles published before 2016. Propofol has a quicker start of action and shorter half-life and it is capable of reproducing UA collapse, although the cardiorespiratory profile is less stable than that with dexmedetomidine.

    Article  PubMed  Google Scholar 

  9. Griffin CE, Kaye AM, Rivera Bueno F, Kaye AD. Benzodiazepine pharmacology and central nervous system-mediated effects. Ochsner J. 2013;13:214–23.

    PubMed  PubMed Central  Google Scholar 

  10. Forster A, Gardaz J-P, Suter PM, Gemperle M. Respiratory depression by midazolam and diazepam. Anesthesiology. 1980;53:494–7.

    Article  CAS  Google Scholar 

  11. •• Viana A, Zhao C, Rosa T, et al. The effect of sedating agents on drug-induced sleep endoscopy findings. Laryngoscope. 2019;129:506–13. https://doi.org/10.1002/lary.27298The only prospective study comparing the 3 drugs regarding UA collapse and respiratory profile. Propofol and midazolam produced an increased collapse at the tongue base and lower O2 saturation than dexmedetomidine.

    Article  CAS  PubMed  Google Scholar 

  12. • Yoon BW, Hong JM, Hong SL, et al. A comparison of dexmedetomidine versus propofol during drug-induced sleep endoscopy in sleep apnea patients. Laryngoscope. 2016;126:763–7. https://doi.org/10.1002/lary.25801Prospective study comparing UA collapse and cardiopulmonary profile with propofol and dexmedetomidine in the same group of OSA patients. The collapse was equal with both drugs but dexmedetomidine produced lower respiratory depression.

    Article  CAS  PubMed  Google Scholar 

  13. Carrasco M, Agostini G, Cuesta MT, et al. Drug-induced sleep endoscopy: a two drug comparison and simultaneous polysomnography. Eur Arch Oto-Rhino-Laryngol. 2014;271:181–7. https://doi.org/10.1007/s00405-013-2548-3.

    Article  Google Scholar 

  14. Norton JR, Ward DS, Karan S, Voter WA, Palmer L, Varlese A, et al. Differences between midazolam and propofol sedation on upper airway collapsibility using dynamic negative airway pressure. Anesthesiology. 2006;104:1155–64. https://doi.org/10.1097/00000542-200606000-00009.

    Article  CAS  PubMed  Google Scholar 

  15. • Kasuya Y, Govinda R, Rauch S, et al. The correlation between bispectral index and observational sedation scale in volunteers sedated with dexmedetomidine and propofol. Anesth Analg. 2009;109:1811–5. https://doi.org/10.1213/ANE.0b013e3181c04e58Prospective study comparing propofol and dexmedetomidine in the same group of 19 volunteers. Propofol produced a higher respiratory depression; and dexmedetomidine, a deeper cardiac depression.

    Article  PubMed  Google Scholar 

  16. Lodenius Å, Ebberyd A, Hårdemark Cedborg A, Hagel E, Mkrtchian S, Christensson E, et al. Sedation with dexmedetomidine or propofol impairs hypoxic control of breathing in healthy male volunteers. Anesthesiology. 2016;125:700–15. https://doi.org/10.1097/ALN.0000000000001236.

    Article  CAS  PubMed  Google Scholar 

  17. Hsu YW, Cortinez LI, Robertson KM, Keifer JC, Sum-Ping ST, Moretti EW, et al. Dexmedetomidine pharmacodynamics: part I - crossover comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers. Anesthesiology. 2004;101:1066–76. https://doi.org/10.1097/00000542-200411000-00005.

    Article  CAS  PubMed  Google Scholar 

  18. • Abdullah VJ, Lee DLY, Ha SCN, Van Hasselt CA. Sleep endoscopy with midazolam: sedation level evaluation with bispectral analysis. Otolaryngol - Head Neck Surg (United States). 2013;148:331–7. https://doi.org/10.1177/0194599812464865Prospective study that compares sleep stages and UA collapse between midazolam and natural sleep. Midazolam was equivalent to natural sleep during N1 and N2 and muscle relaxation was not increased by midazolam.

    Article  Google Scholar 

  19. •• Ordones AB, Grad GF, Cahali MB, et al. Comparison of upper airway obstruction during zolpidem-induced sleep and propofol-induced sleep in patients with obstructive sleep apnea: a pilot study. J Clin Sleep Med. 2020;16:725–32. https://doi.org/10.5664/jcsm.8334Prospective study comparing propofol- and zolpidem-induced sleep in OSA patients. There were no significant differences in any of the parameters studied.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Rabelo FAW, Küpper DS, Sander HH, Fernandes RMF, Valera FCP. Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep disorders and controls. Laryngoscope. 2013;123:2300–5. https://doi.org/10.1002/lary.23664.

    Article  CAS  PubMed  Google Scholar 

  21. Abdelgalel EF. Dexmedetomidine added to propofol for drug-induced sleep endoscopy in adult patients with obstructive sleep apnea: randomized controlled trial. Egypt J Anaesth. 2018;34:151–7. https://doi.org/10.1016/j.egja.2018.09.001.

    Article  Google Scholar 

  22. Padiyara TV, Bansal S, Jain D, Arora S, Gandhi K. Dexmedetomidine versus propofol at different sedation depths during drug-induced sleep endoscopy: a randomized trial. Laryngoscope. 2020;130:257–62. https://doi.org/10.1002/lary.27903.

    Article  CAS  PubMed  Google Scholar 

  23. Zhao LL, Liu H, Zhang YY, Wei JQ, Han Y, Han L, et al. A comparative study on efficacy and safety of propofol versus dexmedetomidine in sleep apnea patients undergoing drug-induced sleep endoscopy: a consort-prospective, randomized, controlled clinical trial. Biomed Res Int. 2018;2018:10–5. https://doi.org/10.1155/2018/8696510.

    Article  CAS  Google Scholar 

  24. Wu W, Chen Q, Zhang L c, Chen W h. Dexmedetomidine versus midazolam for sedation in upper gastrointestinal endoscopy. J Int Med Res. 2014;42:516–22. https://doi.org/10.1177/0300060513515437.

    Article  CAS  PubMed  Google Scholar 

  25. Capasso R, Rosa T, Tsou DYA, Nekhendzy V, Drover D, Collins J, et al. Variable findings for drug-induced sleep endoscopy in obstructive sleep apnea with propofol versus dexmedetomidine. Otolaryngol - Head Neck Surg (United States). 2016;154:765–70. https://doi.org/10.1177/0194599815625972.

    Article  Google Scholar 

  26. De Vito A, Agnoletti V, Berrettini S, et al. Drug-induced sleep endoscopy: conventional versus target controlled infusion techniques-a randomized controlled study. Eur Arch Oto-Rhino-Laryngol. 2011;268:457–62. https://doi.org/10.1007/s00405-010-1376-y.

    Article  Google Scholar 

  27. Elkalla RS, El Mourad MB. Respiratory and hemodynamic effects of three different sedative regimens for drug induced sleep endoscopy in sleep apnea patients. A prospective randomized study. Minerva Anestesiol. 2020;86:132–40. https://doi.org/10.23736/S0375-9393.19.13875-8.

    Article  PubMed  Google Scholar 

  28. Kim N, Yoo YC, Lee SK, Kim H, Ju HM, Min KT. Comparison of the efficacy and safety of sedation between dexmedetomidine-remifentanil and propofol-remifentanil during endoscopic submucosal dissection. World J Gastroenterol. 2015;21:3671–8. https://doi.org/10.3748/wjg.v21.i12.3671.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Shin HJ, Kim EY, Hwang JW, Do SH, Na HS. Comparison of upper airway patency in patients with mild obstructive sleep apnea during dexmedetomidine or propofol sedation: a prospective, randomized, controlled trial. BMC Anesthesiol. 2018;18:1–7. https://doi.org/10.1186/s12871-018-0586-5.

    Article  CAS  Google Scholar 

  30. Kim Y, Park H, Shin J, Choi JH, Park SW, Kang HY. Effect of remifentanil during drug-induced sleep endoscopy in patients with obstructive sleep apnea. Sleep Breath. 2018;22:919–23. https://doi.org/10.1007/s11325-018-1738-z.

    Article  PubMed  Google Scholar 

  31. Kuyrukluyıldız U, Binici O, Onk D, Ayhan Celik S, Torun MT, Unver E, et al. Comparison of dexmedetomidine and propofol used for drug-induced sleep endoscopy in patients with obstructive sleep apnea syndrome. Int J Clin Exp Med. 2015;8:5691–8.

    PubMed  PubMed Central  Google Scholar 

  32. Murabito P, Serra A, Zappia M, Maiolino L, Cocuzza S, Castorina S, et al. Comparison of genioglossus muscle activity and efficiency of dexmedetomidine or propofol during drug-induced sleep endoscopy in patients with obstructive sleep apnea/hypopnea syndrome. Eur Rev Med Pharmacol Sci. 2019;23:389–96. https://doi.org/10.26355/eurrev_201901_16787.

    Article  CAS  PubMed  Google Scholar 

  33. Eastwood PR, Platt PR, Shepherd K, Maddison K, Hillman DR. Collapsibility of the upper airway at different concentrations of propofol anesthesia. Anesthesiology. 2005;103:470–7. https://doi.org/10.1097/00000542-200509000-00007.

    Article  CAS  PubMed  Google Scholar 

  34. Genta PR, Edwards BA, Sands SA, Owens RL, Butler JP, Loring SH, et al. Tube law of the pharyngeal airway in sleeping patients with obstructive sleep apnea. Sleep. 2016;39:337–43. https://doi.org/10.5665/sleep.5440.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Oshima T, Masaki Y, Toyooka H. Flumazenil antagonizes midazolam-induced airway narrowing during nasal breathing in humans. Br J Anaesth. 1999;82:698–702. https://doi.org/10.1093/bja/82.5.698.

    Article  CAS  PubMed  Google Scholar 

  36. Chattopadhyay U, Mallik S, Ghosh S, et al. Comparison between propofol and dexmedetomidine on depth of anesthesia: a prospective randomized trial. J Anaesthesiol Clin Pharmacol. 2014;30:550–4. https://doi.org/10.4103/0970-9185.142857.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clin Pharmacokinet. 2017;56:893–913. https://doi.org/10.1007/s40262-017-0507-7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Kellner P, Herzog B, Plößl S, Rohrmeier C, Kühnel T, Wanzek R, et al. Depth-dependent changes of obstruction patterns under increasing sedation during drug-induced sedation endoscopy: results of a German monocentric clinical trial. Sleep Breath. 2016;20:1035–43. https://doi.org/10.1007/s11325-016-1348-6.

    Article  PubMed  Google Scholar 

  39. Hong SD, Dhong HJ, Kim HY, Sohn JH, Jung YG, Chung SK, et al. Change of obstruction level during drug-induced sleep endoscopy according to sedation depth in obstructive sleep apnea. Laryngoscope. 2013;123:2896–9. https://doi.org/10.1002/lary.24045.

    Article  PubMed  Google Scholar 

  40. Heiser C, Fthenakis P, Hapfelmeier A, Berger S, Hofauer B, Hohenhorst W, et al. Drug-induced sleep endoscopy with target-controlled infusion using propofol and monitored depth of sedation to determine treatment strategies in obstructive sleep apnea. Sleep Breath. 2017;21:737–44. https://doi.org/10.1007/s11325-017-1491-8.

    Article  PubMed  Google Scholar 

  41. Lo YL, Ni YL, Wang TY, Lin TY, Li HY, White DP, et al. Bispectral index in evaluating effects of sedation depth on drug-induced sleep endoscopy. J Clin Sleep Med. 2015;11:1011–20. https://doi.org/10.5664/jcsm.5016.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Demiraran Y, Korkut E, Tamer A, Yorulmaz I, Kocaman B, Sezen G, et al. The comparison of dexmedetomidine and midazolam used for sedation of patients during upper endoscopy: a prospective, randomized study. Can J Gastroenterol. 2007;21:25–9. https://doi.org/10.1155/2007/350279.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Hospital Universitario Dr. Peset, Valencia, Spain

    Silvia Matarredona-Quiles & Noelia Ortega-Beltrá

  2. Hospital Clínico Universitario, Valencia, Spain

    Tomás Pérez-Carbonell

  3. Centro de Electroencefalografia e Neurofisiologia Clínica and ISAMB, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

    Joana Vaz de Castro

  4. Rabin Medical Center, Petach Tikva, Israel

    Uri Alkan

  5. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

    Uri Alkan

  6. Hospital Universitario Dr. Peset., Servicio de ORL, Av/ Gaspar Aguilar 90, 46017, Valencia, Spain

    Marina Carrasco-Llatas

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  1. Silvia Matarredona-Quiles
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  2. Tomás Pérez-Carbonell
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  3. Noelia Ortega-Beltrá
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  4. Joana Vaz de Castro
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  5. Uri Alkan
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  6. Marina Carrasco-Llatas
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Correspondence to Marina Carrasco-Llatas.

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Matarredona-Quiles, S., Pérez-Carbonell, T., Ortega-Beltrá, N. et al. Is There a Perfect Drug for Sedation in DISE?. Curr Otorhinolaryngol Rep 9, 260–270 (2021). https://doi.org/10.1007/s40136-021-00355-5

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