Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

The predictive value of drug-induced sleep endoscopy for CPAP titration in OSA patients

  • 348 Accesses

  • 4 Citations



The aim of this study was to identify possible upper airway obstructions causing a higher continuous positive airway pressure (CPAP) titration level, utilizing drug-induced sleep endoscopy (DISE).


A total of 76 patients with obstructive sleep apnea (OSA) underwent CPAP titration and DISE. DISE findings were recorded using the VOTE classification system. Polysomnographic (PSG) data, anthropometric variables, and patterns of airway collapse during DISE were analyzed with CPAP titration levels.


A significant association was found between the CPAP titration level and BMI, oxygen desaturation index (ODI), apnea-hypopnea index (AHI), and neck circumference (NC) (P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively, by Spearman correlation). Patients with concentric collapse of the velum or lateral oropharyngeal collapse were associated with a significantly higher CPAP titration level (P < 0.001 and P = 0.043, respectively, by nonparametric Mann-Whitney U test; P < 0.001 and P = 0.004, respectively, by Spearman correlation). No significant association was found between the CPAP titration level and any other collapse at the tongue base or epiglottis.


By analyzing PSG data, anthropometric variables, and DISE results with CPAP titration levels, we can better understand possible mechanisms resulting in a higher CPAP titration level. We believe that the role of DISE can be expanded as a tool to identify the possible anatomical structures that may be corrected by oral appliance therapy or surgical intervention to improve CPAP compliance.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2


  1. 1.

    Vanderveken OM, Boudewyns A, Ni Q, Kashyap B, Verbraecken J, de Backer W, van de Heyning P (2011) Cardiovascular implications in the treatment of obstructive sleep apnea. J Cardiovasc Transl Res 4(1):53–60. https://doi.org/10.1007/s12265-010-9238-y

  2. 2.

    Ravesloot MJ, de Vries N, Stuck BA (2014) Treatment adherence should be taken into account when reporting treatment outcomes in obstructive sleep apnea. Laryngoscope 124(1):344–345. https://doi.org/10.1002/lary.24302

  3. 3.

    Ravesloot MJ, de Vries N (2011) Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited. Sleep 34(1):105–110. https://doi.org/10.1093/sleep/34.1.105

  4. 4.

    Neuzeret PC, Morin L (2016) Impact of different nasal masks on CPAP therapy for obstructive sleep apnea: a randomized comparative trial. Clin Respir J 11(6):990–998. http://doi.org/10.1111/crj.12452

  5. 5.

    Zozula R, Rosen R (2001) Compliance with continuous positive airway pressure therapy: assessing and improving treatment outcomes. Curr Opin Pulm Med 7(6):391–398. https://doi.org/10.1097/00063198-200111000-00005

  6. 6.

    Sawyer AM, Canamucio A, Moriarty H, Weaver TE, Richards KC, Kuna ST (2011) Do cognitive perceptions influence CPAP use? Patient Educ Couns 85(1):85–91. https://doi.org/10.1016/j.pec.2010.10.014

  7. 7.

    Friedman M, Soans R, Joseph N, Kakodkar S, Friedman J (2009) The effect of multilevel upper airway surgery on continuous positive airway pressure therapy in obstructive sleep apnea/hypopnea syndrome. Laryngoscope 119(1):193–196. https://doi.org/10.1002/lary.20021

  8. 8.

    Hong SD, Kim HY, Cho HJ, Jang MS, Dhong HJ, Chung SK (2015) Effect of uvulopalatopharyngoplasty on CPAP compliance. Eur Arch Otorhinolaryngol 272(6):1437–1442. https://doi.org/10.1007/s00405-014-3239-4

  9. 9.

    Azbay S, Bostanci A, Aysun Y, Turhan M (2016) The influence of multilevel upper airway surgery on CPAP tolerance in non-responders to obstructive sleep apnea surgery. Eur Arch Otorhinolaryngol 273(9):2813–2818. https://doi.org/10.1007/s00405-015-3865-5

  10. 10.

    Vroegop AV, Vanderveken OM, Dieltjens M et al (2013) Sleep endoscopy with simulation bite for prediction of oral appliance treatment outcome. J Sleep Res 22(3):348–355. https://doi.org/10.1111/jsr.12008

  11. 11.

    Fernandez-Julian E, Garcia-Perez MA, Garcia-Callejo J, Ferrer F, Marti F, Marco J (2014) Surgical planning after sleep versus awake techniques in patients with obstructive sleep apnea. Laryngoscope 124(8):1970–1974. https://doi.org/10.1002/lary.24577

  12. 12.

    Civelek S, Emre IE, Dizdar D, Cuhadaroglu C, Eksioglu BK, Eraslan AK, Turgut S (2012) Comparison of conventional continuous positive airway pressure to continuous positive airway pressure titration performed with sleep endoscopy. Laryngoscope 122(3):691–695. https://doi.org/10.1002/lary.22494

  13. 13.

    Jung SH, Koo SK, Choi JW, Moon JS, Lee SH (2017) Upper airway structural changes induced by CPAP in OSAS patients: a study using drug-induced sleep endoscopy. Eur Arch Otorhinolaryngol 274(1):247–252. https://doi.org/10.1007/s00405-016-4233-9

  14. 14.

    Torre C, Liu SY, Kushida CA, Nekhendzy V, Huon LK, Capasso R (2017) Impact of continuous positive airway pressure in patients with obstructive sleep apnea during drug-induced sleep endoscopy. Clin Otolaryngol 42(6):1218–1223. https://doi.org/10.1111/coa.12851

  15. 15.

    Kushida CA, Chediak A, Berry RB, Brown LK, Gozal D, Iber C, Parthasarathy S, Quan SF, Rowley JA, Positive Airway Pressure Titration Task Force, American Academy of Sleep Medicine (2008) Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med 4(2):157–171

  16. 16.

    Kezirian EJ, Hohenhorst W, de Vries N (2011) Drug-induced sleep endoscopy: the VOTE classification. Eur Arch Otorhinolaryngol 268(8):1233–1236. https://doi.org/10.1007/s00405-011-1633-8

  17. 17.

    Stuck BA, Maurer JT (2008) Airway evaluation in obstructive sleep apnea. Sleep Med Rev 12(6):411–436. https://doi.org/10.1016/j.smrv.2007.08.009

  18. 18.

    De Vito A, Carrasco Llatas M, Vanni A, Bosi M, Braghiroli A, Campanini A, de Vries N, Hamans E, Hohenhorst W, Kotecha BT, Maurer J, Montevecchi F, Piccin O, Sorrenti G, Vanderveken OM, Vicini C (2014) European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath 18(3):453–465. https://doi.org/10.1007/s11325-014-0989-6

  19. 19.

    Oksenberg A, Arons E, Froom P (2006) Does the severity of obstructive sleep apnea predict patients requiring high continuous positive airway pressure? Laryngoscope 116(6):951–955. https://doi.org/10.1097/01.MLG.0000215833.68519.7B

  20. 20.

    Lai CC, Friedman M, Lin HC, Wang PC, Hwang MS, Hsu CM, Lin MC, Chin CH (2015) Clinical predictors of effective continuous positive airway pressure in patients with obstructive sleep apnea/hypopnea syndrome. Laryngoscope 125(8):1983–1987. https://doi.org/10.1002/lary.25125

  21. 21.

    Camacho M, Riaz M, Tahoori A, Certal V, Kushida CA (2015) Mathematical equations to predict positive airway pressures for obstructive sleep apnea: a systematic review. Sleep disorders 2015:293868

  22. 22.

    Bosi M, De Vito A, Vicini C, Poletti V (2013) The predictive value of Muller’s maneuvre for CPAP titration in OSAHS patients. Eur Arch Otorhinolaryngol 270(8):2345–2351. https://doi.org/10.1007/s00405-013-2412-5

  23. 23.

    Vroegop AV, Vanderveken OM, Boudewyns AN, Scholman J, Saldien V, Wouters K, Braem MJ, van de Heyning PH, Hamans E (2014) Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases. Laryngoscope 124(3):797–802. https://doi.org/10.1002/lary.24479

  24. 24.

    Koo SK, Choi JW, Myung NS, Lee HJ, Kim YJ, Kim YJ (2013) Analysis of obstruction site in obstructive sleep apnea syndrome patients by drug induced sleep endoscopy. Am J Otolaryngol 34(6):626–630. https://doi.org/10.1016/j.amjoto.2013.07.013

  25. 25.

    Lan MC, Liu SY, Lan MY, Modi R, Capasso R (2015) Lateral pharyngeal wall collapse associated with hypoxemia in obstructive sleep apnea. Laryngoscope 125(10):2408–2412. https://doi.org/10.1002/lary.25126

  26. 26.

    Ciscar MA, Juan G, Martinez V, Ramon M, Lloret T, Minguez J, Armengot M, Marin J, Basterra J (2001) Magnetic resonance imaging of the pharynx in OSA patients and healthy subjects. Eur Respir J 17(1):79–86. https://doi.org/10.1183/09031936.01.17100790

  27. 27.

    Schwab RJ, Pack AI, Gupta KB, Metzger LJ, Oh E, Getsy JE, Hoffman EA, Gefter WB (1996) Upper airway and soft tissue structural changes induced by CPAP in normal subjects. Am J Respir Crit Care Med 154(4):1106–1116. https://doi.org/10.1164/ajrccm.154.4.8887615

  28. 28.

    Kezirian EJ, White DP, Malhotra A, Ma W, McCulloch CE, Goldberg AN (2010) Interrater reliability of drug-induced sleep endoscopy. Arch Otolaryngol—Head & neck Surg 136(4):393–397. https://doi.org/10.1001/archoto.2010.26

  29. 29.

    Ravesloot MJ, de Vries N (2011) One hundred consecutive patients undergoing drug-induced sleep endoscopy: results and evaluation. Laryngoscope 121(12):2710–2716. https://doi.org/10.1002/lary.22369

  30. 30.

    Rabelo FA, Kupper DS, Sander HH, Fernandes RM, Valera FC (2013) Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep disorders and controls. Laryngoscope 123(9):2300–2305. https://doi.org/10.1002/lary.23664

  31. 31.

    Yoon BW, Hong JM, Hong SL, Koo SK, Roh HJ, Cho KS (2016) A comparison of dexmedetomidine versus propofol during drug-induced sleep endoscopy in sleep apnea patients. Laryngoscope 126(3):763–767. https://doi.org/10.1002/lary.25801

Download references


This study was funded by Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (grant number TCRD-TPE-106-28).

The sponsor had no role in the design or conduct of this research.

Author information

Correspondence to Mei-Chen Yang.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lan, M., Hsu, Y., Lan, M. et al. The predictive value of drug-induced sleep endoscopy for CPAP titration in OSA patients. Sleep Breath 22, 949–954 (2018). https://doi.org/10.1007/s11325-017-1600-8

Download citation


  • Obstructive sleep apnea
  • Continuous positive airway pressure
  • Drug-induced sleep endoscopy
  • Polysomnography
  • Apnea-hypopnea index