Drug induced sleep endoscopy

[DocMcCoy]

Coming to my shop for ENT that wants to do inspire. New to me and sounds risky. Anybody doing these?

Concerns, or no big deal?

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[nycitygas]

I do a ton of these at a surgery center, very routine and takes 5 minutes. Just a little propofol to get them snoring and then take look with the scope and are done.

 

[ASA6]

No big deal. Turn on propofol, turn it up every minute until the patient is snoring, they stick the scope in the nose for a few minutes, case over. Easier and less stimulation than an egd.

 

[Arch Guillotti]

Coming to my shop for ENT that wants to do inspire. New to me and sounds risky. Anybody doing these?

Concerns, or no big deal?

Piece of cake.

 

[DocMcCoy]

Good to know. That settles that. Thanks for the replies!

 

[cchoukal]

One wrinkle: our surgeon used to want them done on room air. I think it was part of grading how bad their OSA was.

 

[DocMcCoy]

One wrinkle: our surgeon used to want them done on room air. I think it was part of grading how bad their OSA was.

This was the concerning part to me. Only had one guy in our group do the first batch, maybe he was being dramatic about all the plunging desats. On the plus side, I’m told there is a BMI cutoff of like 33?

 

[markneil]

Easy procedure and literally takes 5 minutes. When we also first started to place Inspire it took ENT about 3 hours, now he takes half that or faster.

 

[cchoukal]

This was the concerning part to me. Only had one guy in our group do the first batch, maybe he was being dramatic about all the plunging desats. On the plus side, I’m told there is a BMI cutoff of like 33?

I never found it to be too big a deal. You can see what is happening as they obstruct so you can anticipate desaturation and obviously the surgeon needs to not be a dick about you providing airway maneuvers while they do their exam.

 

[Simba1711]

I haven’t done these either. Do they topicalize the nasal airway ? Seems like it would be less stressful than egd. Less risk of laryngospasm too.the obese egd are my least favorite cases.

 

[kidthor]

I’ve done many of them. Our surgeon wanted them to get glyco preop and the do propofol gtt (no bolus) at escalating doses requested by the surgeon. Importantly they wanted no other drugs (as to not confound the study). Overall it’s an easy case with low risk. I never had any issues, but then the surgeon doing them was also one of the best I’ve ever worked with.

 

[nimbus]

Do they ever do sleep endoscopy after the Inspire has been inserted with the Inspire device activated to see if it actually works?

 

[coffeebythelake]

Do the ENT docs allow u to give supplemental O2??

 

[DocMcCoy]

Do the ENT docs allow u to give supplemental O2??

Per the protocol they have for us here, no.

 

[Robotic Wis-Hipple]

Per the protocol they have for us here, no.

Protocol is no supplemental O2. Which is fine, you just expect a little desat and can mask if needed after scope is out.

The more annoying part is CMS now allows the sleep endoscopy and the Inspire insertion to be done the same OR visit (clearly very high pre-test probability), so now you get to induce a pt that has been the exact opposite of pre-oxygenated.

 

[coffeebythelake]

Protocol is no supplemental O2. Which is fine, you just expect a little desat and can mask if needed after scope is out.

The more annoying part is CMS now allows the sleep endoscopy and the Inspire insertion to be done the same OR visit (clearly very high pre-test probability), so now you get to induce a pt that has been the exact opposite of pre-oxygenated.

I'm curious does supplemental oxygen change the airway collapse?

 

[Pharmado]

These patients are CPAP intolerant, so by leaving them on room air and inducing sleep you are trying to mimic exactly what happened each night when they fall asleep. They obstruct and desaturate. If they didn’t, they wouldn’t be there. The cases are quick and easy, but not intervening when their sats are dropping is annoying. Still, these are some of the quickest and easiest cases you can get.

 

[DocMcCoy]

does the device company have a bmi cutoff?

 

[DocMcCoy]

These patients are CPAP intolerant, so by leaving them on room air and inducing sleep you are trying to mimic exactly what happened each night when they fall asleep. They obstruct and desaturate. If they didn’t, they wouldn’t be there. The cases are quick and easy, but not intervening when their sats are dropping is annoying. Still, these are some of the quickest and easiest cases you can get.

They’ve already presumably had a sleep study, no? So if you know they desat why no 02 if all you should be evaluating is airway collapse?

 

[Robotic Wis-Hipple]

does the device company have a bmi cutoff?

<35

 

[Arch Guillotti]

I haven’t done these either. Do they topicalize the nasal airway ? Seems like it would be less stressful than egd. Less risk of laryngospasm too.the obese egd are my least favorite cases.

Negligible risk of laryngospasm. They are not manipulating the airway.

 

[2Fast2Des]

Sounds like a very productive day unit wise

 

[coffeebythelake]

I'm told by ENT surgeon that their compensation for DISE is pretty terrible

 

[woopedazz]

They’ve already presumably had a sleep study, no? So if you know they desat why no 02 if all you should be evaluating is airway collapse?

I've been told they don't want any flow distorting the anatomy

 

[nimbus]

I've been told they don't want any flow distorting the anatomy

So they can implant more devices 😂

 

[coffeebythelake]

I've been told they don't want any flow distorting the anatomy

This is based on evidence?

 

[woopedazz]

This is based on evidence?

I very much doubt it

 

[coffeebythelake]

I very much doubt it

If it's a choice between jaw thrust and supplemental oxygen I'd think the latter would have much less impact on distorting the anatomy

 

[anesthesiadoc]

They’ve already presumably had a sleep study, no? So if you know they desat why no 02 if all you should be evaluating is airway collapse?

You are 100% correct. I sat through a talk on this a couple of weeks ago and the ENT was quick to admit that it's the wild west with these. Every center going with their own "protocol." You don't need to withhold oxygen (that's what the sleep study is for). This should only be to evaluate dynamic collapse in a person who has already been confirmed to have OSA.

 

[DocMcCoy]

You are 100% correct. I sat through a talk on this a couple of weeks ago and the ENT was quick to admit that it's the wild west with these. Every center going with their own "protocol." You don't need to withhold oxygen (that's what the sleep study is for). This should only be to evaluate dynamic collapse in a person who has already been confirmed to have OSA.

At a minimum, I’m thinking when I’m up, giving some solid pre oxygenation then begrudgingly removing/stopping it immediately prior to propofol.

 

[narcusprince]

Our ENT wants these patients intubated.

 

[coffeebythelake]

Our ENT wants these patients intubated.

Huhhh whut?

 

[pgg]

Our ENT wants these patients intubated.

Wait what? For the DISE?

 

[narcusprince]

Wait what? For the DISE?

For the inspire procedure. Intubated no relaxants.

 

[coffeebythelake]

For the inspire procedure. Intubated no relaxants.

That's step 2.