Role of drug-induced sleep endoscopy in guiding non-CPAP therapy in obstructive sleep apnea

Abstract

Background
Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA), but many patients cannot tolerate it. The present study aimed to evaluate the effectiveness of Drug-Induced Sleep Endoscopy (DISE) in guiding treatment selection between mandibular advancement device (MAD) therapy and upper airway surgery in OSA patients with CPAP refusal.


Methods
This prospective interventional experimental study included 35 adult patients with polysomnography-confirmed OSA who refused CPAP. All patients underwent baseline clinical assessment, questionnaires and full-night polysomnography. DISE was performed using propofol sedation and the VOTE classification system. Mandibular advancement simulation (50–75% protrusion) was applied during DISE to predict MAD responsiveness. Patients were allocated to MAD or surgery accordingly. Follow-up polysomnography (PSG) was conducted 3 months post-intervention.


Results

35 adult patients were included in the study. 15 patients received MAD and 20 underwent surgery. Overall treatment significantly reduced AHI (29.6 ± 7.1 to 8.5 ± 7.2 events/h;
p
 < 0.001), ESS (12.4 ± 2.0 to 2.5 ± 2.2;
p
 < 0.001), and snoring frequency, while improving deep sleep percentage and sleep efficiency (
p
 < 0.001). Complete response (AHI < 5) occurred in 26.6% of MAD patients and 40% of surgical patients. Velum collapse was the most prevalent obstruction site (88.6%), followed by tongue base (51.4%).



Conclusion
DISE-guided therapeutic selection results in significant improvements in respiratory and sleep architecture parameters highlighting the importance of personalized non-CPAP treatment for patients with CPAP refusal. Multilevel upper airway collapse, especially at the level of the velum and the base of the tongue, has been observed.