Proposed GLOSSARY: Different sedative agents: Midazolam (M); Propofol (P) Different degrees of sedation (Minimal, Moderate, Deep) Proposal:
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1 SNORING & OSAHS SURGERY International Workshop Sleep Endoscopy > 15 min
2 Filippo Montevecchi M.D. Department of Special Surgery Head & Neck Surgery, Oral Surgery Unit (Head: C.Vicini) G.B. Morgagni L.Pierantoni Hospital ASL of Forlì ITALY University of Pavia School of Medicine ENT Clinic Ronchopathy Surgery Course University of Parma School of Medicine Maxillo-Facial Clinic SDB Surgery Course AIMS Board & ENT-Maxillo Maxillo-Facial Joint Commission Proposed GLOSSARY: Spontaneous Sleep (SS) vs Drug induced Sedation (DiS) Different sedative agents: Midazolam (M); Propofol (P) Different degrees of sedation (Minimal, Moderate, Deep) Proposal: 1. SPONTANEOUS SLEEP ENDOSCOPY (SSE) 2. PROPOFOL induced DEEP SEDATION ENDOSCOPY (PDSE) 3. MIDAZOLAM induced DEEP SEDATION ENDOSCOPY (MDSE)
3 Sleep Endoscopy: Why? Awake Endoscopy -pitfalls if and limits: i the [awake] findings may differ quite dramatically from the sleep-breathing situation Pringle & Croft, 1991 the Mueller maneuver did not discriminate patients groups Woodson & Wooten, 1994 the information obtained is inaccurate and could lead to inappropriate surgery Skatved, 1993
4 Sleep Endoscopy: How? IDEAL Sleep Endoscopy Natural Sleep ( no drug effects!) Both REM & non REM sleep phases included Not disturbing Endoscope (no arousal!) Flexible Endoscope (minimal mechanical bias!) High Resolution Endoscope ( sensitivity!) Digital Endoscope ( UAWs sections calculation ) Easily Reproducible Quick & Easy Not expensive
5 SE: spontaneous vs induced SPONTANEOUS Difficoult falling asleep (except for cases with EDS) INDUCED Easy falling asleep (indipendently from EDS) Possible failure Low compliance Longer time More expensive Physiological No Drug impact Probable success Shorter duration Well tolerated Less expensive Less physiological Drug impact Sleeping doctor after a night of spontaneous sleep endoscopy
6 Focusing on Drug induced d Deep Sedation Endoscopy General Overview Ideal Drug for DiDSE ( Maurer, 2006) Short half-life Antidote available if required Suitable for i.v. administration i ti Minimal impact on breathing drive & muscle tone No anaesthesiologist required
7 Drug Administration modalities mechanical manual target controlled
8 PROPOFOL repeated bolus technique serum concentration mg infusion 1 mg/kg (es.: 75 mg) time T.C.I. Target Controlled Infusion ( Roblin & Coll.,2001) Developed in 1996 Propofol based Age & weight required Pharmacocinetic modeling Desired concentration ti pre defined d and adapted Calculation of absoption, distribution and escretion rate Required infusion rate adapted along the 2 μg/ml 4 μg/ml time Reproducible sedation narrow window (standardization) di ti Sedation closer to spontaneous sleep (?)
9 DEPTH of SEDATION MONITORING O Basic Setting Advanced Setting Videoendoscopy findings po2 (anesthesiology) Videoendoscopy findings po2 (anesthesiology) PSG - EEG - po2 - EOG BIS S Endo findings
10 po2 in anaesthesia monitor ongoing PSG monitoring & registration
11 Patient with PSG PSG Screen
12 BIS ANALOGICAL ENDOSCOPY
13 DIGITAL ENDOSCOPY Sleep Endoscopy Findings : Classification Parameters Sites & Subsites (Staging) Vibration vs Collapse (Mechanics) Collapse Degree (Grading) Collapse Shaping (Pattern)
14 NOHL Classification Sistem according Vicini & Mira, 2007 Four Anatomical Levels are recognised and named as: 1. Nasopharynx (N) 2. Oropharynx, Retropalate (O) 3. Hypopharynx, Retrolingual (H) 4. Laryngeal Supraglottic (a) & Glottic (b)(l) (L) (H) (O) (N) N = Nasopharynx
15 O = Oropharinynx H = Hypopharynx
16 L = Larynx (a = supraglottic) L = Larynx (b = glottic)
17 Pattern Classification Larynx Pharynx I pattern V pattern T pattern O pattern star pattern. pattern ice cream pattern Epiglottis - closing book primary secondary - closing door - pipeline Supraglottis sucking sliding Glottis passive active SLEEP ENDOSCOPY ENT FORLI SETTING
18 Operating Room PROPOFOL induced Deep Sedation Endoscopy adapted from Abdullah & van Hasselt, 2005 One Day Surgery Setting Monitoring: SpO2, ECG, NBP Operating Room facilities propofol CPAP available Topic Xylocaine Digital Pentax Video-NPhL-scope (Ø 3,7 mm) Awake NPhL-scopy + Mueller OR Sleep Endoscopy Propofol +CPAP
19 Sleep Endoscopy Forlì: APPLICATIONS DD Snoring-OSAHS vs Stridor Surgical Failures (residual obstruction/s & snoring) Clinical-Instrumental mismatch Severe OSAHS Clinical Research ( endo-cpap ) Operating Room PROPOFOL induced Deep Sedation Endoscopy PROCEDURE step by step 1. Premedication 2. Patient preparation 3. Patient positioning 4. Local Anaesthesia 5. Sedation 6. Endoscopy 7. Special Maneouvres 8. OR discharge
20 1.Premedication No drug administered Avoid mouth dryness!!! 2.Patient preparation i.v. cannula po2 probe microphone ECG (PSG) (EEG) (BIS) ( )
21 3.Patient Positioning Supine No pillow Dark room or eye covering Quiet room (no noises!) OR Setting
22 Ongoing PSG One works one listens
23 4. Local anaesthesia No spraying of local l anaesthetic ti or vasoconstrictive agents Anaesthetic gel on the scope tip 5.Endoscopy Basic static Awake Endoscopy Dynamic Endoscopy (mueller, jaw lift, phonation)
24 Basic endo setting microphone
25 PROPOFOL repeated bolus technique Digital i.v. drug delivering pump
26 SNORING TARGETING Keep the scope tip in nasopharynx Wait for visible vibration and audible snoring Move the scope and inspect all the levels Don t forget epiglottis and vocal folds Take videos! Summarise the findindgs in a short text including possible treatment options Classify according to NOHL system OSAHS TARGETING Keep the scope tip in nasopharynx Ignore the initial prolonged apnoea phase Wait for repeated respiratory pharyngeal wall collapses Try to remain between previous PSG po2 mean value and nadir (endoscopical window) Keep BIS at index (deep sedation) ( write in final report ) Move the scope and inspect all the levels Try to stay in the centre of the lumen Don t forget epiglottis and vocal folds Take videos Summarise the findindgs in a short text including possible treatment options Classify according to NOHL system
27 STRIDOR TARGETING Keep the scope tip in oropharynx Wait for visible vibration and audible stridor Take videos! Summarise the findindgs in a short text including possible treatment options 6. Special manoeuvres Palate stabilisation (endoscope) Jaw lift Larynx lift Lateral position (?) Tubing g( (?)
28 8.Conclusions
29
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