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The Quest for a DISE Protocol
Kristin L Mooney1, Melissa Brooks Peterson2,3, Jonathan R Skirko4
1Department of Surgery, Children's Hospital Colorado, Broomfield, Colorado, USA.
Insights
A refined drug-induced sleep endoscopy (DISE) protocol improved obstructive sleep apnea diagnosis in children. The modified protocol enhanced surgeon and anesthesiologist satisfaction and patient comfort during the procedure.
Area of Science:
- Otolaryngology
- Pediatric Sleep Medicine
- Anesthesiology
Background:
- Obstructive sleep apnea (OSA) is a common condition in children.
- Drug-induced sleep endoscopy (DISE) is a crucial diagnostic tool for OSA.
- Existing DISE protocols can be lengthy and cause patient discomfort.
Purpose of the Study:
- To modify the institutional drug-induced sleep endoscopy (DISE) protocol.
- To improve the ability to determine obstructive breathing patterns.
- To minimize discomfort for pediatric patients undergoing DISE.
Main Methods:
- A quality improvement initiative using the plan-do-study-act (PDSA) methodology.
- Study conducted at a tertiary children's hospital.
- Involved 81 children with polysomnogram-documented OSA undergoing DISE.
Main Results:
- The DISE protocol was streamlined from 14 to 9 steps after 4 PDSA cycles.
- Significant improvements were noted in all aspects of the DISE procedure.
- Excellent median ratings (1) were achieved for IV placement, scope insertion, and overall satisfaction (P < .01).
Conclusions:
- A modified DISE protocol, incorporating nasal premedication and inhalational volatile gases, enhances procedural efficiency and patient tolerance.
- This optimized protocol allows for predictable sedation, facilitating accurate diagnosis of obstructive breathing patterns.
- The streamlined DISE approach aids otolaryngologists in developing effective OSA treatment plans for children.
Objective:
The objective of this quality initiative project was to modify our existing institutional drug-induced sleep endoscopy (DISE) protocol so that the surgeon could consistently determine obstructive breathing patterns while minimizing children's discomfort.
Methods:
A quality initiative study utilizing the well-described plan-do-study-act (PDSA) process was conducted at a tertiary hospital for children with polysomnogram-documented obstructive sleep apnea who were undergoing DISE. A 4-point Likert measurement tool was created. Change in each Likert rating with subsequent PDSA cycle was tested with the Wilcoxon rank sum test (Mann-Whitney), and change across all PDSA cycles was tested with the Kruskal-Wallis equality-of-populations rank test.
Results:
After a series of 4 PDSA cycles with 81 children, the DISE protocol was streamlined from 14 to 9 steps. There was significant improvement for all aspects of the DISE, with a final overall median rating of 1 (excellent) for intravenous (IV) placement, scope insertion, and anesthesiologist and surgeon satisfaction (P < .01).
Discussion:
For sleep surgeons, DISE is quickly becoming what bronchoscopy is to the airway surgeon. Utilizing inhalational agents to obtain IV access and insert the flexible scope in the rapid "on-off" fashion optimizes DISE success regardless of the primary sedation medication and allows ample time for these agents to dissipate.
Implications For Practice:
Adoption of a DISE protocol that includes nasal premedication and inhalational volatile gases for IV and scope insertion at the onset provides a more predictable level of sedation that is well tolerated by the patient, enabling the otolaryngologist to create an obstructive sleep apnea treatment plan.
