Positive Pressure Titration During Drug Induced Sleep Endoscopy: Implications for Pediatric Obstructive Sleep Apnea

Introduction: The role of drug-induced sleep endoscopy (DISE) in the management of pediatric obstructive sleep apnea (OSA) is evolving. While DISE in children with severe or persistent OSA often shows multilevel collapse, it is unclear if all observed sites require surgical treatment. We evaluated the feasibility of combining DISE with intraoperative positive airway pressure titration (DISE-PAP) to derive a physiologic measure of airway collapsibility, pharyngeal opening pressure (PhOP), and examine its relationship with OSA severity.

Methods: We performed a pilot case series of 15 OSA children who underwent DISE-PAP. Upper airway collapse at seven sites was graded and summed to an aggregate score. CPAP was titrated under endoscopic visualization, and PhOP was defined as the lowest pressure achieving complete airway patency.

Results: Thirteen of 15 patients had successful titration (12 male; mean age 12.3 years; mean BMI z-score 1.5). Six had Trisomy 21 and seven had a prior adenotonsillectomy. Mean PhOP was 7.4 cm H₂O (range 5–11). Multilevel collapse was common, most often at the velum (n=12), tongue base (n=11), and epiglottis (n=11). Mean preoperative AHI was 18.8 events/hour (range ). PhOP did not correlate with aggregate collapse score (p=0.59) nor AHI (p= 0.75).

Conclusions: DISE-PAP is feasible in complex pediatric OSA patients and provides real-time assessment of airway collapse. The lack of correlation between PhOP, anatomic collapse, and OSA severity suggests pediatric OSA may not be driven by pharyngeal collapsibility alone and the underlying physiology of pediatric OSA is disparate from adult disease. Further study is warranted related to the role of physiologic measures in identifying clinically relevant obstruction and informing surgical decision-making.