What is DISE?

1. To locate the problem. A sleep study shows that breathing is disrupted; DISE shows where: the site, pattern, and degree of airway collapse.
2. To choose among CPAP alternatives. The collapse pattern determines which treatment fits: nasal, palatal, tongue-based, or skeletal.
3. To confirm candidacy. Procedures such as Inspire therapy carry specific inclusion and exclusion criteria that only direct observation can verify.
4. To counsel honestly. Some collapse patterns are known to respond better or worse to a given treatment. Seeing them first means realistic expectations, before surgery rather than after.
5. To explain PAP intolerance. Dr. Liu performs DISE with CPAP in place, a proprietary approach that reveals why a patient cannot tolerate their PAP, rather than assuming the machine simply “doesn’t work for them.”

1. The nasal passages are decongested.
2. Monitors for a sedation procedure are placed.
3. Intravenous access (IV) is established.
4. Slow infusion of medication (i.e. Dexmedetomidine/Precedex and other agents).
5. Nasopharyngoscope passed through one of the nasal passages to evaluate the nasopharynx, oropharynx, and hypopharynx.
6. VOTE classification is used to describe findings.
7. Maneuvers such as head position, body position, chin lift may be performed.
8. Adjunctive exams with and without oral appliance and CPAP may also be performed.
9. Awakened in the sedation room (or operating room), and transferred to recovery.

1. Medical conditions that makes routine sedation unsafe (i.e. high body-mass index, difficult airway, ASA Class 3 or above).
2. Known allergies to the sedation (and their reversal agents).
3. Recent upper airway infection (flu, Covid, persistent cough).

When do I stop eating and drinking prior to procedure?

For a morning start, after midnight the day before. OK for sips of water to take medications. However, exact medications to take (and to hold), need to be established with the surgeon.

When do I know the results of my DISE?

As early as the day after the procedure. While it is possible for results to be shared right away, Dr. Liu frequently finds that right after a sedation procedure, patients may not recall details.

What is recovery like after the procedure?

There should be minimal discomfort in the nose and throat. Some irritation may be expected. Nasal bleeding after DISE is very rare, but can happen.

Can I drive home after my DISE?

No. The exam will not start without a friend or family member present upon checking in.

How well do my DISE findings correlate with my sleep study?

While there are correlations, it is important to note that DISE examines anatomy, while the sleep study reveals physiology. Since both bodies of information are important in decision-making for treatment, Dr. Liu sees the two exams as “complementary.”

In 2015, Dr. Liu wrote a technical piece on DISE intended for professional colleagues. While some nuances have evolved, the process and clinical pearls remain largely the same.

Credit to Dr. Vladimir Nekhendzy.

1. 20g IV.
2. No premedication.
3. No supplemental O2.
4. No Glycopyrrolate unless significant brady or secretions (ask the surgeon).
5. Dex IV bolus 1.5 mcg/kg over 10 min, started immediately on arrival, while the monitors are being applied.
6. Can either bolus through the Alaris pump syringe using the bolus duration, or put the bolus in 100 ml bag and use the 60 drops/min microdripper wide open: takes exactly 8.5–10 min to run in. Fast Dex administration, especially above 1 mcg/kg, may result in transient hypertension, apnea or hypoxemia/hypercapnia.
7. Concomitantly, start Dex at 1.5 mcg/kg/hr, and continue during the procedure. D/c Dex 5 min prior to the end of the exam, or immediately after.
8. No airway supporting maneuvers unless directed by the surgeon; usually with SpO2 in low 80s. Airway support to start with innocuous chin pull (tag on the mentum) or head turn, which is usually sufficient to open the airway.
9. Wheel out of the OR when responds to commands.
10. Postop orders: no meds, except Zofran for possible PONV. Fluid bolus for possible Dex-induced hypotension in PACU. High BP meds as required.

With this technique, the patients should be reliably asleep in 10–15 min, and responding to commands, maintaining the airway within 3–5 min after the end of procedure.