Standardized framework to report on the role of sleeping position in sleep apnea patients.

PURPOSE: Sleep apnea is a multifactorial illness which can be differentiated in various physiological phenotypes as a result of both anatomical and non-anatomical contributors (e.g., low respiratory arousal threshold, high loop gain). In addition, the frequency and duration of apneas, in the majority of patients with OSA, are influenced by sleeping position. Differences in characteristics between non-positional patients (NPP) and positional patients (PP) suggest another crucial phenotype distinction, a clinical phenotype focusing on the role of sleeping position on sleep apnea. Since this clinical phenotype distinction has therapeutic implications, further research is necessary to better understand the pathophysiology behind this phenotypic trait and to improve management of PP. Therefore, we suggest a standardized framework that emphasizes the role of sleeping position when reporting clinical and research data on sleep apnea. METHODS: We identified 5 key topics whereby a standardized framework to report on the role of sleeping position would be of added value: (1) sleep study data, (2) anatomical, morphological and physiological factors, (3) drug-induced sleep endoscopy (DISE) findings, (4) sleep apnea management, and (5) effectiveness versus efficacy of positional therapy in sleep apnea management. We performed a literature search to identify evidence to describe and support the rationale behind these 5 main recommendations. RESULTS: In this paper, we present the rationale behind this construct and present specific recommendations such as reporting sleep study indices (disease severity) and sleep time spent in various sleeping positions. The same is suggested for DISE findings and effect of treatment. Sleep study indices (disease severity), anatomical, morphological, and physiological factors in sleep apnea patients should be reported separately for PP and NPP. CONCLUSION: Applying these suggestions in future research will improve patient care, assist in better understanding of this dominant phenotype, and will enhance accurate comparisons across studies and future investigations.

Diagnosis and treatment of isolated snoring-open questions and areas for future research.

STUDY OBJECTIVES: Snoring is a common phenomenon which is generated by vibration of soft tissue of the upper airway during sleep. Due to the high incidence of isolated snoring and the substantial burden for the patient and the bed partner, a thorough examination and appropriate therapy are required. Many recommendations for the treatment of isolated snoring are either not evidence-based or are derived from recommendations for the management of obstructive sleep apnea. Therefore, the aim of this study is the identification and description of open questions in the diagnosis and treatment of isolated snoring and the illustration of areas for further research. METHODS: In the context of the development of the new version of the German guideline "Diagnosis and treatment of isolated snoring in adults," a multidisciplinary team of experts performed a systematic literature search on the relevant medical data and rated the current evidence regarding the key diagnostic and therapeutic measures for snoring. RESULTS: The systematic literature review identified 2293 articles. As a major inclusion criterion, only studies on primary snoring based on objective sleep medical assessment were selected. After screening and evaluation, 33 full-text articles remained for further analysis. Based on these articles, open questions and areas for future research were identified for this review. CONCLUSION: Several major gaps in the literature on the diagnosis and treatment of isolated snoring were identified. For the majority of diagnostic and therapeutic measures for snoring, high-level scientific evidence is still lacking.

Patient-reported outcome: results of the multicenter German post-market study.

PURPOSE: Upper airway stimulation (UAS) is an alternative second-line treatment option for patients with obstructive sleep apnea (OSA). In our substudy of a previous multicentre study of patients implanted with UAS, we focused on patient-related outcomes like Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire (FOSQ), snoring and personal satisfaction 6 and 12 months after the implantation. METHODS: 60 patients, who were initially non-adherent to CPAP and implanted with UAS, were included in a prospective multicentre study. Data were collected preoperative, 6 and 12 months after implantation regarding FOSQ, ESS, snoring, and their experience with the UAS device. RESULTS: Besides relevant Apnoea-Hypopnea Index (AHI) reduction, we saw significant improvements in ESS (p < 0.001), FOSQ (p < 0.001) and snoring under UAS therapy. A strong correlation between AHI results postoperative and the personal satisfaction of the patients after implantation was found as well as between usage results and AHI compared to the preoperative results. CONCLUSION: The more the patients benefit from UAS according to their self-reported outcome, the higher is the therapy use.

[Treatment of supine position-related obstructive sleep apnea with smartphone applications]. / Therapie rückenlagebezogener obstruktiver Schlafapnoe mittels Smartphone-App.

BACKGROUND: Positional obstructive sleep apnea (POSA) is common in mild and moderate forms of obstructive sleep apnea (OSA). Two smartphone applications (apps) professing to avoid the supine position (SP) are available: for Android the "Apnea Sleep Position Trainer" and for iOS the "SomnoPose-Sleep Position Monitor". The smartphone needs to be attached to the chest to recognize SP, which then triggers a vibration alarm. This is intended to encourage the patient to change position and the vibration stops as soon as SP is left. These apps, however, have not yet undergone a systematic evaluation. METHODS: Adult patients with polysomnographically diagnosed POSA were invited to participate in the study. POSA was defined as an apnea-hypopnea index (AHI) in SP >10, with AHI in a lateral position <10 and doubling of the AHI in SP. After 1 month, a control polysomnography (PSG) was performed and compliance (at least 4 h/night on 5 of 7 days) was evaluated after 6 months by phone. A sufficient therapy was defined as reduction in SP to <10% of the total sleep time and to an overall AHI <10. RESULTS: Although 57 patients entered the study, 24 did not appear to the PSG control; therefore, 33 patients finished the study, of whom 25 were treated successfully. The overall AHI in 33 patients was reduced from 14.5 ± 9.0 to 9.5 ± 12.6 and the time in SP decreased significantly from 71.1 ± 50.5 to 25.4 ± 65.0 min. Compliance among the 25 continuously treated patients after 6 months was 79.2%. CONCLUSION: Both smartphone apps have the capability to prevent PS in POSA patients and can potentially offer a cost-effective option in the treatment of POSA.

[Drug-induced sedation endoscopy-quo vadis? : Review and outlook]. / Medikamentös induzierte Schlafendoskopie ­ quo vadis? : Bestandsaufnahme und Ausblick.

BACKGROUND: Drug-induced sedation endoscopy (DISE) is a diagnostic procedure which allows evaluation of the collapsibility of the upper airway. According to expert opinion, it is possible to imitate nocturnal collapsibility and perform a realistic investigation of the site of obstruction and vibration. This should enable sufficient and precise therapeutic advice to be given solely on the basis of clinical assessment. OBJECTIVE: The current publication critically evaluates the present state of development of DISE and its potential indications. MATERIALS AND METHODS: A PubMed literature research was performed using "sleep" and "endoscopy" or "DISE" as keywords. Relevant publications were evaluated. RESULTS: The present publication provides a historical summary of the available publications and relates these to other methods for examining obstructive sleep apnea. The present state of DISE in terms of drugs applied, grading systems, and validity is evaluated. Indications for DISE are described and critically discussed on the basis of literature data. CONCLUSION: DISE provides deep insights into the genesis of obstructions of the upper airway and snoring. Although its value for diagnosis and treatment of sleep-disordered breathing could not yet be demonstrated for all non-CPAP (continuous positive airway pressure) therapies, DISE could identify predictive parameters some methods. Further potential indications for DISE might be predictive examinations for mandibular advancement devices and respiration-synchronous neurostimulation of the hypoglossal nerve. DISE will thus remain a valuable diagnostic tool for obstructive sleep apnea and rhonchopathy.

Recent developments in the diagnosis and treatment of obstructive sleep apnea : English version.

Over the past few years, the diagnostic tools and therapeutic approaches for obstructive sleep apnea (OSA) have evolved further. Based on a review of the current literature and the personal experiences of the authors, the most relevant developments are summarized in this article and discussed with regard to their impact on the clinical management of the disease. In the third edition of the International Classification of Sleep Disorders, the classification of sleep-disordered breathing was modified. Notably, additional clinical criteria for the diagnosis of OSA were established and out-of-center sleep testing was introduced as an alternative to polysomnography. Recent technical advancements in diagnostic tools (e. g., peripheral arterial tonometry and pulse wave analysis) have further expanded the diagnostic possibilities. Drug-induced sleep endoscopy allows for a reliable assessment of the level and degree of upper airway obstruction. Whether this gain in diagnostic information leads to an improvement in surgical outcome is, however, still being discussed. The relevance of positional OSA has received increasing attention - the subgroup of patients in whom sleeping position significantly impacts their disease is reported to be above 50 %. For these patients, the introduction of the sleep position trainer offers a new therapeutic option. Further, hypoglossal nerve stimulation (upper airway stimulation) has substantially expanded the surgical spectrum for the treatment of OSA. In regard to the established surgical treatment options, randomized trials with superior methodology have been published, especially for bimaxillary advancement and tonsillectomy with uvulopalatopharyngoplasty. These developments are of particular interest for the otolaryngologist and will influence daily practice.

[Pathophysiology, diagnosis and treatment of Zenker's diverticulum]. / Pathophysiologie, Diagnose und Therapie des Zenker-Divertikels.

Zenker's diverticulum occurs at the dorsal pharyngoesophageal junction through Killian's dehiscence and is caused by increased intrabolus pressure. Symptomatic disease most frequently affects male elderly patients. Primary symptom is oropharyngeal dysphagia, as well as regurgitation of undigested food, halitosis, and chronic aspiration. A barium swallow study is performed to confirm diagnosis. Treatment options for symptomatic patients include open surgery, as well as transoral rigid or flexible endoscopic procedures. Transoral procedures have become the main treatment approach over the past year thanks to reduced intraoperative complication rates compared to open surgery. The septum dividing the diverticulum from the esophagus is most commonly divided by a stapler device, papillotome, or laser. For high-risk patients who are poor candidates for general anesthesia, the procedure can be performed via flexible endoscopy in awake patients, albeit at an increased risk of recurrence.

ENT-specific therapy of obstructive sleep apnoea in adults : A revised version of the previously published German S2e guideline.

The German Society of Otorhinolaryngology, Head and Neck Surgery recently has released the abbreviated version of its scientific guideline "ENT-specific therapy of obstructive sleep apnoea (OSA) in adults", which has been updated in 2015 and can be found online at the Association of the Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). A summary of the main recommendations is provided in this revised English version. All recommendations are based on a systematic literature research of articles published up until March 2014. Literature research followed the Cochrane Handbook for Systematic Literature Research to create Guidelines published by the German Cochrane Centre. Studies were evaluated with respect to their scientific value according to the recommendations of the Oxford Centre for Evidence-based Medicine, and grades of recommendation are provided regarding each intervention.

[S2e-guideline: "ENT-specific therapy of obstructive sleep apnea in adults" short version : Sleep Medicine Task Force of the German Society for Otorhinolaryngology, Head and Neck Surgery]. / Leitlinie: "HNO-spezifische Therapie der obstruktiven Schlafapnoe bei Erwachsenen" Kurzfassung : ArGe Schlafmedizin der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie.

The present S2e-guideline is an update of the former S2e-guideline "treatment of obstructive sleep apnea in adults". The update was performed on behalf of the German Society for Otorhinolaryngology, Head and Neck Surgery by its Sleep Medicine Task Force. The long version of the guideline is valid from 5.9.2015 to 5.9.2020 and has been available (guideline No. 017-069) since November 2015 on the official AWMF website.The subsequently presented short version of the guideline summarizes the essentials in a legible way. For further information, please refer to the long version.

[Recent developments in the diagnosis and treatment of obstructive sleep apnea]. / Aktuelle Aspekte in der Diagnostik und Therapie der obstruktiven Schlafapnoe.

Over the past years, the diagnostic tools and therapeutic approaches for obstructive sleep apnea (OSA) have further evolved. Based on a review of current literature and the personal experiences of the authors, the most relevant developments are summarized in this article and discussed with regard to their impact on the clinical management of this disease. In the third edition of the "International Classification of Sleep Disorders", the classification of sleep-disordered breathing was modified. Notably, additional clinical criteria for the diagnosis of OSA were established and out-of-center sleep testing was introduced as an alternative to polysomnography. Recent technical advancement of new diagnostic tools (e.g., peripheral arterial tonometry and pulse wave analysis) has further expanded the diagnostic possibilities. Drug-induced sleep endoscopy enables reliable assessment of the level and degree of upper airway obstruction. Whether this gain in diagnostic information leads to an improvement in surgical outcome is, however, still under discussion. The relevance of positional OSA has received increasing attention-the proportion of patients in whom sleeping position significantly impacts disease is reported to be above 50%. For these patients, the introduction of the sleep position trainer has made a new therapeutic option available. Furthermore, hypoglossal nerve stimulation (upper airway stimulation) has substantially expanded the surgical spectrum of OSA treatment. For the established surgical treatment options, randomized trials with superior methodology have been published, particularly for bimaxillary advancement and tonsillectomy with uvulopalatopharyngoplasty. These developments are of particular interest for the otolaryngologist and will influence daily practice.

Functional outcome of tongue motions with selective hypoglossal nerve stimulation in patients with obstructive sleep apnea.

BACKGROUND: Selective upper airway stimulation of the hypoglossal nerve is a novel therapy option for obstructive sleep apnea. Different tongue motions were observed after surgery during active therapy. METHODS: We examined tongue motions in 14 patients (mean age 51 ± 10 years) who received an implantation of an upper airway stimulation system (Inspire Medical Systems) from September 2013 to February 2014 in three different implantation centers in Germany after surgery. Sleep recording was performed preoperatively: 2 months (M02) and 6 months (M06) after surgery. RESULTS: There were three different tongue motions observed after surgery at 1 month (M01), M02, and M06 after surgery: bilateral protrusion (BP), right protrusion (RP), and mixed activation (MA). At M01: 10 BP, 2 RP, and 2 MA; at M02: 12 BP, 0 RP, and 2 MA; and at M06: 12 BP, 0 RP, and 2 MA could be detected. The average apnea-hypopnea index (AHI) was reduced from 32.5 ± 14.2/h before surgery to 17.9 ± 23.3/h at M02 and 14.1 ± 19.8/h at M06. An increased reduction in AHI was found in BP and RP group (Baseline: 29.6 ± 12.6/h; M02: 12.06 ± 14.1/h; M06: 9.7 ± 12.6/h) compared to the MA group (Baseline 49.6 ± 13.8/h; M02: 49.7 ± 5.1/h; M06: 40.5 ± 4.1/h). CONCLUSIONS: These findings suggest that the postoperative tongue motions in upper airway stimulation are associated with the therapy outcome. The stimulation electrode placement on the hypoglossal nerve for selective muscle recruitment may play a role in the mechanism of action.

[Upper airway stimulation in obstructive sleep apnea]. / Stellungnahme der Taskforce "Neurostimulation bei Schlafapnoe" zur Stimulation der oberen Atemwege.

The stimulation of the upper airway represents an effective treatment option in case of CPAP failure in patients with moderate to severe obstructive sleep apnea. The stimulation with respiratory sensing (Inspire Medical Systems) has shown a high level of evidence in larger cohorts and longer follow-up studies. Whether the results of the stimulation without respiratory sensing (ImThera Medical) can be compared with the therapy with sensing, remains open up to now. Additional data are awaited after the planned phase III study THN#2. To optimize both procedure and to provide long term results, more studies are needed. The workgroup "sleep medicine" of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery supports theses activities with the help of the newly founded task force "Neurostimulation in Sleep Apnea".

[Sk2 guidelines"diagnosis and therapy of snoring in adults" : compiled by the sleep medicine working group of the German Society of Otorhinolaryngology, Head and Neck Surgery]. / S2k-Leitlinie "Diagnostik und Therapie des Schnarchens des Erwachsenen" : Vorgelegt von der Arbeitsgemeinschaft Schlafmedizin der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V.

These guidelines aim to facilitate high quality medical care of adults with snoring problems. The guidelines were devised for application in both in- and outpatient environments and are directed primarily at all those concerned with the diagnosis and therapy of snoring. According to the AWMF three-level concept, these represent S2k guidelines.A satisfactory definition of snoring does not currently exist. Snoring is the result of vibration of soft tissue structures in narrow regions of the upper airway during breathing while asleep. Ultimately, these vibrations are caused by the sleep-associated decrease in muscle tone in the area of the upper airway dilator muscles. A multitude of risk factors for snoring have been described and its occurrence is multifactorial. Data relating to the frequency of snoring vary widely, depending on the way in which the data are collected. Snoring is usually observed in middle-aged individuals and affected males predominate. Clinical diagnosis of snoring should comprise a free evaluation of the patient's medical history. Where possible this should also involve their bed partner and the case history can be complimented by questionnaires. To determine the airflow relevant structures, a clinical examination of the nose should be performed. This examination may also include nasal endoscopy. Examination of the oropharynx is particularly important and should be performed. The larynx and the hypopharynx should be examined. The size of the tongue and the condition of the mucous membranes should be recorded as part of the oral cavity examination, as should the results of a dental assessment. Facial skeleton morphology should be assessed for orientation purposes. Technical examinations may be advisable in individual cases. In the instance of suspected sleep-related breathing disorders, relevant comorbidities or where treatment for snoring has been requested, an objective sleep medicine examination should be performed. Snoring is not-at least as we currently understand it-a disease associated with a medical threat; therefore there is currently no medical necessity to treat the condition. All overweight patients with snoring problems should strive to lose weight. If snoring is associated with the supine position, positional therapy can be considered. Some cases of snoring can be appropriately treated using an intraoral device. Selected minimally invasive surgical procedures on the soft palate can be recommended to treat snoring, provided that examinations have revealed a suitable anatomy. The choice of technique is determined primarily by the individual anatomy. At an appropriate interval after the commencement or completion a therapeutic measure, a follow-up examination should be conducted to assess the success of the therapy and to aid in the planning of any further treatments.

[Randomized controlled trials in the surgical treatment of obstructive sleep apnea]. / Kontrollierte Studien in der operativen Therapie der obstruktiven Schlafapnoe.

The need for surgical treatment alternatives for obstructive sleep apnea is unchanged. However, recommendations regarding these treatments can often only be given with caution as there are only a limited number of controlled studies available. To perform controlled trials and even more so placebo controlled trials in the field of sleep surgery is challenging, especially in comparison to studies evaluating conservative approaches. Nevertheless, these studies can be carried out also in the field of sleep surgery. In this review we present recent concepts and high-quality surgical trials with innovative study designs. A Medline search revealed 310 studies regarding surgical treatment of sleep apnea. These studies were assessed regarding quality, execution and number of subjects. A total of 12 randomized controlled studies were identified addressing palatal implants, radio-frequency surgery, nasal surgery, maxillomandibular advancement and laser-assisted uvulopalatoplasty (LAUP). Furthermore this review addresses the limitations of surgical studies and the differences compared to trials dealing with conservative approaches. The studies presented in this review demonstrate that high-quality trials regarding surgical treatment of obstructive sleep apnea are feasible and can lead to recommendations with high evidence levels.

Palatal implants in the treatment of obstructive sleep apnea: a randomised, placebo-controlled single-centre trial.

Palatal implants have been used to treat snoring and mild to moderate obstructive sleep apnea (OSA). Two previous controlled trials have published conflicting results regarding the effects of palatal implants on objective outcome measures, although they both could demonstrate superiority over placebo. The aim of the present study was to assess the effects of palatal implants in patients with mild to moderate sleep apnea in a randomised, placebo-controlled trial. Twenty-two patients with mild to moderate OSA (AHI 18 ± 5, BMI 28 ± 3, age 51 ± 13 years) due to palatal obstruction were enrolled in this randomised, double-blind, placebo-controlled trial. Respiratory parameters and sleep efficiency (evaluated by polysomnography), snoring (evaluated by the bed partner), and daytime sleepiness (evaluated by ESS) were assessed before and 90 days after surgery. One patient in each group did not show up for follow-up. The AHI, HI and LSAT showed statistically significant improvement in the treatment group (p < 0.05). Snoring as rated by bed partners also showed statistically significant improvement within the treatment group (p = 0.025). There was no statistical difference when comparing the means of the treatment group with the placebo group. There were no peri- or post-operative complications and no extrusions during the follow-up period. The study supports the idea that palatal implants lead to a reduction in respiratory events in patients with mild to moderate OSA, although a statistically significant superiority of palatal implants over placebo could not be demonstrated in this trial.

Non-CPAP therapies in obstructive sleep apnoea.

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

[Obstructive sleep apnea in children]. / Die kindliche obstruktive Schlafapnoe.

Obstructive sleep apnea (OSA) is a common disease in children. It is defined by the onset of snoring, hypopneas or apneas with impaired sleep and daytime function. Obstruction of the upper airway during sleep is the underlying pathogenetic mechanism. It is caused either by an anatomic obstruction, increased airway collapsibility or both. Normally OSA in children is diagnosed by its typical anamnesis including snoring and exerted breathing patterns. The diagnosis is confirmed in unclear cases using polysomnography. Treatment consists of conservative measures such as weight reduction and--provided appropriate anatomical findings exist--adenotonsillectomy or adenotonsillotomy. Surgery is an effective treatment for OSA in children as proven by numerous studies of high evidence levels.

[S1 guideline on the "diagnosis and treatment of snoring in adults"]. / S1-Leitlinie "Diagnostik und Therapie des Schnarchens des Erwachsenen".

Due to the frequency of this phenomenon and the often considerable distress caused to the affected person, competent advice, diagnosis and treatment of snoring in adults is of particular importance. The aim of this guideline is to promote high-quality medical care for patients affected by this problem. According to the three-level concept of the AWMF, it corresponds to an S1 guideline. Prior to any therapeutic intervention, relevant sleep medical history, clinical examination, as well as a mandatory objective diagnostic measure are performed. Snoring is only treated if the patient asks for it. In general, invasive methods should be viewed critically and the patient should be advised correspondingly. In the case of surgical therapy, minimally invasive techniques are preferred. Reducing body weight (in the case of overweight snorers), abstinence from alcohol, nicotine and sleep medication, as well as maintaining a healthy sleep-wake cycle can be recommended from a sleep-medicine perspective, although convincing clinical studies are not yet available. Since evidence for the effectiveness of muscle stimulation or various methods for toning and training of the muscles of the floor of mouth is not available, these methods are not recommended. Snoring can be successfully treated with the use of an intraoral device; however, careful patient selection is important. Avoiding a supine position during sleep can be helpful in some cases. Only limited data is available on the success rates of the surgical approaches and long term data is often lacking, and not all techniques have been sufficiently evaluated from a scientific point of view. Nasal surgery is only indicated if the patient suffers from nasal obstruction. Extensive data supports the effectiveness of laser-assisted resection of excessive soft palate tissue (laser-assisted uvuloplasty, LAUP). In principle, however, such resections can be performed using other techniques. Placebo-controlled studies were able to prove the effectiveness of radiofrequency surgery of the soft palate. A reduction in snoring could also be achieved in many cases by means of soft palate implants with minimal post-operative morbidity. The indication for tonsillectomy and uvulopalatopharyngoplasty should be made cautiously due to the comparatively high morbidity associated with these procedures.

[Endoscopy in sleep medicine]. / Endoskopie in der Schlafmedizin.

Endoscopic evaluation of the upper airway in patients with sleep disordered breathing (SDB) using rigid and flexible endoscopes is a typical investigation in otorhinolaryngology. Visualizing the anatomic structure as well as the dynamic mechanism of snoring and pharyngeal obstruction during wakefulness, natural sleep, and under sedation are of special interest. The results obtained have increased our understanding of SDB with obstruction of the upper airway. Videoendoscopy under sedation (ViSe) has become increasingly established as a tool to identify the therapeutic concept in cases of CPAP failure, leading to changes compared to the concept derived from basic awake endoscopy. The success of mandibular advancement devices can be adequately predicted. However, it remains unclear to what extent the success rate of surgery can be improved by ViSe. Further research into these approaches is needed in order to become valuable tools in the diagnostic work-up of patients with sleep apnea.