Obstructive sleep apnea refractory to treatment due to floppy epiglottis.

The standard treatment of obstructive sleep apnea–hypopnea syndrome (OSAHS) is nasal continuous positive airway pressure (CPAP), but 17% of patients do not respond to this intervention.1 Drug induced sleep endoscopy (DISE) is a technique used to evaluate the site of obstruction in the airway of OSAHS patients when planning surgery. We present the case of a 69-year-old patient with severe OSAHS (apnea–hypopnea index: 38.2 h), who began treatment with automatic positive airway pressure (autoPAP). Despite treatment compliance, correction of leaks, abstinence from alcohol and change to bilevel ventilation, obstructive respiratory events persisted, so DISE was performed. During induced sleep with spontaneous breathing, 75% airway obstruction by the soft palate was identified. When IPAP at 18 cmH2O was applied, a floppy epiglottis was observed that completely occluded the airway. The patient began a weight loss program and has joined a respiratory rehabilitation group. He has discontinued bilevel ventilatory support and returned to autoPAP. Weight loss was 11.4% and obstructive events have been corrected: respiratory disturbance index of 3.4 was determined by polysomnography. DISE performed under spontaneous breathing and PAP has proved useful in the evaluation of patients with treatmentrefractory OSAHS, since physiopathological factors inherent to