Inspire Therapy | Implantable Neurostimulator for Obstructive Sleep Apnea

Procedure: Insertion of Inspire Neurostimulator with Nerve Integrity Monitoring

Indication: Obstructive Sleep Apnea

What is Inspire Therapy?

This is a newer device that has been around for 2-3 years that has been introduced to allow people who suffer from obstructive sleep apnea (OSA) to sleep mask-free, without a CPAP machine. This procedure consists of a small implantable device that is placed in your chest wall that has ‘wires” that get connected to the hypoglossal nerve (CN XII) in your neck. The implant is turned on prior to bedtime with a remote and has special settings to turn off after your ‘normal’ sleeping time + an hour or so for good measure. This implant works to deliver pulses that help move your tongue away from the back of your throat to prevent obstruction of the airway (which results in poor sleep quality). Read more about the Inspire implant here.

Nurse’s Set Up for Inspire Implant

Setting up for an inspire implant insertion is pretty similar to setting up for a Thyroidectomy. You will need the NIM machine (a machine that monitors nerves intraoperatively), cautery machine, harmonic, headlight and suction.

Prep Stand Set Up

1% lidocaine with epinephrine 1:100,000, sponges, alcohol wipes, 2 3ml syringes with 27g hypodermic needles, tissue forceps with teeth (longer preferred), gloves for surgeon and RN, NIM electrodes (blue and red placed under tongue by surgeon), green placed by RN, white/red not used, but I never throw off until after all are placed.

The RN should assist the surgeon when injecting the local anesthetic and electrodes. The syringes should be refilled as they are used, and dependent on patients anatomy, you will likely need to hold the lower lip and chin when the surgeon places the electrodes under the tongue.

NIM Machine

The Inspire representative with the help of the Medtronic representative should have created a profile on the NIM machine specifically for Inspire implant insertion. Select this profile, then neck dissection, then you will see this screen. This screen depicts that a NIM endotracheal (ET) tube would be used, however that is not the case. The surgeon will place the red and blue electrodes (pictured above) under the tongue. They will be placed in the red and blue slots on the remote. The remote is housed in the back of the machine and should be removed and placed on a rail of the bed, usually the head of the bed, and secured with a velcro strap (as tempting as tape is- DON’T use it!). The green (grounding) electrode will be placed over the shoulder and plugged into the green slot on the remote. Once the red x’s turn to green check marks advance the screen to monitoring. After draping, the surgical tech will throw off the electrodes for the stimulating bipolar which will be plugged into the “Stim 1” slots according to color. Frequency and volume can be adjusted on the next screen under the direction of the surgeon.

Surgical Tech Set Up for Inspire Implant

There are only a few minor differences from a thyroidectomy set up for the surgical tech. These differences are the addition of a 1010 drape (a clear drape with a sticky edge) Ioban, an angiocath for delicate irrigation when attaching the stimulator to the nerve, and the stimulating bipolar forceps. Why the 1010? This drape will be placed at the jawline and laid over the face to allow visualization of the mouth. This will allow the surgeon and rep to see the tongue protruding when the implant is being tested to ensure it is placed appropriately.

Procedural Steps

The surgeon will begin by identifying the hypoglossal nerve and creating a space where the stimulator will be attached. Then a pocket will be created for the implant itself in the chest wall- the surgeon I work with places them on the right side unless there is something anatomical or a patient preference indicating a need to place it in the left chest. The wires from the implant will be tunneled from the neck to the chest with a tunneler that is made for this procedure. (Tunneling anything gives me the creeps- I do not like this part!) After tunneling and attaching the stimulator to the nerves, the rep will give the surgical tech a pad that will be draped with an ultrasound probe cover and then it will be laid over the implant. The rep has a tablet which is connected and will send test pulses to the implant- this is where the tongue needs to be visualized to ensure that the tongue protrudes as it should with this stimulus. Once satisfied, the surgeon will secure the implant and start closing.

Room Set Up for Inspire Implant

KB= kick bucket