上气道测压在悬雍垂腭咽成形术后失败患者阻塞定位的应用

目的 应用上气道压力测定法判断悬雍垂腭咽成形术（uvulopalatopharyngoplsaty,UPPP）后失败患者气道阻塞部位。方法 对10例UPPP术后仍有打鼾或白天嗜睡的患者同期行整夜睡眠监测和上气道压力测定,判断其呼吸紊乱程度和气道阻塞部位,分析体位对呼吸紊乱低通气指数(apnea hypopnea index,AHI)的影响。结果 3例为中度,7例为重度阻塞性 呼吸暂停。上气道阻塞部位可分上部（主要为腭后区）和下部（主要为舌后区）,10例均为上部和下部联合阻塞,其中6例以上部,4例以下部阻塞为主。仰卧位呼吸暂停AHI（66.52±22.51）次/h,侧卧位AHI（47.82±21.82）次/h,差异有统计学意义（P=0.017）。结论 上气道压力测定法可较好地判断阻塞性睡眠呼吸暂停低通气综合征患者的气道阻塞部位,多数UPPP术后患者以腭后区阻塞为主,且仰卧位较侧卧位更易引起气道塌陷。     

阻塞性睡眠呼吸暂停综合征患者睡眠状态下阻塞定位研究

目的　应用磁共振成像 (magneticresonanceimaging ,MRI)和纤维鼻咽喉镜对阻塞性睡眠呼吸暂停综合征 (obstructivesleepapneasyndrome,OSAS)患者睡眠状态下上气道的阻塞部位进行定位 ,并探讨上述两种方法对阻塞定位的应用价值。方法　对经多导睡眠监测 (polysomnography ,PSG)确诊的 15例OSAS患者应用超快速MRI在睡眠状态下对其上气道进行了矢状位和轴位扫描动态观察 ,对患者软腭后区 (retropalatalregion ,RP)、舌后区 (retroglossalregion ,RG)和会厌区 (epiglottalregion ,EPG)的上气道阻塞情况进行了观察分析。另外对其中的 8例患者在睡眠状态下进行了纤维鼻咽喉镜检查。结果　MRI检查 15例患者 ,发现仅有RP区阻塞者 3例 ,仅有RG区阻塞者 2例 (均为悬雍型腭咽成形术后患者 ) ,另外 10例患者同时有RP和RG区阻塞。 8例患者进行睡眠状态下纤维鼻咽喉镜检查者 ,除 1例外检查结果与MRI检查相符合。结论　睡眠状态下MRI和纤维鼻咽喉镜检查能够对上呼吸道的阻塞进行定位 ,对确定治疗措施具有一定指导意义。     

内镜检查及上气道压力测定对阻塞性睡眠呼吸暂停低通气综合征患者上气道的评估价值

目的 通过比较清醒时内镜检查及夜间上气道压力测定法在阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者术前上气道评估中的作用,探讨内镜检查对OSAHS上气道评估的临床价值。 方法 对OSAHS患者125例进行内镜检查判断上气道阻塞部位及塌陷方式,同期应用睡眠监测及上气道阻塞定位系统(AG)行整夜的睡眠监测上气道压力测定,对两种检查方法进行比较。 结果 内镜检查示,患者均有腭后区阻塞,舌后区阻塞74例,但塌陷方式不同;比较内镜检查的单纯腭后区阻塞组及腭后区、舌后区多平面阻塞组的AG测量值,下部阻塞低通气指数(AHI)及下部阻塞构成比的差异有统计学意义(P均<0.01)。 结论 内镜检查对于判断上气道阻塞部位及塌陷方式具有一定的临床价值,与AG相结合,指导手术方案的选择。     

阻塞性睡眠呼吸暂停低通气综合征患者上气道极速CT测量

目的：通过极速CT测量阻塞性睡眠呼吸暂停低通气综合征（0SAHS）患者上气道,利用上气道各分区的测量值及顺应性来评估OSAHS患者气道阻塞平面,以期为临床诊治提供帮助。方法：随机选取82例OSAHS患者（OSAHS组）,无打鼾的健康人45例作为正常对照组,应用PHILIPS256层螺旋CT（极速CT）对其进行平静呼吸状态（吸气末）测量,及Mailer动作下鼻咽区、腭后区、舌后区、会厌后区各区最窄平面各径线及各区气道容积的测量。结果：①OSAHS组行平静呼吸与MUller动作时CT扫描,2种状态下鼻咽区左右径、会厌后区前后径及横截面积差异无统计学意义,其余各组参数间有差异,其中腭后区体积、舌后区前后径、舌后区体积有显著性差异。②Mailer动作时,2组会厌后区体积比较差异无统计学意义,鼻咽区左右径、鼻咽区体积、腭后区横截面积、舌后区前后径有差异,其余各组参数间有显著性差异。③2组的气道顺应性（Mailer相）比较,各组参数间均有差异,其中鼻咽区前后径、腭后区体积有显著性差异。同时,同一平面内,OSAHS组与正常对照组的左右径均大于前后径。④对阻塞平面的预测,咽腔容积测量与纤维内镜检查结果基本相符。结论：用极速CT测量OSAHS患者上气道,阻塞平面多位于腭后区及舌后区。上气道容积的CT测量可用于OSAHS患者上气道阻塞平面的评估。     

上气道测压阻塞定位在阻塞性睡眠呼吸暂停低通气综合征外科治疗中的应用

目的 通过分析上气道测压阻塞定位指导的中、重度阻塞性睡眠呼吸暂停低通气综合征(OSAHS)外科随诊疗效,了解上气道测压阻塞定位的临床应用价值.方法 对51例中、重度OSAHS患者应用睡眠呼吸监测阻塞定位仪(ApneaGraph,AG)进行整夜睡眠呼吸监测和同步上气道压力测定.根据阻塞层面,分成2组.腭后区阻塞组:以上部阻塞为主,行腭后区手术;舌后区阻塞组:最低阻塞层面以下部为主,结合纤维喉镜观察阻塞结构,行腭部及不同的舌后区联合手术.以上两组患者,有鼻塞症状的,均同期行鼻部手术.术后6个月再次应用AG随访,评估手术疗效.结果 51例患者中,中度5例,重度46例,其中4例为UPPP失败再手术者.术后随访时间6～24个月,中位数为9个月.Epworth嗜睡评分(ESS)由术前(17.6±4.7)分((-x)±s,下同)降至(4.3±4.3)分(t=15.195,P<0.001),呼吸暂停低通气指数(AHI)由(52.4±17.5)次/h降至(16.3±18.2)次/h(t=10.873,P<0.001),最低血氧饱和度(LSaO2)由0.706±0.099提高至0.823±0.092(t=-8.396,P<0.001),差异均有统计学意义.总手术成功率(术后AHI<20次/h,且降幅≥50%)为76.5%,其中治愈14例,显效25例,有效6例,无效6例.腭后区阻塞组27例,手术成功率81.5%;舌后区阻塞组24例,成功率75.0%.结论 上气道压力测定法能较准确地判断上气道阻塞平面,与传统检查相结合,制定个体化手术方案,可能提高中重度OSAHS的手术疗效.     

阻塞性睡眠呼吸暂停低通气综合征的定位诊断研究——纤维喉镜与上气道压力测定的比较

目的:比较纤维喉镜结合Müller检查 (FPMM)和整夜上气道压力测定(UAPM)2种方法判定阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者腭后区和舌后区阻塞的差别.方法:对36例OSAHS患者行FPMM和UAPM法判定阻塞部位.FPMM法对腭后区和舌后区分别采用2种不同的阻塞判定标准,UAPM以阻塞构成比>30%作为判定阻塞的标准.结果:UAPM显示腭后区阻塞26例(72%), 舌后区阻塞21例(58%).FPMM以塌陷度≥75%作为判定腭后区阻塞的标准时,检出腭后区阻塞35例(97%),与UAPM符合率为75%,kappa值(一致性系数)为0.138;以塌陷度≥90%作为判定腭后区阻塞的标准时,检出腭后区阻塞30例(83%),与UAPM符合率为83%,kappa值为0.526;以塌陷率≥75%作为判定舌后区阻塞的标准时,检出舌后区阻塞10例(28%),与UAPM符合率为53%,kappa值为0.121;以塌陷率≥50%作为判定舌后区阻塞的标准时,检出舌后区阻塞18 例(50%),与UAPM符合率为69%,kappa值为0.389.结论:FPMM和UAPM法判定腭后区阻塞的一致性高于舌后区,适当提高FPMM判定腭后区阻塞的标准而降低其判定舌后区阻塞的标准可使两法的一致性有一定程度的提高.     

OSAHS患者UPPP手术前后上气道形态学变化

目的研究阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者行悬雍垂腭咽成形术（UPPP）前后上气道形态学的变化。方法对经多导睡眠呼吸监测（PSG）确诊的32例OSAHS患者，应用多层螺旋CT在UPPP手术前后行上气道连续扫描，观察上气道形态学的改变，并根据手术疗效分级进行对比研究。结果OSAHS患者UPPP术后2～3年，平静呼吸时腭后区截面积和左右径增加；深吸气末腭后区和舌后区的截面积和左右径均增加，腭后区塌陷度减轻。各疗效组患者手术前后腭后区截面积的变化差异有统计学意义。结论OSAHS患者上气道阻塞平面主要位于腭后区者，行UPPP疗效较好。上气道CT测量数据可作为OSAHS患者行UPPP手术的参考标准。     

上气道压力测定在阻塞性睡眠呼吸暂停低通气综合征诊治中的应用

目的:利用压力测定法在上呼吸道内更直接地了解发生睡眠呼吸暂停低通气事件时上气道的动态变化.方法:经PSG确诊为阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的21例患者行ApneaGraph上气道压力测定,获得不同体位时的呼吸紊乱指标、判定阻塞平面及各平面阻塞出现的频率.结果:①21例患者不同体位时平均发生的异常呼吸事件AHI:仰卧睡眠时AHI为(47.83±18.05)次/h,侧卧位AHI为(35.11±18.88)次/h,两者差异有统计学意义(P<0.05),②阻塞平面以软腭悬雍垂以上部位(成人主要是腭后区)为主,占异常呼吸事件的84.48%;软腭悬雍垂以下部位(舌后区为主)占异常呼吸事件的12.58%.结论:通过上气道压力测定,可较好地判断睡眠时患者气道阻塞部位,压力测定装置还可作为便携PSG,对OSAHS作出初步定性诊断,为治疗方案的选择提供了有参考价值的资料.     

电影磁共振及纤维喉镜对阻塞性睡眠呼吸暂停低通气综合征患者上气道阻塞部位检查对比研究

目的 探讨电影磁共振(cine magnetic resonance,CMR)检查及纤维喉镜下Müller试验对阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome , OSAHS)患者进行上气道阻塞部位定位的应用价值.方法 选取2015年9月~2016年4月到郑州大学第一附属医院咽喉头颈外科就诊并经多导睡眠监测(PSG)及专科检查确诊的阻塞性睡眠呼吸暂停低通气综合征患者22例,于术前行纤维喉镜下Müller试验检查并分别在睡眠及清醒状态下行电影磁共振检查,观察软腭区、舌后区及会厌区狭窄或阻塞发生情况.结果 电影磁共振与纤维喉镜下Müller试验对于软腭区阻塞的定位(22例对22例)具有完全的一致性(Kappa=1),而对于舌后区(13例对6例)(Kappa=0.412)、会厌区(4例对2例)(Kappa=0.621)及多部位同时阻塞的定位(13例对6例)(Kappa=0.412),二者一致性一般.结论 对多部位阻塞的中重度OSAHS患者,术前应用电影磁共振及纤维喉镜检查能够更好地明确阻塞部位.     

阻塞性睡眠呼吸暂停低通气综合征患者自然睡眠时上气道及相关结构电影磁共振测量研究

目的：采用电影磁共振（cine magnetic resonance,CMR）定量评估不同上气道阻塞模式下阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者的上气道及其相关结构的变化特点。方法30例男性重度OSAHS患者成功完成清醒时和自然睡眠时上气道正中矢状位CMR扫描。根据上气道阻塞模式将患者分为三组,并对患者的上气道及相关结构进行测量,评估其形态及位置变化特点。结果与清醒时相比,自然睡眠时OSAHS患者软腭后区、舌后区和会厌后区上气道矢状径均明显减小,硬腭-软腭间夹角增大,舌骨上肌群长度减小（P<0.01）。三型阻塞模式患者在清醒时,舌后区上气道矢状径存在显著差异（P<0.01）;自然睡眠时,舌后区上气道矢状径、舌体上部矢状径、硬腭-软腭间夹角、舌体角及上述测量指标的变化值均有显著差异（P<0.05）。结论 CMR可定量评估不同上气道阻塞模式的OSAHS患者之间上气道及相关结构的变化特点。     

上气道测压与Friedman分型在上气道阻塞平面判断中的相关性研究

目的 通过比较上气道压力测定法与Friedman气道阻塞临床分型在阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)患者术前评估判定阻塞平面中的作用,分析Friedman气道阻塞临床分型预测阻塞平面的价值.方法 对103例有打鼾及白天嗜睡已经多道睡眠监测确诊为OSAHS患者进行Friedman气道阻塞临床分型后,同期应用Apnea Graph(AG)行整夜的睡眠监测和上气道压力测定,以下部阻塞层面(主要为舌后区)构成比分析Friedman 气道阻塞临床分型与上气道压力测定所显示上气道阻塞部位的关系.结果 根据Friedman临床分型、舌位高度分级(Friedman tongue position,FTP)、扁桃体分度分组,AG判断的下部阻塞构成比的差异有统计学意义(F值分别为13.876、7.655、10.207,P值均＜0.05).两两比较,下部阻塞构成比在Friedman临床分型的Ⅳ型与Ⅰ、Ⅱ、Ⅲ型之间差异均有统计学意义(P值均＜0.01),且有随着分型级别增高,下部阻塞构成比也有增高的趋势;在FTP分级的2级与3、4级之间差异有统计学意义(P值均＜0.05),也有随着分级增高下部阻塞构成比增高的趋势;在扁桃体分度的4度与1度、2度、3度之间差异均有统计学意义(P值＜0.01或0.05).结论 Friedman临床分型,特别是其中的FTP分级与AG对下部阻塞的判定有相关性趋势,可以作为预测OSAHS患者睡眠时上气道阻塞平面的参考.     

Expiratory pharyngeal airway obstruction during sleep: a multiple element model

OBJECTIVE/HYPOTHESIS: In patients with obstructive sleep apnea and snoring, airway obstruction during sleep is not limited to inspiration but may also occur with expiration. The aim of this study was to assess the segmental mechanics of expiratory obstruction. DESIGN: Experimental study of a convenience sample of 20 patients with snoring and mild obstructive sleep apnea. METHODS: During sedated sleep, airflow, airway pressure measurements (supraglottic, oropharyngeal, nasopharyngeal, and nasal mask), and either supraglottic/retroglossal or retropalatal areas were simultaneously measured. Nasal continuous positive airway pressures were experimentally adjusted during single breath tests (SBTs) to modify upper airway size. Airway mechanics were evaluated during pressure drops on expiration. RESULTS: The predominant level of expiratory obstruction was supraglottic/retroglossal level alone (65%) or combined supraglottic/retroglossal and retropalatal (17.6%). In nonobstructed SBTs, compliance curves derived from supraglottic/retroglossal and retropalatal pressures were similar but diverged in obstructed breaths. Compliance during expiration was greater in the supraglottic/retroglossal segment compared to the retropalatal segment. Retropalatal cross-sectional size was smaller during early and late expiration on obstructed than on nonobstructed breaths independent of airway pressure measures. The rate of expiratory collapse was increased at all time points measured (P <.005) in the retropalatal segment on obstructed as compared with nonobstructed breaths. CONCLUSIONS: During expiration, the supraglottic/retroglossal level is obstructed more frequently and has greater compliance than the retropalatal segment. Failure of upstream pressures to describe pharyngeal obstruction supports a multi-element model of collapse. Segments interact during expiration, with increased retropalatal collapse on obstructed as compared with nonobstructed breaths. Increased collapse on expiration provides a mechanism for increased obstruction on subsequent inspiratory breaths.     

Flextube reflectometry and pressure-recordings for level diagnosis in obstructive sleep apnoea

The objective of this study was to compare sound reflections in a flexible tube (flextube reflectometry) with pressure-catheter recordings (ApneaGraph) for identifying the predominant obstructive level of the upper airway during sleep. Seventeen males with suspected obstructive sleep apnoea syndrome (OSAS) were included in the study. The mean (standard deviation = SD) number of flextube narrowings per hour recording was 50.2 (20.4) and the mean (SD) RDI (respiratory disturbance index = apnoeas and hypopnoeas per hour recording) determined by the ApneaGraph was 45.7 (20.2). The mean difference (SD) between the number of flextube narrowings per hour recording and the RDIs determined by the ApneaGraph was not statistically significantly different from 0. There was no statistically significant correlation between the percentage of retropalatal narrowing of the total narrowing (retropalatal and retrolingual narrowing) measured by flextube reflectometry and the percentage of retropalatal ("upper") obstructive apnoeas and hypopnoeas of the total number ("upper", "intermediate" and "lower") measured by ApneaGraph (Spearman's correlation coefficient r = 0.24, p = 0.36, N = 17). In conclusion diverging results were found in flextube reflectometry studies and pressure-recordings performed on different nights regarding the level distribution of obstructions during sleep. Possible explanations of this discrepancy are discussed.     

Evaluation of ApneaGraph in the diagnosis of sleep-related breathing disorders

ApneaGraph relies on measuring pressure and airflow simultaneously at different levels in the pharynx identifying the segment of airway obstruction and providing baseline respiratory parameters. This study aims to evaluate ApneaGraph and correlate results with both sleep nasendoscopy and polysomnography. This was a prospective study of 49 patients with snoring and/or obstructive sleep apnoea. Thirty of the these patients underwent a PSG and an ApneaGraph study simultaneously in the Sleep Lab. Nineteen patients attended the day surgery unit and had a sleep nasendoscopy with a 10-min ApneaGraph analysis. Polysomnography was used to validate the ApneaGraph system. There are no significant differences (independent t test, P > 0.15) between ApneaGraph compared to Polysomnography based on the apnoea–hypopnoea index, total number of apnoeic events, average oxygen saturations and maximum desaturation. This suggests that the ApneaGraph can be used to assess OSA. Statistically, there is poor correlation between the two groups (Spearman’s ρ 0.29). In the cases of discordance, ApneaGraph places greater emphasis on a lower pharyngeal contribution. This unique study analyses the ApneaGraph system in the diagnosis of obstructive sleep apnoea and snoring. It demonstrates the benefits of this new system and highlights certain limitations in localizing the site and level of pharyngeal obstruction in patients with sleep disorders.     

短睡眠上气道测压评估阻塞性睡眠呼吸暂停低通气综合征阻塞

目的:了解OSAHS患者白天短时睡眠监测(dAG)时,呼吸事件和上气道阻寒情况是否和整夜睡眠监测(nAG)一致.方法:用睡眠监测及阻塞定位系统(AG)对经PSG确诊的24例OSAHS患者分别进行nAG和dAG.监测内容为:①上气道阻塞:腭后区和舌后区阻塞的构成比(UPPER,LOWER);②呼吸事件:呼吸暂停低通气指数(AHI)、呼吸暂停指数(AI)、阻塞性呼吸暂停指数(OAHI)、中枢性呼吸暂停指数(CAHI)、混合性呼吸暂停低通气指数(MAHI)、LSaO<,2>.结果:24例患者中AHI、AI、OAHI、CAHI、MAHI、UPPER、LOWER、LSaO<,2>差异均无统计学意义(均P>0.05),除CAHI外,AHI、AI、MAHI、OAHI、UPPER、LOWER和LSaO<,2>均有明显相关性.结论:dAG监测到的上气道阻塞和呼吸事件情况与nAG的结果近似.提示比较省时的dAG对OS-AHS呼吸事件和上气道阻塞的分析有较好参考价值.     

阻塞性睡眠呼吸暂停低通气综合征患者上气道的MRI研究

目的:应用MRI比较阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者和正常健康人上气道及其周围软组织的差异,分析判断阻塞部位,为OSAHS的临床诊疗提供参考.方法:对经PSG确诊的33例OSAHS患者(OSAHS组)应用超快速MRI对其上气道进行扫描观察,对患者软腭后区、舌后区和会厌后区的截面积、咽壁厚度等进行测量.选择20例无打鼾的同年龄组健康人作为对照组.结果:不同程度OSAHS患者咽部气道面积均小于对照组,程度越重,相应的气道面积越小、咽壁厚度越大.OSAHS组软腭截面积、长度和厚度均大于对照组,OSAHS程度越重,软腭截面积、长度和厚度越大.OSAHS组软腭后区气道截面积与AHI呈负相关,舌后区气道截面积与颈围呈负相关.结论:运用MRI进行上气道扫描并辅以形态测量可有效判定OSAHS患者上气道咽腔狭窄情况,对确定治疗措施具有一定指导意义.     

How Does Open‐Mouth Breathing Influence Upper Airway Anatomy?

OBJECTIVES/HYPOTHESIS: Open-mouth breathing during sleep may increase the severity of obstructive sleep apnea (OSA) and complicate nasal continuous positive airway pressure (CPAP) therapy in patients with OSA. The aim of this study was to assess the effect of open-mouth breathing on upper airway anatomy using lateral cephalometry and fiberoptic nasopharyngoscopy. STUDY DESIGN: This was a cross-sectional study. METHODS: Lateral cephalometry and fiberoptic nasopharyngoscopy were carried out on 28 subjects with a mean age of 36.7 years. We compared the effect of the mouth being open or closed on the results in lateral cephalometry (pharyngeal length, distance between the mandible and hyoid bone [MP-H], angles from the sella-nasion to mandibular points A and B [SNA, SNB, respectively], retropalatal, retroglossal, and hypopharyngeal distance) and fiberoptic nasopharyngoscopy (retropalatal and retroglossal cross-sectional area). RESULTS: On lateral cephalometric measurements, retropalatal distance (P = .000), retroglossal distance (P = .000), and MP-H (P = .002) were lower with mouth open, and pharyngeal length (P = .000) was greater. However, there were no significant differences in SNA and hypopharyngeal distance. On fiberoptic nasopharyngoscopy, retropalatal (P = .005) and retroglossal (P = .000) cross-sectional areas were significantly reduced with the mouth open. CONCLUSIONS: Open-mouth breathing is associated with reduction of the retropalatal and retroglossal areas, lengthening of the pharynx and shortening of the MP-H in the upper airway. We suggest that knowledge of these anatomic changes improves our understanding of the increase of OSA severity and the low adherence to nasal CPAP therapy in mouth breathers.