阻塞性睡眠呼吸暂停患者临床表现与上气道阻塞部位关系的探讨

目的 观察一组AHI接近的阻塞性睡眠呼吸暂停综合征（OSAS）患者中上气道阻塞部位对多导睡眠监测（PSG）图及临床表现的影响。方法选取36例AHI为30—40的成年男性OSAS患者行再次整夜PSG，加同步上气道及食道压力监测确定上气道最低阻塞部位。比较上气道最低阻塞部位在软腭水平、舌根水平和下咽水平的不同患者中PSG相关参数：平均SaO2、最低SaO2、最长阻塞性呼吸暂停事件时间、呼吸暂停事件中SaO2下降率（dSaO2／dt）、微觉醒指数；以及部分临床表现参数：白日嗜睡程度、入睡前收缩压／清晨收缩压、入睡前舒张压／清晨舒张压以及高血压发生率。结果平均SaO2、最长阻塞性呼吸暂停事件时间和入睡前收缩压／清晨收缩压比值在3种不同上气道最低阻塞部位患者中差异无显著性（P〉0．05），但与软腭水平相比，舌根水平和下咽水平的最低Sa02降低（P〉0．05），dSaO2／dt（％／s）比值增高（P〈0．05），微觉醒指数及白日嗜睡评分增高（P〈0．01），入睡前舒张压／清晨舒张压比值降低（P〈0．05），最低SaO2〈80％的发生率增高（P〈0．01）以及高血压的发生率增高（P〈0．01）。结论AHI接近的OSAS患者上气道阻塞部位在舌根水平以下者与软腭以上水平者相比，阻塞性呼吸暂停事件的致缺氧效率和程度提高，OSAS的临床表现加重。     

Pressure stability of nasal CPAP and bilevel devices

Summary Question of the study   Nasal continuous positive airway pressure (CPAP) prevents collapse of the upper airway during sleep in patients with obstructive sleep apnea provided that a positive transmural pressure can be maintained during inspiration. We examined pressure-flow characteristics in seven CPAP and bilevel devices during spontaneous breathing.
Methods   The CPAP devices were set to a pressure level of 9.8  hPa (10  cm H₂O) and adapted to a pneumotachograph using a standard CPAP hose and an outlet valve. We continuously measured flow, volume and pressure during resting ventilation and increasing voluntary hyperventilation and analysed the dependence of the variables on a breath-to-breath basis.
Results   Mean CPAP pressures differed between the devices (9.9 – 10.6  hPa) despite the same settings. In all machines pressure fell during inspiration to 8.4 – 9.8  hPa and increased during expiration to 11.1 – 11.7  hPa. This effect increased with higher flow rates. Maximum expiratory pressures rose to 12 – 19  hPa at peak flow rates of 2 l/s, mean expiratory pressures to 9.5 – 16  hPa. Inspiratory pressures dropped to 8.5 – 4.5  hPa (minimum) and 10.5 – 6.0 (mean). Bilevel devices showed a higher stability than CPAP devices. Pressure swings during the respiratory cycle increased the additional work of breathing.
Conclusions   Due to differences in mean and effective CPAP levels CPAP devices are not simply exchangeable but should be individually adapted. Patients with higher minute ventilation might benefit from more stable CPAP machines. The impact on patients' compliance remains to be evaluated.     

梗阻性黄疸引起肾脏病理学及超微病理学改变的实验与临床研究

作者对梗阻性黄疸（梗黄）大鼠及６例临床梗黄病人的肾脏组织进行了光镜和电镜观察。目的是描述肾脏损害的病理和超微病理改变，并试图从病理改变来探讨肾脏损害的可能病因及肾脏功能的改变。观察发现主要病变为肾小球萎缩，鲍曼氏囊间隙扩大，肾小球毛细血管基膜明显增厚，其三层结构消失，内有大量胆色素颗粒沉积，血管内皮窗孔明显减少，足突融合；近曲小管上皮细胞变性、坏死，胞质内有大量胆色素颗粒沉积，小管腔内可见脱落的坏死细胞、胆泥、胆栓及蛋白管型，微绒毛紊乱、稀疏、脱落，线粒体高度水肿，内质网扩张，脂滴、溶酶体明显增多。据此，我们认为：（１）梗黄可引起明显肾脏损害，其病变同时累及肾小球和肾小管，但以近曲小管病变为重；（２）胆汁成分于肾脏内的沉积在梗黄引起肾脏损害的发病中起一定作用；（３）梗黄可导致肾脏功能改变。     

阻塞性睡眠呼吸暂停低通气综合征和肥胖及正常体重人群血清瘦素水平的研究

目的:探讨阻塞性睡眠呼吸暂停低通气综合征(OSAHS)、肥胖和正常体重人群的血清瘦素水平。方法:将经PSG检测的患者分为OSAHS组(53例)和单纯肥胖组(41例),另选正常体重者(正常体重组)62例,用放射免疫法测定3组的血清瘦素水平,同时测量每例受检者的身高、体重、颈围、腰围和臀围。结果:①无论男性还是女性,OSAHS组和单纯肥胖组的血清瘦素水平均比正常体重组高(均P<0.05);OSAHS组血清瘦素水平[男(8.06±2.58)μg/L,女(12.83±2.67μg/L)]均高于单纯肥胖组[男(5.75±1.27)μg/L,女(9.83±1.99μg/L)](均P<0.05)。②单纯肥胖组及OSAHS组血清瘦素水平分别与体质指数(BMI)呈显著正相关(均P<0.01),OSAHS组血清瘦素水平与AHI、颈围及腰臀围比(WHR)也呈显著正相关(均P<0.01)。结论:单纯性肥胖患者血清瘦素水平升高与机体内发生瘦素抵抗有关;OSAHS患者的血清瘦素水平与AHI呈正相关,说明OSAHS本身可能是引起血清瘦素升高的因素之一,瘦素可能有兴奋呼吸中枢的作用。     

Comparison of Sputum and Serum Eosinophil Cationic Protein (ECP) Levels in Nonatopic Asthma and Chronic Obstructive Pulmonary Disease

The aim of the present study was to investigate whether sputum eosinophil cationic protein (ECP) concentrations could be a useful marker in the differential diagnosis between intrinsic asthma and chronic obstructive pulmonary disease (COPD). For this purpose total blood eosinophil counts were obtained and concentrations of serum and sputum ECP from 10 nonatopic asthmatics with a mild attack and 9 COPD patients with acute exacerbation were measured by radioimmunoassay. Mean serum ECP concentration was 54.3 ± 23.0 g/L in the asthmatic group and 83.3 ± 79.2 g/L in the COPD group (p: n.s.). In the group of asthmatics mean sputum ECP level was 984.5 ± 1245.5 mg/L/g sputum and in the COPD group it was 417.5 ± 363.5 mg/L/g sputum. There was no significant difference in sputum ECP levels between patients with asthma and COPD. We conclude that neither sputum nor serum ECP levels are useful markers in differential diagnosis of asthma attack and acute exacerbation of COPD.     

Utility of pulmonary function testing in the management of chronic obstructive pulmonary disease

This study sought to measure the effect of pulmonary function testing (PFT) data on the decisions made by generalist physicians in the management of chronic obstructive pulmonary disease (COPD). 148 physicians were randomly assigned to two groups, both of which were asked to manage two identical fictitious but representative cases of COPD, which included history, physical, x-ray, and laboratory results. The experimental group received PFT results in addition. No significant difference was noted between the two groups in management based on availability of PFT data. The optimum utility of PFT data in the management of COPD may be exaggerated and has yet to be determined. Received from the Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. Presented at the Annual Scientific Meeting of the American College of Chest Physicians, October 28, 1992, Chicago, Illinois.     

超声引导结合X线透视下PTCD治疗阻塞性黄疸

目的探讨超声引导结合X线透视下PTCD的操作技术及其临床应用价值。方法51例阻塞性黄疸患者,40例为恶性阻塞性病变,11例为良性阻塞性病变,在超声引导结合X线透视下行PTCD术,穿刺右叶胆管44例,穿刺左叶胆管7例,并常规造影。结果穿刺成功率100%,未出现出血、胆汁性腹膜炎等并发症。术后1周胆红素平均下降75.2ummol/L。结论超声引导结合X线透视下PTCD是一种治疗阻塞性黄疸的有效方法,具有安全、简便、经济、并发症少的优点。     

舒利迭加无创通气治疗稳定期慢性阻塞性肺疾病的临床研究

目的探讨舒利迭(吸入型肾上腺皮质激素与长效β2-受体激动剂的预混制剂)联合双水平气道正压通气(B iPAP)对稳定期慢性阻塞性肺疾病(COPD)的治疗作用。方法稳定期COPD病人52例,舒利迭TM50/250,1吸/次,2次/d;B iPAP,吸气压力(IPAP)10~20cm H2O,呼气压力(EPAP,也称PEEP)3~6cm H2O,吸氧浓度(FiO2)3L/m in,每天夜间通气6~8h。观察治疗前、治疗后12周病人临床症状、生活质量、健康状态和肺功能。结果治疗前、治疗后12周病人的临床症状、急性加重次数及严重程度、健康状态和生活质量、肺功能等指标比较差异有统计学意义(P<0.05)。结论舒利迭联合B iPAP治疗稳定期COPD病人能够明显改善其症状,提高生活质量,有一定的临床应用价值,对减缓COPD病人肺功能下降有积极意义。     

慢性阻塞性肺疾病呼吸驱动影响因素分析

目的:探讨慢性阻塞性肺疾病(COPD)病人呼吸驱动与肺功能、血气及静息能量代谢之间的关系.方法:26例COPD和21例正常对照者分别测定口腔阻断压P0.1、呼吸肌功能[最大吸气压(PIMAX)、最大呼气压(P EMAX)]、肺通气功能[努力肺活量(FVC)、一秒率(FEV,%)]、残气(RV/TLC)、弥散功能(DLCO)、静息能量代谢(REE)、呼吸商(RQ)、血气分析及Borg分级等.结果:COPD组P0.1和P0.1/PIMAX高于对照组(P＜0.01).相关分析COPD组P0.1与PaO2、SaO2负相关(r分别为-0.62,-0.53,P均＜0.05),而与PaCO2相关性不明显.Borg分级与P0.1正相关(r=0.63,P＜0.05),P0.1与FVC、FEV1%、RV/TLC、DLCO以及RQ无相关性,P0.1/PIMAX与REE有正相关关系(r=0.41,P＜0.05).结论:COPD呼吸驱动增高,不仅与PaO2,SaO2相关,还与静息能量代谢及Borg分级等相关.