阻塞性睡眠呼吸暂停诊治流程——案例分析

阻塞性睡眠呼吸暂停是指阻塞性睡眠呼吸暂停低通气综合征（Obstructive sleep apnea syndrome,OSAS）,是一种常见的睡眠呼吸障碍,在人群中的流行率约为5%.经整夜多导睡眠监测（polysomonography,PSG ）发现呼吸暂停低通气指数（Apnea Hypopnea Index,AHI）大于5次/h即可确诊[1].鼾声大、睡眠中被观察到的呼吸暂停、高血压和日间嗜睡是阻塞性睡眠呼吸暂停患者常见的伴随症状.由于睡眠呼吸暂停的临床症状表现多样化,故患者选择就诊的临床科室分布甚广,包括神经内科、精神科、耳鼻喉科和呼吸内科等.但是又由于目前一般国人甚至临床医护人员对该病的认识不够深入,往往造成患者就医诊治过程的波折及医疗资源的浪费.下面,以1例重度阻塞性睡眠呼吸暂停患者的诊治流程为例,说明广大医务人员对OSAS认识的必要性.     

阻塞性睡眠呼吸暂停与觉醒型卒中的关系分析

目的讨论阻塞性睡眠呼吸暂停(obstructive sleep apnea,OSA)与觉醒型卒中(wake-up stroke,WUS)的关系。方法回顾性分析伴阻塞性睡眠呼吸暂停低通气综合征的急性缺血性卒中患者资料,患者均接受夜间睡眠监测检查,分为WUS组和非WUS组,比较两组间一般临床资料、美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分及睡眠呼吸参数等指标的差异。结果共入组96例患者,其中WUS组22例,非WUS组74例,WUS组的体质指数(body mass index,BMI)(P=0.030)、呼吸暂停低通气指数(apnea-hypopnea index,AHI)(P=0.001)、血氧饱和度下降指数(oxygen desaturation index,ODI)(P=0.001)均显著高于非WUS组,平均血氧饱和度(P=0.002)显著低于非WUS组;Logistic回归分析显示,AHI增高[比值比(odds ratio,OR)1.162,95%可信区间(confidence interval,CI)1.007~1.341]是WUS的独立危险因素。结论 BMI、AHI、ODI和平均血氧饱和度与阻塞性睡眠呼吸暂停低通气综合征患者发生WUS有关,其中AHI是WUS的独立危险因素。     

老年阻塞性睡眠呼吸暂停低通气综合征的临床特点与护理

本文通过对62例60岁以上老人阻塞性睡眠呼吸暂停低通气综合征的临床观察与护理,总结了老年阻塞性睡眠呼吸暂停低通气综合征临床特点与护理措施如下.     

伴有惊恐障碍的阻塞性睡眠呼吸暂停低通气综合征睡眠结构特征

目的 分析阻塞性睡眠呼吸暂停低通气综合征合并惊恐障碍(obstructive sleep apnea syndrome com?bined with panic disorder,OCP)患者的睡眠结构特征,探讨OCP睡眠结构变化在临床上的意义.方法 纳入25例OCP患者、29例阻塞性睡眠呼吸暂停低通气综合征(obst...     

阻塞性睡眠呼吸暂停综合征并高血压的危险因素分析

目的 分析阻塞性睡眠呼吸暂停综合征并阻塞性睡眠呼吸暂停综合征的危险因素.方法 选取我院阻塞性睡眠呼吸暂停综合征患者96并例,根据呼吸暂停低通气指数(AHI)分为3组,3组患者均于22:00与08:00进行血压测量并记录,比较3组患者的血压水平,进行危险因素分析.结果 3组高血压患病率差异无统计学意义(P>0.05);3组08:00与22:00进行血压水平检测,2个时间段的舒张压、收缩压对比差异有统计学意义(P<0.05).且C组22:00、08:00的舒张压、收缩压明显高于A组(P<0.05);C组22:00、08:00收缩压明显高于B组(P<0.05);单纯阻塞性睡眠呼吸暂停综合征患者组40例,阻塞性睡眠呼吸暂停综合征并高血压患者组56例,阻塞性睡眠呼吸暂停综合征并高血压患者组体重指数、腹围、血糖、总胆固醇、三酰甘油、高密度脂蛋白胆固醇指标明显高于单纯阻塞性睡眠呼吸暂停综合征患者组(P<0.05),但低密度脂蛋白胆固醇明显低于单纯阻塞性睡眠呼吸暂停综合征患者组(P<0.05).结论 在阻塞性睡眠呼吸暂停综合征临床治疗中,要注重危险因素的预防,以降低高血压发生率.     

急性脑梗死患者的阻塞性睡眠呼吸暂停低通气综合征临床分析

目的 本研究初步探讨了急性脑梗死合并阻塞性睡眠呼吸暂停低通气综合征的临床特点.方法 评价19例连续收住的首次、非昏迷急性脑梗死患者和同期10例健康成人的年龄、性别、体重指数(BMI)、睡眠打鼾史、高血压病史、吸烟史、饮酒史、动脉血压,研究组还记录入院时和7d时斯堪的纳维亚卒中量表得分(SSS),使用多导睡眠监测系统记录睡眠过程中的多项生理事件,评价AHI和最低动脉血氧饱和度(SaO2).结果 急性脑梗死后74%患者有阻塞性或混合性睡眠呼吸暂停,63%的急性脑梗死患者出现了具有临床意义的睡眠呼吸暂停,AHI与患者年龄、BMI、最低SaO2、睡眠打鼾史、吸烟史、高血压、SSS有关,呼吸事件主要为阻塞性或混合性睡眠呼吸暂停,中枢性睡眠呼吸暂停在所有呼吸事件中约占8%.既往有心脏病史的患者甚至会出现Cheyne-Stokes呼吸.结论 应重视评价急性脑梗死患者OSAHS发生的可能性,对于病情重、存在多种脑血管病危险因素的患者更应作为常规评价的一部分.     

快速动眼睡眠型和非快速动眼睡眠型阻塞性睡眠呼吸暂停综合征患者的临床特征分析

目的 比较快速动眼睡眠(REM)型和非REM(NREM)型阻塞性睡眠呼吸暂停综合征(OSA)患者的临床特征、多导睡眠监测(PSG)参数和血清学指标间的差异.方法 收集2018年1月至2019年6月住院且PSG提示总呼吸暂停低通气指数(AHI)≥5的OSA患者129例.统计REM期AHI值(AHIREM)和NREM期AH...     

行为认知治疗对阻塞性睡眠呼吸暂停导致低通气综合征的患儿的影响

目的 探讨阻塞性睡眠呼吸暂停导致的低通气综合征患儿应用行为认知治疗后的效果.方法 将我院91例阻塞性睡眠呼吸暂停导致的低通气综合征患儿采用随机数字表法进行分组,对照组45例患儿给予糠酸莫米松鼻喷雾喷鼻联合孟鲁司特钠口服治疗,观察组46例患者在对照组基础上增加认知行为治疗,对比两组患儿干预后睡眠过程中暂停次数、动脉血氧饱...     

急性脑血管病合并睡眠呼吸暂停综合征的临床研究

目的分析急性脑血管病（CVD）患者合并睡眠呼吸暂停综合征（SAS）的发生率和类型,探讨脑血管病（CVD）合并SAS事件的发病机制。方法随机抽取急性CVD患者82例,利用多导睡眠图（PSG）进行睡眠呼吸监测,观察睡眠呼吸监测指标。结果（1）82例急性CVD患者中存在SAS者61例（74．39％）,其中阻塞性睡眠呼吸暂停综合征（OSAS）40例（65．57％）,混合性睡眠呼吸暂停综合征（MSAS）14例（22．95％）,中枢性睡眠呼吸暂停综合征（CSAS）7例（11．48％）;（2）急性CVD患者中存在SAS组的呼吸暂停低通气指数、低氧时间、平均和最低血氧饱和度与不存在SAS组差别显著（P〈0．01）。结论SAS与CVD关系密切,认为SAS是CVD被忽视的危险因素,但不排除CVD诱发了SAS的可能,两者形成恶性循环,影响CVD康复。     

缺血性脑卒中睡眠呼吸特点及对血压的影响

目的 探讨缺血性脑卒中患者病情与睡眠呼吸暂停低通气综合征的关系及血压变化的临床特点.方法 选取缺血性脑卒中患者84例,在入院当天行睡眠呼吸监测、动态血压监测,在入院24h内行神经功能缺损程度评分.结果 缺血性脑卒中急性期阻塞性睡眠呼吸暂停低通气综合征(OSAHA)患者57(67.86%)例,OSAHA患者血压明显高于无睡眠呼吸暂停患者(P＜0.05),神经功能缺损程度越重OSAHA发生率越高(P＜0.05).结论 缺血性脑卒中急性期伴有OSAHA的患者血压高于无OSAHA患者,OSAHA发生与神经功能缺损程度相关.     

Polysomnography in patients with intracranial tumors before and after operation

OBJECTIVE : To evaluate the breathing and sleep patterns in patients with brain tumors before and after operation, and assess their relation to the location and size of the tumor, as well as to the post-operative outcome. METHODS : Polysomnographic studies were performed in 11 patients with intracranial tumors (nine supra- and two infratentorial) before and after surgery. RESULTS : Pre-operatively, the mean apnea-hypopnea index (AHI) was 23.3. Six patients demonstrated signs of obstructive sleep apnea (SA) and one had mixed obstructive and central type SA. After operation, the mean AHI decreased to 8.1(P < 0.05). The duration of random eye movement sleep stage increased after tumor removal (P < 0.04). No relation was found between the characteristics of the tumor, nor the post-operative outcome and SA. CONCLUSIONS : Patients with brain tumors often suffer from SA and this can further worsen their symptoms related to increased intracranial pressure. Removal of the tumor results in a substantial decrease in sleep-related disturbances and may thus play a role in clinical recovery.     

Uvulopalatopharyngoplasty for obstructive sleep-related breathing disorders: one-year follow up

The effectiveness of uvulopalatopharyngoplasty was evaluated in 28 patients (25 men and three women; mean age 47.6 years) with obstructive sleep apnea by comparing preoperative daytime polysomnography with those carried out 6 months and 1 year postoperatively. The mean apnea plus hypopnea index (AHI) in the supine position decreased from 51.0/h to 23.0/h 6 months postoperatively and 57.1% of patients showed a 50% or more reduction of AHI. By changing the sleep position from supine to lateral, 71.4% of the 28 patients indicated a 50% or more reduction in AHI before surgery, which increased to 92.3% of 26 patients 6 months postoperatively. The positive results of uvulopalatopharyngoplasty were maintained at least until 1 year after surgery.     

伴有阻塞性睡眠呼吸暂停低通气综合征的缺血性脑血管病患者血同型半胱氨酸的变化

目的 探讨伴有阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea-hypopnea syndrome,OSAHS)的缺血性脑血管病患者(ischemie cerebrovascular disease,ICVD)血同型半胱氨酸(homocysteine,Hey)水平.方法 从南京脑卒中注册系统中筛选76例ICVD患者,行多导睡眠图(PSG)监测,并检测纤维蛋白原(FBG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、甘油三酯(TG)、血浆Hcy.结果 76例患者中有57例存在呼吸暂停现象,其中53例(69.7%)诊断为OSAHS;排除4例中枢性呼吸暂停患者,将72例ICVD患者根据呼吸暂停加低通气指数(AHI)值分为4组:无呼吸暂停组19例,AHI值2.38±0.96,Hcy值(8.78±2.01)μmol/L;轻度OSAHS 21例,AHI值14.14±4.37,Hcy值(12.91±3.00)μmoL/L;中度OSAHS24例,AHI值29.62±5.81,Hcy值(14.85±4.15)μmoL/L;重度OSAHS 8例,AHI值46.75±2.82,Hey值(19.30±4.82)μmoL/L.4组间Hcy值差异有统计学意义(F=40.32,P<0.01).Hey与AHI存在显著相关性(r=0.598,P<0.01).结论 在ICVD患者中,OSAHS患病率较高,且以轻中度为主;Hcy在ICVD合并OSAHS患者时具有升高趋势,且随着阻塞程度的进展而加重.     

阻塞型睡眠呼吸暂停低通气综合征对急性缺血性卒中患者脑血管反应性的影响

目的 探讨阻塞型睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS） 对急性缺血性卒中患者脑血管反应性（cerebrovascular reactivity,CVR）的影响。 方法 前瞻性连续入组2017年10月-2020年8月住院治疗的急性缺血性卒中患者,入院2周内完善多 导睡眠监测,根据是否合并OSAHS及呼吸暂停低通气指数（apnea hypopnea index,AHI）将患者分为非 OSAHS组、轻度OSAHS组（AHI 5～15次/小时）和中重度OSAHS组（AHI>15次/小时）。在完成多导睡眠 监测后24 h内对患者进行TCD检查,检测CVR指标包括平静呼吸时、屏气后大脑中动脉的平均血流速 度（Vm）,计算屏气指数（breath holding index,BHI）。比较三组间CVR指标的差异,并在中重度OSAHS组 中分析CVR指标与入院时和发病3个月时NIHSS评分的相关性。 结果 共纳入228例急性缺血性卒中患者,男性140例（61.4%）,其中非OSAHS组49例,轻度OSAHS 组42例,中重度OSAHS组137例。中重度OSAHS组BMI、高血压比例、3个月时NIHSS评分均高于非OSAHS 组,差异有统计学意义。中重度OSAHS组平静呼吸时Vm低于非OSAHS组（57.4±10.6 cm/s vs 62.1±12.2 cm/s,P =0.010）和轻度OSAHS组（57.4±10.6 cm/s vs 59.6±11.2 cm/s,P =0.007）,BHI 低于非OSAHS组 （1.4%±0.6% vs 1.7%±0.7%,P =0.002）和轻度OSAHS组（1.4%±0.6% vs 1.5%±0.6%,P =0.001）。中重 度OSAHS组发病3个月时NIHSS评分与平静呼吸时Vm（r =-0.696,P＜0.001）和BHI（r =-0.832,P＜0.001） 呈负相关。 结论 伴中重度OSAHS的急性缺血性卒中患者CVR明显下降,而且CVR的下降可能与急性缺血性卒中 患者的预后不良有关。     

Effectiveness of prosthetic mandibular advancement for obstructive sleep apnea:Analysis by sleep position

Abstract Fifteen patients with obstructive sleep apnea were treated using prosthetic mandibular advancement (PMA). Each patient was evaluated in the supine and lateral decubitus positions with and without PMA. After PMA treatment, the mean intraesophageal pressure (Peso) in the supine position improved from -42.6 to -27.3 cmH₂O and the mean apnea + hypopnea index (AHI) decreased from 48.8/h to 23.7/h. The mean Peso in the lateral decubitus position improved from -27.9 to -18.6 cmH₂O and the mean AHI decreased from 9.6/h to 6.6/h. With PMA, respiratory disturbance during sleep further improved by changing the body position from the supine to lateral decubitus position.     

Prevalence of sleep apnea and daytime sleepiness in professional truck drivers

IntroductionThe prevalence of obstructive sleep apnea (OSA) among professional truck drivers has varied from 28 to 78% in previous studies. In this study we wanted to estimate the prevalence of OSA and OSA with both subjectively measured sleepiness and objectively measured ability to stay awake (ie obstructive sleep apnea syndrome, OSAS) among professional truck drivers in Finland.Subjects and methodsAltogether 2066 professional truck drivers received a structured questionnaire. 175 drivers had a clinical examination and sleep laboratory studies, which included respiratory polygraphy (RP) and maintenance of wakefulness test (MWT). Three groups were formed: 75 subjects with suspected sleep apnea, 75 healthy controls and a random sample of 25 subjects.Results1095 drivers answered the questionnaire. RP was performed on 172 drivers and 167 drivers participated in MWT. The mean age was 40.7 years and the mean BMI was 27.7 kgm⁻². The prevalence of sleep apnea in professional truck drivers using various criteria were: AHI ≥5: 40.1%, AHI≥ 15: 16.2% and, AHI≥ 30: 7.2%. The prevalence depended on clinical history. Prevalence of AHI≥5 varied between 20 and 56.9% and prevalence of AHI≥15 was 4.3–25%. Altogether 4.8% of subjects with AHI ≥15 had abnormally short sleep latency in MWT (<19.4 min).ConclusionsModerate sleep apnea is common among professional truck drivers but significant inability to stay awake, defined as MWT <19.4 min, is found in about one of twenty professional drivers.     

A pilot study evaluating acute use of eszopiclone in patients with mild to moderate obstructive sleep apnea syndrome

OBJECTIVE: To evaluate the effects of eszopiclone on measures of respiration and sleep using polysomnography in patients with mild to moderate obstructive sleep apnea syndrome (OSAS). METHODS: This double-blind, randomized crossover study included patients (35-64 years) with mild-to-moderate OSAS [apnea and hypopnea index (AHI) range 10 and 40]. Patients received either eszopiclone 3mg or placebo for two consecutive nights, with a 5-7 day washout between treatments. Continuous positive airway pressure (CPAP) was not allowed on nights in the sleep laboratory. RESULTS: The primary endpoint, mean total AHI, was not significantly different from placebo (16.5 with placebo and 16.7 with eszopiclone; 90% confidence interval (CI) -1.7, 1.9). No significant differences in total arousals, respiratory arousals, duration of apnea and hypopnea episodes, or oxygen saturation were noted. Significant differences in spontaneous arousals (13.6 versus 11.4 for placebo and eszopiclone, respectively; 90% CI -3.7, -0.7), sleep efficiency (85.1% and 88.4%; p=0.0075), wake time after sleep onset (61.8 and 48.1 min; p=0.0125), and wake time during sleep (55.9 and 43.2 min; p=0.013) were noted after eszopiclone treatment. Eszopiclone was well tolerated. CONCLUSIONS: In this pilot study, eszopiclone did not worsen AHI, and it improved sleep maintenance and efficiency. Further study is warranted to determine whether eszopiclone could improve CPAP compliance or next-day function in patients with OSAS.     

An investigation of the validity of the Lifeshirt in comparison to standard polysomnography in the detection of obstructive sleep apnea

BackgroundDue to the cost and waiting times for traditional sleep studies, there is great interest in finding alternatives for the diagnosis of sleep apnea. Several alternatives exist, including ambulatory devices. Our laboratory utilized one such device, a form-fitting vest called the Lifeshirt, and compared its accuracy to that of polysomnography (PSG).MethodsPSG was performed with simultaneous utilization of the Lifeshirt on 50 individuals who met screening criteria for obstructive sleep apnea. Participants came to the sleep laboratory approximately 2 h before their normal bedtime. A sleep technician prepared each participant for PSG and Lifeshirt monitoring. “Lights Out” occurred when the participant was ready for bed, and time in bed was standardized to approximately 7 h. PSGs were scored by experienced personnel in our laboratory, while Lifeshirt data were sent electronically to the Lifeshirt manufacturer for analysis. The major variable that was compared between PSG and Lifeshirt was the apnea hypopnea index (AHI), or the number of apneas and hypopneas per hour. Due to incomplete data on two participants, analyses were completed on 48 individuals.ResultsSensitivity of the Lifeshirt ranged from .85 (AHI of ?5) to 1.00 (AHI of ?25). Specificity ranged from .67 to 1.00. Using the Bland–Altman technique of determining agreement, the mean difference between the AHI of the Lifeshirt and PSG was 1.02 (±16.36). When these values are plotted, every case falls within the limits of agreement, with one exception.ConclusionsThe Lifeshirt compared favorably with PSG and could be used with considerable confidence for the screening of patients with suspected obstructive sleep apnea.     

Frequent breathing-related electroencephalogram arousals in four patients with mild obstructive sleep apneas

We report cases of four patients with mild obstructive sleep apnea syndrome (OSAS) with frequent breathing-related electroencephalogram (EEG) arousals which led to excessive daytime sleepiness. In spite of a relatively low apnea hypopnea index (AHI), sleep was disrupted by frequent EEG arousals associated with respiratory effort as observed in upper airway resistance syndrome. The effects of sleep stage and sleep position on EEG arousals were also investigated. We consider that AHI alone is not a sufficient index to assess severity of OSAS, and it is very important to examine microarousals by the alteration of esophageal pressure in addition to the effect of sleep position.     

Half of patients with obstructive sleep apnea have a higher NREM AHI than REM AHI

BACKGROUND AND PURPOSE: To determine the percentage of sequential patients with obstructive sleep apnea with a higher non-rapid eye movement (NREM) apnea-hypopnea index (AHI) than rapid eye movement (REM) AHI and those with a higher REM AHI than NREM AHI, and to look for factors that might influence the AHI to be higher in one of these two groups versus the other and thus ascertain the factors that cause an AHI to be higher in NREM than REM. A high body mass index (BMI) and a supine body position are well known as exacerbating factors for obstructive sleep apnea (OSA). Males, as well as older individuals, are generally more predominantly affected with OSA than females. Usually OSA is worse in REM sleep than in NREM sleep, although this is not always true. METHODS: A retrospective study of sequential patients from one month's admission to a single sleep laboratory was conducted. We determined the age, sex, BMI, body position, duration of apnea, amount of time spent in REM and oxygen desaturation in patients who had a higher NREM AHI than REM AHI versus those who had a higher REM AHI than NREM AHI. To minimize variability, the sleep studies were scored by a single individual. RESULTS: A higher NREM AHI than REM AHI was found in 50% of the 66 patients with OSA. Males predominated in each group and there was no age difference between the groups. Although AHI for both groups tended to become higher with an increase in BMI, the BMI was not statistically different between the two experimental groups. OSA was worse in the supine position in both experimental groups consistent with previous literature. Percentage of time spent in REM or the duration of the apnea did not determine whether a patient fell into the NREM AHI>REM AHI group versus the REM AHI>NREM AHI. The severity of oxygen desaturation was not significantly different between the NREM AHI>REM AHI versus the REM AHI>NREM AHI group. However, when we combined and analyzed the two groups as a whole, the apneas were longer in REM, consistent with previous literature. CONCLUSIONS: Although it is well known that OSA is generally worse in REM sleep because of the degree of desaturation and duration of apnea, a higher NREM AHI than REM AHI is found in up to one half of individuals. Most of the usual predictors for severity of OSA as a whole did not discriminate these groups. Further work needs to be done to determine the factors that discriminate these two groups and thus make AHI higher in NREM than REM.