重度OSAHS患者手术前后鼻腔容积的变化

【摘要】 目的 研究无鼻腔疾病的重度阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者手术前后鼻腔容积的差异。方法 102例健康成年人作为正常组;46例行等离子辅助改良悬雍垂腭咽成形术+舌体打孔消融术(H-UPPP+CCT)的仅腭咽合并舌咽平面阻塞的重度OSAHS患者作为观察组。利用鼻声反射仪测量观察组术前、术后6个月及正常组的单侧鼻腔0～5cm容积(V5)、2～5cm容积(V2～5)、鼻腔最小截面积(MCA)、最小截面积距前鼻孔的距离(DCAN);利用多导睡眠监测仪记录观察组术前、术后6个月的鼾声指数(SI)、呼吸暂停低通气指数(AHI)、最低血氧饱和度(LSaO2)、平均血氧饱和度(SaO2),并对检测结果进行统计分析。结果 观察组术前V5、V2～5均较正常组减小(P<0.01)。观察组术后V5、V2～5均较术前增大(P<0.05),与正常组比较差异无统计学意义(P>0.05);术后SI、AHI、LSaO2、SaO2均较术前改善(P<0.05)。结论 无鼻腔疾病的重度OSAHS患者鼻腔容积较正常人明显减小,手术改善上气道塌陷的同时亦能增大鼻腔容积,改善鼻通气。      

鼻内镜下切割吸引刀与腺样体刮勺盲刮治疗腺样体肥大的疗效比较

目的 探究鼻内镜下切割吸引刀与腺样体刮勺盲刮治疗腺样体肥大的疗效。方法 选取江苏省如皋市人民医院2017年3月至2018年3月收治的腺样体肥大患者90例,按随机数字表法分为观察组和对照组,每组各45例。对照组采用腺样体刮勺盲刮治疗,观察组采用鼻内镜下切割吸引刀治疗。对比两组患者的临床疗效、并发症发生率、手术前后血清相关指标及鼻通气功能变化。结果 观察组治疗总有效率高于对照组,差异有统计学意义（P<0.05）;观察组并发症发生率低于对照组,差异有统计学意义（P<0.05）;观察组手术前后白细胞介素4（IL-4）、IL-6嗜酸性细胞阳离子蛋白（ECP）、肿瘤坏死因子-α（TNF-α）、重组人细胞间黏附因子-1（ICAM-1）水平差值均低于对照组,差异均有统计学意义（P<0.05）;观察组手术前后双侧呼气总阻力（TER）、吸气总阻力（TIR）、鼻呼气量差异比（NPRe）、鼻吸气量差异比（NPRi）、鼻腔呼气量（EC）、鼻腔吸气量（IC）差值均高于对照组,差异有统计学意义（P<0.05）。结论 鼻内镜下切割吸引刀治疗腺样体肥大较刮勺盲刮治疗疗效更好,患者术后炎症反应低,并发症少,值得临床推广。     

鼻声反射以及鼻阻力测量在评定OSAHS患者术前、术后鼻腔狭窄和阻力方面的应用

目的对鼻声反射以及鼻阻力测量在评定OSAHS患者术前、术后鼻腔狭窄和阻力方面的应用价值进行评价分析,为今后的临床工作提供有价值的参考依据。方法选择2017年1月～2018年6月我院收治的获得临床确诊的OSAHS患者56例作为研究对象,对患者在进行鼻腔扩容术前、术后6个月进行鼻腔容积、鼻阻力、鼻腔最小横截面积、最小横截面距前鼻孔距离等数据进行测量,并对测量结果进行统计学分析。结果 56例患者中,轻度OSAHS患者35例,中度OSAHS患者21例。轻度、中度患者术前和术后6个月鼻腔容积、鼻阻力、鼻腔最小横截面积等数据比较,差异有统计学意义(P <0.05),术前术后患者最小横截面距前鼻孔距离比较,差异无统计学意义(P> 0.05)。结论鼻声反射可以对鼻腔扩容术OSAHS患者的鼻腔功能进行客观评估,临床价值显著,在临床诊疗中,应对其给予足够的重视。     

阻塞性睡眠呼吸暂停低通气综合征患者鼻阻力变化及意义

目的：探讨阻塞性呼吸睡眠暂停低通气综合征（ OSAHS）与鼻阻力的相关性。方法收集阻塞性睡眠呼吸暂停低通气综合征（ OSAHS）患者30例（ OSAHS组）、30例打鼾但不伴OSAHS者30例（鼾症组）及正常组30例进行多导睡眠检测的基础上行鼻阻力的检测。结果 OSAS组和鼾症组鼾声指数（42．7±27.3）、（19．4±18．5）,夜间睡眠呼吸紊乱指数（AHI）（38．7±30．2）、（5．9±1．6）,左右侧鼻阻力（Resl＋r）（1.63±1.11）Pa· s^-1· mL^-1、（0．72±0．31）Pa· s^-1· mL^-1,明显高于正常组（t＝6．451、7．444、7．698,均P＜0.05）;最低血氧饱和度（SaO2）、左右侧鼻气流（Fowl＋r）明显低于正常组（t＝7．551、7．334,均P＜0．05）;鼻阻力与鼾声指数呈明显的正相关（r＝5．658,P＜0．01）;鼻阻力与AHI指数（r＝0．002,P＞0．05）,与醒觉次数（r＝0．083,P＞0．05）,与最低SaO2均无明显相关（r＝0．105,P＞0．05）;OSAS患者X线头影测量结果提示,多数鼾症或OSAS患者其症状在仰卧位明显。结论 OSAHS患者的鼻阻力增加,可能与OSAHS的发生有关。     

鼻咽通气道在鼻源性阻塞性睡眠呼吸暂停低通气综合征患者中的应用研究

目的:探讨鼻咽通气道(NPA)在鼻源性阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者中的应用效果。方法:选择住院治疗的鼻源性阻塞性OSAHS患者130例,随机分为观察组与对照组,每组65例。两组患者均进行鼻功能性手术,对照组术后未放置NPA,观察组术后放置NPA。比较两组患者的术后疼痛评分及生理指标变化。结果:观察组患者鼻疼痛感、头痛、咽干痛、换药时疼痛、鼻阻塞感等评分均显著低于对照组,差异有统计学意义(P<0.05);观察组患者术后最低血氧饱和度(LSaO_2)、心率(HR)、平均动脉压(MAP)、舒张压(DBP)、收缩压(SBP)及率压积(RPP)等水平均显著低于对照组,差异有统计学意义(P<0.05)。结论:鼻源性阻塞性OSAHS患者术后放置NPA可保持患者鼻腔通畅,减少上呼吸道阻塞,减轻患者痛苦,保证了血流动力学的稳定性,避免低氧血症的发生。     

阻塞性呼吸睡眠暂停与鼻阻力的研究

目的探讨阻塞性呼吸睡眠暂停(OSA)与鼻阻力的相关性.方法40例OSA患者及30例鼾症患者在进行多导睡眠检测的基础上行鼻阻力的检测.结果OSA组鼻阻力为(1.84±6.69)Pa@s/ml,对照组为(0.40±0.13)Pa@s/ml(P＜0.05).鼻阻力与鼾声指数呈正相关(r=0.679,P＜0.05),但鼻阻力与睡眠呼吸紊乱指数(AHI)、觉醒次数、最低血氧、平均血氧饱和度无相关性.结论鼾症、OSA患者的鼻阻力增加,可能与OSA的发生有关.     

鼻部手术对阻塞性睡眠呼吸暂停综合征治疗的意义

目的探讨鼻部手术对阻塞性睡眠呼吸暂停低通气综合征（OSAHS）的治疗意义。方法34例OSAHS患者均经PSG、鼻内镜、鼻咽纤维镜检查确诊,同时存在鼻阻塞性病变并行鼻部相关手术。术后2月复查PSG,26例无效患者再联合UPPP。结果34例患者鼻部手术后2月行PSG检查有效8例,术前AHI 11．9±5．8,最低SaO2 87．8±2．9,术后AHI 5．8±5．2,最低SaO2 91．8±4．4,均为轻度OSAHS。26例无效病例再联合UPPP术,术后半年复查PSG,AHI有明显改善。随访1年均无复发。结论单纯鼻部手术对部分以鼻阻塞为主的轻度OSAHS有效。术后再行睡眠监测对是否选择联合腭咽手术有指导意义。     

鼻阻塞对阻塞性睡眠呼吸暂停低通气综合征的影响研究

目的 分析研究鼻阻塞对阻塞性睡眠呼吸暂停低通气综合征（OSAHS）的影响.方法 回顾性分析该院在2011年12月-2012年12月期间收治的118例OSAHS患者的临床资料,其中59例伴有鼻阻塞为实验组,59例无鼻阻塞为对照组,对比分析两组的舌位评分的分布、AHI检查情况及鼻声反射的测试情况.结果 两组患者的舌位评分和睡眠呼吸暂停低通气指数（AHI）为正相关性（r=0.301,P ＜0.01） .且实验组Ⅲ及Ⅳ型相对危险度显著高于对照组,同时鼻声反射的测试值显著低于对照组,差异具有统计学意义（P＜0.05或P＜0.01）.结论 对于舌位评分为Ⅲ及Ⅳ型的OSAHS患者来说,鼻阻塞可增加AHI值及相对危险度,在临床中需要严格重视.     

鼻声反射指导下鼻腔扩容术的临床分析

目的:观察并探讨鼻声反射技术在指导鼻内镜下鼻腔扩容术中的作用和临床疗效。方法:随机选取某院采用鼻声反射指导下鼻腔扩容术的105例鼻腔阻塞患者,对其临床资料和治疗效果进行回顾性分析,术前及术后3个月,患者需接受鼻声反射检查,对NV(鼻腔容积)、MCA(最小截面积)、MNCA(鼻腔平均截面积)以及鼻阻力(NR)进行计算,指导进行鼻腔扩容术,并进行统计学分析。结果:鼻腔平均截面积(MNCA)、鼻腔最小横截面积(MCA)、鼻腔容积(NV)检测结果术后较术前显著变大,鼻阻力(NR)较术前减小,3项指标的差异有统计学意义(P0.05)。结论:鼻声反射可以很好地指导鼻腔扩容手术并可以作为术后效果的客观评价指标。     

重症阻塞性睡眠呼吸暂停低通气综合征序列治疗的作用探讨

目的探讨重症阻塞性睡眠呼吸暂停低通气综合征的治疗方法。方法对14例重度阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者上气道各平面解剖结构进行详细检查,并对每例患者各狭窄平面进行鼻内镜手术和（或）韩氏悬雍垂腭咽成形术（H-UPPP）、等离子刀系统辅助舌根减容术等序列治疗。结果重度OSAHS患者大多存在上气道多平面解剖结构的阻塞,鼻腔、腭咽平面及舌咽平面阻塞者常见。全部患者在术前、术后6个月及术后1年进行临床随访和PSG监测。序列治疗后6个月有效率为100%,1年有效率为93%,术后PSG监测示AHI和LSaO_2均较术前有明显变化（均P＜0．01）。结论对重度OSAHS患者进行序列治疗效果确切可靠。     

Nasal spirometery

Nasal obstruction is a common symptom which is difficult to quantify clinically. Rhinomanometry, Acoustic Rhinometry and Forced Oscillation methods are available for estimating nasal resistance but, these require sophisticated machines. Because of limited availability of these techniques, this potential physiological measure has not been tapped fully for research and clinical purposes. Here, we describe the use of pulmonary spirometer with little modification for quantification of nasal flow. Nasal inspiratory and expiratory flow rates along with oral inspiratory and expiratory flow rates are used to derive different nasal resistance indices. This way of reporting nasal resistance is not new but, the data for these variables is currently not available in published literature. The reproducibility of nasal flow rates were tested as variation after one day and the interclass coefficient for inspiratory and expiratory nasal flow rates were found to be with in acceptable limits. Thus, nasal spirometery is able to describe the nasal resistance in a reliable manner and may be used to quantify nasal obstruction in pathological condition and also to study the physiological phenomenon like nasal cycle.     

64层多排螺旋CT在阻塞性睡眠呼吸暂停低通气综合征诊断中的临床价值

目的探讨64层多排螺旋CT在阻塞性睡眠呼吸暂停低通气综合征（OSAHS）诊断中的临床价值。方法选取2013年1月~2014年6月于本院经PSG确诊为OSAHS的患者42例（观察组）及正常健康志愿者30例（对照组）,所有对象分别于平静呼吸、深呼气末、闭口堵鼻深吸气、深吸气末4个时相行上气道64层多排螺旋CT扫描。测量各咽部截面面积、横径、矢径,软腭厚度及长度,观察研究对象的上气道阻塞状况。结果观察组的腭后区、舌后区及咽喉部塌陷度均明显高于对照组（P〈0.05）。观察组的软腭长度长于对照组,软腭厚度大于对照组（P〈0.05）;42例OSAHS患者中,单点阻塞20例,阻塞长度为7.7~44.1 mm,多点阻塞5例,阻塞长度为34.8~45.1 mm;单时相阻塞19例,阻塞长度为1.3~45.1 mm,多时相阻塞6例,阻塞长度为14.3~38.8 mm间;其中17例未见明显阻塞点。结论 OSAHS患者腭后区、舌后区及咽喉部气道狭窄、堵塞及气道塌陷度提升是导致OSAHS的重要原因,应用64层多排螺旋CT观察OSAHS患者的上气道变化情况准确、快捷,在OSASH的临床诊断中有较高的应用价值。     

Safety pharmacology of the respiratory system: Techniques and study design

The known effects of drugs from a variety of pharmacologic/therapeutic classes on the respiratory system and worldwide regulatory requirements support the need for conducting respiratory evaluations in safety pharmacology. The objective of these studies is to evaluate the potential for drugs to cause secondary pharmacologic or toxicologic effects that influence respiratory function. Changes in respiratory function can result either from alterations in the pumping apparatus that controls the pattern of pulmonary ventilation or from changes in the mechanical properties of the lung that determine the transpulmonary pressures (work) required for lung inflation and deflation. Defects in the pumping apparatus are classified as hypo- or hyperventilation syndromes and are evaluated by examining ventilatory parameters in a conscious animal model. The ventilatory parameters include respiratory rate, tidal volume, minute volume, peak (or mean) inspiratory flow, peak (or mean) expiratory flow, and fractional inspiratory time. Defects in mechanical properties of the lung are classified as obstructive or restrictive disorders and can be evaluated in animal models by performing flow-volume and pressure-volume maneuvers, respectively. The parameters used to detect airway obstruction include peak expiratory flow, forced expiratory flow at 25 and 75% of forced vital capacity, and a timed forced expiratory volume, while the parameters used to detect lung restriction include total lung capacity, inspiratory capacity, functional residual capacity, and compliance. Measurement of dynamic lung resistance and compliance, obtained continuously during tidal breathing, is an alternative method for evaluating obstructive and restrictive disorders, respectively, and is used when the response to drug treatment is expected to be immediate (within minutes post-dose). The species used in the safety pharmacology studies conducted in our laboratory are the same as those used in toxicology studies since pharmacokinetic and toxicologic/pathologic data are available in these species. These data can be used to help select test measurement intervals and doses and to aid in the interpretation of functional change. The techniques and procedures for measuring respiratory function parameters are well established in guinea pigs, rats, and dogs.     

Evidence of adequacy of the performance of the Pulvinal by measuring through-device peak inspiratory flow rate in severe airways obstruction in adults and children.

Pulvinal is a novel DPI designed to deliver inhaled drugs to the airways. Previous in vitro and in vivo data has suggested that the peak inspiratory flow rate (PIFR), measured through Pulvinal, does not depend on the severity of expiratory airflow obstruction and that the lowest PIFR values seem sufficient to deliver an effective bronchodilator dose. To study this further, we have investigated through-Pulvinal PIFR in categories of patients who are likly to generate low inspiratory flow rates. Three different patients' groups were selected (severe asthmatics, n = 52, including elderly) patients with severe chronic obstructive pulmonary disease (COPD, n = 21) and children with asthma (n = 16). This study aimed to measure the through-device PIFR and also to assess whether this correlated with measures of expiratory flow rate. Inspiratory flow measurements were made with a Pulvinal inhaler inserted into the adapted mouthpiece of a pneumotochograph. No significant correlations were seen between through-device PIFR and expiratory volumes or flow rates when expressed as percent predicted normal (forced expiratory volume in 1 sec [FEV1] and peak expiratory flow rate [PEFR]) in any of the three studied populations. A significant correlation was present for FEV1 (when expressed in liters) and through-device PIFR in the adult asthmatic and COPD study groups. In spite of the disease severity in adult populations and the age of children, the lowest generated PIFR values were within the range producing adequate performance of Pulvinal DPI (>20 L/min). We conclude that inspiratory flow rates generated through the Pulvinal inhaler can be adequate in asthma and COPD, including patients at the extremes of severity and age, who may theoretically have a limitation in their inspiratory flow.     

中重度阻塞性睡眠呼吸低通气综合征UPPP联合鼻内镜手术的综合治疗

目的分析阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者的临床资料,探讨中重度OSAHS患者的治疗经验。方法对56例中重度OSAHS患者,实施UPPP手术联合鼻中隔矫正等多平面手术,其中部分不接受CPAP治疗的重症OSAHS患者实施气管切开术,予以控烟、戒酒等行为治疗等综合治疗措施,术后随访6个月以上,判断疗效。对是否行气管切开手术的两组患者的年龄、打鼾病史、BMI等进行比较分析。结果患者术后打鼾明显减轻,呼吸暂停次数明显减少,血压、血糖等控制较为理想,气管切开术的重症患者出院前能顺利拔管。两组患者打鼾病史、BMI比较有统计学意义,气管切开组患者的打鼾病史较长[（13.40±9.74）年/（7.98±3.04）年,P=0.02]、年龄普遍偏大[（45.74±6.27）岁/（41.76±9.76）岁,P=0.11）、BMI指数提示超重和肥胖居多[（32.38±10.34）/（26.34±3.15）,P=0.02]。结论 UPPP联合鼻内镜手术的综合治疗是中重度OSAHS的有效措施;对于病史较长、年龄偏大、超重甚至肥胖的重度OSAHS患者,气管切开术是重要的预防措施之一。     

悬雍垂鄂咽成形术和鼻部手术同时完成治疗阻塞性睡眠呼吸暂停低通气量综合征

目的研究对合并鼻部和口咽部阻塞性睡眠呼吸暂停低通气量综合征,同时完成改良鄂咽成形手术（H-UPPP）和鼻内窥镜手术,探讨一次完成多平面手术对OSAHS患者的治疗方法。方法32例OSAHS的患者,年龄23～45岁,平均34.3岁,其中男30例,女2例,体重指数为21.8～35.7 kg/m2,术前睡眠呼吸暂停低通气指数（apnea and hypopnea index,AHI）15.4～39.7次/h,平均25.7次/h,最低血氧饱和度67～87,平均77术前鼻咽镜检查阻塞平面均位于鼻腔和口咽部,舌根和会厌均无狭窄。术前均行CT断层扫描鼻腔和口咽部明确诊断狭窄平面以确定个性化术士,手术全麻鼻腔插管现行鼻内镜手术术后硅胶管压迫支撑,再行H-UPPP手术。结果术后一周、两个月、六个月复查PTT睡眠监测,32例患者总有效100%。     

Effect of inspiratory and expiratory air flow on congestion and decongestion in the nasal cycle

The role of the inspiratory and expiratory airflow through nostrils during the process of breathing in the reflex reciprocal congestion and decongestion of the nasal cycle was examined in this study. Air flow through each nostril was measured separately in male subjects before and after four types of breathing practices for 15 min each consisting of (1) inspiration through the patent nostril and expiration through the congested nostril, (2) inspiration through congested nostril and expiration through patent nostril, (3) inspiration through both nostrils and expiration through mouth and (4) inspiration through mouth and expiration through both nostrils. The breathing practices had no effect on the congested nostril but caused decrease in air flow through the patent nostril, indicating congestion. It is suggested that the inspiratory and expiratory air flow through the nostrils caused reflex congestion of the patent nostril. The stimuli arising from the nasal mucosa due to air flow during breathing may form the basis for the reflex reciprocal congestion and decongestion of nostrils in the nasal cycle.     

POSTNATAL DEVELOPMENT OF RESPONSES TO AIRFLOW OBSTRUCTION

1. Obstruction of the upper airway could be an initiating factor in the Sudden Infant Death Syndrome (SIDS). Responses to upper airway obstruction include augmentation of respiratory efforts, active dilation of the upper airway and electrocortical arousal. Vulnerable individuals may fail to mount these responses effectively. 2. Respiratory and arousal responses to obstruction of the upper airway have been investigated in newborn lambs. In conscious lambs, nasal obstruction causes a profound augmentation of inspiratory efforts, mild asphyxiation and eventual formation of an oral airway. The ability to establish an oral airway involves both chemoreception and mechanoreception and improves with age. 3. In sleeping lambs, obstruction of tidal airflow leads to progressive hypoxaemia, augmentation of inspiratory efforts, bradycardia and arousal. Arousal occurs earlier and with less hypoxaemia and bradycardia in non-REM sleep than in REM sleep. Arousal occurs after inspiratory efforts have increased to the same extent during both sleep states, suggesting that mechanoreception, or a sense of inspiratory effort, is important in initiating arousal. 4. Obstruction of nasal tubes tends to cause arousal from sleep earlier, and with less hypoxaemia and less augmentation of inspiratory effort, than when a more compliant face mask is obstructed. This supports the suggestion that mechanoreception, which may be involved in the perception of inspiratory effort, is a determinant of arousal. 5. With increasing postnatal age, lambs become less arous-able in response to airflow obstruction when in REM sleep. This suggests that lambs may become progressively more vulnerable to the effects of airway obstruction during the immediate newborn period. 6. The ability to respond to upper airway obstruction is well developed at birth in normal lambs. Responses are affected by sleep-wake states, mode of airflow obstruction and postnatal age. Future studies will determine whether prenatal compromises, such as those thought to have influenced neural development in some SIDS victims, affect the ability of the neonate to respond adequately to upper airway obstruction.     

Vibratory stimulation of expiratory muscles inhibits respiration

Induced vibration of the respiratory muscles alters the breathing pattern but controversy persists concerning the most effective site to vibrate, the relative merits of sustained versus phase-locked vibration, and the neural mechanisms involved. In this study we applied a sustained vibratory stimulus to the expiratory intercostal or the external oblique abdominal muscle and compared its effects on tidal volume, inspiratory duration and mean inspiratory flow. Our objective was to deduce from the changes in these respiratory variables whether the sensory input evoked by the vibratory stimulation modulated the central inspiratory drive, the termination of inspiration, or both. Subjects rebreathed from a spirometer which initially contained pure oxygen without a CO2 absorber. Either unilateral or bilateral sustained vibration (100 Hz, 2 mm amplitude) was applied to the 7th or 8th intercostal space anterior to the midaxillary line where the intercostal muscle is a single layer and functions in expiration. Bilateral chest wall vibration suppressed the tidal volume in 7 of 9 subjects. In 4 of 9 subjects, the inspiratory duration was shortened, reflecting premature termination of inspiration. In 5 of 9 subjects, the mean inspiratory flow was reduced, reflecting depression of the central inspiratory drive. Sustained abdominal vibration suppressed tidal volume and reduced inspiratory duration in 4 of 5 subjects. Thus, sustained vibration of either of the expiratory muscles resulted in a reduction in tidal volume. We concluded that sensory input initiated by sustained vibration of abdominal muscles acts centrally to suppress the level of activity in inspiratory neurons.