手术治疗对阻塞性睡眠呼吸暂停综合征患儿睡眠结构的影响

目的观察扁桃体和(或)腺样体切除术后阻塞性睡眠呼吸暂停综合征(OSAS)儿童睡眠结构的改变，探讨OSAS儿童术后症状改善的病理生理学基础。 方法对1998年12月至2003年10月广州市儿童医院收治的115例OSAS儿童进行扁桃体和(或)腺样体切除，并分别于术前及术后3个月于夜间睡眠时进行多导睡眠监测。比较手术前后宏观睡眠结构和微观睡眠结构的变化。 结果手术治疗对OSAS儿童宏观睡眠结构无明显改善。微观睡眠结构：术后觉醒指数(27±02)较术前(62±04)明显减小(t=725,P<001)。 结论扁桃体和(或)腺样体切除对OSAS儿童睡眠结构的改善主要体现在微观睡眠结构上，即觉醒指数明显减小。因此微观睡眠结构的改善应该是OSAS儿童术后症状改善的病理生理学基础。     

小儿睡眠呼吸暂停综合症与监测体会

目的：对50例腺样体肥大、打鼾患儿进行睡眠监测,分析睡眠指数。方法：采用美国伟康公司Alice4多导睡眠监测仪,每例患儿监测的参数包括脑电图、眼电图、下颌肌电图、口鼻气流、胸腹呼吸运动、SpO_2、体位、心电图等。结果：睡眠指数与腺样体肥大程度呈正比。轻度13例,中度15例,重度19例,其余3例在正常范围内。结论：在临床工作中发现,睡眠指数偏高多数发生于肥胖、腺样体肥大患儿,通过睡眠监测,正确评估和诊断小儿阻塞性睡眠呼吸暂停低通气综合症（OSAHS）。     

儿童药物诱导睡眠内镜检查的回顾与展望

阻塞性睡眠呼吸暂停是一种常见的儿童睡眠呼吸障碍性疾病。虽然腺样体扁桃体切除术是儿童阻塞性睡眠呼吸暂停的一线治疗方案,但据报道仍有很多患儿在术后出现持续性的症状或体征。药物诱导睡眠内镜是近年来逐渐受到关注并迅速发展起来的一项检查技术,它可以让临床医师在模拟生理睡眠的状态下直接观察上气道塌陷情况,为患儿制定个体化治疗方案,提高手术的成功率。目前关于儿童药物诱导睡眠内镜的检查仍存在很多争议,本文的目的是对其近期的发展进行系统性的综述,以便未来进一步的研究。     

等离子扁桃体切除术治疗儿童鼾症的疗效观察

目的探讨低温等离子扁桃体切除术与常规扁桃体剥离术对儿童鼾症患者的影响。方法选取我科2019年7~11月入院的儿童阻塞性睡眠型呼吸暂停综合征患儿146例为研究对象,随机分为观察组76例与对照组70例。所有患儿均行扁桃体切除,对照组采用常规剥离,观察组采用等离子消融术,两组合并腺样体肥大的患儿均采用等离子消融术,上述操作由同一术者完成。比较双侧扁桃体切除所需时间以及术中出血量;比较术后1~4 d的咽痛情况;白膜完全脱落的时间以及两组患儿手术前后生活质量的改善程度。比较两组中单纯扁桃体切术与合并腺样体肥大术后咽痛情况及白膜脱落时间。结果观察组手术时间、术中出血量低于对照组,差异有统计学意义(P<0.05);术后1 d观察组咽痛轻于观察组,术后4 d,单纯扁桃体咽痛轻于合并腺样体肥大,差异有统计学意义(P<0.05);观察组白膜完全脱落时间较对照组长,差异有统计学意义(P<0.05);术后生活质量改善程度比较差异无统计学意义(P>0.05)。结论等离子扁桃体切除术较常规扁桃体剥离术手术时间短,术中出血少,术后早期咽部不适症状较轻,应对复杂的扁桃体切除术具有明显的优势。     

300例低温等离子辅助鼻内窥镜儿童腺样体及扁桃体切除术体会

目的分析应用低温等离子刀完整切除腺样体及扁桃体患儿术中、术后的效果。方法选取2015年1月至2016年5月在沈阳市儿童医院行腺样体及扁桃体切除术患儿300例,应用低温等离子刀切除扁桃体及腺样体。结果应用等离子刀辅助鼻内窥镜切除扁桃体及腺样体手术术中出血少、手术切除精确、手术时间短、术后疼痛少、手术创面及腺样体并发症恢复良好。结论应用等离子刀辅助鼻内窥镜切除扁桃体及腺样体手术,临床效果显著,有效减少术中出血量,缩短手术时间,减轻术后疼痛,是治疗扁桃体肥大、腺样体肥大以及由腺样体肥大引起相关并发症非常有效的治疗方法。     

儿童阻塞性睡眠呼吸暂停低通气综合征合并与不合并注意缺陷/多动障碍的多导睡眠图的比较

目的通过对比合并与不合并注意缺陷多动障碍(ADHD)的阻塞性睡眠呼吸暂停低通气综合征(OSAHS)儿童的多导睡眠监测指标，试图从睡眠结构和 睡眠主要参数的层次上来探讨ADHD的发病机制。 方法选择2004-01—2006-10于广州市儿童医院就诊的OSAHS患儿36例作为OSAHS组，合并有OSAHS的ADHD患儿20例作为观察组，选取无OSAHS及 ADHD的儿童30例作为对照组，三组之间在年龄、性别、体重指数等方面相比，差异无显著性。通过多导睡眠监测(PSG)，并由神经康复科专科医 生对其是否患有ADHD作出诊断。采用相应的统计学方法，对OSAHS组、观察组及对照组的睡眠结构进行比较，并对OSAHS组和观察组进行呼吸事 件及血氧状况的比较。 结果(1)与对照组相比，OSAHS组及观察组睡眠Ⅰ期增加，睡眠Ⅱ期、SWS及REM睡眠减少，差异有统计学意义(P<0.05)，OSAHS组的REM%为8.66± 3.94，观察组的REM%为5.65±5.41，REM%的改变有统计学意义(P<0.05)。(2)观察组儿童呼吸事件的次数与持续时间及血氧饱和度下降较OSAHS 儿童严重，差异有统计学意义(P<0.05)。 结论观察组儿童REM%及血氧饱和度的下降可能在ADHD的发病中起一定的作用。     

多导睡眠图在儿童阻塞性睡眠呼吸暂停低通气综合征及鼾症中的应用

目的探讨阻塞性睡眠呼吸暂停低通气综合征(OSAHS)儿童及鼾症儿童多导睡眠图的特点及多导睡眠图对儿童睡眠障碍的临床应用价值。 方法对2002年12月至2004年9月新疆医科大学第一附属医院儿科74例OSAHS儿童及62例同年龄组原发性鼾症儿童进行整夜多导睡眠(PSG)监测，并进行比较，观察呼吸紊乱指数、觉醒次数、周期性腿动指数、睡眠最低血氧饱和度等16项指标。 结果与鼾症组相比，OSAHS儿童周期性腿动指数、呼吸紊乱指数、平均血氧饱和度、最低血氧饱和度、发生在非快速眼动期的呼吸紊乱指数有显著性差异(P<0.05)。 结论PSG是鉴别诊断儿童OSAHS与鼾症的重要方法，通过对PSG各项指标进行比较，强调PSG是诊断儿童睡眠有关疾患，特别是OSAHS的分型、病情评价的有用和重要方法。     

妇科手术合并睡眠呼吸暂停低通气综合征三例分析

睡眠呼吸暂停低通气综合征是发病率较高、具有一定潜在危险的疾患，表现为睡眠时反复发作性呼吸暂停和(或)低通气，产生低氧血症，并可导致多系统器官功能损害，在围手术期如不给予足够的重视，有可能发生猝死等严重后果。现对我院妇科近期手术病例中出现的3例此类病例资料总结分析如下。     

经鼻持续气道正压通气(NCPAP)治疗早产儿原发性呼吸暂停

目的:探讨经鼻持续气道正压通气(NCPAP)治疗早产儿原发性呼吸暂停的有效性及临床价值。方法:回顾性分析我院新生儿科2006～2010年收治132例原发性呼吸暂停早产儿。结果:132例患儿中11例患儿应用NCPAP治疗失败,改用呼吸机通气,余121例未使用呼吸机通气,均治愈出院。结论:经鼻持续气道正压通气(NCPAP)是治疗早产儿原发性呼吸暂停的有效方法。     

七氟醚复合瑞芬太尼在耳鼻喉科小儿扁桃体腺样体切除手术中的应用

目的探讨七氟醚复合瑞芬太尼在耳鼻喉科小儿扁桃体腺样体切除手术中的应用和安全性。方法选择2016年5月至10月开封市中心医院耳鼻喉科收治的行扁桃体腺样体手术治疗患儿120例,随机分为观察组和对照组各60例。观察组患儿采用七氟醚复合瑞芬太尼麻醉,对照组患儿采用丙泊酚复合瑞芬太尼麻醉。记录比较两组患儿不同时段心率、收缩压、舒张压的变化,麻醉恢复情况及不良反应发生情况。结果两组患儿麻醉前和拔管后5min的心率、收缩压、舒张压比较差异均无统计学意义(P0.05)。观察组插管后5min和手术开始后5min的心率、收缩压、舒张压均高于对照组,差异有统计学意义(P0.05)。手术结束后观察组患儿自主呼吸恢复时间、主观意识恢复时间和气管拔管时间均显著短于对照组,差异有统计学意义(P0.05)。两组患儿均未出现呼吸抑制、心律失常、喉痉挛、喉水肿。观察组躁动、哭闹、恶心呕吐发生率显著低于对照组,差异有统计学意义(P0.05)。结论耳鼻喉科小儿扁桃体腺样体切除手术中,采用七氟醚复合瑞芬太尼麻醉,具有较好的麻醉效果,术中血流动力学影响小,麻醉恢复快,不良反应发生率低,安全性高。     

Melnick-Needles syndrome with obstructive sleep apnea successfully treated with nasal continuous positive airway pressure ventilation.

Melnick-Needles syndrome is a rare disorder characterized by short stature, prominent forehead, bilateral exophthalmos, fullness of the cheeks and retrognathia. We report a 31-year-old female with Melnick-Needles syndrome complicated with severe obstructive sleep apnea syndrome (OSAS). Polysomnography demonstrated a respiratory disturbance index of 76.8/hour. Severe restrictive ventilatory impairment was also evident on pulmonary function tests. Surgical correction of the upper airway failed to improve OSAS symptoms, but nasal continuous positive airway pressure (CPAP) ventilation successfully improved both OSAS and restrictive ventilatory impairment. OSAS should be excluded in patients with Melnick-Needles syndrome and, if diagnosed, nasal CPAP may be a helpful treatment.     

Twin pregnancy and severe obstructive sleep apnea

Obstructive sleep apnea during pregnancy, associated with arterial hypertension, pre-eclampsia and adverse outcome of the newborn, has been described. Usually it can successfully be treated with non-invasive ventilation. A 36-year-old, twin-pregnant woman at 28 + 6 weeks of gestation presented with the complaints of snoring and nocturnal oxygen desaturations. Polysomnography confirmed the diagnosis of severe obstructive sleep apnea (respiratory disturbance index [RDI] 104/h, minimal oxygen saturation in pulse oximetry [SpO2/min] 75%). First therapeutic approaches including oxygen supplementation, non-invasive ventilation with continuous positive airway pressure (CPAP) or bilevel positive airway pressure--spontaneous (BiPAP-S) remained without success. Only after ventilation with bilevel positive airway pressure in spontaneous/timed modus (BiPAP-ST) combined with additional oxygen supplementation a satisfactory treatment result could be achieved (RDI 32/h, SpO2/min 85%). Because of progressive pre-eclampsia despite therapy at 31 + 0 weeks of gestation cesarean section was performed and 2 healthy children were delivered. After surgery non-invasive ventilation had to be continued for another six weeks before the condition improved. In contrast to the documented benefits of non-invasive positive pressure ventilation in pregnant women the literature, in our case even with sufficient therapy of sleep apnea progressive pre-eclampsia and premature delivery could not be prevented. Possible explanations include the short treatment duration and existence of twin pregnancy.     

Effects of nasal continuous positive airway pressure on patients with obstructive sleep apnea syndrome]

To evaluate the efficacy of nasal continuous positive airway pressure (CPAP) on patients with obstructive sleep apnea syndrome, 20 patients with moderate to severe obstructive sleep apnea syndrome (respiratory disturbance index greater than or equal to 20) were studied. The patients were evaluated using the Grass polysomnograph model 78 during an overnight sleep one to two weeks apart with and without a nasal CPAP produced by 10 to 15 cm of water. The results showed that nasal CPAP significantly reduced the respiratory disturbance index (RDI) (p less than 0.001) and the desaturation index (p less than 0.001), and significantly raised the lowest oxygen saturation level. Nasal CPAP not only reduced RDI, but also improved the respiratory patterns during obstructive apnea events by shifting the obstructive apnea events to hypopnea events. Nasal CPAP also significantly decreased the relative time spent in stage 1 NREM sleep (p less than 0.001), and increased the relative time spent in stages 3+4 NREM and REM sleep (p less than 0.05). Most of the patients also felt better the morning after using nasal CPAP. Nasal CPAP significantly reduced the frequency and duration of apnea and the degree of nocturnal oxygen desaturation, and improved the respiratory patterns during obstructive apnea events, as well as the sleep architecture in obstructive sleep apnea patients. We conclude that nasal CPAP is effective in moderate to severe obstructive sleep apnea syndrome patients.     

Continuous negative pressure in the treatment of infants with pulmonary hypertension and respiratory failure

We report the successful use of continuous negative pressure (CNP) with standard intermittent mandatory ventilation (IMV) in five patients suffering from respiratory failure and persistent pulmonary hypertension of the newborn (PPHN). These infants all fulfilled criteria for use of extracorporeal membrane oxygenation (ECMO) with PaO2 less than 40 torr, alveolar-arterial oxygen difference (AaDO2) greater than 620 mm Hg, and oxygenation index (OI) greater than 50. Despite a considerable amount of conventional ventilation with mean airway pressures (PAW) between 14 and 26 cm water, none of these patients were able to improve oxygenation. All infants demonstrated significant improvement in ventilation requirements after initiation of CNP as reflected by a decrease in PAW, proximal inspiratory pressure (PIP), and IMV. Oxygenation dramatically improved in all infants. All five patients survived without any pulmonary or neurological complications at discharge. Availability of CNP may circumvent the need for ECMO in infants with severe lung disease and PPHN.     

联合降阶梯方案治疗婴幼儿喘息 疗效及安全性研究

目的    探讨联合降阶梯方案治疗婴幼儿喘息的疗效和安全性。方法    以2010年10 至12月于上海交通大学医学院附属新华医院哮喘专科门诊及普通儿科呼吸门诊就诊的婴幼儿喘息患儿97例作为研究对象，以规范采用联合降阶梯疗法患儿作为治疗组，以仅采用门诊常规治疗的患儿作为对照组（非联合降阶梯疗法组）。两组均采用相同综合性治疗，包括吸氧、退热等对症处理。治疗组口服泼尼松5 mg/d，每天1次，疗程3 d；口服阿奇霉素0.1 g/（kg·d），疗程3 d；每晚用妥洛特罗贴剂1贴（0.5 mg/d），疗程7 d；口服氯雷他定3 mL/d，疗程 14 d；口服孟鲁司特钠4 mg/d，疗程 21 d。对照组采用目前门诊常用治疗方案，包括采用静脉滴注琥珀氢考或甲强龙、平喘药物、抗生素、祛痰止咳合剂、雾化吸入激素等。 结果    治疗组患儿咳嗽、喘息、哮鸣音评分及症状体征消失天数显著低于对照组（P < 0.05），治疗组1个月内复发次数、治疗费用、家长误工天数显著低于对照组（P < 0.05），且治疗组患儿对该方案接受度较高（P < 0.05）。 结论    联合降阶梯疗法应用于婴幼儿喘息疗效肯定，且方便、安全，值得临床应用推广。     

Rigid spine syndrome with chronic respiratory failure.

Rigid spine syndrome (RSS) is a rare myopathic ailment characterized by mild axial and proximal muscle weakness. Muscle contraction in these patients causes limitation of neck and trunk flexion, scoliosis, and mild joint deformity. We report the case of a 30-year-old man with RSS who presented with severe restrictive ventilatory defect (forced vital capacity, 1.53 L, 39% of predicted), mild scoliosis (Cobb's angle 12), proximal muscle weakness and stiff back. Creatine phosphokinase was 986 IU/L. Muscle biopsy of the right vastus lateralis revealed increased variation in muscle fiber diameter, proliferation of endomysium, and type I fiber atrophy. Round and whorled fibers indicating myopathic change were found on sections stained with nicotinamide adenine dinucleotide dehydrogenase and succinate dehydrogenase. RSS was diagnosed based on myopathic findings and clinical presentation. Nocturnal chronic respiratory failure and fragmented sleep developed. He was treated with continuous positive airway pressure and had recovered his normal daily activity by 1-year follow-up. We suggest that patients with RSS should be assessed for possible ventilatory failure; treatment with nasal continuous positive airway pressure or bilevel continuous positive airway pressure therapy should be considered.     

Anästhesie bei Adipositas

The proportion of the overweight population is steadily growing so that the anesthesiologist is increasingly confronted with patients who exhibit extensive pathophysiological characteristics. Comorbidities such as arterial hypertension, coronary heart disease, pulmonary hypertension, right and left heart failure, type 2 diabetes, sleep apnea syndrome, or gastroesophageal reflux are often observed. In addition to knowledge of the special features involved in these conditions, careful planning and good interdisciplinary teamwork are necessary to reduce the perioperative risk of these patients. When possible, methods of regional anesthesia should be given preference in these patients. During general anesthesia, the overweight patient with limited cardiopulmonary reserve is particularly at risk due to airway obstruction, perioperative hypoxemia, and aspiration.     

Clinical effectiveness and safety of permissive hypercapnia

Experimental and clinical data indicate that ventilator strategies with permissive hypercapnia may reduce lung injury by a variety of mechanisms. Seven randomized controlled trials in preterm neonates suggest that permissive hypercapnia started early, before the initiation of mechanical ventilation (in conjunction with continuous positive airway pressure), followed by prolonged permissive hypercapnia if mechanical ventilation is needed is an alternative to early ventilation and surfactant. Permissive hypercapnia may improve pulmonary outcomes and survival.     

超声新指标和脑利钠肽评估小儿室间隔缺损 合并肺动脉高压右室功能损害价值分析

目的    探讨组织多普勒（TDI）、二维斑点追踪技术（STI）和血清脑利钠肽（BNP）评估室间隔缺损（VSD）合并不同程度肺动脉高压（PH）患儿右心室功能的价值。方法    2008年6月至2010年6月在苏州大学附属儿童医院住院的VSD合并PH患儿68例,根据三尖瓣反流压差测得肺动脉压力程度分为轻度组（23例）、中度组（21例）、重度组（24例）。同时选择24名健康体检者作为正常对照组。采用GE VIVID7仪器测量右室长轴整体收缩期应变（GLS）和应变率（GLSR）,三尖瓣环脉冲组织多普勒图测量三尖瓣环收缩期峰值速度（Sa）、等容收缩加速度（IVA）、Tei指数,用M型超声测量三尖瓣环收缩期位移（TAPSE）。采用ELIASA法测血清脑钠钛（BNP）浓度。结果    （1） IVA和TAPSE随着PAH升高而降低,而Tei指数随着PAH增加而增大,3个指标除正常对照组和轻度组间差异无统计学意义外（P > 0.05）,其他各组间差异均有统计学意义（P < 0.05）。Sa在中、重度组间差异无统计学意义（P > 0.05）,在正常对照、轻度组间差异无统计学意义（P > 0.05）,其余组间有统计学意义（P < 0.05）。（2）右室GLS、GLSR随着PAH升高而减小,GLS在4组间两两比较差异有统计学意义（P < 0.05）;GLSR中度和重度组与正常对照组和轻度组差异有统计学意义（P < 0.05）,中重度间及正常对照组和轻度间差异无统计学意义（P>0.05）。（3）血清BNP浓度在VSD组中随着PAH程度的加重而升高,在4组间两两比较差异有统计学意义（P < 0.05）。（4）BNP与Tei指数及心功能分级相关性最好。结论    TDI和STI各个参数均能反映VSD合并PH患儿右心室功能,其中BNP和Tei指数与心功能相关性最好,而BNP和GLS可以反映轻度PAH时右室功能受损。     

Severe bronchopulmonary dysplasia – incidence and predictive factors in a prospective,multicenter study in very preterm infants with respiratory distress syndrome

Background: Severe bronchopulmonary dysplasia (BPD) remains a major complication of prematurity and can have significant impact on long-term pulmonary sequelae and adverse neurodevelopmental outcomes.

Objective: To assess the incidence and evaluate the predictive factors for severe BPD in very preterm infants with respiratory distress syndrome.

Methods: Of the 846 premature infants born at ≤32-week gestation who developed respiratory distress syndrome (RDS), 707 infants with known oxygen dependency at 36 weeks gestational age were included in the analysis of BPD incidence. With univariate and multiple logistic regression models we evaluated the risk factors for the development of severe BPD and calculated odds ratios (ORs).

Results: The overall incidence of BPD was 45.2%. Severe BPD accounted for 6%, with morbidity pertaining mainly to infants <29-week gestation (incidence 10%). The risk factors for severe BPD included male gender (OR 3.02 95%CI 1.30–7.46), intubation in the delivery room (OR 2.57, 95%CI 1.00–7.18), and invasive ventilation >7 days (OR 7.05, 95%CI 2.63–22.4). The protective factors were early continuous positive airway pressure (CPAP) in the univariate analysis and receiving surfactant <15?min after birth in the multivariate model.

Conclusions: Mechanical ventilation >7 days is the most prevalent risk factor for severe BPD. CPAP initiated in the delivery room and early surfactant are key preventive measures.