持续气道正压通气对阻塞性睡眠呼吸暂停患者睡眠结构的影响

目的探讨患者白天嗜睡等症状的原因,评估经鼻持续气道内正压通气(nCRAP)治疗对阻塞性睡眠呼吸暂停患者睡眠结构的影响。方法选择2001-2004年广东省佛山市第一人民医院呼吸科34例OSAS病人在睡眠多导生理记录仪监测下,进行nCPAP治疗,观察治疗前后呼吸紊乱指数、血氧饱和度和睡眠结构的变化。结果治疗后呼吸紊乱指数下降,最低血氧饱和度上升,睡眠结构明显改善。结论nCRAP能有效地改善OSAS病人的睡眠结构和呼吸紊乱。     

Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea

In an attempt to identify predictors of long-term compliance with nasal continuous positive airway pressure (CPAP), we reviewed the records of 125 patients with obstructive sleep apnea (OSA) referred to our center for nasal CPAP trials. Severity of sleep apnea, sleep staging, daytime hypersomnolence, effectiveness of nasal CPAP, previous palatal surgery, and adverse reactions were compared in compliant and noncompliant patients. Nineteen patients did not tolerate a nasal CPAP trial in the laboratory or refused home nasal CPAP therapy. Ten patients were unavailable for follow-up. Of the remaining 96 patients, 23 (24 percent) had discontinued therapy, while 73 (76 percent) were still using nasal CPAP at 14.5 +/- 10.7 months (mean +/- SD). There were no statistically significant differences between the compliant and noncompliant patients in baseline apnea plus hypopnea index (AHI), baseline sleep staging, AHI while receiving nasal CPAP, sleep staging while receiving nasal CPAP, or frequency of adverse reactions during therapy. Severe daytime sleepiness was present in 65 of the 73 compliant patients and in 12 of the 23 noncompliant patients (p less than 0.05). Ten of 43 in the compliant group had previous palatal surgery compared with ten of 23 noncompliant patients (p less than 0.05). Our data confirm earlier observations in smaller samples that compliant and noncompliant patients have equally severe sleep apnea and good initial responses to nasal CPAP. Long-term compliance with nasal CPAP may be associated with the severity of daytime hypersomnolence on presentation. Previous palatal surgery was more frequent in patients who did not tolerate long-term nasal CPAP therapy.     

Efficacy of nasal masks versus nasal pillows masks during continuous positive airway pressure titration for patients with obstructive sleep apnea

Purpose

Nasal masks are usually the first choice for CPAP therapy, but patients may experience side effects. There are limited data regarding the efficacy of nasal pillows masks during CPAP titration. This study aimed to compare the polysomnography outcomes during CPAP titration while comparing two types of masks (nasal and pillows) and to assess whether or not the patient characteristics differed between mask preferences.

Methods

In a sleep-disorders clinic, we prospectively analyzed all patients undergoing CPAP titration for three consecutive months. CPAP pressures were manually titrated. Anthropometric data (age, sex, body mass index, and neck and waist circumferences) and OSA severity were documented. Patients completed a self-administered questionnaire that measured nasal obstruction (NOSE scale). Before titration, both types of masks were presented to patients, and each of them chose the one they preferred.

Results

Of 157 patients, 55% (n = 86) used nasal masks, and 45% (n = 71) used nasal pillows masks. There was no difference according to mask type chosen by age, sex, body mass index, neck and waist circumferences, and NOSE scale. Polysomnography outcomes were similar between the mask groups. The mean CPAP level was 9.4 ± 1.8 cm H₂O for nasal masks and 9.1 ± 2.0 cm H₂O for nasal pillows (p = 0.61). Residual apnea-hypopnea index was 3.0 ± 2.8 events/h for nasal mask and 3.5 ± 4.1 events/h for pillow mask (p = 0.28). Baseline AHI, body mass index, neck and waist circumferences, and residual AHI were independent predictors of a higher CPAP pressure for both groups (p < 0.0001).

Conclusions

Nasal pillows masks seem to be as effective as nasal masks and may be considered to be an initial choice for CPAP titration.

     

Treatment of obstructive sleep apnea, other than with continuous positive airway pressure

Treatment, other than with continuous positive airway pressure, for patients with obstructive sleep apnea remains an active area of investigation. The long-established behavior modification approaches (eg, weight loss and avoidance of alcohol and sedatives) are applicable to many patients, though unlikely to be curative. Oral appliances and surgical techniques are used, although treatment success is hindered by the site-specific nature of the therapies. These treatments are traditionally used for the patient with mild sleep apnea, but more recent studies are questioning their possible benefits in a moderate-to-severe apnea patient population. Surgical techniques range from uvulopalatopharyngoplasty and more extensive skeletal modifications (maxillomandibular advancement), to laser-assisted uvulopalatoplasty and newer minimally invasive techniques. Preoperative evaluation, patient selection, and measures of success vary somewhat between publications, making comparison of treatments and their application to the individual patient challenging.     

Effect of nocturnal nasal continuous positive airway pressure on blood pressure in obstructive sleep apnea

Obstructive sleep apnea (OSA) is a very common risk factor for hypertension, and continuous positive airway pressure (CPAP) has been widely used to treat OSA. We conducted a meta-analysis of randomized, controlled trials to evaluate the effects of CPAP on blood pressure, reported as either a primary or secondary end point, among patients with OSA. Studies were retrieved by searching Medline (January 1980 to July 2006), the Cochrane Database of Systematic Reviews, conference abstracts, and bibliographies of review and original articles. From 255 relevant reports, 16 randomized clinical trials were selected that compared CPAP to control among participants with OSA, had a minimum treatment duration of 2 weeks, and reported blood pressure changes during the intervention or control period. Data on sample size, participant characteristics, study design, intervention methods, duration, and treatment results were independently abstracted by 2 investigators using a standardized protocol. Data from 16 trials representing 818 participants were examined using a random-effects model. Mean net change in systolic blood pressure for those treated with CPAP compared with control was -2.46 mm Hg (95% CI: -4.31 to -0.62); mean net change in diastolic blood pressure was -1.83 mm Hg (95% CI: -3.05 to -0.61); and mean net change in mean arterial pressure was -2.22 mm Hg (95% CI: -4.38 to -0.05). Net reductions in blood pressure were not statistically different between daytime and nighttime. These results indicate that CPAP decreases blood pressure among those with OSA and may help prevent hypertension.     

经鼻持续气道正压通气对阻塞性睡眠呼吸暂停综合征的综合疗效

经鼻持续气道正压通气（CPAP）是目前治疗阻塞性呼吸暂停综合征（OSAS）最有效的内科治疗方法,通过向气道内增加一定程度的正压,保持上气道通畅,消除患者夜间缺氧,改善患者夜间打鼾,白天嗜睡等临床症状,恢复睡眠结构,并治疗与此相关的各系统疾病,提高患者长期的生活质量。     

经鼻无创正压通气治疗阻塞性睡眠呼吸暂停综合征血栓前状态效果评价

目的评价经鼻无创正压通气(nCPAP)对阻塞性睡眠呼吸暂停综合征(OSAS)血栓前状态(PTS)的治疗效果。方法收集北京世纪坛医院2003年9月至2005年9月确诊的OSAS患者30例及同期健康对照者30名,血样采取均在经过前一夜睡眠监测及睡眠监测并nCPAP治疗后(OSAS组)仰卧位时立即进行。结果OSAS组与健康对照组比较,OSAS患者血液中血小板α颗粒膜蛋白-140(GMP-140)升高;部分凝血活酶时间(APTT)、抗凝血酶Ⅲ复合物(AT-Ⅲ)以及血浆组织型纤溶酶原激活物(t-PA)降低,血浆组织型纤溶酶原抑制物(PAI)升高,与健康对照组比较各个指标在两组之间的差异均有统计学意义。nCPAP治疗后OSAS组呼吸紊乱指数由(63.21±23.23)/h降至(0.56±0.84)/h,夜间最低血氧饱和度由0.68±0.07上升至0.90±0.02,GMP-140和PAI分别降至(17.07±7.97)%、(95.83±5.91)%,AT-Ⅲ和t-PA分别升高至(95.20±6.67)%、(5.45±1.61)μg/L。结论OSAS患者存在PTS,nCPAP治疗可部分或全部逆转PTS,减少与OSAS相关的心脑血管栓塞性疾病的发生。     

Prediction of continuous positive airway pressure in obstructive sleep apnea

Continuous positive airway pressure (CPAP) prediction formulas can potentially simplify the treatment of obstructive sleep apnea (OSA). However, they can be difficult to derive and validate. We tested a statistical method to derive and validate a CPAP prediction formula using the same sample population. Seventy-six OSA patients underwent polysomnography and CPAP titration. Anthropometric measures, sleep parameters, and the Epworth sleepiness scale (ESS) were evaluated as predictors. All subsets regression was used to determine the optimum number of variables in the model. The Bayes information criterion was used to find the best-fit model. The model was then evaluated by a tenfold cross-validation procedure. Subjects were obese (BMI 31.3 ± 5.4) and had significant daytime somnolence (ESS 11.9 ± 5). Mean respiratory disturbance index (RDI) was 53.5 ± 31.3. The ESS was not predictive of titrated CPAP. The best-fit model included three variables (CPAP_pred = 30.8 + RDI × 0.03 − nadir saturation × 0.05 − mean saturation × 0.2). This model explained 67% of the variance. Our data and the literature suggest that a combination of two to three factors is predictive of titrated CPAP: RDI, oxyhemoglobin saturation, and obesity. Except for RDI, the specific factors vary in each population. A CPAP prediction formula that explains a high proportion of the titrated CPAP variance can be easily derived from parameters measured during the diagnostic work-up of OSA patients using a unique statistical model that allows derivation and validation of the formula in the same test population.     

Periodic leg movements in sleep following treatment of obstructive sleep apnea with nasal continuous positive airway pressure

Periodic leg movements in sleep are shown to be a common finding in patients with OSA and may become evident or increase in severity after treatment of the OSA with NCPAP. Periodic leg movements in sleep were measured during baseline polysomnography, a NCPAP treatment trial, and a repeat NCPAP recording in 33 patients treated with NCPAP for OSA. During baseline PSG, nine patients had five or more PLMS per hour of sleep (index), while 14 patients had a PLMSI of 5 or more during the NCPAP trial and the repeat NCPAP recording. Among those patients with a PLMSI of 5 or more during repeat NCPAP studies, the PLMSI showed a significant increase from baseline to initial NCPAP (16.9 +/- 25.3 vs 39.3 +/- 29.4; p less than 0.001) and from baseline to repeat NCPAP (16.9 +/- 25.3 vs 42.9 +/- 39.8; p less than 0.05). The number of PLMS associated with electroencephalographic arousal also increased significantly from baseline to initial NCPAP (4.3 +/- 7.4 vs 9.7 +/- 8.9; p less than 0.05) and from baseline to repeat NCPAP (4.3 +/- 7.4 vs 16.5 +/- 18.6; p less than 0.05). The 14 patients with a PLMSI of 5 or more on the repeat NCPAP had significantly more stage 1 sleep and less REM sleep than 19 patients with a PLMSI of less than 5. Bilateral anterior tibialis EMG must be measured during NCPAP recordings in order to recognize sleep disruption caused by PLMS.     

经鼻持续气道正压通气对阻塞性睡眠呼吸暂停低通气综合征患者睡眠结构近远期的影响

目的　观察经鼻持续气道正压 (nCPAP)通气对阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者睡眠结构近远期的影响。方法　 17例对照者行多导睡眠图 (PSG)监测 ,对 30例经PSG诊断的OSAHS患者行nCPAP治疗 ,治疗第 1夜行PSG监测 ,连续家庭nCPAP治疗 6个月后行第 2次PSG监测 ,分析比较睡眠结构的变化。结果　OSAHS患者治疗前睡眠转换次数、1期、2期睡眠比例较对照组增加 (P <0 0 5 ) ,慢波睡眠期、快动眼 (REM )期比例较对照组低 (P <0 0 5 ) ;nCPAP治疗第 1夜睡眠转换次数、1期、2期睡眠比例较治疗前降低 (P <0 0 5 ) ,慢波睡眠期、REM期比例较治疗前升高 (P <0 0 5 ) ;nCPAP治疗 6个月后睡眠转换次数、1期、2期、慢波睡眠期比例与治疗第 1夜比较差异均无显著性 (P >0 0 5 ) ,而REM期比例较治疗第 1夜降低 (P <0 0 5 )。结论　OSAHS患者睡眠转换次数明显增多 ,1期睡眠增加而REM期睡眠减少 ,睡眠结构紊乱。nCPAP治疗第 1夜及6个月后睡眠结构得到有效纠正 ,是OSAHS长期有效的治疗方法之一。     

Arbitrary-pressure continuous positive airway pressure for obstructive sleep apnea syndrome

Current resources are inadequate to meet the demand for polysomnography, resulting in long waiting lists. This study aimed to evaluate the role of arbitrary-pressure continuous positive airway pressure (CPAP) as a method to reduce delays in commencing treatment. The study was of an open, randomized, parallel design. Ninety-one subjects with obstructive sleep apnea syndrome were randomized to either arbitrary-pressure CPAP based on body mass index before treatment polysomnography or to CPAP at settings determined by polysomnography. Both interventions resulted in similar improvements in clinical outcomes as determined by Epworth Sleepiness Score, Short Form-36 Quality of Life questionnaire, objective compliance, and subjective attitudes to treatment. There was higher sleep efficiency at treatment polysomnography in the group commenced at arbitrary pressure (81.8 +/- 10.1% [mean +/- SD] compared with 72.2 +/- 18.0%, p = 0.01). Subjects unable to tolerate CPAP were identified by the use of arbitrary pressure, leading to a reduction in the proportion of "wasted" treatment polysomnograms (studies performed in subjects not persisting with treatment) relative to commencing therapy after treatment polysomnography (3 of 39 compared with 12 of 35, p = 0.01). This approach to initiating treatment with CPAP appears feasible when there are long waiting lists for polysomnography.     

Neuropsychologic symptoms in obstructive sleep apnea improve after treatment with nasal continuous positive airway pressure

To describe the affective changes associated with sleep restoration we assessed psychologic symptoms using the Profile of Mood States questionnaire before and two months after treatment with nasal continuous positive airway pressure (NCPAP) in seven men with obstructive sleep apnea (OSA). The results were compared with those of a control group of patients with OSA who did not receive NCPAP. Two of six mood factors, depression and fatigue, improved significantly following treatment with NCPAP. Total Mood Disturbance (TMD) score was used to assess global mood differences. The mean TMD score for the patients before treatment was 1.7 and during treatment decreased to -7.6 (p less than 0.05). This mean decrease of 9.3 in the TMD score implies generalized improvement in mood. These findings support the opinion that sleep fragmentation and abnormalities of respiration during sleep are at least partially responsible for affective changes seen in sleep apnea. These psychologic disturbances improve after treatment with NCPAP.     

Effect of continuous positive airway pressure vs placebo continuous positive airway pressure on sleep quality in obstructive sleep apnea

STUDY OBJECTIVES: Continuous positive airway pressure (CPAP) therapy has become the treatment of choice for obstructive sleep apnea (OSA). However, the efficacy of CPAP therapy has not been evaluated against a suitable control. We investigated the effectiveness of CPAP therapy in improving sleep quality in patients with OSA. We hypothesized that CPAP improves sleep quality. PATIENTS: Forty-eight CPAP-naive OSA patients were evaluated. None were receiving antihypertensive medications, and none had major medical illnesses. DESIGN: Patients were randomized to receive either CPAP or placebo CPAP (CPAP at an ineffective pressure) for 7 days in a double-blind fashion. Forty-one patients completed the protocol. Sleep quality variables, arousals, sleep arterial oxygen saturation (SaO(2)), and respiratory disturbance index (RDI) were assessed at baseline, after 1 day of treatment, and after 7 days of treatment. Repeated measures analysis of variance was used to evaluate the effects of treatment, time, and the interaction of the two. RESULTS: As expected, CPAP lowered RDI and number of arousals, and increased SaO(2) over time (p = 0.001). Contrary to expectations, both CPAP and placebo CPAP had comparable effects on sleep quality as assessed by sleep architecture, sleep efficiency, total sleep time, and wake after sleep onset time. CONCLUSIONS: This study confirms the effectiveness of CPAP in lowering the number of arousals and the RDI, and in raising SaO(2). However, our data suggest that short-term CPAP is no different than placebo in improving sleep architecture. Further evaluation of the effectiveness of CPAP using a suitable placebo CPAP in prospective randomized studies is needed     

The effects of nasal continuous positive airway pressure on platelet activation in obstructive sleep apnea syndrome

OBJECTIVE: A case-controlled study to assess the effects of nasal continuous positive airway pressure (CPAP) on platelet activation in patients with obstructive sleep apnea (OSAS) syndrome. METHODS: We recruited 65 patients with suspected OSAS for this study. Blood samples were taken with the patient in the supine position in the morning immediately after polysomnography, and 1 night and 3 months after the start of nasal CPAP therapy to measure an index of platelet activation (IPA+), which reflected both the quantity and quality of platelet activation. Significant OSAS was defined as an apnea-hypopnea index (AHI) of > or = 10 events per hour. RESULTS: There were 42 patients with significant OSAS and 23 control subjects with AHI < 10 events per hour. The mean (+/- SD) age for the OSAS patients was 48 +/- 9 years, the mean body mass index was 30.7 +/- 4.8, the mean AHI was 47 +/- 25 events per hour, the mean arousal index (AI) was 37 +/- 23 events per hour, and the mean minimum arterial oxygen saturation was 74 +/- 11%. Following multiple linear regression analyses of the clinical and polysomnography parameters, AI was the independent factor that correlated best with the baseline IPA+ (beta-coefficient, 0.386; p = 0.006). Following nasal CPAP treatment with a mean objective CPAP compliance of 3.9 +/- 1.9 h per night, there was a significant decrease in IPA+ from 15.1 +/- 12.2 U (at baseline) to 12.2 +/- 5.2 U (p < 0.001) and 9.8 +/- 4.3 U (p = 0.005), respectively, after 1 night and 3 months, whereas no significant change was noted among the control subjects. Using univariate analysis of variance to compare the changes in IPA+ between the two groups at 3 months with adjustment for the baseline value, nasal CPAP reduced IPA+ by 5.63 (SE, 1.85), whereas IPA+ increased in control subjects by 1.33 (SE, 1.27) [least-squared mean difference between groups, 3.34; 95% confidence interval, 0.42 to 6.26; p = 0.026]. CONCLUSIONS: OSAS, through repeated episodes of arousals, may lead to platelet activation, which can be reduced by nasal CPAP therapy.     

Long-term acceptance of continuous positive airway pressure in obstructive sleep apnea

We studied the long-term acceptability of nasal continuous positive airway pressure (CPAP) treatment in 168 consecutive patients, 147 with obstructive sleep apnea (OSA) and 21 with snoring. Follow-up was between 1.5 and 78 months. At latest follow-up 107 of 168 (64%) were still using CPAP. Acceptance of CPAP was least for patients with snoring alone (6 of 21 persisted) and best for patients with both excessive daytime somnolence and severe hypoxemia (minimum SaO2 less than 75%), of whom 40 of 45 (89%) persisted with treatment. Patients with excessive daytime somnolence but without severe hypoxemia were less tolerant of CPAP (39 of 71, 55%, persisted) than patients with no symptoms of excessive somnolence but with severe hypoxemia (21 of 30, 70%, persisted). The most common reasons for discontinuing CPAP were intolerance of the mask (26 of 61), the inconvenience of treatment (16 of 61), and the lack of symptomatic benefit from treatment (10 of 61). We concluded that long-term acceptance of CPAP was difficult to predict in advance but that it was most likely in patients with the most severe sleep apnea. Because intolerance of the mask and inconvenience were the most common reasons for ceasing treatment, improvements in the design of CPAP systems and careful patient training may improve the acceptability of CPAP substantially.     

Renal function in patients with obstructive sleep apnea. Effects of nasal continuous positive airway pressure

Patients with obstructive sleep apnea (OSA) often exhibit nocturnal polyuria, which disappears with nasal continuous positive airway pressure (CPAP) treatment. We measured water and electrolyte urinary excretion, creatinine and osmolal clearances, and water transport during sleep in 13 polygraphically monitored patients with OSA during two consecutive nights, either untreated or treated with nasal CPAP, and in eight normal subjects. Untreated patients with OSA had greater urinary flows and greater urinary sodium, chloride, and potassium excretions than did controls. Nasal CPAP treatment in patients with OSA resulted in a reduction in urinary flow and in sodium and chloride excretion, with a concomitant increase in sodium resorption. None of these effects was observed in CPAP-treated normal subjects. The only effect of nasal CPAP common to normal subjects and patients was a trend toward decreased glomerular filtration rate.