复杂性睡眠呼吸暂停综合征诊断与治疗进展

目前持续气道正压通气(continuous positive airway pressure,CPAP)已被广泛用来治疗阻塞性睡眠呼吸暂停综合征(obstuctive sleep apnea syndrome,OSAS),然而部分OSAS患者经CPAP治疗后,当阻塞性呼吸暂停事件消除后中枢性睡眠呼吸暂停综合征和陈-施呼吸却增加,我们称这种睡眠呼吸紊乱为复杂性睡眠呼吸暂停综合征(complex sleep apnea syndrome,CompSAS).然而,它的概念、机制、治疗尚未完全明确,本文综述了近年来国内外学者对CompSAS的研究进展.     

内科危重症患者的诊治中应当注意睡眠呼吸暂停问题

睡眠呼吸暂停低通气综合征包括阻塞型睡眠呼吸暂停低通气综合征（obstructive sleep apnea-hypopnea syndrome,OSAHS）、中枢型睡眠呼吸暂停综合征（central sleep apnea syndrome,CSAS）、睡眠低通气综合征（sleep hypoventilation syndromeSHS）等。临床上以OSAHS最为常见。     

复杂型睡眠呼吸暂停综合征12例分析

目的 分析复杂型睡眠呼吸暂停综合征(complex sleep apnea syndrome,CompSAS)患者临床特点.方法 收集我院12例CompSAS患者作回顾性分析,比较经鼻持续气道正压通气(continuous positive airway pressure,CPAP)治疗前后睡眠质量、呼吸紊乱、压力变化...     

阻塞性睡眠呼吸暂停综合征的无创正压通气治疗

阻塞性睡眠呼吸暂停综合征（OSAHS）是较常见的呼吸道疾患,其特征是在夜间睡眠中反复发生上气道完全和（或）不完全阻塞,导致阻塞性睡眠呼吸暂停,伴有间断低氧血症或高碳酸血症。国外流行病学调查显示,成人OSAHS患病率为2％-4％,习惯性打鼾者中64％为OSAHS患者,尤以老年及老年鼾症者OSAHS的检出率高。自1981年澳大利亚学者首次报道用持续气道正压通气（CPAP）成功治疗OSAHS以来,无创通气已成为中、重度OSAHS患者最常用的治疗手段,其中无创正压通气（NIPPV）是其首选治疗方法,其疗效肯定。     

阻塞型睡眠呼吸暂停低通气综合征与血管内皮功能

睡眠呼吸暂停低通气综合征（sleep apnea-hypopnea syndrome，SAHS）是指每晚7小时睡眠中，呼吸暂停反复发作在30次以上或睡眠呼吸暂停低通气指数（AHI）超过5次以上。阻塞型睡眠呼吸低通气综合征（OSAHS）是最常见的一种类型，占90％以上。它以睡眠中反复出现的呼吸暂停、觉醒、低氧血症和高碳酸血症为特征，在临床上常可引起心、脑、肾等多系统器官功能损害。     

老年阻塞睡性眠呼吸暂停低通气综合征发病机制的研究进展

<正>睡眠呼吸暂停低通气综合征(sleep apnea hypopnea syndrome,SAHS)主要是指睡眠过程中由于上气道完全或部分阻塞和(或)呼吸中枢驱动降低导致的呼吸暂停和(或)低通气,造成低氧血症、高碳酸血症及睡眠中断的综合征,临床上最常见的类型为阻塞型(obstructive sleep apnea hypopnea syndrome,OSAHS),但在老年患者中中枢性睡眠呼吸暂停低通气综合征(cen-     

阻塞性睡眠呼吸暂停低通气综合征与扩张性心肌病

阻塞性睡眠呼吸暂停低综合征（obstructive sleep apnea hypopnea syndrome,OSAHS）在睡眠呼吸障碍疾病中发病率最高,对人体健康和生命的危害最大。OSAHS是一种以睡眠过程中反复发生的上气道完全或不完全阻塞而导致频繁发生的呼吸暂停或低通气量为特征的睡眠呼吸障碍性疾病,其成年人患病率约为4％[1]。     

复杂性睡眠呼吸暂停的现状及进展

近年来,睡眠医学发展迅速,对睡眠疾病的诊断和治疗也日益规范.睡眠呼吸障碍,作为最常见的睡眠障碍之一,也引起了越来越多临床医生和科研人员的关注.对于睡眠呼吸暂停,人们早已熟知的是阻塞型睡眠呼吸暂停(obstructive sleep apnea,OSA)、中枢性睡眠呼吸暂停(central sleep apnea,CSA)、和混合型睡眠呼吸暂停,而在临床上有一种特殊的情况,那就是复杂性睡眠呼吸暂停(complex sleep apnea syndrome,CompSAS),至今人们对它还没有足够的了解,且世界各地的睡眠学者们一直对于CompSAS是不是一个独立的疾病存在争议[1-2].美国睡眠医学会(American academy of sleep medicine,AASM)称,睡眠障碍国际分类第三版(ICSD-3)将于2013年问世,其中一个重要的改变,就是要将复杂性睡眠呼吸暂停这一项独立列出.因此,本文将基于现有的研究结果介绍CompSAS,旨在让更多的人对其加深了解.     

睡眠呼吸暂停综合征与2型糖尿病

睡眠呼吸暂停综合征(sleep apnea syndrome,SAS)与糖尿病均为老年人常见病.2008年国际糖尿病联盟指出2型糖尿病与阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea-hypopnea syndrome,OSAHS)具有较强相关性.约30％OSAHS患者患有糖尿病,这些糖尿病患者中新发病例占40 ％[1];而且这些患者同时患有SAS的比率高达58％,患有OSAHS的比率为23％[23].     

氧化应激与睡眠呼吸暂停综合征

睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnen syndrome，OSAHS）是一种常见的呼吸系统疾病，它严重危害人类的健康。OSAHS患者在睡眠过程中，间断上气道阻塞引起反复呼吸暂停、血氧饱和度的下降及组织缺氧，继之发生高通气血氧恢复，这种现象叫做缺氧／再氧合（hypoxia／reoxygenation），     

Complex sleep apnea unmasked by the use of a mandibular advancement device

According to most accepted definitions, complex sleep apnea syndrome (CompSAS) is described as an emergence of central apneas in a patient with obstructive sleep apnea (OSA) upon introduction of continuous positive airway pressure therapy (CPAP). We present two patients who developed comparable central apnea activity when treated with either a CPAP device or a mandibular advancement device. As similar findings have been previously documented in patients with OSA treated with maxillofacial surgery or tracheostomy, we propose that the current definition of CompSAS should broaden to include diagnosis of CompSAS in non-PAP-treated patients, who are managed with either a dental appliance or a surgical procedure.     

Continuous positive airway pressure intolerance associated with elevated nasal resistance is possible mechanism of complex sleep apnea syndrome

Purpose

Complex sleep apnea syndrome (CompSAS) is diagnosed after an elimination of obstructive events with continuous positive airway pressure (CPAP), when a central apnea index ??5/h or Cheyne?CStokes respiration pattern emerges in patients with obstructive sleep apnea syndrome (OSAS). However, the pathophysiology of CompSAS remains controversial.

Methods

Of the 281 patients with suspected OSAS, all of whom underwent polysomnography conducted at Nagoya University Hospital, we enrolled 52 patients with apnea?Chypopnea index ??15/h (age 51.4?±?13.3?years). The polysomnographic findings, left ventricular ejection fraction (LVEF), and nasal resistance were compared between the CompSAS patients and OSAS patients.

Results

Forty-three patients were diagnosed with OSAS and nine patients with central sleep apnea syndrome by natural sleep PSG. Furthermore, 43 OSAS patients were classified into the OSAS patients (OSAS group, n?=?38) and the CompSAS patients (CompSAS group, n?=?5) by the night on CPAP PSG. The nasal resistance was significantly higher in CompSAS group than in OSAS group (0.30?±?0.10 vs. 0.19?±?0.07?Pa/cm³/s, P?=?0.004). The arousal index, percentage of stage 1 sleep, and oxygen desaturation index were significantly decreased, and the percentage of stage REM sleep was significantly increased in the OSAS group with the initial CPAP treatment, but not in the CompSAS group. In addition, the patients with CompSAS showed normal LVEF.

Conclusion

CPAP intolerance secondary to an elevated nasal resistance might relate to frequent arousals, which could presumably contribute to an increase in central sleep apnea. Further evaluation in a large study is needed to clarify the mechanism of CompSAS.     

Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes

BACKGROUND: Complex sleep apnea syndrome (CompSAS) is recognized by the concurrence of mixed or obstructive events with central apneas, the latter predominating on exposure to continuous positive airway pressure (CPAP). Treatment of CompSAS or central sleep apnea (CSA) syndrome with adaptive servoventilation (ASV) is now an option, but no large series exist describing the application and effectiveness of ASV. METHODS: Retrospective chart review of the first 100 patients who underwent polysomnography using ASV at Mayo Clinic Sleep Center. RESULTS: ASV titration was performed for CompSAS (63%), CSA (22%), or CSA/Cheyne Stokes breathing patterns (15%). The median diagnostic sleep apnea hypopnea index (AHI) was 48 events per hour (range, 24 to 62). With CPAP, obstructive apneas decreased, but the appearance of central apneas maintained the AHI at 31 events per hour (range, 17 to 47) [p = 0.02]. With bilevel positive airway pressure (BPAP) in spontaneous mode, AHI trended toward worsening vs baseline, with a median of 75 events per hour (range, 46 to 111) [p = 0.055]. BPAP with a backup rate improved the AHI to 15 events per hour (range, 11 to 31) [p = 0.002]. Use of ASV dramatically improved the AHI to a mean of 5 events per hour (range, 1 to 11) vs baseline and vs CPAP (p < 0.0001). ASV also resulted in an increase in rapid eye movement sleep vs baseline and CPAP (18% vs 12% and 10%, respectively; p < 0.0001). Overall, 64 patients responded to the ASV treatment with a mean AHI < 10 events per hour. Of the 44 successful survey follow-up patients contacted, 32 patients reported some improvement in sleep quality. CONCLUSION: The ASV device appears to be an effective treatment of both CompSAS and CSA syndromes that are resistant to CPAP.     

Natural course of complex sleep apnea—a retrospective study

Patients with complex sleep apnea syndrome (CompSAS) have obstructive sleep apnea but develop troublesome central sleep apnea activity or Cheyne–Stokes breathing when provided continuous positive airway pressure (CPAP) therapy. We examined whether CompSAS activity persists with long-term CPAP treatment. We retrospectively identified all patients with CompSAS who underwent two therapeutic polysomnograms (PSGs) separated by at least 1 month during 2003–2005. We compared PSG findings between the initial and follow-up study and noted clinical responses to therapy. We identified 13 CompSAS patients meeting criteria. Most follow-up PSGs were ordered after an abnormal overnight oximetry on CPAP or because of CPAP intolerance after 195 (49–562) days. The residual apnea–hypopnea index (AHI) on CPAP decreased from 26 (23–40) on the first PSG to 7 (3–21.5) on the follow-up PSG. Only seven patients reached AHI < 10 and 6 had AHI ≥ 10 (“CPAP nonresponders”) at follow-up. “CPAP nonresponders” were sleepier (Epworth Sleepiness Score 13 [12.5–14] vs 9 [6–9.5], p = 0.03) and trended toward lower body mass index (29.7 [28.6–31.6] vs 34.3 [32.5–35.1], p = 0.06). Both groups were equally compliant with CPAP therapy. Although the AHI tends to improve over time in CompSAS patients treated with CPAP, in this retrospective study nearly half-maintained a persistently elevated AHI. A prospective trial is merited to determine the optimal treatment for these patients.     

适应性伺服通气治疗复杂性睡眠呼吸暂停综合征的长期疗效分析

目的 探讨适应性伺服通气(adaptive servo ventilation,ASV)治疗复杂性睡眠呼吸暂停综合征(complex sleep apnea syndrome,CompSAS)的长期疗效.方法 收集2014年6月至2016年6月在民航总医院睡眠中心诊断为CompSAS且愿意接受长期(90 d以上)ASV治疗的患者.于治疗前、持续气道正压通气(continuous positive airway pressure,CPAP)滴定、ASV滴定及ASV治疗90 d时进行睡眠呼吸监测,观察长期ASV治疗对睡眠结构及睡眠呼吸事件的改变;分析长期ASV治疗依从性及相关不良事件.结果 本研究共收集42例CompSAS患者,其中接受长期ASV治疗的患者共有22例.该22例CompSAS患者均为男性,均患有严重OSAHS,平均睡眠呼吸暂停低通气指数(apnea hyponea index,AHI)为(45.76±10.08)次/h;其中平均仰卧位AHI达(55.76±8.25)次/h.左室射血分数大致正常.经过CPAP滴定治疗CompSAS患者AHI、阻塞性睡眠呼吸暂停指数(obstructive apnea index,OAI)、混合性睡眠呼吸暂停指数(mix apnea index,MAD较治疗前显著下降,中枢性睡眠呼吸暂停指数(central apnea index,CAI)较治疗前显著升高;最低血氧饱(lowest oxygen saturation,LSpO2)和度较治疗前显著升高;快动眼(rapid eye movement,REM)睡眠比例较治疗前显著增加.与治疗前及CPAP滴定治疗时相比,ASV滴定及ASV治疗90 d时N3期显著增加,N1期+N2期显著降低;AHI、CAI及MAI均显著降低;LSpO2显著升高.此外,与CPAP滴定时比较,ASV滴定及ASV治疗90 d时睡眠效率显著提高;与治疗前比较,REM期在ASV滴定及ASV治疗90 d时显著提高.长期治疗过程中,ASV平均使用时间为4.8 h/晚.3例患者曾有胸闷表现,调整治疗后胸闷消失.结论 对于无严重心肺疾病及脑血管病的CompSAS患者,ASV长期治疗几乎完全能够消除睡眠呼吸事件,提高睡眠质量,患者依从性好且未见严重不良反应.     

Clinical heterogeneity of patients with complex sleep apnea syndrome

Background

The definition of complex sleep apnea (CompSAS) encompasses patients with obstructive sleep apnea (OSA) who develop central apnea activity upon restitution of airway patency. Presence of arterial hypertension (HTN), coronary artery disease (CAD) and heart failure (HF) have been proposed as risk factors for CompSAS among OSA patients. Using our database of patients with CompSAS, we examined the prevalence of these risk factors and defined other clinical characteristics of patients with CompSAS.

Methods

Through retrospective search of the database, we examined the medical and clinical characteristics of consecutive patients diagnosed with CompSAS between 11/1/2006 and 6/30/2011 at NorthShore University HealthSystem.

Results

One hundred and fifty patients with CompSAS were identified. Among patients included in the study, 97 (64.7 %) had at least one risk factor for CompSAS, while 53 (35.3 %) did not have any of them. Prevalence of low left ventricular ejection fraction and hypocapnia were low. Therapeutic interventions consisted of several positive airway pressure therapies, mainly adaptive servo ventilation. A hundred and ten patients (73.3 %) complied with recommended therapy and improved clinically.

Conclusions

Although most patients with CompSAS have cardiac comorbidities, about one third of patients do not have any risk factors of CompSAS prior to sleep testing. Further research on factors involved in development of CompSAS will allow for better tailoring of therapy to pathophysiology involved in an individual case.     

A continuous positive airway pressure trial as a novel approach to the diagnosis of the obstructive sleep apnea syndrome

OBJECTIVES: Treatment of obstructive sleep apnea syndrome (OSA) is often delayed because polysomnography, the recommended standard diagnostic test, is not readily available. We evaluated whether the diagnosis of sleep apnea could be inferred from the response to a treatment trial with nasal continuous positive airway pressure (CPAP). DESIGN: Study on diagnostic accuracy. SETTING: Sleep-disorders clinic of a university hospital. PATIENTS: Seventy-six sleepy snorers consecutively referred for sleep apnea evaluation. INTERVENTIONS: CPAP treatment trial over 2 weeks as an initial diagnostic test in comparison with polysomnography, and treatment success over > or = 4 months. MEASUREMENTS AND RESULTS: The main outcome was diagnostic accuracy of the CPAP trial. The trial result was positive if the patient had used CPAP for > 2 h per night and wished to continue therapy. This suggested sleep apnea. The trial was evaluated in terms of predicting an obstructive apnea/hypopnea index (AHI) > 10/h during polysomnography performed for validation, and in terms of identifying sleep apnea patients treated successfully over > or = 4 months. Forty-four of 76 patients (58%) had sleep apnea as confirmed by an AHI > 10/h. The CPAP trial predicted sleep apnea with a sensitivity of 80%, a specificity of 97%, and positive and negative predictive values of 97% and 78%, respectively. In 35 of 76 sleep apnea patients (46%) with positive CPAP trial results, polysomnography could have been avoided. These patients were prescribed long-term CPAP therapy. After 4 months, 33 of 35 patients (94%) still used CPAP, and their symptoms remained improved. These patients were identified by the CPAP trial with positive and negative predictive values of 92% and 100%, respectively. CONCLUSIONS: In a selected population, a CPAP trial may help to diagnose OSA, to identify patients who benefit from CPAP, and to reduce the need for polysomnography.     

Obesity, Sleep Apnea Syndrome, and Rhythmogenic Risk

Obstructive sleep apnea is a common disorder and affects approximately 4% of middle-aged men and 2% of middle-aged women. Obstructive sleep apnea is clearly associated with obesity, with more than 50% of patients having a body mass index>30 kg/m2. Substantial evidence identified obstructive sleep apnea as risk factor not only for excessive daytime sleepiness and road traffic accidents, but also for increased cardiovascular morbidity and mortality. In addition, all kinds of arrhythmias have been observed in patients with sleep apnea ranging from asymptomatic sinus bradycardia to sudden cardiac death. Approximately 5-10% of patients with obstructive sleep apnea show marked apnea-related bradyarrhythmias due to enhanced vagal tone and pronounced hypoxia. Therapeutic options in obese patients with obstructive sleep apnea include consequent weight loss and nasal continuous positive airway pressure (CPAP) ventilation as the therapy of first choice. Weight reduction and effective nasal CPAP therapy significantly decrease cardiovascular morbidity and mortality and eliminate sleep-related bradyarrhythmias in 80-90% of patients obviating the need for pacemaker implantation in these patients.     

The effects of continuous positive airway pressure on prehypertension and masked hypertension in men with severe obstructive sleep apnea

Obstructive sleep apnea and hypertension are common conditions that frequently coexist. Continuous positive airway pressure (CPAP) reduces blood pressure in patients with obstructive sleep apnea and sustained hypertension. However, the impact of CPAP on patients with obstructive sleep apnea and prehypertension and masked hypertension, conditions associated with increased cardiovascular risk, is unknown. Thirty-six male patients (age, 43 ± 7 years; body mass index, 28.8 ± 3.0 kg/m(2)) with untreated severe obstructive sleep apnea (apnea-hypopnea index, 56 ± 22 events/hr on polysomnography) with diagnostic criteria for prehypertension and/or masked hypertension, based on office and 24-hour ambulatory blood pressure monitoring, respectively, were studied. The patients randomized to no treatment (control; n=18) or CPAP (n=18) for 3 months had similar frequency of prehypertension and masked hypertension at study entry. There were no significant changes in blood pressure in patients randomized to the control group. In contrast, patients randomized to CPAP presented significant reduction in office systolic (from 126 ± 5 to 121 ± 7 mm Hg; P=0.001) and a trend for diastolic blood pressure (from 75 ±7 to 73 ± 8 mm Hg; P=0.08) as well as a significant decrease in daytime and nighttime systolic and diastolic blood pressure (P<0.05 for each comparison). There was a significant reduction in the frequency of prehypertension (from 94% to 55%; P=0.02) and masked hypertension (from 39% to 5%; P=0.04) only in the CPAP group. In conclusion, effective CPAP therapy promotes significant reduction in the frequency of prehypertension and masked hypertension by promoting significant blood pressure reductions in patients with severe obstructive sleep apnea.