小儿阻塞性睡眠呼吸暂停综合征并肺动脉高压２例围术期处理回顾分析

摘要：目的　探讨阻塞性睡眠呼吸暂停综合征（OSAHS）并肺动脉高压患儿的围术期处理方案。方法　回顾性分析2006年4月至2009年5月广州儿童医院收治的2例OSAHS并肺动脉高压患儿的临床资料并复习相关文献。1例患儿在肺动脉高压未纠正前接受传统方法扁桃体剥离联合腺样体刮除手术，1例患儿术前进行持续正压通气治疗，纠正肺动脉高压后接受等离子双扁桃体切除联合腺样体消融手术。结果　术前纠正肺动脉高压患儿手术顺利，术中及术后未出现任何并发症，术前未纠正肺动脉高压患儿术后反复出现严重低血氧症，导致不能正常拔除气管插管，在重症监护室2d后才转入普通病房。对2例患儿进行3个月以上随访，睡眠打鼾、张口呼吸、憋气均明显改善，呼吸暂停指数术前分别为90.0、29.2，术后为3.5、4.6；夜间最低血氧饱和度0.43、0.63，手术后为0.95、0.92，取得了满意的效果。结论　伴扁桃体腺样体肥大的OSAHS患儿，手术是一线治疗方案，但OSAHS并肺动脉高压患儿手术风险大，并发症出现率高，围术期处理非常重要，持续正压通气治疗可纠正患儿肺动脉高压，从而提高手术安全性。

Perioperative management of children with obstructive sleep apnea-hypopnea syndrome accompanied by pulmonary hypertension.

Abstract：Objective　To determine the appropriate perioperative management of children with obstructive sleep apnea-hypopnea syndrome accompanied by pulmonary hypertension. Methods　Two children with obstructive sleep apnea-hypopnea syndrome accompanied by pulmonary hypertension were admitted to our department from April 2006 to May 2009； their cases were analyzed and relevant literature was reviewed.  Conventional adenotonsillectomy was performed for one child before controlling pulmonary hypertension.  The other child received preoperative continuous positive airway pressure ventilation， then coblation-assisted adenotonsillectomy was performed. Results　The child who had received preoperative continuous positive airway pressure ventilation underwent an uneventful operation； no intra-or postoperative complications were reported.  In contrast， the child who did not receive preoperative pulmonary hypertension control experienced severe hypoxemia recurrently after surgery， leading to difficulty of extubation.  The child remained in the intensive care unit for two days before being transferred to the general ward.  The two children were followed up for more than three months and both showed improved sleeping with less snoring， open mouth breathing， and dyspnea.  Preoperative apnea-hypopnea indices were 90.0 and 29.2，and postoperative apnea-hypopnea indices were 3.5 and 4.6 for the children.  Lowest nocturnal oxygen saturation also improved after surgery for both children （0.43 and 0.63 vs 0.95 and 0.92）. Conclusion　Pulmonary hypertension is a rare but severe complication of obstructive sleep apnea-hypopnea syndrome in children.  It can result in severe consequences or even death if not appropriately managed.  Surgery is the first-line treatment for children with this syndrome who have enlarged tonsils and adenoids； however， the risk is considerable when accompanied by pulmonary hypertension， and incidence of complications is high.  Thus， perioperative management with continuous positive airway pressure ventilation to control pulmonary hypertension is critical.