睡眠呼吸暫停低通氣睡眠監(jiān)測

1、Review ArticleObstructive Sleep ApneaDXY: POLKARafael E. Coplin, MDIntroductionw“Damn That Boy” Said the old men, “Hes gone to sleep again”.w“Very Extraordinary boy”, said Mr. Pickwick. Does he always sleep in this way?Introductionw“Sleep” said the old gentleman, “hes always asleep”. “Goes on errand

2、s fast asleep and snores as he waits at table”wIn 1837 Charles Dickens, in one of his novels describes some of the features of the disease that I am going to present. IntroductionwObstructive sleep apnea syndrome(OSAS) is by far the single most common disorder seen at sleep centers and is responsibl

3、e for more mortality and morbidity than any other sleep disorder.IntroductionwAlthough OSAS was identified more than 3 decades ago, the majority of physicians have had no formal training in recognizing or treating the conditionIntroductionwFurthermore, new information concerning the diagnosis and tr

4、eatment of obstructed breathing during sleep is emerging faster than older concepts can be disseminated. The result is that most patients with treatable sleep-related breathing disorders currently remain undiagnosedDefinitionswOSA is describe as repetitive episodes of complete or partial upper airwa

5、y obstruction during sleep. As a result affected persons have unrestful sleep and excessive daytime sleepiness.DefinitionswOften presents other features, such as loud snoring, morning headaches, and dry mouth on awakening.wDuring obstructive apnea, respiratory efforts persist, but airflow is absent

6、at the nose and mouth while on central apnea both airflow and respiratory efforts are absent. OTHER DEFINITIONS OF OBSTRUCTIVE SLEEP APNEAwAHI 10 (46)wAHI 15 (12)wAHI 5 + symptoms (49)wAI 2 (23)wAI 20 (25)AHI = Apnea-plus-hypopnea index; AI= apnea indexEpidemiologywThe prevalence of OSA in the Unite

7、d States is 2% to 4% in middle-aged adults which is similar in magnitude to the prevalence of major diseases such as Asthma and Diabetes.EpidemiologyEpidemiologywPreliminary studies suggest an association between untreated OSAS and an increased risk for cardiovascular disease including HTN and CAD.E

8、pidemiologywA history of heavy snoring is reported in more than 70% of adult patients with OSA.wSymptoms related to apnea are more frequent in family members of affected patients than in age, sex, and socioeconomically matched control familiesPathophysiologywObstructive Apneas are periods of cessati

9、on of breathing despite a continued effort to breath, and this is a result of narrowing of the respiratory passage which may occur at one or more sites in the upper airway: (oropharynx, velopharynx, or hypopharynx).nFIGURE 1B. Abnormal airway during sleep. Multiple sites of obstruction often occur i

10、n patients with obstructive sleep apnea. An elongated and enlarged soft palate impinges on the posterior airway at the level of the nasopharynx and oral pharynx. In addition, a retruding jaw pushes an enlarged tongue posteriorly to impinge on the hypopharyngeal space.wFigure 1. Anatomy of obstructiv

11、e sleep apnoea. Coronal section of the head and neck showing the segment over which sleep related narrowing can occur (arrows). PathophysiologywAnatomic compromises of the upper airway is worse during sleep and those events are more prominent during REM sleep because of the hypotonia and atonia that

12、 involve most skelethal muscles, including the respiratory accessories muscles.PathophysiologywIt is also clear that airflow obstruction in patients with OSAS there is an increase in the pharyngeal critical pressurePathophysiologywCephalometry has demonstrated a variety of craniofacial and upper air

13、way soft tissue anatomy that may predispose patients to obstruction during sleep, and affect the severity of OSA.FIGURE 6. A 24-year-old woman with facial abnormalities that contribute to obstructive sleep apnea. (Left) The receding lower jaw provides inadequate support for the lower lip, resulting

14、in lip curling and a deep mental-labial fold (curved arrow). (Right) Shortness of the lower one third of the face (arrows) contributes to inadequacy of the airway.PathophysiologywMany patients with OSA have been shown to have a small posterior airway space , an enlarged tongue and soft palate ,an in

15、feriorly placed hyoid bone, or a combination of these.PathophysiologynFIGURE 4. Enlarged uvula resting on the base of the tongue (large arrow), along with hypertrophied tonsils (small arrows). The posterior pharyngeal erythema may be secondary to repeated trauma from snoring or gastroesophageal refl

16、uxPathophysiologynFIGURE 5. Elongated soft palate (arrows). In this patient, an increased anteroposterior dimension caused the soft palate to rest on the base of the tongue in the relaxed position.PathophysiologywAn important cause of upper airway narrowing is the deposition of adipose tissue in the

17、 soft tissue sorrounding the pharynx.wDysfunction of the upper airway muscles is another factor that contribute to the development of OSA.PathophysiologynFIGURE 3. An obese young woman with the short, thick neck typically seen in patients with obstructive sleep apnea.Clinical ManifestationwThe most

18、significant complaints of patients with OSA are:n-Daytime Fatigue n-SleepinessCommon Features in Patients with Sleep ApneaLoud snoring Disrupted sleep Nocturnal gasping and choking Witnessed apnea Daytime sleepiness and fatigue Crowded posterior airway Short, thick neck Clinical ManifestationnFamily members or partners complaint that the patient has loud snoring, nocturnal gasping or choking.Clinical ManifestationwMost patients are overweight and typically have a short, thick neck. They have enlarged tonsils and uvula, elongated soft p