睡眠醫(yī)學的最新進展課件

睡眠醫(yī)學的最新進展新光醫(yī)院胸腔內科美國斯坦福大學睡眠研究中心林嘉謨醫(yī)師睡眠醫(yī)學的最新進展新光醫(yī)院胸腔內科1演講內容大綱介紹睡眠呼吸問題睡眠呼吸問題與疾病的關系兒童睡眠呼吸問題猝睡癥肢動癥失眠癥的行為治療討論演講內容大綱介紹2白天嗜睡的主要原因睡眠的質或量不夠如睡眠時間不足或間斷性的睡眠(睡眠呼吸中止癥或身心癥)中樞神經病変生理時鐘與環(huán)境的互動失調藥物的影響白天嗜睡的主要原因睡眠的質或量不夠如睡眠時間不足或間斷性的睡3正常睡眠的階段非快速動眼期(Non-REM)睡眠--較規(guī)則的呼吸,較理性化的夢境,stage1,2,3,4.(stage3+4=slowwavesleep,SWS)快速動眼期(REM)睡眠--較不規(guī)則的呼吸,較情緒化的夢境,呼吸驅動力較弱,較易缺氧一個典型夜晚的睡眠是以70-90分鐘的非快速動眼期睡眠開始,然后進入約十分鐘的快速動眼期睡眠,如此重復循環(huán)整個夜晚正常睡眠的階段非快速動眼期(Non-REM)睡眠--較規(guī)則的4阻塞性睡眠呼吸中止阻塞性睡眠呼吸中止5睡眠呼吸中止癥之

上呼吸道特徵鼻腔阻塞扁桃腺(tonsil),咽扁桃腺(nasaladenoid)肥大咽顎帆區(qū)(velopharyngealspace)淺而狹窄舌頭肥大(Macroglossia)下顎狹小,后縮(Micro,retro-gnatia)上呼吸道感覺神經異常睡眠呼吸中止癥之

上呼吸道特徵鼻腔阻塞6SignsandsymptomssuggestiveofsleepapneaAtuletal.Lancet2002;360:237-45SnoringWitnessedapneas,gasping,orbothObesity(especiallyneckcircumference)HypertensionExcessivedaytimesleepinessFamilyhistoryNocturiaNon-restorativesleepSignsandsymptomssuggestive7AreFar-EastAsianMorePronetohaveSleepApnea?AreFar-EastAsianMoreProne8亞洲人與美洲人睡眠呼吸中止癥候群病人的比較亞洲的睡眠呼吸中止癥候群的病人較瘦,沒有像美洲的病人那么胖亞洲人先天上顱骨底面積較美洲人小,所以亞洲人上呼吸道會比美洲人更小,更容易有睡眠呼吸問題亞洲人與美洲人睡眠呼吸中止癥候群病人的比較亞洲的睡眠呼吸中止9行為治療維持理想體重側睡避免睡前鎮(zhèn)靜藥物避免睡眠不足避免睡前喝酒床頭搖高(肥胖特別是肚子大的人）感冒及過敏一定要治好睡前避免吃太多戒菸行為治療維持理想體重10MedicalTreatmentofOSASRespiratoryCenterStimulants(?)MedroxyprogesteroneAcetateAcetazolamideClomipramineHydrochlorideTheophyllineNeuroactiveDrugs(?)ProtriptylineStrychnineModafinilOxygentherapy(avoidCO2retention)IntranasalsteroidorradiofrequencyTongueRetainingDevice(Oralappliant)(onlymildOSA,needfollowupsleepstudy)NasalCPAP-goldstandardoftreatment)MedicalTreatmentofOSASRespi11SurgicalTreatmentofOSASTracheostomy-100%successratebut….Removaloftheunderlyingobstruction---enlargedtonsils,adenoid,thyroid.etcTonsillo-adenoidectomyPalatopharyngoplasty(PPP)Uvulopalatopharyngoplasty(UPPP)Laser-assistedUvulopalatoplasty(LAUP)GenioglossaladvancementRadiofrequencypalatoplastyandtonguebaseablationMandibularOsteostomy&HyoidBoneAdvancement(PhaseII)SurgicalTreatmentofOSASTrac12RadiofrequencyUsageinOSASRadiofrequencyUsageinOSAS13ChildOSASChildOSAS14猝睡癥(Narcolepsy)猝睡癥(Narcolepsy)15TheNarcolepsy“Tetrad＂Excessivedaytimesleepiness(sleepattack)Cataplexy(suddenlossofmuscletone)Hypnogogichallucination(vividdream-likeimagesjustbeforesleeponset)Sleepparalysis(muscleparalysisonmorningawakening)Disruptednocturnalsleep?TheNarcolepsy“Tetrad＂Excessi16PeriodicLegMovementPeriodicLegMovement17RestlessLegSyndromeRestlessLegSyndrome18RLSEpidemiology10-15%oftheresponders(in2019subjects)SimilarprevalenceamongmaleandfemaleThemeanageofonsetwasfoundtobetween27.2and41.0yearsTwolargesurveyfoundthat38.3and45%ofRLSpatients,respectively,experiencedtheirfirstsymptomsbeforetheageof20RLSEpidemiology10-15%ofthe19PeriodicLegsMovementsDefinitionOriginallycalled“nocturnalmyoclonus＂,PLMSisbestdescribedasrhythmicalextensionsofthebigtoeanddorsiflexionsoftheanklewithoccasionalflexionsofthekneeandhip,eachmovementlastingapproximately0.5to5.0secwithafrequencyofaboutoneevery20to40secTheprevalenceofPLMSiscorrelatewithage,rarelydiagnosedin<30yearsp＇t,5%30-50years,29%>50years,44%>65years.APLMSindex(numberofthePLMSperhourofsleep)>5fortheentirenightofsleepisconsideredpathological.PeriodicLegsMovementsDefini20SecondaryRLSduetoUnderlyingConditionsIron-deficiencyanemiaUremia(20-40%ofdialysispatients)Pregnancy(upto27%)Fibromyalgiaandrheumatoidarthritis(30%)Diabetes&parkinson＇sdiseaseNeurologicallesionsbothspinalcordandperipheralnervelesionsDrug-induced(includewithdrawal)tricyclics,SSRI＇s,lithium,dopamineblockers(e.g.,neuroleptics),xanthines,beta-blockers,caffeine,alcohol,andhistamineblockersSecondaryRLSduetoUnderlyin21InsomniaDefinedInsomniaischaracterizedbyanyofthefollowing:DifficultyfallingasleepDifficultystayingasleepEarlymorningawakeningFeelingunrefreshedinthemorningInsomniaDefinedInsomniaisch22InsomniaEpidemiologyApproximately35%adultspopulationisafflictedwithinsomniaduringthecourseofayear.9-12%ofthepopulationoccuronaregularbasis(chronicinsomnia)BoththeincidenceandthecomplaintofinsomniaincreaseacrossthelifecyclesInsomniaEpidemiologyApproxima23ComplicationsofInsomniaInsomniaisafrequentsymptomofpsychiatricdisordersandisoftenariskfactorforfuturepsychiatricillness-Depression-Anxiety-Alcoholabuse-DrugabuseComplicationsofInsomniaInsom24DiagnosingInsomniaCompletesleephistoryMedicalandpsychiatricassessment--substanceuseAlcohol,caffeine,andconcomitantmedicationPrescriptionand/orOTCmedicationDrugsSleepdiaryPolysomnographyDiagnosingInsomniaCompletesl25Non-pharmacologicalInsomniaTreatment/CognitiveBehavioralTherapy(CBT)OutcomeReducesleeplatencyDecreasefrequencyanddurationofarousalIncreasesleepqualityDecreasesleep-relatedanxietyImprovedaytimefunctionandmoodNon-pharmacologicalInsomniaT26ProcedureofCBTComprehensiveevaluationOvernightsleepstudyIndividualofgroupformatWeeklysession(6-8weeks)DailysleeplogsMultiplecomponentapproachConcomitantdrugstreatmentProcedureofCBTComprehensive27IndicationsofCBTPersistentdifficultyfallingasleepPsychogenicinsomniaInadequetsleephygieneCircadianrhythmdisorderLongtermsleepmedicationtreatmentfailureSecondaryorresidualinsomniacomplaintsIndicationsofCBTPersistentd28DiscussionDiscussion29睡眠醫(yī)學的最新進展新光醫(yī)院胸腔內科美國斯坦福大學睡眠研究中心林嘉謨醫(yī)師睡眠醫(yī)學的最新進展新光醫(yī)院胸腔內科30演講內容大綱介紹睡眠呼吸問題睡眠呼吸問題與疾病的關系兒童睡眠呼吸問題猝睡癥肢動癥失眠癥的行為治療討論演講內容大綱介紹31白天嗜睡的主要原因睡眠的質或量不夠如睡眠時間不足或間斷性的睡眠(睡眠呼吸中止癥或身心癥)中樞神經病変生理時鐘與環(huán)境的互動失調藥物的影響白天嗜睡的主要原因睡眠的質或量不夠如睡眠時間不足或間斷性的睡32正常睡眠的階段非快速動眼期(Non-REM)睡眠--較規(guī)則的呼吸,較理性化的夢境,stage1,2,3,4.(stage3+4=slowwavesleep,SWS)快速動眼期(REM)睡眠--較不規(guī)則的呼吸,較情緒化的夢境,呼吸驅動力較弱,較易缺氧一個典型夜晚的睡眠是以70-90分鐘的非快速動眼期睡眠開始,然后進入約十分鐘的快速動眼期睡眠,如此重復循環(huán)整個夜晚正常睡眠的階段非快速動眼期(Non-REM)睡眠--較規(guī)則的33阻塞性睡眠呼吸中止阻塞性睡眠呼吸中止34睡眠呼吸中止癥之

上呼吸道特徵鼻腔阻塞扁桃腺(tonsil),咽扁桃腺(nasaladenoid)肥大咽顎帆區(qū)(velopharyngealspace)淺而狹窄舌頭肥大(Macroglossia)下顎狹小,后縮(Micro,retro-gnatia)上呼吸道感覺神經異常睡眠呼吸中止癥之

上呼吸道特徵鼻腔阻塞35SignsandsymptomssuggestiveofsleepapneaAtuletal.Lancet2002;360:237-45SnoringWitnessedapneas,gasping,orbothObesity(especiallyneckcircumference)HypertensionExcessivedaytimesleepinessFamilyhistoryNocturiaNon-restorativesleepSignsandsymptomssuggestive36AreFar-EastAsianMorePronetohaveSleepApnea?AreFar-EastAsianMoreProne37亞洲人與美洲人睡眠呼吸中止癥候群病人的比較亞洲的睡眠呼吸中止癥候群的病人較瘦,沒有像美洲的病人那么胖亞洲人先天上顱骨底面積較美洲人小,所以亞洲人上呼吸道會比美洲人更小,更容易有睡眠呼吸問題亞洲人與美洲人睡眠呼吸中止癥候群病人的比較亞洲的睡眠呼吸中止38行為治療維持理想體重側睡避免睡前鎮(zhèn)靜藥物避免睡眠不足避免睡前喝酒床頭搖高(肥胖特別是肚子大的人）感冒及過敏一定要治好睡前避免吃太多戒菸行為治療維持理想體重39MedicalTreatmentofOSASRespiratoryCenterStimulants(?)MedroxyprogesteroneAcetateAcetazolamideClomipramineHydrochlorideTheophyllineNeuroactiveDrugs(?)ProtriptylineStrychnineModafinilOxygentherapy(avoidCO2retention)IntranasalsteroidorradiofrequencyTongueRetainingDevice(Oralappliant)(onlymildOSA,needfollowupsleepstudy)NasalCPAP-goldstandardoftreatment)MedicalTreatmentofOSASRespi40SurgicalTreatmentofOSASTracheostomy-100%successratebut….Removaloftheunderlyingobstruction---enlargedtonsils,adenoid,thyroid.etcTonsillo-adenoidectomyPalatopharyngoplasty(PPP)Uvulopalatopharyngoplasty(UPPP)Laser-assistedUvulopalatoplasty(LAUP)GenioglossaladvancementRadiofrequencypalatoplastyandtonguebaseablationMandibularOsteostomy&HyoidBoneAdvancement(PhaseII)SurgicalTreatmentofOSASTrac41RadiofrequencyUsageinOSASRadiofrequencyUsageinOSAS42ChildOSASChildOSAS43猝睡癥(Narcolepsy)猝睡癥(Narcolepsy)44TheNarcolepsy“Tetrad＂Excessivedaytimesleepiness(sleepattack)Cataplexy(suddenlossofmuscletone)Hypnogogichallucination(vividdream-likeimagesjustbeforesleeponset)Sleepparalysis(muscleparalysisonmorningawakening)Disruptednocturnalsleep?TheNarcolepsy“Tetrad＂Excessi45PeriodicLegMovementPeriodicLegMovement46RestlessLegSyndromeRestlessLegSyndrome47RLSEpidemiology10-15%oftheresponders(in2019subjects)SimilarprevalenceamongmaleandfemaleThemeanageofonsetwasfoundtobetween27.2and41.0yearsTwolargesurveyfoundthat38.3and45%ofRLSpatients,respectively,experiencedtheirfirstsymptomsbeforetheageof20RLSEpidemiology10-15%ofthe48PeriodicLegsMovementsDefinitionOriginallycalled“nocturnalmyoclonus＂,PLMSisbestdescribedasrhythmicalextensionsofthebigtoeanddorsiflexionsoftheanklewithoccasionalflexionsofthekneeandhip,eachmovementlastingapproximately0.5to5.0secwithafrequencyofaboutoneevery20to40secTheprevalenceofPLMSiscorrelatewithage,rarelydiagnosedin<30yearsp＇t,5%30-50years,29%>50years,44%>65years.APLMSindex(numberofthePLMSperhourofsleep)>5fortheentirenightofsleepisconsideredpathological.PeriodicLegsMovementsDefini49SecondaryRLSduetoUnderlyingConditionsIron-deficiencyanemiaUremia(20-40%ofdialysispatients)Pregnancy(upto27%)Fibromyalgiaandrheumatoidarthritis(30%)Diabetes&parkinson＇sdiseaseNeurologicallesionsbothspinalcordandperipheralnervelesionsDrug-induced(includewithdrawal)tricyclics,SSRI＇s,lithium,dopamineblockers(e.g.,neuroleptics),xanthines,beta-blockers,caffeine,alcohol,andhistamineblockersSecondaryRLSduetoUnderlyin50InsomniaDefinedInsomniaischaracterizedbyanyofthefollowing:DifficultyfallingasleepDifficultystayingasleepEarlymorningawakeningFeelingunrefreshedinthemorningInsomniaDefinedInsomniaisch51InsomniaEpidemiologyApproximately35%adultspopulationisafflictedwithinsomniaduringthecourseofayear.9-12%ofthepopulationoccuronaregularbasis(chronicinsomnia)BoththeincidenceandthecomplaintofinsomniaincreaseacrossthelifecyclesInsomniaEpidemiologyApproxima52ComplicationsofInsomniaInsomniaisafrequentsymptomofp