睡眠呼吸暂停低通气睡眠监测

ReviewArticleObstructiveSleepApneaDXY:POLKARafaelE.Coplin,MDIntroduction“DamnThatBoy”Saidtheoldmen,“He’sgonetosleepagain”.“VeryExtraordinaryboy”,saidMr.Pickwick.Doeshealwayssleepinthisway?Introduction“Sleep”saidtheoldgentleman,“he’salwaysasleep”.“Goesonerrandsfastasleepandsnoresashewaitsattable”In1837CharlesDickens,inoneofhisnovelsdescribessomeofthefeaturesofthediseasethatIamgoingtopresent.IntroductionObstructivesleepapneasyndrome(OSAS)isbyfarthesinglemostcommondisorderseenatsleepcentersandisresponsibleformoremortalityandmorbiditythananyothersleepdisorder.IntroductionAlthoughOSASwasidentifiedmorethan3decadesago,themajorityofphysicianshavehadnoformaltraininginrecognizingortreatingtheconditionIntroductionFurthermore,newinformationconcerningthediagnosisandtreatmentofobstructedbreathingduringsleepisemergingfasterthanolderconceptscanbedisseminated.Theresultisthatmostpatientswithtreatablesleep-relatedbreathingdisorderscurrentlyremainundiagnosedDefinitionsOSAisdescribeasrepetitiveepisodesofcompleteorpartialupperairwayobstructionduringsleep.Asaresultaffectedpersonshaveunrestfulsleepandexcessivedaytimesleepiness.DefinitionsOftenpresentsotherfeatures,suchasloudsnoring,morningheadaches,anddrymouthonawakening.Duringobstructiveapnea,respiratoryeffortspersist,butairflowisabsentatthenoseandmouthwhileoncentralapneabothairflowandrespiratoryeffortsareabsent.OTHERDEFINITIONSOFOBSTRUCTIVESLEEPAPNEAAHI>10(46)AHI>15(12)AHI>5+symptoms(49)AI>2(23)AI>20(25) AHI=Apnea-plus-hypopneaindex;AI=apneaindexEpidemiologyTheprevalenceofOSAintheUnitedStatesis2%to4%inmiddle-agedadultswhichissimilarinmagnitudetotheprevalenceofmajordiseasessuchasAsthmaandDiabetes.EpidemiologyEpidemiologyPreliminarystudiessuggestanassociationbetweenuntreatedOSASandanincreasedriskforcardiovasculardiseaseincludingHTNandCAD.EpidemiologyAhistoryofheavysnoringisreportedinmorethan70%ofadultpatientswithOSA.Symptomsrelatedtoapneaaremorefrequentinfamilymembersofaffectedpatientsthaninage,sex,andsocioeconomicallymatchedcontrolfamiliesPathophysiologyObstructiveApneasareperiodsofcessationofbreathingdespiteacontinuedefforttobreath,andthisisaresultofnarrowingoftherespiratorypassagewhichmayoccuratoneormoresitesintheupperairway:(oropharynx,velopharynx,orhypopharynx).FIGURE1B.Abnormalairwayduringsleep.Multiplesitesofobstructionoftenoccurinpatientswithobstructivesleepapnea.Anelongatedandenlargedsoftpalateimpingesontheposteriorairwayatthelevelofthenasopharynxandoralpharynx.Inaddition,aretrudingjawpushesanenlargedtongueposteriorlytoimpingeonthehypopharyngealspace.Figure1.Anatomyofobstructivesleepapnoea.Coronalsectionoftheheadandneckshowingthesegmentoverwhichsleeprelatednarrowingcanoccur(arrows).PathophysiologyAnatomiccompromisesoftheupperairwayisworseduringsleepandthoseeventsaremoreprominentduringREMsleepbecauseofthehypotoniaandatoniathatinvolvemostskelethalmuscles,includingtherespiratoryaccessoriesmuscles.PathophysiologyItisalsoclearthatairflowobstructioninpatientswithOSASthereisanincreaseinthepharyngealcriticalpressurePathophysiologyCephalometryhasdemonstratedavarietyofcraniofacialandupperairwaysofttissueanatomythatmaypredisposepatientstoobstructionduringsleep,andaffecttheseverityofOSA.FIGURE6.A24-year-oldwomanwithfacialabnormalitiesthatcontributetoobstructivesleepapnea.(Left)Therecedinglowerjawprovidesinadequatesupportforthelowerlip,resultinginlipcurlingandadeepmental-labialfold(curvedarrow).(Right)Shortnessoftheloweronethirdoftheface(arrows)contributestoinadequacyoftheairway.PathophysiologyManypatientswithOSAhavebeenshowntohaveasmallposteriorairwayspace,anenlargedtongueandsoftpalate,aninferiorlyplacedhyoidbone,oracombinationofthese.PathophysiologyFIGURE4.Enlargeduvularestingonthebaseofthetongue(largearrow),alongwithhypertrophiedtonsils(smallarrows).TheposteriorpharyngealerythemamaybesecondarytorepeatedtraumafromsnoringorgastroesophagealrefluxPathophysiologyFIGURE5.Elongatedsoftpalate(arrows).Inthispatient,anincreasedanteroposteriordimensioncausedthesoftpalatetorestonthebaseofthetongueintherelaxedposition.PathophysiologyAnimportantcauseofupperairwaynarrowingisthedepositionofadiposetissueinthesofttissuesorroundingthepharynx.DysfunctionoftheupperairwaymusclesisanotherfactorthatcontributetothedevelopmentofOSA.PathophysiologyFIGURE3.Anobeseyoungwomanwiththeshort,thicknecktypicallyseeninpatientswithobstructivesleepapnea.ClinicalManifestationThemostsignificantcomplaintsofpatientswithOSAare:-DaytimeFatigue-SleepinessCommonFeaturesinPatientswithSleepApneaLoudsnoringDisruptedsleepNocturnalgaspingandchokingWitnessedapneaDaytimesleepinessandfatigueCrowdedposteriorairwayShort,thickneckClinicalManifestationFamilymembersorpartnerscomplaintthatthepatienthasloudsnoring,nocturnalgaspingorchoking.ClinicalManifestationMostpatientsareoverweightandtypicallyhaveashort,thickneck.Theyhaveenlargedtonsilsanduvula,elongatedsoftpalateandlowerfaceabnormalitiesPathophysiologicConsequencesSleepApneaSyndromeisprofoundlyassociatedwithhypertensionindependentofallrelevantriskfactors.Arrhythmiasfrommildtosevere.Motorvehicleaccident:Sixtimeincreasedaccidentratecomparedtothegeneralpopulation.