睡眠呼吸暂停低通气睡眠监测

Introduction “DamnThatBoy”Saidtheoldmen,“He’sgonetosleepagain”. “VeryExtraordinaryboy”,saidMr.Pickwick.Doeshealwayssleepinthisway?Introduction “Sleep”saidtheoldgentleman,“he’salwaysasleep”.“Goesonerrandsfastasleepandsnoresashewaitsattable” In1837CharlesDickens,inoneofhisnovelsdescribessomeofthefeaturesofthediseasethatIamgoingtopresent.Introduction Obstructivesleepapneasyndrome(OSAS)isbyfarthesinglemostcommondisorderseenatsleepcentersandisresponsibleformoremortalityandmorbiditythananyothersleepdisorder.Introduction AlthoughOSASwasidentifiedmorethan3decadesago,themajorityofphysicianshavehadnoformaltraininginrecognizingortreatingtheconditionIntroduction Furthermore,newinformationconcerningthediagnosisandtreatmentofobstructedbreathingduringsleepisemergingfasterthanolderconceptscanbedisseminated.Theresultisthatmostpatientswithtreatablesleep-relatedbreathingdisorderscurrentlyremainundiagnosedDefinitions OSAisdescribeasrepetitiveepisodesofcompleteorpartialupperairwayobstructionduringsleep.Asaresultaffectedpersonshaveunrestfulsleepandexcessivedaytimesleepiness.Definitions Oftenpresentsotherfeatures,suchasloudsnoring,morningheadaches,anddrymouthonawakening. Duringobstructiveapnea,respiratoryeffortspersist,butairflowisabsentatthenoseandmouthwhileoncentralapneabothairflowandrespiratoryeffortsareabsent.OTHERDEFINITIONSOFOBSTRUCTIVESLEEPAPNEA AHI>10(46) AHI>15(12) AHI>5+symptoms(49) AI>2(23) AI>20(25) AHI=Apnea-plus-hypopneaindex;AI=apneaindexEpidemiology TheprevalenceofOSAintheUnitedStatesis2%to4%inmiddle-agedadultswhichissimilarinmagnitudetotheprevalenceofmajordiseasessuchasAsthmaandDiabetes.EpidemiologyEpidemiology PreliminarystudiessuggestanassociationbetweenuntreatedOSASandanincreasedriskforcardiovasculardiseaseincludingHTNandCAD.Epidemiology Ahistoryofheavysnoringisreportedinmorethan70%ofadultpatientswithOSA. Symptomsrelatedtoapneaaremorefrequentinfamilymembersofaffectedpatientsthaninage,sex,andsocioeconomicallymatchedcontrolfamiliesPathophysiology ObstructiveApneasareperiodsofcessationofbreathingdespiteacontinuedefforttobreath,andthisisaresultofnarrowingoftherespiratorypassagewhichmayoccuratoneormoresitesintheupperairway:(oropharynx,velopharynx,orhypopharynx). FIGURE1B.Abnormalairwayduringsleep.Multiplesitesofobstructionoftenoccurinpatientswithobstructivesleepapnea.Anelongatedandenlargedsoftpalateimpingesontheposteriorairwayatthelevelofthenasopharynxandoralpharynx.Inaddition,aretrudingjawpushesanenlargedtongueposteriorlytoimpingeonthehypopharyngealspace. Figure1.Anatomyofobstructivesleepapnoea.Coronalsectionoftheheadandneckshowingthesegmentoverwhichsleeprelatednarrowingcanoccur(arrows). Pathophysiology AnatomiccompromisesoftheupperairwayisworseduringsleepandthoseeventsaremoreprominentduringREMsleepbecauseofthehypotoniaandatoniathatinvolvemostskelethalmuscles,includingtherespiratoryaccessoriesmuscles.Pathophysiology ItisalsoclearthatairflowobstructioninpatientswithOSASthereisanincreaseinthepharyngealcriticalpressurePathophysiology Cephalometryhasdemonstratedavarietyofcraniofacialandupperairwaysofttissueanatomythatmaypredisposepatientstoobstructionduringsleep,andaffecttheseverityofOSA.FIGURE6.A24-year-oldwomanwithfacialabnormalitiesthatcontributetoobstructivesleepapnea.(Left)Therecedinglowerjawprovidesinadequatesupportforthelowerlip,resultinginlipcurlingandadeepmental-labialfold(curvedarrow).(Right)Shortnessoftheloweronethirdoftheface(arrows)contributestoinadequacyoftheairway.Pathophysiology ManypatientswithOSAhavebeenshowntohaveasmallposteriorairwayspace,anenlargedtongueandsoftpalate,aninferiorlyplacedhyoidbone,oracombinationofthese.Pathophysiology FIGURE4.Enlargeduvularestingonthebaseofthetongue(largearrow),alongwithhypertrophiedtonsils(smallarrows).TheposteriorpharyngealerythemamaybesecondarytorepeatedtraumafromsnoringorgastroesophagealrefluxPathophysiology FIGURE5.Elongatedsoftpalate(arrows).Inthispatient,anincreasedanteroposteriordimensioncausedthesoftpalatetorestonthebaseofthetongueintherelaxedposition.Pathophysiology Animportantcauseofupperairwaynarrowingisthedepositionofadiposetissueinthesofttissuesorroundingthepharynx. DysfunctionoftheupperairwaymusclesisanotherfactorthatcontributetothedevelopmentofOSA.Pathophysiology FIGURE3.Anobeseyoungwomanwiththeshort,thicknecktypicallyseeninpatientswithobstructivesleepapnea.ClinicalManifestation ThemostsignificantcomplaintsofpatientswithOSAare:-DaytimeFatigue-SleepinessCommonFeaturesinPatientswithSleepApneaLoudsnoringDisruptedsleepNocturnalgaspingandchokingWitnessedapneaDaytimesleepinessandfatigueCrowdedposteriorairwayShort,thickneck