OSAS与COPD

OSAS和COPD重叠综合征的诊治,吴江第一人民医院 呼吸科 吴巧珍,主要内容,OS的流行病学OS的病理生理特点OS的临床特点OS的诊断OS的治疗,重叠综合征(Overlap Syndrome, OS),Respirology,2013;18:421431,COPD和OSAS患者中OS的发病率,Association of chronic obstructive pulmonary disease and obstructive sleep apnea consequences.International Journal of COPD.2008:3(4);671682.,OS病理生理学,COPD是指具有气流受限为特征的疾病，患者由于慢性气道炎症，形成下呼吸道的阻塞性改变，通气血流比例失调，晚期更合并弥散功能减退，故低氧血症为COPD的常见并发症。OSAS是以上气道的狭窄或阻塞，睡眠中严重打鼾、反复发生呼吸暂停和低通气、睡眠结构紊乱、白天嗜睡为特征的疾病，伴有间断的低氧血症和(或)高碳酸血症。,Integrating the overlap of obstructive lung disease and obstructive sleep apnoea: OLDOSA syndrome. Respirology.2013;18, 421431.,OS是COPD合并OSAS，上、下气道异常存在着交互影响其危害性更大，有严重的与睡眠相关的低氧血症，同时也可致高碳酸血症，严重者可导致神经调节功能失调，儿茶酚胺、肾素-血管紧张素、内皮素分泌增加，微血管收缩，内分泌功能紊乱及血流动力学改变，可引起组织器官缺血、缺氧，可导致多器官功能损害。,Integrating the overlap of obstructive lung disease and obstructive sleep apnoea: OLDOSA syndrome. Respirology.2013;18, 421431.,OS患者睡眠呼吸紊乱以低通气为主，出现持续肺泡低通气的情况较多，低通气指数在呼吸紊乱指数中所占比例较大，单纯发生呼吸暂停的患者较少。OS患者出现与睡眠相关的低氧是由肺泡通气不足引起，而非呼吸暂停。,Sleep and sleep-disordered breathing in adults with predominantly mild obstructive airway diseaseAm J Respir Crit Care Med2003，167：7一14,OS睡眠呼吸紊乱的类型,COPD、OSA重叠及相互影响的机理,年龄：二种疾病均随增龄而加重； 吸烟：共同相关； 局部或全身的炎症状态、肺内蛋白酶/抗蛋白酶 和氧化还原失衡； 交感神经张力增加； 胃食道反流； 低氧血症； 肺动脉高压； 内皮功能损害。,Overlaps in Pathophysiology, Systemic Inflammation ,and Cardiovascular Disease. Am J Respir Crit Care Med 2009; 180:692700,重叠综合征临床特点及合并症,重叠综合征的主要症状,重叠综合征临床特点,“重叠综合征”与任何单一疾病比较：夜间低氧血症和日间低氧与高碳酸血症更严重，持续时间更长。睡眠结构破坏更为严重，睡眠质量更差，嗜睡更明显，交通事故致死致残率更高。认知功能损伤更突出，生活质量更差。更易发生肺动脉高压、心律失常等心血管疾病。死亡率增加。,Diagnostic and therapeutic approach to coexistent chronic obstructive pulmonary disease and obstructive sleep apnea. International Journal of COPD, 2008:3;269275.,OS患者PaO2 PaCO2,Sleep-Disordered Breathing and COPD: The Overlap Syndrome. Respir Care. 2010;55:13331346.,重叠综合征夜间持续低氧,Sleep disorders in COPD: the forgotten dimension. Eur Respir Rev 2013; 22: 365375.,OS患者睡眠质量 生活质量,Sleep Quality and Quality of Life in COPD Patients with and without Suspected Obstructive Sleep Apnea .Sleep Disord, 2014; ID 508372.,139位COPD患者，OS有71位。行肺功能、柏林问卷、ESS、匹兹堡睡眠质量量表（5分为睡眠质量差）、圣乔治呼吸问卷。结果提示104位（74.8%）患者睡眠质量较差，其中OS患者更差。,OS步行能力,Nocturnal CPAP improves walking capacity in COPD patients with obstructive sleep apnoea. Respiratory Research.2013,14:66.,OSAS和COPD认知损伤,与健康对照组相比，COPD患者发生认知功能损伤危险性的OR值是2.42，基础氧饱和度降低是认知功能损伤的高危因素，氧饱和度88%时的OR值是5.45。与匹配年龄的健康对照组相比，OSAS的老年女性5年后发展为认知损伤的OR值是2.3，且缺氧是主要危险因素。,Sleep-Disordered Breathing, Hypoxia,and Risk of Mild Cognitive Impairment and Dementia in Older Women. JAMA. 2011;306:613-619.COPD and cognitive impairment: the role of hypoxemia and oxygen therapy. International Journal of Chronic Obstructive Pulmonary Disease 2010:5 263269.,OS肺功能 SaO2 ESS,Inflammatory Processes and Effects of Continuous Positive Airway Pressure (CPAP) in Overlap Syndrome.Inflammation.2013,36;66-74.,吴巧珍，等.重叠综合征患者夜间缺氧与生活质量评分的相关性研究.医学研究杂志，2011，41（7）：118-123.,OS肺功能 动脉硬化,Overlap syndrome: Additive effects of COPD on the cardiovascular damages in patients with OSA.Respiratory Medicine (2012)106, 1335-1341.,OS患者房颤发生率,Risk of new-onset atrial fibrillation in elderly patients with the overlap syndrome: a retrospective cohort study.Journal of Geriatric Cardiology .2013;10:129134.,OS新发房颤危险性,Risk of new-onset atrial fibrillation in elderly patients with the overlap syndrome: a retrospective cohort study.Journal of Geriatric Cardiology .2013;10:129134.,OS的死亡率,Outcomes in Patients with Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. Am J Respir Crit Care Med,2010,182:325331.,前瞻性研究，筛查4241患者，最终651人入组：CPAP治疗OS患者228，未治疗OS 213位，210位单纯COPD，平均随访时间9.4年（3.3-12.7年），终点事件是全因死亡和第一次因COPD加重而住院。,OS死亡率升高，主要死因是心血管疾病,Outcomes in Patients with Chronic Obstructive Pulmonary Disease and Obstructive Sleep ApneaAm J Respir Crit Care Med,2010,182:325331.,右心室功能 右心室重构,Evaluation of Right Ventricular Remodeling Using Cardiac Magnetic Resonance Imaging in Co-Existent Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea.COPD, 2013;10:410.,右心室质量指数与氧减指数相关,Evaluation of Right Ventricular Remodeling Using Cardiac Magnetic Resonance Imaging in Co-Existent Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea.COPD, 2013;10:410.,重叠综合征的诊断,ATS/ERS指南强调，轻度COPD伴有肺动脉高压者需要做PSG监测，夜间氧疗的COPD患者出现晨起头痛者需要做PSG监测。GOLDI或II期COPD患者，如果有OSA临床症状需要进行PSG监测，即使OSA的症状很轻，也需要监测。,Sleep-Disordered Breathing and COPD: The Overlap Syndrome. Respir Care. 2010;55:13331346.,重叠综合征的治疗,治疗方法有如下几种：1、控制饮食和改变生活方式：控制体重对OSA和肥胖有益，但对于COPD来讲，低体重又意味着高病死率，因此尚无证据推荐OS时要减轻体重，但是对于那些COPD程度不重的患者来说，适当的饮食和运动计划还是有益的。2、戒烟：对于OSAS或COPD都有益处。,Sleep-Disordered Breathing and COPD: The Overlap Syndrome. Respir Care. 2010;55:13331346.,3、氧疗有研究表明每天吸氧18小时以上可改善COPD患者缺氧情况和睡眠质量，降低死亡率。研究显示：4L/分氧治疗20位重叠综合征患者，虽然夜间缺氧改善，但是呼吸暂停的时间由25.7s延长到31.4s，PaCO2由52.8mmHg增加至62.3mmHg，PH值也发生相应改变，提示对于OS患者不宜单独氧疗。,Sleep-Disordered Breathing and COPD: The Overlap Syndrome. Respir Care. 2010;55:13331346.Acute oxygen in patients with sleep apnea and COPD. Chest.1986; 89(1):3038,4、支气管扩张剂和类固醇激素：积极治疗COPD可以改善夜间低氧血症，有证据显示胆碱能扩张剂、长效受体激动剂及激素治疗均可改善夜间血氧，提高睡眠质量，说明对于COPD的治疗可以改善夜间低氧，减少除CPAP治疗之外夜间氧疗的需求。但是，对于OS患者，治疗COPD是否对OSA有影响目前尚不清楚，相关文献很少。,Effects of salmeterol on sleeping oxygen saturation in chronic obstructive pulmonary disease. Respiration. 2009Long-acting inhaled anticholinergic therapy improves sleeping oxygen saturation in COPD.Eur Respir J. 2004;23(6):825831.Sleep-Disordered Breathing and COPD: The Overlap Syndrome. Respir Care. 2010;55(10): 13331346.,5、无创正压通气治疗：CPAP是OSAS的一线治疗方法，可以明显减少呼吸暂停和低通气，从而减少睡眠相关的低氧血症。CPAP/BiPAP治疗可减少呼吸肌做功，减少呼吸肌氧耗和二氧化碳产生，增加肺泡通气量，是目前重叠综合征的理想治疗措施。,Sleep-Disordered Breathing and COPD: The Overlap Syndrome.Respir Care. 2010;55(10): 13331346.Effects of continuous positive airway pressure on lung function in patients with chronic obstructive pulmonary disease and sleep disordered breathing. Respirology.1999; 4(4):365370.,OS患者的CPAP治疗,对于OS来说，当单独无创通气不能完全纠正夜间缺氧时，需增加氧疗。尽管对于CPAP治疗能否改善稳定期COPD的肺功能存在争议，但有动物研究表明，上呼吸道刺激、纠正反复的上呼吸道塌陷可改善肺功能。,Reflex effects of upper airway irritation on total lung resistance and blood pressure. J Appl Physiol. 1962;17:861865.Nasal continuous positive airway pressure with supplemental oxygen in coexistent sleep apnoea-hypopnoea syndrome and severe chronic obstructive pulmonary disease. Eur Respir J. 1996; 9(1):111116,CPAP治疗可降低OS死亡率,前瞻性研究，共入组603位COPD患者（均接受长期氧疗），其中95位合并有OSAS。OSAS患者中，61位接受CPAP治疗且依从性良好，34位未接受CPAP治疗。平均随访时间为41个月（范围6-106个月）。结果提示5年生存率OS治疗组为71%，未治疗组为26%（P0.01）。,CPAP and survival in moderate-to-severe obstructive sleep apnoea syndrome and hypoxaemic COPD. Eur Respir J 2010; 35: 132137.,CPAP治疗可降低OS炎症水平,Inflammatory Processes and Effects of Continuous Positive Airway Pressure (