循证医学治疗案例分析.docx

循证医学实践教学案例分析 2014年2月18日修訂科別:口腔正畸科住院号:38871初诊日期：2013年1月报告者姓名:职务: 住院医师 基地医师 实习医师 完成时间:2014.4.12病例摘要黄某，男，21岁。初诊日期：2013年1月；结束时间：2014年4月。主 诉：夜间睡眠打鼾憋气5年。诊 断：骨性类，牙性类，轻度睡眠呼吸暂停综合征矫治设计：正畸治疗，IST矫治器初期：效果不佳，改用TAP矫治器效果：1. 睡眠呼吸暂停症状彻底解除。2. 上下颌牙齿排齐整平，前牙覆牙合、覆盖正常，中线对齐，磨牙、尖牙关系中性，侧貌有所改善。提出可回答的临床问題(Asking)P: 轻中度OSAHS患者I: TAP矫治器C: IST矫治器O:治疗效果提高检索最有用的证据(Acquire)关键词( Key word )：OSAHS，oral appliances数据库来源 ( Database )：PubMed Clinical Queries主要內容：A randomized prospective long-term study of two oral appliances for sleep apnoea treatmentSUMMARY Various types of mandibular protrusive appliances have revealed dierent treatment success in mild-to-moderate obstructive sleep apnoea (OSA). The present study compared the long-term eect of two dierent appliances in the treatment of OSA. A total of 103 patients with OSA were randomized and treated with an ISTor Thornton Anterior Positioner (TAP) appliance. They were followed-up after a short-term treatment period of 6 months and long-term treatment period of over 24 months. Sleep studies in the sleep laboratory were conducted with and without the appliances, and various questionnaires assessing subjective daytime sleepiness, sleep quality, quality of life and symptom scores were administered at each time interval. Quality of life, sleep quality, sleepiness, symptoms and sleep outcome showed signicant improvement in the short-term evaluation with both appliances, but the TAP appliance revealed a signicantly greater eect. After more than 2 years of treatment, sleep outcomes revealed an equal eect with both appliances. The subjective benets achieved initially lessened signicantly. This study illustrates that both the ISTand the TAP appliances are eective therapeutic devices for OSA after a period of over 24 months. Lack of compliance may be due to insucient improvement in anticipated subjective symptoms and or a recurrence of symptoms over time.证据评价 (Appraisal )证据等級：A级Worksheet：一、真实性随机分组，隐藏措施（计算机随机），基线一致，short-term时间短，失访率低，long-termT2随访时间长，失访率高，无具体指出而是引用其他文献方法，可推测ITT，采用盲法，测量指标客观，基础治疗一致二、强度与精度：1. short-term：P 0.05，P 0.001 compared without the appliance，P 0.05 IST appliance versus TAP appliance. IST appliance: n = 47; TAP appliances: n = 48.Values are means SD, medians (quartiles ranges).2. long-term：Signicant with the device compared without it，signicant comparison between T1 and T2，signicant comparison between IST appliance and TAP appliance, IST : n = 24, TAP: n = 21.Values are means SD, medians (quartiles ranges)三、实用性1研究对象： Patients were recruited between July 2001 and December 2003 through the sleep laboratory of the department of Respiratory Care at the University Hospital of Freiburg (Germany) (17 females and 86 males; age: 55.5 10.6 years, body mass index (BMI): 25.9 2.9 kg/ m2)存在社会人口学差异2. 可行性好3. 无危险性评估4. 结合病人期望，爱好，病人决定治疗证据解读及证据应用( Apply ) 随着社会经济的发展，阻塞性睡眠呼吸暂停低通气综合征（OSAHS）发病率有明显增长的趋势。OSAHS以睡眠期间上气道反复发生阻塞为特征，引起呼吸暂停，低通气及睡眠紊乱，一般表现为睡眠打鼾、低氧血症及白天嗜睡等。有三大主要治疗方法，一、持续正压通气治疗（呼吸机）。二、手术治疗：如扁桃体腺样体摘除、鼻腔手术，舌咽成形术及口腔正颌手术等。三、口腔矫治器治疗：口腔矫治器适用于单纯鼾症患者及轻、中度OSAHS患者。另外，对那些拒绝或无法耐受呼吸机治疗或经手术治疗后复发的患