SAS诊疗进展

睡眠呼吸暂停低通气综合征的诊疗进展,北京大学人民医院呼吸科 韩芳,睡眠呼吸暂停低通气综合征 患病率高 2-4% 危害大 可以治疗 慢性病 2007,睡眠呼吸暂停低通气综合征诊疗进展,实验医学临床医学 复杂简单化, 家庭化 多学科联合, 呼吸学科为主,睡眠呼吸暂停综合征的临床症状,0,10,20,30,40,50,60,70,呼吸暂停,白天嗜睡,疲劳,失眠,其他,打鼾,肢体活动,其他行为异常,恶梦,癫痫,性欲减退,夜间憋气,晨起口干,每小时氧饱和度降低4%的次数与呼吸紊乱指数相关性好,女性, 33 岁, 近来夜里2-3点憋醒,不敢睡觉支气管激发试验(-)PSG睡眠监测(-),上气道阻力综合征,仰卧位呼吸暂停,呼吸暂停患者吸氧后,脉搏及血氧饱和度,REM睡眠低通气,治疗前 治疗后,OSA 治疗目标：维持上气道开放,呼吸事件 SaO2 气流 Apnea/Hypopnea Snoring Airflow limitation 阻力(高频振荡),压力发生器,+,_,+,_,感受系统,效应系统,AUTO-CPAP,Auto-CPAP FOT,Flow,Snoring,Artefact detection,反馈信号,监测事件,Central events,Volume Contour,Obstructive events,Severe Obstructions Slight Obstructions Incipient Obstructions,Flow,Snoring,OPS,压力调整,Event,Snoring及Airflow limitation 标志上气道的狭窄去除二者后可消除呼吸暂停及低通气,apnea,Normal breathing,snoring,Flow limitation,hypopnea,Hypopnea,Normal,气 流 受 限 (Flow limitation),CSR: Why Does it Occur?,0,5,8,15,Diaphragm EMG,Mask Pressure,centralhyperpnea,centralhypopnea,spontaneous,spontaneous,timed,centralhyperpnea,Adaptive Servo Ventilation (ASV),以静息通气量的 90% 为目标通气量以容量为目标的压力支持通气有自己的节律,AUTO-BiPAP,Enhanced Expiratory Rebreathing Space (Dead space) adjunct to PAP,Dead space -400+ patients with complex disease (20+ CHF)- non-vented oronasal mask- 50-150 ml additional DS- immediate good lab control with PAP: 70% (leak and a more recently recognized “sleep effect” are problems- home use is effective in about 60% (these patients are often otherwise virtually untreatable),呼气末压力释放技术,Mode for home sleep apnea testing,Patient 1,2,3,4,5,6,internet,Central lab,家庭环境睡眠过程中监测同一时间监测例数增加,降低患者花费提高医疗服务效率和质量,SLEEP APNEA: a model of Homecare,家庭治疗,家庭监测,管理机制管理经验管理梯队,睡眠呼吸医学：家庭医疗的先行者,家庭呼吸机治疗,The Mechanisms of Sleep ApneaAnatomic and/or Functional,Pathogenesis of Sleep Apnea,Airway Obstruction,Small pharyngeal airway,Ventilatory control instability,Poor upper airway response,Low arousal threshold,录象,SLEEP APNEA,central,obstructive,拉萨 4300 m SaO2 3% 60/h 平均SaO2为 67%,西宁 2600 m SaO2 3% 14/h 平均SaO2为 87%,北京 100 m SaO2 3% 0 /h 平均SaO2为 97%,睡眠呼吸障碍的两个主要机制,SDB is really a “spectrum disorder” with TWO possible underlying causes: Anatomy and breathing control“Complexity” is when breathing control is unstable,Anatomically Vulnerable Airway,Neurologically Unstable Breathing Control,Mixed Apnea“Complex”,稳定睡眠,机械梗阻,Minimize SW transitionsInduce n-CAP,Obstruction: PAP, ASVHypoventilationMinimize iatrogenic,The target is to change system behavior,呼吸调节,Oxygen , CO2Adaptive VentilationDrugs: T, Ac, others to come (I hope),睡眠呼吸暂停低通气综合征患者管理模式的转变,临床管理应集中于患者预后CPAP治疗对预后的改善涉及患者的心理因素和技术因素OSAHS 管理将集中于长期治疗，并成为睡眠医学学科领域的一部分。,OSAHS 是一种慢性疾病: 2007,1964-1998,睡眠呼吸暂停低通气综合征患者疾病管理模式的转变,2007-,睡眠呼吸暂停,其他系统性疾患,睡眠呼吸障碍其他睡眠障碍疾患,睡眠医学: 一门新兴的边缘学科发轫于睡眠呼吸暂停的诊疗,普通内科医师 3.5%7 % PhD ENT 7% - 45mmHg,COPD患者的睡眠呼吸紊乱,神经肌肉患者的睡眠呼吸紊乱,睡眠状态下最需要通气支持 无创通气技术的发展有赖于睡眠呼吸医学的发展,无创通气技术,67.8,4.9,3.2,2.7,2.6,2.3,2.2,2.1,1.7,1.5,1.2,1.0,0.8,6.1,0,10,20,30,40,50,60,70,80,阻塞性睡眠呼吸暂停,发作性睡病,不宁腿综合征,精神性失眠,周期性腿动,上气道阻力综合征,原发性嗜