睡眠呼吸暂停,麻醉医师应知道些什么双语

O S A What an Anesthesiologist Should Know?睡眠呼吸暂停麻醉医师应知道些什么？,福建医科大学附属协和医院麻醉科规培住院医师 吴金华,OSA is a disease characterized by recurrent episodic cessation of breathing lasting 10s during sleep睡眠时呼吸停止10秒，反复发作。There is exaggerated depression of pharyngeal muscle tone during sleep and anesthesia, resulting in a cyclical pattern of partial or complete upper airway obstruction with impaired respiration.睡眠和麻醉过程中咽肌失去张力，导致部分或完全的上气道梗阻气道This manifests as repeated nocturnal arousals and increased sympathetic output, daytime hypersomnolence, memory loss, and executive and psychomotor dysfunction.反复的夜间觉醒和交感神经兴奋，白天嗜睡，记忆力减退，以及行为和精神运动功能障碍。 Its estimated prevalence are 1 in 4 males and 1 in 10 females for mild OSA，and 1 in 9 males and 1 in 20 females for moderate OSA.预计的发生率为：轻度OSA男性4人中有1人，女性10人中有1人；中等OSA男性9人中有1人，女性20人中有1人。,OSA Diagnostic Criteria,An overnight polysomnography or sleep study. The AHI defined as the average number of abnormal breathing events per hour of sleep, is used to determine the presence of and the severity of OSA. AHI被定义为每小时睡眠的呼吸异常事件的平均数量，是用于确定是否存在OSA及严重程度。An apneic event refers to cessation of airflow for 10s, while hypopnea occurs with reduced airflow with desaturation 4%呼吸暂停事件：气流停止10s，而血氧至少下降4%. The American Academy of Sleep Medicine (AASM) diagnostic criteria for OSA requires either an AHI 15, or AHI 5 with symptoms, such as daytime sleepiness, loud snoring, or observed obstruction during sleep如白天嗜睡，鼾声如雷，或观察的到的梗阻睡眠The Canadian Thoracic Society guidelines for the diagnosis of OSA specifies the presence of an AHI 5 on polysomnography, and either of (1) daytime sleepiness or (2) at least 2 other symptoms of OSA (e.g.choking or gasping during sleep, recurrent awakenings, unrefreshing sleep, daytime fatigue). 多导睡眠图提示AHI 5，及（1）白天嗜睡或（ 2）至少2个其他OSA的症状 如睡眠中有窒息或喘息，经常醒来，不能恢复精神的睡眠，白天疲劳。OSA severity is mild for AHI 5 to15, moderate for AHI 15 to 30, and severe for AHI 30.,Comorbidities Associated with OSAOSA的合并症,OSA is associated with multiple comorbidities such as myocardial ischemia, heart failure, hypertension, arrhythmias, cerebrovascular disease, metabolic syndrome, insulin resistance, gastroesophageal reflux, and obesity.心肌缺血，心脏衰竭，高血压，心律失常，脑血管疾病，代谢综合征，胰岛素抵抗，胃食管反流，肥胖Various pathophysiological, demographic and lifestyle factors also predispose to OSA. These include anatomical abnormalities which cause a mechanical reduction in airway lumen diameter(e.g. craniofacial deformities, macroglossia, retrognathia), endocrine diseases (e.g. Cushing disease,hypothyroidism), connective tissue diseases (e.g. Marfan Syndrome), male gender, age above 50 years, neck circumference 40 cm, and lifestyle factors of smoking and alcohol consumption.各种病理生理，人口结构和生活方式等因素与OSA有关.包括导致机械降低气道管腔直径的解剖异常（如颅面畸形，巨舌，下颌后缩），内分泌疾病（如皮质醇增多症，甲状腺功能减退），结缔组织病（如马凡氏综合症），男性，年龄50岁以上，颈围40公分和吸烟、饮酒的生活方式因素,Postoperative Complications in Patients with OSAOSA患者术后并发症,Chronic untreated OSA leads to multisystemic adverse consequences and is an independent risk factor for increased all-cause mortality in the general population.慢性未经治疗的OSA可导致多系统的不良后果，也是普通人死亡率增加的独立危险因素。The anatomical inherent collapsibility of the airway and the systemic effects of the disease also place the surgical OSA patients at increased risk of serious complications. OSA患者气道解剖结构的改变和疾病的全身影响也增加其手术的严重并发症的风险。Memtsoudis et al found a 2X higher risk of pulmonary complications in OSA patients after non-cardiac surgery vs non-OSA.在非心脏手术中，与非OSA 相比OSA患者肺部并发症的风险更高一倍。In bariatric surgical patients, the presence of OSA was found to be an independent risk factor for adverse postoperative events. Flink et al reported a 53% incidence of postoperative delirium in OSA patients vs 20% in non-OSA patients.在减肥手术患者中，OSA是术后不良事件的独立危险因素。弗林克等人报道了53%的OSA患者和20%非OSA患者术后谵妄的发生率。,A meta analysis by Kaw et al showed that the presence of OSA increased the odds of postoperative cardiac events including myocardial infarction, cardiac arrest and arrhythmias (OR 2.1), respiratory failure (OR2.4),desaturation (OR 2.3), ICU transfers (OR 2.8), and reintubations (OR2.1). OSA的存在增加了术后心脏事件However, a recent study found that neither an OSA diagnosis nor suspected OSA was associated with increased 30-day or 1-year postoperative mortality. Also, Mokhlesi et al examinated large nationally representative cohorts in elective orthopedic, prostate, abdominal and CV surgery in 1 million patients and 90,000 patients undergoing bariatric surgery. Both studies showed increased complications but not an increase in mortality. OSA除了增加死亡率也增加术后并发症。Given the body of evidence associating a diagnosis of OSA with adverse perioperative outcomes, precautions should be taken perioperatively to reduce complications in this vulnerable group of patients.鉴于OSA的诊断与围手术期不良事件的相关性，应采取预防措施，减少这一弱势群体患者的围手术期的并发症,Preoperative Evaluation of the Patient with Diagnosed OSAOSA患者的术前评估,A thorough history and physical examination are essential. Focused questions regarding OSA symptoms should be asked. Polysomnography results should be reviewed to confirm the diagnosis of OSA and evaluate the severity of the disease. Patients with long standing OSA may manifest a myriad of signs and symptoms suggesting the development of systemic complications, such as hypoxemia, hypercarbia, polycythemia and cor pulmonale.彻底的病史和体格检查是必不可少的。与OSA症状相关的问题应被询问到。多导睡眠监测结果应进行复习以确认OSA的诊断和评估疾病的严重程度。在长期的OSA患者会表现出各种的体征和症状，提示系统性并发症的发展，如缺氧，高碳酸血症，红细胞增多症和肺心病。,The patient should also be assessed for significant comorbidities including morbid obesity, uncontrolled hypertension, arrhythmias, cerebrovascular disease, heart failure and metabolic syndrome. Obesity hypoventilaton syndrome occurs in 0.15-0.3 of the general population. Pulmonary arterial hypertension is a fairly common long term complication of OSA, occurring in 15-20% of patients. Its significance lies in the fact that certain physiological derangements may raise pulmonary artery pressures further and should be avoided intraoperatively. 应评估重要的合并症包括病态肥胖，未控制的高血压，心律失常，脑血管疾病，心脏衰竭，代谢综合征。肥胖低通气综合征发生在普通人群中的0.15-0.3 。肺动脉高压是OSA相当常见的长期并发症，发生率达15-20。其意义在于某些生理紊乱可提高肺动脉压力，术中应进一步避免。The American College of Chest Physicians does not recommend routine evaluation for pulmonary arterial hypertension in patients with known OSA. However, should there be anticipated intraoperative triggers for acute elevations in pulmonary arterial pressures, for example, high risk surgical procedures of long duration, a preoperative transthoracic echocardiography may be considered.美国胸科医师不建议常规评估已知的OSA患者肺动脉高压。 然而，如果有预期的术中的触发在肺动脉压力急性升高的因素，例如，持续时间长的高风险的外科手术，可考虑做术前经胸超声心动图检查以评估肺动脉高压。,Simple bedside investigations may be performed in the preoperative clinic to screen for OSA related complications. In the absence of other attributable causes for hypoxemia, a baseline oximetry reading of 94% on room air suggests severe long standing OSA, and may be a red flag signaling postoperative adverse outcome术前进行的简单的床头调查可能筛查出OSA相关的并发症。没有其他原因引起低氧血症，室内空气下血氧94，表明存在严重的长期的OSA，并可能是标志着术后不良事件的红色信号,The compliance of OSA patients to such treatment should be evaluated. The patients updated PAP (Positive airway pressure) therapy settings should be obtained. Reassessment by a sleep medicine physician may be indicated in patients who have defaulted follow up, have been non-compliant to treatment, have had recent exacerbation of symptoms, or have undergone upper airway surgery to relieve OSA symptoms. Patients who default PAP use should be advised to resume therapy. OSA患者的治疗依从性应评估.病人的最新PAP治疗的设置应该得到的。通过睡眠医师的重新评估可表明：谁放弃治疗，谁不按规定治疗，谁近期症状加重，谁进行了上气道手术来缓解OSA症状。放弃PAP治疗的患者应建议其恢复治疗。,Interestingly, there is to date insufficient evidence to prove conclusively the benefit of PAP therapy in the preoperative setting; and the duration of therapy required to effectively reduce perioperative risks has not been delineated.有趣的是，迄今没有足够的证据证明在术前PAP治疗的获益；以及有效地减少围手术期的风险，治疗所需的时间尚未确定。 A recent study showed that the preoperative patients identified to have OSA and treated with CPAP have long term health benefits in terms of improved snoring, sleep quality, daytime sleepiness and reduction of medications for comorbidites. However, adherence to prescribed CPAP therapy during the perioperative period was extremely low.最近的一项研究表明，术前确诊为OSA并进行CPAP治疗在长期改善打鼾，睡眠质量，白天嗜睡和减少合并症的用药有意义。然而，在围手术期遵守规定给予CPAP治疗者非常少。,Current guidelines recommend that patients with moderate or severe OSA already on PAP therapy should continue PAP use prior to surgery.目前的指南建议中度或重度OSA已经进行PAP治疗者应该继续治疗至手术前。 The anesthesia team should be informed early to allow for advanced intraoperative management planning and risk mitigation.麻醉团队应被提前告知以便制定更好的术中管理计划降低手术风险 Mild OSA may not be a significant disease entity for patients undergoing surgery and anesthesia. 轻度OSA患者不是暂停手术和麻醉的实质疾病。From the published results of the Busselton Health Cohort Study, mild OSA was not an independent risk factor for higher mortality in the general population.轻度的OSA不是增加普通人群死亡率的独立危险因素。 Based on expert opinion and symptomatology of OSA patients, preoperative PAP use may not be indicated in patients with mild OSA. PAP不是轻度OSA患者治疗的指征。,Methods for Perioperative Screening for OSA 对OSA的围手术期的筛选方法,PSG 多导睡眠监测 金标准 昂贵questionnaire-based methods the Epworth Sleepiness Scale, the Berlin Questionnaire, the ASA checklist, the Sleep Apnea Clinical Score,the P-SAP score and the STOP-Bang questionnaire.,Table 1: Obstructive Sleep Apnea Screening Questionnaire STOP-Bang,Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes NoTired: Do you often feel tired, fatigued, or sleepy during daytime? Yes NoObserved: Has anyone observed you stop breathing during your sleep? Yes NoBlood Pressure: Do you have or are you being treated for high blood pressure? Yes NoBMI: BMI more than 35 kg/m2? Yes No Age: Age over 50 years old? Yes No Neck circumference: Neck circumference greater than 40 cm? Yes No Gender: Male? Yes NoLow risk of OSA: Yes 0-2 At risk of OSA: Yes 3 or more questions High risk of OSA: Yes 5-8,Patients with STOP-Bang scores 0-2 may be considered low risk, 3-4 intermediate risk, and 5-8 high risk of OSA. Apnea/hypopnea during sleep can lead to intermittent hypercapnia and result in serum bicarbonate retention. The addition of serum bicarbonate level to the STOP-Bang questionnaire may improve its specificity.The STOP-Bang questionnaire is useful in the preoperative setting to predict OSA severity, triage patients for further confirmatory testing, and exclude those without disease 。得分0-2可能是低风险， 3-4中间风险，和5-8 OSA的高危人群。睡眠时呼吸暂停/低通气可导致间歇性高碳酸血症，导致血清碳酸氢盐潴留。增加血清碳酸氢盐水平，以STOP-Bang调查问卷可提高术前OSA诊断的特异性， STOP-Bang问卷有利于评估OSA的严重程度，筛选出一些病人作进一步确定性测试，并排除那些没有OSA的病人。,Preoperative Evaluation of the Patient with Suspected OSA疑似OSA患者的术前评估,In patients suspected of OSA, a thorough clinical examination should be performed with emphasis on pertinent symptoms and signs of OSA.在疑似OSA患者的，彻底的临床检查应着重于与OSA相关的症状和体征The subsequent management is determined by the urgency of surgery.后续的处理取决于手术的紧迫性Where non-urgent elective surgery is planned, the decision for further evaluation rests on (1) the risk of surgery, and (2) the presence of other significant comorbidities suggestive of chronic OSA, such as uncontrolled hypertension, heart failure, arrhythmias, pulmonary hypertension, cerebrovascular disease, morbid obesity and metabolic syndrome.计划非紧急的择期手术时，作出进一步评价这一决定取决于（1）手术的风险，（2）OSA其他明显并发症的存在For patients with STOP-Bang score 5-8, scheduled for major elective surgery, and have comorbid disease(s) associated with long standing OSA, a preoperative assessment by the sleep physician and a polysomnography should be considered for diagnosis and treatment患者STOP-Bang得分5-8，进行重大手术，长期的OSA相关的合并症，术前评估应考虑进行多导睡眠检查和睡眠医师协助诊断和治疗,Sometimes, major elective surgery may have to be deferred to allow adequate evaluation and optimization of suspected severe OSA. 有时大的择期手术可能被推迟，以便进行足够的术前评估及疑似严重OSA患者的身体的优化。We suggest that patients scored as high risk but without significant comorbidities be considered for further evaluation with portable monitoring devices, or proceed with surgery with a presumed diagnosis of moderate OSA and with perioperative OSA precautions. These patients can be referred after surgery我们建议高危但无明显合并症患者可以使用便携式设备进一步评估，或对疑似中等程度的OSA患者继续进行手术，但围手术期采取针对OSA的预防措施。这些病人可以监测直到术后,Portable Polysomnography and Overnight Oximetry便携式多导睡眠图和夜间血氧饱和度仪,The level 2 portable polysomnography has been shown to have a diagnostic accuracy similar to standard polysomnography, while nocturnal oximetry is both sensitive and specific for detecting OSA in STOP-Bang positive surgical patients. 2级的便携式多导睡眠图已被证明与标准多导睡眠诊断有一致的准确性，而夜间血氧饱和度在STOP-Bang阳性的手术患者中鉴别出OSA有一定的敏感和特异性The oxygen desaturation index derived from nocturnal oximetry correlates well with the AHI obtained from polysomnography. Furthermore, patients with mean preoperative overnight SpO2 28.5 events/h are at higher risk for postoperative adverse events. 夜间血氧饱和度仪所得到的氧饱和度指数与多导睡眠监测获得的AHI很好的相关性。患者术前平均血氧饱和度过夜28.5次/ h在手术后不良事件发生的风险较高。,The Portable Monitoring Task Force of the American Academy of Sleep Medicine (AASM) suggests that portable devices may be considered when there is high pretest likelihood for moderate to severe OSA without other substantial comorbidities. AASM建议在中度至重度OSA没有其他实质性合并症的患者考虑使用便携式设备。 The Canadian Thoracic Society 2011 update on the diagnosis and treatment of sleep disordered breathing recommended that level 2, 3 and 4 portable monitoring devices including nocturnal oximetry may be used as confirmatory tests for the diagnosis of OSA, provided that proper standards for conducting the test and interpretation of results are met. CTS提出如果正确地进行测试并对结果进行解释，那么2级，3和4的便携式监测设备包括夜间血氧饱和度可作为诊断为OSA的确认测试。,Intraoperative Risk Reduction Strategies for OSA Patients OSA患者围手术期预防和减少风险措施,注：1 slight neck extension; 2 elevation of the mandible 3 mouth opening,Postoperative Disposition of Known and Suspected OSA Patients after General Anesthesia,The postoperative disposition of the OSA patient will depend on three main components: the invasiveness of the surgery, the severity of OSA, and the requirement for postoperative opioids .OSA患者的术后处置将取决于三个主要组成部分：手术的级别，OSA的严重程度，及术后阿片类药物需求The final decision regarding the level of monitoring is determined by the attending anesthesiologist, taking into account all patient-related, logistical and circumstantial factors.对于监测水平，最终的决定由麻醉医师决定，应考虑到病人相关症状，经济和环境因素。,All patients with known or suspected OSA who had received general anesthesia should have extended monitoring in PACU with continuous oximetry.所有曾接受全身麻醉的已知或怀疑OSA患者在PACU中应继续血氧饱和度监测There are currently no evidence-based guidelines addressing the optimal length of monitoring required in PACU. 没有明确的循证指南指导PACU的最佳监测时间The ASA guidelines, which were based on expert opinion, recommended prolonged observation for 7 hours in PACU if respiratory events such as apnea or airway obstruction occur. ASA指南推荐若呼吸事件如呼吸暂停或气道阻塞出现， PACU观察延长至7小时。 Such recommendations are difficult to adhere to, especially in the context of community hospitals. We propose extended PACU observation for an additional 30-60 minutes in a quiet environment after the modified Aldrete criteria for discharge has been met.这些建议是很难坚持的，尤其是在社区医院。我们建议如果患者能满足改良Aldrete出院的评分标准，那么仅需额外的30-60分钟PACU观察时间。,The occurrence of recurrent respiratory events in PACU is another indication for continuous postoperative monitoring.在PACU中复发的呼吸事件是继续术后监测的另一个指征。PACU respiratory events are: (1) episodes of apnea 10 seconds, (2) bradypnea 8 breaths/min, (3) pain-sedation mismatch, or (4) repeated O2 desaturation 90%. Any of the above events occurring repeatedly in separate 30-minute intervals may be considered recurrent PACU respiratory events. PACU呼吸事件：（1）暂停10秒发作，（2）呼吸徐缓8次分，（3）疼痛镇静不匹配，或（4）重复血氧90%。上述事件重复出现在单独的30分钟的时间间隔，可以认为复发的PACU呼吸事件Patients with suspected OSA and who develop recurrent PACU respiratory events are at increased risk of postoperative respiratory complications.增加术后气道并发症的风险Continuous monitoring with oximetry in a unit with ready access to medical intervention is advocated. These would include ICU, step down units, or the surgical ward equipped with remote telemetry and oximetry monitoring. These patients may require postoperative PAP therapy.提倡在重症监护病房，二级病房（手术暂留区）或外科病房连续监测血氧饱和度以便随时获得医疗干预。这些患者可能需要手术后PAP治疗,One should consider discharging a patient with known OSA to a monitored environment if the patient has severe OSA, is non-compliant to PAP therapy, or has recurrent PACU respiratory events .如果病人有严重的OSA，而没有进行规范的PAP治疗，或有复发的PACU呼吸事件,应该考虑其监控环境Monitoring with continuous oximetry is recommended with parenteral opioids due to possible drug induced respiratory depression. 肠外阿片类药物可能引起呼吸抑制，推荐连续血氧饱和度监测 Patients with moderate OSA who require high dose oral opioids should be managed in a surgical ward with continuous oximetry regardless of the number of PACU respiratory events.无论PACU呼吸事件的数目多少，需要大剂量口服阿片类药物治的中度OSA患者应在外科病房进行连续血氧饱和度的监测。,Known OSA patients already on PAP devices should continue PAP therapy postoperatively，may mitigate the risk of postoperative complications.已知的已使用PAP设备的OSA患者术后应继续PAP治疗，可以减轻术后并发症的风险A multimodal approach to analgesia should be employed to minimize the use of opioids postoperatively.应用多模式镇痛减少术后阿片类药物的使用。If postoperative parenteral opioids are necessary, consideration should be made for the use of patient controlled analgesia with no basal infusion and a strict hourly dose limit, as this may help reduce the total amount of opioid used.如果术后的肠外阿片类药物是必要的，应考虑使用PCA，但不使用基础输注量并严格限制每小时剂量，这可能有助于减少阿片类药物使用的总量。OSA patients may have an upregulation of the central opioid receptors secondary to recurrent hypoxemia, and are therefore more susceptible to the respiratory depressant effects of opioids. As such, they may benefit from supplemental oxygen while on parenteral opioids. OSA患者反复低氧血症后可能继发中枢阿片受体上调，更容易受到阿片类药物的呼吸抑制作用。因此，肠外阿片类药物使用时患者应进行吸氧。,Anesthesiologists should consider the factors and events associated with higher risk of complications from OSA, diagnostic follow-up and possible sleep medicine consult.麻醉医师需关注OSA患者并发症的高危因素和事件，跟进诊断和睡眠专科医师会诊For the perioperative management, it is important to educate surgeons, nurses, patients, and their family. Pharmacy involvement to prevent multiple drugs with potential to cause sedation and limiting the upper dose of opioids is essential. Nurse training in detecting respiratory depression and in rapid administration of naloxone will prevent mortality and morbidity.对于围手术期管理，外科医生，护士，患者和他们的家属共同学习认知是很重要的。药店参与，在避免多种镇静药物使用和控制阿片类药物的剂量上是必不可少的。训练护士发现呼吸抑制和纳洛酮快速给药可以防止死亡率和发病率。,Preoperative AHI, male gender and 72h opioid dose were positively associated with postoperative AHI.术前的AHI，男性及72h内的阿片类药物的剂量与术后AHI呈正相关At present, deciding on the optimal level and duration of monitoring for OSA patients remains a daunting challenge.目前，确定OSA患者监测的最佳水平和持续时间仍然是一个艰巨的挑战。Granted, the incidence of postoperati