睡眠医学的最新进展

睡眠醫學的最新進展,新光醫院胸腔內科美國史丹佛大學睡眠研究中心林嘉謨醫師,演講內容大綱,介紹睡眠呼吸問題睡眠呼吸問題與疾病的關係兒童睡眠呼吸問題猝睡症肢動症失眠症的行為治療討論,白天嗜睡的主要原因,睡眠的質或量不夠如睡眠時間不足或間斷性的睡眠(睡眠呼吸中止症或身心症)中枢神經病変生理時鐘與環境的互動失調藥物的影響,正常睡眠的階段,非快速動眼期(Non-REM)睡眠-較規則的呼吸,較理性化的夢境,stage1,2,3,4.(stage3+4=slowwavesleep,SWS)快速動眼期(REM)睡眠-較不規則的呼吸,較情緒化的夢境,呼吸驅動力較弱,較易缺氧一個典型夜晚的睡眠是以70-90分鐘的非快速動眼期睡眠開始,然後進入約十分鐘的快速動眼期睡眠,如此重複循環整個夜晚,阻塞性睡眠呼吸中止,睡眠呼吸中止症之上呼吸道特徵,鼻腔阻塞扁桃腺(tonsil),咽扁桃腺(nasaladenoid)肥大咽顎帆區(velopharyngealspace)淺而狹窄舌頭肥大(Macroglossia)下顎狹小,後縮(Micro,retro-gnatia)上呼吸道感覺神經異常,SignsandsymptomssuggestiveofsleepapneaAtuletal.Lancet2002;360:237-45,SnoringWitnessedapneas,gasping,orbothObesity(especiallyneckcircumference)HypertensionExcessivedaytimesleepinessFamilyhistoryNocturiaNon-restorativesleep,AreFar-EastAsianMorePronetohaveSleepApnea?,亞洲人與美洲人睡眠呼吸中止症候群病人的比較,亞洲的睡眠呼吸中止症候群的病人較瘦,沒有像美洲的病人那麼胖亞洲人先天上顱骨底面積較美洲人小,所以亞洲人上呼吸道會比美洲人更小,更容易有睡眠呼吸問題,行為治療,維持理想體重側睡避免睡前鎮靜藥物避免睡眠不足避免睡前喝酒床頭搖高(肥胖特別是肚子大的人）感冒及過敏一定要治好睡前避免吃太多戒菸,MedicalTreatmentofOSAS,RespiratoryCenterStimulants(?)MedroxyprogesteroneAcetateAcetazolamideClomipramineHydrochlorideTheophyllineNeuroactiveDrugs(?)ProtriptylineStrychnineModafinilOxygentherapy(avoidCO2retention)IntranasalsteroidorradiofrequencyTongueRetainingDevice(Oralappliant)(onlymildOSA,needfollowupsleepstudy)NasalCPAP-goldstandardoftreatment),SurgicalTreatmentofOSAS,Tracheostomy-100%successratebut.Removaloftheunderlyingobstruction-enlargedtonsils,adenoid,thyroid.etcTonsillo-adenoidectomyPalatopharyngoplasty(PPP)Uvulopalatopharyngoplasty(UPPP)Laser-assistedUvulopalatoplasty(LAUP)GenioglossaladvancementRadiofrequencypalatoplastyandtonguebaseablationMandibularOsteostomy&HyoidBoneAdvancement(PhaseII),RadiofrequencyUsageinOSAS,ChildOSAS,猝睡症(Narcolepsy),TheNarcolepsy“Tetrad”,Excessivedaytimesleepiness(sleepattack)Cataplexy(suddenlossofmuscletone)Hypnogogichallucination(vividdream-likeimagesjustbeforesleeponset)Sleepparalysis(muscleparalysisonmorningawakening)Disruptednocturnalsleep?,PeriodicLegMovement,RestlessLegSyndrome,RLSEpidemiology,10-15%oftheresponders(in2019subjects)SimilarprevalenceamongmaleandfemaleThemeanageofonsetwasfoundtobetween27.2and41.0yearsTwolargesurveyfoundthat38.3and45%ofRLSpatients,respectively,experiencedtheirfirstsymptomsbeforetheageof20,PeriodicLegsMovementsDefinition,Originallycalled“nocturnalmyoclonus”,PLMSisbestdescribedasrhythmicalextensionsofthebigtoeanddorsiflexionsoftheanklewithoccasionalflexionsofthekneeandhip,eachmovementlastingapproximately0.5to5.0secwithafrequencyofaboutoneevery20to40secTheprevalenceofPLMSiscorrelatewithage,rarelydiagnosedin50years,44%65years.APLMSindex(numberofthePLMSperhourofsleep)5fortheentirenightofsleepisconsideredpathological.,SecondaryRLSduetoUnderlyingConditions,Iron-deficiencyanemiaUremia(20-40%ofdialysispatients)Pregnancy(upto27%)Fibromyalgiaandrheumatoidarthritis(30%)Diabetes&parkinsonsdiseaseNeurologicallesionsbothspinalcordandperipheralnervelesionsDrug-induced(includewithdrawal)tricyclics,SSRIs,lithium,dopamineblockers(e.g.,neuroleptics),xanthines,beta-blockers,caffeine,alcohol,andhistamineblockers,InsomniaDefined,Insomniaischaracterizedbyanyofthefollowing:DifficultyfallingasleepDifficultystayingasleepEarlymorningawakeningFeelingunrefreshedinthemorning,InsomniaEpidemiology,Approximately35%adultspopulationisafflictedwithinsomniaduringthecourseofayear.9-12%ofthepopulationoccuronaregularbasis(chronicinsomnia)Boththeincidenceandthecomplaintofinsomniaincreaseacrossthelifecycles,ComplicationsofInsomnia,Insomniaisafrequentsymptomofpsychiatricdisordersandisoftenariskfactorforfuturepsychiatricillness-Depression-Anxiety-Alcoholabuse-Drugabuse,DiagnosingInsomnia,CompletesleephistoryMedicalandpsychiatricassessment-substanceuseAlcohol,caffeine,andconcomitantmedicationPrescriptionand/orOTCmedicationDrugsSleepdiaryPolysomnography,Non-pharmacologicalInsomniaTreatment/CognitiveBehavioralTherapy(CBT)Outcome,ReducesleeplatencyDecreasefrequencyanddurationofarousalIncreasesleepqualityDecreasesleep-relatedanxietyImprovedaytimefunctionandmood,ProcedureofCBT,ComprehensiveevaluationOvernightsleepstudyIndividualofgroupformatWeeklysession(6-8weeks)DailysleeplogsMultiplecomponentapproachConcomitant