睡眠呼吸暂停基础知识

睡眠呼吸暂停基础知识介绍M.D.MBA人一生有1/3的时间在

睡眠

中度过世界

卫

生组

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三成人存在睡眠问题睡眠的重要性高铁2003年的重大事故，原因是驾驶员驾驶入睡

The

Jap s:

February

28th,

2003CHALLENGERSPACESHUTTLEDISASTERWRONGDECISION

BYSHIFTWORKINGENGINEERSCHERNOBYL

1986Supervising

staff

atnuclear

reactorwere

sleep

deprivedCorrect

operatingproceduresignoredand

then

incorrectsafety

procedure

usedUS$300

MILLIONRECALL

OFFirestone

tyresEXXON

VALDEZ

oil

spill-

accident

caused

by

sleepinessFlying

requires

certain

skills……睡眠医学历史1924HansBerger

首先观察到脑波1929发现人类EEG1937EEG

作为参数来测量睡眠1956Aserinsky

And

Kletmann发现睡眠REM1968Rechtschaffen

and

Kales

进行睡眠分期1979分类睡眠-清醒失常1990国际睡眠疾患分类睡眠疾患90多种已知睡眠疾患.阻塞性睡眠呼吸暂停(25%+),周期性腿动(10%),失眠(7%),发作性睡病(3%),DSPS(3%),Hypoventilation

2%),Bruxism(1%),睡眠惊恐(1%)¹.睡眠异常导致身心疲惫，认知功能下降.睡眠疾患与高血压，中风和心脏病密切相关.仅在 就有3000多万患有

OSA.¹

Johns

MW,

Med

J

Aust

1992

155:

303-3085.2

亿人

38%中国睡眠状况不完全统计13.68亿人睡眠失眠睡眠呼吸暂停低通气不宁腿综合症发作性睡病异常睡眠夜游症REM期行为异常癫痫样行为=decrease,

=increase,-=no

change健康睡眠结构To

talsleepStage%m

inWake15N

REM

1525N

REM

249235N

REM

3838N

REM

424115REM2411520-30岁健康人睡眠分期及分布图睡眠呼吸暂停睡眠结构中国呼吸暂停患者总量庞大据统计，中国有2亿打鼾人群——其中出现呼吸暂停的有5千万人每夜七小时睡眠过程中呼吸暂停及低通气反复发作在30次以上，或睡眠呼吸暂停低通气指数（AHI）≥5次/小时睡眠呼吸暂停低通气综合征？哪些人容易患OSAHS？肥胖：体重超过标准体重的20%或以上，体重指数（BMI）≥25kg/㎡（颈围>43cm）：

患者多于女性：成年后随

增长患病率增加；遗传：流行病学

发现：SAHSSAHS的许多易患因素具有，症状在直系亲属中2－4倍于对照组及遗传基础（如肥胖及颌面结构 ）哪些人容易患OSAHS？长期大量饮酒和/或服用

药物长期重度吸烟其它相关疾病：包括甲状腺功能低下、肢端肥大症、其他神经肌肉疾患（如帕金森氏病）解剖结构异常：鼻腔阻塞（鼻中隔偏曲，鼻甲肥大，鼻息肉，鼻部肿瘤）、扁桃体肥大、软腭低垂松弛、悬雍垂肥大、咽腔狭窄、舌体肥大、舌根后坠、下颌后缩、小颌畸形等阻塞性睡眠呼吸暂停4%人群中多余女性(9:4)多发40-60

岁30%高血压高

率“Joe”

1800’s睡眠呼吸暂停国际标准定义低通气中枢性阻塞性混合性气流下降的幅度50%noairflow20%noairflow呼吸驱动的下降normaltoreducednorespiratorydrivereduced,variabelcentralandpt.持续时间10s10s10s10s阻塞性中枢性混合性正常上气道横面图上气道横面图阻塞性睡眠呼吸暂停OSA的症状主要症状大而不规则的鼾声夜间呼吸暂停(apneas/hypopneas)白天易困，嗜睡白天易疲劳，晨起无力OSA的症状进一步常见症状力下降睡不解乏易疲劳，工作效率下降晨起头疼晨起口干注意力，性格改变多汉夜间憋醒阳痿抑郁症高血压心脑管疾病心律失常内失调肾功能损伤激素紊乱代谢紊乱心梗塞睡眠打鼾呼吸暂停上气道阻力增加 张口呼吸、睡醒咽干舌燥负压增加

食道反流

打嗝、烧心、咽炎窒息血氧 血二氧化降低 碳升高血酸度增加觉醒植物神经功能紊乱睡眠 睡眠片断 不宁下丘脑垂体内功能紊乱肾功能

红细胞生

动脉硬

体循环血

肺循环血损

害

成增多

化加速

管收缩

管收缩心律不齐睡眠质

辗转翻量下降

动易诱发癫痫生长激素

夜尿增加减少，糖、

蛋白尿脂肪代谢紊乱，肥胖，减退红细胞增多症心肌梗塞脑栓塞

脑卒中心脑血

高血压管疾病肺动脉高压肺心病心律失常猝死白天嗜睡精神神经症状病理生理及临床表现7/30/2015PT

Resindo36OSA心血管病高脂血症高血压肥胖心血管病的7/30/2015PT

Resindo37OSA在动脉硬化中Gami

et

al

Circulation

2004PT

Resindo38AHI

在稳定期心衰Javaheri

S

et

al.Circulation

1998;97:2154-59.More

than

57%

have

AHI7/30/20>1957/30/2015PT

Resindo39睡眠呼吸暂停在其他疾病中的Logan

et

al.J.

Hypertension

2001Javaheri

et

al.Circulation

1999Somers

et

al.Circulation

2004Sjostrom

et

al.Thorax

2003Schafer

et

al.Cardiology

1999Sanner

et

al.Clin

Cardiology

2001Control

ArmTherapeutic

ArmAverage

10

mm

Hgreduction

in

BPcorresponds

to:Coronaryarterydisease

riskreduced

by

37%Stroke

riskreduced

by56%40

Emerging

Markets

for

Sleep

Apnea

©

ResMed

20046080100120140MAP(mmHg)baselineeffective

n

C

P

A

P715

pm1115

pm315

am715

am60

80

100

120

140

MAP

(mmHg)baselinesubtherapeutic

n

C

P

A

P715

pm1115

pm315

am715

amN=60p=0.01使用CPAP治疗后对血压的影响(Becker

et

al,

Circulation

2003)PT

Resindo41SDB

和充血性心衰(CHF)50%

people

with

CHF

haveSDB

(Javaheri

et

al,

Circulation

1999)Common

in

moderate

tosevereheart

failure

patients–

increased

mortalityEffective

SDB

treatmentleads

to

Improved

Left

VentricularFunction

(Milleron

et

al,

EuropeanHeart

Journal,

2004)Improved

quality

of

lifeIncreased

survival7/30/20157/30/2015ndo42SDB和冠状动脉疾病(CAD)30

%

of

CAD

patients

haveSDB

(Schafer

et

al,

Cardiology

1999)OSA

treatment

associatedwith

decrease

in

occurrenceof

of

newcardiovascularevents

and

increase

time

toevents7/30/2015PT

Resindo43SDB

和心律失常Cardiac

arrythmias

50-75%Bradycardia

(slow

heart

rate)Ventricular

arrhythmiasSinus

pauseOSA

50%

of

all

Atrial

Fibrillation

(AF)

patients(Somers

et

al.

Circulation,

2004)AF

patients

on

effective

CPAP

treatmenthave

lower

risk

of

AF

recurrence

than

thosewith

untreated

OSA.

(Kanagala

et

al,Circulation,

2003)7/30/2015PT

Resindo44SDB

和2型Up

to

60%

people

with

Type

2

Diabetes

suffer

SDB

(Brooks

1994,Chizhova

2003)SDB

may

have

a

causal

role

in

the

development

of

diabetes(Al-Delaimy,

Rei uth2003)Associated

with

insulin (independent

of

obesity)(Ip

2002,

Punjabi

2002)30%

patients

presenting

to

sleep

clinics

have

impairedglucose

tolerance

or

diabetes,

of

which

40%

undiagnosed(Meslier

2003)PT

ResindoCPAP

降低血糖的水平Ambika

R.

Babu,

MD,

James

Herdegen,

MDDepar7t/m3e0n/2t

0o1f5Medicine,

Rush

University

Medical

Ctr.Archives

of

Internal

MedicineVOL

165,

FEB

28,

200545After-meal

blood

glucose

levels

can

be

reduced

with

compliant

CPAP

therapy

23–Suggests

that

sustained

CPAP

use

can

be

an

important

therapy

for

diabetes

patients

with

SDBCPAP

use

>4

hrs.(n=12)CPAP

use

<4

hrs.(n=12)Glucose

Mean

mg/dLPT

ResindoIAHarschDepart7m/e3n0t/2o0f1M5edicine

I,

Friedrich-AlexanderUniversityErlangen

Nuremburg,

Erlangen,

Germany.Am

J

Respir

Crit

Care

Med.2004;169(2):156-16246CPAP

改善胰岛素敏感度Shows

improvement

of

insulinsensitivity

index

(ISI)

at

baseline,2

days

and

3

months

after

onsetof

CPAP

treatment

in

31

patentsWithin

48

hours,

significant

improvements

have

been

demonstratedin

Insulin

Sensitivity

using

CPAP

therapy

217/30/2015PT

Resindo47SDB

和脑中分65%

patients

who

suffer

a

stroke

have

SDB(Bassetti

C

Sleep

1999)Up

to

70%

of

patients

in

rehabilitation

therapyfollowing

stroke

have

significant

SDB

(AHI>10)(Good

1996)SDB

in

stroke

patients

associated

with

increasedmortality7/30/2015PT

Resindo48SDB

和肥胖Obesity

is

a

significant

riskfactor

forOSA60

–

70%

of

OSA

patients

areobese77%

of

morbidly

obeseadults

have

OSA–

(BMI

>35)7/30/2015PT

Resindo49Plunging

bloodoxygensaturationApneaSurge

in

sympatheticnerve

activityNegative

swingsin

intra-thoracicpressureIncrease

inblood

pressure睡眠呼吸暂停的生理改变(Morgan

et

al.,Sleep1996)儿童1大声打鼾2静下来则入睡，精神萎靡，力↓智力↓，学习成绩不佳3夜多汗4肥胖，发育迟缓（只胖不长高）5尿床（6－7

岁以后）6行为异常，多动，好打斗7）Night

terros等级I级II级III级IV级导联数PSG》8PSG》8PG》5筛查1-2项目描述多导睡眠便携式多到睡眠或便携睡眠监测仪便携睡眠初筛仪AASM

睡眠呼吸暂停的标准多导睡眠系统便携睡眠监测仪口鼻气流心电腿动血氧/胸式呼吸鼾声腹式呼吸压力传感多导睡眠图记录的参数(C3

-

A2

，C4

-

A1)(上，下眼角对称眼动)(下颌肌电)（指尖末端）脑电EEG眼动EOG肌电EMG口鼻气流AF胸式呼吸腹式呼吸血氧SPO2心电ECG鼾声SnoringBP脉搏PIUSE多导睡眠图示例脑电图形示例各睡眠期波形分布情况EEGEOGEMG

(Chinn)Wake>8Hz,alpha-andbeta-wavesrapideyemovement(EM)highStage14-8Hzslow

rolingEMdeceasingStage2plexes,spindels,Theta-wavesnoEMdecrasingStage30,5-4Hz,Delta-wavesin20-50%

ofanepochnoEMlowStage4Delta-wavesin>50%

ofanepochnoEMlowREMTheta-wavesrapidEMlow多导睡眠图的分析结果睡眠结构是否紊乱，包含各期睡眠的时间比例，睡眠潜伏期，微

，REM周期等等呼吸事件的发生情况，AHI，AI，HI指数血氧饱和度的变化情况，氧减情况其他事件的变化情况，如鼾声与

的关系，

与呼吸事件的关系等等疾病判定的主要参数AHI—呼吸暂停低通气指数OSA,CSA,MSA

次数AI-暂停指数HI-低通气指数SI—鼾声指数ODI4—4%氧减指数最低血氧饱和度最长呼吸暂停时间呼吸暂停程度的分类病情严重程度睡眠呼吸暂停指数最低血氧饱和度轻

度5----15次85%---90%中

度15—30次80%---85%重

度>30次<80%阻塞性睡眠呼吸暂停治疗方法一般治疗减肥/规律锻炼睡眠规律(regular

sleep-wake-cycle)禁酒，禁侧卧睡药物治疗治疗 病

(bronchial

asthma)呼吸驱动/兴奋药(Theophyllin)阻塞性睡眠呼吸暂停治疗方法矫形器鼻扩张器下颚纠形器Protra