多频道生理纪录法在睡眠呼吸中止症的应用

Goldstandard:Polysomnography(overnight)

多频道生理纪录法Parameter:EEGEOGChinEMGEKGChestmovementAbdomenmovementLegmovementAirflowOxygensaturationBodypositionSnoringLightvideorecordingEEG,EOG,chinEMG

电极黏贴位置示意图-3EEGchannels:C3/A2,C4/A1,O1/A2,GND,REFC4/A1-2EOGchannels:ROC(1cmabove)/A1,LOC(1cmbelow)/A2LOCROCROC/A1-1EMGchannel:beneaththechin(4cmbetween2electrodes)EMG1EMG2EMGGRDWhatissleepapnea?Apnea:completecessationofairflow(atleast<90%ofbaseline)foratleast10sec>10secWhatissleephypopnea?Hypopnea:airflow<50%ofbaseline,ordesaturationofatleast4%,orarousalfromsleepThreetypesofSleepapneasyndromeCentraltypeObstructivetypeMixedtypeCentraltypesleepapnea(睡眠呼吸中止中枢型)定义：1.呼吸波减至10%以下2.每次至少10秒3.无胸腹部的呼吸动作

15seconds不会过胖咽喉通道不狭窄抱怨晚上失眠但白天想睡觉打鼾不严重<10%有睡眠呼吸症状者显着---CNSorneuromusculardisorder.Obstructivesleepapnea(睡眠呼吸中止阻塞型)*定义：呼吸波减至10%以下每次至少10秒喉咽气道阻塞胸腹部呼吸动作持续，但无气流交换75seconds较常见>90%台湾约有11%中老年人口罹患中度或重度阻塞型睡眠呼吸中止症Mixedtypeapnea睡眠呼吸中止混合型定义：1.呼吸波减至10%以下2.每次至少10秒3.先中枢型再接阻塞型4.>25%的中枢型30secondsHypopnea定义：每次至少有90%的呼吸波减至50%以下每次至少10秒血氧饱和度下降至少3%32seconds阻塞型睡眠呼吸中止症临床症状打鼾白天嗜睡无法熟睡注意力不集中

晨醒头痛夜间频尿性情改变sleepapnea的影响sleepapnea相关危险因素年纪男性>女性肥胖颈围过粗(男>43公分，女>38公分)

酒精或镇静剂、安眠药颅面结构异常如后缩颚、下颚狭小、鼻中膈弯曲、舌头过大、暴牙、舌头过大、扁桃腺肥大、悬壅垂肥大咽颚帆区狭小、口鼻咽软组织过多甲状腺功能过低症、唐氏症RDI及AHI的定义AHI:apnea/hypopneaindex(#/hour)Theaverageofepisodesofapneaandhypopneaperhourofsleep

每小时apneaandhypopnea的平均发生次数RDI:respiratorydisturbanceindex(#/hour)#:eventsofapnea,hypopnea,snores,snoreresultinginarousalsTheseverityofsleepapneaDiagnosisNormalMildModerateSevereRDI/AHI(episodes/hour)<552020-40>40DiagnosisMildModerateSevereMeanSaO290%90%<90%MinimumSaO285%70%<70%ICSIhealthguideliine,Diagnosisandtreatmentofobstructivesleepapnea,2003*严重度的睡眠呼吸中止症可领轻度残障手册，已有提议修法改为向健保局申领购买阳压呼吸器补助费。如何治疗睡眠呼吸中止症维持理想体重侧睡避免睡前服用镇静药物避免睡眠不足避免睡前喝酒床头摇高

(肥胖特别是肚子大的人）感冒及过敏一定要治好睡前避免吃太多戒菸手术一个月后

98公斤手术前135公斤扁桃腺肥大1.行为治疗如何治疗睡眠呼吸中止症Fujita(1981),UvulopalatopharygoplastyMostcommonprocedure----removeexcesstissueoftonsils,uvulaandpartofthesoftpalate.1stlinetreatmentforretropalatalcollapse10-50%success2.UPPP(悬壅颚咽成形术)(侵袭性治疗)3.DentalAppliances齿科装置(非侵袭性治疗)NearlyaseffectiveasCPAPinmildtomoderateOSARepositionthemandible

如何治疗睡眠呼吸中止症4.NasalCPAP鼻腔阳压呼吸器(非侵袭性治疗)

NasalContinuousPositiveAirwayPressure

(APAP):AutoPositiveAirwayPressure

10cmH2Otoovercomeupperairwaynarrowing,notover20-25cmH20)

如何治疗睡眠呼吸中止症R&K,1968(Rechtschaffen&Kales)AwakeNon-REMsleep(非快速动眼期)stage1stage2stage3stage4REMsleep(快速动眼期Rapid-Eye-Movement)正常睡眠的分期AmericanAcademySleepMedicine美国睡眠医学会,2007StageWStageN1StageN2StageN3(deepsleep)StageR

正常睡眠分期的周期关系睡眠记录常用名词1.TotalRecordingTime(记录总分钟数)TimeinBed(躺在床上的总分钟数)2.TotalSleepTime(睡眠总分钟数)(stage1+stage2+stage3+stage4+REM)3.SleepEfficiency(睡眠效率,>85%)(TotalSleepTime/TotalRecordingTime)X1004.SleepLatecy(入眠时间,<15分钟)5.REMlatency(入快速动眼期时间,80-120分钟)

N-REMandREMstage在生理上的比较

Non-REMREM呼吸速率规则较快且有变异性血压规则较高且有变异性心跳规则较快且有变异性大脑血流速率规则增加体温稳定变异肌肉张力放松消失作梦很少时常阴茎或阴蒂勃起较少时常

N-REMandREMstage在功能上的比较

Non-REM(deepsleep)REM生长激素的分泌脑部生长脑部发育与智力及记忆有关PolysomnographyReportPolysomnographyReportPolysomnographyReport脑波频率Delta<4HzHerzTheta4-7HzAlpha8-13HzBeta>13Hz

脑波形状KComplexsharpnegativewave,followedbyslowerpositivecomponent,>0.5secseeninStage2Spindleshortrhythmicwaveformclustersof12-14Hz>0.5secseeninstage2lowamplitudesawtoothappearanceseeninREMSawtoothwavessharppositivewaves,thetafrequencyrange,occurringlatterpartofStage1VertexwavesRelaxedWakefulnessrapideyemovement,blinkstonicactivity,relativelyhigh,voluntarymovementαwave(8-13cps),predominantlyinO1,O2Pattern:Bladesofgrass

lowvoltage,mixedfrequency,θ(4to7cps),Vertexsharpwavesmaybepresent.NON-REMStage1(5%ofTotalSleepTime)slowrollingeyemovementtonicactivitylowerthanawakeSleepspindle:>0.5sec,11-16cps,3-8/minKcomplex:＞0.5sec,1~3/minnegative-positiveLowleveltonicactivitySloweyemovementNon-REMStage2(50%oftotalsleep)Stage1withvertexsharpwaveStage2withsleepspindle&kcomplex(1epoch=30seconds)Comparisonbetweenstages1&2(1epoch=30seconds)vertexsharpwave,>75uv,<0.5sec,upwardsleepspindlekcomplex(3minute-rule)EMG:lowleveltonicEEG:0.5~2cps,highvoltage>75uVStage3:20%~50%slowwaveSleepspindlesmaybepresentNREMStage3(slowwavesleep)(1epoch=30seconds)EOGsimilartoEEGEMG:lowleveltonicEEG:slowwave<2cps,highvoltage>75uVStage4:>50%slowwaveNREMStage4(slowwavesleep)(1epoch=30seconds)Slowwavesleep10~15%oftotalsleeptimeREMstage(rapideyemovement,20~25oftotalsleeptime)EEG:Sawtooth,2-6cps,precedingaburstofREMsEOG:RapideyemovementEMG:T