持续正压通气治疗慢性心力衰竭合并睡眠呼吸紊乱的研究进展

心力衰竭是严重影响公共健康的心血管疾病之一,睡眠呼吸紊乱是心力衰竭中不可忽视的并发症,其引起的一系列病理生理反应,使得心力衰竭患者死亡的危险性增加,持续性正压通气可以显著改善心力衰竭患者睡眠呼吸紊乱,甚至提高心功能.这篇文章对睡眠呼吸紊乱与心力衰竭间病理生理的相互作用,以及持续性正压通气治疗对心力衰竭伴睡眠呼吸紊乱患者的影响方面做相关的回顾性评价.     

Refractory Insomnia and Sleep-Disordered Breathing: A Pilot Study

Objective: To assess an uncontrolled, open-label trial of sleep-disordered breathing (SDB) treatment on two different samples of chronic insomnia patients. Method: In Study 1 (Retrospective), data from one diagnostic and one continuous positive airway pressure (CPAP) titration polysomnogram were compiled from 19 chronic insomnia patients with SDB. Objective polysomnogram indicators of sleep and arousal activity and self-reported sleep quality were measured. In Study 2 (Prospective), clinical outcomes were assessed after sequential cognitive-behavioral therapy (CBT) and SDB therapy (CPAP, oral appliances, or bilateral turbinectomy) were provided to 17 chronic insomnia patients with SDB. Repeat measures included the Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, Pittsburgh Sleep Quality Index, and self-reported insomnia indices and CPAP use. Results: In Study 1, seven objective measures of sleep and arousal demonstrated or approached significant improvement during one night of CPAP titration. Sixteen of 19 patients reported improvement in sleep quality. In Study 2, Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, and Pittsburgh Sleep Quality Index improved markedly with CBT followed by SDB treatment and achieved an average outcome equivalent to curative status. Improvements were large for each treatment phase; however, of 17 patients, only 8 attained a nonclinical level of insomnia after CBT compared with 15 patients after SDB therapy was added. Self-reported insomnia indices also improved markedly, and self-reported SDB therapy compliance was high. Conclusions: In one small sample of chronic insomnia patients with SDB, objective measures of insomnia, arousal, and sleep improved during one night of CPAP titration. In a second small sample, validated measures of insomnia, sleep quality, and sleep impairment demonstrated clinical cures or near-cures after combined CBT and SDB therapies. These pilot results suggest a potential value in researching the pathophysiological relationships between SDB and chronic insomnia, which may be particularly relevant to patients with refractory insomnia.     

Cerebrovascular Diseases and Sleep-Disordered Breathing

Sleep-disordered breathing (SDB) is more probably the cause rather than the consequence of stroke because: apneas are essentially obstructive rather than central; the frequency of SDB is not different between transient ischemic attack and cerebral infarction; and previous excessive daytime sleepiness is significantly more frequent among stroke patients with SDB than those without. The presence of SDB in stroke patients could lead to a poor outcome. Pathophysiological relationships between strokes and SDB are multiple. Experimental and clinical studies have shown that both short- and long-term factors may play a role in increasing the susceptibility to stroke in patients with obstructive sleep apnea syndrome. The former include changes in cerebral hemodynamics, hematologic alterations, and cardiocirculatory dysfunctions that typically and repeatedly occur during apnea episodes and also may persist during wakefulness. Regarding long-term factors, some changes in the anatomical characteristics of carotid arteries wall have been recognized in SDB patients. This finding seems to suggest that the link between SDB and cerebrovascular disease might be explained, at least in part, by an increase in the progression of the atherosclerosis process involving cerebral vessels.There are several practical implications from the demonstrated significant role of sleep apnea in increasing the predisposition to developing stroke. Specific investigation is fundamental in the presence of a clinical suspect of SDB, especially in patients with history of transient ischemic attacks and stroke. Specific treatment of SDB may reduce the possibility of further cerebrovascular disturbances.     

Nitric Oxide (NO) and Obstructive Sleep Apnea (OSA)

Nitric oxide (NO) and obstructive sleep apnea are inseparable. Obstructive sleep apnea could be described as the intermittent failure to transport the full complement of nasal NO to the lung with each breath. There NO matches perfusion to ventilation. NO is utilized by the efferent pathways that control the unequal, inspiratory battle between the pharyngeal dilators and the closing negative pressures induced by the thoracic musculature. Recurrent cortical arousals are a major short-term complication, and the return to sleep after each arousal uses NO. The long-term complications, namely hypertension, myocardial infarction, and stroke, might be due to the repeated temporary dearth of NO in the tissues, secondary to a lack of oxygen, one of NOs two essential substrates.     

CPAP治疗重度OSAHS的疗效观察

目的 观察持续气道正压通气(CPAP)治疗重度阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的疗效、影响因素.方法 36例确诊为重度OSAHS的患者经CPAP治疗后,观察其治疗前后的呼吸暂停低通气指数(AHI)、夜间最低血氧饱和度(SaO2)及临床症状的变化.结果 治疗后AHI明显下降,夜间最低SaO2及临床症状明显改善.结论 CPAP是治疗重度OSAHS的有效方法.患者的依从性对重度OSAHS的治疗有决定性的意义.     

Improvement in Obstructive Sleep Apnea in the Supine “Knees-Up” Position

We report a 38-year-old man with obstructive sleep apnea whose sleep-disordered breathing was substantially reduced by sleep in the supine, knees-up position, relative to his sleep in the customary supine, knees-down position. No obvious anatomic or pathophysiologic alterations explained this phenomenon. The effect was reproducible in the patient 4 years later. Potential mechanisms underlying such improvement, including alterations in upper airway/lung volume dependence and venous supply to upper airway vasculature, are discussed. This manipulation could be an important adjunctive treatment for a subset of obstructive sleep apnea patients demonstrating such an effect.     

Effect of continuous positive airway pressure ventilation on nocturnal ST-segment changes in patients with sleep-disordered breathing

Objective To determine whether sleep-disordered breathing (SDB) may lead to nocturnal myocardial ischemia and whether the severity of this ischemia may be relieved by nasal continuous positive airway pressure (CPAP). Methods Overnight polysomnogram examination and simultaneous 3-channel Holter monitoring were performed on 76 patients with moderate to severe SDB and no history of coronary heart disease. All the cases were treated with CPAP for one night. ST depression was defined as a ST segment decrease of more than 1 mm from baseline and lasting 1 min or more. The total duration (minutes) of ST depression was indexed to the total sleep time (minutes per hour of sleep). Results Twenty-eight patients (37%) showed ST segment depression during their sleep. Before CPAP treatment, the respiratory disturbance index (RDI) and arousal index were significantly higher during periods of ST depression than when ST segments were isoelectric, whereas no significant difference was found in blood oxygen saturation (SaO2). After the CPAP treatment of patients with ST depression, the duration of ST depression was significantly reduced from 36.8±18.9 to 11.4±13.2 min/h (P＜0.05). ST depression-related indexes, including RDI, arousal index and the percentage of sleep time spent at SaO2 below 90% (TS90/ TST), were all significantly decreased, with RDI from 63.4±23.8 to 8.1±6.6 /h, arousal index from 51.2±18.9 to 9.6±5.4 /h, and TS90/ TST from 50.6±21.4 to 12.9±14.7% (P＜0.05). Conclusion ST-segment depression is rather common in patients with moderate to severe SDB, and CPAP treatment can significantly reduce the duration of ST depression. ST depression in these patients may reflect the myocardial ischemia that really exists and the non-ischemic changes associated with recurrent SDB.     

Long-Term Results of Maxillomandibular Advancement Surgery

Surgery is a major modality in the treatment of obstructive sleep apnea syndrome (OSAS), and maxillomandibular advancement (MMA) has been shown to be the most effective surgical option. However, despite the successful short-term (6–9 months) results reported by various investigators, little is known of the long-term clinical outcomes. A review of our long-term clinical results demonstrated that MMA achieves long-term cure in most patients. Aging and minor weight gain did not appear to have a significant adverse effect on the long-term results; however, major weight gain did seem to have a significant negative impact on the long-term outcomes. Therefore, long-term follow-up with proper counseling on weight maintenance or reduction is essential in improving long-term results.     

Continuous positive airway pressure reduces subjective daytime sleepiness in patients with mild to moderate Alzheimer's disease with sleep disordered breathing

OBJECTIVES: Studies have reported that 33% to 70% of patients with Alzheimer's disease (AD) have sleep-disordered breathing (SDB). Continuous positive airway pressure (CPAP) treatment has been shown to reduce daytime sleepiness and improve health-related quality of life in nondemented older people with SDB. The effect of therapeutic CPAP treatment on daytime sleepiness in patients with mild-moderate AD with SDB was assessed. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Patients' home and the University of California San Diego, General Clinical Research Center, J. Christian Gillin Laboratory of Sleep and Chronobiology. PARTICIPANTS: Thirty-nine community-dwelling elderly patients with mild-moderate probable AD with SDB. INTERVENTION: Patients were randomly assigned to receive 6 weeks of therapeutic CPAP or 3 weeks of sham CPAP followed by 3 weeks of therapeutic CPAP. MEASUREMENTS: Epworth Sleepiness Scale (ESS) was administered at baseline, 3 weeks, and 6 weeks. Changes in daytime sleepiness in subjects who received optimal therapeutic CPAP were compared with changes in the sham CPAP group. RESULTS: Within the therapeutic CPAP group, ESS scores were reduced from 8.89 during baseline to 6.56 after 3 weeks of treatment (P=.04) and to 5.53 after 6 weeks of treatment (P=.004). In the sham CPAP group, there was no significant difference after 3 weeks of sham CPAP but a significant decrease from 7.68 to 6.47 (P=.01) after 3 weeks of therapeutic CPAP. CONCLUSION: These data provide evidence of the effectiveness of CPAP in reducing subjective daytime sleepiness in patients with AD with SDB.     

Natural course of complex sleep apnea—a retrospective study

Patients with complex sleep apnea syndrome (CompSAS) have obstructive sleep apnea but develop troublesome central sleep apnea activity or Cheyne–Stokes breathing when provided continuous positive airway pressure (CPAP) therapy. We examined whether CompSAS activity persists with long-term CPAP treatment. We retrospectively identified all patients with CompSAS who underwent two therapeutic polysomnograms (PSGs) separated by at least 1 month during 2003–2005. We compared PSG findings between the initial and follow-up study and noted clinical responses to therapy. We identified 13 CompSAS patients meeting criteria. Most follow-up PSGs were ordered after an abnormal overnight oximetry on CPAP or because of CPAP intolerance after 195 (49–562) days. The residual apnea–hypopnea index (AHI) on CPAP decreased from 26 (23–40) on the first PSG to 7 (3–21.5) on the follow-up PSG. Only seven patients reached AHI < 10 and 6 had AHI ≥ 10 (“CPAP nonresponders”) at follow-up. “CPAP nonresponders” were sleepier (Epworth Sleepiness Score 13 [12.5–14] vs 9 [6–9.5], p = 0.03) and trended toward lower body mass index (29.7 [28.6–31.6] vs 34.3 [32.5–35.1], p = 0.06). Both groups were equally compliant with CPAP therapy. Although the AHI tends to improve over time in CompSAS patients treated with CPAP, in this retrospective study nearly half-maintained a persistently elevated AHI. A prospective trial is merited to determine the optimal treatment for these patients.     

持续气道正压通气对阻塞性睡眠呼吸暂停患者睡眠结构的影响

目的探讨患者白天嗜睡等症状的原因,评估经鼻持续气道内正压通气(nCRAP)治疗对阻塞性睡眠呼吸暂停患者睡眠结构的影响。方法选择2001-2004年广东省佛山市第一人民医院呼吸科34例OSAS病人在睡眠多导生理记录仪监测下,进行nCPAP治疗,观察治疗前后呼吸紊乱指数、血氧饱和度和睡眠结构的变化。结果治疗后呼吸紊乱指数下降,最低血氧饱和度上升,睡眠结构明显改善。结论nCRAP能有效地改善OSAS病人的睡眠结构和呼吸紊乱。     

复杂型睡眠呼吸暂停综合征12例分析

目的 分析复杂型睡眠呼吸暂停综合征(complex sleep apnea syndrome,CompSAS)患者临床特点.方法 收集我院12例CompSAS患者作回顾性分析,比较经鼻持续气道正压通气(continuous positive airway pressure,CPAP)治疗前后睡眠质量、呼吸紊乱、压力变化...     

持续气道正压通气治疗对OSAHS患者血液流变学的影响

目的探讨阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者经鼻持续气道正压通气(ncpap)治疗对其血液流变学指标的影响。方法随机选择我科确诊为中度或重度OSAHS的患者30例,其中男20例,女10例,年龄45~68岁,平均年龄(58±3)岁,治疗前14d内未服用过非甾体类消炎药及阿斯匹林,潘生丁等抗凝剂,并排除其它呼吸系疾病、紫绀性先心病、肾脏疾病及原发性红细胞增多症,分别于治疗前及治疗30d后检测血细胞比容、全血比粘度(高切度、中切度、低切度),红细胞聚集指数。结果治疗后血细胞比容、全血比粘度(高切度、中切度、低切度)、红细胞聚集指数较治疗前显著降低(P<0.01)。结论OSAHS存在显著血栓栓塞高危因素,ncpap对其有明显防治作用。     

Mechanisms and management of central sleep apnea

Central sleep apnea is not a single disease but represents the final pathway in a large group of heterogeneous disorders. Control of normal breathing during sleep relies upon finely coordinated anatomical and physiological mechanisms and their destabilization leads to central apnea. The causes of central sleep apnea can be classified into 4 groups: neurologic disorders, periodic breathing, upper airway abnormalities, and idiopathic syndromes. Clinical features result from the interaction between the underlying disorder and control of respiration. Two different prototypes emerge: patients who are hypercapnic (central hypoventilation and/or impaired respiratory mechanics) and those who are eucapnic or hypocapnic (periodic breathing and idiopathic hyperventilation). The causes and severity of apnea can be determined by clinical assessment, pulmonary function testing, and overnight polysomnography. Further management involves specific treatment of the underlying condition and reducing the sequelae of recurrent apneas during sleep, namely cardiorespiratory dysfunction and sleep disruption. This review outlines an approach to the management of central sleep apnea based upon an understanding of its pathophysiology.     

Sleep‐disordered breathing in spinal cord‐injured patients: A short‐term longitudinal study

Background and objective: Previous studies have demonstrated an increased incidence of sleep apnoea in spinal cord‐injured patients. Many of these studies were performed in long‐term, stable spinal cord injury (SCI). The aims of this study were: (i) to determine the prevalence of sleep‐disordered breathing (SDB) in acute SCI; (ii) to document the change in SDB over time during the rehabilitation period; and (iii) to correlate the degree of SDB with ventilatory parameters. Methods: Sixteen subjects with an acute SCI level T12 and above with complete motor impairment (American Spinal Injury Association impairment scale A or B) were recruited. Assessment, including polysomnography, respiratory function testing, and hypoxic and hypercapnic ventilatory responses, were performed 6–8 weeks post SCI, and repeated 6 months post SCI. Results: Eleven of 16 subjects (73%) had evidence of sleep apnoea, five of whom were moderate to severe. This high incidence persisted during the acute admission, with 9 of 12 subjects (75%) having sleep apnoea on polysomnography 20 weeks following injury. There was no correlation between the severity of SDB and other measures, such as level or completeness of injury, respiratory function tests or measures of ventilatory responses. Conclusions: We have demonstrated a high incidence of sleep apnoea in the acute phase of SCI that persisted during the acute admission. Despite the high incidence of sleep apnoea, patients were relatively asymptomatic. Screening of this population would appear worthwhile given the high prevalence, although the significance of the sleep apnoea and clinical impact is not known.     

Obstructive sleep apnea syndrome as an uncommon cause of fibromyalgia: a case report

Fibromyalgia syndrome (FMS) is characterized by chronic widespread musculoskeletal pain, stiffness and tenderness at multiple points. Sleep disturbances are common in FMS and patients usually complain about nonrestorative sleep. Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive pharyngeal collapse during sleep. Recurrent arousals from sleep occurs to restore pharyngeal patency in OSAS and this results in increased sympathetic activity and fragmentation of sleep. Sleep disturbances may lead to musculoskeletal pain and some studies suggest a relation between OSAS and FMS. Since OSAS is strongly associated with increased risk of myocardial infarction, cerebrovascular accidents and congestive heart failure, its diagnosis and treatment are of particular importance. Herein we present a female patient with diagnosis of FMS for 10 years who had complaints of morning fatigue, restless sleep, sleepiness during day and snoring besides musculoskeletal symptoms. Severe OSAS was diagnosed after polysomnographic analysis and FMS symptoms were totally improved with nasal continuous positive airway pressure treatment.     

持续气道正压通气治疗阻塞性睡眠呼吸暂停综合征对其胰岛素抵抗影响的meta分析

目的 通过系统评价总结持续气道正压通气(CPAP)治疗阻塞性睡眠呼吸暂停综合征对其胰岛素抵抗影响的相关循证医学证据.方法 关键词、主题词、引文追溯等途径检索Pubmed、Elsevier-SDOL、Embase、Foreign medical journals service、万方医学期刊库和中国学术期刊全文数据库,电子检索1990-2011年CPAP治疗睡眠呼吸暂停综合征(OSA)对其胰岛素抵抗影响的临床随机对照试验(RCT),逐一评价纳入研究的质量,提取入选文献资料,采用RevMan 4.3软件进行meta分析.结果 最终纳入4个RCT,共240例OSA患者,meta分析表明CPAP无显著改善OSA患者胰岛素抵抗作用(WMD=-0.29,95％CI-0.86～0.29,P=0.33),纳入文献表明CPAP干预不显著降低OSA患者空腹血糖、血浆胰岛素和糖化血红蛋白.结论 CPAP治疗并没有改善OSA患者胰岛素抵抗、空腹血糖、血浆胰岛素及糖化血红蛋白水平作用.     

Comparison of Primary-Care Practitioners and Sleep Specialists in the Treatment of Obstructive Sleep Apnea

We wished to determine if being treated for sleep apnea by a sleep specialist increased patient awareness or long-term continuous positive airway pressure (CPAP) compliance. We performed a retrospective telephone survey and laboratory chart review in patients with a diagnosis of sleep apnea evaluated either at a laboratory in which only sleep specialists can order polysomnography (University Specialty Hospital, noted as USH) or at a laboratory serving the medical community at large (Kernan Hospital, noted as K). Both laboratories are under the same medical director, use the same policies and procedures, equipment, and technician pool. One hundred three patients participated in the survey (approximately 37% of those contacted), 59 from USH and 44 from K. The groups were comparable in terms of demographics, presenting complaints, and apnea severity. In patients treated by sleep specialists, awareness of the disease process was greater and the evaluation was timelier than in patients treated by generalists. However, there was no difference between the groups long-term self-reported CPAP acceptance or compliance. The most robust predictor of continued CPAP use was the patients self-report of feeling better.     

Effect of CPAP treatment on inspiratory arousal threshold during NREM sleep in OSAS

The maximal inspiratory effort recorded at the end of apnea has been considered as an index of arousal threshold in obstructive sleep apnea syndrome (OSAS). Previous investigations have shown that the arousal threshold is higher in patients with OSAS than in normal subjects. The aim of the present study was to investigate the effect of continuous positive airway pressure (CPAP) treatment on the inspiratory-effort-related arousal threshold in patients with OSAS. In ten male patients, 40 episodes of apnea during stage 2 non-REM (NREM) sleep were analyzed. Apnea duration (t), esophageal pressure (Pes) at the first occluded breath (Pes1), the minimum of the three initial Pes swings (Pes min), the maximum of the three final Pes swings (Pes Max), Pes (Pes Max–Pes min), RPes (rate of increase of intrathoracic pressure, Pes/t), n (number of occluded breaths during apnea), Pes/n, n/t, and SaO₂ were determined before and after occlusion. These apneic episodes were compared to ten episodes of apnea provoked by a mask occlusion device after 1, 7, 30, and 90 days of CPAP treatment. The therapy resulted in a decrease in the inspiratory-effort-related arousal threshold, as measured by a reduction of Pes Max, without significant changes in apnea duration and apnea-related hypoxemia. Pes1 and Pes/n, which are markers of respiratory drive, significantly decreased between observations. CPAP treatment decreases the inspiratory-effort-related arousal threshold and induces a decrease in ventilatory drive in response to upper airway occlusion.     

AutoCPAP治疗阻塞性睡眠呼吸暂停低通气综合征40例疗效观察

目的探讨自动调节持续气道正压通气呼吸机(Auto-CPAP)治疗不同程度阻塞性睡眠呼吸暂停低通气综合征(OS-AHS)患者的短期临床疗效。方法给予经多导睡眠图(PSG)确诊的不同程度OSAHS患者使用Auto-CPAP治疗(2d),观察治疗前后患者呼吸暂停/低通气指数(AHI)、最低血氧饱和度(LSaO2)和血氧饱和度<90%的累积时间(<90%SaO2时间)的变化。结果应用Auto-CPAP呼吸机治疗OSAHS患者,治疗后AHI由(49.03±21.82)次/h降为(7.49±5.34)次/h、LSaO2由(71.78±11.41)%升至(90.43±3.49)%和<90%SaO2时间由(73.16±84.80)min减至(0.82±3.17)min,与治疗前比较差异有统计学意义。结论应用Auto-CPAP治疗可以使不同程度OSAHS患者的呼吸事件和夜间低氧血症在短期内明显改善。