多頻道生理紀(jì)錄法在睡眠呼吸中止癥的應(yīng)用

多頻道生理紀(jì)錄法在睡眠呼吸中止癥的應(yīng)用第1頁(yè)/共39頁(yè)EEG,EOG,chinEMG

電極黏貼位置示意圖-3EEGchannels:C3/A2,C4/A1,O1/A2,GND,REFC4/A1-2EOGchannels:ROC(1cmabove)/A1,LOC(1cmbelow)/A2LOCROCROC/A1-1EMGchannel:beneaththechin(4cmbetween2electrodes)EMG1EMG2EMGGRD第2頁(yè)/共39頁(yè)Whatissleepapnea?Apnea:completecessationofairflow(atleast<90%ofbaseline)foratleast10sec>10sec第3頁(yè)/共39頁(yè)Whatissleephypopnea?Hypopnea:airflow<50%ofbaseline,ordesaturationofatleast4%,orarousalfromsleep第4頁(yè)/共39頁(yè)ThreetypesofSleepapneasyndromeCentraltypeObstructivetypeMixedtype第5頁(yè)/共39頁(yè)Centraltypesleepapnea(睡眠呼吸中止中樞型)定義：1.呼吸波減至10%以下2.每次至少10秒3.無(wú)胸腹部的呼吸動(dòng)作

15seconds不會(huì)過(guò)胖咽喉通道不狹窄抱怨晚上失眠但白天想睡覺打鼾不嚴(yán)重<10%有睡眠呼吸癥狀者顯著---CNSorneuromusculardisorder.第6頁(yè)/共39頁(yè)Obstructivesleepapnea(睡眠呼吸中止阻塞型)*定義：呼吸波減至10%以下每次至少10秒喉咽氣道阻塞胸腹部呼吸動(dòng)作持續(xù)，但無(wú)氣流交換75seconds較常見>90%臺(tái)灣約有11%中老年人口罹患中度或重度阻塞型睡眠呼吸中止癥第7頁(yè)/共39頁(yè)Mixedtypeapnea睡眠呼吸中止混合型定義：1.呼吸波減至10%以下2.每次至少10秒3.先中樞型再接阻塞型4.>25%的中樞型30seconds第8頁(yè)/共39頁(yè)Hypopnea定義：每次至少有90%的呼吸波減至50%以下每次至少10秒血氧飽和度下降至少3%32seconds第9頁(yè)/共39頁(yè)阻塞型睡眠呼吸中止癥臨床癥狀打鼾白天嗜睡無(wú)法熟睡注意力不集中

晨醒頭痛夜間頻尿性情改變第10頁(yè)/共39頁(yè)sleepapnea的影響第11頁(yè)/共39頁(yè)sleepapnea相關(guān)危險(xiǎn)因素年紀(jì)男性>女性肥胖頸圍過(guò)粗(男>43公分，女>38公分)

酒精或鎮(zhèn)靜劑、安眠藥顱面結(jié)構(gòu)異常如后縮顎、下顎狹小、鼻中膈彎曲、舌頭過(guò)大、暴牙、舌頭過(guò)大、扁桃腺肥大、懸壅垂肥大咽顎帆區(qū)狹小、口鼻咽軟組織過(guò)多甲狀腺功能過(guò)低癥、唐氏癥第12頁(yè)/共39頁(yè)RDI及AHI的定義AHI:apnea/hypopneaindex(#/hour)Theaverageofepisodesofapneaandhypopneaperhourofsleep

每小時(shí)apneaandhypopnea的平均發(fā)生次數(shù)RDI:respiratorydisturbanceindex(#/hour)#:eventsofapnea,hypopnea,snores,snoreresultinginarousals第13頁(yè)/共39頁(yè)TheseverityofsleepapneaDiagnosisNormalMildModerateSevereRDI/AHI(episodes/hour)<552020-40>40DiagnosisMildModerateSevereMeanSaO290%90%<90%MinimumSaO285%70%<70%ICSIhealthguideliine,Diagnosisandtreatmentofobstructivesleepapnea,2003*嚴(yán)重度的睡眠呼吸中止癥可領(lǐng)輕度殘障手冊(cè)，已有提議修法改為向健保局申領(lǐng)購(gòu)買陽(yáng)壓呼吸器補(bǔ)助費(fèi)。第14頁(yè)/共39頁(yè)如何治療睡眠呼吸中止癥維持理想體重側(cè)睡避免睡前服用鎮(zhèn)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(guò)敏一定要治好睡前避免吃太多戒菸手術(shù)一個(gè)月后

98公斤手術(shù)前135公斤扁桃腺肥大1.行為治療第15頁(yè)/共39頁(yè)如何治療睡眠呼吸中止癥Fujita(1981),UvulopalatopharygoplastyMostcommonprocedure----removeexcesstissueoftonsils,uvulaandpartofthesoftpalate.1stlinetreatmentforretropalatalcollapse10-50%success2.UPPP(懸壅顎咽成形術(shù))(侵襲性治療)第16頁(yè)/共39頁(yè)3.DentalAppliances齒科裝置(非侵襲性治療)NearlyaseffectiveasCPAPinmildtomoderateOSARepositionthemandible

如何治療睡眠呼吸中止癥第17頁(yè)/共39頁(yè)4.NasalCPAP鼻腔陽(yáng)壓呼吸器(非侵襲性治療)

NasalContinuousPositiveAirwayPressure

(APAP):AutoPositiveAirwayPressure

10cmH2Otoovercomeupperairwaynarrowing,notover20-25cmH20)

如何治療睡眠呼吸中止癥第18頁(yè)/共39頁(yè)R&K,1968(Rechtschaffen&Kales)AwakeNon-REMsleep(非快速動(dòng)眼期)stage1stage2stage3stage4REMsleep(快速動(dòng)眼期Rapid-Eye-Movement)正常睡眠的分期AmericanAcademySleepMedicine美國(guó)睡眠醫(yī)學(xué)會(huì),2007StageWStageN1StageN2StageN3(deepsleep)StageR

第19頁(yè)/共39頁(yè)正常睡眠分期的周期關(guān)系第20頁(yè)/共39頁(yè)睡眠記錄常用名詞1.TotalRecordingTime(記錄總分鐘數(shù))TimeinBed(躺在床上的總分鐘數(shù))2.TotalSleepTime(睡眠總分鐘數(shù))(stage1+stage2+stage3+stage4+REM)3.SleepEfficiency(睡眠效率,>85%)(TotalSleepTime/TotalRecordingTime)X1004.SleepLatecy(入眠時(shí)間,<15分鐘)5.REMlatency(入快速動(dòng)眼期時(shí)間,80-120分鐘)第21頁(yè)/共39頁(yè)

N-REMandREMstage在生理上的比較

Non-REMREM呼吸速率規(guī)則較快且有變異性血壓規(guī)則較高且有變異性心跳規(guī)則較快且有變異性大腦血流速率規(guī)則增加體溫穩(wěn)定變異肌肉張力放松消失作夢(mèng)很少時(shí)常陰莖或陰蒂勃起較少時(shí)常第22頁(yè)/共39頁(yè)

N-REMandREMstage在功能上的比較

Non-REM(deepsleep)REM生長(zhǎng)激素的分泌腦部生長(zhǎng)腦部發(fā)育與智力及記憶有關(guān)第23頁(yè)/共39頁(yè)P(yáng)olysomnographyReport第24頁(yè)/共39頁(yè)P(yáng)olysomnographyReport第25頁(yè)/共39頁(yè)P(yáng)olysomnographyReport第26頁(yè)/共39頁(yè)腦波頻率Delta<4HzHerzTheta4-7HzAlpha8-13HzBeta>13Hz第27頁(yè)/共39頁(yè)

腦波形狀KComplexsharpnegativewave,followedbyslowerpositivecomponent,>0.5secseeninStage2Spindleshortrhythmicwaveformclustersof12-14Hz>0.5secseeninstage2lowamplitudesawtoothappearanceseeninREMSawtoothwavessharppositivewaves,thetafrequencyrange,occurringlatterpartofStage1Vertexwaves第28頁(yè)/共39頁(yè)RelaxedWakefulnessrapideyemovement,blinkstonicactivity,relativelyhigh,voluntarymovementαwave(8-13cps),predominantlyinO1,O2Pattern:Bladesofgrass第29頁(yè)/共39頁(yè)

lowvoltage,mixedfrequency,θ(4to7cps),Vertexsharpwavesmaybepresent.NON-REMStage1(5%ofTotalSleepTime)slowrollingeyemovementtonicactivitylowerthanawake第30頁(yè)/共39頁(yè)Sleepspindle:>0.5sec,11-16cps,3-8/minKcomplex:＞0.5sec,1~3/minnegative-positiveLowleveltonicactivitySloweyemovementNon-REMStage2(50%oftotalsleep)第31頁(yè)/共39頁(yè)Stage1withvertexsharpwaveStage2withsleepspindle&kcomplex(1epoch=30seconds)Comparisonbetweenstages1&2(1epoch=30seconds)vertexsharpwave,>75uv,<0.5sec,upwardsleepspindlekcomplex(3minute-rule)第32頁(yè)/共39頁(yè)EMG:lowleveltonicEEG:0.5~2cps,highvoltage>75uVStage3:20%~50%slowwaveSleepspindlesmaybepresentNREMStage3(slowwavesleep)(1epoch=30seconds)EOGsimilartoEEG第33頁(yè)/共39頁(yè)EMG:lowleveltonicEEG:slowwave<2cps,highvoltage>75uVStage4:>50%slowwaveNREMStage