肥胖低通氣綜合征麻醉演示文稿

肥胖低通氣綜合征麻醉演示文稿當前第1頁\共有62頁\編于星期六\9點優(yōu)選肥胖低通氣綜合征麻醉當前第2頁\共有62頁\編于星期六\9點幾個概念OHS睡眠呼吸暫停綜合癥上氣道阻力綜合癥單純性鼾癥正常人OSAHS當前第3頁\共有62頁\編于星期六\9點單純性鼾癥：夜間可出現(xiàn)不同程度鼾癥，AHI<5次/h，白天無癥狀。上氣道阻力綜合征：夜間可出現(xiàn)不同頻度、程度鼾癥，雖上氣道阻力增高，但AHI<5次/h，白天嗜睡或疲勞，試驗性無創(chuàng)通氣治療有效。OSAHS：睡眠時上氣道塌陷阻塞引起的呼吸暫停和通氣不足、伴有打鼾、睡眠結構紊亂，頻繁發(fā)生血氧飽和度下降、白天嗜睡等病癥。AHI:睡眠時患者平均每小時發(fā)生的呼吸暫停（>10s)以及低通氣次數(shù)。用于評價患者OSAHS嚴重程度和治療效果的最重要指標。幾個概念當前第4頁\共有62頁\編于星期六\9點IntroductionObesityhypoventilationsyndrome(OHS)：

ObesityDaytimehypoventilationSleep-disorderedbreathingWithoutanalternativeneuromuscular,mechanical,ormetaboliccauseofhypoventilation當前第5頁\共有62頁\編于星期六\9點IntroductionPresentwithincreasingmorbidityandmortalityupperairwayobstructionrestrictivechestphysiologybluntedcentralrespiratorydrivepulmonaryhypertension當前第6頁\共有62頁\編于星期六\9點TherapynoninvasivepositiveairwaypressureimprovesgasexchangeImproveslungvolumesImprovessleep-disorderedbreathingreducesmortality當前第7頁\共有62頁\編于星期六\9點Objective當前第8頁\共有62頁\編于星期六\9點ToexaminetheprevalenceofOHS;Reviewthecurrentdataondiseasemechanisms,screening,andtreatment;DiscusstheoptimalperioperativemanagementofOHS.當前第9頁\共有62頁\編于星期六\9點MaterialsandMethods當前第10頁\共有62頁\編于星期六\9點prevalenceandtreatmentofpatientswithOHS.OHSwasdefinedasDaytimehypercapniaandhypoxemia(PaCO2>45mmHgandPaO2<70mmHg)Obesepatients(BMI>30kg/m2)Sleep-disorderedbreathingAbsenceofanyothercauseofhypoventilation.當前第11頁\共有62頁\編于星期六\9點WhatIsthePrevalenceofOHS?當前第12頁\共有62頁\編于星期六\9點11%8%16%0.15–0.3%

OSApatientsbariatricsurgicalpatientssleeplaboratorygeneraladultpopulation當前第13頁\共有62頁\編于星期六\9點當前第14頁\共有62頁\編于星期六\9點WhataretheMechanisms?

當前第15頁\共有62頁\編于星期六\9點DaytimehypercapniaOHSobesityandOSA當前第16頁\共有62頁\編于星期六\9點LeptinResistanceLeptinisaproteinproducedspecificallybytheadiposetissuethatregulatesappetite,energyexpenditure,andincreasesventilationforthecarbondioxideproduction.AssociatedwithBMI.Leptinleveldropsafterpositiveairwaypressure(PAP)therapy.當前第17頁\共有62頁\編于星期六\9點ThepathogenesisofchronicdaytimehypoventilationofOHSThreeleadinghypothesesImpairedrespiratorymechanicsbecauseofobesityLeptinresistanceleadingtocentralhypoventilationImpairedcompensatoryresponsetoacutehypercapnia當前第18頁\共有62頁\編于星期六\9點IncreasedMechanicalLoadandImpairedRespiratoryMechanics

ObesityBMI當前第19頁\共有62頁\編于星期六\9點ImpairedCompensationofAcuteHypercapniainSleep-disorderedBreathing

HyperventilationduringbriefperiodsofarousalChronichypercapniainOHSWhenapneasbecomethreetimeslongerthanthebreathinginterval,CO2accumulates.AreduceddurationofventilationduringapneaAgradualadaptationofchemoreceptorssecondarytomildelevationofserumHCO3-.當前第20頁\共有62頁\編于星期六\9點當前第21頁\共有62頁\編于星期六\9點DoPatientswithOHSPossessDifferentClinicalFeaturesthanObesePatientswithEucapnia?當前第22頁\共有62頁\編于星期六\9點SignificantlyhigherBMI,increasedhypoxemiaandhypercapnia,morerestrictiverespiratorymechanics,andmoreseveresleep-disorderedbreathing.當前第23頁\共有62頁\編于星期六\9點當前第24頁\共有62頁\編于星期六\9點More……SevereupperairwayobstructionImpairedrespiratorymechanicsBluntedcentralrespiratorydriveIncreasedincidenceofpulmonaryhypertension當前第25頁\共有62頁\編于星期六\9點UpperAirwayObstructionBoththesittingandsupineposition當前第26頁\共有62頁\編于星期六\9點RespiratoryMechanicsExcessiveload,Chestwallcompliance,pulmonaryresistance--doubletheworkofbreathing當前第27頁\共有62頁\編于星期六\9點CentralRespiratoryDriveResultfromleptinresistanceandsleep-disorderedbreathing當前第28頁\共有62頁\編于星期六\9點PulmonaryHypertensionSecondarytochronicalveolarhypoxiaandhypercapniaishigherinpatientswithOHS,rangingfrom30%to88%.當前第29頁\共有62頁\編于星期六\9點DoPatientswithOHSExperienceHigherMorbidityandMortalitythanObesePatientswithOSAandComparableBMI?

當前第30頁\共有62頁\編于星期六\9點YES！當前第31頁\共有62頁\編于星期六\9點Morelikely

todevelop……h(huán)eartfailureanginapectorisandcorpulmonalelong-termcareatdischargeinvasivemechanicalventilation當前第32頁\共有62頁\編于星期六\9點Especially……Previoushistoryofvenousthromboembolism,morbidobesity,malesex,hypertension,increasingage,andnoncompliancewithPAPtreatmentmayfurtherincreasemortalityrisk.Surgicalmortalityrateinhigh-riskOHSpatientsundergoingbariatricsurgeryisbetween2–8%.當前第33頁\共有62頁\編于星期六\9點WhatIstheMainstayofTherapy?

當前第34頁\共有62頁\編于星期六\9點PAPtherapysupplementaloxygenweightreductionsurgerypharmacologicrespiratorystimulants當前第35頁\共有62頁\編于星期六\9點PAPTherapy:Short-termandLong-termBenefits

CPAPandbi-levelPAP.Short-termbenefitsincludeanimprovementingasexchangeandsleep-disorderedbreathing.AsignificantdecreaseinPaCO2,increaseinPaO2.AsignificantimprovementinAHIandoxygensaturationduringsleep.Long-termbenefitsofPAPincludeanimprovementingasexchange,lungvolumes,andcentralrespiratorydrivetocarbondioxide,pulmonaryfunction(FEV1和FVC).PAPmayalsoreducemortalityinOHS.當前第36頁\共有62頁\編于星期六\9點PAPisconsideredthefirst-linetherapyforOHS.當前第37頁\共有62頁\編于星期六\9點當前第38頁\共有62頁\編于星期六\9點Bothshort-termandlong-termpositiveairwaypressuretherapyincreasePaO2anddecreasePaCO2inpatientswithOHS.當前第39頁\共有62頁\編于星期六\9點Bothshort-termandlong-termpositiveairwaypressuretherapyimproveAHIandoxygensaturationduringsleepinpatientswithOHS.當前第40頁\共有62頁\編于星期六\9點Long-termpositiveairwaypressuretherapyimprovesFEV1,FVC,andCO2sensitivityinpatientswithOHS.當前第41頁\共有62頁\編于星期六\9點EfficacyofBilevelPAPversusCPAP

WhenCPAPfailure,definedbyaresidualAHI>5orameannocturnalSpO2<90%,ThesecanbeimprovedwithbilevelPAP.BilevelPAPwasnotconsiderablysuperiortoCPAP,ifCPAPtitrationwassuccessful.當前第42頁\共有62頁\編于星期六\9點SupplementalOxygenApproximately40%ofpatientswithOHScontinuetodesaturatetoSpO2_90%duringsleepwhileonadequateCPAPsettings,therebyrequiringsupplementaloxygen.Thelowestconcentration,particularlyinOHSexperiencinganexacerbationorrecoveringfromsedatives/narcoticsorgeneralanesthesia.當前第43頁\共有62頁\編于星期六\9點WeightReductionSurgery1yraftersurgery,BMI,AHI,PaO2,PaCO2,FEV1,andFVCallimprovedsignificantly.AlthoughthereisadrasticreductioninOSAseverity,somepatientsstillhavemoderateOSA--stillrequirePAPtherapyafterweightloss.當前第44頁\共有62頁\編于星期六\9點Pharmacotherapymedroxyprogesteroneacetate(醋酸甲羥孕酮片)acetazolamide（乙酰唑胺）。目前文獻報道較少，療效不是十分確切，不推薦作為主要治療措施。當前第45頁\共有62頁\編于星期六\9點PerioperativeManagementofPatientswithOHS

當前第46頁\共有62頁\編于星期六\9點HowDoWeScreenforOHSinthePreoperativeSetting?

ThreeclinicalpredictorsofOHS:serumHCO3,AHI,andlowestoxygensaturationduringsleep.HighBMIandAHIArterialbloodgasesHypercapnia

pulmonaryfunctiontesting,chestimaging,

thyroid-stimulatinghormoneRuleoutotherimportantcausesofhypoventilation.當前第47頁\共有62頁\編于星期六\9點HowDoWeAssessandOptimizeaPatientwithSuspectedOHSbeforeElectiveSurgery?

當前第48頁\共有62頁\編于星期六\9點當前第49頁\共有62頁\編于星期六\9點Additionaltests

pulmonaryhypertensionsleep-disorderedbreathingreasons.當前第50頁\共有62頁\編于星期六\9點GeneralConsiderationsMainchallenges---OSA,obesity,andhypoventilation(hypercapniaandhypoxemia),cardiachemodynamics.History(CAD,DM,CHF與體重成正比).Afocusedcardiopulmonaryexamination.Adetailedexaminationoftheairwayandsitesforvenousaccess.當前第51頁\共有62頁\編于星期六\9點ScreeningforOHSTheSTOP-Bangquestionnaire:STOP(snoring,tiredness,observedapneas,andincreasedbloodpressure),Bang(BMI>35,age>50yr,neckcircumference>40cm,andmalegender)PolysomnographyandtotitratePAPtherapy.Evenforshortdays當前第52頁\共有62頁\編于星期六\9點PreoperativeRiskStratificationandCardiovascularTesting

Cardiacriskindex,pulmonaryhypertension,historyofvenousthromboembolism,hypertension,BMI>50kg/m2,malesex,age>45yr,pulmonaryhypertension.Mortalityrisk---low(zerooronecomorbidity),intermediate(twotothreecomorbidities)andhigh(fourtofivecomorbidities).Mortalityrateswere0.2%,1.2%,and2.4%.Themostcommoncausesofdeathwerepulmonaryembolism(30%),cardiaccauses(27%)andgastrointestinalleak(21%).當前第53頁\共有62頁\編于星期六\9點PreoperativePulmonaryTestingPulmonaryfunctiontestsArterialbloodgasmeasurements.當前第54頁\共有62頁\編于星期六\9點WhatAretheKeyConsiderationsSpecifictoIntraoperativeManagementofOHS?

當前第55頁\共有62頁\編于星期六\9點AirwayManagementBothdifficultmaskventilationandtrachealintubation---與AHI成正相關。Fiveriskfactorslimitedmandibularprotrusionthick/obeseneckanatomyOSAsnoringBMI>30kg/m2當前第56頁\共有62頁\編于星期六\9點DuringinductionofanesthesiaRamppositionwithelevationofthetorsoandhead；Preoxygenationformorethan3minwithatightlyfittedmask；TheapplicationofCPAPandPEEPduringpreoxygenation；Avar