阻塞性睡眠呼吸暂停综合征与困难气道的研究

发布时间：2018-04-30 03:38

本文选题：阻塞性睡眠呼吸暂停 + 问卷调查　；参考：《山东大学》2012年博士论文

【摘要】：研究背景阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea—hypopnea syndrome,OSAHS,)是指由于患者睡眠时上气道完全或部分阻塞,或伴有呼吸中枢驱动降低,从而导致呼吸暂停,出现夜间反复慢性间歇性低氧、二氧化碳潴留、反复微觉醒及睡眠结构异常的一种疾病。由于患者夜间间歇缺氧及二氧化碳潴留引发全身应激反应,可引发多脏器功能损害,患者可伴发高血压、冠心病、心律失常、心力衰竭、脑卒中、糖尿病及胰岛素抵抗等严重危及人群健康的一系列疾病,并且成为多种全身性疾病的独立危险因素。同时由于夜间反复微觉醒、睡眠中断及睡眠结构紊乱,导致白天嗜睡,患者工伤意外及交通事故发生率明显增加。因此,OSAHS已经成为严重影响人们生活质量和健康寿命的全身性疾病[1,2,3,4,5]。 20世纪50、60年代以来,美国及欧洲西方国家开始了该疾病的临床及基础研究,随着对疾病发病机理的逐步认识及临床流行病学资料的调查,OSAHS作为发病率较高的全身性疾病越来越受到关注。1979年,美国睡眠协会联合会对睡眠疾病进行分类,将睡眠呼吸暂停综合症分为阻塞性、中枢性及混合性三类。1994年,美国睡眠障碍协会联合会明确将睡眠呼吸暂停综合症纳入睡眠障碍疾病之一。1996年,睡眠医学作为医学的一个学科分支被美国医学会认定,1999年美国睡眠医学科学院(American Academy of Sleep Medicine, AASM)成立并且代替了了睡眠障碍协会联合会,AASM成立后制定并且修订了关于OSAHS诊断及治疗的临床指南,这些指南的制定对于该疾病的治疗起到了规范指导及规避风险的作用。手术作为OSAHS的一个重要的外科治疗手段,于70年代早期开始尝试气管切开和扁桃体摘除,1982年Fujita首先以悬雍垂腭咽成形术(uvulopalatopharyngoplasty, UPPP)治疗OSAHS,适用于口咽部软组织堵塞为主造成的气道狭窄。1997年以来UPPP术式开始改良,即保留了悬雍垂的生理功能,有效地减少了术后并发症并提高了手术疗效。据报道UPPP的近期有效率在50%-60%,远期有效率低于近期。开展UPPP及不同层面的手术治疗手段以来,围术期的并发症尤其是急性呼吸道梗阻导致死亡的报道引起了人们的重视。美国麻醉医师协会(the American Society of Anesthesiologists, ASA)于2006年制定了关于OSAHS麻醉的临床指南,着重于OSAHS病人围术期困难呼吸道的管理。我们国家于80年代初陆续有关于OSAHS的个案报道,之后有关的临床研究逐年增多。1987年北京协和医院黄席珍教授成立了我国第一个睡眠医学实验室。随着对OSAHS认识的不断深入,我国睡眠实验室在一些医院陆续建立,近十几年来睡眠实验室相对普及,能够开展OSAHS的睡眠监测及诊断工作。从事OSAHS的临床科室涉及呼吸科、耳鼻咽喉科、口腔科等多个学科,OSAHS作为一涉及多学科的危害全身多系统的重要疾病逐渐被认识,并引起了医学界的关注。然而,在我们国家各学科对于OSAHS的认识是不均衡的,缺乏对OSAHS疾病全身性疾病的总体认识,钟南山呼吁深入开展睡眠呼吸暂停的研究与多学科间的有效协作。随着我国对OSAHS疾病治疗干预的开展,需要以UPPP手术为主多层面手术治疗的病人逐年增多,围术期患者死亡的报道再次引起了我国的关注,国内多篇文献报道了OSAHS患者围术期死亡的回顾性分析,气管插管失败导致的急性呼吸道梗阻是患者围术期死亡的首要原因。而且文献报道,OSAHS术后出血及心脏、呼吸系统并发症的发生与全身麻醉困难气管插管有关。遗憾的是,回顾性分析OSAHS围术期严重并发症及死亡并发症发生的文献几乎均来自耳鼻咽喉科医生的报道,气管插管失败导致的麻醉相关并发症并未引起麻醉医生的足够警惕。这与目前我门国家能开展OSAHS疾病诊断与手术治疗的医疗机构分布局限有关,但同时也反映了我国麻醉医生对于OSAHS疾病的认识不足,关于OSAHS疾病导致困难呼吸道发生的知识缺失。 Schotland于2003年设计制定了OSAHS知识及态度的调查问卷(the obstructive sleep apnea knowledge and attitudes questionnaire, OSAKA questionnaire),用来判断医生对于OSAHS疾病的认识。Southwell、Tamay及Uong EC也利用该问卷开展了对内科医生及儿科医生的问卷调查及分析,对于判断不同学科的医生对于该疾病的了解程度、医学生关于OSAHS疾病的学科设置及制定继续医学教育计划均有借鉴指导价值。目前,关于我们国家临床医生对于OSAHS疾病认知调查的报道尚缺乏。美国等较早开展OSAHS手术治疗的国家,麻醉医生也同时开始了关于OSAHS困难气管插管及困难面罩通气的研究。肥胖、OSAHS疾病严重程度,Mallampati口咽部暴露分级等多种因素被考虑与OSAHS病人困难气道有关,但是,不同文献报道的观察结果不尽相同,可以预测OSAHS病人困难气道的危险因素仍不确定,有些报道甚至是矛盾的。国内尚缺乏关于OSAHS病人困难气道的临床研究。因此,本课题关于OSAHS疾病的研究分拟为两部分进行。第一部分采用Schotland设计的问卷调查表,开展麻醉医生关于OSA HS疾病知识的问卷调查,并且参照美国ASA制定的OSAHS临床麻醉指南,补充了有关OSAHS麻醉管理知识的问题选项,以此判断麻醉医生对于OSAHS疾病的认知,期望引起麻醉医生对OSAHS疾病的重视,加强麻醉医生关于OSAHS的继续学习,减少或者避免由于麻醉医生OSAHS知识缺陷引起的OSAHS病人呼吸道梗阻急症事件的发生。第二部分,我们参照美国麻醉医师协会及我国麻醉学会制定的困难气道处理指南,结合OSAHS病人肥胖、舌体肥大、颈粗短等特点,观察并记录OSAHS病人体重指数、颈围、腰围,颏甲距离,Mallampati咽部暴露分级,直接喉镜清醒局部粘膜表面麻醉下Cormack and Lehane's声门分级等与气道管理有关的指标,采用筛选流行病学危险因素广为采用的方法建立Logisogistic回归模型,从众多混杂因素中分析OSAHS病人困难面罩通气及困难气管插管的危险因素,从而预见性地避免OSAHS病人因困难面罩控制通气及困难气管导致的急性呼吸道梗阻的发生,减少OSAHS病人围术期死亡及麻醉相关并发症的发生。目的采用Schotland HM设计的阻塞性睡眠呼吸暂停知识和态度(the obstructive sleep apnea knowledge and attitudes questionnaire)问卷调查,了解麻醉医生关于OSA疾病知识的掌握及关注态度,判断麻醉医生关于OSAHS疾病的认知状况,了解麻醉医生OSAHS疾病继续学习的必要性。方法取得Schotland HM授权,OSAKA问卷被翻译为中文,每份问卷放在张贴邮票的信封内方便调查者寄回,400份OSAKA调查问卷发放至山东省20余家地市级及省级医院的麻醉医生。问卷分为两部分,第一部分为关于OSAHS知识的问题,涉及5个方面共18个条目,包括OSAHS流行病学知识,发病机理,临床症状,诊断和治疗等知识点。第二部分为管理OSAHS病人自信程度的判断,从不重要(或非常不自信)至非常重要(或非常自信)分为5个等级。18个知识点的问题每题正确回答记1分,回答错误记0分,计算问题正确回答的百分率。态度5个等级依次记为1-5分,记录医生关于OSAHS知识及管理OSAHS病人态度自信程度的分值,并进一步分析麻醉医生知识掌握及管理OSAHS病人自信程度的关系。结果321份有效问卷收回,18条关于OSAHS疾病的知识点每题1分,正确回答的分值为11.21±2.89,所有问题回答正确的平均值为62%。关于OSAHS疾病发病机理的知识点回答的正确率最高为86%,有关OSAHS疾病治疗的知识点回答的正确率最低33%。对于OSAHS病人的判定、麻醉管理及术后管理有信心的概率分别为51.71%,66.36%,55.46%。麻醉医生的知识和麻醉医生对于OSAHS疾病的自信态度呈正相关。麻醉医生性别、年龄、受教育程度,工作所在医院的级别与问卷知识的分值无关。结论麻醉医生对于OSAHS疾病的有关知识缺乏；对于OSAHS疾病的认知程度较低；对OSAHS病人的麻醉管理自信心较低；有必要进行关于OSAHS疾病的继续学习。目的通过临床资料调查分析,筛选阻塞性睡眠呼吸暂停患者困难面罩通气及困难气管插管发生的危险因素,从而能预见性地减少阻塞性睡眠呼吸暂停病人困难气道的发生。方法120例阻塞性睡眠呼吸暂停病人经多导睡眠监测仪监测确认。非熟悉课题设计的特定麻醉住院医生测量并记录所有的观察指标,包括年龄,体重指数(body mass index, BMI),病人呼吸暂停低通气指数(apnea-hypopnea index, AHI),最低血氧饱和度(the lowest oxygen saturation, LSaO2),最长呼吸暂停时间(the longest sleep apnea time, LSAT),颈围(neck circumference, NC),腰围(waist circumference, WC),颏甲距离(thyromental distance, TMD),上下切牙间距离(interincisor distance, ICD),下颌骨水平长度(horizontal length of the mandible, HLM), Mallampati分级及Cormack and Lehane's喉头分级,根据logistic回归模型,分析困难面罩通气及困难气管插管的危险因素。结果阻塞性睡眠呼吸暂停病人的平均年龄39.98岁,体重指数的平均值为29.45kg/m2,颈围和腰围的平均值分别为100.5cm、42.08cm。困难面罩通气发生的概率为41.7%,困难气管插管发生的百分比为25.8%。困难面罩通气的危险因素为病人的颈围(OR=1.857)及口咽Mallampati分级(0R=12.508)两个指标,困难气管插管的危险因素为病人Cormack and Lehane's喉头分级(OR=7.799),疾病严重程度判断的指标AHI(OR=1.045),以及病人上下切牙间距离(OR=0.090)。结论阻塞性睡眠呼吸暂停病人中肥胖尤其是中心性肥胖普遍存在。困难面罩通气及困难气管插管的比例较高,Mallampati口咽暴露分级及Cormack and Lehane's声门分级是判断阻塞性睡眠呼吸暂停病人困难气道的两重要危险因素,颈围的测量对于困难通气有预测价值,体重指数及腰围作为判断肥胖的指标与困难通气有关,AHI、病人上下切牙间距离对于困难气管插管有预测价值。
[Abstract]:Research background
Obstructive sleep apnea hypopnea syndrome (obstructive sleep apnea - hypopnea syndrome, OSAHS) is caused by a complete or partial obstruction of the upper airway in the patient's sleep, or a decrease in the drive of the respiratory center, resulting in apnea, recurrent nocturnal intermittent hypoxia, retention of carbon dioxide, repeated micro arousal and sleep. A disease of abnormal structure. It can cause multiple organ dysfunction due to intermittent hypoxia and retention of carbon dioxide, which can cause multiple organ dysfunction. Patients can be accompanied by high blood pressure, coronary heart disease, arrhythmia, heart failure, stroke, diabetes and insulin resistance, which seriously threaten the health of the population, and become a variety of diseases. OSAHS has become a systemic disease [1,2,3,4,5]. that seriously affects the quality of life and life of the people.
Since the twentieth Century 50,60 years, the United States and Western European countries have begun the clinical and basic research of the disease. With the gradual understanding of the pathogenesis of the disease and the investigation of clinical epidemiological data, the OSAHS, as a systemic disease with higher incidence, has attracted more and more attention for.1979 years. The American Sleep Association Federation has carried out the sleep disease. The sleep apnea syndrome is divided into three categories of obstructive, central and mixed.1994 years. The American Association for Sleep Disorders Association explicitly incorporates sleep apnea syndrome into one of the sleep disorders.1996 years. Sleep medicine as a branch of medicine is identified by the American Medical Association and 1999 American Sleep Medicine Science. The hospital (American Academy of Sleep Medicine, AASM) established and replaced the Association for the Sleep Disorders Association. After the establishment of the AASM, a clinical guide for the diagnosis and treatment of OSAHS has been formulated and revised. The formulation of these guidelines has played a regulatory role in the treatment of the disease. The operation is an important part of the OSAHS. Surgical treatment, in the early 70s, began to try tracheotomy and tonsillectomy. In 1982, Fujita was first treated with uvulopalatopharyngoplasty (uvulopalatopharyngoplasty, UPPP) for the treatment of OSAHS. It was suitable for the airway stenosis caused by the blockage of the mouth and pharynx of the soft tissue for.1997 years to improve the UPPP operation, that is, the uvula was retained. Function, effectively reducing postoperative complications and improving the effectiveness of the operation. It is reported that the recent efficiency of UPPP is in the 50%-60%, and the long-term efficiency is lower than the near term. Since the operation of UPPP and different levels of surgical treatment, the perioperative complications, especially the report of acute respiratory obstruction, cause death and death. The the American Society of Anesthesiologists (ASA) set up a clinical guide for OSAHS anesthesia in 2006, focusing on the management of difficult respiratory tract during the perioperative period of OSAHS patients.
In the early 80s, there was a case of OSAHS in our country. After the number of clinical studies increased year by year, Professor Huang Xizhen, the Peking Union Medical College Hospital, established the first sleep medical laboratory in China. With the deepening of the understanding of OSAHS, our sleep laboratory has been established in some hospitals in recent years. The laboratory is relatively popular and can carry out OSAHS's sleep monitoring and diagnosis. The clinical departments engaged in OSAHS involve Department of respiration, otolaryngology, Department of Stomatology and other disciplines. OSAHS is gradually recognized as an important disease involving multidisciplinary systemic multisystems, and has attracted the attention of the medical community. However, in our national disciplines, The understanding of OSAHS is unbalanced and lacks general understanding of systemic disease of OSAHS disease. Zhong Nan Shan calls for the in-depth study of sleep apnea and effective collaboration between multidisciplinary.
With the intervention of the treatment of OSAHS disease in China, the number of patients requiring UPPP surgery is increasing year by year. The reports of death in the perioperative period have aroused the attention of our country again. A retrospective analysis of the perioperative death of OSAHS patients and the acute respiratory obstruction caused by the failure of tracheal intubation are reported. It is the primary cause of perioperative death in patients. Moreover, it is reported that hemorrhage and heart, respiratory complications after OSAHS operation are related to the difficult tracheal intubation of general anesthesia. Unfortunately, the review of the literature on severe complications and death complications in OSAHS perioperative period is from the report of the otorhinolaryngology, the trachea The anesthetic related complications caused by the failure of intubation did not cause enough vigilance by the anesthesiologist. This is associated with the limitations of the current distribution of OSAHS disease diagnosis and surgical treatment in our country, but it also reflects the lack of awareness of OSAHS diseases by the anesthesiologists in our country and the incidence of difficult respiratory tract caused by OSAHS disease. Lack of knowledge.
In 2003, Schotland designed a questionnaire on the knowledge and attitude of OSAHS (the obstructive sleep apnea knowledge and attitudes questionnaire, OSAKA questionnaire) to judge doctors' understanding of the disease. Examination and analysis are useful for judging the degree of understanding of the disease by doctors in different disciplines, the subject setting of OSAHS diseases and the formulation of the continuing medical education program. At present, the report of our national clinicians on the cognitive investigation of OSAHS disease is still lacking.
Anesthesiologists have also started a study of OSAHS difficult tracheal intubation and difficult mask ventilation in the United States and other countries with earlier OSAHS surgery. Obesity, OSAHS disease severity, Mallampati throat exposure classification, and other factors are considered to be related to the difficult gas path of OSAHS patients, but the observations in different literature have been observed. The risk factors for the difficult airway in OSAHS patients are still uncertain, and some reports are even contradictory. There is still a lack of clinical research on the difficult airway in OSAHS patients.
Therefore, the research on OSAHS disease is divided into two parts. The first part uses a questionnaire designed by Schotland to carry out a questionnaire on the knowledge of OSA HS disease by the anesthesiologist and to judge the questions on the management knowledge of OSAHS anesthesia with reference to the OSAHS clinical anesthesia guide made by ASA in the United States. The anesthesiologist's understanding of the OSAHS disease is expected to cause the attention of the anesthesiologist to the OSAHS disease, to strengthen the anesthesiologist's continuing study of OSAHS, to reduce or avoid the occurrence of acute respiratory obstruction in OSAHS patients due to the knowledge defect of the anesthesiologist's OSAHS.
In the second part, we observe and record the body mass index, neck circumference, waist circumference, Chin a distance, Mallampati pharynx exposure classification and direct laryngoscope lucid local mucosal surface anaesthesia, according to the characteristics of OSAHS patients, such as obesity, hypertrophy of tongue and short neck, according to the guidelines of the United States anesthesiologist and the national anesthesiology society. Cormack and Lehane's glottal classification and other indicators related to airway management, using the method of screening epidemiological risk factors to establish a Logisogistic regression model, from a number of confounding factors to analyze the risk factors of OSAHS patients' difficult mask ventilation and difficult tracheal intubation, thus foreseeable to avoid the difficulties of OSAHS patients. Mask airway control ventilation and difficult airway lead to acute respiratory obstruction, reduce perioperative mortality and anesthesia related complications in patients with OSAHS.
Objective to investigate the knowledge and attitude of obstructive sleep apnea (the obstructive sleep apnea knowledge and attitudes questionnaire) designed by Schotland HM, to understand the anesthesiologist's knowledge of OSA disease and the attitude of concern, to judge the anesthesiologist's cognitive status on the OSAHS disease and to understand the anesthesiologist's disease. The necessity of continuing to study.
Methods the Schotland HM authorization was obtained. The OSAKA questionnaire was translated into Chinese. Each questionnaire was placed in the envelopes of postage stamps and sent back to the investigators. 400 OSAKA questionnaires were sent to more than 20 local and provincial hospitals in Shandong province. The questionnaire was divided into two parts. The first part was divided into OSAHS knowledge, involving 5 aspects of 18. Items, including OSAHS epidemiological knowledge, pathogenesis, clinical symptoms, diagnosis and treatment, and other knowledge points. The second part is to manage the confidence level of OSAHS patients, never important (or very unconfident) to very important (or very confident) to be divided into 5 grades.18 knowledge points, the correct answer of each question 1 points, the answer error notes 0 points, The percentage of correct answers was calculated. 5 grades were recorded in turn as 1-5 points. The score of doctors' knowledge of OSAHS and management of attitude confidence in OSAHS patients was recorded, and the relationship between the knowledge mastery of anesthesiologists and the management of the confidence level of OSAHS patients was further analyzed.
Results 321 valid questionnaires were recovered, 18 of the knowledge points for OSAHS disease were 1 points per question, the correct answer was 11.21 + 2.89. The correct average answer of all questions was the highest of 86% for the knowledge point of the pathogenesis of OSAHS disease. The lowest correct rate of knowledge points on the treatment of OSAHS disease was 33%. to OSA The probabilities of HS patients, anesthesia management and postoperative management were 51.71%, 66.36%, and 66.36%. The knowledge of the anesthesiologist and the anesthesiologist were positively related to the confidence attitude of the OSAHS disease. The sex, age, education level of the anesthesiologist, the level of the hospital, and the level of the hospital were not related to the score of the questionnaire.
Conclusions the anesthesiologist's lack of knowledge about OSAHS disease; low awareness of OSAHS disease; low confidence in anesthesia management for OSAHS patients; it is necessary to continue learning about OSAHS disease.
Objective to screen the risk factors of difficult facial mask ventilation and difficult tracheal intubation in patients with obstructive sleep apnea, so as to reduce the incidence of difficult airway in obstructive sleep apnea patients.
Methods 120 patients with obstructive sleep apnea were monitored by polysleep monitor. The specific anesthetized inpatients designed by unfamiliar subjects measured and recorded all the observation indexes, including age, body mass index (body mass index, BMI), the patient apnea hypopnea index (apnea-hypopnea index, AHI), and the lowest oxygen saturation (T). He lowest oxygen saturation, LSaO2), the longest apnea time (the longest sleep apnea time, LSAT), neck circumference (neck), the distance between the waist and the chin, the distance between the upper and lower teeth, the horizontal length of the mandible. Ndible, HLM), Mallampati classification and Cormack and Lehane's larynx classification, according to the logistic regression model, the risk factors of difficult mask ventilation and difficult tracheal intubation were analyzed.
Results the average age of the patients with obstructive sleep apnea was 39.98 years, the average value of body mass index was 29.45kg/m2, the average value of neck circumference and waist circumference was 100.5cm, the probability of 42.08cm. difficult mask ventilation was 41.7%, and the risk factor of difficult tracheal intubation was the neck circumference of the patients with 25.8%. difficult mask ventilation (OR=1.85 7) and two indexes of oropharyngeal Mallampati classification (0R=12.508), the risk factors for difficult tracheal intubation were Cormack and Lehane's larynx (OR=7.799), AHI (OR=1.045) for judging the severity of the disease, and the distance between the upper and lower incisors (OR=0.090).
Conclusions obesity, especially central obesity, is prevalent in patients with obstructive sleep apnea. The proportion of difficult mask ventilation and difficult tracheal intubation is higher. Mallampati oropharynx exposure classification and Cormack and Lehane's glottis classification are difficult airway for obstructive sleep apnea patients.

【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2012
【分类号】：R766

【参考文献】