阻塞性睡眠呼吸暂停低通气综合征患者CPAP治疗1月后睡眠结构、治疗压力及血糖的变化

发布时间：2018-07-11 16:06

本文选题：阻塞性睡眠呼吸暂停低通气综合征 + 年龄　；参考：《南方医科大学》2015年硕士论文

【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)是国际公认的主要公共卫生问题之一,是一种睡眠由口咽部塌陷、咽腔狭窄等导致上气道反复堵塞而反复出现呼吸暂停和(或)低通气,引起间歇性缺氧、睡眠片段化、高碳酸血症等,从而使机体发生一系列病理生理改变的临床综合征,主要表现是睡眠打鼾、呼吸暂停、晨起口干,睡眠不解乏,白日嗜睡,夜尿增多等症状,可引起自主神经及内分泌紊乱,产生炎症反应,损伤组织、多器官,与多系统疾病相关,如高血压、脑卒中、心律失常、心绞痛等,严重影响人们的身心健康,若治疗不及时,可危及生命。OSAHS患者普遍存在,成年人OSAHS患病率男性高达4%,女性高达2%。据研究,OSAHS患者的年平均医疗费用比健康对照组显著增高,而且OSAHS的严重程度与医疗费用呈正相关。除了医疗费用,OSAHS导致的经济损失,还包括工伤、机动车交通事故、生产量下降等产生的费用。OSAHS患者发生工伤事故的风险是对照组的2.2倍,造成机动车交通事故的风险是对照组的3-7倍。人有三分之一的时间在睡眠,人们的生长发育、体力恢复等多在睡眠中完成,长期低质量睡眠会使人注意力不集中,脾气暴躁,攻击性强,精神疲劳,记忆力减退,抵抗力下降,内分泌紊乱,也可诱发冠心病、高血压、脑卒中、月经失调等疾病。睡眠质量的好坏与人们的身体健康、生活质量密切相关。而OSAHS是睡眠障碍的疾病之一,OSAHS患者可出现微觉醒增加,睡眠片段化,导致白日嗜睡。而年龄亦是影响睡眠的因素之一,研究发现不同年龄段的睡眠质量不一样,老年人更容易出现入睡困难、睡眠时间缩短,易醒、早醒。而且年龄与OSAHS的发生发展相关。但是,OSAHS和年龄各自对患者睡眠结构影响的研究尚缺乏,大多数对OSAHS患者睡眠结构的研究忽略了年龄对睡眠结构的影响,而研究各年龄组的OSAHS患者睡眠结构特点未排除OSAHS对睡眠结构的影响。OSAHS患者得到及时准确的诊断和治疗,不但可以预防或控制心脑血管疾病、代谢性疾病等疾病的发生与发展,而且可以减少卫生资源的消耗,提高OSAHS患者的生活质量,提升幸福指数。OSAHS诊断的金标准是多导睡眠监测(polysomnography, PSG),首选治疗方法是经鼻持续气道正压通气(continuous positive airway pressure, CPAP), CPAP治疗成功的关键因素之一是设定合适的治疗压力,测定最佳治疗压力的标准方法是人工气道压力滴定试验。设定合适的CPAP治疗压力可提高治疗的舒适性及有效性,提高患者的依从性。而OSAHS患者长期CPAP治疗后治疗压力和睡眠结构的变化尚未明确,相关的研究尚缺乏,尤其是在发布2007年版新的AASM判读手册后。现有的文献大多数只研究了OSAHS患者初始CPAP治疗后睡眠结构和低氧血症的变化,缺乏对长期CPAP治疗的效果及压力变化的研究。糖尿病亦是重大公共卫生问题之一,在中国,糖尿病的患病率为9.7%,糖尿病前期为15.5%。据研究,每年由糖尿病产生的直接和间接医疗费用高达1740亿美元,且每年导致近25万人死亡。但只有23.66%的患者意识到自己的糖尿病。心血管疾病是2型糖尿病的主要致死因素,此外,糖尿病还可损害眼睛、肾及神经系统等。OSAHS与糖尿病的关系已成为研究热点。有研究统计,在OSAHS患者中,2型糖尿病的患病率在15%-30%之间,糖尿病前期在20%-67%之间。然而,部分研究却未发现OSAHS与糖代谢紊乱独立相关。OSAHS的两大特征是慢性间歇性低氧血症和睡眠片段化,而两者与血糖代谢的关系如何尚缺乏综合研究。经鼻持续气道正压通气(continuous positive airway pressure, CPAP)能够有效的降低呼吸暂停低通气指数,改善低氧血症,提高患者的睡眠质量,改善患者的嗜睡、认知功能障碍,提高生活质量。据研究CPAP治疗可以降低合并高血压的OSAHS患者的血压,减少心脑血管疾病的发生,改善心律失常,增强心功能；但是OSAHS患者CPAP治疗后血糖代谢是否改善仍存在争议,而且,我国对OSAHS患者CPAP治疗1月后血糖如何改变尚缺乏研究。以下我们将研究OSAHS患者Auto-CPAP治疗1月前后睡眠结构、治疗压力、血糖代谢的特点。第一章阻塞性睡眠呼吸暂停低通气综合征患者CPAP治疗1月前后睡眠结构及治疗压力的变化目的：综合分析阻塞性睡眠呼吸暂停低通气综合征与年龄分别对睡眠结构的影响,并探讨阻塞性睡眠呼吸暂停低通气综合征患者经鼻持续气道正压通气(CPAP)治疗1月后睡眠结构及治疗压力的变化。方法：根据标准,从因睡眠打鼾就诊并行多导睡眠呼吸监测(PSG)的成年患者中筛选出222例患者,分析睡眠结构,再分别控制呼吸暂停低通气指数(AHI)及年龄后,比较各年龄组以及不同严重程度OSAHS患者的睡眠结构。再从中筛选出149例经多导睡眠呼吸监测初诊为OSAHS的患者,并已接受Auto-CPAP治疗1月及其前后共2次人工气道压力滴定试验,比较Auto-CPAP治疗前后睡眠结构、通气功能、治疗压力的变化。结果：1.N3睡眠与AHI的相关性最大(r=-0.361,P0.001),REM睡眠及睡眠觉醒与年龄的相关性最大(REM睡眠：r=-0.211,P=0.002;睡眠觉醒r=0.216.P=0.001)。2.四年龄组的AHI无显著差异下,睡眠效率、N1、N2及REM睡眠、睡眠觉醒均存在显著差异(F=7.558,3.565,3.669,3.050,5.456；P0.001,P=0.015,0.013,0.030,0.001),N3睡眠无显著差异(F=1.518；P=0.211)。随年龄增加,REM睡眠减少,睡眠觉醒增加。3.四组不同严重程度OSAHS患者中,控制年龄后,患者的N1、N2及N3睡眠存在显著差异(F= 3.389,3.490,5.800; P= 0.011,0.017,0.001), REM睡眠无显著差异(F=0.232,P=0.874)。中重度OSAHS患者N3睡眠随AHI增加而减少。4. OSAHS患者中,第1天及Auto-CPAP治疗1月后人工气道压力滴定的浅睡眠(N1、N2)比治疗前显著减少,慢波睡眠(N3)及REM睡眠显著增加,P值均0.001。第1天人工滴定的觉醒次数较治疗前显著减少(P=0.012)。Auto-CPAP 1月后睡眠效率较治疗前显著升高(P=0.018),觉醒时间显著减少(P= 0.035)。Auto-CPAP 1月后N2睡眠较第一次人工滴定增加(P=0.010),睡眠潜伏期缩短(P=0.022)。5. Auto-CPAP治疗的最佳治疗压力随OSAHS的严重程度增加而增加(CPAP-1d:F= 28.812, P 0.001; CPAP-1m:F= 19.366, P 0.001)重度OSAHS患者Auto-CPAP治疗1月后最佳治疗压力下降(CPAP-1d:CPAP-1m= (9.73 ±2.6) cmH20:(9.10±2.5) cmH20, P=0.001),结论：OSAHS与年龄均与睡眠结构相关,REM睡眠及睡眠觉醒受年龄影响较大,N3睡眠受OSAHS影响较大。初始及CPAP治疗1月均可改善OSAHS患者的睡眠,重度OSAHS患者CPAP治疗1月后所需的治疗压力下降。第二章阻塞性睡眠呼吸暂停低通气综合征患者CPAP治疗1月前后血糖的变化第一节CPAP 治疗前 OSAHS与血糖代谢的关系目的：探讨阻塞性睡眠呼吸暂停低通气综合征与血糖代谢的关系,并全面分析其影响因素。方法：回顾性分析180例打鼾患者,已接受多导睡眠呼吸监测(PSG)、空腹血糖测量及葡萄糖耐量试验(oral glucose tolerance test,OGTT),分析呼吸暂停低通气指数(AHI)、血氧饱和度、睡眠结构及肥胖指标与空腹血糖、OGTT-1h及OGTT-2h血糖的相关性,并比较不同严重程度OSAHS患者及不同程度低氧血症患者的空腹血糖、OGTT-1h及OGTT-2h血糖的差异。结果：OSAHS患者中糖代谢紊乱的患病率高于非OSAHS患者(糖尿病：21.4%vs.5%;糖尿病前期：34.3% vs.25%)。血糖与AHI、血氧饱和度、肥胖指标显著相关,但与各期睡眠比例及睡眠效率无显著相关。不同程度OSAHS患者中,空腹血糖、OGTT-1h血糖、OGTT-2h血糖都存在显著差异(F=77.728,P0.001:P=9.003,P0.001；P=5.078,p=0.002),控制颈围后,餐后血糖仍存在显著差异(OGTT-1h:F= 4.679,P=0.004:OGTT-2h:F=2.683,P=0.048)。不同程度睡眠低氧血症患者中,空腹、OGTT-1h和OGTT-2h血糖都存在显著差异(F-75.655,P=0.004;F=5.517,P=0.001;F=76.346,P= 0.014).结论：糖代谢紊乱的风险随OSAHS的严重程度增加而增加。与空腹血糖相比,餐后血糖受OSAHS的影响更大,且独立于肥胖。相比于睡眠结构和睡眠效率,睡眠低氧血症与血糖代谢的相关性可能更大。第二节OSAHS患者Auto-CPAP治疗1月后血糖的变化目的：探讨Auto-CPAP治疗1月是否改善OSAHS患者的血糖代谢。方法：根据标准从2013年1月1日-2014年5月30日因打鼾就诊于睡眠医学中心的患者中筛选出共53例男性患者,接受多导睡眠监测、人工气道压力滴定试验、在家Auto-CPAP治疗1月。分正常血糖、糖尿病前期(pre-DM)、糖尿病3组,比较OSAHS患者Auto-CPAP治疗1月前后空腹血糖、OGTT-1h、 OGTT-2h的差异。结果：1. OSAHS患者Auto-CPAP治疗1月后,pre-DM组中,空腹血糖及OGTT-lh血糖显著下降(FPG:t= 4.160, P 0.001; OGTT-lh血糖：t=2.306,P=-0.031)；糖尿病组中,OGTT-lh及OGTT-2h血糖均显著下降(OGTT-lh血糖：t= 2.731, P= 0.039; OGTT-2h血糖：t=2.766,P=0.025);正常基础血糖组中空腹血糖、OGTT-lh及OGTT-2h血糖均无显著改变。2. OSAHS患者Auto-CPAP治疗1月后,重度OSAHS组中,OGTT-1h及OGTT-2h血糖均显著下降(OGTT-lh血糖：t= 3.367, P= 0.002; OGTT-2h血糖：t=2.664,P=0.011)；轻中度OSAHS组中,空腹血糖、OGTT-1h及OGTT-2h血糖均无显著改变。3. OSAHS患者Auto-CPAP治疗1月后,肥胖组中,OGTT-1h血糖显著下降(t=3.195,P=0.003),而OGTT-2h血糖的改变无统计学意义(t=1.919,P=0.064)；非肥胖组中,空腹血糖、OGTT-1h及OGTT-2h血糖均无显著改变。结论：Auto-CPAP治疗1月可改善合并血糖代谢障碍的OSAHS患者的血糖代谢,尤其是重度、肥胖OSAHS患者。
[Abstract]:Background obstructive sleep apnea hypopnea syndrome (obstructive sleep apnea hypopnea syndrome, OSAHS) is one of the internationally recognized major public health problems. It is a kind of sleep from the collapse of the mouth pharynx, the stenosis of the pharynx and so on, which leads to the repeated obstruction of the upper airway and reproduces the intermittent breathing and / or hypoventilation, causing intermittent hypoxia, Sleep fragmentation, hypercapnia, and so on, so as to make a series of clinical syndromes of pathophysiological changes. The main manifestations are sleep snoring, apnea, morning dryness, no lack of sleep, daylight sleepiness, and nocturia, which can cause autonomic and internal secretion disorders, produce inflammatory reactions, damaged tissues, multiple organs, and multilineage. Related diseases, such as hypertension, stroke, arrhythmia, angina and so on, seriously affect people's physical and mental health. If the treatment is not timely, the life of.OSAHS patients can be endanger, the prevalence rate of adult OSAHS is 4%, the female is as high as 2%., and the average annual medical cost of OSAHS patients is significantly higher than that of the healthy control group, and OSAHS In addition to medical costs, the economic losses caused by OSAHS, including industrial injuries, motor vehicle accidents, and the decrease of production, were 2.2 times as high as the control group, and the risk of vehicle traffic accidents was 3-7 times as much as the control group. The risk of vehicle traffic accidents was 3-7 times as much as the control group. There were 1/3 people. Time in sleep, people's growth, physical recovery and so on are done in sleep. Long term low quality sleep will make people lose attention, temper irritable, aggressive, mental fatigue, memory impairment, decline of resistance, endocrine disorder, and can also induce diseases such as coronary heart disease, hypertension, stroke, menstruation and so on. It is closely related to people's health and quality of life. And OSAHS is one of the diseases of sleep disorders. OSAHS patients can appear to increase in micro awakening, sleep fragmentation, and lead to daytime sleepiness. And age is one of the factors that affect sleep. The study found that sleep quality in different ages is different, and the elderly are more prone to sleep difficulties and sleep. Time is shorter, easy to wake up and wake up. And age is related to the development of OSAHS. However, there is a lack of study on the effects of OSAHS and age on the sleep structure of patients. Most of the sleep structures in OSAHS patients neglect the effect of age on sleep structure, and the sleep structure of OSAHS patients in each age group is not excluded from OSAHS to sleep. The effect of sleep structure on the diagnosis and treatment of.OSAHS patients can not only prevent or control the occurrence and development of diseases such as cardiovascular and cerebrovascular diseases, metabolic diseases and other diseases, but also reduce the consumption of health resources, improve the quality of life of OSAHS patients, and improve the gold standard of.OSAHS diagnosis of happiness refers to polysomnography (polyso Mnography, PSG), the preferred treatment is continuous positive airway pressure (CPAP). One of the key factors for the success of CPAP treatment is the setting of appropriate treatment pressure. The standard method for determining the best treatment pressure is artificial airway pressure titration test. The setting of appropriate CPAP treatment pressure can improve the treatment. The changes in stress and sleep structure after long-term CPAP treatment in OSAHS patients are not clear, and the related research is still lacking, especially after the release of the new AASM Reading manual of the 2007 edition. Most of the existing literature only studied the sleep structure and hypoxia after the initial CPAP treatment of OSAHS patients. Diabetes is also one of the major public health problems. Diabetes is also one of the major public health problems. In China, the prevalence of diabetes is 9.7%, the pre diabetes is 15.5%., the direct and indirect medical costs of diabetes are up to $174 billion per year, and nearly 250 thousand people die each year. But only 23.66% of the patients are aware of their own diabetes. Cardiovascular disease is the major cause of death in type 2 diabetes. In addition, diabetes can also damage the eyes, kidney and nervous system, such as.OSAHS and diabetes, the relationship between diabetes has become a research hotspot. In the study of OSAHS patients, the prevalence rate of type 2 diabetes is between 15%-30%, diabetes Early in 20%-67%. However, some of the studies have not found that the two major features of OSAHS independent of glucose metabolism disorder.OSAHS are chronic intermittent hypoxemia and sleep fragmentation, and the relationship between the two and blood glucose metabolism is still lacking a comprehensive study. Transnasal continuous positive airway pressure (continuous positive airway pressure, CPAP) Effectively reducing the apnea hypopnea index, improving hypoxemia, improving the quality of sleep, improving the patient's lethargy, cognitive dysfunction, and improving the quality of life. According to the study of CPAP treatment, the blood pressure of OSAHS patients with hypertension can be reduced, the occurrence of cardio cerebrovascular disease, arrhythmia, and cardiac function are improved; but OS There is still controversy about the improvement of blood glucose metabolism in patients with AHS after CPAP treatment, and there is still a lack of study on how the blood glucose changes after the January CPAP treatment in OSAHS patients. We will study the characteristics of OSAHS patients' sleep structure, treatment stress, and blood glucose metabolism before and after January. The first chapter of obstructive sleep apnea hypopnea syndrome The change of sleep structure and treatment pressure in patients with CPAP before and after January: a comprehensive analysis of the effects of obstructive sleep apnea hypopnea syndrome and age on sleep structure, and the treatment of sleep structure and treatment after January by nasal continuous positive airway pressure ventilation (CPAP) in patients with obstructive sleep apnea hypopnea syndrome. Methods: according to the standard, 222 patients were selected from the adult patients with sleep snoring and PSG. The sleep structure was analyzed, and the apnea hypopnea index (AHI) and age were controlled respectively. The sleep structure of all age groups and OSAHS patients with different severity was compared. 149 patients who were first diagnosed as OSAHS by polymorphic breathing were selected, and 2 artificial airway pressure titration tests were accepted in January and before and after Auto-CPAP treatment. The changes of sleep structure, ventilation function, and treatment pressure were compared before and after Auto-CPAP treatment. Results: the correlation between 1.N3 sleep and AHI was the greatest (r=-0.361, P0.001), REM sleep and sleep. The relationship between awakening and age was the greatest (REM sleep: r=-0.211, P=0.002, sleep awakening r=0.216.P=0.001).2. four age group AHI no significant difference, sleep efficiency, N1, N2 and REM sleep, sleep awakening had significant differences (F=7.558,3.565,3.669,3.050,5.456; P0.001, P=0.015,0.013,0.030,0.001), there was no significant difference in sleep. =0.211). As the age increased, REM sleep decreased and the sleep awakening increased.3. four with different severity OSAHS. After controlling the age, there were significant differences in N1, N2 and N3 sleep (F= 3.389,3.490,5.800; P= 0.011,0.017,0.001), and no significant difference in REM sleep (0.232). In the patients with OSAHS, first days and Auto-CPAP treatment after January, the superficial sleep (N1, N2) of artificial airway pressure titration was significantly lower than that before treatment, slow wave sleep (N3) and REM sleep were significantly increased, P values were significantly reduced (P=0.012) in 0.001. first days compared with before treatment (P=0.012), and the sleep efficiency was significantly higher than before the treatment (P=0.018) (P=0.018). ), the awakening time decreased significantly (P= 0.035).Auto-CPAP after January, N2 sleep was increased compared with the first artificial titration (P=0.010), and the optimal treatment pressure of.5. Auto-CPAP treatment was increased with the increase of OSAHS's severity (CPAP-1d:F= 28.812, P 0.001; CPAP-1m:F= 19.366, P 0.001) 1 severe patients. The best treatment pressure dropped after the month (CPAP-1d:CPAP-1m= (9.73 + 2.6) cmH20: (9.10 + 2.5) cmH20, P=0.001). Conclusion: OSAHS and age are related to sleep structure, REM sleep and sleep awakening are greatly influenced by age, N3 sleep is greatly influenced by OSAHS. Initial and CPAP treatment can improve the sleep of OSAHS patients in January, CPAP treatment in severe OSAHS patients. The decrease of treatment pressure required after January. The change of blood sugar in the second chapter of the patients with obstructive sleep apnea hypopnea syndrome (CPAP) before and after January, the relationship between OSAHS and blood glucose metabolism before CPAP treatment: the relationship between obstructive sleep apnea hypopnea syndrome and blood glucose metabolism, and the comprehensive analysis of the influence causes Methods: a retrospective analysis of 180 snoring patients who had received polymorphic sleep monitoring (PSG), fasting blood glucose measurement and glucose tolerance test (oral glucose tolerance test, OGTT), analyzed the apnea hypopnea index (AHI), oxygen saturation, sleep structure, and obesity index with fasting blood glucose, OGTT-1h, and OGTT-2h blood sugar. The differences in fasting blood glucose, OGTT-1h and OGTT-2h blood glucose in different severity OSAHS patients and patients with different degrees of hypoxemia were compared. Results: the prevalence of glucose metabolism disorder in OSAHS patients was higher than that of non OSAHS patients (diabetes: 21.4%vs.5%; prediabetes: 34.3% vs.25%). Blood glucose was significantly associated with AHI, blood oxygen saturation, and obesity index. There was no significant correlation between the proportion of sleep and sleep efficiency at all stages. There were significant differences in fasting blood glucose, OGTT-1h blood glucose and OGTT-2h blood glucose in different levels of OSAHS (F=77.728, P0.001:P=9.003, P0.001; P=5.078, p=0.002). After controlling the neck circumference, there were significant differences in postprandial blood glucose (OGTT-1h:F= 4.679, P=0.004:OGTT-2h:F=2.683, P=0.048). In patients with the same degree of sleep hypoxemia, there were significant differences in fasting, OGTT-1h and OGTT-2h blood sugar (F-75.655, P=0.004; F=5.517, P=0.001; F=76.346, P= 0.014). Conclusion: the risk of glucose metabolism disorder increases with the increase of the severity of OSAHS. Compared with fasting blood glucose, postprandial blood glucose is more influenced by OSAHS, and is independent of obesity. Sleep structure and sleep efficiency, sleep hypoxemia and blood glucose metabolism may be more related. Second OSAHS patients Auto-CPAP treatment after January blood glucose changes aim: To explore whether Auto-CPAP treatment in January to improve the blood glucose metabolism of OSAHS patients. Methods: according to the standard from May 30th January 1, 2013, snoring in sleep medicine A total of 53 male patients were selected from the study center, receiving polysomnography monitoring, artificial airway pressure titration test, and in the family Auto-CPAP treatment in January. Divided normal blood sugar, prediabetes (pre-DM), diabetes 3 groups, compared OSAHS patients with Auto-CPAP for the difference in fasting blood sugar, OGTT-1h, OGTT-2h before and after January. Results: Auto-CPA of 1. OSAHS patients. After P treatment in January, the fasting blood glucose and OGTT-lh blood glucose decreased significantly in the pre-DM group (FPG:t= 4.160, P 0.001; OGTT-lh blood glucose: t=2.306, P=-0.031). In the diabetic group, OGTT-lh and OGTT-2h blood glucose decreased significantly (OGTT-lh glucose: t= 2.731, 0.039; blood glucose); and the fasting blood glucose in the normal basic blood glucose group There was no significant change in OGTT-2h blood sugar in the patients with.2. OSAHS after January. In the severe OSAHS group, the blood sugar of OGTT-1h and OGTT-2h decreased significantly (t= 3.367, P= 0.002, OGTT-2h glucose, t=2.664,). After January, the blood glucose of OGTT-1h decreased significantly (t=3.195, P=0.003) in the obese group, but there was no significant change in OGTT-2h blood glucose (t=1.919, P=0.064). There was no significant change in fasting blood glucose, OGTT-1h and OGTT-2h in non obese group. Conclusion: Auto-CPAP treatment can improve the blood glucose metabolism in OSAHS patients with blood glucose metabolism disorder in January. It is a severe, obese OSAHS patient.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R766

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