不同术式对阻塞性睡眠呼吸暂停综合征患儿免疫功能的影响

发布时间：2018-07-28 17:36

【摘要】：研究背景：阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea-hypopnea syndrome, OSAHS)是指睡眠过程中上气道反复发生部分或全部阻塞,导致通气不足甚至呼吸暂停,是一种儿童常见的睡眠相关呼吸障碍性疾病,主要表现为：睡眠时张口呼吸,伴有憋气甚至呼吸困难；白天多动、学习困难、伴攻击性行为等认知异常表现,甚至并发肺源性心脏病等呼吸、循环系统病变。其在流行病学和病理生理学特点上,与成人相比具有较大不同,治疗方面,扁桃体和腺样体手术能显著改善OSAHS病情,是儿童OSAHS的首选治疗方法,而作为成人一线治疗方法的持续正压通气仅用于围手术期以及患有21-三体综合征、严重畸形等无法采用手术治疗的重度OSAHS患儿。但腺样体和扁桃体参与咽淋巴环的组成,发挥重要作用,尤其是对儿童的体液及细胞免疫防御有重要意义,此外,其滤泡上皮也有一定的屏障作用。近年来,等离子扁桃体部分切除术以其疼痛反应轻、术后恢复快而被逐渐应用,该术式可否既解决呼吸道梗阻问题、又将隐窝上皮的屏障功能尽可能地保留,受到了广泛关注,同时目前各种形式的扁桃体腺样体相关手术的研究中,对于OSAHS患儿手术前后免疫功能变化的观点尚不一致,有关不同术式对儿童OSAHS的治疗效果的研究并不多。目的：研究单纯腺样体切除、腺样体切除伴扁桃体部分切除、腺样体切除伴扁桃体全部切除三种术式对OSAHS患儿体液及细胞免疫功能的影响,探讨不同术式的适用情况,为个体化的临床治疗提供理论依据。方法：本研究为前瞻性临床试验。1.选取2014年06月至2014年12月因睡眠时打鼾或张口呼吸于山东大学齐鲁医院就诊、并经多导睡眠监测确诊的符合纳入标准的150例儿童OSAHS患者,根据扁桃体分级分为单纯腺样体切除组(A组)、腺样体切除伴扁桃体部分切除组(B组)、腺样体切除伴扁桃体全部切除组(C组)三组,每组各50例。2.于PSG检查后次日和术后6个月时进行血液标本的采集,采集时间均为7：00-8：OOam,送化验室检测Ig水平及T细胞亚群百分比,并做好记录。3.随访期间随时记录并发症发生情况,术后前三天对所有患儿采用Wong-Baker FACES疼痛评分表评估疼痛程度,术后6个月时,采用多导睡眠监测与临床症状相结合的方法判定手术疗效,术后未做睡眠监测者以临床症状改善程度作为评定依据,同时统计各种术式的有效率。结果：1.与术前相比,三组患儿术后6个月时的免疫指标水平变化无统计学意义(P0.05)。2.术后第1天、第2天,A、B、C三组的疼痛评分依次升高,差异均有统计学意义(P0.05)；术后第3天时,A、B两组的疼痛评分无明显差异(P0.05),但均明显低于C组(P0.05)。3.A组有3例患儿的扁桃体较术前明显增大(Ⅲ级),B组有2例扁桃体较术前增大(Ⅱ级),C组无扁桃体再增生。术后6个月时对三种术式有效的概率进行评估,根据临床症状和PSG结果,A、B、C三组分别为93.94%、96.67%、97.30%,无明显差异(P0.05)。结论：单纯腺样体切除术、腺样体切除伴扁桃体部分切除、腺样体切除伴扁桃体全部切除术对患儿的体液及细胞免疫功能均无明显影响,且均可达到治疗儿童OSAHS的效果。单纯腺样体切除术、腺样体切除伴扁桃体部分切除患儿术后疼痛性低。可以考虑根据扁桃体肥大程度来决定扁桃体的保留与否或者是否行部分切除术。
[Abstract]:Background: obstructive sleep apnea-hypopnea syndrome (OSAHS) refers to the repeated partial or full obstruction of the upper airway in the process of sleep, resulting in insufficient ventilation and even apnea. It is a common sleep related respiratory disorder in children, which is mainly manifested in mouth breathing during sleep. It is accompanied by suffocation or even breathing difficulties, cognitive abnormalities such as daytime hyperactivity, learning difficulties, and aggressive behavior, and even pulmonary heart disease, such as respiratory and circulatory diseases, which are significantly different from adults in epidemiological and pathophysiological characteristics. Tonsillar and adenoid surgery can significantly improve OSAHS The disease is the preferred treatment for OSAHS in children, and continuous positive pressure ventilation, as a first-line treatment for adults, is only used in the perioperative period and in severe OSAHS children with 21- trisomy syndrome and severe malformation, but adenoids and tonsils are involved in the composition of the pharyngeal ring, especially for children. In recent years, the plasma tonsillectomy has been used in recent years for its mild response to pain and rapid recovery after operation. The operation can not only solve the problem of respiratory obstruction, but also retain the barrier function of the recess epithelium as far as possible. In the study of all forms of tonsillar adenoid related surgery, there is no agreement on the changes of immune function in children with OSAHS before and after operation. There are few studies on the therapeutic effect of different surgical methods on children's OSAHS. Objective: To study the simple adenoidectomy, adenoidectomy with tonsillectomy, The effects of adenoidectomy with all three kinds of tonsillectomy on the humoral and cellular immune function of children with OSAHS were used to explore the application of different surgical procedures and to provide a theoretical basis for the individualized clinical treatment. Methods: This study was a prospective clinical trial of.1. from 2014 to December 2014 for snoring or mouth breathing during sleep. 150 cases of children OSAHS diagnosed in Qilu Hospital of East University were diagnosed by polysomnography and were divided into simple adenoidectomy group (group A), adenoidectomy with tonsillectomy group (group B), adenoidectomy with all three groups of almond excision group (group C), 50 cases in each group of.2. were examined by PSG. After the next day and 6 months after the operation, the blood samples were collected and collected for 7:00-8:OOam. The Ig level and the percentage of T cell subgroups were detected in the laboratory. The complications were recorded at any time during the follow-up period of the record.3.. The pain degree was assessed by the Wong-Baker FACES pain score table in all the children after the operation, and 6 after the operation. At the end of the month, polysomnography was combined with clinical symptoms to determine the effect of the operation. The patients who did not do sleep monitoring were based on the improvement of clinical symptoms. At the same time, the effective rate of various kinds of surgical procedures was measured. Results: 1. compared with the preoperative, the level of immune indexes at 6 months after operation in the three groups was not statistically significant (P0 .05) first days after.2., second days, A, B, C three groups of pain scores increased in turn, the difference was statistically significant (P0.05), third days after the operation, A, B two no significant difference in pain score (P0.05), but obviously lower than C group (P0.05).3.A group 3 cases of flat peach body significantly increased (grade III), 2 cases of tonsils increased before surgery (II). C group had no tonsillar hyperplasia. Three kinds of effective probability were evaluated at 6 months after operation. According to clinical symptoms and PSG results, A, B, C three groups were 93.94%, 96.67%, 97.30%, respectively. Conclusion: adenoidectomy, adenoidectomy with tonsillectomy, adenoidectomy with all tonsillectomy There is no obvious effect on the humoral and cellular immune function of the children, and it can be achieved in the treatment of children's OSAHS. Simple adenoidectomy, adenoidectomy with partial tonsillectomy in children with low pain after surgery can consider the tonsil hypertrophy to determine the tonsils or not.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R766.9

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