鼻腔扩容术治疗睡眠呼吸暂停低通气综合征的临床疗效和成本—效益分析

发布时间：2019-05-28 09:24

【摘要】：【目的】1.通过对睡眠暂停低通气综合征(Obstructive sleep apnea/hypopnea syndrome,OSAHS)患者在鼻腔扩容术前后进行上气道CT扫描,后经软件三维重建,了解不同疾病严重程度的OSAHS患者术前上气道结构和术后上气道结构改变情况,评价鼻腔扩容术的效果。2.探讨鼻腔扩容术治疗OSAHS患者疗效的主客观指标变化,评价鼻腔扩容术的临床意义。3.对OSAHS患者诊断方法和治疗手段包括气道持续正压通气(continuous positive airway pressure,CPAP)和鼻腔扩容手术进行成本-效益分析,优化治疗策略。【方法】1.对36例行鼻腔扩容术的成年OSAHS患者术前及术后6个月上气道CT图像进行三维重建,测量其鼻腔横截面积,鼻腔容积和黏膜表面积以及咽后壁软组织厚度。2.观察36例行鼻腔扩容术的成年OSAHS患者,所有患者于术前进行客观评估睡眠状况进行多导睡眠图(PSG)描记,填写白天嗜睡主观评分(ESS)量表、鼻堵主观视觉模拟评分(VAS)、鼾声评分(SOS)量表,以上主客观检查于鼻腔手术后6个月重复记录。所有患者接受鼻腔扩容术(鼻中隔三线减张成形术、双侧下鼻甲外移、双侧中鼻甲内移和双侧中鼻道对称性开放)。3.应用Markov模型比较FN-PSG,SN-PSG和UPHM三种诊断方法和CPAP,鼻腔手术两种治疗手段的成本-效益分析。结果采用生命年(Life-years,LY)和质量调整生命年(quality-adjusted life-year,QALYs),以及心血管疾病,中风,机动车交通事故减少数量体现。【结果】1.行鼻腔扩容术后患者的三维重建CT测量结果,其各横截面积较术前显著增加,容积显著增加,鼻腔的面积与体积比(area-to-volume ratio,SAVR)较术前明显下降,且接近正常人水平。2.行鼻腔扩容术后患者的三维重建测量结果,其总体咽后壁软组织厚度较术前明显下降。其中重度OSAHS患者咽后壁软组织厚度较术前没有显著性改变。3.鼻腔扩容术后患者鼻堵VAS评分显著降低,白天嗜睡ESS评分显著降低。轻度OSAHS和中度OSAHS患者AHI指数较术前显著下降,最低血氧饱和度较术前显著升高。重度OSAHS患者术后AHI和最低血氧饱和度较术前没有显著变化。36例OSAHS患者鼻腔扩容术的总体显效率为27.8%4.整夜多导睡眠监测(FN-PSG)是一种相对于其他诊断方法更加经济有效的诊断策略。经过CPAP治疗的OSAHS患者其伴有其他慢性疾病如心脑血管疾病、中风、认知障碍等的生存质量和生命预期较未经治疗的OSAHS患者有明显增加。CPAP联合鼻腔手术与单独CPAP相比,可增加OSAHS患者的生存预期和生存质量,但同时其治疗成本也会明显增加。【结论】1.鼻腔扩容术可明显增加OSAHS患者鼻腔各层面横截面积,鼻腔有效通气容积,降低鼻腔黏膜表面积与鼻腔通气容积比,缓解鼻腔狭窄。2.由于气道的自适应功能,鼻腔扩容术对轻、中度OSAHS患者具有减轻腭咽区域狭窄的作用。3.鼻腔扩容手术可以改善OSAHS患者的鼻堵及白天嗜睡、睡眠打鼾等相关睡眠主观症状,并在一定程度上改善OSAHS患者的阻塞性睡眠呼吸暂停的严重程度,应适当选择其手术适应症。4.OSAHS患者需要规范、全面的诊断和治疗管理。规范化诊疗流程有助于降低OSAHS患者疾病本身和其伴随的其他慢性疾病的医疗成本。整夜多导睡眠监测(FN-PSG)是一种相对于其他诊断方法更加经济有效的诊断策略。5.经过CPAP治疗的OSAHS患者其伴有其他慢性疾病如心脑血管疾病、中风、认知障碍等的生存质量和生命预期较未经治疗的OSAHS患者有明显增加。对于不能耐受CPAP,且符合鼻腔手术的OSAHS患者,根据本研究结果,我们推荐其行鼻腔手术。CPAP联合鼻腔手术与单独CPAP相比,可增加OSAHS患者的生存预期和生存质量,但同时不可否认的是其治疗成本也会明显增加。
[Abstract]:[Objective] 1. To evaluate the effect of nasal dilation in patients with OSAHS with low-ventilation syndrome (OSAHS) before and after nasal dilation, and to evaluate the effect of nasal dilation.2. To evaluate the main objective index of the treatment of OSAHS in patients with OSAHS, and to evaluate the clinical significance of nasal dilation.3. The method of diagnosis and treatment of OSAHS patients, including the continuous positive airway pressure (CPAP) and the expansion of the nasal cavity, is used to analyze the cost-benefit and optimize the treatment strategy. [Methods] 1. Three-dimensional reconstruction of the airway CT images was performed before and after the operation of 36 patients with OSAHS, and the cross-sectional area of the nasal cavity, the volume of the nasal cavity and the surface area of the mucosa and the thickness of the soft tissue of the posterior wall of the pharynx were measured. [Results] 1. The results of three-dimensional reconstruction of the patients with severe OSAHS were significantly increased, the volume was significantly increased, the area of the nasal cavity and the area-to-volume ratio (SAVR) decreased significantly before the operation, and it was close to the normal level.2. The thickness of the soft tissue in the posterior wall of the patients with severe OSAHS was significantly lower than that before operation. [Conclusion] 1. The nasal cavity expansion can obviously increase the cross-sectional area of the nasal cavity of the patients with OSAHS, the effective ventilation volume of the nasal cavity, decrease the surface area of the nasal cavity and the volume ratio of the nasal cavity to relieve the nasal stenosis.
【学位授予单位】：首都医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R766.9

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