【作者】 王春玲；

【导师】 潘新良；

【作者基本信息】 山东大学 ， 耳鼻咽喉科学， 2012， 博士

【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。更多还原

【Abstract】 BackgroundObstructive sleep apnea hyponea syndrome(OSAHS) is a breathing disorder during sleep that results from a complete or partial obstruction of the upper airway,or is accompanied by respiratory drive reduced,and thereby results in repeated chronic intermittent hypoxia, carbon dioxide retention, repeated arousals and sleep structure changes. The systemic nervous stress response of patients is induced with nocturnal intermittent hypoxia and hypercapnia, which can cause multiple organ dysfunction,patients can be associated with a series of serious diseases which include:hypertension, coronary heart disease, arrhythmia, heart failure, stroke, diabetes and insulin resistance so on.OSAHS is considered as an independent risk factor for a variety of systemic disease. At the same time, duing to repeated arousals and sleep disruption,the incidence of occupational accidents and traffic accidents increase significantly to parients with OSAHS. Thus, OSAHS has become a serious disease which affects people’s life quality and the health to people’s survival.Since20th fifties and sixties,the clinical and basic researches on OSAHS have been carried out in the United States and European countries, with the gradual awareness in pathogenesis of OSAHS and epidemiological survey data on OSAHS,OSAHS recognized as a high incidence of systemic diseases has been paied more and more attention. In1979, the America Association of Sleep divided the sleep apnea syndrome into three categories:obstructive sleep apnea syndrome, central sleep apnea syndrome and mixed sleep apnea syndrome. In1994, the America Association of Sleep Disorder considered sleep apnea syndrome as one of the diseases of sleep disorder. In1996, sleep medicine was identified as a medical branch by the America Association of Medicine. In1999, the American Academy of sleep medicine(AASM) was established,which replaced the American Association of Sleep Disorders.The clinical guidelines on OSAHS have been formulated and revised by AASM since then.These guidelines can standard the treatment of OSAHS and avoid risks in managing OSAHS patients.Surgery was an important means to treat OSAHS patients, in the early1970th, tracheotomy and tonsillectomy were tried, In1982,uvulopalatopharyngoplasty(UPPP) was firstly developed to treat OSAHS patients by Fujita.UPPP has been improved to preserve uvula physiological function since1997. According to the report, recent efficiency of UPPP was50%～60%, the long-term efficiency was inferior to the recent efficiency.The fact that death is caused by perioperative complications especially acute airway obstruction have caused attention of people,practice guidelines for the perioperative management of patients with obstructive sleep apnea was recommended by the American Society of anesthesiologists in2006,which focused on difficult airway management to patients with obstructive sleep apnea perioperatively.Case report about OSAHS was begun in1980th in our country, clinical researches have increased year by year since then. In1987,professor Huang Xizhen set up the first sleep medicine laboratory in our country in Peking Union Medical College Hospital. With OSAHS being recognized, sleep laboratories in some hospitals have been established one after another, sleep laboratories have begun popular for the nearest ten years, sleep monitoring and the diagnosis of OSAHS can be finished in these laboratories. OSAHS has been gradually recognized as a disease associated with multisystem and harmful to health. However, in our country, physicians lack the ability in recognizing patients with OSAHS in general, there are differences in ability to deal with patients with OSAHS between physicians specialized in different medicine.Zhong Nanshan called for further development of OSAHS study and cooperaton between different medical speciality.With the treatment interventions to OSAHS, the need to be operated for OSAHS patients has increased year by year, the death duing to airway obstruction in the perioperative period has been reported repeatedly,which arouse our attention once again. The failure of tracheal intubation has been considered as primary cause of death to OSAHS patients perioperatively. Furthermore, article reports showed that difficult tracheal intubation was associated with postoperative complications including:bleeding, cardiac accidents and respiratory adverse outcomes. Unfortunately, all retrospective studies in severe complications and death complications to OSAHS patients came from otolaryngologists’ analysis,anesthesia-related complications induced by failure in tracheal intubation to OSAHS patients haven’t caused enough vigilance to anesthesiologists.At present,OSAHS can be diagnosized and treated in limited hospitals, anesthesiologists have limited chance to deal with OSAHS patients,which should be the partial reason why anesthesiologists lack enough knowledge on OSAHS.However,the truth is that anesthesiologists haven’t paied enough attention on managing OSAHS patients with difficult airway.The obstructive sleep apnea knowledge and attitudes questionnaire was developed by Schotland to judge physicians’knowledge about OSAHS. Southwell、Tamay and Uong EC carried out surveies to evaluate physicians and pediatricians’knowledge about OSAHS with OSAKA questionnaire,too. OSAKA questionnaire was considered as a useful tool to judge physician’s knowledge on OSAHS,to evaluate the reasonability of medical course setted to medical students,and to assess the need of the continuous medical education to physicians.There is no survey among anesthesiologists with OSAKA questionnaire in our country.In the United States and other countries,with the surgery being done to treat OSAHS,anesthesiologists had begun the study on the relationship between OSAHS and difficult intubation or difficult mask ventilation.Factors including obesity,the severity of OSAHS and Mallampati classification had been considered associated with difficult airway among OSAHS patients. But,the results in different reports were not the same,no single risk factor or certain risk factors were sure to predict difficult airway in OSAHS patients,some reports were conflicting. Study on the relationship between OSAHS and difficult airway is still lacked in our country. Our study included two sections.In the first section,we carried out a survey about OSAHS among anesthesiologists with OSAKA questionnaire.We revised the questionnaire with knowledge associated with anesthesia according to practice guidelines for the perioperative management of patients with obstructive sleep apnea developed by ASA.We hoped that anesthesiologists can pay more attention on OSAHS and be active in continuous medical education on OSAHS after finishing the questionnaire,so that emergency accidents to OSAHS patients can be avoided or be decreased duing to anesthesiologists’ neglect.In the second section,we established Logisogistic regression model to screen risk factors for difficult airway among OSAHS patients.According to recommendations in managing OSAHS patients suggested by ASA and Chinese Medical Association of Anesthesiology,combining with the characteristics of OSAHS patients,we determined to observe certain variables as risk factors for difficult airway,which included:body mass index(BMI),neck circumference(NC),waist circumference(WC),thyromental distance(TMD),interincisor distance (ICD), horizontal length of the mandible(HLM), the modifed Mallampati score and the Cormack and Lehane’s classification so on. We hoped that risk factors predicted to difficult airway can be distinguished from confounding factors, so that emergency airway obstruction can be avoided in advance,anesthesia-related morbidity and death in the perioperative period can be decreased. OBJECTIVE TO measure the anesthesiologists’knowledge and attitudes about obstructive sleep apnea (OSA)and assess the need for additional educational programs focusing on OSA.METHODS We was permitted to use questionnaire developed by Schotland HM,the Obstructive Sleep Apnea Knowledge and Attitude Questionnaire was translated into Chinese,400questionnaires were distributed to anesthesiologists from Shandong Province. The Questionnaire included two sections regarding knowledge and attitudes about obstructive sleep apnea.The first section was about knowledge on OSA, with eighteen statements covering five domains:(1) epidemiology,(2) pathophysiology,(3) symptoms,(4) diagnosis, and (5) treatments. The score of "true"was1; the other choice was scored0. The second section was about attitudes on OSA, attitude choice was measured on a five-point Likert scale, ranging from1to5(1, strongly disagree;2,disagree;3, neither agree nor disagree;4, agree; and5,strongly agree). The OSAKA questionnaire finished completely by Anesthesiologists was valid,which score about knowledge and attitudes was documented respectively. The relationship between knowledge and attitudes was analysized.RESULTS A total of321questionnaires were completed. The mean total knowledge scores were11.21,ranging from2o17.The total correct score ratio was62%. The knowledge about pathophysiology of obstructive sleep apnea gained the highest correct ratio,which was86%.The score of knowledge on treatment to patients with obstructive sleep apnea was the lowest,the correct score ratio was33%.The ratio of positive attitude in recognizing OSA patients,managing OSA patients during the period of surgery and managing OSA patients postoperatively was51.71%,66.36%,55.46%respectively.The knowledge score positively associated with particents’s job title and attitude score.None of the dependent variables,such as sex, age, education, and working in different levele hospital,affected the score. CONCLUSION The study showed that anesthesiologists lacked adequate knowledge about OSA, they had few confidience in managing OSA patients. It is necessary to develop special training program of OSA regularly for anesthesiologists after gradution. Objectives The purpose of this study was to find risk factors for difficult mask ventilation and difficult intubation in OSA patient,and to predict decreasing the incidence of difficult airway.Methods120OSA patients diagnosed by polysomnography were enrolled in the study, The characteristics of the OSA patients were documented,which included:gender,age,body mass index(BMI), the lowest oxygen saturation(LSa02), the longest sleep apnea time(LSAT),apnea-hypopnea index(AHI), neck circumference (NC), waist circumference(WC),thyromental distance(TMD),interincisor distance (ICD), horizontal length of the mandible(HLM),The modifed Mallampati score of the oropharynx view and the Cormack and Lehane’s classification of the glottis visualized were assessed, difficult mask ventilation and difficult intubation were recorded. Correlation analysis identified potential risk factors for difficult mask ventilation and difficult intubation,?<0.05was regarded as significant.Factors that had significant association with difficult mask ventilation and difficult intubation on correlation analysis were then subjected to stepwise multiple logistic regression analysis to evaluate confounding among these predictors.Results The mean age was39.98years old,the mean BMI was29.45kg/m2, the mean waist circumference and neck circumference was100.5cm and42.08cm respectively The ratio of difficult mask ventilation and difficult intubation was41.7%and25.8%respectively. Risk factors for difficult intubation were the Cormack and Lehane’s score (OR=7.799), AHI(OR=1.045),and ICD(OR=0.090).The predicting risk factors for difficult mask ventilation were neck circumference (OR=1.857) and the Mallampati score(OR=12.508).BMI and waist circumference were not risk factors for predicting difficult intubation,.but were correlated with difficult mask ventilation. Conclusion Obesity especially central obesity in OSA patients are common. The incidence of difficult mask ventilation and difficult intubation is high in OSA patients. The Mallampati score and the Cormack-Lehane score are considered as two important risk factors to judge the difficult airway in OSA patients.Neck circumference is important to predict difficult mask ventilation.BMI and waist circumference are not independent risk factors for predicting difficult intubation in OSA patients,but have the correlationship with difficult mask ventilation.AHI and ICD are associated with difficult intubation.更多还原