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当前位置:首页 > 商业/管理/HR > 销售管理 > OSAS和COPD—重叠综合征的诊治(吴江一院吴巧珍).
OSAS和COPD——重叠综合征的诊治吴江第一人民医院呼吸科吴巧珍主要内容OS的流行病学OS的病理生理特点OS的临床特点OS的诊断OS的治疗重叠综合征(OverlapSyndrome,OS)Respirology,2013;18:421–431COPD和OSAS患者中OS的发病率Associationofchronicobstructivepulmonarydiseaseandobstructivesleepapneaconsequences.InternationalJournalofCOPD.2008:3(4);671–682.OS病理生理学COPD是指具有气流受限为特征的疾病,患者由于慢性气道炎症,形成下呼吸道的阻塞性改变,通气/血流比例失调,晚期更合并弥散功能减退,故低氧血症为COPD的常见并发症。OSAS是以上气道的狭窄或阻塞,睡眠中严重打鼾、反复发生呼吸暂停和低通气、睡眠结构紊乱、白天嗜睡为特征的疾病,伴有间断的低氧血症和(或)高碳酸血症。Integratingtheoverlapofobstructivelungdiseaseandobstructivesleepapnoea:OLDOSAsyndrome.Respirology.2013;18,421–431.OS是COPD合并OSAS,上、下气道异常存在着交互影响其危害性更大,有严重的与睡眠相关的低氧血症,同时也可致高碳酸血症,严重者可导致神经调节功能失调,儿茶酚胺、肾素-血管紧张素、内皮素分泌增加,微血管收缩,内分泌功能紊乱及血流动力学改变,可引起组织器官缺血、缺氧,可导致多器官功能损害。Integratingtheoverlapofobstructivelungdiseaseandobstructivesleepapnoea:OLDOSAsyndrome.Respirology.2013;18,421–431.OS患者睡眠呼吸紊乱以低通气为主,出现持续肺泡低通气的情况较多,低通气指数在呼吸紊乱指数中所占比例较大,单纯发生呼吸暂停的患者较少。OS患者出现与睡眠相关的低氧是由肺泡通气不足引起,而非呼吸暂停。Sleepandsleep-disorderedbreathinginadultswithpredominantlymildobstructiveairwaydisease.AmJRespirCritCareMed.2003,167:7一14.OS睡眠呼吸紊乱的类型COPD、OSA重叠及相互影响的机理年龄:二种疾病均随增龄而加重;吸烟:共同相关;局部或全身的炎症状态、肺内蛋白酶/抗蛋白酶和氧化还原失衡;交感神经张力增加;胃食道反流;低氧血症;肺动脉高压;内皮功能损害。OverlapsinPathophysiology,SystemicInflammation,andCardiovascularDisease.AmJRespirCritCareMed2009;180:692–700重叠综合征临床特点及合并症重叠综合征的主要症状重叠综合征临床特点“重叠综合征”与任何单一疾病比较:夜间低氧血症和日间低氧与高碳酸血症更严重,持续时间更长。睡眠结构破坏更为严重,睡眠质量更差,嗜睡更明显,交通事故致死致残率更高。认知功能损伤更突出,生活质量更差。更易发生肺动脉高压、心律失常等心血管疾病。死亡率增加。Diagnosticandtherapeuticapproachtocoexistentchronicobstructivepulmonarydiseaseandobstructivesleepapnea.InternationalJournalofCOPD,2008:3;269–275.OS患者PaO2PaCO2Sleep-DisorderedBreathingandCOPD:TheOverlapSyndrome.RespirCare.2010;55:1333–1346.重叠综合征夜间持续低氧SleepdisordersinCOPD:theforgottendimension.EurRespirRev2013;22:365–375.OS患者睡眠质量生活质量SleepQualityandQualityofLifeinCOPDPatientswithandwithoutSuspectedObstructiveSleepApnea.SleepDisord,2014;ID508372.139位COPD患者,OS有71位。行肺功能、柏林问卷、ESS、匹兹堡睡眠质量量表(5分为睡眠质量差)、圣乔治呼吸问卷。结果提示104位(74.8%)患者睡眠质量较差,其中OS患者更差。OS步行能力NocturnalCPAPimproveswalkingcapacityinCOPDpatientswithobstructivesleepapnoea.RespiratoryResearch.2013,14:66.OSAS和COPD认知损伤与健康对照组相比,COPD患者发生认知功能损伤危险性的OR值是2.42,基础氧饱和度降低是认知功能损伤的高危因素,氧饱和度88%时的OR值是5.45。与匹配年龄的健康对照组相比,OSAS的老年女性5年后发展为认知损伤的OR值是2.3,且缺氧是主要危险因素。Sleep-DisorderedBreathing,Hypoxia,andRiskofMildCognitiveImpairmentandDementiainOlderWomen.JAMA.2011;306:613-619.COPDandcognitiveimpairment:theroleofhypoxemiaandoxygentherapy.InternationalJournalofChronicObstructivePulmonaryDisease2010:5263–269.OS肺功能SaO2ESSInflammatoryProcessesandEffectsofContinuousPositiveAirwayPressure(CPAP)inOverlapSyndrome.Inflammation.2013,36;66-74.吴巧珍,等.重叠综合征患者夜间缺氧与生活质量评分的相关性研究.医学研究杂志,2011,41(7):118-123.OS肺功能动脉硬化Overlapsyndrome:AdditiveeffectsofCOPDonthecardiovasculardamagesinpatientswithOSA.RespiratoryMedicine(2012)106,1335-1341.OS患者房颤发生率Riskofnew-onsetatrialfibrillationinelderlypatientswiththeoverlapsyndrome:aretrospectivecohortstudy.JournalofGeriatricCardiology.2013;10:129−134.OS新发房颤危险性Riskofnew-onsetatrialfibrillationinelderlypatientswiththeoverlapsyndrome:aretrospectivecohortstudy.JournalofGeriatricCardiology.2013;10:129−134.OS的死亡率OutcomesinPatientswithChronicObstructivePulmonaryDiseaseandObstructiveSleepApnea.AmJRespirCritCareMed,2010,182:325–331.前瞻性研究,筛查4241患者,最终651人入组:CPAP治疗OS患者228,未治疗OS213位,210位单纯COPD,平均随访时间9.4年(3.3-12.7年),终点事件是全因死亡和第一次因COPD加重而住院。OS死亡率升高,主要死因是心血管疾病OutcomesinPatientswithChronicObstructivePulmonaryDiseaseandObstructiveSleepApneaAmJRespirCritCareMed,2010,182:325–331.右心室功能右心室重构EvaluationofRightVentricularRemodelingUsingCardiacMagneticResonanceImaginginCo-ExistentChronicObstructivePulmonaryDiseaseandObstructiveSleepApnea.COPD,2013;10:4–10.右心室质量指数与氧减指数相关EvaluationofRightVentricularRemodelingUsingCardiacMagneticResonanceImaginginCo-ExistentChronicObstructivePulmonaryDiseaseandObstructiveSleepApnea.COPD,2013;10:4–10.重叠综合征的诊断ATS/ERS指南强调,轻度COPD伴有肺动脉高压者需要做PSG监测,夜间氧疗的COPD患者出现晨起头痛者需要做PSG监测。GOLDI或II期COPD患者,如果有OSA临床症状需要进行PSG监测,即使OSA的症状很轻,也需要监测。Sleep-DisorderedBreathingandCOPD:TheOverlapSyndrome.RespirCare.2010;55:1333–1346.重叠综合征的治疗治疗方法有如下几种:1、控制饮食和改变生活方式:控制体重对OSA和肥胖有益,但对于COPD来讲,低体重又意味着高病死率,因此尚无证据推荐OS时要减轻体重,但是对于那些COPD程度不重的患者来说,适当的饮食和运动计划还是有益的。2、戒烟:对于OSAS或COPD都有益处。Sleep-DisorderedBreathingandCOPD:TheOverlapSyndrome.RespirCare.2010;55:1333–1346.3、氧疗有研究表明每天吸氧18小时以上可改善COPD患者缺氧情况和睡眠质量,降低死亡率。研究显示:4L/分氧治疗20位重叠综合征患者,虽然夜间缺氧改善,但是呼吸暂停的时间由25.7s延长到31.4s,PaCO2由52.8mmHg增加至62.3mmHg,PH值也发生相应改变,提示对于OS患者不宜单独氧疗。Sleep-DisorderedBreathingandCOPD:TheOverlapSyndrome.RespirCare.2010;55:1333–1346.AcuteoxygeninpatientswithsleepapneaandCOPD.Chest.1986;89(1):30–384、支气管扩张剂和类固醇激素:积极治疗COPD可以改善夜间低氧血症,有证据显示胆碱能扩张剂、长效β受体激动剂及激素治疗均可改善夜间血氧,提高睡眠质量,说明对于COPD的治疗可以改善夜间低氧,减少除CPAP治疗之外夜间氧疗的需求。但是,对于OS患者,治疗COPD是否对OSA有影响目前尚不清楚,相关文献很少。Effectsofsalmeterolonsleepingoxygensaturationinchronicobstructivepulmonarydisease.Respiration.2009Long-actinginhaledanticholinergictherapyimprovessleepingoxygensaturationinCOPD.EurRespirJ.2004;23(6):825–831.Sleep-DisorderedBreathingandCOPD:TheOverlapSyndrome.RespirCare.2010;55(1
本文标题:OSAS和COPD—重叠综合征的诊治(吴江一院吴巧珍).
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