多频道生理纪录法在睡眠呼吸中止症的应用.ppt

PolysomnographyPolysomnography (PSG) (PSG)多频道生理纪录法多频道生理纪录法 ----------------在睡眠呼吸中止症在睡眠呼吸中止症(Sleep (Sleep Apnea)Apnea)的应用的应用梁丽丽 2008年11月19日Gold standard: Polysomnography (over night) 多频道生理纪录法Parameter:Parameter: EEG EEG EOG EOG Chin EMG Chin EMG EKG EKG Chest movement Chest movement Abdomen movement Abdomen movement Leg movement Leg movement Airflow Airflow Oxygen saturation Oxygen saturation Body position Body position Snoring Snoring Light Light video recording video recordingEEG, EOG, chin EMG 电极黏贴位置示意图- 3 EEG channels: C3/A2, C4/A1, O1/A2, GND, REF- 3 EEG channels: C3/A2, C4/A1, O1/A2, GND, REF- 3 EEG channels: C3/A2, C4/A1, O1/A2, GND, REF- 3 EEG channels: C3/A2, C4/A1, O1/A2, GND, REFC4/A1- 2 EOG channels: ROC( 1 cm above)/A1, LOC(1cm below)/A2- 2 EOG channels: ROC( 1 cm above)/A1, LOC(1cm below)/A2- 2 EOG channels: ROC( 1 cm above)/A1, LOC(1cm below)/A2- 2 EOG channels: ROC( 1 cm above)/A1, LOC(1cm below)/A2LOCROCROC/A1ROC/A1- 1 EMG channel: beneath the chin( 4cm between 2 electrodes)- 1 EMG channel: beneath the chin( 4cm between 2 electrodes)- 1 EMG channel: beneath the chin( 4cm between 2 electrodes)- 1 EMG channel: beneath the chin( 4cm between 2 electrodes)EMG1EMG2EMGEMGGRDGRDWhat is sleep apnea?•Apnea: complete cessation of airflow Apnea: complete cessation of airflow (at least <90% of baseline) for at (at least <90% of baseline) for at least 10 secleast 10 sec> 10 secWhat is sleep hypopnea?•HypopneaHypopnea: airflow <50% of baseline, : airflow <50% of baseline, or or desaturationdesaturation of at least 4%, or of at least 4%, or arousal from sleeparousal from sleepThree types of Sleep apnea syndrome•Central type•Obstructive type•Mixed typeCentral type sleep apnea(睡眠呼吸中止中枢型)定义：1. 呼吸波减至10%以下2. 每次至少10秒3. 无胸腹部的呼吸动作 15seconds1.不会过胖2.咽喉通道不狭窄3.抱怨晚上失眠但白天想睡觉4.打鼾不严重5.<10% 有睡眠呼吸症状者6.显着--- CNS or neuromuscular disorder. Obstructive sleep apnea (睡眠呼吸中止阻塞型)*定义：呼吸波减至10%以下每次至少10秒喉咽气道阻塞胸腹部呼吸动作持续，但无气流交换75 seconds1.较常见>90 %2.台湾约有 11%中老年人口3. 罹患中度或重度阻塞型4. 睡眠呼吸中止症Mixed type apnea 睡眠呼吸中止混合型•定义：•1. 呼吸波减至10%以下•2. 每次至少10秒•3. 先中枢型再接阻塞型•4. >25% 的中枢型30 secondsHypopnea定义：每次至少有90 %的呼吸波减至50%以下每次至少10秒血氧饱和度下降至少 3% 32 seconds阻塞型睡眠呼吸中止症临床症状打鼾白天嗜睡无法熟睡注意力不集中 晨醒头痛夜间频尿性情改变sleep apnea 的影响sleep apnea相关危险因素•年纪•男性 > 女性•肥胖•颈围过粗 (男>43公分，女>38公分)• •酒精或镇静剂、安眠药 •颅面结构异常如后缩颚、下颚狭小、鼻中膈弯曲、舌头过大、暴牙、舌头过大、扁桃腺肥大、悬壅垂肥大咽颚帆区狭小、口鼻咽软组织过多•甲状腺功能过低症、唐氏症RDI 及 AHI 的定义•AHI: apnea/hypopnea index (#/hour) • The average of episodes of apnea and hypopnea per hour of sleep• 每小时apnea and hypopnea 的平均发生次数 •RDI: respiratory disturbance index (#/hour)• #: events of apnea, hypopnea, snores, snore resulting in arousalsThe severity of sleep apnea DiagnosisNormalMildModerateSevereRDI/AHI (episodes/hour)< 55 2020 - 40> 40DiagnosisMildModerateSevereMean SaO2 90% 90%<90%Minimum SaO2 85% 70%<70%ICSI health guideliine, Diagnosis and treatment of obstructive sleep apnea, 2003*严重度的睡眠呼吸中止症可领轻度残障手册，已有提议修法改为向健保局申领 购买阳压呼吸器补助费。

如何治疗睡眠呼吸中止症•维持理想体重维持理想体重•侧睡侧睡•避免睡前服用镇静药物避免睡前服用镇静药物•避免睡眠不足避免睡眠不足•避免睡前喝酒避免睡前喝酒•床头摇高床头摇高• ( (肥胖特别是肚子大的肥胖特别是肚子大的人）人）•感冒及过敏一定要治好感冒及过敏一定要治好•睡前避免吃太多睡前避免吃太多•戒菸戒菸手术 一个月后 98公斤手术前 135公斤扁桃腺肥大1. 行为治疗如何治疗睡眠呼吸中止症•Fujita (1981), Uvulopalatopharygoplasty•Most common procedure---- remove excess tissue of tonsils, uvula and part of the soft palate. •1st line treatment for retropalatal collapse•10-50% success2. UPPP (悬壅颚咽成形术) ( 侵袭性治疗) 3. Dental Appliances 齿科装置 (非侵袭性治疗)•Nearly as effective as CPAP in mild to moderate OSA•Reposition the mandible• 如何治疗睡眠呼吸中止症4. Nasal CPAP 鼻腔阳压呼吸器(非侵袭性治疗) Nasal Continuous Positive Airway Pressure (APAP): Auto Positive Airway Pressure10 cmH2O to overcome upper airway narrowing, not over 20-25 cmH20) 如何治疗睡眠呼吸中止症R & K, 1968 (Rechtschaffen & Kales) AwakeNon-REM sleep(非快速动眼期) stage 1 stage 2 stage 3 stage 4REM sleep (快速动眼期Rapid-Eye-Movement)正常睡眠的分期正常睡眠的分期American Academy Sleep Medicine美国睡眠医学会, 2007Stage WStage N1Stage N2Stage N3 (deep sleep )Stage R 正常睡眠分期的周期关系正常睡眠分期的周期关系睡眠记录常用名词•1. Total Recording Time (记录总分钟数)• Time in Bed (躺在床上的总分钟数)•2. Total Sleep Time (睡眠总分钟数)• (stage1+stage2+stage3+stage4+REM)•3. Sleep Efficiency (睡眠效率, >85%)• (Total Sleep Time/ Total Recording Time ) X 100•4. Sleep Latecy (入眠时间, <15 分钟) •5. REM latency (入快速动眼期时间, 80-120分钟)N-REM and REM stage 在生理上的比较Non-REMNon-REMREMREM呼吸速率呼吸速率规则规则较快且有变异性较快且有变异性 血压血压规则规则较高且有变异性较高且有变异性 心跳心跳规则规则 较快且有变异性较快且有变异性 大脑血流速率大脑血流速率 规则规则增加增加体温体温稳定稳定变异变异肌肉张力肌肉张力放松放松消失消失作梦作梦很少很少时常时常阴茎或阴蒂勃起阴茎或阴蒂勃起较少较少时常时常N-REM and REM stage 在功能上的比较Non-REMNon-REM(deep sleep )(deep sleep )REMREM生长激素的分泌生长激素的分泌脑部生长脑部生长脑部发育脑部发育与智力及记忆有关与智力及记忆有关 PolysomnographyPolysomnography Report ReportPolysomnographyPolysomnography Report ReportPolysomnographyPolysomnography Report Report脑波频率DeltaDelta< 4 < 4 HzHzHerzThetaTheta4-7 4-7 HzHzAlphaAlpha8 - 13 8 - 13 HzHzBetaBeta> 13 > 13 HzHz 脑脑 波波 形形 状状K ComplexK ComplexK ComplexK Complexsharp negative wave, followed by slower positive component,> 0.5 secseen in Stage 2SpindlSpindlSpindlSpindle e e eshort rhythmic waveform clustersof 12-14 Hz> 0.5 secseen in stage2low amplitudesawtooth appearanceseen in REMSawtoothSawtoothSawtoothSawtooth waves waves waves wavessharp positive waves, theta frequency range,occurring latter part of Stage1Vertex wavesVertex wavesVertex wavesVertex wavesRelaxed Wakefulness rapid eye movement, blinks tonic activity, relatively high, voluntary movementαwaveαwave (8-13 cps), (8-13 cps), predominantly in O1, O2 predominantly in O1, O2 Pattern: Blades of grass Pattern: Blades of grass  low voltage, mixed frequency, θ(4 to7 cps), Vertex sharp waves may be present. NON-REM Stage 1 ( 5% of Total Sleep Time)NON-REM Stage 1 ( 5% of Total Sleep Time)slow rolling eye movementtonic activity lower than awakeSleep spindle: >0.5 Sleep spindle: >0.5 sec, sec, 11-16cps, 11-16cps, 3-8/min 3-8/min K complex: K complex: ＞＞0.5 sec, 1~3/min0.5 sec, 1~3/min negative-positive negative-positive Low level tonic activitySlow eye movementNon-REM Stage 2 ( 50% of total Non-REM Stage 2 ( 50% of total sleep )sleep )Stage 1 with vertex sharp wave Stage 2 with sleep spindle & k complex( 1 epoch= 30 seconds)Comparison between stages 1 & 2( 1 epoch= 30 seconds)vertex sharp wave, >75uv,<0.5sec, upwardsleep spindlek complex( 3 minute-rule )( 3 minute-rule )EMG: low level tonicEEG: 0.5 ~ 2cps, high voltage > 75 uVStage 3 : 20%~50% slow waveSleep spindles may be presentNREM Stage 3 ( slow wave sleep) ( 1 epoch= 30 seconds)EOG similar to EEGEMG: low level tonicEEG: slow wave < 2cps, high voltage > 75 uVStage 4: >50% slow waveNREM Stage 4 ( slow wave sleep ) ( 1 epoch= 30 seconds)Slow wave sleep 10~15 % of total sleep Slow wave sleep 10~15 % of total sleep timetimeREM stage ( rapid eye movement, 20~25 of total REM stage ( rapid eye movement, 20~25 of total sleep time)sleep time)EEG: Saw tooth,2-6 cps, preceding a burst of REMs EOG: Rapid eye movementEOG: Rapid eye movementEMG: Tonic suppressionEEG: Theta waves 3-7 cps, low voltage, mixed frequency,Alpha waves may be present REM stage without rapid eye movementREM stage with rapid eye movement( 1 epoch= 30 seconds)动作期动作期 (MT)(MT)* * 模糊记录模糊记录 1515秒钟秒钟, , 放大器阻断讯号放大器阻断讯号, , 前后页必须入前后页必须入睡睡* * 过度的肌电波活动过度的肌电波活动: : 如改变体位或身体移动如改变体位或身体移动( 1 epoch= 30 seconds)。