自动三水平气道正压通气对肥胖低通气合并中、重度阻塞性睡眠呼吸暂停综合征患者的疗效

Efficacy of auto-trilevel positive airway ventilation on patients with both obesity hypoventilation and moderate to severe obstructive sleep apnea syndromes

目的通过与双水平气道正压通气（BiPAP）模式比较，观察自动三水平正压通气（Auto—Trilevel PAP）模式对肥胖低通气综合征（OHS）合并中、重度阻塞性睡眠呼吸暂停综合征（OSAS）患者的疗效。方法选择17例OHS合并中、重度OSAS患者，采用SOMNOventauto-S型无创呼吸机（Weinmann Inc，Germany）治疗，比较3种不同通气模式的疗效，3种模式中吸气相气道正压（IPAP）值存每例患者中一致，均根据PaCO2滴定出，但呼气相气道正压（EPAP）不同，模式1和模式2均为固定的BiPAP模式，模式1的EPAP为能消除睡眠期鼾声的最低正压，而模式2的EPAP较模式1高3cm H2O2。模式3为Auto-Trilevel PAP模式，EPAP的初期压同模式1，但EPAP末期压（EEPAP）为自动调节升压，每种模式均给予一夜间8h的治疗，不同模式治疗问间隔两夜未给予治疗，分别比较与治疗前和不同模式治疗之间患者的睡眠期呼吸暂停低通气指数（AHI）、最低脉氧饱和度（MiniSpO2）、微觉醒指数、睡眠效率、治疗毕清晨PaCO2和治疗次日的ESS评分。结果与治疗前相比，三种模式治疗中AHI值和微觉醒指数均显著降低（P〈0．01），而MiniSpO2和睡眠效率均明显增高（P〈0．01）。此外治疗毕的清晨PaCO2和治疗结束当天的白日ESS评分也均明显降低（P〈0．01）。但三种模式问比较显示模式3治疗时的睡眠效率最高，治疗毕的白日ESS评分最低。与模式1相比，模式3治疗时的AHI更低、MiniSpO2更高（P值均＜0．01），但治疗毕的清晨PaCO2差异无统计学意义（P〉0．05）。与模式2相比，模式3治疗时的AHI和MiniSpO2差异无统计学意义（P值均〉0．05），但治疗毕的PaCO2显著降低（P〈0．01）。结论治疗OHS合并中、重度OSAS时Auto-Trilevel PAP模式在同时有效消除残余呼吸暂停低通气事件、纠正高碳酸血症、提高睡眠质量和降低白日嗜睡方面上较BiPAP模式更为优越。

Objective To observe the efficacy of auto-trilevel positive airway pressure （Auto- trilevel PAP） ventilation on patients with both obesity hypoventilation syndrome （OHS） and moderate to severe obstructive sleep apnea syndromes （OSAS） by comparison of fixed bilevel positive airway pressure （BiPAP） ventilation. Methods 17 patients with both OHS and moderate to severe OSAS were recruited. Three different positive airway pressure （PAP） modes issued by the ventilators （SOMNOvent auto-S, Weinmann Inc,Germany） were used for 8 hours per night with each mode at each night and two nights＂ interval without any treatment among different modes. In mode one, the EPAP issued by BiPAP was titrated as the Minimal positive pressure for disappearance of snoring. The same inspiratory positive airway pressure （IPAP） titrated by PaCO2 in mode 1 was used in mode 2 and 3 as well. However, the EPAP issued by BiPAP in mode 2 was 3 cm H2O higher than that in mode 1. In mode 3 with autotrilevel PAP, the beginning of EPAP was set the same as that in mode 1 while the end of EPAP （EEPAP） was automatically adjusted to elevate based on upper airway patency condition. Comparisons were made for parameters before and after treatment as well as among different ventilation modes. The following parameters were compared such as nocturnal apnea hypopnea index （AHI）, Minimal SpO2 （MiniSpO2）, arousal index, sleep efficiency, morning PaCO2 and daytime ESS. Results Compared with the parameters before ventilation therapies, there was a significant decrease in nocturnal AHI, arousal index, morning PaCO, and daytime ESS, but a significant increase in nocturnal MiniSpO2 and sleep efficiency caused by all three modes of ventilation （all P〈0.01）. Comparison among three modes demonstrated that with the same IPAP, the mode 3 could result in the lowest arousal index, daytime ESS and the highest sleep efficiency. Comparison between mode 1 and 2 revealed there was a statistically lower AHI but higher MiniSpO2 and morning PaCO2 in mode 2 （all P 〈0.01）. Compared with mode 1, in mode 3 there was a lower AHI, higher MiniSpO2 （all P〈0.01）, but no significant difference in morning PaCO2 at the end of therapy. Compared with mode 2, in mode 3 there was a significant lower morning PaCO2 （ P 〈0.01）, but no significant difference in AHI and MiniSpO2. Conclusions Auto trilevel PAP ventilation is superior over fixed BiPAP ventilaiton for treatment of OHS with coexisting moderate to severe OSAS, since this novel PAP mode can achieve a higher efficacy in simultaneous removal of residual apnea hypopnea events and correction of hypercapnia as well as in achieving a higher sleep quality and lower daytime sleepiness.