阻塞性睡眠呼吸暂停低通气综合征患者围术期上气道评估

Evaluation of upper airway during perioperative period in patients with obstructive sleep apnea hypopnea syndrome

目的本研究拟在肌松后观察阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)患者上气道各平面的特点,为该类患者围术期的气道管理提供依据。方法选择经多导睡眠监测符合OSAHS诊断标准并拟择期行悬雍垂腭咽成形术(uvulopalatopharyngoplasty,UPPP)的男性患者30例。慢诱导经鼻气管内插管后,给予维库溴铵0.08 mg/kg,完全肌松后,取平卧位,使用连接图像工作站的纤维鼻咽喉镜观察咽腔并记录影像。给予软腭后气道内正压,分析使软腭后咽腔刚刚开放所需的腔内压。后期进行图形和数据分析,并与睡眠监测指标进行相关分析。结果所有患者均顺利接受手术治疗,围术期无意外和合并症发生。患者的体质量指数(body mass index,BMI)为(28.39±3.99)kg/m2;呼吸暂停低通气指数(apnea hypopnea index,AHI)为(52.3±23.8)次/h;仰卧位AHI为(68.9±23.6)次/h;夜间最低血氧饱和度为(72.5±9.3)%。完全肌松后,30例OSAHS患者,软腭悬雍垂平面完全塌陷(100%),硬腭平面完全塌陷1例(3.3%),舌咽平面全部塌陷的患者23例(76.7%)。软腭后区平均临界开放压力的中位数为8.3(5.9,11.5)cmH2O(1 cm H2O=0.098 kPa),且临界开放压力与AHI呈正相关(r=0.377,P=0.040)。结论 OSAHS患者气道被动塌陷性异常增加,围术期存在严重的呼吸道梗阻风险,所有患者软腭悬雍垂平面塌陷;舌咽平面塌陷的占76.7%。若气道完全塌陷无法正压通气且使用口咽通气道不能改善,则需考虑使用鼻咽通气道将塌陷部位扩张。由于阻塞的平面和程度不同,术前应对气道进行个体化评估。OSAHS患者的临界开放压和AHI,尤其是AHIs具有相关性。因此,术前根据多导睡眠监测(polysomnography,PSG)结果,估算临界开放压力,以指导临床实践,提高围术期安全。

Objective Obstructive sleep apnea hypopnea syndrome （OSAHS） is a severe respiratory sleep disorder, with repeated episodes of nocturnal apnea and hypoxemia as the main clinical features. This study aimed to observe the characteristics of upper airway collapse under general anesthesia with muscle relaxation to provide evidences for better perioperative airway management. Methods Thirty male cases, who met the diagnostic criteria by polysomnography （ PSG ） for OSAHS, and received elective uvulopalatopharyngoplasty. Vecuronium （0. 08 mg/kg） was given to achieve complete muscle relaxation after the nasal endotracheal intubation was achieved with slow induction. The image workstation with fiberscope was used to observe the pharynx cavity and record images. The cavity pressure, which represents the passive collapse of the airway and can just open the soft palate pharyngeal cavity, was analyzed. The correlation of the graphics and data with sleep monitoring indicators were analyzed. Results All patients were successfully operated on with no accidents and perioperative complications. The body mass index （BMI） was （28.39 ± 3.99） kg/m^2. The apnea hypopnea index （AHI） was （52. 3 ± 23.8） times/h. The supine AHI （AHIs） was （68.9 ± 23.6） times/h. The minimum nocturual pulse oxygen saturation was （ 72. 5 ± 9.3 ） %. With full muscle relaxation, in 1 case （ 3.3% ） the upper airway was completely collapsed at the flat of hard palate. The flat of soft palate and uvula completely collapsed in all patients （ 100% ）. The tongue pharynx plane collapsed in 23 patients （76. 7% ）. The median critical opening pressure of post soft palate was 8.3 （5.9, 11.5） cm H2O（ 1 cm H2O=0. 098 kPa）. It was positively correlated with AHI （ r = 0. 377, P = 0. 040）. Conclusion The abnormalities of the airway passive collapse in OSAHS patients increase. The perioperative risk of serious respiratory tract obstruction is high. Retropalatal and retroglossal airway are the most collapsible segments. If the airway completely collapses and the positive ventilation is not improved with oropharyngeal airway, the use of nasopharyngeal airways should be considered. The individualized airway assessment can improve the perioperative security for OSAHS patients. The critical opening pressure was positively correlated with AHI, especially with AHIs. Therefore the critical opening pressure can be estimated to guide clinical practice.