持续气道正压通气对脑卒中合并阻塞性睡眠呼吸暂停低通气综合征患者的睡眠状况及神经心理特征的影响

Influence of continuous positive airway pressure on sleep status, neuropsychological characteristics in patients with stroke combined with obstructive sleep apnea syndrome

目的探讨持续气道正压通气（CPAP）对脑卒中合并阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者的睡眠状况及神经心理特征的影响。方法收集2014年5月至2016年1月在天津医科大学总医院神经内科门诊就诊及住院的伴有打鼾的脑卒中且符合OSAHS诊断标准的患者54例，采用完全随机化分组方法随机分为CPAP联合药物治疗组（25例）和单纯药物治疗组（29例）。采用多导睡眠图（PSG）监测患者睡眠结构、呼吸参数；使用Epworth嗜睡量表（ESS）和匹茨堡睡眠质量指数（PsQI）评估主观睡眠状况，应用蒙特利尔认知评估量表（MoCA）、数字记忆广度测定（DST）、Hopkins词语学习测验（HVIJT）评估神经认知功能的变化；采用9条目患者健康问卷（PHQ9）评估抑郁情绪状态。分别比较CPAP联合药物治疗3个月后CPAP联合药物治疗组自身及其与单纯药物治疗组两组间的睡眠状况、认知功能及情绪的变化。结果CPAP联合药物治疗组脱落5例，2组有效例数分别为CPAP联合药物治疗组20例和单纯药物治疗组29例。CPAP联合药物连续治疗3个月后自身比较：治疗后睡眠呼吸暂停低通气指数（AHI；29．32±16．57）较治疗前（41．66±21．84）显著下降（t=3．926，P=0．001）、最低血氧饱和度（LSa02；82．11％±5．66％）较治疗前（76．11％±8．90％）明显升高（t=-5．054，P=0．000），治疗后的睡眠结构参数较治疗前差异无统计学意义；治疗后的ESS、PSQI、PHQ9评分[分；4．53±3．86、3．00±2．45、0．00（0．00，2．00）]较治疗前[10．58±7．82、7．53±2．87、3．00（1．00，9．00）l降低（t=-3．883，P=0．001；t=-6．522，P：0．000；Z=-3．549，P=0．000），治疗后MoCA、HVLT（总分、延迟）、DSTl、DST2评分（分；23．37±4．75、22．32±6．90、7．47±3．82、7．84±2．59、5．32±2．81）较治疗前（22．16±4．94、19．16±7．66、6．68±3．74、7．32±2．67、5．00±3．00）显著增高（t=-2．773，P=0．013；t=-6．857，P=0．000；t=-2．704，P=0．015；t=-2．249，P=0．037；t=-2．882，P：0．010）。CPAP联合药物连续治疗3个月CPAP联合药物治疗组与单纯药物治疗组比较：CPAP联合药物治疗组ESS、PSQI、PHQ9评分（分）较单纯药物治疗组[8．76±6．92、7．59±5．49、5．00（2．50，9．50）]显著降低（t=-2．711，P=0．009；t=-3．941，P=0．000；Z=-4．555，P=0．000），DSTl评分（分）较单纯药物治疗组（6．45±1．43）升高（t=2．144，P=0．042）。结论CPAP联合药物连续治疗3个月显著改善脑卒中合并OSAHS患者的日间嗜睡及抑郁情绪，认知功能以注意力方面改善明显，低通气、缺氧程度得到缓解，而睡眠结构紊乱无明显改善。

Objective To investigate the effects of continuous positive airway pressure （CPAP） on sleep status, neuropsychological characteristics in patients with stroke combined with obstructive sleep apnea syndrome （OSAHS）. Methods Fifty-four patients hospitalized with stroke in Tianjin Medical University General Hospital from May 2014 to January 2016, who were with snoring and met the OSAHS diagnostic criteria, were randomly divided into CPAP combined with drug treatment group （25 cases ） and drug treatment alone group （29 cases ）. The sleep structure and respiratory parameters were evaluated by polysomnography, and the changes of the patients＇ sleep status was assessed by Epworth Sleepiness Scale （ESS） and Pittsburgh Sleep Quality Index （PSQI）. The changes of neurocognitive function were assessed by Montreal Cognitive Assessment （ MoCA）, Digital Span Test （DST） and Hopkins Verbal Learning Test- revised （HVLT）, and Patient Health Questionnaire-9 （PHQ9） was used to evaluate the depression mood changes. The changes of sleep status, cognitive function and mood in the CPAP combined with drug treatment group were compared before and three months after CPAP combined with drug treatment, and with the drug treatment alone group. Results Because five cases were dropped off, there were 20 patients in the CPAP combined with drug treatment group and 29 patients in the drug treatment alone group who completed the study. After three months of CPAP combined with drug treatment, the respiratory parameters apnea hypopnea index （AHI） in the CPAP combined with drug treatment group （29.32 ± 16. 57） was significantly lower than that before treatment （41.66 ± 21.84 ; t = 3. 926, P = 0. 001 ）, and the minimum blood oxygen saturation （LSaO2; 82. 11% ± 5.66% ） was significantly higher than that before treatment （76. 11%± 8.90%; t = -5. 054, P = 0. 000）. However, the sleep structure parameters did not show statistically significant changes compared with those before treatment. The ESS, PSQI and PHQ9 scores in the CPAP combined with drug treatment group （4. 53 ± 3.86, 3.00± 2.45, 0. 00 （ 0.00,2. 00 ） ） were significantly decreased compared with those before treatment （ 10. 58 ± 7.82, 7.53± 2. 87, 3.00 （1.00,9.00） ; t = -3. 883 ,P = 0. 001 ; t = -6. 522, P = 0. 000 ; Z = - 3. 549, P = 0.000 ）, whereas MoCA, HVLT （ total scores, recall and recognition ） and DST 1,2 scores in the CPAP combined with drug treatment group （23. 37±4. 75, 22. 32±6. 90, 7. 47 ±3.82, 7. 84±2. 59, 5. 32 ±2. 81 ） were increased compared with those before treatment （22.16 ±4.94, 19. 16±7.66, 6. 68±3.74, 7.32 ±2.67, 5.00 ±3.00; t= -2.773,P=0.013;t= - 6. 857, P=0.000;t= - 2.704,P=0.015;t= - 2.249, P=0.037;t= -2. 882 ,P =0. 010）. The ESS, PSQI and PHQ9 scores were significantly reduced in the CPAP combined with drug treatment group compared with the drug treatment alone group （ 8.76±6. 92, 7.59 ± 5.49, 5.00 （2.50,9.50）; t= -2.711,P=0.009;t= -3.941,P=0.000;Z= -4.555,P=0.000）, whereas the DST1 score was significantly increased compared with the drug treatment alone group （ 6.45 ± 1.43 ; t = 2. 144, P = O. 042）. Conclusions Three-month CPAP combined with drugs mainly improved the daytime sleepiness and depression of patients with stroke combined with OSAHS. Cognition especially in attention was significantly improved, and the degree of low ventilation and hypoxia was alleviated, whereas there was no significant change in sleep structure disorder.