阻塞性睡眠呼吸暂停低通气综合征患者呼吸调控稳定性对持续正压通气治疗效果的影响

Predictive value of ventilatory steability in determining positive airway pressure efficacy in patients with obstructive sleep apnea

目的证实不稳定的呼吸调控对持续气道正压通气(PAP)治疗阻塞性睡眠呼吸暂停低通气综合征(OSAHS)短期效果的影响。方法 42例成人OSAHS患者,男性39例,女性3例,行多道睡眠图(PSG)监测、肺功能检查及环路增益评估。环路增益评估较高代表呼吸调控不稳定。行自动单水平正压通气机进行短期治疗,分析疗效与患者睡眠指标、环路增益等因素的关系。佩戴PAP治疗时呼吸暂停低通气指数(AHI)仍≥10次/h者视为疗效不佳,分析疗效不佳患者的临床特点。结果研究对象平均年龄(40±8)岁,AHI 68.2[42.9,81.0]次/h,环路增益值中位数为0.63[0.47,0.81]。疗效较好者具有较低的环路增益,即呼吸调控较稳定(P=0.035),较高的肺总量实际值/预计值(P=0.019)和较低的混合性呼吸暂停指数(P=0.004)。26例环路增益值>0.6、即呼吸调控相对不稳定的患者中,8例(30.8%)戴机后平均AHI<5次/h,视为疗效好;9例(34.6%)5次/h≤AHI<10次/h,视为疗效尚可;9例(34.6%)AHI≥10次/h,视为疗效不佳。16例环路增益值<0.6、即呼吸调控较为稳定的患者中,无戴机疗效不佳者。两组比较差异显著(P=0.007)。结论不稳定的呼吸调控可能影响PAP短期治疗疗效。对环路增益和混合性呼吸暂停指数较高的患者,采用单水平自动呼吸机治疗有相对更高的失败率。

OBJECTIVE We hypothesized that unstable ventilatory control（high loop gain,LG） could predict the short-term efficacy of positive airway pressure therapy in patients with obstructive sleep apnea（OSA）.METHODS 42 adult patients with OSA,M/F=39/3, were studied. The stability of the ventilatory control system（LG）was quantified by fitting a simplified mathematical model to the spontaneous ventilatory pattern obtained via polysomnography. LG, pulmonary function test results, and other PSG parameters were analyzed in patients who had post-treatment AHI≥10 events/hr（non-responders） using auto-positive airway pressure therapy. RESULTS The subjects aged（40±8） years,apnea-hypopnea index（AHI）were 68.2[42.9, 81.0]events/hr）. Nine patients（34.6%）were non-responders. Twenty patients（47.6%） had residual AHI5 events/hr. Loop gain and pre-treatment mixed apnea index were higher in the non-responders versus responders（0.74 [0.62, 0.82] vs 0.49[0.37, 0.77],P=0.035） and（11.0[4.3, 22.9] vs 2.0[0.2, 5.3], P=0.004）.In the 26 patients with LG0.6, nine（34.9%） had posttreatment 5 events/hr≤AHI10 events/hr. And all of the non-responders had LG（n=9, 34.9%）. The difference was significant between the LG0.6 and LG0.6 group（P = 0.007）. CONCLUSION Loop gain and mixed apnea index was higher in patients with residual AHI10 events/hr after short-term auto-PAP therapy.Ventilatory control stability evaluation might have predictive value for PAP treatment efficacy in OSA patients.