减重人群中阻塞性睡眠呼吸暂停的围手术期评估

Perioperative Evaluation of Obstructive Sleep Apnea in Bariatric Surgery Population

目的总结减重手术人群中阻塞性睡眠呼吸暂停(OSA)患者的流行病学和临床特征。方法回顾性分析2009年1月至2015年12月因肥胖症至北京协和医院行腹腔镜下减重手术患者的临床资料,收集患者的年龄、性别、打鼾、疲乏、呼吸暂停、嗜睡、合并症、呼吸暂停低通气指数、血气分析、肺通气功能、术前气道正压治疗和术后并发症等资料,以呼吸暂停低通气指数(AHI)≥5次/h和AHI≥15次/h为阈值分组比较不同严重程度的OSA的临床情况,行相关分析明确AHI的临床相关因素。结果有完整睡眠呼吸监测结果的42例减重手术患者中,30例(71. 4%)合并OSA,14例(33. 3%)为中重度OSA,11例(26. 2%)为重度OSA。25例(83. 3%,25/30)在因减重手术就诊前未诊断OSA。AHI≥5次/h组患者的平均年龄(t=2. 869,P=0. 007)、目击呼吸暂停的发生比例(P=0. 035)、AHI (z=-4. 592,P=0. 000)和夜间脉搏血氧饱和度(SpO_2)低于90%的比例(z=-2. 746,P=0. 006)明显高于AHI <5次/h组,平均SpO_2(t=-2. 071,P=0. 046)和最低SpO_2(t=-3. 914,P=0. 000)明显低于AHI <5次/h组。AHI≥15次/h组的BMI (t=2. 281,P=0. 043)、男性(P=0. 005)、高血压(P=0. 011)、目击的呼吸暂停(P=0. 001)、吸烟史的比例(P=0. 017)、动脉二氧化碳分压(PaCO_2)(t=3. 478,P=0. 002)、AHI (z=-4. 592,P=0. 000)、夜间SpO_2低于90%的比例(z=-4. 530,P=0. 000)均明显高于AHI <15次/h组;而第1秒用力呼气量(FEV1)占预计值的比例(t=-3. 377,P=0. 002)、用力肺活量(FVC)占预计值的比例(t=-2. 342,P=0. 026)、夜间平均SpO_2(t=-3. 392,P=0. 007)、最低SpO_2(t=-5. 535,P=0. 000)均较AHI <15次/h组显著下降。相关性分析结果显示,在PaCO_2正常的人群(n=36)中,AHI与年龄(r=0. 450,P=0. 006)、BMI (r=0. 384,P=0. 021)呈正相关,与FEV1占预计值的比例(r=-0. 457,P=0. 008)、FVC占预计值的比例呈负相关(r=-0. 432,P=0. 013)。进一步偏相关分析显示,在控制了年龄和BMI后,AHI与FEV1占预计值的比例(r=-0. 287,P=0. 125)和FVC占预计值的比例(r=-0. 241,P=0. 200)无相关性。结论在减重手术人群中,OSA的发病率和漏诊率高。应该在减重人群中常规筛查OSA,以减少术后并发症。

Objective To evaluate the prevalence and clinical characteristics of obstructive sleep apnea(OSA)in bariatric surgery population.Methods Consecutive patients undergoing preoperative evaluation for bariatric surgery and referred for sleep monitoring in Peking Union Medical College Hospital from January 2009 to December 2015 were retrospectively analyzed.Age,gender,symptoms of snoring,fatigue,apnea and somnolence,apnea hyponea index(AHI),arterial blood gas,pulmonary function,sleep respiratory monitoring,positive airway therapy of OSA,and postoperative complications were recorded.The clinical characteristics of OSA groups at different severity were compared using AHI≥5 events/hour and AHI≥15 events/hour as cut-off values.Correlation analysis was applied to identify the clinical factors associated with AHI.Results Of 42 patients with complete sleeping monitoring data before bariatric surgery,30(71.4%)were diagnosed as OSA,14(33.3%)were moderate or severe and 11(26.2%)were severe.Also,OSA was not detected before the bariatric surgery in 25 cases(83.3%).Compared with patients with AHI<5 events/hour,patients with AHI≥5 events/hour had significantly older age(t=2.869,P=0.007),higher proportion of observed apnea(P=0.035),higher AHI(z=-4.592,P=0.000),higher proportion of night pulse oxygen saturation(SpO 2)below 90%(z=-2.746,P=0.006),lower mean SpO 2(t=-2.071,P=0.046)and lower lowest SpO 2(t=-3.914,P=0.000).Compared with AHI<15 events/hour group,the AHI≥15 events/hour group had significantly higher BMI(t=2.281,P=0.043),male ratio(P=0.005),incidence of hypertension(P=0.011),proportion of observed apnea(P=0.001),percentage of smoking history(P=0.017),partial pressure of carbon dioxide(PaCO 2)(t=3.478,P=0.002),AHI(z=-4.592,P=0.000),and proportion of night SpO 2 below 90%(z=-4.530,P=0.000);in addition,the forced expiratory volume in one second(FEV1)%predicted(t=-3.377,P=0.002),forced vital capacity(FVC)%predicted(t=-2.342,P=0.026),night time mean SpO 2(t=-3.392,P=0.007),lowest SpO 2(t=-5.535,P=0.000)were significantly decreased.Correlation analysis showed that,in populations with normal PaCO 2(n=36),AHI was positively correlated with age(r=0.450,P=0.006)and BMI(r=0.384,P=0.021)and negatively correlated with FEV1%predicted(r=-0.457,P=0.008)and FVC%predicted(r=-0.432,P=0.013).Partial correlation analysis showed that,after age and BMI were adjusted,AHI was not correlated with FEV1%predicted(r=-0.287,P=0.125)and FVC%predicted(r=-0.241,P=0.200).Conclusions The incidence and underdiagnosis rate of OSA are high in bariatric surgery population.OSA should be routinely screened in bariatric population to reduce the postoperative complication.