OSAS患儿清醒和睡眠状态下上气道阻塞差异的比较及干预

Comparison and intervention of differences in upper airway obstruction in children with OSAS between awake and asleep

目的:拟通过药物诱导的睡眠内镜(DISE)研究儿童上气道在清醒和药物模拟的睡眠状态下阻塞平面和阻塞类型及程度之间的差异,评价DISE介导的上气道手术在OSAS患儿中的收益。方法:回顾性分析在上海儿童医学中心就诊的腺样体肥大(内镜下腺样体阻塞后鼻孔的面积>2/3)、扁桃体≤2度(Friedman分级法)的OSAS患儿资料。所有患儿均于术前和术后通过脉搏血氧仪进行了PSG。愿意接受DISE检查的患儿纳入DISE组,在进行腺样体切除术之前接受睡眠诱导,进行DISE检查;术前不愿进行DISE检查的患儿纳入对照组。如果DISE发现扁桃体对口咽层面造成阻塞或是上气道存在其他层面阻塞,则会在接受腺样体切除术的同时进行扁桃体切除术或者其他干预。分析DISE组在清醒和药物诱导下图像视频资料的中上气道阻塞程度及类型的差异。结果:本研究共有126例患儿纳入DISE组,200例患儿纳入对照组。DISE组中有56例(44.4%)扁桃体为2度,70例(55.6%)患儿的扁桃体为1度。DISE组患儿在清醒和睡眠不同的状态下,上气道在腭咽、舌根和会厌这3个层面的阻塞类型发生了改变,差异均有统计学意义(P<0.05),而在腺样体和口咽侧壁阻塞方向具有一致性。口咽侧壁和舌根的内镜评分比较差异均有统计学意义(P<0.05)。DISE检查发现57例(45.2%)患儿的口咽层面出现2级阻塞,其中44例(34.9%)扁桃体为2度,13例(10.3%)扁桃体为1度。术后1年,2组呼吸紊乱指数(RDI)和最低血氧饱和度均得到显著改善(P<0.05),术后1年DISE组较对照组RDI改善程度更佳(P=0.04)。结论:DISE是一种评估OSAS患儿上气道阻塞层面及严重程度的有效方法,有利于上气道个性化手术方案的制定。

Objective:Drug induced sleep endoscopy(DISE)is a useful tool to locate the upper airway obstructions in patients with obstructive sleep apnea syndrome(OSAS).The goal of our research was to compare the sites,degree and patterns of upper airway obstruction detected by DISE versus endoscopy in awake children.The benefit of DISE-mediated upper airway surgery in pediatric OSAS was evaluated.Method:This is a retrospective case series of children with OSAS who had adenoid hypertrophy(the area where adenoids block the postnaris≥2/3)and tonsils≤2 degrees(Friedman classification method).All children underwent sleep monitoring by pulse oximeter before and after operation.DISE was performed before adenoidectomy in DISE group.If obstruction of oropharynx caused by tonsils was found,tonsillectomy was performed at the same time with adenoidectomy.The children who did not undergo DISE before operation were enrolled in the control group.Differences in the degrees and patterns of upper airway obstruction in the DISE group under wakefulness and drug induction were analyzed.Result:The study included 126 children in DISE group,and 200 children in control group.In the DISE group,56 cases(44.4%)had grade 2 tonsils,and 70 cases(55.6%)had grade 1 tonsils.The patterns of obstruction at velum,tongue base and epiglottis were significantly different in DISE compared with awake endoscopy(P<0.05);the patterns of obstruction at adenoid and oropharynx were the same in both techniques.There were significant differences in endoscopy scores between the lateral wall of oropharynx and the tongue base(P<0.05).DISE revealed 57(45.2%)cases had grade 2 obstruction in the oropharyngeal level.Among them,44 cases(34.9%)had tonsils at 2 degrees and 13 cases(10.3%)had tonsils at 1 degrees..There was an improvement in respiratory disturbance index(RDI)and oxygen saturation nadir in the DISE and control groups 1 year after surgery(P<0.05),and the RDI improvement was better in the DISE group compared with controls(P=0.04).Conclusion:DISE is an effective method to evaluate the sites and severity of upper airway obstruction in children with OSAS,which was conductive to make the upper airway personalized surgical plan for patients.