三水平和双水平正压通气对合并中重度阻塞性睡眠呼吸暂停的肥胖低通气综合征患者疗效的比较

The efficacy of trilevel and bilevel positive airway pressure treatment for patients with both obesity hypoventilation and moderate to severe obstructive sleep apnea syndromes

目的:比较肥胖低通气综合征(obesity hypoventilation syndrome, OHS)合并中或重度阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea syndrome, OSAS)患者使用自动三水平正压通气(positive airway pressure, PAP)和传统的双水平PAP (bi-level PAP, BiPAP)治疗时的临床疗效有何异同。方法:2015年1月至2017年9月期间23例OHS合并中或重度OSAHS接受整晚8 h 3种不同模式PAP治疗的患者入组。第一晚采用单变量模式,以后的两晚不采用任何PAP作为每个模式之间的洗脱期。通过呼气末CO2(end tidal CO2, ETCO2)水平滴定确定吸气相PAP(inspiratory PAP, IPAP),且在模式1、2及3中保持一致。模式1为BiPAP通气模式,其呼气相PAP (expiratory PAP,EPAP)为使鼾声消退的最低EPAP水平。模式2仍为BiPAP通气模式,其EPAP固定设置比模式1高3 cmH2O(1 cmH2O=0.098 kPa)。模式3为自动三水平PAP模式,其IPAP和初期的EPAP设置与模式1相同,但是呼气末期EPAP(end EPAP, EEPAP)根据上气道通畅情况自动调节升压。并比较呼吸暂停低通气指数(apnea hypopnea index,AHI)、最低脉搏氧饱和度(minimal pulse oxyhemoglobin saturation, miniSpO2)、睡眠时的觉醒指数和睡眠效率、3种PAP治疗前和治疗后进行日间Epword嗜睡评分(Epword sleepiness score, ESS)。结果:与通气治疗前参数相比,所有3种可变的通气模式均可使夜间AHI明显降低,且miniSpO2和睡眠效率明显增高(均P<0.01)。3种可变模式比较显示,模式3治疗的觉醒指数和日间ESS评分最低,而睡眠效率最高。与模式1相比较,模式2显示夜间AHI显著降低,夜间miniSpO2和晨PaCO2升高(均P<0.05),而模式3除显示AHI下降和miniSpO2升高外(均P<0.05),PAP治疗结束后PaCO2较模式1差异无统计学意义(P>0.05)。与模式2比较,模式3的PaCO2显著降低(P<0.05),但AHI与miniSpO2无明显变化(P>0.05)。结论:与Bi PAP通气模式相比,自动三水平PAP通气模式能更有效地纠正高碳酸血症,降低夜间AHI,提高睡眠质量,降低日间ESS评分。因此,对于同时伴有中度或重度OSAS的OHS患者无创通气治疗中,自动三水平PAP通气模式比传统的BiPAP通气模式更为有效。

Objective To compare the efficacy of auto-trilevel positive airway pressure(auto-trilevel PAP)ventilator and conventional fixed bilevel positive airway pressure(BiPAP)ventilator in treatment of obesity hypoventilation syndrome(OHS)patients with moderate or severe obstructive sleep apnea syndrome(OSAS).Methods Twenty-three OHS patients with moderate or severe OSAS enrolled between January 2015 and September 2017 underwent ventilation by three differ-ent modes of positive airway pressure(PAP)for 8 h per night.A single variable mode was applied at the first night fol-lowed by two nights of washout period with no PAP therapy.The inspiratory positive airway pressure(IPAP)decided by PaCO2 was consistently used for mode 1,2 and 3.The expiratory positive airway pressure(EPAP)issued by BiPAP was de-cided by the minimal PAP levels for cessation of snoring in mode 1,and was fixed at 3 cmH2 O(1 cmH2 O=0.098 kPa)higher in mode 2.Adopting auto-trilevel PAP,the EPAP of mode 3 was set to initially match that of mode 1,but the end of EPAP(EEPAP)was automatically elevated according to upper airway patency condition.The parameters including apnea hypopnea index(AHI),minimal SpO2(miniSpO2),arousal index and sleep efficiency during sleep,PaCO2 in the morning and Epword sleepiness score(ESS)at daytime were acquired prior to and during PAP treatment as well as between three selected PAP modes.Results All three modes of ventilation led to a higher nocturnal miniSpO2 and sleep efficiency(all P<0.01),with mode 3 yielded the lowest arousal index,daytime ESS and the highest sleep efficiency.Compared to mode 1,mode 2 treatment significantly reduced AHI and increased miniSpO2 and morning PaCO2(all P<0.05).The mode 3 was associated with a decreased AHI,an increased miniSpO2(all P<0.05),however,its impact on the level of PaCO2 following the end of PAP treatment(P>0.05)was not significantly different from that of mode 1.Comparison between mode 2 and mode3 revealed that patient receiving mode 3 treatment had a significantly lower PaCO2(P<0.05),but displayed no remarkable changes of AHI and miniSpO2(all P>0.05).Conclusions Compared to fixed Bi PAP ventilation,auto-trilevel PAP ventilation correct hypercapnia more effectively,achieving lower index of nocturnal apnea and hypopnea,improving sleep quality and lowering daytime sleepiness score.Auto-trilevel PAP ventilation is thus more efficacious than conventional Bi PAP ventilation in non-invasive ventilation therapy for OHS patients with concurrent moderate or severe OSAS.