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Ann Intern Med:美国阻塞性睡眠呼吸暂停指南解读

2014-06-11 佚名 不详

2013年9月,美国医师协会(ACP)发布的最新版阻塞性睡眠呼吸暂停(OSA)临床指南建议:医生应鼓励肥胖的OSA患者减肥,并将持续气道正压通气(CPAP)作为所有OSA患者的初始治疗;如果使用CAPA出现不良反应,则建议改用下颌前移装置(MAD)。 指南编写的领导者,ACP临床政策主任Qaseem博士等表示:“因为肥胖与阻塞性睡眠呼吸暂停综合症的风险增加有关;减肥不但可以减少OSA患者的症状,

2013年9月,美国医师协会(ACP)发布的最新版阻塞性睡眠呼吸暂停(OSA)临床指南建议:医生应鼓励肥胖的OSA患者减肥,并将持续气道正压通气(CPAP)作为所有OSA患者的初始治疗;如果使用CAPA出现不良反应,则建议改用下颌前移装置(MAD)。

指南编写的领导者,ACP临床政策主任Qaseem博士等表示:“因为肥胖与阻塞性睡眠呼吸暂停综合症的风险增加有关;减肥不但可以减少OSA患者的症状,还有许多其他的健康益处所以,临床医生应该鼓励肥胖的患者减肥”。

新版指南不推荐OSA患者采用外科手术和药物治疗。

据统计,超过一千八百万美国成年人患有睡眠呼吸暂停,并成为他们白天过度嗜睡的主要原因。OSA患者在睡眠期间存在气道塌陷或阻塞,是睡眠呼吸暂停最常见的类型。有证据表明,OSA的发病率正在逐渐上升,这或许肥胖的发病率增加有关。

新版OSA指南的作者认为,医生应该对不明原因的白天嗜睡患者,进行有针对性的OSA评估和治疗。

CPAP装置可向气道内提供压缩空气,并使气道保持开放状态。但由于诸如使用时的不舒服、皮肤刺激、噪音和幽闭恐惧症等问题,患者选用此类装置的依从性较低。为此,人们又研发了口腔矫治器或称MAD作为其替代产品。除了这些装置和减肥治疗外,其他治疗措施包括外科干预去除造成阻塞的组织和药物治疗等。

研究终点排序

ACP的临床指南委员会搜索了与OSA治疗相关的研究文献,并评估了其作为研究结果的证据。为了能做出合理的推荐建议,他们根据研究终点的临床重要性,对其进行了从死亡开始,并包括了心血管疾病终点,如充血性心力衰竭,高血压,中风,及心肌梗死等的排序。

其他关注的终点事件包括睡眠研究评估指标,如睡眠呼吸暂停低通气指数(AHI,一个衡量睡眠期间每小时呼吸暂停或呼吸浅慢发作次数的指标);心血管状态评估指标,如血压;糖尿病评估指标,如血红蛋白A1水平;以及生活质量评估指标等。

指南编写组将证据质量分为高、中、低3类,并根据证据质量将每个建议的推荐力度分为强、弱2档。其中,强档建议实施后的获益明显大于或小于其风险和负担;而弱档建议实施后的获益与其风险和负担基本相当。

总体而言,有证据表明一些强力减肥方案可以有效减少有或无糖尿病肥胖患者的OSA征象和症状。因此,指南建议鼓励患者减肥,其推荐力度为强,但证据低质量为低。

指南作者表示,CPAP是目前被研究最多的OSA治疗方法。研究表明,这种治疗能提高患者的Epworth嗜睡量表评分(ESS)及自填式问卷调查评分;减少其AHI和微觉醒指数评分;并能增加患者的血氧饱和度。然而,CPAP并未显示出可以提高患者生活质量的效果。而且其对患者心血管疾病、高血压以及2型糖尿病的影响,目前仍缺少足够的证据。

数据显示,一些改良后的CPAP技术,如固定和自动式CPAP、C-Flex(飞利浦医疗)等,具有与传统CPAP相似的依从性和疗效,但其它的CPAP改良技术则因为数据不足,而无法确定其相对疗效。

AHI和ESS评分较高的患者通常与更好的CPAP依从性相关。

患者的偏好

指南建议将CPAP作为OSA的初始治疗,其推荐力度为强,证据质量为中等。指南编写者指出,临床医生在启动CPAP治疗前,应综合考虑患者对治疗措施的偏好和依从性,不依从的具体原因,以及成本因素等,以便作出适当的决定。

指南认为,尽管提示患者将明显受益于替代的MAD装置的证据并不充分,但在患者使用CPAP出现不良反应、不能耐受或对其不依从的情况下,可以考虑选用这些替代装置。指南对于MAD装置使用的推荐力度为弱,证据质量级别为低。

指南编写者表示,目前的证据不支持对患者进行药物治疗,因此不应该为OSA患者处方药物。此外,OSA的外科治疗与患者危险而严重的不良后果相关,再加上其目前的证据有限,不足以显示获益,因此,不应将手术作为OSA的初始治疗。

在应约对ACP的OSA新指南进行评论时,美国睡眠医学学会(AASM)发表声明指出,OSA是严重影响患者健康和福祉的一种“慢性疾病,而有效的治疗可以改变患者的生活。”

AASM声明表示:“AASM支持ACP指南推荐为超重或肥胖的OSA患者减肥。但考虑到饮食减肥计划的成功率低,且单用减肥疗法对OSA的治愈率低,所以,应强调减肥与其他OSA治疗措施(如CPAP)结合应用的重要性”。

AASM表示,ACP的OSA新指南将“CPAP作为一线治疗,口腔矫治器作为一种替代治疗”的建议,与AASM先前发表的临床指南是一致的。他们表示:“AASM鼓励OSA患者聘请经过睡眠医学委员会认证的医师为其评估治疗方案。并由经过AASM认证的睡眠障碍中心睡眠治疗小组对患者进行疾病教育、治疗指导和长期随访”。

原始出处

Shekelle P, Holty JE, Owens DK, Qaseem A.Management of obstructive sleep apnea in adults.Ann Intern Med. 2014 Mar 4

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Chest:阻塞性睡眠呼吸暂停影响急症患者预后

在美国,每年有超过100万人因肺炎而住院,住院死亡率达到4%-9%。肺炎的并发症包括脓胸、败血症、急性呼吸窘迫综合征和呼吸衰竭等。阻塞性睡眠呼吸暂停(OSA)以睡眠中上呼吸道反复塌陷、阻塞为特征,可使患者频繁发生低通气、呼吸暂停和血氧饱和度下降。女性中度OSA的患病率约为2%-7%,而男性则为7%-14%。 已知OSA与患者术后呼吸系统并发症风险增加相关,但两者间的联系对急症患者预后的影响尚不明确

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