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(1.中國(guó)醫(yī)科大學(xué) 七年制，遼寧 沈陽(yáng) 110001；2.大連醫(yī)科大學(xué) 七年制，遼寧 大連 116044；大連醫(yī)科大學(xué) 附屬第二醫(yī)院 呼吸科，遼寧 大連 116027)

綜述

圍手術(shù)期阻塞性睡眠呼吸暫停綜合征患者的識(shí)別及其管理

王彥喆1，陳瑩2，王鎮(zhèn)山3

(1.中國(guó)醫(yī)科大學(xué) 七年制，遼寧 沈陽(yáng) 110001；2.大連醫(yī)科大學(xué) 七年制，遼寧 大連 116044；大連醫(yī)科大學(xué) 附屬第二醫(yī)院 呼吸科，遼寧 大連 116027)

阻塞性睡眠呼吸暫停綜合征(obstructive sleep apnea syndrome, OSAS)是一種常見(jiàn)的與睡眠相關(guān)的呼吸功能紊亂，發(fā)病率約2%～25%，在擇期手術(shù)人群中OSAS的患病率更高。一方面，鎮(zhèn)靜劑和麻醉藥會(huì)增加上呼吸道的塌陷性，增加了這部分患者發(fā)生術(shù)后并發(fā)癥的風(fēng)險(xiǎn)；另一方面，大部分OSAS患者沒(méi)有被確診也增加了手術(shù)期間的危險(xiǎn)。因此，這部分OSAS患者的識(shí)別和診斷，對(duì)能否在手術(shù)期間給予及時(shí)合理的處理有重要作用。本文將如何在手術(shù)前識(shí)別OSAS患者及其圍手術(shù)期的管理進(jìn)行綜述。

阻塞性睡眠呼吸暫停綜合征；圍手術(shù)期；并發(fā)癥

阻塞性睡眠呼吸暫停綜合征(obstructive sleep apnea syndrome, OSAS)的特征是睡眠中間斷反復(fù)出現(xiàn)的上呼吸道部分或全部阻塞，引起睡眠結(jié)構(gòu)紊亂，導(dǎo)致睡眠片段化和白天困倦。許多研究證實(shí)OSAS與多種健康相關(guān)的不良后果有關(guān)，包括增加交通事故、高血壓、糖尿病、充血性心力衰竭、腦卒中的發(fā)生率以及全因病死率[1-9]。

近來(lái)很多研究提出OSAS患者圍手術(shù)期出現(xiàn)并發(fā)癥的風(fēng)險(xiǎn)高，包括低氧血癥、肺炎、氣管插管困難、心肌梗死、肺栓塞、肺不張、心律失常以及非預(yù)料入住ICU。大部分OSAS患者住院時(shí)未被確診，推測(cè)其潛在的睡眠呼吸暫停是增加圍手術(shù)期并發(fā)癥發(fā)生風(fēng)險(xiǎn)的原因。因此手術(shù)前OSAS的明確診斷以及圍手術(shù)期采取適當(dāng)?shù)奶幚硎欠浅Ｖ匾摹?/p>

1 流行病學(xué)

OSAS是一種常見(jiàn)的與睡眠相關(guān)的呼吸障礙疾病，由于肥胖和人口老齡化，發(fā)病率逐年增高。依據(jù)OSAS不同定義，發(fā)病率一般在2%～25%。Young等[10]在一項(xiàng)流行病學(xué)調(diào)查中，將睡眠呼吸暫停低通氣指數(shù)(apnea-hypopnea index, AHI)≥5 次/h作為OSAS的診斷標(biāo)準(zhǔn)，其發(fā)病率在女性為9%，男性為24%。然而診斷標(biāo)準(zhǔn)為AHI≥5次/h并且伴隨白天困倦癥狀時(shí)，其發(fā)病率在女性為2%，男性為4%。2005年美國(guó)國(guó)家睡眠基金會(huì)(national sleep foundation, NSF)根據(jù)柏林問(wèn)卷調(diào)查，提出1/4的美國(guó)人具有罹患OSAS的高風(fēng)險(xiǎn)[11]。接受外科手術(shù)的患者中OSAS的發(fā)病率更高，在手術(shù)減肥治療人群中，OSAS的發(fā)病率甚至超過(guò)70%[12-13]。標(biāo)準(zhǔn)化的作法是在進(jìn)行減肥手術(shù)前進(jìn)行規(guī)范的睡眠評(píng)估。在接受普外科手術(shù)的患者中OSAS的發(fā)病率也較高[14]。Chung等[15]在術(shù)前對(duì)患者進(jìn)行柏林問(wèn)卷調(diào)查，發(fā)現(xiàn)24%的患者具有罹患OSAS的高風(fēng)險(xiǎn)。運(yùn)用STOP-BANG問(wèn)卷調(diào)查發(fā)現(xiàn)擇期手術(shù)的患者中，41%的患者有發(fā)生睡眠呼吸暫停的風(fēng)險(xiǎn)[16]。在一項(xiàng)橫斷面研究中，39例接受癲癇手術(shù)患者術(shù)前進(jìn)行夜間多導(dǎo)睡眠圖檢查(nocturnal polysomnography，NPSG)，結(jié)果發(fā)現(xiàn)1/3的患者存在睡眠呼吸暫停[17]。另一項(xiàng)研究發(fā)現(xiàn)，在接受顱內(nèi)腫瘤手術(shù)的患者中，睡眠呼吸暫停的發(fā)病率達(dá)到了64%[18]，其中大部分患者在擇期手術(shù)前并沒(méi)意識(shí)到自己有睡眠呼吸暫停。Finkel等[14]的觀察性研究提出，超過(guò)80%接受外科手術(shù)的患者術(shù)前并不知道自己存在睡眠呼吸暫停。

2 病理生理學(xué)

外科患者在圍手術(shù)期接受鎮(zhèn)靜劑、麻醉藥、阿片類(lèi)藥物治療。這些藥物會(huì)增加咽部氣道的塌陷、減少通氣反應(yīng)、損害覺(jué)醒反應(yīng)，導(dǎo)致手術(shù)期間的OSAS進(jìn)一步加重。

2.1 鎮(zhèn)靜劑和麻醉藥以及阿片類(lèi)藥物的影響

OSAS患者睡眠中反復(fù)發(fā)生上呼吸道部分或完全阻塞，通常發(fā)生在吸氣肌運(yùn)動(dòng)產(chǎn)生的負(fù)壓超過(guò)上呼吸道舒張肌的作用(臨界氣道壓力)時(shí)[19-20]。通常麻醉藥可以降低上呼吸道舒張肌活動(dòng)度，且麻醉藥物此作用的強(qiáng)弱和用量呈劑量相關(guān)，從而增加了上呼吸道的塌陷性[21-23]。有研究觀察了12例接受小手術(shù)的健康者，發(fā)現(xiàn)丙泊酚麻醉深度的增加與臨界氣道壓進(jìn)行性增加和上呼吸道萎陷有密切的關(guān)系。上呼吸道塌陷增加繼發(fā)于頦舌肌活動(dòng)度減低，上氣道塌陷可能會(huì)導(dǎo)致睡眠呼吸暫停惡化、增加低氧血癥、心律失常和術(shù)后并發(fā)癥的風(fēng)險(xiǎn)[23-24]。

麻醉藥物也同樣損害覺(jué)醒反應(yīng)這一對(duì)抗睡眠呼吸暫停的保護(hù)防御機(jī)制。麻醉劑、阿片類(lèi)藥物、安眠藥、苯二氮卓類(lèi)藥物會(huì)引起呼吸抑制，減少每分鐘通氣量。有研究顯示，氟烷降低人類(lèi)對(duì)低氧血癥和高碳酸血癥的通氣反應(yīng)[25-26]。這種呼吸抑制很可能繼發(fā)于氟烷對(duì)外周化學(xué)反射弧的選擇性作用。同樣亞麻醉劑量的異氟烷通過(guò)外周化學(xué)感受器減弱低氧血癥的通氣反應(yīng)[27-28]。

手術(shù)患者常會(huì)接受阿片類(lèi)藥物以控制疼痛。阿片類(lèi)藥物作用于外周和中樞的二氧化碳化學(xué)反射弧而損害通氣功能[29-30]。研究表明硬膜外給予低劑量的麻醉劑同樣會(huì)降低呼吸功能，即使是健康成人[31-33]。鴉片類(lèi)藥物引起呼吸抑制也受性別和種族等因素的影響[34-35]。嗎啡可降低女性對(duì)于低氧血癥和高碳酸血癥的通氣反應(yīng)，但是對(duì)男性無(wú)影響[34]。另一方面，嗎啡增加男性呼吸暫停的閾值，而對(duì)女性則無(wú)影響[34]。阿片類(lèi)藥物和苯二氮卓類(lèi)藥物聯(lián)合應(yīng)用會(huì)導(dǎo)致更加明顯的低氧血癥和呼吸暫停發(fā)作[36]，這很可能是由于阿片類(lèi)與苯二氮卓類(lèi)藥物都會(huì)明顯減弱低氧血癥的通氣反應(yīng)[37-39]。

2.2 快動(dòng)眼(REM)睡眠反跳現(xiàn)象

外科患者手術(shù)后的1～2 d常出現(xiàn)睡眠高度片斷化，隨著REM睡眠和慢波睡眠的明顯減少，非快動(dòng)眼(NREM)2期睡眠增加[40-46]。這些睡眠結(jié)構(gòu)紊亂常繼發(fā)于外科手術(shù)產(chǎn)生的應(yīng)激、疼痛以及麻醉和鎮(zhèn)痛藥物的使用[41, 47-48]。外科手術(shù)創(chuàng)傷應(yīng)激會(huì)導(dǎo)致皮質(zhì)醇水平增加，而皮質(zhì)醇會(huì)明顯引起REM睡眠減少[49-50]。外科手術(shù)創(chuàng)傷同樣會(huì)引起明顯的炎癥反應(yīng)，這種炎癥反應(yīng)的特征為前炎癥標(biāo)志物水平的增高，如腫瘤壞死因子-α(tumor necrosis factor-α, TNF-α)，白介素-1(interleukin-1，IL-1)及白介素-6(interleukin-6，IL-6)[51-53]。這些炎癥標(biāo)志物，特別是IL-1 和TNF-α，會(huì)抑制REM睡眠[54-56]。

有些研究顯示手術(shù)后1～2 d內(nèi)通常缺少REM睡眠，但其后恢復(fù)期的3～5 d，REM睡眠的質(zhì)與量明顯增加(REM睡眠反跳現(xiàn)象)[44, 57-59]。由于REM期肌張力降低和呼吸不穩(wěn)定，REM睡眠中的睡眠呼吸障礙和低氧血癥發(fā)作通常會(huì)加重。REM睡眠伴有交感神經(jīng)過(guò)度興奮，導(dǎo)致心動(dòng)過(guò)速、血液動(dòng)力學(xué)不穩(wěn)定以及心肌缺血[60-64]。

眾所周知外科手術(shù)后的1周內(nèi)最容易發(fā)生并發(fā)癥，特別是手術(shù)后2～5天，與出現(xiàn)REM睡眠反跳現(xiàn)象出現(xiàn)的時(shí)間一致。有報(bào)道手術(shù)后低氧血癥也最可能出現(xiàn)在術(shù)后2～5天的夜間[58-59, 65]，這些可能會(huì)增加手術(shù)切口感染、大腦功能障礙以及心律失常的風(fēng)險(xiǎn)[66]。有研究發(fā)現(xiàn)手術(shù)后第3天急性心肌梗死的發(fā)生率最高，同樣，術(shù)后譫妄、噩夢(mèng)以及精神運(yùn)動(dòng)功能障礙也常發(fā)生在手術(shù)后的3～5天的夜間[67-70]。

3 如何確診OSAS

夜間多導(dǎo)睡眠圖(NPSG)是診斷OSAS的金標(biāo)準(zhǔn)[71]。然而，圍手術(shù)期因多方面因素很難實(shí)施，如拖延手術(shù)程序并增加手術(shù)費(fèi)用等，很多醫(yī)院未必具備N(xiāo)PSG。確診患者是否有OSAS風(fēng)險(xiǎn)的其他方法如問(wèn)卷調(diào)查、脈搏血氧飽和度測(cè)定、家庭睡眠監(jiān)測(cè)證實(shí)也有效。

3.1 問(wèn)卷調(diào)查

有很多問(wèn)卷調(diào)查用于識(shí)別手術(shù)患者有無(wú)OSAS的高風(fēng)險(xiǎn)。針對(duì)外科手術(shù)人群，有3種問(wèn)卷調(diào)查證實(shí)有效，Berlin問(wèn)卷、美國(guó)麻醉學(xué)家學(xué)會(huì)(ASA)列表和STOP-BANG [打鼾(snoring)、日間疲倦(tiredness during daytime)、觀察到呼吸暫停(observed apnea)、 高血壓(high blood pressure)、體重指數(shù)(body mass index)、年齡(age)、頸圍(neck circumference)、性別(gender)]問(wèn)卷調(diào)查。

Abrishami等[72]系統(tǒng)回顧和評(píng)價(jià)不同的睡眠呼吸暫停問(wèn)卷，提出柏林問(wèn)卷和STOP-BANG問(wèn)卷在預(yù)測(cè)中度或重度睡眠呼吸暫停方面具有較高的敏感性和特異性。但是STOP和STOP-BANG問(wèn)卷方法學(xué)上最有效，使用也非常方便。

3.2 夜間脈搏血氧飽和度測(cè)定

夜間脈搏血氧飽和度測(cè)定也常用于篩查OSAS。Malbois等[73]比較了氧減飽和法和便攜式睡眠呼吸監(jiān)測(cè)儀法在肥胖癥手術(shù)治療前確診OSAS的敏感度，將夜間脈搏血氧飽和度下降3%作為OSAS篩查標(biāo)準(zhǔn)，不僅可以除外很多OSAS(AHI>10)患者，也可檢出嚴(yán)重的OSAS患者，這種便宜而廣泛應(yīng)用的技術(shù)可以加快患者手術(shù)前的準(zhǔn)備工作。

3.3 家庭睡眠監(jiān)測(cè)

便攜式監(jiān)測(cè)是另外一種用于有OSAS高風(fēng)險(xiǎn)的患者監(jiān)測(cè)方法，然而，這種方法僅推薦用于OSAS幾率高的患者，不推薦用于伴有心肺并發(fā)癥的患者[74]，患者使用有一定局限性。有研究顯示，某大型醫(yī)療中心手術(shù)前使用便攜式監(jiān)測(cè)儀對(duì)將要接受外科手術(shù)伴有OSAS高風(fēng)險(xiǎn)因素成人患者進(jìn)行檢查，發(fā)現(xiàn)82%的患者為OSAS[14]，這種方法對(duì)特定的外科患者確診OSAS很有幫助。

4 圍手術(shù)期處理

2006年美國(guó)麻醉師協(xié)會(huì)發(fā)表了OSAS患者圍手術(shù)期處理實(shí)踐指南，其中提到OSAS評(píng)分系統(tǒng)評(píng)價(jià)圍手術(shù)期危險(xiǎn)性[74]?；谶@些指南，圍手術(shù)期護(hù)理包括3部分：術(shù)前評(píng)價(jià)，術(shù)中處理，術(shù)后處理。

4.1 術(shù)前評(píng)價(jià)

患者術(shù)前應(yīng)詳細(xì)詢(xún)問(wèn)病史和體格檢查，要特別注意評(píng)價(jià)睡眠呼吸暫停。與睡眠呼吸暫停相關(guān)的病史包括打鼾、白天過(guò)度困倦、他人證實(shí)存在呼吸暫停、夜間頻繁覺(jué)醒、晨起頭痛等。體格檢查的重點(diǎn)是測(cè)量頸圍、體重指數(shù)、改良版Mallampati評(píng)分、舌的體積、扁桃體大小以及鼻咽部特征。柏林問(wèn)卷、ASA列表或STOP-BANG問(wèn)卷對(duì)于識(shí)別OSAS風(fēng)險(xiǎn)高的患者是非常重要的，這些問(wèn)卷調(diào)查簡(jiǎn)單易行，并在外科患者中得到了驗(yàn)證。對(duì)高風(fēng)險(xiǎn)患者在圍手術(shù)期要采取一定措施。某些情況下，麻醉師和外科醫(yī)生手術(shù)前可以讓患者接受規(guī)范的睡眠評(píng)價(jià)以便對(duì)睡眠呼吸暫停做出處理。

4.2 術(shù)中處理

術(shù)中處理常決定于手術(shù)方式及麻醉類(lèi)型。應(yīng)當(dāng)將手術(shù)產(chǎn)生的應(yīng)激反應(yīng)和手術(shù)時(shí)間降到最低，因?yàn)檫@些因素會(huì)增加圍手術(shù)期并發(fā)癥的風(fēng)險(xiǎn)。盡可能考慮采用阻滯麻醉或局部麻醉來(lái)代替全身麻醉。最好是在患者完全清醒時(shí)，取半臥位拔出氣管插管。

4.3 術(shù)后處理

合并OSAS患者圍手術(shù)期發(fā)生并發(fā)癥的風(fēng)險(xiǎn)較大，應(yīng)在麻醉后監(jiān)護(hù)室(PACU)內(nèi)密切觀察以防止低氧血癥及其他并發(fā)癥的發(fā)生。應(yīng)通過(guò)脈搏血氧飽和度檢測(cè)儀連續(xù)監(jiān)測(cè)氧合功能。這些患者手術(shù)后應(yīng)當(dāng)盡可能保持非仰臥位以降低呼吸暫停的嚴(yán)重程度。這些患者對(duì)阿片類(lèi)藥物和苯二氮卓類(lèi)藥物非常敏感，圍手術(shù)期應(yīng)當(dāng)盡可能減少這兩種藥物的使用，控制疼痛可考慮使用非甾體類(lèi)抗炎藥、醋氨酚、曲馬多以及阻滯麻醉。右美托咪啶可起到很好的鎮(zhèn)靜作用，且不抑制呼吸。已經(jīng)確診為OSAS的患者，術(shù)后要應(yīng)用持續(xù)氣道正壓通氣(continuos positive airway pressure, CPAP)。雖然沒(méi)有隨機(jī)試驗(yàn)證明CPAP對(duì)于術(shù)后有益，且對(duì)于從來(lái)沒(méi)有用過(guò)CPAP的患者圍手術(shù)期去適應(yīng)它很困難，但OSAS風(fēng)險(xiǎn)高的患者手術(shù)后仍可以使用自動(dòng)CPAP(Auto-CPAP)。以前Auto-CPAP從未在這樣的人群中進(jìn)行正式的研究，需要進(jìn)行隨機(jī)對(duì)照試驗(yàn)來(lái)評(píng)估Auto-CPAP的療效，同時(shí)這部分患者在出院后還應(yīng)繼續(xù)評(píng)估睡眠。

Zarbock等[75]對(duì)于擇期心臟外科手術(shù)患者預(yù)防性使用經(jīng)鼻CPAP顯著降低了肺部并發(fā)癥的發(fā)生率。9項(xiàng)隨機(jī)對(duì)照試驗(yàn)的薈萃分析表明，腹部外科手術(shù)患者圍手術(shù)期使用CPAP減少了肺不張、術(shù)后肺部并發(fā)癥和肺炎的發(fā)生率[76]。

5 結(jié) 論

OSAS是呼吸紊亂的常見(jiàn)類(lèi)型，手術(shù)人群中的患病率很高。但大部分OSAS的患者手術(shù)前沒(méi)被確診，手術(shù)時(shí)也沒(méi)意識(shí)到，增加了這部分患者圍手術(shù)期發(fā)生并發(fā)癥的風(fēng)險(xiǎn)。鎮(zhèn)靜藥物、麻醉藥物、阿片類(lèi)藥物以及REM睡眠反跳現(xiàn)象會(huì)加重圍手術(shù)期OSAS并增加圍手術(shù)期并發(fā)癥的發(fā)生率。手術(shù)前識(shí)別OSAS的患者以便手術(shù)期采取合適的處理措施是非常重要的。篩查問(wèn)卷如柏林問(wèn)卷、STOP-NANG問(wèn)卷或ASA列表等可以識(shí)別OSAS高危患者，術(shù)前也容易操作。對(duì)高危患者的圍手術(shù)期處理要制定標(biāo)準(zhǔn)以減少其并發(fā)癥的發(fā)生率，高?；颊叱鲈汉笠惨M(jìn)行長(zhǎng)期正規(guī)的睡眠呼吸評(píng)估和管理。

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Perioperativeidentificationandmanagementofpatientswithobstructivesleepapneasyndrome

WANGYan-zhe1，CHENYing2，WANGZhen-shan3

(1.Seven-yearSystemofChinaMedicalUniversity,Shenyang110001,China；2.Seven-yearSystemofDalianMedicalUniversity,Dalian116044,China；3.DepartmentofRespiratoryMedicine,theSecondHospitalofDalianMedicalUniversity,Dalian116027,China)

Obstructive sleep apnea syndrome (OSAS) is a common sleep related breathing disorder. Its prevalence is estimated to be between 2% and 25% in the general population. However, the prevalence of sleep apnea is much higher in patients undergoing selective surgery. Sedation and anesthesia have been shown to increase the upper airway collapsibility and therefore increasing the risk of having postoperative complications in these patients.Furthermore, the majority of patients with sleep apnea are undiagnosed and therefore are at risk during the perioperative period. It is important to identify these patients so that appropriate actions can be taken in a timely fashion. In this review article, we will review how to identify these patients preoperatively and the steps that can be taken for their perioperative management.

obstructive sleep apnea syndrom；perioperative period；complications

10.11724/jdmu.2013.04.19

R563.9

A

1671-7295(2013)04-0384-06

王彥喆，陳瑩，王鎮(zhèn)山. 圍手術(shù)期阻塞性睡眠呼吸暫停綜合征患者的識(shí)別及其管理[J].大連醫(yī)科大學(xué)學(xué)報(bào)，2013,35(4)：384-389.

王彥喆(1989-)，女，遼寧大連人，中國(guó)醫(yī)科大學(xué)七年制。E-mail：407069692@qq.com

王鎮(zhèn)山，教授。E-mail：WZSDL@yahoo.com

2013-04-04；

2013-06-17)