望! Clinical!ques0on 2014 5 12 ! JHOSPITALISTnetwork ! ! (Obstruc*ve!Sleep!Apnea!Syndrome OSAS)!! ! PGY3 ! PGY4 ! ! ! ! ! 38 • 38 , .! , , • , , ,SAS .! .! Clinical!ques*on OSAS , , ! ,! ! CPAP ! OSAS ! . ! ! ,! 10 ! 1 ! • • • OSAS 5 AHI 5 .! 4 , 3.3 200 OSAS ! 2 , 85% (N!Engl!J!Med!1993;328:1230A5) ! 0.5 ! ! 0ALATALSURGICALPROCEDURESTENDTOALLEVIATESNORINGBUTARE NOTCONSISTENTLYEFFECTIVEINTREATINGSLEEPAPNEA FOR ORAL APPLIANCES WHICH MAY COST OR MORE-OREOVERFINDINGADENTISTWHOCANFIT THEAPPROPRIATEDEVICEANDFOLLOWTHEPATIENT MAYBEACHALLENGE-ORERESEARCHISNECESSARY BEFOREANYUNIVERSALRECOMMENDATIONCANBE MADEABOUTTHEUSEOFORALAPPLIANCESINTHE TREATMENTOFOBSTRUCTIVESLEEPAPNEA , , , , 3URGERY 0!,!4!, 352'%29 0ATIENTS WHO CANNOT BE TREATED ADEQUATELY WITH #0!0 OR OTHER CONSERVATIVE MEASURES AND WHO HAVE CLINICALLY SIGNIFICANT DISEASE MAY WANT TO CONSIDER MORE INVASIVE TREAT MENT5VULOPALATOPLASTYISASURGICALORLASER PROCEDURETHATREMOVESPARTOFTHEUVULAAND SOFT PALATE IN AN ATTEMPT TO ALLEVIATE SNOR HP INGANDSLEEPDISORDEREDBREATHING2ADIOFRE ! ! ! ! QUENCY METHODS IE SOMNOPLASTY ALSO CAN REDUCEPALATALSOFTTISSUE 0ALATALSURGICALPROCEDURESTENDTOALLEVIATE SNORING BUT ARE NOT CONSISTENTLY EFFECTIVE IN TREATINGSLEEPAPNEA-ANYPATIENTSWITHSLEEP APNEA HAVE AIRWAY OBSTRUCTION BEYOND THE PALATAL AREA THAT IS NOT TREATED BY SOFT TISSUE PROCEDURES , , , WITH MAXILLOMANDIBULAR ANATOMY 0ATIENTS THAT PREDISPOSES THEM TO AIRWAY OBSTRUCTION , , MAYBECONSIDEREDFORJAWSURGERY&IGURE ,! *!7 352'%29 )N ONE STUDY MAXILLOMANDIBULAR ADVANCE MENT SURGERY EFFECTIVELY TREATED SLEEP APNEA INASMANYASPERCENTOFPATIENTSHOWEVER NO RANDOMIZED STUDIES ARE AVAILABLE 2ADIO GRAPHS OF THE JAW AND SKULL CEPHALOMETRICS ARE OBTAINED BEFORE SURGERY TO HELP THE ORAL SURGEONMAKERELATIONALMEASUREMENTSOFTHE JAWTEETHANDAIRWAY !MONG THE LESS INVASIVE JAW PROCEDURES IS GENIAL TUBERCLE AND TONGUE ADVANCEMENT IN WHICH THE ANTERIOR TIP OF THE MANDIBLE IS MOVED FORWARD ALONG WITH ITS LINGUAL ATTACH MENTS BRINGING THE TONGUE FORWARD AND INCREASINGTHEDIAMETEROFTHEAIRWAY !DVANCEMENTOFBOTHTHEUPPERANDLOWER JAWS WITH BIMAXILLARY AND MANDIBULAR OSTE OTOMIESISAMOREDEFINITIVEBUTMUCHMORE INVASIVESURGERY0ATIENTSWHOHAVETHISTYPE OF SURGERY SHOULD EXPECT A PROLONGED POST OPERATIVE RECOVERY TIME WHILE THE JAWS ARE FIXED OR WIRED SHUT TO ALLOW HEALING #OM PLICATIONS INCLUDE LINGUAL OR ORAL NUMBNESS AND MALPOSITIONING OF THE JAW !DOLESCENTS AND YOUNG ADULTS WITH MORE SEVERE APNEA WHO CANNOT TOLERATE #0!0 AND ARE WILLING AND HEALTHY ENOUGH TO UNDERGO EXTENSIVE ORAL SURGERY MAY BE CANDIDATES FOR THE PRO CEDURES ! ,! MallampaG : : : : → /4(%2 352')#!, 02/#%$52%3 ! ! ! ! ! ! • ! SAS (ICSDA2) A B D, ! C D .! A" , , B"" ! ! 5 B ! ! 15 , , , , , , ! C" D" , " , , " " ! , ! ! , , " RERA))! RERA))! , ICSDA2 InternaGonal!ClassificaGon!of!Sleep!Disorders!2nd!EdiGon , ! • STOPABang:! score3 →Sn84 , ,BMI, , , ! ,Sp56% AHI>5)/Sn93 ,Sp43% AHI>15)! • Sleep!apnea!clinical!score(SACS)! , 0A100 , .15 , ! AHI>10 25A50%! • Berlin!quesGonnaire! , , , , ,BMI !!!! 10 .! !!!! risk→Sn80%,Sp46%(AHI>5),Sn!91%,Sp37%(AHI>15)! ! ! ! Epworth!Sleepiness!Scale ESS • 8 10/11 AHI30 Sn36A50 Sp!70A79%!→ SAS ! • PM(portable!monitors) ,SpO2 ! .PSG PSG PM . • PSG polysomnography !!! AHI AHI , , , 5 /h 5 15 ! , , , . ! Apnea!Hypopnea!Index AHI SAS ,15 30 ,30 ,SpO2, !!! ! ! PSG/PM OSAS ! ! 1. 2. ! 3.bed!partner ! 4. !!5. ! 6. !7. ! 8. 9. ! 10. ! 11. 12. 13. ! 14. ! 17inch >43.18cm) 16inch >40.64cm ! 15. 16. 17. 18. 19. 20. ! 21. 22. 23. ! 24. " ! →→ 52%, 84 ! OSAS >2 ! MissionAcriGcal!worker! ex PSGor ! ! !Dose!this!paGent!have!obstrucGve!sleep!apnea?;JAMA2013!310:731!Myers!KA! PSG • • • • CPAP ! ! ! ! ! ! , ! ! • • • • • QOL SAS CPAP ! ! ! SAS !AHI5 15 ! ! 3 1 5000 3 Up!to!date! ! ! (1) (2)CPAP! (3) (4) OSA.!! .!! .! , .! , ! UPPP uvulopalatopharyngoplasty! 24 AHI<5 ! RFA( ! ,MMA Uvulopalatopharyngoplasty"in"the"Management"of"Obstruc=ve"Sleep"Apnea:"The"Mayo"Clinic"ExperienceAkram!Khan,!MD,!! LngDterm"followDup"of"pa=ents"operated"with"Uvulopalatopharyngoplasty"from"1985"to"1991.Värendh!M1,! ! • (1) • (2)CPAP! • (3) • (4) !!!!!!! !!!!!!! OSA.!! .!! .! , .! ! , , !! .! CPAP Con*nuous!Posi*ve!Airway!Pressure ! • CPAP • ! ! 3 • • ! AHI! 40) SAS! 5,000 PSG AHI 6 ! 20!or! ! ACP Ann!Intern!Med.!2013;159:471–!483. OSA ! (Grade:!strong!recommendaGon;!lowAquality!evidence)! OSA (Grade:!strong!recommendaGon;!moderateAquality!evidence)! OSA CPAP CPAP CPAP (Grade:!weak!recommendaGon;!lowAquality!evidence) OSA ! CPAP ! Diagnosis of Obstructive Sleep Apnea in Adults Clinical Guidel Table 4. The AHI as a Predictor of Clinical Outcomes Outcome Evidence Overall Quality of Evidence Reference All-cause mortality Cardiovascular mortality Nonfatal cardiovascular disease Association with increased risk with AHI score Ͼ30 events/h Inconsistent results Association with increased risk with AHI score Ն30 events/h and no CPAP treatment No association Unclear conclusions Association with increased risk with AHI score Ͼ30 events/h No association High Insufficient Insufficient 19, 20, 171, 17 5, 20 5, 177 Insufficient Insufficient Low Insufficient 169 10, 173, 178 170, 174 175 Stroke Hypertension Type 2 diabetes Quality of life AHI ϭ apnea–hypopnea index; CPAP ϭ continuous positive airway pressure. Clinical Prediction Rules Versus PSG Ann!Intern!Med.!2014;161:210A220.! portable monitors (types II, III, and IV) can be use SAS OSAS CPAP OSAS → ! ! ! OSAS CPAP ! ! RCT QOL ! ! CPAP consercvaGve ! ! .! ! CPAP CPAP 5/8 ! 4/6: 7/8 CPAP ! ! .! OSAS • OSAS 50 83 OSAS • AHI SHHS 30 30 AHI 30 AHI OSAS 1.5 ! 1.37 ! ! AssociaGon!of!SleepADisordered!Breathing,!Sleep!Apnea,!and!Hypertension!in!a!Large!CommunityABased! Study JAMA.!2000;283(14):1829A1836! OSAS ! CPAP OSAS ①ESS!score10 CPAP 2 6 CPAP SAS QOL CPAP 55 CAP BarbéF,MayoralasLR,DuranJ,etal:Treatmentwith!conGnuous!posiGve!airway!pressure!is!not!effecGve!in!paGents!with!sleep!apnea!but!no!dayGme!sleepiness.!a! randomized,!controlled!trial.!Ann#Intern#Med#2001!;!134!:!1015A1023!! ! ! ② CPAP CPAP OSAS 35 CPAP Robinson!GV,!Smith!DM,! Langford!BA,!et!al!:!ConGnuA!ous!posiGve!airway!pressure!does!not!reduce!blood!pressure!in!nonsleepy!hypertensive!OSA!paGents.!Eur#Respir#J#2006!;!27!:! 1229A1235!! OSAS ③ESS!score11! 2! ! 1.89 .!! 5.6 OSAS! CPAP 359! CPAP ! 2.19mmHg! . 1! ! CPAP! Barbé!F,!DuránACantolla!J,!Capote!F,!et!al .!Am#J#Respir#Crit#Care#Med#2010!;!181!:!718A726! ! ! →→ .! , OSAS . CPAP .! ! ! ! OSAS OSAS ,! • AHI! !11 • • OSA !!!!!!!!!!!! ! ! ! 2.38 11 37 ! 1.2 6.9 ! ! ! ! ! LVEF OSA ! ! ! CPAP 1.27! ! ! ! ! Class a! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!:2013!ACCF/AHA!Guideline!for!the!Management!of!Heart!Failure!!!e172!! • EF<45% CHF →CPAP OSAS ! 24! ,1! , !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Yasuyuki!Kaneko,!M.D.! N!Engl!J!Med!2003;!348!:!1233!–!41!! ! 12! 10!mmHg±4 CPAP ! 12! OSAS • ! OSAS ! • OSAS CPAP ! ! PAI ! Spontaneous!Platelet!AcGvaGon!and!AggregaGon!During!ObstrucGve!Sleep!Apnea!and!Its! Response!to!Therapy!With!Nasal!ConGnuous!PosiGve!Airway!Pressure!:George!Bokinsky;! Michael!Miller;!Kenneth!Ault;!Philip!Husband;!Jane!Mitchell OSAS AHI! • OSAS • , , 50 , ! ! ,2 , 2 4 • , AHI! ,BMI, ! ! ! 30 ! 4.02 , 3.40 , 1.74 OSAS • 65 • !!!!AHI , OSAS , HDL AHI , TG , .! ,BMI, ,!!!!!! ! .! SleepDdisordered"Breathing"and"Insulin"Resistance"in"MiddleDaged"and"Overweight"Men"" NARESH"M."PUNJABI,"JOHN"D."SORKIN,"LESLIE"I."KATZEL,"ANDREW"P."GOLDBERG,"ALAN"R." SCHWARTZ,"and"PHILIP"L."SMITH"" CPAP • CRP • • • LDL • HDL • → ! CPAP ! ! ! ! ! meanBP 7kg ! CPAP ! ! , ! !JAMA!2000!Dec!20;284(23):3015 5 129 • ! AHI 6.27 BMI 1.37 1.6m 5.75% ESS 3 →BMI ! AHI ! 3kg ! ! ! Lung.!2014!Feb;192(1):175A84. Effects"of"exercise"training"on"sleep"apnea:"a"metaDanalysis." 2 OSAS ! Samuel!T.!Kuna Arch#Intern#Med 2009;169:1619=26.!! ,AHI ! ! ! ! snack!bar 175 / ! ! ! Topics OSAS SAS CPAP ! ! ! OSAS ! ! … !? H26.9.1 ! ! ! !!!!!!Topics SAS H26.9.1 ! ! ! ! ! ! → 30 ! ! ( ! ) ! ! ! HP ! Topics SAS ③ ! ! ! ! ! ! ! ! 3 Answer , OSAS , ,! CPAP → 8kg . OSAS ,CPAP OSAS ! ! ?! ! CPAP .! AHI , , ,CPAP .! ! , Answer • OSAS , ! CPAP ESS! """""""""""""""""""""""""""Arousal ,CPAP QOL CPAP , → .! ! , ,AHI ! ,"" ,SpO2 .! ,2 .! , ,RCT , .! .! SAS ! ! ! ! ! ! OSAS ! CPAP !
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