中重度阻塞性睡眠呼吸暂停低通气综合征儿童无创正压

doi:10.6040/j.issn.1673-3770.0.2018.041

摘要/Abstract

摘要： 目的探讨家庭无创正压通气对中重度阻塞性睡眠呼吸暂停低通气综合征(OSAS)患儿,尤其是对于腺样体、扁桃体切除术后仍有中重度OSAS残留儿童的临床应用效果。方法采取病例随访的研究方式,收集自2012年10月至2017年10月因伴有基础疾病不宜手术治疗或腺样体、扁桃体切除术后效果欠佳,经多导睡眠监测(PSG)诊断为中重度OSAS的患儿,并需要家庭无创正压通气(NPPV)支持的儿童病例信息。入组患儿均在专业睡眠中心进行PSG监测,根据情况选择不同模式呼吸机,并进行手工压力滴定,记录并比较NPPV治疗前后PSG客观指标的变化。出院后继续进行家庭NPPV支持治疗的患儿,在第3个月、第6个月及之后每隔6个月对其进行随访或返院复查PSG,监测PSG指标及临床症状的相应改变,并对可能影响儿童NPPV治疗依从性的相关因素进行分析。结果截至2017年10月,共有30例中重度OSAS患儿接受NPPV治疗。其中男26例,女4例,平均(7.2±3.7)岁。11例(36.7%)患儿在住院期间接受NPPV治疗,出院后即终止,19例(63.3%)患儿出院后继续进行家庭NPPV辅助治疗。分析所有入组患儿住院期间PSG治疗前后的指标,发现患儿呼吸暂停低通气指数(P<0.001)、最低血氧饱和度(P<0.001)、血氧饱和度低于0.90占睡眠时间的百分比(P<0.001)在治疗后均有明显改善。长期随访发现,接受家庭NPPV治疗的中重度OSAS儿童,其夜间打鼾、睡眠时的呼吸费力、呼吸暂停或憋醒、白日嗜睡的临床症状较治疗前有明显改善,易激惹、注意力分散较治疗前无明显变化。对可能影响OSAS儿童家庭NPPV治疗依从性的相关因素进行分析,发现家长对患儿呼吸疾病较重视(P=0.002)、患儿有颅面畸形(P=0.008)治疗前存在频繁呼吸暂停/憋醒(P=0.029)者,其依从性高于其他患儿。结论 NPPV治疗对儿童睡眠呼吸障碍中一些特殊人群是可供选择的有效方法。长期NPPV呼吸支持,可明显改善中重度OSAS儿童的临床症状及呼吸、血氧情况,尤其是伴有基础疾病或腺样体、扁桃体切除术后手术效果欠佳,仍有中重度OSAS残留的儿童。加强对家长睡眠呼吸相关疾病的宣传教育,提高家长对患儿疾病的重视程度,缓解治疗过程中的不良反应,有望提高儿童家庭NPPV治疗的依从性。

关键词: 无创正压通气, 睡眠呼吸暂停, 阻塞性, 儿童, 随访研究

Abstract: Objective To investigate the long-term efficacy of non-invasive ventilation in children with moderate to severe obstructive sleep apnea-hypopnea syndrome(OSAS), especially those with residual postoperative OSAS after tonsillectomy and/or adenoidectomy. Methods We conducted a follow-up study between October 2012 and October 2017 in children who were diagnosed with moderate to severe OSAS through polysomnography(PSG)and were treated with non-invasive positive pressure ventilation(NPPV). Most of them had underlying diseases or postoperative residual OSAS after tonsillectomy and/or adenoidectomy. Polysomnography was performed during non-invasive ventilatory support; pressure titration was performed manually in the sleep center, while the mode was chosen based on disease conditions in individual patients. Polysomnography data were recorded and compared between before and after treatment with NPPV. Patients who received NPPV support after discharge were examined at follow-up visits 3 and 6 months later, and every 6 months after that. Clinical symptoms and PSG parameters were monitored during therapy, and factors associated with compliance were evaluated. Results Thirty patients received non-invasive ventilation treatment through October 2017; 26 of them were boys. The average age was 7.2±3.7 years. Ventilation was stopped in 11(36.7%)children after discharge, while 19(63.3%)children received non-invasive ventilation at home. The apnea-hypopnea index(P<0.001), the lowest SpO₂(P<0.001), and the percentage of sleep time with the SpO₂<0.90(P<0.001)were improved in all children receiving NPPV treatment at the time of hospitalization. Most OSAS patients experienced relief from snoring and apnea and improvement in respiratory distress and daytime symptoms. However, there was no improvement in irritability and distraction after 6 months of treatment. Parental awareness of the importance of this disease(P=0.001), craniofacial malformation(P=0.008), and frequent sleep apnea or dyspnea before treatment(P=0.029)were associated with compliance with NPPV treatment. Conclusion Non-invasive ventilation therapy can be performed successfully in special pediatric populations. Long-term NPPV treatment can improve clinical symptoms considerably in children with moderate to severe OSAS, especially those with underlying diseases or residual OSAS after tonsillectomy and/or adenoidectomy. Education for parents about sleep-disordered breathing and reducing adverse reactions might improve compliance with NPPV treatment in children.

Key words: Sleep apnea, obstructive, Child, Follow-up study, Non-invasive positive pressure ventilation

中图分类号:

R766.7

杨微,郑莉,许志飞. 中重度阻塞性睡眠呼吸暂停低通气综合征儿童无创正压[J]. 山东大学耳鼻喉眼学报, 2018, 32(2): 19-24.

YANG Wei, ZHENG Li, XU Zhifei. Long-term follow-up study on non-invasive ventilation in children with moderate to severe[J]. JOURNAL OF SHANDONG UNIVERSITY (OTOLARYNGOLOGY AND OPHTHALMOLOGY), 2018, 32(2): 19-24.

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