围手术期阻塞性睡眠呼吸暂停综合征患者的识别及其管理

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(1.中国医科大学 七年制，辽宁 沈阳 110001；2.大连医科大学 七年制，辽宁 大连 116044；大连医科大学 附属第二医院 呼吸科，辽宁 大连 116027)

综述

围手术期阻塞性睡眠呼吸暂停综合征患者的识别及其管理

王彦喆1，陈莹2，王镇山3

(1.中国医科大学 七年制，辽宁 沈阳 110001；2.大连医科大学 七年制，辽宁 大连 116044；大连医科大学 附属第二医院 呼吸科，辽宁 大连 116027)

阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea syndrome, OSAS)是一种常见的与睡眠相关的呼吸功能紊乱，发病率约2%～25%，在择期手术人群中OSAS的患病率更高。一方面，镇静剂和麻醉药会增加上呼吸道的塌陷性，增加了这部分患者发生术后并发症的风险；另一方面，大部分OSAS患者没有被确诊也增加了手术期间的危险。因此，这部分OSAS患者的识别和诊断，对能否在手术期间给予及时合理的处理有重要作用。本文将如何在手术前识别OSAS患者及其围手术期的管理进行综述。

阻塞性睡眠呼吸暂停综合征；围手术期；并发症

阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea syndrome, OSAS)的特征是睡眠中间断反复出现的上呼吸道部分或全部阻塞，引起睡眠结构紊乱，导致睡眠片段化和白天困倦。许多研究证实OSAS与多种健康相关的不良后果有关，包括增加交通事故、高血压、糖尿病、充血性心力衰竭、脑卒中的发生率以及全因病死率[1-9]。

近来很多研究提出OSAS患者围手术期出现并发症的风险高，包括低氧血症、肺炎、气管插管困难、心肌梗死、肺栓塞、肺不张、心律失常以及非预料入住ICU。大部分OSAS患者住院时未被确诊，推测其潜在的睡眠呼吸暂停是增加围手术期并发症发生风险的原因。因此手术前OSAS的明确诊断以及围手术期采取适当的处理是非常重要的。

1 流行病学

OSAS是一种常见的与睡眠相关的呼吸障碍疾病，由于肥胖和人口老龄化，发病率逐年增高。依据OSAS不同定义，发病率一般在2%～25%。Young等[10]在一项流行病学调查中，将睡眠呼吸暂停低通气指数(apnea-hypopnea index, AHI)≥5 次/h作为OSAS的诊断标准，其发病率在女性为9%，男性为24%。然而诊断标准为AHI≥5次/h并且伴随白天困倦症状时，其发病率在女性为2%，男性为4%。2005年美国国家睡眠基金会(national sleep foundation, NSF)根据柏林问卷调查，提出1/4的美国人具有罹患OSAS的高风险[11]。接受外科手术的患者中OSAS的发病率更高，在手术减肥治疗人群中，OSAS的发病率甚至超过70%[12-13]。标准化的作法是在进行减肥手术前进行规范的睡眠评估。在接受普外科手术的患者中OSAS的发病率也较高[14]。Chung等[15]在术前对患者进行柏林问卷调查，发现24%的患者具有罹患OSAS的高风险。运用STOP-BANG问卷调查发现择期手术的患者中，41%的患者有发生睡眠呼吸暂停的风险[16]。在一项横断面研究中，39例接受癫痫手术患者术前进行夜间多导睡眠图检查(nocturnal polysomnography，NPSG)，结果发现1/3的患者存在睡眠呼吸暂停[17]。另一项研究发现，在接受颅内肿瘤手术的患者中，睡眠呼吸暂停的发病率达到了64%[18]，其中大部分患者在择期手术前并没意识到自己有睡眠呼吸暂停。Finkel等[14]的观察性研究提出，超过80%接受外科手术的患者术前并不知道自己存在睡眠呼吸暂停。

2 病理生理学

外科患者在围手术期接受镇静剂、麻醉药、阿片类药物治疗。这些药物会增加咽部气道的塌陷、减少通气反应、损害觉醒反应，导致手术期间的OSAS进一步加重。

2.1 镇静剂和麻醉药以及阿片类药物的影响

OSAS患者睡眠中反复发生上呼吸道部分或完全阻塞，通常发生在吸气肌运动产生的负压超过上呼吸道舒张肌的作用(临界气道压力)时[19-20]。通常麻醉药可以降低上呼吸道舒张肌活动度，且麻醉药物此作用的强弱和用量呈剂量相关，从而增加了上呼吸道的塌陷性[21-23]。有研究观察了12例接受小手术的健康者，发现丙泊酚麻醉深度的增加与临界气道压进行性增加和上呼吸道萎陷有密切的关系。上呼吸道塌陷增加继发于颏舌肌活动度减低，上气道塌陷可能会导致睡眠呼吸暂停恶化、增加低氧血症、心律失常和术后并发症的风险[23-24]。

麻醉药物也同样损害觉醒反应这一对抗睡眠呼吸暂停的保护防御机制。麻醉剂、阿片类药物、安眠药、苯二氮卓类药物会引起呼吸抑制，减少每分钟通气量。有研究显示，氟烷降低人类对低氧血症和高碳酸血症的通气反应[25-26]。这种呼吸抑制很可能继发于氟烷对外周化学反射弧的选择性作用。同样亚麻醉剂量的异氟烷通过外周化学感受器减弱低氧血症的通气反应[27-28]。

手术患者常会接受阿片类药物以控制疼痛。阿片类药物作用于外周和中枢的二氧化碳化学反射弧而损害通气功能[29-30]。研究表明硬膜外给予低剂量的麻醉剂同样会降低呼吸功能，即使是健康成人[31-33]。鸦片类药物引起呼吸抑制也受性别和种族等因素的影响[34-35]。吗啡可降低女性对于低氧血症和高碳酸血症的通气反应，但是对男性无影响[34]。另一方面，吗啡增加男性呼吸暂停的阈值，而对女性则无影响[34]。阿片类药物和苯二氮卓类药物联合应用会导致更加明显的低氧血症和呼吸暂停发作[36]，这很可能是由于阿片类与苯二氮卓类药物都会明显减弱低氧血症的通气反应[37-39]。

2.2 快动眼(REM)睡眠反跳现象

外科患者手术后的1～2 d常出现睡眠高度片断化，随着REM睡眠和慢波睡眠的明显减少，非快动眼(NREM)2期睡眠增加[40-46]。这些睡眠结构紊乱常继发于外科手术产生的应激、疼痛以及麻醉和镇痛药物的使用[41, 47-48]。外科手术创伤应激会导致皮质醇水平增加，而皮质醇会明显引起REM睡眠减少[49-50]。外科手术创伤同样会引起明显的炎症反应，这种炎症反应的特征为前炎症标志物水平的增高，如肿瘤坏死因子-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]。这些炎症标志物，特别是IL-1 和TNF-α，会抑制REM睡眠[54-56]。

有些研究显示手术后1～2 d内通常缺少REM睡眠，但其后恢复期的3～5 d，REM睡眠的质与量明显增加(REM睡眠反跳现象)[44, 57-59]。由于REM期肌张力降低和呼吸不稳定，REM睡眠中的睡眠呼吸障碍和低氧血症发作通常会加重。REM睡眠伴有交感神经过度兴奋，导致心动过速、血液动力学不稳定以及心肌缺血[60-64]。

众所周知外科手术后的1周内最容易发生并发症，特别是手术后2～5天，与出现REM睡眠反跳现象出现的时间一致。有报道手术后低氧血症也最可能出现在术后2～5天的夜间[58-59, 65]，这些可能会增加手术切口感染、大脑功能障碍以及心律失常的风险[66]。有研究发现手术后第3天急性心肌梗死的发生率最高，同样，术后谵妄、噩梦以及精神运动功能障碍也常发生在手术后的3～5天的夜间[67-70]。

3 如何确诊OSAS

夜间多导睡眠图(NPSG)是诊断OSAS的金标准[71]。然而，围手术期因多方面因素很难实施，如拖延手术程序并增加手术费用等，很多医院未必具备NPSG。确诊患者是否有OSAS风险的其他方法如问卷调查、脉搏血氧饱和度测定、家庭睡眠监测证实也有效。

3.1 问卷调查

有很多问卷调查用于识别手术患者有无OSAS的高风险。针对外科手术人群，有3种问卷调查证实有效，Berlin问卷、美国麻醉学家学会(ASA)列表和STOP-BANG [打鼾(snoring)、日间疲倦(tiredness during daytime)、观察到呼吸暂停(observed apnea)、 高血压(high blood pressure)、体重指数(body mass index)、年龄(age)、颈围(neck circumference)、性别(gender)]问卷调查。

Abrishami等[72]系统回顾和评价不同的睡眠呼吸暂停问卷，提出柏林问卷和STOP-BANG问卷在预测中度或重度睡眠呼吸暂停方面具有较高的敏感性和特异性。但是STOP和STOP-BANG问卷方法学上最有效，使用也非常方便。

3.2 夜间脉搏血氧饱和度测定

夜间脉搏血氧饱和度测定也常用于筛查OSAS。Malbois等[73]比较了氧减饱和法和便携式睡眠呼吸监测仪法在肥胖症手术治疗前确诊OSAS的敏感度，将夜间脉搏血氧饱和度下降3%作为OSAS筛查标准，不仅可以除外很多OSAS(AHI>10)患者，也可检出严重的OSAS患者，这种便宜而广泛应用的技术可以加快患者手术前的准备工作。

3.3 家庭睡眠监测

便携式监测是另外一种用于有OSAS高风险的患者监测方法，然而，这种方法仅推荐用于OSAS几率高的患者，不推荐用于伴有心肺并发症的患者[74]，患者使用有一定局限性。有研究显示，某大型医疗中心手术前使用便携式监测仪对将要接受外科手术伴有OSAS高风险因素成人患者进行检查，发现82%的患者为OSAS[14]，这种方法对特定的外科患者确诊OSAS很有帮助。

4 围手术期处理

2006年美国麻醉师协会发表了OSAS患者围手术期处理实践指南，其中提到OSAS评分系统评价围手术期危险性[74]。基于这些指南，围手术期护理包括3部分：术前评价，术中处理，术后处理。

4.1 术前评价

患者术前应详细询问病史和体格检查，要特别注意评价睡眠呼吸暂停。与睡眠呼吸暂停相关的病史包括打鼾、白天过度困倦、他人证实存在呼吸暂停、夜间频繁觉醒、晨起头痛等。体格检查的重点是测量颈围、体重指数、改良版Mallampati评分、舌的体积、扁桃体大小以及鼻咽部特征。柏林问卷、ASA列表或STOP-BANG问卷对于识别OSAS风险高的患者是非常重要的，这些问卷调查简单易行，并在外科患者中得到了验证。对高风险患者在围手术期要采取一定措施。某些情况下，麻醉师和外科医生手术前可以让患者接受规范的睡眠评价以便对睡眠呼吸暂停做出处理。

4.2 术中处理

术中处理常决定于手术方式及麻醉类型。应当将手术产生的应激反应和手术时间降到最低，因为这些因素会增加围手术期并发症的风险。尽可能考虑采用阻滞麻醉或局部麻醉来代替全身麻醉。最好是在患者完全清醒时，取半卧位拔出气管插管。

4.3 术后处理

合并OSAS患者围手术期发生并发症的风险较大，应在麻醉后监护室(PACU)内密切观察以防止低氧血症及其他并发症的发生。应通过脉搏血氧饱和度检测仪连续监测氧合功能。这些患者手术后应当尽可能保持非仰卧位以降低呼吸暂停的严重程度。这些患者对阿片类药物和苯二氮卓类药物非常敏感，围手术期应当尽可能减少这两种药物的使用，控制疼痛可考虑使用非甾体类抗炎药、醋氨酚、曲马多以及阻滞麻醉。右美托咪啶可起到很好的镇静作用，且不抑制呼吸。已经确诊为OSAS的患者，术后要应用持续气道正压通气(continuos positive airway pressure, CPAP)。虽然没有随机试验证明CPAP对于术后有益，且对于从来没有用过CPAP的患者围手术期去适应它很困难，但OSAS风险高的患者手术后仍可以使用自动CPAP(Auto-CPAP)。以前Auto-CPAP从未在这样的人群中进行正式的研究，需要进行随机对照试验来评估Auto-CPAP的疗效，同时这部分患者在出院后还应继续评估睡眠。

Zarbock等[75]对于择期心脏外科手术患者预防性使用经鼻CPAP显著降低了肺部并发症的发生率。9项随机对照试验的荟萃分析表明，腹部外科手术患者围手术期使用CPAP减少了肺不张、术后肺部并发症和肺炎的发生率[76]。

5 结 论

OSAS是呼吸紊乱的常见类型，手术人群中的患病率很高。但大部分OSAS的患者手术前没被确诊，手术时也没意识到，增加了这部分患者围手术期发生并发症的风险。镇静药物、麻醉药物、阿片类药物以及REM睡眠反跳现象会加重围手术期OSAS并增加围手术期并发症的发生率。手术前识别OSAS的患者以便手术期采取合适的处理措施是非常重要的。筛查问卷如柏林问卷、STOP-NANG问卷或ASA列表等可以识别OSAS高危患者，术前也容易操作。对高危患者的围手术期处理要制定标准以减少其并发症的发生率，高危患者出院后也要进行长期正规的睡眠呼吸评估和管理。

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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

王彦喆，陈莹，王镇山. 围手术期阻塞性睡眠呼吸暂停综合征患者的识别及其管理[J].大连医科大学学报，2013,35(4)：384-389.

王彦喆(1989-)，女，辽宁大连人，中国医科大学七年制。E-mail：407069692@qq.com

王镇山，教授。E-mail：WZSDL@yahoo.com

2013-04-04；

2013-06-17)