， ，

(1.中國醫(yī)科大學 七年制，遼寧 沈陽 110001；2.大連醫(yī)科大學 七年制，遼寧 大連 116044；大連醫(yī)科大學 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別及其管理

王彥喆1，陳瑩2，王鎮(zhèn)山3

(1.中國醫(yī)科大學 七年制，遼寧 沈陽 110001；2.大連醫(yī)科大學 七年制，遼寧 大連 116044；大連醫(yī)科大學 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)癥的風險；另一方面，大部分OSAS患者沒有被確診也增加了手術(shù)期間的危險。因此，這部分OSAS患者的識別和診斷，對能否在手術(shù)期間給予及時合理的處理有重要作用。本文將如何在手術(shù)前識別OSAS患者及其圍手術(shù)期的管理進行綜述。

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，導致睡眠片段化和白天困倦。許多研究證實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]。

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

1 流行病學

OSAS是一種常見的與睡眠相關(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]在一項流行病學調(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的診斷標準，其發(fā)病率在女性為9%，男性為24%。然而診斷標準為AHI≥5次/h并且伴隨白天困倦癥狀時，其發(fā)病率在女性為2%，男性為4%。2005年美國國家睡眠基金會(national sleep foundation, NSF)根據(jù)柏林問卷調(diào)查，提出1/4的美國人具有罹患OSAS的高風險[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70%[12-13]。標準化的作法是在進行減肥手術(shù)前進行規(guī)范的睡眠評估。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)前對患者進行柏林問卷調(diào)查，發(fā)現(xiàn)24%的患者具有罹患OSAS的高風險。運用STOP-BANG問卷調(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險[16]。在一項橫斷面研究中，39例接受癲癇手術(shù)患者術(shù)前進行夜間多導睡眠圖檢查(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)病率達到了64%[18]，其中大部分患者在擇期手術(shù)前并沒意識到自己有睡眠呼吸暫停。Finkel等[14]的觀察性研究提出，超過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

外科患者在圍手術(shù)期接受鎮(zhèn)靜劑、麻醉藥、阿片類藥物治療。這些藥物會增加咽部氣道的塌陷、減少通氣反應(yīng)、損害覺醒反應(yīng)，導致手術(shù)期間的OSAS進一步加重。

2.1 鎮(zhèn)靜劑和麻醉藥以及阿片類藥物的影響

OSAS患者睡眠中反復發(fā)生上呼吸道部分或完全阻塞，通常發(fā)生在吸氣肌運動產(chǎn)生的負壓超過上呼吸道舒張肌的作用(臨界氣道壓力)時[19-20]。通常麻醉藥可以降低上呼吸道舒張肌活動度，且麻醉藥物此作用的強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)于頦舌肌活動度減低，上氣道塌陷可能會導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)癥的風險[23-24]。

麻醉藥物也同樣損害覺醒反應(yīng)這一對抗睡眠呼吸暫停的保護防御機制。麻醉劑、阿片類藥物、安眠藥、苯二氮卓類藥物會引起呼吸抑制，減少每分鐘通氣量。有研究顯示，氟烷降低人類對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)于氟烷對外周化學反射弧的選擇性作用。同樣亞麻醉劑量的異氟烷通過外周化學感受器減弱低氧血癥的通氣反應(yīng)[27-28]。

手術(shù)患者常會接受阿片類藥物以控制疼痛。阿片類藥物作用于外周和中樞的二氧化碳化學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降低呼吸功能，即使是健康成人[31-33]。鴉片類藥物引起呼吸抑制也受性別和種族等因素的影響[34-35]。嗎啡可降低女性對于低氧血癥和高碳酸血癥的通氣反應(yīng)，但是對男性無影響[34]。另一方面，嗎啡增加男性呼吸暫停的閾值，而對女性則無影響[34]。阿片類藥物和苯二氮卓類藥物聯(lián)合應(yīng)用會導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與苯二氮卓類藥物都會明顯減弱低氧血癥的通氣反應(yīng)[37-39]。

2.2 快動眼(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)激會導致皮質(zhì)醇水平增加，而皮質(zhì)醇會明顯引起REM睡眠減少[49-50]。外科手術(shù)創(chuàng)傷同樣會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]。這些炎癥標志物，特別是IL-1 和TNF-α，會抑制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)作通常會加重。REM睡眠伴有交感神經(jīng)過度興奮，導致心動過速、血液動力學不穩(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)的時間一致。有報道手術(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]，這些可能會增加手術(shù)切口感染、大腦功能障礙以及心律失常的風險[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、噩夢以及精神運動功能障礙也常發(fā)生在手術(shù)后的3～5天的夜間[67-70]。

3 如何確診OSAS

夜間多導睡眠圖(NPSG)是診斷OSAS的金標準[71]。然而，圍手術(shù)期因多方面因素很難實施，如拖延手術(shù)程序并增加手術(shù)費用等，很多醫(yī)院未必具備NPSG。確診患者是否有OSAS風險的其他方法如問卷調(diào)查、脈搏血氧飽和度測定、家庭睡眠監(jiān)測證實也有效。

3.1 問卷調(diào)查

有很多問卷調(diào)查用于識別手術(shù)患者有無OSAS的高風險。針對外科手術(shù)人群，有3種問卷調(diào)查證實有效，Berlin問卷、美國麻醉學家學會(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)]問卷調(diào)查。

Abrishami等[72]系統(tǒng)回顧和評價不同的睡眠呼吸暫停問卷，提出柏林問卷和STOP-BANG問卷在預測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問卷方法學上最有效，使用也非常方便。

3.2 夜間脈搏血氧飽和度測定

夜間脈搏血氧飽和度測定也常用于篩查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篩查標準，不僅可以除外很多OSAS(AHI>10)患者，也可檢出嚴重的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)前的準備工作。

3.3 家庭睡眠監(jiān)測

便攜式監(jiān)測是另外一種用于有OSAS高風險的患者監(jiān)測方法，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)測儀對將要接受外科手術(shù)伴有OSAS高風險因素成人患者進行檢查，發(fā)現(xiàn)82%的患者為OSAS[14]，這種方法對特定的外科患者確診OSAS很有幫助。

4 圍手術(shù)期處理

2006年美國麻醉師協(xié)會發(fā)表了OSAS患者圍手術(shù)期處理實踐指南，其中提到OSAS評分系統(tǒng)評價圍手術(shù)期危險性[74]。基于這些指南，圍手術(shù)期護理包括3部分：術(shù)前評價，術(shù)中處理，術(shù)后處理。

4.1 術(shù)前評價

患者術(shù)前應(yīng)詳細詢問病史和體格檢查，要特別注意評價睡眠呼吸暫停。與睡眠呼吸暫停相關(guān)的病史包括打鼾、白天過度困倦、他人證實存在呼吸暫停、夜間頻繁覺醒、晨起頭痛等。體格檢查的重點是測量頸圍、體重指數(shù)、改良版Mallampati評分、舌的體積、扁桃體大小以及鼻咽部特征。柏林問卷、ASA列表或STOP-BANG問卷對于識別OSAS風險高的患者是非常重要的，這些問卷調(diào)查簡單易行，并在外科患者中得到了驗證。對高風險患者在圍手術(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)范的睡眠評價以便對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)方式及麻醉類型。應(yīng)當將手術(shù)產(chǎn)生的應(yīng)激反應(yīng)和手術(shù)時間降到最低，因為這些因素會增加圍手術(shù)期并發(fā)癥的風險。盡可能考慮采用阻滯麻醉或局部麻醉來代替全身麻醉。最好是在患者完全清醒時，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)癥的風險較大，應(yīng)在麻醉后監(jiān)護室(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)通過脈搏血氧飽和度檢測儀連續(xù)監(jiān)測氧合功能。這些患者手術(shù)后應(yīng)當盡可能保持非仰臥位以降低呼吸暫停的嚴重程度。這些患者對阿片類藥物和苯二氮卓類藥物非常敏感，圍手術(shù)期應(yīng)當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)。雖然沒有隨機試驗證明CPAP對于術(shù)后有益，且對于從來沒有用過CPAP的患者圍手術(shù)期去適應(yīng)它很困難，但OSAS風險高的患者手術(shù)后仍可以使用自動CPAP(Auto-CPAP)。以前Auto-CPAP從未在這樣的人群中進行正式的研究，需要進行隨機對照試驗來評估Auto-CPAP的療效，同時這部分患者在出院后還應(yīng)繼續(xù)評估睡眠。

Zarbock等[75]對于擇期心臟外科手術(shù)患者預防性使用經(jīng)鼻CPAP顯著降低了肺部并發(fā)癥的發(fā)生率。9項隨機對照試驗的薈萃分析表明，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是呼吸紊亂的常見類型，手術(shù)人群中的患病率很高。但大部分OSAS的患者手術(shù)前沒被確診，手術(shù)時也沒意識到，增加了這部分患者圍手術(shù)期發(fā)生并發(fā)癥的風險。鎮(zhèn)靜藥物、麻醉藥物、阿片類藥物以及REM睡眠反跳現(xiàn)象會加重圍手術(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。篩查問卷如柏林問卷、STOP-NANG問卷或ASA列表等可以識別OSAS高?；颊?，術(shù)前也容易操作。對高?；颊叩膰中g(shù)期處理要制定標準以減少其并發(fā)癥的發(fā)生率，高?；颊叱鲈汉笠惨M行長期正規(guī)的睡眠呼吸評估和管理。

[1] Yaggi HK, Concato J, Kernan WN, et al. Obstructive sleep apnea as a risk factor for stroke and death[J]. N Engl J Med, 2005, 353(19): 2034-2041.

[2] Punjabi NM, Caffo BS, Goodwin JL, et al. Sleep-disordered breathing and mortality: a prospective cohort study[J]. PLoS Med, 2009, 6(8): e1000132.

[3] Marshall NS, Wong KK, Liu PY, et al. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study[J]. Sleep, 2008, 31(8): 1079-1085.

[4] Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study[J]. Lancet, 2005, 365(9464): 1046-1053.

[5] Sharma B, Owens RMalhotra A. Sleep in congestive heart failure[J]. Med Clin North Am, 2010, 94(3): 447-464.

[6] Tregear S, Reston J, Schoelles K, et al. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis[J]. J Clin Sleep Med, 2009, 5(6): 573-581.

[7] Tasali E, Mokhlesi BV，Van Cauter E. Obstructive sleep apnea and type 2 diabetes: interacting epidemics[J]. Chest, 2008, 133(2): 496-506.

[8] Peppard PE, Young T, Palta M, et al. Prospective study of the association between sleep-disordered breathing and hypertension[J]. N Engl J Med, 2000, 342(19): 1378-1384.

[9] Howard ME, Desai AV, Grunstein RR, et al. Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers[J]. Am J Respir Crit Care Med, 2004, 170(9): 1014-1021.

[10] Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults[J]. N Engl J Med, 1993, 328(17): 1230-1235.

[11] Hiestand DM, Britz P, Goldman M, et al. Prevalence of symptoms and risk of sleep apnea in the US population: Results from the national sleep foundation sleep in America 2005 poll[J]. Chest, 2006, 130(3): 780-786.

[12] Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery[J]. Obes Surg, 2003, 13(5): 676-683.

[13] O'Keeffe T, Patterson EJ. Evidence supporting routine polysomnography before bariatric surgery[J]. Obes Surg, 2004, 14(1): 23-26.

[14] Finkel KJ, Searleman AC, Tymkew H, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center[J]. Sleep Med, 2009, 10(7): 753-758.

[15] Chung F, Ward B, Ho J, et al. Preoperative identification of sleep apnea risk in elective surgical patients, using the Berlin questionnaire[J]. J Clin Anesth, 2007, 19(2): 130-134.

[16] Vasu TS, Doghramji K, Cavallazzi R, et al. Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOP-BANG questionnaire[J]. Arch Otolaryngol Head Neck Surg, 2010, 136(10): 1020-1024.

[17] Malow BA, Levy K, Maturen K, et al. Obstructive sleep apnea is common in medically refractory epilepsy patients[J]. Neurology, 2000, 55(7): 1002-1007.

[18] Pollak L, Shpirer I, Rabey JM, et al. Polysomnography in patients with intracranial tumors before and after operation[J]. Acta Neurol Scand, 2004, 109(1): 56-60.

[19] Gold AR, Marcus CL, Dipalo F, et al. Upper airway collapsibility during sleep in upper airway resistance syndrome[J]. Chest, 2002, 121(5): 1531-1540.

[20] Gold ARS, chwartz AR. The pharyngeal critical pressure. The whys and hows of using nasal continuous positive airway pressure diagnostically[J]. Chest, 1996, 110(4): 1077-1088.

[21] Drummond GB. Influence of thiopentone on upper airway muscles[J]. Br J Anaesth, 1989, 63(1): 12-21.

[22] Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity[J]. Br J Anaesth, 1996, 76(5): 663-667.

[23] Eastwood PR, Platt PR, Shepherd K, et al. Collapsibility of the upper airway at different concentrations of propofol anesthesia[J]. Anesthesiology, 2005, 103(3): 470-477.

[24] Hillman DR, Walsh JH, Maddison KJ, et al. Evolution of changes in upper airway collapsibility during slow induction of anesthesia with propofol[J]. Anesthesiology, 2009, 111(1): 63-71.

[25] Dahan A, van den Elsen MJ, Berkenbosch A, et al. Effects of subanesthetic halothane on the ventilatory responses to hypercapnia and acute hypoxia in healthy volunteers[J]. Anesthesiology, 1994, 80(4): 727-738.

[26] Knill RL,Clement JL. Site of selective action of halothane on the peripheral chemoreflex pathway in humans[J]. Anesthesiology, 1984, 61(2): 121-126.

[27] Knill RL, Kieraszewicz HT, Dodgson BG, et al. Chemical regulation of ventilation during isoflurane sedation and anaesthesia in humans[J]. Can Anaesth Soc J, 1983, 30(6): 607-614.

[28] van den Elsen M, Dahan A, De Goede J, et al. Influences of subanesthetic isoflurane on ventilatory control in humans[J]. Anesthesiology, 1995, 83(3): 478-490.

[29] Berkenbosch A, Teppema LJ, Olievier CN, et al. Influences of morphine on the ventilatory response to isocapnic hypoxia[J]. Anesthesiology, 1997, 86(6): 1342-1349.

[30] Borison HL. Central nervous respiratory depressants--narcotic analgesics[J]. Pharmacol Ther B, 1977, 3(2): 227-237.

[31] Christensen V. Respiratory depression after extradural morphine[J]. Br J Anaesth, 1980, 52(8): 841.

[32] Reiz S, Westberg M. Side-effects of epidural morphine[J]. Lancet, 1980, 2(8187): 203-204.

[33] Knill RL, Lam AM Thompson WR. Epidural morphine and ventilatory depression[J]. Anesthesiology, 1982, 56(6): 486-488.

[34] Dahan A, Sarton E, Teppema L, et al. Sex-related differences in the influence of morphine on ventilatory control in humans[J]. Anesthesiology, 1998, 88(4): 903-913.

[35] Sarton E, Teppema L，Dahan A. Sex differences in morphine-induced ventilatory depression reside within the peripheral chemoreflex loop[J]. Anesthesiology, 1999, 90(5): 1329-1338.

[36] Bailey PL, Pace NL, Ashburn MA, et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl[J]. Anesthesiology, 1990, 73(5): 826-830.

[37] Alexander CM,Gross JB. Sedative doses of midazolam depress hypoxic ventilatory responses in humans[J]. Anesth Analg, 1988, 67(4): 377-382.

[38] Bailey PL, Lu JK, Pace NL, et al. Effects of intrathecal morphine on the ventilatory response to hypoxia[J]. N Engl J Med, 2000, 343(17): 1228-1234.

[39] Weil JV, McCullough RE, Kline JS, et al. Diminished ventilatory response to hypoxia and hypercapnia after morphine in normal man[J]. N Engl J Med, 1975, 292(21): 1103-1106.

[40] Aurell JE,lmqvist D. Sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving postoperative care[J]. Br Med J (Clin Res Ed), 1985, 290(6474): 1029-1032.

[41] Ellis BW,Dudley HA. Some aspects of sleep research in surgical stress[J]. J Psychosom Res, 1976, 20(4): 303-308.

[42] Kavey NB,Ahshuler KZ. Sleep in herniorrhaphy patients[J]. Am J Surg, 1979, 138(5): 683-687.

[43] Lehmkuhl P, Prass DPichlmayr I. General anesthesia and postnarcotic sleep disorders[J]. Neuropsychobiology, 1987, 18(1): 37-42.

[44] Knill RL, Moote CA, Skinner MI, et al. Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week[J]. Anesthesiology, 1990, 73(1): 52-61.

[45] Rosenberg J. Sleep disturbances after non-cardiac surgery[J]. Sleep Med Rev, 2001, 5(2): 129-137.

[46] Rosenberg-Adamsen S, Skarbye M, Wildschiodtz G, et al. Sleep after laparoscopic cholecystectomy[J]. Br J Anaesth, 1996, 77(5): 572-575.

[47] Helton MC, Gordon SH，Nunnery SL. The correlation between sleep deprivation and the intensive care unit syndrome[J]. Heart Lung, 1980, 9(3): 464-468.

[48] de Andres I，Corpas I. Morphine effects in brainstem-transected cats: II. Behavior and sleep of the decerebrate cat[J]. Behav Brain Res, 1991, 44(1): 21-26.

[49] Fehm HL, Benkowitsch R, Kern W, et al. Influences of corticosteroids, dexamethasone and hydrocortisone on sleep in humans[J]. Neuropsychobiology, 1986, 16(4): 198-204.

[50] Moser NJ, Phillips BA, Guthrie G, et al. Effects of dexamethasone on sleep[J]. Pharmacol Toxicol, 1996, 79(2): 100-102.

[51] Lin E, Calvano SE，Lowry SF. Inflammatory cytokines and cell response in surgery[J]. Surgery, 2000, 127(2): 117-126.

[52] Menger MD，Vollmar B. Surgical trauma: hyperinflammation versus immunosuppression?[J].Langenbecks Arch Surg, 2004, 389(6): 475-484.

[53] Ni Choileain N，Redmond HP. Cell response to surgery[J]. Arch Surg, 2006, 141(11): 1132-1140.

[54] Opp MR, Kapas L, Toth LA. Cytokine involvement in the regulation of sleep[J]. Proc Soc Exp Biol Med,1992,201(1):16-27.

[55] Kapas L, Hong L, Cady AB, et al. Somnogenic, pyrogenic, and anorectic activities of tumor necrosis factor-alpha and TNF-alpha fragments[J]. Am J Physiol-RegI, 1992, 263(3): R708-R715.

[56] Krueger JM, Fang J, Taishi P, et al. Sleep. A physiologic role for IL-1 beta and TNF-alpha[J]. Ann N Y Acad Sci, 1998, 856: 148-159.

[57] Knill RL, Moote CA, Skinner MI, et al. Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week[J]. Anesthesiology, 1990, 73(1): 52-61.

[58] Rosenberg J, Ullstad T, Rasmussen J, et al. Time course of postoperative hypoxaemia[J]. Eur J Surg, 1994, 160(3): 137-143.

[59] Rosenberg J, Wildschi dtz G, Pedersen M, et al. Late postoperative nocturnal episodic hypoxaemia and associated sleep pattern[J].Br J Anaesth,1994,72(2):145-150.

[60] Knill RL, Skinner MI, Novick T, et al. The night of intense REM sleep after anesthesia and surgery increases urinary catecholamines[J]. Can J Anaesth, 1990, 37(4 Pt 2): S12.

[61] Reeder MK, Muir AD, Foex P, et al. Postoperative myocardial ischaemia: temporal association with nocturnal hypoxaemia[J]. Br J Anaesth, 1991, 67(5): 626-631.

[62] Somers VK, Dyken ME, Mark AL, et al. Sympathetic-nerve activity during sleep in normal subjects[J]. N Engl J Med, 1993, 328(5): 303-307.

[63] Mancia G. Autonomic modulation of the cardiovascular system during sleep[J]. N Engl J Med, 1993, 328(5): 347-349.

[64] Gogenur I, Rosenberg-Adamsen S, Lie C, et al. Relationship between nocturnal hypoxaemia, tachycardia and myocardial ischaemia after major abdominal surgery[J]. Br J Anaesth, 2004, 93(3): 333-338.

[65] Galatius-Jensen S, Hansen J, Rasmussen V, et al. Nocturnal hypoxaemia after myocardial infarction: association with nocturnal myocardial ischaemia and arrhythmias[J]. Br Heart J, 1994, 72(1): 23-30.

[66] Kehlet H，Rosenberg J. Late post-operative hypoxaemia and organ dysfunction[J]. Eur J Anaesthesiol Suppl, 1995, 10: 31-34.

[67] Tarhan S, Moffitt EA, Taylor WF, et al. Myocardial infarction after general anesthesia[J]. JAMA, 1972, 220(11): 1451-1454.

[68] Edwards H, Rose EA, Schorow M, et al. Postoperative deterioration in psychomotor function[J]. JAMA, 1981, 245(13): 1342-1343.

[69] Brimacombe J, Macfie AG. Peri-operative nightmares in surgical patients[J]. Anaesthesia, 1993, 48(6): 527-529.

[70] Galanakis P, Bickel H, Gradinger R, et al. Acute confusional state in the elderly following hip surgery: incidence, risk factors and complications[J]. Int J Geriatr Psychiatry, 2001, 16(4): 349-355.

[71] Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005[J]. Sleep, 2005, 28(4): 499-521.

[72] Abrishami A, Khajehdehi A，Chung F. A systematic review of screening questionnaires for obstructive sleep apnea[J]. Can J Anaesth, 2010, 57(5): 423-438.

[73] Malbois M, Giusti V, Suter M, et al. Oximetry alone versus portable polygraphy for sleep apnea screening before bariatric surgery[J]. Obes Surg, 2010, 20(3): 326-331.

[74] Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelin of unattended portable monitors in the diagnosis of obstructive sleep in adult patients. Portable Monitoring Task Force of the America Sleep Medicine[J]. J Clin Sleep Med,2007,3:737-747.

[75] Zarbock A, Mueller E, Netzer S, et al. Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients[J]. Chest, 2009, 135(5): 1252-1259.

[76] Ferreyra GP, Baussano I, Squadrone V, et al. Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis[J]. Ann Surg, 2008, 247(4): 617-626.

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別及其管理[J].大連醫(yī)科大學學報，2013,35(4)：384-389.

王彥喆(1989-)，女，遼寧大連人，中國醫(yī)科大學七年制。E-mail：407069692@qq.com

王鎮(zhèn)山，教授。E-mail：WZSDL@yahoo.com

2013-04-04；

2013-06-17)