向编辑:
连续正气道压力(CPAP)被认为是中度至严重阻塞性睡眠呼吸暂停(OSA)患者的金标准治疗。使用CPAP处理OSA的处理首先使用鼻界面概念化,因为通过鼻子传递的压力将传递到上气道的后部,并向上方推动口感[1]。自第一个描述以来,CPAP行业已经开发出大量不同的界面,以提高患者的舒适和依从性。OSA常常存在鼻塞和口服界面的患者可用于提供CPAP。鼻腔和口服掩模通常可互换使用,并且对于OSA治疗的CPAP交付界面的选择仍然基于临床经验。然而,由于不完全理解的原因,OSA上的OSA上的OSA患者依赖于CPAP [2]。最近一项随机试验[3.] and a preliminary report [4.]建议,在Oronasal界面交付时,CPAP用于治疗OSA的有效性是可变的。我们描述了一种记录良好的患者,其中CPAP由于舌头的后部位移而使用Oronasal掩模时CPAP无效。
一位69岁的日本巴西,体重指数26.1千克·m-2,呈现给门诊睡眠诊所,抱怨典型的症状,暗示OSA,包括大声打鼾,目睹Apnoeas和过度的白天嗜睡。患者具有积极的系统性高血压和糖尿病的疗程。标准隔夜多瘤摄影(Alice 5; Philips Respironics,Murrysville,Pa,USA)确认了严重的OSA,呼吸暂停症症(AHI)每H和最低氧饱和度58%。由于睡眠期间的口腔呼吸,用Oronasal面膜进行了实验室手动CPAP滴定研究。CPAP逐渐增加到16厘米2o在任何单一CPAP都没有清楚地消除OSA。使用Oronasal掩模的CPAP滴定期间的总体AHI为每H 32个事件,最低氧饱和度为78%。然后调度患者进行新的CPAP滴定研究,该研究是用鼻掩模引发的,在7 CMH的CPAP中消除OSA2O. The mask was changed to an oronasal mask during the second half of the study. In contrast to the first half and similar to the first titration study, OSA was not abolished and obstructive hypopnoeas persisted despite a progressive raise of CPAP up to 16 cmH2o(图。1)。因此,我们假设Oronasal界面所提供的CPAP由于口腔压力引起的舌头后部位移而无效。患者在清晨在清晨提交睡眠内窥镜检查,使用Midazolam的静脉输注,这缓慢滴定滴定,直至睡眠开始,如下所述[5.]。通过掩模中的胶乳密封孔插入内窥镜,直接可视化上气道。患者使用鼻腔和口服面膜时观察到口咽区域。腹咽在患者在7 cmh的cpap上的鼻孔面膜上开放2O but was partially obstructed while on oronasal mask at CPAP of 16 cmH2o由于舌头的后部位移。图像被仔细审查了线,帧框架,并且在每种条件期间在最小的上气道维度上拍摄图像,对应于早期启发(图。1)。一种ir leak with oronasal mask at CPAP of 16 cmH2O was 57 and 30 L·min-1during the CPAP titration night and induced sleep, respectively. During the latter condition pressure at the mask and was equal to the set by the equipment. A nasal CPAP of 7 cmH2O was prescribed and the patient reported significant improvement of symptoms after 3 months of follow-up.
本案例报告传达了两个重要信息,这些消息可能与一些患者相关,了解有关治疗OSA的CPAP界面的选择。首先,与鼻界面相比,Oronasal界面交付的CPAP在治疗OSA方面并不完全有效。在我们的患者中,鼻腔CPAP相对较低(7 CMH2O) was able to abolish OSA. In contrast, three independent sleep studies (including two natural sleep studies and one induced sleep study with midazolam) showed that CPAP titrated up to 16 cmH2o使用Oronasal界面没有充分处理OSA。其次,CPAP滴定期间上气道的直接可视化提供了解释这一表观悖论的机制。我们表明,正如所预期的那样,上呼吸道在7厘米的鼻腔CPAP开放2o.相比之下,在口服CPAP的16 CMH的同时,口咽气道部分阻碍2o由于舌头后部位移导致的面罩。因此,研究表明,通过嘴递送的压力可以向后推动舌头。该假设与先前的报告一致,表明即使在用鼻面罩获得的计算临界闭合压力高于上高于计算的临界关闭压力,CPAP通过Oronasal掩模的CPAP也无法打开上升通道[6.]。一种significant air leak on oronasal mask could lead to insufficient mask pressure and explain the lack of treatment effect. However, the pressure delivered at the mask during induced sleep was equal to that displayed by the equipment. Because obstruction occurred immediately after the interface was changed, it is unlikely that obstruction was caused by an increase in surface tension due to dryness of the upper airways associated with oral breathing. One alternative explanation is that the oronasal mask pushed the mandible backwards, causing a false retrognathism. Although we did not use any imaging method to detect changes in mandibular position in our patient, one recent preliminary study that compared nasal and oronasal interface with and without a mandibular advancement device (MAD) in a group of OSA patients with a history of difficult CPAP titration showed no impact of MAD on the titrated oronasal CPAP in most cases. Interestingly enough, in this preliminary study, four out of eight patients had obstructive events even after a CPAP of 20 cmH2O was reached while using an oronasal mask [4.]。我们的案例报告的一个限制是,在使用Oronasal面膜时,我们无法量化鼻腔和口腔呼吸的比例。这可能是Oronasal界面如何影响鼻和口腔段中的压力分布的主要决定因素。有证据表明睡眠期间的上气道阻力和对阻塞性睡眠呼吸暂停的倾向显着降低,同时呼吸而不是口头呼吸[7.]。
T.eo.等。[3.] have recently reported the first randomised trial that compared CPAP titration with nasal and oronasal masks in patients with newly diagnosed OSA. While the CPAP pressures achieved by nasal and oronasal interfaces was similar (∼11 cmH2o)鼻膜上的AHI显着降低(5.3±3.4与11。0±10.4 events per h, respectively; p=0.01). Moreover, the high AHI standard deviation while on oronasal mask indicates a wide effectiveness variability. In the study of Teo.等。[3.使用Oronasal面膜的使用也与睡眠质量更差,漏洞较高,患者满意度较高。我们推测观察到的,我们患者的观察机制可能有助于解释为什么在Oronasal CPAP上没有有效地治疗几个患者。这些机制可能有助于较高的漏洞和较差的治疗满意度。
总之,我们的案例报告符合最近的研究表明,OSAL界面提供的CPAP在OSA患者的亚组中可能无效[3.那4.]。Our case report suggests that CPAP delivered through an oronasal interface may push the tongue backwards in some patients. Therefore, a nasal mask should be preferred as the first option as a CPAP interface. Patients on an oronasal mask should be carefully followed. The low compliance to CPAP when an oronasal interface is used may be partially explained by suboptimal therapeutic effectiveness.
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