肥胖低通氣綜合征麻醉演示文稿當(dāng)前第1頁\共有62頁\編于星期六\9點(diǎn)優(yōu)選肥胖低通氣綜合征麻醉當(dāng)前第2頁\共有62頁\編于星期六\9點(diǎn)幾個(gè)概念OHS睡眠呼吸暫停綜合癥上氣道阻力綜合癥單純性鼾癥正常人OSAHS當(dāng)前第3頁\共有62頁\編于星期六\9點(diǎn)單純性鼾癥：夜間可出現(xiàn)不同程度鼾癥，AHI<5次/h，白天無癥狀。上氣道阻力綜合征：夜間可出現(xiàn)不同頻度、程度鼾癥，雖上氣道阻力增高，但AHI<5次/h，白天嗜睡或疲勞，試驗(yàn)性無創(chuàng)通氣治療有效。OSAHS：睡眠時(shí)上氣道塌陷阻塞引起的呼吸暫停和通氣不足、伴有打鼾、睡眠結(jié)構(gòu)紊亂，頻繁發(fā)生血氧飽和度下降、白天嗜睡等病癥。AHI:睡眠時(shí)患者平均每小時(shí)發(fā)生的呼吸暫停（>10s)以及低通氣次數(shù)。用于評價(jià)患者OSAHS嚴(yán)重程度和治療效果的最重要指標(biāo)。幾個(gè)概念當(dāng)前第4頁\共有62頁\編于星期六\9點(diǎn)IntroductionObesityhypoventilationsyndrome(OHS)：

ObesityDaytimehypoventilationSleep-disorderedbreathingWithoutanalternativeneuromuscular,mechanical,ormetaboliccauseofhypoventilation當(dāng)前第5頁\共有62頁\編于星期六\9點(diǎn)IntroductionPresentwithincreasingmorbidityandmortalityupperairwayobstructionrestrictivechestphysiologybluntedcentralrespiratorydrivepulmonaryhypertension當(dāng)前第6頁\共有62頁\編于星期六\9點(diǎn)TherapynoninvasivepositiveairwaypressureimprovesgasexchangeImproveslungvolumesImprovessleep-disorderedbreathingreducesmortality當(dāng)前第7頁\共有62頁\編于星期六\9點(diǎn)Objective當(dāng)前第8頁\共有62頁\編于星期六\9點(diǎn)ToexaminetheprevalenceofOHS;Reviewthecurrentdataondiseasemechanisms,screening,andtreatment;DiscusstheoptimalperioperativemanagementofOHS.當(dāng)前第9頁\共有62頁\編于星期六\9點(diǎn)MaterialsandMethods當(dāng)前第10頁\共有62頁\編于星期六\9點(diǎn)prevalenceandtreatmentofpatientswithOHS.OHSwasdefinedasDaytimehypercapniaandhypoxemia(PaCO2>45mmHgandPaO2<70mmHg)Obesepatients(BMI>30kg/m2)Sleep-disorderedbreathingAbsenceofanyothercauseofhypoventilation.當(dāng)前第11頁\共有62頁\編于星期六\9點(diǎn)WhatIsthePrevalenceofOHS?當(dāng)前第12頁\共有62頁\編于星期六\9點(diǎn)11%8%16%0.15–0.3%

OSApatientsbariatricsurgicalpatientssleeplaboratorygeneraladultpopulation當(dāng)前第13頁\共有62頁\編于星期六\9點(diǎn)當(dāng)前第14頁\共有62頁\編于星期六\9點(diǎn)WhataretheMechanisms?

當(dāng)前第15頁\共有62頁\編于星期六\9點(diǎn)DaytimehypercapniaOHSobesityandOSA當(dāng)前第16頁\共有62頁\編于星期六\9點(diǎn)LeptinResistanceLeptinisaproteinproducedspecificallybytheadiposetissuethatregulatesappetite,energyexpenditure,andincreasesventilationforthecarbondioxideproduction.AssociatedwithBMI.Leptinleveldropsafterpositiveairwaypressure(PAP)therapy.當(dāng)前第17頁\共有62頁\編于星期六\9點(diǎn)ThepathogenesisofchronicdaytimehypoventilationofOHSThreeleadinghypothesesImpairedrespiratorymechanicsbecauseofobesityLeptinresistanceleadingtocentralhypoventilationImpairedcompensatoryresponsetoacutehypercapnia當(dāng)前第18頁\共有62頁\編于星期六\9點(diǎn)IncreasedMechanicalLoadandImpairedRespiratoryMechanics

ObesityBMI當(dāng)前第19頁\共有62頁\編于星期六\9點(diǎn)ImpairedCompensationofAcuteHypercapniainSleep-disorderedBreathing

HyperventilationduringbriefperiodsofarousalChronichypercapniainOHSWhenapneasbecomethreetimeslongerthanthebreathinginterval,CO2accumulates.AreduceddurationofventilationduringapneaAgradualadaptationofchemoreceptorssecondarytomildelevationofserumHCO3-.當(dāng)前第20頁\共有62頁\編于星期六\9點(diǎn)當(dāng)前第21頁\共有62頁\編于星期六\9點(diǎn)DoPatientswithOHSPossessDifferentClinicalFeaturesthanObesePatientswithEucapnia?當(dāng)前第22頁\共有62頁\編于星期六\9點(diǎn)SignificantlyhigherBMI,increasedhypoxemiaandhypercapnia,morerestrictiverespiratorymechanics,andmoreseveresleep-disorderedbreathing.當(dāng)前第23頁\共有62頁\編于星期六\9點(diǎn)當(dāng)前第24頁\共有62頁\編于星期六\9點(diǎn)More……SevereupperairwayobstructionImpairedrespiratorymechanicsBluntedcentralrespiratorydriveIncreasedincidenceofpulmonaryhypertension當(dāng)前第25頁\共有62頁\編于星期六\9點(diǎn)UpperAirwayObstructionBoththesittingandsupineposition當(dāng)前第26頁\共有62頁\編于星期六\9點(diǎn)RespiratoryMechanicsExcessiveload,Chestwallcompliance,pulmonaryresistance--doubletheworkofbreathing當(dāng)前第27頁\共有62頁\編于星期六\9點(diǎn)CentralRespiratoryDriveResultfromleptinresistanceandsleep-disorderedbreathing當(dāng)前第28頁\共有62頁\編于星期六\9點(diǎn)PulmonaryHypertensionSecondarytochronicalveolarhypoxiaandhypercapniaishigherinpatientswithOHS,rangingfrom30%to88%.當(dāng)前第29頁\共有62頁\編于星期六\9點(diǎn)DoPatientswithOHSExperienceHigherMorbidityandMortalitythanObesePatientswithOSAandComparableBMI?

當(dāng)前第30頁\共有62頁\編于星期六\9點(diǎn)YES！當(dāng)前第31頁\共有62頁\編于星期六\9點(diǎn)Morelikely

todevelop……h(huán)eartfailureanginapectorisandcorpulmonalelong-termcareatdischargeinvasivemechanicalventilation當(dāng)前第32頁\共有62頁\編于星期六\9點(diǎn)Especially……Previoushistoryofvenousthromboembolism,morbidobesity,malesex,hypertension,increasingage,andnoncompliancewithPAPtreatmentmayfurtherincreasemortalityrisk.Surgicalmortalityrateinhigh-riskOHSpatientsundergoingbariatricsurgeryisbetween2–8%.當(dāng)前第33頁\共有62頁\編于星期六\9點(diǎn)WhatIstheMainstayofTherapy?

當(dāng)前第34頁\共有62頁\編于星期六\9點(diǎn)PAPtherapysupplementaloxygenweightreductionsurgerypharmacologicrespiratorystimulants當(dāng)前第35頁\共有62頁\編于星期六\9點(diǎn)PAPTherapy:Short-termandLong-termBenefits

CPAPandbi-levelPAP.Short-termbenefitsincludeanimprovementingasexchangeandsleep-disorderedbreathing.AsignificantdecreaseinPaCO2,increaseinPaO2.AsignificantimprovementinAHIandoxygensaturationduringsleep.Long-termbenefitsofPAPincludeanimprovementingasexchange,lungvolumes,andcentralrespiratorydrivetocarbondioxide,pulmonaryfunction(FEV1和FVC).PAPmayalsoreducemortalityinOHS.當(dāng)前第36頁\共有62頁\編于星期六\9點(diǎn)PAPisconsideredthefirst-linetherapyforOHS.當(dāng)前第37頁\共有62頁\編于星期六\9點(diǎn)當(dāng)前第38頁\共有62頁\編于星期六\9點(diǎn)Bothshort-termandlong-termpositiveairwaypressuretherapyincreasePaO2anddecreasePaCO2inpatientswithOHS.當(dāng)前第39頁\共有62頁\編于星期六\9點(diǎn)Bothshort-termandlong-termpositiveairwaypressuretherapyimproveAHIandoxygensaturationduringsleepinpatientswithOHS.當(dāng)前第40頁\共有62頁\編于星期六\9點(diǎn)Long-termpositiveairwaypressuretherapyimprovesFEV1,FVC,andCO2sensitivityinpatientswithOHS.當(dāng)前第41頁\共有62頁\編于星期六\9點(diǎn)EfficacyofBilevelPAPversusCPAP

WhenCPAPfailure,definedbyaresidualAHI>5orameannocturnalSpO2<90%,ThesecanbeimprovedwithbilevelPAP.BilevelPAPwasnotconsiderablysuperiortoCPAP,ifCPAPtitrationwassuccessful.當(dāng)前第42頁\共有62頁\編于星期六\9點(diǎn)SupplementalOxygenApproximately40%ofpatientswithOHScontinuetodesaturatetoSpO2_90%duringsleepwhileonadequateCPAPsettings,therebyrequiringsupplementaloxygen.Thelowestconcentration,particularlyinOHSexperiencinganexacerbationorrecoveringfromsedatives/narcoticsorgeneralanesthesia.當(dāng)前第43頁\共有62頁\編于星期六\9點(diǎn)WeightReductionSurgery1yraftersurgery,BMI,AHI,PaO2,PaCO2,FEV1,andFVCallimprovedsignificantly.AlthoughthereisadrasticreductioninOSAseverity,somepatientsstillhavemoderateOSA--stillrequirePAPtherapyafterweightloss.當(dāng)前第44頁\共有62頁\編于星期六\9點(diǎn)Pharmacotherapymedroxyprogesteroneacetate(醋酸甲羥孕酮片)acetazolamide（乙酰唑胺）。目前文獻(xiàn)報(bào)道較少，療效不是十分確切，不推薦作為主要治療措施。當(dāng)前第45頁\共有62頁\編于星期六\9點(diǎn)PerioperativeManagementofPatientswithOHS

當(dāng)前第46頁\共有62頁\編于星期六\9點(diǎn)HowDoWeScreenforOHSinthePreoperativeSetting?

ThreeclinicalpredictorsofOHS:serumHCO3,AHI,andlowestoxygensaturationduringsleep.HighBMIandAHIArterialbloodgasesHypercapnia

pulmonaryfunctiontesting,chestimaging,

thyroid-stimulatinghormoneRuleoutotherimportantcausesofhypoventilation.當(dāng)前第47頁\共有62頁\編于星期六\9點(diǎn)HowDoWeAssessandOptimizeaPatientwithSuspectedOHSbeforeElectiveSurgery?

當(dāng)前第48頁\共有62頁\編于星期六\9點(diǎn)當(dāng)前第49頁\共有62頁\編于星期六\9點(diǎn)Additionaltests

pulmonaryhypertensionsleep-disorderedbreathingreasons.當(dāng)前第50頁\共有62頁\編于星期六\9點(diǎn)GeneralConsiderationsMainchallenges---OSA,obesity,andhypoventilation(hypercapniaandhypoxemia),cardiachemodynamics.History(CAD,DM,CHF與體重成正比).Afocusedcardiopulmonaryexamination.Adetailedexaminationoftheairwayandsitesforvenousaccess.當(dāng)前第51頁\共有62頁\編于星期六\9點(diǎn)ScreeningforOHSTheSTOP-Bangquestionnaire:STOP(snoring,tiredness,observedapneas,andincreasedbloodpressure),Bang(BMI>35,age>50yr,neckcircumference>40cm,andmalegender)PolysomnographyandtotitratePAPtherapy.Evenforshortdays當(dāng)前第52頁\共有62頁\編于星期六\9點(diǎn)PreoperativeRiskStratificationandCardiovascularTesting

Cardiacriskindex,pulmonaryhypertension,historyofvenousthromboembolism,hypertension,BMI>50kg/m2,malesex,age>45yr,pulmonaryhypertension.Mortalityrisk---low(zerooronecomorbidity),intermediate(twotothreecomorbidities)andhigh(fourtofivecomorbidities).Mortalityrateswere0.2%,1.2%,and2.4%.Themostcommoncausesofdeathwerepulmonaryembolism(30%),cardiaccauses(27%)andgastrointestinalleak(21%).當(dāng)前第53頁\共有62頁\編于星期六\9點(diǎn)PreoperativePulmonaryTestingPulmonaryfunctiontestsArterialbloodgasmeasurements.當(dāng)前第54頁\共有62頁\編于星期六\9點(diǎn)WhatAretheKeyConsiderationsSpecifictoIntraoperativeManagementofOHS?

當(dāng)前第55頁\共有62頁\編于星期六\9點(diǎn)AirwayManagementBothdifficultmaskventilationandtrachealintubation---與AHI成正相關(guān)。Fiveriskfactorslimitedmandibularprotrusionthick/obeseneckanatomyOSAsnoringBMI>30kg/m2當(dāng)前第56頁\共有62頁\編于星期六\9點(diǎn)DuringinductionofanesthesiaRamppositionwithelevationofthetorsoandhead；Preoxygenationformorethan3minwithatightlyfittedmask；TheapplicationofCPAPandPEEPduringpreoxygenation；Avar