nCPAP治疗伴轻中度OSAHS缺血性卒中患者的随访研究

摘要/Abstract

摘要：

目的比较合并轻中度阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea-hypopnea syndrome，OSAHS）非急性缺血性卒中患者接受经鼻持续气道正压通气（nasal continuous positive airway pressure，nCPAP）治疗与未接受nCPAP治疗患者2年内缺血性卒中复发事件及相关指标变化。方法前瞻性连续选取2008年3月～2010年3月北京市海淀医院神经内科住院及门诊的非急性缺血性卒中患者30例，发病90 d后进行多导睡眠图（polysomnography，PSG）监测，符合轻中度OSAHS诊断标准，纳入研究，根据是否应用nCPAP治疗，将患者分为nCPAP治疗组（14例）和非nCPAP治疗组（16例），分别于入组后第6、12、18、24个月随访观察缺血性卒中复发、呼吸暂停低通气指数（apnea hypopnea index，AHI）、血压、体重指数（body mass index，BMI）、Epworth嗜睡量表评分（Epworth Sleepiness Scale，ESS）、焦虑和抑郁状态发生率等。结果 nCPAP治疗组和非nCPAP治疗组，入组时年龄、性别、糖尿病、高血压病史、AHI、收缩压、舒张压、BMI、改良Rankin量表评分、ESS评分、焦虑和抑郁状态发生率评分差异无显著性（P值均＞0.05）。随访2年中两组均无缺血性卒中复发事件。第6、12、18、24个月nCPAP治疗组AHI（3.9±0.6、3.8±0.5、3.9±0.5、3.8±0.5）较非nCPAP治疗组（20.8±4.1、21.7±4.5、22.6±4.2、26.8±6.1）改善，差异具有显著性（t值分别为16.2、15.9、17.8、15.0，P值均＜0.001）。治疗组ESS评分在第6、12、18、24个月（3.5±1.7、2.6±1.5、2.2±1.4、2.1±1.1）较对照组（6.8±1.2、7.0±1.3、7.1±1.2、7.2±1.6）改善，差异具有显著性（t值分别为6.1、8.8、9.9、10.0，P值均＜0.001）。在第24个月焦虑发生率改善（nCPAP组7.1%、非nCPAP组43.8%），差异具有显著性（P=0.039），抑郁发生率在第6、12、18、24个月无明显变化（nCPAP组14.3%、14.3%、14.3%、14.3%）（非nCPAP组18.8%、18.8%、18.8%、18.8%），差异无显著性（P值均＞0.05）。在第6、12、18、24个月BMI nCPAP组（22.8±1.4、23.1±1.4、22.7±1.4、22.6±1.4）与非nCPAP组（23.3±1.4、23.7±1.6、23.5±1.6、23.0±1.3）差异无显著性（P值均＞0.05）。结论 nCPAP治疗可降低合并轻中度OSAHS缺血性卒中患者的AHI，降低患者ESS评分及改善焦虑状态。

文章导读： 通过前瞻性研究，发现使用经鼻持续气道正压通气治疗可降低伴轻中度阻塞性睡眠呼吸暂停低通气综合征的缺血性卒中患者的呼吸暂停低通气指数、Epworth嗜睡量表评分及改善焦虑状态。

关键词: 缺血性卒中; 经鼻持续正压通气; 阻塞性睡眠呼吸暂停低通气综合征

Abstract:

Objective To observe the clinical results of ischemic stroke patients with mild and moderate obstructive sleep apnea-hypopnea syndrome treated by nasal continuous positive airway pressure (nCPAP). Methods Sixty-two cases were selected from March 2008 to March 2010 who suffered acute ischemic stroke. After 90 days, thirty patients with mild or moderate obstructive sleep apnea-hypopnea syndrome were enrolled into the study by using polysomnography. Then they were divided into two groups by whether using nCPAP or not:one group (14 cases) accepted treatment with nCPAP, while the other group (16 cases) rejected it. The recurrence rate of stroke, apnea hypopnea index (AHI), blood pressure, body mass index (BMI), Epworth Sleepiness Score (ESS), Hospital Anxiety and Depression Scale (HAD) at the 6th, 12th, 18th, 24th month were measured. Results There were no significant differences between two groups in age, sex, diabetes mellitus,hypertension disease, AHI, systolic pressure, diastolic pressure, BMI, modified Rankin Scale score, ESS, HAD (P value >0.05). There are no recurrent ischemic strokes through two years of observation. The nCPAP group performs better than non-nCPAP group in reducing AHI (nCPAP group AHI:3.9±0.6, 3.8±0.5, 3.9±0.5, 3.8±0.5, non-CPAP group AHI:20.8±4.1, 21.7±4.5, 22.6±4.2, 26.8±6.1, t value 16.2, 15.9, 17.8, 15.0, P value <0.001) and ESS scores (nCPAP group 3.5±1.7, 2.6±1.5, 2.2±1.4, 2.1±1.1, t value 6.1, 8.8, 9.9, 10.0, all P values <0.001), improving the ratio of anxiety in 24th month (P=0.039), while there is subtle difference in the ratio of depression level in the 6th, 12th, 18th, 24th month (nCPAP group:14.3%, 14.3%, 14.3%,14.3%, non-CPAP group:18.8%, 18.8%, 18.8%, 18.8%, P value 1.0, 1.0, 1.0, 1.0) and there is subtle difference in BMI in the 6th, 12th, 18th, 24th month (nCPAP group:22.8±1.4, 23.1±1.4, 22.7±1.4, 22.6±1.4, non-CPAP group:23.3±1.4, 23.7±1.6, 23.5±1.6, 23.0±1.3, P value >0.05). Conclusion It proves that treatment with nCPAP can reduce AHI, decrease ESS scores, and improve the level of anxiety.

Key words: Ischemic stroke; Nasal continuous positive airway pressure; Obstructive sleep apnea-hypopnea syndrome

唐晓梅，于逢春，孟晓梅，陈新平，刘伟，冯浩，朱健. nCPAP治疗伴轻中度OSAHS缺血性卒中患者的随访研究[J]. 中国卒中杂志, 2013, 8(11): 881-886.

TANG Xiao-Mei, YU Feng-Chun, MENG Xiao-Mei,CHEN Xin-Ping, LIU Wei, FENG Hao, ZHU Jian.. Investigation of Ischemic Stroke Patients with Mild or Moderate Obstructive Sleep Apnea-hypopnea Syndrome Treated by Nasal Continuous Positive Airway Pressure[J]. Chinese Journal of Stroke, 2013, 8(11): 881-886.

参考文献

1 卫生部新闻办公室. 第三次全国死因调查主要情况[J]. 中国肿瘤, 2008, 5:344-345.

2 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, 353:2034-2041.

3 Mannarino MR, Di Filippo F, Pirro M. Obstructive sleep apnea syndrome[J]. Eur J Intern Med, 2012, 23:586-593.

4 Minnerup J, Ritter MA, Wersching H, et al. Continuous positive airway pressure ventilation for acute ischemic stroke:a randomized feasibility study[J]. Stroke, 2012, 43:1137-1139.

5 中华神经科学会. 各类脑血管疾病诊断要点[J]. 中华神经科杂志, 1996, 29:379-380.

6 中华医学会呼吸病学会分会睡眠呼吸障碍学组. 阻塞性睡眠呼吸暂停低通气综合征诊治指南[J]. 中华结核和呼吸杂志, 2012, 35:9-12.

7 中国高血压防治指南修订委员会. 中国高血压防治指南2010[J]. 中华心血管病杂志, 2011, 39:579-616.

8 中华医学会糖尿病学分会. 中国2型糖尿病防治指南(2010年版)[J]. 中华糖尿病杂志, 2010, 增刊2:1-56.

9 van Swieten JC, Koudstaal PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients[J]. Stroke, 1988, 19:604-607.

10 Zigmond AS, Snaith RP. The hospital anxiety and depression scale[J]. Acta Psychiatr Stand, 1983, 67:361-370.

11 中华医学会神经病学分会脑血管学组缺血性脑卒中二级预防指南撰写组. 中国缺血性脑卒中和短暂性脑缺血发作二级预防指南2010[J]. 中华神经科杂志, 2010, 43:1-7.

12 Sacoo RI, Foulkes MA, Mohr JP, et al. Determinants of early recurrence of cerebral infarction. The stroke data bank[J]. Stroke, 1989, 20:983-989.

13 Arzt M, Young T, Finn L, et al. Association of sleep-disordered breathing and the occurrence of stroke[J]. Am J Respir Crit Care Med, 2005, 172:1447-1451.

14 Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea and hypertension in a large community-based study. Sleep Heart Health Study[J]. JAMA, 2000, 283:1829-1836.

15 Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients:a meta-analysis[J]. J Clin Sleep Med, 2010, 6:131-137.

16 Iyer SR, Iyer RR. Sleep, ageing and stroke--newer directions in management of stroke[J]. J Assoc Physicians India, 2010, 58:442-446.

17 Dziewas R, Humpert M, Hopmann B, et al. Increased prevalence of sleep apnea in patients with recurring ischemic stroke compared with first stroke victims[J]. J Neurol, 2005, 252:1394-1398.

18 Martínez-García MA, Soler-Cataluna J, Ejarque-Martinez L, et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea:a 5-year follow-up study[J]. Am J Respir Crit Care Med, 2009, 180:36-41.

19 Yurtlu S, Sariman N, Levent E, et al. Short-term positive airway pressure therapy response in obstructive sleep apnea patients:impact of treatment on the quality of life[J]. Tuberk Toraks, 2012, 60:327-335.

20 Diamanti C, Manali E, Ginieri-Coccossis M, et al. Depression, physical activity, energy consumption, and quality of life in OSA patients before and after CPAP treatment[J]. Sleep Breath, 2013, 17:1109-1115.

21 Calhoun DA, Harding SM. Sleep and hypertension[J]. Chest, 2010, 138:434-443.

22 Zhang W, Si LY. Obstructive sleep apnea syndrome (OSAS) and hypertension:pathogenic mechanisms and possible therapeutic approaches[J]. Ups J Med Sci, 2012, 117:372-380.

23 Börgel J, Sanner BM, Keskin F, et al. Obstructive sleep apnea and blood pressure. Interaction between the blood pressure-lowering effects of positive airway pressure therapy and antihypertensive drugs[J]. Am J Hypertens, 2004, 7:1081-1087.

24 Lopez PP, Stefan B, Schulman CI, et al. Prevalence of sleep apnea in morbidly obese patients who presented for weight loss surgery evaluation:more evidence for routine screening for obstructive sleep apnea before weight loss surgery[J]. Am Surg, 2008, 74:834-838.

25 Lam DC, Xu A, Lam KS, et al. Serum adipocyte-fatty acid binding protein level is elevated in severe OSA and correlates with insulin resistance[J]. Eur Respir J, 2009, 33:346-351.

[1]	吴娱倩, 张玉梅, 范小伟, 王安心, 逄文斌. 运动想象-动觉治疗对缺血性卒中患者手功能康复效果的研究[J]. 中国卒中杂志, 2022, 17(12): 1366-1371.
[2]	伊珞, 周宏宇, 仇鑫, 李子孝, 王拥军. 动脉粥样硬化性疾病的DNA甲基化改变[J]. 中国卒中杂志, 2022, 17(11): 1163-1170.
[3]	王誉博, 李子孝, 王拥军. 表观遗传学与缺血性卒中后氧化应激的相关性研究进展[J]. 中国卒中杂志, 2022, 17(11): 1171-1177.
[4]	崔凌云, 仇鑫, 周宏宇, 李子孝, 王拥军. DNA甲基化与2型糖尿病的相关性研究进展[J]. 中国卒中杂志, 2022, 17(11): 1183-1188.
[5]	刘光亮, 韩凯月, 苏文龙, 张皓. 不同强度有氧踏车训练对不同病程缺血性卒中患者运动和心肺适能的影响 [J]. 中国卒中杂志, 2022, 17(11): 1203-1208.
[6]	徐莹鑫, 张爽, 周晓梅, 袁景林, 赵留庄, 杨海华. 非狭窄性颈动脉斑块与前循环不明原因栓塞性卒中的相关性研究 [J]. 中国卒中杂志, 2022, 17(11): 1233-1237.
[7]	程实, 李静, 郭军平, 胡爱香, 于鑫玮, 韩玮, 梁瑛, 张越巍, 冀瑞俊. 急性卒中患者住院期间感染的临床特征及危险因素分析[J]. 中国卒中杂志, 2022, 17(10): 1065-1070.
[8]	向薇, 徐璐瑶, 张曼曼, 魏红春, 梁志刚. 缺血性卒中急性期磁敏感加权成像不对称突出静脉征的发生率及影响因素分析[J]. 中国卒中杂志, 2022, 17(10): 1097-1102.
[9]	赵永瑞, 刘展会. 弥散张量成像在缺血性卒中患者运动功能预后评估中的研究进展[J]. 中国卒中杂志, 2022, 17(10): 1114-1119.
[10]	张伯煜, 郭玉成, 崔玉霞, 李英丽, 吕雨梅. 急性缺血性卒中患者就医行为决策现状及影响因素研究进展[J]. 中国卒中杂志, 2022, 17(10): 1127-1132.
[11]	吴亭亭, 刘亚飞, 闫世曦, 武一平, 张忠波, 张邯菲, 房娉平. “互联网+”在急性缺血性卒中救治中的应用进展[J]. 中国卒中杂志, 2022, 17(10): 1133-1138.
[12]	徐蔚海, 李顺, 程安琪. 青年卒中的诊治：勿过激[J]. 中国卒中杂志, 2022, 17(09): 915-918.
[13]	张一歌, 张婉, 张璐阳, 王鑫, 丁澜, 王玉莹, 裴璐璐, 方慧, 许予明, 宋波. 责任动脉闭塞与夹层相关缺血性卒中复发的相关性分析[J]. 中国卒中杂志, 2022, 17(09): 932-936.
[14]	吕微, 王安心, 田雪, 张晓丽, 许玉园, 孟霞. 心血宁胶囊对伴高同型半胱氨酸水平缺血性卒中患者短期功能预后的影响[J]. 中国卒中杂志, 2022, 17(09): 972-976.
[15]	张心邈, 潘岳松, 向祥龙, 王拥军, 孟霞. 早期临床路径干预改善卒中医疗服务质量关键绩效指标研究[J]. 中国卒中杂志, 2022, 17(09): 977-984.