睡眠相关的呼吸异常与脑血管病
第二军医大学长征医院神经内科 (200003)
睡眠相关的呼吸异常(SDB，sleep-disordered breathing)与脑血管病一样，都有较高的发病率、致死率和致残率。流行病学调查显示SDB是脑血管病的独立危险因素。SDB包括习惯性打鼾、上气道高压综合征(upper airway resistance syndrome ，UARS)、周期性呼吸和睡眠呼吸暂停等。在30-60岁美国人中，有9%-15%的男性和4%-9%的女性患SDB。SDB患者的脑血管病多发生于睡眠中，31篇文献的荟萃分析(包括11816例脑血管病患者)结果显示脑血管病清晨发病率较其它时间段高49%。
SDB增加脑血管病发病率和死亡率的可能机制。睡眠呼吸暂停时的脑灌注不足和血液的高凝状态是这组人群脑血管病危险性增高的病理生理学基础。在睡眠呼吸暂停期间，SDB患者的血压和脑血流量急剧波动。OSA患者夜间的低氧血症诱发红细胞生成素分泌增加，出现红细胞增多症。OSA患者外凝集旁路的标记物凝血因子VII活性增强。SBD患者因低氧血症可使颈内动脉内皮受损，脂质代谢紊乱，易形成粥样斑块沉积于内膜下。B超检查发现，与不伴有SDB的人群比较，SDB的颈总动脉的内膜厚度增加50%(1.429比0.976mm)。
, http://www.100md.com
SDB患者的临床表现有日间思睡，认知功能减退，注意力不集中，记忆力降低，人格改变，疲劳和头痛、头晕等。在夜晚出现间断性打鼾、呼吸的突然中止和较多的肢体动作，还可出现睡眠中多动、咳嗽、夜间憋醒、夜尿增多等。SDB主动就诊者极少，老年患者常被误认为是衰老表现，而长期漏诊。SDB常与多种疾病并存，症状相互掩盖，使病情更为复杂。
体格检查可见各种原因引起的上气道狭窄，如鼻中隔偏曲、鼻甲肿胀、下颌后缩、舌体增大、悬雍垂肥大、软腭松弛和声带麻痹等。患者的夜间心律失常加重、清晨的血压偏高。需要排除甲状腺机能减退、肢端肥大症、神经肌肉疾病、酗酒、过量应用镇静催眠剂和睡眠剥夺等。PSG和/或多次睡眠潜伏期试验检测，能对SBD的严重程度进行监控，并有指导治疗的作用。积极治疗SDB患者，能够降低脑血管病的发病率和死亡率。
Sleep-related Breathing Disorders and Stroke
, 百拇医药
ZHAO Zhongxin
Department of Neurology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003
Stroke and sleep-related breathing disorders are both common and are associated with significant morbidity and mortality. Several recent large epidemiological studies have shown a strong association between these 2 disorders independent of known risk factors for stroke. Sleep related breathing disorders are composed of habitual snoring, increased upper airway resistance syndrome, periodic breathing, and sleep apnea disorder. In the United States, the prevalence of obstructive sleep apnea disorder has been estimated to be 9% to 15% for men and 4% to 9% for women between the ages of 30 and 60 years. A meta-analysis of 31 publications with 11 816 patients found a 49% increase in all types of stroke (ischemic, hemorrhagic, transient ischaemic attack) during the morning hours, as compared with the rest of the day.
, http://www.100md.com
There are several mechanisms of stroke in sleep-related breathing disorders. The combination of cerebral hypoperfusion and hypercoagulability in sleep apnea disorder may be the underlying pathophysiological mechanism for increased risk of stroke in this population. During and after obstructive apnea episodes, there are sharp swings of arterial blood pressure and cerebral blood flow. The OSA patients ’s erythrogenin level was higher ,and there exist a prothrombotic shift in coagulation balance, with increased factor VII clotting activity, which is a marker of the extrinsic coagulation pathway. Almost 50% increase in the intima-media thickness, as examined by B-mode Duplex sonography of the common carotid artery (1.429 versus 0.976 mm) in OSA individuals as compared with controls without SDB with matched age and comorbid factors.
, 百拇医药
The most common daytime manifestation of SBD is excessive daytime sleepiness, frequently associated with signs of intellectual impairment, poor concentration, memory loss, personality changes, headache and fatigue. During the night, patients may have snoring, cessation of airflow, nocturia or enuresis, automatic behavior, sleep drunkenness (disorientation, confusion upon awakening), hypnagogic hallucinations and night sweats. The rate of seeking medical advice on patients own initiative is very low, some patients misunderstanding it as senescence. SDB always combined with other diseases, thus make the condition more complex.
, 百拇医药
Physical examination of the upper airways may disclose a deviated nasal septum or swollen turbinates, retrognathia, retrognathia, an enlarged tongue, a hypertrophic uvula, a redundant soft palate, or paralyzed vocal cords. There were a high prevalence of cardiac rhythm disturbances in the night and hypertension in the morning among patients with SBD. The diagnosis need exclude other diseases, such as hypothyroidism, acromegaly, neuromuscular disorders, alcohol, sedative-hypnotics and sleep deprivation. Polysomnography and/or multiple sleep latency test (MSLT) are useful methods to monitor the patients’sleep codition with SDB. Take active treatment to the sleep-related breathing disorders may decrease the morbidity and mortality of cerbral vascular diseases., 百拇医药(赵忠新)
睡眠相关的呼吸异常(SDB，sleep-disordered breathing)与脑血管病一样，都有较高的发病率、致死率和致残率。流行病学调查显示SDB是脑血管病的独立危险因素。SDB包括习惯性打鼾、上气道高压综合征(upper airway resistance syndrome ，UARS)、周期性呼吸和睡眠呼吸暂停等。在30-60岁美国人中，有9%-15%的男性和4%-9%的女性患SDB。SDB患者的脑血管病多发生于睡眠中，31篇文献的荟萃分析(包括11816例脑血管病患者)结果显示脑血管病清晨发病率较其它时间段高49%。
SDB增加脑血管病发病率和死亡率的可能机制。睡眠呼吸暂停时的脑灌注不足和血液的高凝状态是这组人群脑血管病危险性增高的病理生理学基础。在睡眠呼吸暂停期间，SDB患者的血压和脑血流量急剧波动。OSA患者夜间的低氧血症诱发红细胞生成素分泌增加，出现红细胞增多症。OSA患者外凝集旁路的标记物凝血因子VII活性增强。SBD患者因低氧血症可使颈内动脉内皮受损，脂质代谢紊乱，易形成粥样斑块沉积于内膜下。B超检查发现，与不伴有SDB的人群比较，SDB的颈总动脉的内膜厚度增加50%(1.429比0.976mm)。
, http://www.100md.com
SDB患者的临床表现有日间思睡，认知功能减退，注意力不集中，记忆力降低，人格改变，疲劳和头痛、头晕等。在夜晚出现间断性打鼾、呼吸的突然中止和较多的肢体动作，还可出现睡眠中多动、咳嗽、夜间憋醒、夜尿增多等。SDB主动就诊者极少，老年患者常被误认为是衰老表现，而长期漏诊。SDB常与多种疾病并存，症状相互掩盖，使病情更为复杂。
体格检查可见各种原因引起的上气道狭窄，如鼻中隔偏曲、鼻甲肿胀、下颌后缩、舌体增大、悬雍垂肥大、软腭松弛和声带麻痹等。患者的夜间心律失常加重、清晨的血压偏高。需要排除甲状腺机能减退、肢端肥大症、神经肌肉疾病、酗酒、过量应用镇静催眠剂和睡眠剥夺等。PSG和/或多次睡眠潜伏期试验检测，能对SBD的严重程度进行监控，并有指导治疗的作用。积极治疗SDB患者，能够降低脑血管病的发病率和死亡率。
Sleep-related Breathing Disorders and Stroke
, 百拇医药
ZHAO Zhongxin
Department of Neurology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003
Stroke and sleep-related breathing disorders are both common and are associated with significant morbidity and mortality. Several recent large epidemiological studies have shown a strong association between these 2 disorders independent of known risk factors for stroke. Sleep related breathing disorders are composed of habitual snoring, increased upper airway resistance syndrome, periodic breathing, and sleep apnea disorder. In the United States, the prevalence of obstructive sleep apnea disorder has been estimated to be 9% to 15% for men and 4% to 9% for women between the ages of 30 and 60 years. A meta-analysis of 31 publications with 11 816 patients found a 49% increase in all types of stroke (ischemic, hemorrhagic, transient ischaemic attack) during the morning hours, as compared with the rest of the day.
, http://www.100md.com
There are several mechanisms of stroke in sleep-related breathing disorders. The combination of cerebral hypoperfusion and hypercoagulability in sleep apnea disorder may be the underlying pathophysiological mechanism for increased risk of stroke in this population. During and after obstructive apnea episodes, there are sharp swings of arterial blood pressure and cerebral blood flow. The OSA patients ’s erythrogenin level was higher ,and there exist a prothrombotic shift in coagulation balance, with increased factor VII clotting activity, which is a marker of the extrinsic coagulation pathway. Almost 50% increase in the intima-media thickness, as examined by B-mode Duplex sonography of the common carotid artery (1.429 versus 0.976 mm) in OSA individuals as compared with controls without SDB with matched age and comorbid factors.
, 百拇医药
The most common daytime manifestation of SBD is excessive daytime sleepiness, frequently associated with signs of intellectual impairment, poor concentration, memory loss, personality changes, headache and fatigue. During the night, patients may have snoring, cessation of airflow, nocturia or enuresis, automatic behavior, sleep drunkenness (disorientation, confusion upon awakening), hypnagogic hallucinations and night sweats. The rate of seeking medical advice on patients own initiative is very low, some patients misunderstanding it as senescence. SDB always combined with other diseases, thus make the condition more complex.
, 百拇医药
Physical examination of the upper airways may disclose a deviated nasal septum or swollen turbinates, retrognathia, retrognathia, an enlarged tongue, a hypertrophic uvula, a redundant soft palate, or paralyzed vocal cords. There were a high prevalence of cardiac rhythm disturbances in the night and hypertension in the morning among patients with SBD. The diagnosis need exclude other diseases, such as hypothyroidism, acromegaly, neuromuscular disorders, alcohol, sedative-hypnotics and sleep deprivation. Polysomnography and/or multiple sleep latency test (MSLT) are useful methods to monitor the patients’sleep codition with SDB. Take active treatment to the sleep-related breathing disorders may decrease the morbidity and mortality of cerbral vascular diseases., 百拇医药(赵忠新)