1、睡眠医学的最新进展睡眠医学的最新进展新光医院胸腔内科美国斯坦福大学睡眠研究中心林嘉谟医师演讲内容大纲演讲内容大纲n介绍n睡眠呼吸问题n睡眠呼吸问题与疾病的关系n儿童睡眠呼吸问题n猝睡症n肢动症n失眠症的行为治疗n讨论白天嗜睡的主要原因白天嗜睡的主要原因n睡眠的质或量不够如睡眠时间不足或间断性的睡眠(睡眠呼吸中止症或身心症)n中枢神经病変n生理时钟与环境的互动失调n药物的影响正常睡眠的阶段正常睡眠的阶段n非快速动眼期(Non-REM)睡眠-较规则的呼吸,较理性化的梦境,stage 1,2,3,4.n (stage 3+4=slow wave sleep,SWS)n快速动眼期(REM)睡眠-较不规
2、则的呼吸,较情绪化的梦境,呼吸驱动力较弱,较易缺氧n一个典型夜晚的睡眠是以70-90分钟的非快速动眼期睡眠开始,然后进入约十分钟的快速动眼期睡眠,如此重复循环整个夜晚阻塞性睡眠呼吸中止阻塞性睡眠呼吸中止睡眠呼吸中止症之睡眠呼吸中止症之上呼吸道特徵上呼吸道特徵n鼻腔阻塞n扁桃腺(tonsil),咽扁桃腺(nasal adenoid)肥大n咽颚帆区(velopharyngeal space)浅而狭窄n舌头肥大(Macroglossia)n下颚狭小,后缩(Micro,retro-gnatia)n上呼吸道感觉神经异常Signs and symptoms suggestive of sleep Sign
3、s and symptoms suggestive of sleep apnea apnea Atul et al.Lancet 2002;360:237-45Atul et al.Lancet 2002;360:237-45nSnoringnWitnessed apneas,gasping,or bothnObesity(especially neck circumference)nHypertensionnExcessive daytime sleepinessnFamily historynNocturianNon-restorative sleepAre Far-East Asian
4、More Prone to Are Far-East Asian More Prone to have Sleep Apnea?have Sleep Apnea?亚洲人与美洲人睡眠呼吸中止症候亚洲人与美洲人睡眠呼吸中止症候群病人的比较群病人的比较n亚洲的睡眠呼吸中止症候群的病人较瘦,没有像美洲的病人那么胖n亚洲人先天上颅骨底面积较美洲人小,所以亚洲人上呼吸道会比美洲人更小,更容易有睡眠呼吸问题行为治疗行为治疗n维持理想体重n侧睡n避免睡前镇静药物n避免睡眠不足n避免睡前喝酒n床头摇高(肥胖特别是肚子大的人）n感冒及过敏一定要治好n睡前避免吃太多n戒菸Medical Treatment of O
5、SASMedical Treatment of OSASnRespiratory Center Stimulants(?)n Medroxyprogesterone Acetaten Acetazolamiden Clomipramine Hydrochloriden TheophyllinenNeuroactive Drugs(?)n Protriptylinen Strychninen ModafinilnOxygen therapy(avoid CO2 retention)nIntranasal steroid or radiofrequencynTongue Retaining Dev
6、ice(Oral appliant)(only mild OSA,need follow up sleep study)nNasal CPAP-gold standard of treatment)Surgical Treatment of OSASSurgical Treatment of OSASnTracheostomy-100%success rate but.nRemoval of the underlying obstruction-enlarged tonsils,adenoid,thyroid.etcnTonsillo-adenoidectomynPalatopharyngop
7、lasty(PPP)nUvulopalatopharyngoplasty(UPPP)nLaser-assisted Uvulopalatoplasty(LAUP)nGenioglossal advancementnRadiofrequency palatoplasty and tongue base ablationnMandibular Osteostomy&Hyoid Bone Advancement(Phase II)Radiofrequency Usage in OSASRadiofrequency Usage in OSASChild OSASChild OSAS猝睡症猝睡症(Nar
8、colepsy)(Narcolepsy)The Narcolepsy“TetradThe Narcolepsy“TetradnExcessive daytime sleepiness(sleep attack)nCataplexy(sudden loss of muscle tone)nHypnogogic hallucination(vivid dream-like images just before sleep onset)nSleep paralysis(muscle paralysis on morning awakening)nDisrupted nocturnal sleep?P
9、eriodic Leg MovementPeriodic Leg MovementRestless Leg SyndromeRLS EpidemiologyRLS Epidemiologyn10-15%of the responders(in 2019 subjects)nSimilar prevalence among male and femalenThe mean age of onset was found to between 27.2 and 41.0 yearsnTwo large survey found that 38.3 and 45%of RLS patients,res
10、pectively,experienced their first symptoms before the age of 20Periodic Legs Movements Periodic Legs Movements DefinitionDefinitionnOriginally called“nocturnal myoclonus,PLMS is best described as rhythmical extensions of the big toe and dorsiflexions of the ankle with occasional flexions of the knee
11、 and hip,each movement lasting approximately 0.5 to 5.0 sec with a frequency of about one every 20 to 40 secnThe prevalence of PLMS is correlate with age,rarely diagnosed in 50 years,44%65 years.nA PLMS index(number of the PLMS per hour of sleep)5 for the entire night of sleep is considered patholog
12、ical.Secondary RLS due to Secondary RLS due to Underlying ConditionsUnderlying ConditionsnIron-deficiency anemianUremia(20-40%of dialysis patients)nPregnancy(up to 27%)nFibromyalgia and rheumatoid arthritis(30%)nDiabetes&parkinsons diseasenNeurological lesionsnboth spinal cord and peripheral nerve l
13、esionsnDrug-induced(include withdrawal)ntricyclics,SSRIs,lithium,dopaminenblockers(e.g.,neuroleptics),xanthines,beta-blockers,caffeine,alcohol,and histamine blockersInsomnia DefinednInsomnia is characterized by any of the following:nDifficulty falling asleepnDifficulty staying asleepnEarly morning a
14、wakeningnFeeling unrefreshed in the morningInsomnia EpidemiologyInsomnia EpidemiologynApproximately 35%adults population is afflicted with insomnia during the course of a year.n9-12%of the population occur on a regular basis(chronic insomnia)nBoth the incidence and the complaint of insomnia increase
15、 across the life cyclesComplications of InsomnianInsomnia is a frequent symptom of psychiatric disorders and is often a risk factor for future psychiatric illnessn-Depressionn-Anxietyn-Alcohol abusen-Drug abuseDiagnosing InsomnianComplete sleep historynMedical and psychiatric assessment n -substance
16、 usenAlcohol,caffeine,and concomitant medicationnPrescription and/or OTC medicationnDrugsnSleep diarynPolysomnographyNon-pharmacological Insomnia Non-pharmacological Insomnia Treatment/Cognitive Behavioral Treatment/Cognitive Behavioral Therapy(CBT)OutcomeTherapy(CBT)OutcomenReduce sleep latencynDec
17、rease frequency and duration of arousalnIncrease sleep qualitynDecrease sleep-related anxietynImprove daytime function and moodProcedure of CBTProcedure of CBTnComprehensive evaluationnOvernight sleep studynIndividual of group formatnWeekly session(6-8 weeks)nDaily sleep logsnMultiple component approachnConcomitant drugs treatmentIndications of CBTIndications of CBTnPersistent difficulty falling asleepnPsychogenic insomnianInadequet sleep hygienenCircadian rhythm disordernLong term sleep medication treatment failurenSecondary or residual insomnia complaintsDiscussionDiscussion
