肥胖低通氣綜合征麻醉演示文稿現(xiàn)在是1頁\一共有62頁\編輯于星期四優(yōu)選肥胖低通氣綜合征麻醉現(xiàn)在是2頁\一共有62頁\編輯于星期四幾個概念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現(xiàn)在是3頁\一共有62頁\編輯于星期四單純性鼾癥：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，試驗性無創(chuàng)通氣治療有效。OSAHS：睡眠時上氣道塌陷阻塞引起的呼吸暫停和通氣不足、伴有打鼾、睡眠結構紊亂，頻繁發(fā)生血氧飽和度下降、白天嗜睡等病癥。AHI:睡眠時患者平均每小時發(fā)生的呼吸暫停（>10s)以及低通氣次數(shù)。用于評價患者OSAHS嚴重程度和治療效果的最重要指標。幾個概念現(xiàn)在是4頁\一共有62頁\編輯于星期四IntroductionObesityhypoventilationsyndrome(OHS)：

ObesityDaytimehypoventilationSleep-disorderedbreathingWithoutanalternativeneuromuscular,mechanical,ormetaboliccauseofhypoventilation現(xiàn)在是5頁\一共有62頁\編輯于星期四IntroductionPresentwithincreasingmorbidityandmortalityupperairwayobstructionrestrictivechestphysiologybluntedcentralrespiratorydrivepulmonaryhypertension現(xiàn)在是6頁\一共有62頁\編輯于星期四TherapynoninvasivepositiveairwaypressureimprovesgasexchangeImproveslungvolumesImprovessleep-disorderedbreathingreducesmortality現(xiàn)在是7頁\一共有62頁\編輯于星期四Objective現(xiàn)在是8頁\一共有62頁\編輯于星期四ToexaminetheprevalenceofOHS;Reviewthecurrentdataondiseasemechanisms,screening,andtreatment;DiscusstheoptimalperioperativemanagementofOHS.現(xiàn)在是9頁\一共有62頁\編輯于星期四MaterialsandMethods現(xiàn)在是10頁\一共有62頁\編輯于星期四prevalenceandtreatmentofpatientswithOHS.OHSwasdefinedasDaytimehypercapniaandhypoxemia(PaCO2>45mmHgandPaO2<70mmHg)Obesepatients(BMI>30kg/m2)Sleep-disorderedbreathingAbsenceofanyothercauseofhypoventilation.現(xiàn)在是11頁\一共有62頁\編輯于星期四WhatIsthePrevalenceofOHS?現(xiàn)在是12頁\一共有62頁\編輯于星期四11%8%16%0.15–0.3%

OSApatientsbariatricsurgicalpatientssleeplaboratorygeneraladultpopulation現(xiàn)在是13頁\一共有62頁\編輯于星期四現(xiàn)在是14頁\一共有62頁\編輯于星期四WhataretheMechanisms?

現(xiàn)在是15頁\一共有62頁\編輯于星期四DaytimehypercapniaOHSobesityandOSA現(xiàn)在是16頁\一共有62頁\編輯于星期四LeptinResistanceLeptinisaproteinproducedspecificallybytheadiposetissuethatregulatesappetite,energyexpenditure,andincreasesventilationforthecarbondioxideproduction.AssociatedwithBMI.Leptinleveldropsafterpositiveairwaypressure(PAP)therapy.現(xiàn)在是17頁\一共有62頁\編輯于星期四ThepathogenesisofchronicdaytimehypoventilationofOHSThreeleadinghypothesesImpairedrespiratorymechanicsbecauseofobesityLeptinresistanceleadingtocentralhypoventilationImpairedcompensatoryresponsetoacutehypercapnia現(xiàn)在是18頁\一共有62頁\編輯于星期四IncreasedMechanicalLoadandImpairedRespiratoryMechanics

ObesityBMI現(xiàn)在是19頁\一共有62頁\編輯于星期四ImpairedCompensationofAcuteHypercapniainSleep-disorderedBreathing

HyperventilationduringbriefperiodsofarousalChronichypercapniainOHSWhenapneasbecomethreetimeslongerthanthebreathinginterval,CO2accumulates.AreduceddurationofventilationduringapneaAgradualadaptationofchemoreceptorssecondarytomildelevationofserumHCO3-.現(xiàn)在是20頁\一共有62頁\編輯于星期四現(xiàn)在是21頁\一共有62頁\編輯于星期四DoPatientswithOHSPossessDifferentClinicalFeaturesthanObesePatientswithEucapnia?現(xiàn)在是22頁\一共有62頁\編輯于星期四SignificantlyhigherBMI,increasedhypoxemiaandhypercapnia,morerestrictiverespiratorymechanics,andmoreseveresleep-disorderedbreathing.現(xiàn)在是23頁\一共有62頁\編輯于星期四現(xiàn)在是24頁\一共有62頁\編輯于星期四More……SevereupperairwayobstructionImpairedrespiratorymechanicsBluntedcentralrespiratorydriveIncreasedincidenceofpulmonaryhypertension現(xiàn)在是25頁\一共有62頁\編輯于星期四UpperAirwayObstructionBoththesittingandsupineposition現(xiàn)在是26頁\一共有62頁\編輯于星期四RespiratoryMechanicsExcessiveload,Chestwallcompliance,pulmonaryresistance--doubletheworkofbreathing現(xiàn)在是27頁\一共有62頁\編輯于星期四CentralRespiratoryDriveResultfromleptinresistanceandsleep-disorderedbreathing現(xiàn)在是28頁\一共有62頁\編輯于星期四PulmonaryHypertensionSecondarytochronicalveolarhypoxiaandhypercapniaishigherinpatientswithOHS,rangingfrom30%to88%.現(xiàn)在是29頁\一共有62頁\編輯于星期四DoPatientswithOHSExperienceHigherMorbidityandMortalitythanObesePatientswithOSAandComparableBMI?

現(xiàn)在是30頁\一共有62頁\編輯于星期四YES！現(xiàn)在是31頁\一共有62頁\編輯于星期四Morelikely

todevelop……h(huán)eartfailureanginapectorisandcorpulmonalelong-termcareatdischargeinvasivemechanicalventilation現(xiàn)在是32頁\一共有62頁\編輯于星期四Especially……Previoushistoryofvenousthromboembolism,morbidobesity,malesex,hypertension,increasingage,andnoncompliancewithPAPtreatmentmayfurtherincreasemortalityrisk.Surgicalmortalityrateinhigh-riskOHSpatientsundergoingbariatricsurgeryisbetween2–8%.現(xiàn)在是33頁\一共有62頁\編輯于星期四WhatIstheMainstayofTherapy?

現(xiàn)在是34頁\一共有62頁\編輯于星期四PAPtherapysupplementaloxygenweightreductionsurgerypharmacologicrespiratorystimulants現(xiàn)在是35頁\一共有62頁\編輯于星期四PAPTherapy:Short-termandLong-termBenefits

CPAPandbi-levelPAP.Short-termbenefitsincludeanimprovementingasexchangeandsleep-disorderedbreathing.AsignificantdecreaseinPaCO2,increaseinPaO2.AsignificantimprovementinAHIandoxygensaturationduringsleep.Long-termbenefitsofPAPincludeanimprovementingasexchange,lungvolumes,andcentralrespiratorydrivetocarbondioxide,pulmonaryfunction(FEV1和FVC).PAPmayalsoreducemortalityinOHS.現(xiàn)在是36頁\一共有62頁\編輯于星期四PAPisconsideredthefirst-linetherapyforOHS.現(xiàn)在是37頁\一共有62頁\編輯于星期四現(xiàn)在是38頁\一共有62頁\編輯于星期四Bothshort-termandlong-termpositiveairwaypressuretherapyincreasePaO2anddecreasePaCO2inpatientswithOHS.現(xiàn)在是39頁\一共有62頁\編輯于星期四Bothshort-termandlong-termpositiveairwaypressuretherapyimproveAHIandoxygensaturationduringsleepinpatientswithOHS.現(xiàn)在是40頁\一共有62頁\編輯于星期四Long-termpositiveairwaypressuretherapyimprovesFEV1,FVC,andCO2sensitivityinpatientswithOHS.現(xiàn)在是41頁\一共有62頁\編輯于星期四EfficacyofBilevelPAPversusCPAP

WhenCPAPfailure,definedbyaresidualAHI>5orameannocturnalSpO2<90%,ThesecanbeimprovedwithbilevelPAP.BilevelPAPwasnotconsiderablysuperiortoCPAP,ifCPAPtitrationwassuccessful.現(xiàn)在是42頁\一共有62頁\編輯于星期四SupplementalOxygenApproximately40%ofpatientswithOHScontinuetodesaturatetoSpO2_90%duringsleepwhileonadequateCPAPsettings,therebyrequiringsupplementaloxygen.Thelowestconcentration,particularlyinOHSexperiencinganexacerbationorrecoveringfromsedatives/narcoticsorgeneralanesthesia.現(xiàn)在是43頁\一共有62頁\編輯于星期四WeightReductionSurgery1yraftersurgery,BMI,AHI,PaO2,PaCO2,FEV1,andFVCallimprovedsignificantly.AlthoughthereisadrasticreductioninOSAseverity,somepatientsstillhavemoderateOSA--stillrequirePAPtherapyafterweightloss.現(xiàn)在是44頁\一共有62頁\編輯于星期四Pharmacotherapymedroxyprogesteroneacetate(醋酸甲羥孕酮片)acetazolamide（乙酰唑胺）。目前文獻報道較少，療效不是十分確切，不推薦作為主要治療措施?，F(xiàn)在是45頁\一共有62頁\編輯于星期四PerioperativeManagementofPatientswithOHS

現(xiàn)在是46頁\一共有62頁\編輯于星期四HowDoWeScreenforOHSinthePreoperativeSetting?

ThreeclinicalpredictorsofOHS:serumHCO3,AHI,andlowestoxygensaturationduringsleep.HighBMIandAHIArterialbloodgasesHypercapnia

pulmonaryfunctiontesting,chestimaging,

thyroid-stimulatinghormoneRuleoutotherimportantcausesofhypoventilation.現(xiàn)在是47頁\一共有62頁\編輯于星期四HowDoWeAssessandOptimizeaPatientwithSuspectedOHSbeforeElectiveSurgery?

現(xiàn)在是48頁\一共有62頁\編輯于星期四現(xiàn)在是49頁\一共有62頁\編輯于星期四Additionaltests

pulmonaryhypertensionsleep-disorderedbreathingreasons.現(xiàn)在是50頁\一共有62頁\編輯于星期四GeneralConsiderationsMainchallenges---OSA,obesity,andhypoventilation(hypercapniaandhypoxemia),cardiachemodynamics.History(CAD,DM,CHF與體重成正比).Afocusedcardiopulmonaryexamination.Adetailedexaminationoftheairwayandsitesforvenousaccess.現(xiàn)在是51頁\一共有62頁\編輯于星期四ScreeningforOHSTheSTOP-Bangquestionnaire:STOP(snoring,tiredness,observedapneas,andincreasedbloodpressure),Bang(BMI>35,age>50yr,neckcircumference>40cm,andmalegender)PolysomnographyandtotitratePAPtherapy.Evenforshortdays現(xiàn)在是52頁\一共有62頁\編輯于星期四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%).現(xiàn)在是53頁\一共有62頁\編輯于星期四PreoperativePulmonaryTestingPulmonaryfunctiontestsArterialbloodgasmeasurements.現(xiàn)在是54頁\一共有62頁\編輯于星期四WhatAretheKeyConsiderationsSpecifictoIntraoperativeManagementofOHS?

現(xiàn)在是55頁\一共有62頁\編輯于星期四AirwayManagementBothdifficultmaskventilationandtrachealintubation---與AHI成正相關。Fiveriskfactorslimitedmandibularprotrusionthick/obeseneckanatomyOSAsnoringBMI>30kg/m2現(xiàn)在是56頁\一共有62頁\編輯于星期四DuringinductionofanesthesiaRamppositionwithelevationofthetorsoandhead；Preoxygenationformorethan3minwithatightlyfittedmask；TheapplicationofCPAPandPEEPduringpreoxygenation；Avari