睡眠医学的最新进展

1、睡眠醫學的最新進展睡眠醫學的最新進展新光醫院胸腔內科美國史丹佛大學睡眠研究中心林嘉謨醫師演講內容大綱演講內容大綱n介紹n睡眠呼吸問題n睡眠呼吸問題與疾病的關係n兒童睡眠呼吸問題n猝睡症n肢動症n失眠症的行為治療n討論白天嗜睡的主要原因白天嗜睡的主要原因n睡眠的質或量不夠如睡眠時間不足或間斷性的睡眠(睡眠呼吸中止症或身心症)n中枢神經病変n生理時鐘與環境的互動失調n藥物的影響正常睡眠的階段正常睡眠的階段n非快速動眼期(Non-REM)睡眠-較規則的呼吸,較理性化的夢境, stage 1,2,3,4. ( stage 3+4=slow wave sleep, SWS)n快速動眼期(REM)睡眠-較

2、不規則的呼吸,較情緒化的夢境,呼吸驅動力較弱,較易缺氧n一個典型夜晚的睡眠是以70-90分鐘的非快速動眼期睡眠開始,然後進入約十分鐘的快速動眼期睡眠,如此重複循環整個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咽顎帆區(velopharyngeal space)淺而狹窄n舌頭肥大(Macroglossia)n下顎狹小, 後縮(Micro,retro-gnatia)n上呼吸道感覺神經異常Signs and symptoms suggestive of Signs

3、and symptoms suggestive of sleep apneasleep apnea Atul Atul et al. Lancet 2002; 360:237-45 et al. Lancet 2002; 360:237-45nSnoringnWitnessed apneas, gasping, or bothnObesity (especially neck circumference)nHypertensionnExcessive daytime sleepinessnFamily historynNocturianNon-restorative sleepAre Far-

4、East Asian More Prone to have Sleep Are Far-East Asian More Prone to have Sleep Apnea?Apnea?亞洲人與美洲人睡眠呼吸中止症候亞洲人與美洲人睡眠呼吸中止症候群病人的比較群病人的比較n亞洲的睡眠呼吸中止症候群的病人較瘦,沒有像美洲的病人那麼胖n亞洲人先天上顱骨底面積較美洲人小,所以亞洲人上呼吸道會比美洲人更小,更容易有睡眠呼吸問題行為治療行為治療n維持理想體重n側睡n避免睡前鎮靜藥物n避免睡眠不足n避免睡前喝酒n床頭搖高(肥胖特別是肚子大的人）n感冒及過敏一定要治好n睡前避免吃太多n戒菸Medical Tre

5、atment of OSASMedical Treatment of OSASnRespiratory Center Stimulants (?) Medroxyprogesterone Acetate Acetazolamide Clomipramine Hydrochloride TheophyllinenNeuroactive Drugs (?) Protriptyline Strychnine ModafinilnOxygen therapy (avoid CO2 retention)nIntranasal steroid or radiofrequencynTongue Retain

6、ing Device (Oral appliant) (only mild OSA, need follow up sleep study)nNasal CPAP-gold standard of treatment)Nasal CPAP-gold standard of treatment)Surgical Treatment of OSASSurgical Treatment of OSASnTracheostomy-100% success rate but.nRemoval of the underlying obstruction-enlarged tonsils, adenoid,

7、 thyroid.etcnTonsillo-adenoidectomynPalatopharyngoplasty (PPP)nUvulopalatopharyngoplasty (UPPP)nLaser-assisted Uvulopalatoplasty (LAUP)nGenioglossal advancementnRadiofrequency palatoplasty and tongue base ablationnMandibular Osteostomy & Hyoid Bone Advancement (Phase II)Radiofrequency Usage in O

8、SASRadiofrequency Usage in OSASChild OSASChild OSAS猝睡症猝睡症(Narcolepsy)(Narcolepsy)The Narcolepsy “Tetrad”The Narcolepsy “Tetrad”nExcessive daytime sleepiness (sleep attack)nCataplexy (sudden loss of muscle tone)nHypnogogic hallucination (vivid dream-like images just before sleep onset)nSleep paralysi

9、s (muscle paralysis on morning awakening)nDisrupted nocturnal sleep?Periodic 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

10、 41.0 yearsnTwo large survey found that 38.3 and 45% of RLS patients, respectively, experienced their first symptoms before the age of 20Periodic Legs Movements DefinitionPeriodic Legs Movements DefinitionnOriginally called “nocturnal myoclonus”, PLMS is best described as rhythmical extensions of th

11、e big toe and dorsiflexions of the ankle with occasional flexions of the knee 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

12、 the PLMS per hour of sleep) 5 for the entire night of sleep is considered pathological.Secondary RLS due to Underlying Secondary RLS due to Underlying ConditionsConditionsnIron-deficiency anemianUremia (20-40% of dialysis patients)nPregnancy (up to 27%)nFibromyalgia and rheumatoid arthritis (30%)nD

13、iabetes & parkinsons diseasenNeurological lesionsboth spinal cord and peripheral nerve lesionsnDrug-induced (include withdrawal)tricyclics, SSRIs, lithium, dopamine blockers (e.g., neuroleptics), xanthines, beta-blockers, caffeine, alcohol, and histamine blockersInsomnia DefinednInsomnia is char

14、acterized by any of the following:nDifficulty falling asleepnDifficulty staying asleepnEarly morning awakeningnFeeling unrefreshed in the morningInsomnia EpidemiologynApproximately 35% adults population is afflicted with insomnia during the course of a year.n9-12 % of the population occur on a regul

15、ar basis (chronic insomnia)nBoth the incidence and the complaint of insomnia increase across the life cyclesComplications of InsomnianInsomnia is a frequent symptom of psychiatric disorders and is often a risk factor for future psychiatric illness-Depression-Anxiety-Alcohol abuse-Drug abuseDiagnosin

16、g InsomnianComplete sleep historynMedical and psychiatric assessment -substance usenAlcohol, caffeine, and concomitant medicationnPrescription and / or OTC medicationnDrugsnSleep diarynPolysomnographyNon-pharmacological Insomnia Treatment/Cognitive Behavioral Therapy (CBT) OutcomenReduce sleep latencynDecrease frequency and duration of arousalnIncrease sleep qualitynDecrease sleep-related anxietynImprove daytime function and moodProcedure of CBTnComprehensive evaluationnOvernight sleep studynIndividual of group formatnWeekly session (6-8 weeks)nDaily sleep logsnMultiple co