肥胖低通气综合征麻醉演示文稿

肥胖低通气综合征麻醉演示文稿现在是1页\一共有62页\编辑于星期四优选肥胖低通气综合征麻醉现在是2页\一共有62页\编辑于星期四几个概念OHS睡眠呼吸暂停综合症上气道阻力综合症单纯性鼾症正常人OSAHS现在是3页\一共有62页\编辑于星期四单纯性鼾症：夜间可出现不同程度鼾症，AHI<5次/h，白天无症状。上气道阻力综合征：夜间可出现不同频度、程度鼾症，虽上气道阻力增高，但AHI<5次/h，白天嗜睡或疲劳，试验性无创通气治疗有效。OSAHS：睡眠时上气道塌陷阻塞引起的呼吸暂停和通气不足、伴有打鼾、睡眠结构紊乱，频繁发生血氧饱和度下降、白天嗜睡等病症。AHI:睡眠时患者平均每小时发生的呼吸暂停（>10s)以及低通气次数。用于评价患者OSAHS严重程度和治疗效果的最重要指标。几个概念现在是4页\一共有62页\编辑于星期四IntroductionObesityhypoventilationsyndrome(OHS)：

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

OSApatientsbariatricsurgicalpatientssleeplaboratorygeneraladultpopulation现在是13页\一共有62页\编辑于星期四现在是14页\一共有62页\编辑于星期四WhataretheMechanisms?

现在是15页\一共有62页\编辑于星期四DaytimehypercapniaOHSobesityandOSA现在是16页\一共有62页\编辑于星期四LeptinResistanceLeptinisaproteinproducedspecificallybytheadiposetissuethatregulatesappetite,energyexpenditure,andincreasesventilationforthecarbondioxideproduction.AssociatedwithBMI.Leptinleveldropsafterpositiveairwaypressure(PAP)therapy.现在是17页\一共有62页\编辑于星期四ThepathogenesisofchronicdaytimehypoventilationofOHSThreeleadinghypothesesImpairedrespiratorymechanicsbecauseofobesityLeptinresistanceleadingtocentralhypoventilationImpairedcompensatoryresponsetoacutehypercapnia现在是18页\一共有62页\编辑于星期四IncreasedMechanicalLoadandImpairedRespiratoryMechanics

ObesityBMI现在是19页\一共有62页\编辑于星期四ImpairedCompensationofAcuteHypercapniainSleep-disorderedBreathing

HyperventilationduringbriefperiodsofarousalChronichypercapniainOHSWhenapneasbecomethreetimeslongerthanthebreathinginterval,CO2accumulates.AreduceddurationofventilationduringapneaAgradualadaptationofchemoreceptorssecondarytomildelevationofserumHCO3-.现在是20页\一共有62页\编辑于星期四现在是21页\一共有62页\编辑于星期四DoPatientswithOHSPossessDifferentClinicalFeaturesthanObesePatientswithEucapnia?现在是22页\一共有62页\编辑于星期四SignificantlyhigherBMI,increasedhypoxemiaandhypercapnia,morerestrictiverespiratorymechanics,andmoreseveresleep-disorderedbreathing.现在是23页\一共有62页\编辑于星期四现在是24页\一共有62页\编辑于星期四More……SevereupperairwayobstructionImpairedrespiratorymechanicsBluntedcentralrespiratorydriveIncreasedincidenceofpulmonaryhypertension现在是25页\一共有62页\编辑于星期四UpperAirwayObstructionBoththesittingandsupineposition现在是26页\一共有62页\编辑于星期四RespiratoryMechanicsExcessiveload,Chestwallcompliance,pulmonaryresistance--doubletheworkofbreathing现在是27页\一共有62页\编辑于星期四CentralRespiratoryDriveResultfromleptinresistanceandsleep-disorderedbreathing现在是28页\一共有62页\编辑于星期四PulmonaryHypertensionSecondarytochronicalveolarhypoxiaandhypercapniaishigherinpatientswithOHS,rangingfrom30%to88%.现在是29页\一共有62页\编辑于星期四DoPatientswithOHSExperienceHigherMorbidityandMortalitythanObesePatientswithOSAandComparableBMI?

现在是30页\一共有62页\编辑于星期四YES！现在是31页\一共有62页\编辑于星期四Morelikely

todevelop……heartfailureanginapectorisandcorpulmonalelong-termcareatdischargeinvasivemechanicalventilation现在是32页\一共有62页\编辑于星期四Especially……Previoushistoryofvenousthromboembolism,morbidobesity,malesex,hypertension,increasingage,andnoncompliancewithPAPtreatmentmayfurtherincreasemortalityrisk.Surgicalmortalityrateinhigh-riskOHSpatientsundergoingbariatricsurgeryisbetween2–8%.现在是33页\一共有62页\编辑于星期四WhatIstheMainstayofTherapy?

现在是34页\一共有62页\编辑于星期四PAPtherapysupplementaloxygenweightreductionsurgerypharmacologicrespiratorystimulants现在是35页\一共有62页\编辑于星期四PAPTherapy:Short-termandLong-termBenefits

CPAPandbi-levelPAP.Short-termbenefitsincludeanimprovementingasexchangeandsleep-disorderedbreathing.AsignificantdecreaseinPaCO2,increaseinPaO2.AsignificantimprovementinAHIandoxygensaturationduringsleep.Long-termbenefitsofPAPincludeanimprovementingasexchange,lungvolumes,andcentralrespiratorydrivetocarbondioxide,pulmonaryfunction(FEV1和FVC).PAPmayalsoreducemortalityinOHS.现在是36页\一共有62页\编辑于星期四PAPisconsideredthefirst-linetherapyforOHS.现在是37页\一共有62页\编辑于星期四现在是38页\一共有62页\编辑于星期四Bothshort-termandlong-termpositiveairwaypressuretherapyincreasePaO2anddecreasePaCO2inpatientswithOHS.现在是39页\一共有62页\编辑于星期四Bothshort-termandlong-termpositiveairwaypressuretherapyimproveAHIandoxygensaturationduringsleepinpatientswithOHS.现在是40页\一共有62页\编辑于星期四Long-termpositiveairwaypressuretherapyimprovesFEV1,FVC,andCO2sensitivityinpatientswithOHS.现在是41页\一共有62页\编辑于星期四EfficacyofBilevelPAPversusCPAP

WhenCPAPfailure,definedbyaresidualAHI>5orameannocturnalSpO2<90%,ThesecanbeimprovedwithbilevelPAP.BilevelPAPwasnotconsiderablysuperiortoCPAP,ifCPAPtitrationwassuccessful.现在是42页\一共有62页\编辑于星期四SupplementalOxygenApproximately40%ofpatientswithOHScontinuetodesaturatetoSpO2_90%duringsleepwhileonadequateCPAPsettings,therebyrequiringsupplementaloxygen.Thelowestconcentration,particularlyinOHSexperiencinganexacerbationorrecoveringfromsedatives/narcoticsorgeneralanesthesia.现在是43页\一共有62页\编辑于星期四WeightReductionSurgery1yraftersurgery,BMI,AHI,PaO2,PaCO2,FEV1,andFVCallimprovedsignificantly.AlthoughthereisadrasticreductioninOSAseverity,somepatientsstillhavemoderateOSA--stillrequirePAPtherapyafterweightloss.现在是44页\一共有62页\编辑于星期四Pharmacotherapymedroxyprogesteroneacetate(醋酸甲羟孕酮片)acetazolamide（乙酰唑胺）。目前文献报道较少，疗效不是十分确切，不推荐作为主要治疗措施。现在是45页\一共有62页\编辑于星期四PerioperativeManagementofPatientswithOHS

现在是46页\一共有62页\编辑于星期四HowDoWeScreenforOHSinthePreoperativeSetting?

ThreeclinicalpredictorsofOHS:serumHCO3,AHI,andlowestoxygensaturationduringsleep.HighBMIandAHIArterialbloodgasesHypercapnia

pulmonaryfunctiontesting,chestimaging,

thyroid-stimulatinghormoneRuleoutotherimportantcausesofhypoventilation.现在是47页\一共有62页\编辑于星期四HowDoWeAssessandOptimizeaPatientwithSuspectedOHSbeforeElectiveSurgery?

现在是48页\一共有62页\编辑于星期四现在是49页\一共有62页\编辑于星期四Additionaltests

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

现在是55页\一共有62页\编辑于星期四AirwayManagementBothdifficultmaskventilationandtrachealintubation---与AHI成正相关。Fiveriskfactorslimitedmandibularprotrusionthick/obeseneckanatomyOSAsnoringBMI>30kg/m2现在是56页\一共有62页\编辑于星期四DuringinductionofanesthesiaRamppositionwithelevationofthetorsoandhead；Preoxygenationformorethan3minwithatightlyfittedmask；TheapplicationofCPAPandPEEPduringpreoxygenation；Avari