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当前第1页\共有62页\编于星期六\9点优选肥胖低通气综合征麻醉当前第2页\共有62页\编于星期六\9点几个概念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当前第3页\共有62页\编于星期六\9点单纯性鼾症：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。几个概念当前第4页\共有62页\编于星期六\9点IntroductionObesityhypoventilationsyndrome(OHS)：

ObesityDaytimehypoventilationSleep-disorderedbreathingWithoutanalternativeneuromuscular,mechanical,ormetaboliccauseofhypoventilation当前第5页\共有62页\编于星期六\9点IntroductionPresentwithincreasingmorbidityandmortalityupperairwayobstructionrestrictivechestphysiologybluntedcentralrespiratorydrivepulmonaryhypertension当前第6页\共有62页\编于星期六\9点TherapynoninvasivepositiveairwaypressureimprovesgasexchangeImproveslungvolumesImprovessleep-disorderedbreathingreducesmortality当前第7页\共有62页\编于星期六\9点Objective当前第8页\共有62页\编于星期六\9点ToexaminetheprevalenceofOHS;Reviewthecurrentdataondiseasemechanisms,screening,andtreatment;DiscusstheoptimalperioperativemanagementofOHS.当前第9页\共有62页\编于星期六\9点MaterialsandMethods当前第10页\共有62页\编于星期六\9点prevalenceandtreatmentofpatientswithOHS.OHSwasdefinedasDaytimehypercapniaandhypoxemia(PaCO2>45mmHgandPaO2<70mmHg)Obesepatients(BMI>30kg/m2)Sleep-disorderedbreathingAbsenceofanyothercauseofhypoventilation.当前第11页\共有62页\编于星期六\9点WhatIsthePrevalenceofOHS?当前第12页\共有62页\编于星期六\9点11%8%16%0.15–0.3%

OSApatientsbariatricsurgicalpatientssleeplaboratorygeneraladultpopulation当前第13页\共有62页\编于星期六\9点当前第14页\共有62页\编于星期六\9点WhataretheMechanisms?

当前第15页\共有62页\编于星期六\9点DaytimehypercapniaOHSobesityandOSA当前第16页\共有62页\编于星期六\9点LeptinResistanceLeptinisaproteinproducedspecificallybytheadiposetissuethatregulatesappetite,energyexpenditure,andincreasesventilationforthecarbondioxideproduction.AssociatedwithBMI.Leptinleveldropsafterpositiveairwaypressure(PAP)therapy.当前第17页\共有62页\编于星期六\9点ThepathogenesisofchronicdaytimehypoventilationofOHSThreeleadinghypothesesImpairedrespiratorymechanicsbecauseofobesityLeptinresistanceleadingtocentralhypoventilationImpairedcompensatoryresponsetoacutehypercapnia当前第18页\共有62页\编于星期六\9点IncreasedMechanicalLoadandImpairedRespiratoryMechanics

ObesityBMI当前第19页\共有62页\编于星期六\9点ImpairedCompensationofAcuteHypercapniainSleep-disorderedBreathing

HyperventilationduringbriefperiodsofarousalChronichypercapniainOHSWhenapneasbecomethreetimeslongerthanthebreathinginterval,CO2accumulates.AreduceddurationofventilationduringapneaAgradualadaptationofchemoreceptorssecondarytomildelevationofserumHCO3-.当前第20页\共有62页\编于星期六\9点当前第21页\共有62页\编于星期六\9点DoPatientswithOHSPossessDifferentClinicalFeaturesthanObesePatientswithEucapnia?当前第22页\共有62页\编于星期六\9点SignificantlyhigherBMI,increasedhypoxemiaandhypercapnia,morerestrictiverespiratorymechanics,andmoreseveresleep-disorderedbreathing.当前第23页\共有62页\编于星期六\9点当前第24页\共有62页\编于星期六\9点More……SevereupperairwayobstructionImpairedrespiratorymechanicsBluntedcentralrespiratorydriveIncreasedincidenceofpulmonaryhypertension当前第25页\共有62页\编于星期六\9点UpperAirwayObstructionBoththesittingandsupineposition当前第26页\共有62页\编于星期六\9点RespiratoryMechanicsExcessiveload,Chestwallcompliance,pulmonaryresistance--doubletheworkofbreathing当前第27页\共有62页\编于星期六\9点CentralRespiratoryDriveResultfromleptinresistanceandsleep-disorderedbreathing当前第28页\共有62页\编于星期六\9点PulmonaryHypertensionSecondarytochronicalveolarhypoxiaandhypercapniaishigherinpatientswithOHS,rangingfrom30%to88%.当前第29页\共有62页\编于星期六\9点DoPatientswithOHSExperienceHigherMorbidityandMortalitythanObesePatientswithOSAandComparableBMI?

当前第30页\共有62页\编于星期六\9点YES！当前第31页\共有62页\编于星期六\9点Morelikely

todevelop……heartfailureanginapectorisandcorpulmonalelong-termcareatdischargeinvasivemechanicalventilation当前第32页\共有62页\编于星期六\9点Especially……Previoushistoryofvenousthromboembolism,morbidobesity,malesex,hypertension,increasingage,andnoncompliancewithPAPtreatmentmayfurtherincreasemortalityrisk.Surgicalmortalityrateinhigh-riskOHSpatientsundergoingbariatricsurgeryisbetween2–8%.当前第33页\共有62页\编于星期六\9点WhatIstheMainstayofTherapy?

当前第34页\共有62页\编于星期六\9点PAPtherapysupplementaloxygenweightreductionsurgerypharmacologicrespiratorystimulants当前第35页\共有62页\编于星期六\9点PAPTherapy:Short-termandLong-termBenefits

CPAPandbi-levelPAP.Short-termbenefitsincludeanimprovementingasexchangeandsleep-disorderedbreathing.AsignificantdecreaseinPaCO2,increaseinPaO2.AsignificantimprovementinAHIandoxygensaturationduringsleep.Long-termbenefitsofPAPincludeanimprovementingasexchange,lungvolumes,andcentralrespiratorydrivetocarbondioxide,pulmonaryfunction(FEV1和FVC).PAPmayalsoreducemortalityinOHS.当前第36页\共有62页\编于星期六\9点PAPisconsideredthefirst-linetherapyforOHS.当前第37页\共有62页\编于星期六\9点当前第38页\共有62页\编于星期六\9点Bothshort-termandlong-termpositiveairwaypressuretherapyincreasePaO2anddecreasePaCO2inpatientswithOHS.当前第39页\共有62页\编于星期六\9点Bothshort-termandlong-termpositiveairwaypressuretherapyimproveAHIandoxygensaturationduringsleepinpatientswithOHS.当前第40页\共有62页\编于星期六\9点Long-termpositiveairwaypressuretherapyimprovesFEV1,FVC,andCO2sensitivityinpatientswithOHS.当前第41页\共有62页\编于星期六\9点EfficacyofBilevelPAPversusCPAP

WhenCPAPfailure,definedbyaresidualAHI>5orameannocturnalSpO2<90%,ThesecanbeimprovedwithbilevelPAP.BilevelPAPwasnotconsiderablysuperiortoCPAP,ifCPAPtitrationwassuccessful.当前第42页\共有62页\编于星期六\9点SupplementalOxygenApproximately40%ofpatientswithOHScontinuetodesaturatetoSpO2_90%duringsleepwhileonadequateCPAPsettings,therebyrequiringsupplementaloxygen.Thelowestconcentration,particularlyinOHSexperiencinganexacerbationorrecoveringfromsedatives/narcoticsorgeneralanesthesia.当前第43页\共有62页\编于星期六\9点WeightReductionSurgery1yraftersurgery,BMI,AHI,PaO2,PaCO2,FEV1,andFVCallimprovedsignificantly.AlthoughthereisadrasticreductioninOSAseverity,somepatientsstillhavemoderateOSA--stillrequirePAPtherapyafterweightloss.当前第44页\共有62页\编于星期六\9点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。当前第45页\共有62页\编于星期六\9点PerioperativeManagementofPatientswithOHS

当前第46页\共有62页\编于星期六\9点HowDoWeScreenforOHSinthePreoperativeSetting?

ThreeclinicalpredictorsofOHS:serumHCO3,AHI,andlowestoxygensaturationduringsleep.HighBMIandAHIArterialbloodgasesHypercapnia

pulmonaryfunctiontesting,chestimaging,

thyroid-stimulatinghormoneRuleoutotherimportantcausesofhypoventilation.当前第47页\共有62页\编于星期六\9点HowDoWeAssessandOptimizeaPatientwithSuspectedOHSbeforeElectiveSurgery?

当前第48页\共有62页\编于星期六\9点当前第49页\共有62页\编于星期六\9点Additionaltests

pulmonaryhypertensionsleep-disorderedbreathingreasons.当前第50页\共有62页\编于星期六\9点GeneralConsiderationsMainchallenges---OSA,obesity,andhypoventilation(hypercapniaandhypoxemia),cardiachemodynamics.History(CAD,DM,CHF与体重成正比).Afocusedcardiopulmonaryexamination.Adetailedexaminationoftheairwayandsitesforvenousaccess.当前第51页\共有62页\编于星期六\9点ScreeningforOHSTheSTOP-Bangquestionnaire:STOP(snoring,tiredness,observedapneas,andincreasedbloodpressure),Bang(BMI>35,age>50yr,neckcircumference>40cm,andmalegender)PolysomnographyandtotitratePAPtherapy.Evenforshortdays当前第52页\共有62页\编于星期六\9点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%).当前第53页\共有62页\编于星期六\9点PreoperativePulmonaryTestingPulmonaryfunctiontestsArterialbloodgasmeasurements.当前第54页\共有62页\编于星期六\9点WhatAretheKeyConsiderationsSpecifictoIntraoperativeManagementofOHS?

当前第55页\共有62页\编于星期六\9点AirwayManagementBothdifficultmaskventilationandtrachealintubation---与AHI成正相关。Fiveriskfactorslimitedmandibularprotrusionthick/obeseneckanatomyOSAsnoringBMI>30kg/m2当前第56页\共有62页\编于星期六\9点DuringinductionofanesthesiaRamppositionwithelevationofthetorsoandhead；Preoxygenationformorethan3minwithatightlyfittedmask；TheapplicationofCPAPandPEEPduringpreoxygenation；Avar