睡眠医学的进展课件

,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,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,睡眠医学的最新进展新光医院胸腔内科,1,演讲内容大纲,介绍,睡眠呼吸问题,睡眠呼吸问题与疾病的关系,儿童睡眠呼吸问题,猝睡症,肢动症,失眠症的行为治疗,讨论,演讲内容大纲介绍,2,白天嗜睡的主要原因,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,),中枢神经病変,生理时钟与环境的互动失调,药物的影响,白天嗜睡的主要原因睡眠的质或量不够如睡眠时间不足或间断性的睡,3,正常睡眠的阶段,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.,( stage 3+4=slow wave sleep, SWS),快速动眼期,(REM),睡眠,-,较不规则的呼吸,较情绪化的梦境,呼吸驱动力较弱,较易缺氧,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,正常睡眠的阶段非快速动眼期(Non-REM)睡眠-较规则的,4,阻塞性睡眠呼吸中止,阻塞性睡眠呼吸中止,5,睡眠呼吸中止症之上呼吸道特徵,鼻腔阻塞,扁桃腺(tonsil), 咽扁桃腺(nasal adenoid)肥大,咽颚帆区(velopharyngeal space)浅而狭窄,舌头肥大(Macroglossia),下颚狭小, 后缩(Micro,retro-gnatia),上呼吸道感觉神经异常,睡眠呼吸中止症之上呼吸道特徵鼻腔阻塞,6,Signs and symptoms suggestive of sleep apnea Atul et al. Lancet 2002; 360:237-45,Snoring,Witnessed apneas, gasping, or both,Obesity (especially neck circumference),Hypertension,Excessive daytime sleepiness,Family history,Nocturia,Non-restorative sleep,Signs and symptoms suggestive,7,Are Far-East Asian More Prone to have Sleep Apnea?,Are Far-East Asian More Prone,8,亚洲人与美洲人睡眠呼吸中止症候群病人的比较,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,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,亚洲人与美洲人睡眠呼吸中止症候群病人的比较亚洲的睡眠呼吸中止,9,行为治疗,维持理想体重,侧睡,避免睡前镇静药物,避免睡眠不足,避免睡前喝酒,床头摇高,(,肥胖特别是肚子大的人）,感冒及过敏一定要治好,睡前避免吃太多,戒菸,行为治疗维持理想体重,10,Medical Treatment of OSAS,Respiratory Center Stimulants (?),Medroxyprogesterone Acetate,Acetazolamide,Clomipramine Hydrochloride,Theophylline,Neuroactive Drugs (?),Protriptyline,Strychnine,Modafinil,Oxygen therapy (avoid CO2 retention),Intranasal steroid or radiofrequency,Tongue Retaining Device (Oral appliant) (only mild OSA, need follow up sleep study),Nasal CPAP-gold standard of treatment),Medical Treatment of OSASRespi,11,Surgical Treatment of OSAS,Tracheostomy-100% success rate but.,Removal of the underlying obstruction-enlarged tonsils, adenoid, thyroid.etc,Tonsillo-adenoidectomy,Palatopharyngoplasty (PPP),Uvulopalatopharyngoplasty (UPPP),Laser-assisted Uvulopalatoplasty (LAUP),Genioglossal advancement,Radiofrequency palatoplasty and tongue base ablation,Mandibular Osteostomy & Hyoid Bone Advancement (Phase II),Surgical Treatment of OSASTrac,12,Radiofrequency Usage in OSAS,Radiofrequency Usage in OSAS,13,Child OSAS,Child OSAS,14,猝睡症(Narcolepsy),猝睡症(Narcolepsy),15,The Narcolepsy “Tetrad,Excessive daytime sleepiness (sleep attack),Cataplexy (sudden loss of muscle tone),Hypnogogic hallucination (vivid dream-like images just before sleep onset),Sleep paralysis (muscle paralysis on morning awakening),Disrupted nocturnal sleep?,The Narcolepsy “TetradExcessi,16,Periodic Leg Movement,Periodic Leg Movement,17,Restless Leg Syndrome,Restless Leg Syndrome,18,RLS Epidemiology,10-15% of the responders (in 2019 subjects),Similar prevalence among male and female,The mean age of onset was found to between 27.2 and 41.0 years,Two large survey found that 38.3 and 45% of RLS patients, respectively, experienced their first symptoms before the age of 20,RLS Epidemiology10-15% of the,19,Periodic Legs Movements Definition,Originally 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 and hip, each movement lasting approximately 0.5 to 5.0 sec with a frequency of about one every 20 to 40 sec,The prevalence of PLMS is correlate with age, rarely diagnosed in 50 years, 44% 65 years.,A PLMS index (number of the PLMS per hour of sleep) 5 for the entire night of sleep is considered pathological.,Periodic Legs Movements Defini,20,Secondary RLS due to Underlying Conditions,Iron-deficiency anemia,Uremia (20-40% of dialysis patients),Pregnancy (up to 27%),Fibromyalgia and rheumatoid arthritis (30%),Diabetes & parkinsons disease,Neurological lesions,both spinal cord and peripheral nerve lesions,Drug-induced (include withdrawal),tricyclics, SSRIs, lithium, dopamine,blockers (e.g., neuroleptics), xanthines, beta-blockers, caffeine, alcohol, and histamine blockers,Secondary RLS due to Underlyin,21,Insomnia Defined,Insomnia is characterized by any of the following:,Difficulty falling asleep,Difficulty staying asleep,Early morning awakening,Feeling unrefreshed in the morning,Insomnia DefinedInsomnia is ch,22,Insomnia Epidemiology,Approximately 35% adults population is afflicted with insomnia during the course of a year.,9-12 % of the population occur on a regular basis (chronic insomnia),Both the incidence and the complaint of insomnia increase across the life cycles,Insomnia EpidemiologyApproxima,23,Complications of Insomnia,Insomnia is a frequent symptom of psychiatric disorders and is often a risk factor for future psychiatric illness,-Depression,-Anxiety,-Alcohol abuse,-Drug abuse,Complications of InsomniaInsom,24,Diagnosing Insomnia,Complete sleep history,Medical and psychiatric assessment,-substance use,Alcohol, caffeine, and concomitant medication,Prescription and / or OTC medication,Drugs,Sleep diary,Polysomnography,Diagnosing InsomniaComplete sl,25,Non-pharmacological Insomnia Treatment/Cognitive Behavioral Therapy (CBT) Outcome,Reduce sleep latency,Decrease frequency and duration of arousal,Increase sleep quality,Decrease sleep-related anxiety,Improve daytime function and mood,Non-pharmacological Insomnia T,26,Procedure of CBT,Comprehensive evaluation,Overnight sleep study,Individual of group format,Weekly session (6-8 weeks),Daily sleep logs,Multiple component approach,Concomitant drugs treatment,Procedure of CBTComprehensive,27,Indications of CBT,Persistent difficulty falling asleep,Psychogenic insomnia,Inadequet sleep hygiene,Circadian rhythm disorder,Long term sleep medication treatment failure,Secondary or residual insomnia complaints,Indications of CBTPersistent d,28,Discussion,Discussion,29,