【摘要】目的探讨阻塞性睡眠呼吸暂停综合征(OSAS)患者上气道阻塞与睡眠状态下呼吸中枢控制功能的低下是否有关。方法通过经鼻气管插管建立鼻咽通气道测定了16例重度OSAS患者在清醒状态、非快动眼(NREM)Ⅰ+Ⅱ睡眠期、Ⅲ+Ⅳ睡眠期、快动眼(REM)睡眠期的口腔阻断压(P_0.1)、低氧反应指标(ΔP_0.1/ΔSaO₂、Δ_E/ΔSaO₂)及高二氧化碳反应指标(ΔP_0.1/ΔSaO₂、Δ_E/ΔSaO₂)。应用鼻罩经鼻测定了11名非打鼾的正常人，观察各睡眠时相呼吸控制功能的变化情况，作为对照。结果(1)在清醒状态下，插管前后OSAS组的P_0.1、ΔP_0.1/ΔSaO₂、Δ_E/ΔSaO₂、ΔP_0.1/ΔPaCO₂、Δ_E/ΔPaCO₂相关性好，差异无显著性(P＞0.1)。受试者耐受性好，无明显副作用。OSAS组的P_0.1高于对照组，呼吸中枢的低氧及高二氧化碳(CO₂)反应性与对照组差异无显著性(P＞0.1)。(2)与清醒状态相比：在NREMⅠ+Ⅱ、Ⅲ+Ⅳ睡眠期，对照组的P_0.1、ΔP_0.1/ΔSaO₂、ΔP_0.1/ΔPaCO₂无变化(P＞0.05)，但Δ_E/ΔSaO₂、Δ_E/ΔPaCO₂明显下降(P＜0.05)，REM睡眠期的P_0.1无明显变化(P＞0.05)，低氧及高CO₂反应均降低(P＜0.05)。OSAS组的P_0.1在NREMⅡ及REM睡眠期均有所下降(P＜0.05)。在NREMⅢ+Ⅳ期降低不明显(P＞0.1)。而ΔP_0.1/ΔSaO₂、Δ_E/ΔSaO₂、ΔP_0.1/ΔPaCO₂、Δ_E/ΔPaCO₂在各个睡眠期均下降(P＜0.01)，以白天CO₂潴留者下降最明显。OSAS组及对照组在睡眠状态下的Δ_E/ΔSaO₂分别下降52%±30%，34%±26%；Δ_E/ΔPaCO₂分别下降57%±26%，41%±18%；与对照组相比，OSAS组各指标的下降幅度更大(P＜0.05)。结论建立人工鼻咽通气道测定P_0.1、ΔP_0.1/ΔSaO₂、Δ_E/ΔSaO₂、ΔP_0.1/ΔPaCO₂、Δ_E/ΔPaCO₂是在睡眠状态下检测OSAS患者呼吸控制功能的一种可行的方法；OSAS患者睡眠时的P_0.1降低，呼吸中枢对低氧和高CO₂刺激的反应下降，证实呼吸控制功能低下在OSA的发生中起重要作用。

【关键词】睡眠无呼吸综合征呼吸

Breathing control of patients with obstructive sleep apnea syndrome (OSAS) during sleep

Han Fang, Cheng Erzhang, Wei Hailin, et al. Department of Respirology, People′s Hospital, Beijing Medical University, Beijing 100044

【Abstract】ObjectiveIt is assumed that reduced ventilatory control function during sleep may be one of the mechanisms resulting in obstructive sleep apnea syndrome (OSAS), but the breathing drive has never been measured in patients with OSAS during sleep. MethodP_0.1，ΔP_0.1/ΔSaO₂, Δ_E/ΔSaO₂, ΔP_0.1/ΔPaCO₂ and Δ_E/ΔPaCO₂ in sixteen patients with severe OSAS were measured via nasopharyngeal tubes connected with nasal mask to maintain upper airway patent, during wake and NREMⅠ+Ⅱ, NREMⅢ+Ⅳ, REM sleep stages, and the same parameters in eleven normal subjects, non-snorers were also measured, by nasal mask as control.Result(1) During wake:P_0.1 in all the OSAS patients was remarkably higher than that of the normal subjects (P＜0.05), but there was no difference in Δ_E/ΔSaO₂, ΔP_0.1/ΔSaO₂, Δ_E/ΔPaCO₂ and ΔP_0.1/ΔPaCO₂ between the two groups (P＞0.05). (2) The above parameters measured during sleep compared with that measured during wake: In NREMⅠ+Ⅱ and NREMⅢ+Ⅳ, normal subjects showed no significant decrease in P_0.1, ΔP_0.1/ΔSaO₂, ΔP_0.1/ΔPaCO₂ (P＞0.05), but Δ_E/ΔSaO₂ and Δ_E/ΔPaCO₂ decreased significantly (P＜0.05). In REM₁ P_0.1 maintained the same level as that during wake, but both hypoxic and hypercapnic responses decreased remarkably (P＜0.05). In the OSAS patients, P_0.1 decreased during NREMⅠ+Ⅱ and REM sleep (P＜0.5), but not during NREM Ⅲ+Ⅳ(P＞0.05). Δ_E/ΔSaO₂, ΔP_0.1/ΔSaO₂, ΔP_0.1/ΔPaCO₂ and Δ_E/ΔPaCO₂ decreased markedly during all sleep stages (P＜0.01). (3) From wake to sleep, Δ_E/ΔSaO₂ decreased by 51.6±30.4% (Mean±SD) in the OSAS patients vs 33.6±26.0% decreased in the normal subjects; Δ_E/ΔPaCO₂ decreased by 56.9±25.5% in OSAS vs 40.8±17.5% in the normal subjects; The hypoxic and hypercapnic responses in OSAS patients decreased much more than those in the normal subjects during sleep (P＜0.05). ConclusionThis is the first study to measure the hypoxic and hypercapnic responses successfully in OSAS patients during sleep. It was found that the breathing drive was significantly reduced in sleeping OSAS patients, which may play an important role in the development of OSAS, possibly through the reduced action upon the dilators causing the upper airway in predilection for collapse.

【Key words】Sleep apnea syndromesRespiration

睡眠期间呼吸控制功能低下可能是阻塞性睡眠呼吸暂停综合征(OSAS)发病的关键^［1］。但是由于技术上的困难，目前尚无OSAS患者在睡眠状态下呼吸控制功能变化的研究资料。仅有的研究提示，在清醒状态下，OSAS患者的呼吸中枢驱动升高，对低氧及高CO₂反应性并不降低^［2］。清醒与睡眠是二个截然相反的生理状态，因此，建立在睡眠状态下测定呼吸中枢控制功能的方法，了解OSAS患者在睡眠时呼吸控制功能的变化，对研究阻塞性睡眠呼吸暂停(OSA)的发生机理，探讨合理的治疗途径是极其重要的。

对象与方法

1.对象：(1)对照组：11名无习惯性打鼾及睡眠呼吸暂停史、无心肺疾患、无重度烟酒史及体检未发现咽腔明显狭窄的健康者，其中男7<