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標題: | 以下顎前突口內裝置治療阻塞性睡眠呼吸中止症患者:成功與失敗病例之探討 The success and failure of using mandible andvancing device in treating obstructive sleep apnea patients |
作者: | Guo-Chiang Ye 葉國強 |
指導教授: | 陳韻之 |
關鍵字: | 阻塞性睡眠呼吸中止症,口內裝置,測顱分析,SF-36自覺症狀評量問卷, obstructive sleep apnea,oral appliance,cephalometric analysis,SF-36 questionaire, |
出版年 : | 2010 |
學位: | 碩士 |
摘要: | 目的:
阻塞性睡眠呼吸中止(Obstructive sleep apnea , OSA) 是一好發於40歲以上成年人的睡眠呼吸問題,它可導致影響健康與生活品質的不良後果,因此必須加以處理。下顎前突口內裝置(Mandibular advancing device, MAD)能於睡眠中將下顎前突,被證實能有效的減緩某些OSA病患的嚴重度,由於它兼具療效與接受度,MAD的使用已日漸普遍,美國睡眠醫學會(AASM)建議在輕中度OSA病患身上能以其取代nCPAP的治療腳色。 然而造成睡眠呼吸中止的致病因子有許多因素,每位患者的致病機轉也不盡相同,所以口內裝置的治療也並非對每位病患皆有明顯效果。 因此,本研究的目的是分析在台大門診中,阻塞性睡眠呼吸中止症病患於接受口內裝置治療後,其治療效果與患者之基礎生理指數、顱顏構造、睡眠評估指數及病患自覺症狀之相關性研究,並試圖找出臨床上簡單易用的口內裝置效果評估方法,以期精準的預估治療效果之成功率,並且從失敗的案例當中,來了解各口內裝置的影響。 實驗材料與方法: 本實驗的對象為118位由國立台大醫院睡眠中心特別門診就診病患中,具有OSA臨床症狀及經PSG測定之後,判定為輕度以上之OSA患者(AHI>5),並至台大醫院牙科部睡眠特別門診接受下顎前突口內裝置之治療。上述患者於治療前紀錄其年齡,量取基礎生理指數包括身高、體重,計算身體質量指數;此外並拍攝側顱X光片進行測顱分析,並發予睡眠日誌評估其合作程度,並於口內裝置治療後三個月至睡眠中心回診,再度接受PSG之測定。此外,治療前與治療後三個月回診時均請患者填寫自覺症狀評量問卷。治療成功率之分類,是以AHI reduction的比例>50%為responder,若<50%則為non-responder。 統計方法包括以成對樣本T檢定測試治療前後的改變,並使用單變項分析與多變項迴歸分析,以找出與口內裝置治療效果相關之預測因子。 結果: 本實驗的responder一共為72位,成功率約佔全體實驗對象的61.0%。受試者的身體質量指數,於治療後有顯著下降的情形,而PSG的各項測定值也均有改善。 本實驗也成功的找出影響口內裝置效果之預測因子,並獲得具臨床參考價值之迴歸模式。其中發現,Responder的患者,其顱顏型態具有以下特徵:年紀較輕,上顎前突(<SNA較大),前後顱底長度較長(N-Ba),上顎骨長度較長(ANS-PNS>47mm)、後顱底長度較長(S-Ba),軟顎長度較短(PNS_P<38mm),上下牙齒垂直覆蓋在正常範圍內(Overbite, 3.8~5mm)。Non-responder的患者,其顱顏型態具有以下特徵:年紀較大,上顎較不前突(<SNA較小),前後顱底長度較長短(N-Ba),上顎骨長度較短(ANS-PNS)、後顱底長度較短(S-Ba),軟顎長度較長(PNS_P),上下牙齒垂直覆蓋不在正常範圍內(Overbite)。 在PSG data預測因子方面,responde的患者,主要為治療前AHI值大於25(I_AHI_25),睡眠第二期小於63%(I_S2_63),初期嗜睡指數越低(I_ESS),混和型呼吸中止越低(I_mixed_apnea)。而non-responde的患者,治療前AHI值小於25(I_AHI_25),睡眠第二期大於63%(I_S2_63),初期嗜睡指數越高(I_ESS),混和型呼吸中止越高(I_mixed_apnea)。 Responder治療前後自覺症狀皆較non-responder為佳,但是治療前與治療後之差異皆不具顯著統計意義。 結論: 臨床上使用口內裝置對阻塞性睡眠呼吸中止症的患者治療,其成功率與許多因素相關,包括年齡、體重、顱顏構造、治療前的多功能睡眠評估指數等。因此未來在治療時,可以參考本實驗所得到的預估因子,較準確的篩選患者,並告知可能之成功率高低,使患者與醫師對治療的配合度及共識能夠更加提高。 Objectives: Obstructive sleep apnea (OSA) is a common sleep disordered breathing affecting especially for adults over 40. It can result in some medical and life quality consequences, and needs to be solved. Mandibular advancing device (MAD), which can bring and maintain the lower jaw in a forward posture during sleep, is demonstrated to be effective in alleviating the severity of OSA in some cases. Due to a good compromise between efficacy and acceptance, MAD is getting popular as a treatment option of OSA. The American Academy of Sleep Medicine (AASM) suggests MAD as a treatment alternative of nasal continuous positive air pressure (nCPAP) for mild to moderate OSA patient. There are several treatment modalities of OSA and oral appliance is a simple, effective and popular treatment option among them. The etiologic factors and pathogenesis of each patient are different, so the treatment effect of oral appliance varies from each other. The purpose of this study was to evaluate the treatment effect of oral appliance in OSA patients in relation to their basic medical condition, craniofacial features, polysomnographic data and the improvement of self-estimated symptoms. We hope to illustrate an effective and specific method for predicting treatment response of oral appliance. Materials and methods: A total of 118 patients from Sleep Center in National Taiwan University had related clinical symtoms and signs, and were diagnosed as OSAS by polysomnography. Then patients were arranged for mandibular advancing oral appliance therapy in Special Clinic of Oral Appliance in Dental Department of NTU. Pre-treatment age, height and weight were recored, so the BMI were derived. Besides, baseline cephalometry was performed on each patient. Three months after treatment, patients came back to Sleep Center for follow-ups and received post-treatment polysomnography. In the meanwhile, patients were asked to answer the questionnaire of SF-36 before treatment and 3 months after treatment to assess the self-estimated responses of the treatment. The subjects were divided into two groups on the basis of the degree of changes in AHI: responders (>50% AHI reduction) and non-responders (<50% AHI reduction). Paired t test was performed to examine the changes after treatment. Univariate and multivariate regression analyses were used for searching possible variables to predict the response of treatment. Results: The number of responders in this study was 72. The success rate of oral appliance therapy in this study was 61.0%. The BMI of all the samples significantly decreased after treatment. Improvement in polysomnographic findings were noted as well. Predictors of oral appliance treatment outcome were successfully derived in clinically valid regression models. The characteristics of responders were younger,with larger SNA, longer N-Ba, lager maxilla length, longer S-Ba, short soft palate, normal overbite. However, non-responders usually had retrognathic maxilla, short N-Ba, short maxilla length, short posterior basicranial length, longer soft palate, unnormal overbite. Besides, the pre-treatment rate of oxygen saturation <90% was higher in non-responders. The PSG data predictors of responders were initial AHI more than 25, the 2nd sleep stage under 63%, the less of ESS score, less of mixed apnea. And the non-responders were initial AHI less than 25, the 2nd sleep stage more than 63%, the higher of ESS score, higher of mixed apnea. From the analysis of questionnaire, all conditions were better in responders than in non-responders either before or after oral appliance treatment, though pretreatment and posttreatment didn’t reached statisical difference. Conclusion: The treatment effects of oral appliance in patients with OSA were related to multiple factors, including age, weight, craniofacial structures and pre-treatment polysomnography. Therefore, clinicians can predict better treatment outcome if proper indication was established for different treatment modalities. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/47502 |
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