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完整後設資料紀錄
DC 欄位 | 值 | 語言 |
---|---|---|
dc.contributor.advisor | 陳韻之 | |
dc.contributor.author | Guo-Chiang Ye | en |
dc.contributor.author | 葉國強 | zh_TW |
dc.date.accessioned | 2021-06-15T06:03:10Z | - |
dc.date.available | 2010-09-09 | |
dc.date.copyright | 2010-09-09 | |
dc.date.issued | 2010 | |
dc.date.submitted | 2010-08-17 | |
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dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/47502 | - |
dc.description.abstract | 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。 | zh_TW |
dc.description.abstract | 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. | en |
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dc.description.tableofcontents | 口試委員會審定書‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥i
致謝‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ii 總目錄‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥iii 圖目錄‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥vi 表目錄‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥viii 中文摘要‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥x 英文摘要‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥xiii 第一章 背景‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 1 第二章 文獻回顧‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 3 第一節 阻塞性睡眠呼吸中止症之盛行率‥‥‥‥‥‥‥‥‥ 3 第二節 阻塞性睡眠呼吸中止症之臨床特徵‥‥‥‥‥‥‥‥ 3 第三節 阻塞性睡眠呼吸中止症之診斷‥‥‥‥‥‥‥‥‥‥ 4 第四節 阻塞性睡眠呼吸中止症之解剖特徵‥‥‥‥‥‥‥‥ 5 第五節 阻塞性睡眠呼吸中止症之致病機轉與潛在因素‥‥‥ 6 第六節 阻塞性睡眠呼吸中止症之治療方式與作用機制‥‥‥ 8 第七節 上呼吸道解剖型態的研究方法‥‥‥‥‥‥‥‥‥‥ 11 第八節 口內裝置之治療效果與臨床預估‥‥‥‥‥‥‥‥‥ 12 第九節 研究目的‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 15 第三章 實驗材料與方法‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 16 第一節 實驗對象‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 16 第二節 實驗儀器與設備‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 16 一、基礎生理指數(身高、體重、身體質量指數) ‥‥‥‥‥‥17 二、多功能睡眠生理監測儀(PSG)‥‥‥‥‥‥‥‥‥‥ ‥ 17 三、口內裝置(MAD, monoblock)‥‥‥‥‥‥‥‥‥‥.‥ 18 四、測顱分析‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 19 五、自覺症狀評量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 22 第三節 實驗流程與方法‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 22 第四節 實驗資料處理及分析‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 23 第四章 實驗結果‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 24 第一節 實驗對象特性分析結果‥‥‥‥‥‥‥‥‥‥‥‥‥ 24 第二節 影響口內裝置治療效果之因素分析‥‥‥‥‥‥‥‥ 25 第三節 口內裝置治療效果與自覺評量指數之相關性‥‥‥‥ 28 第四節 口內裝置失敗案例的治療改善‥‥‥‥‥‥‥‥‥‥ 29 第五章 討論‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 31 第一節 實驗對象之治療效果分析‥‥‥‥‥‥‥‥‥‥‥‥ 31 第二節 口內裝置治療效果之因素分析‥‥‥‥‥‥‥‥‥‥ 34 第三節 口內裝置治療效果與自覺症狀之關係‥‥‥‥‥‥‥ 38 第四節 對於口內裝置治療失敗的病患分析‥‥‥‥‥‥‥‥ 39 第六章 結論‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 44 第七章 未來展望‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 45 參考文獻‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥117 附錄一:支撐舌頭的下顎前突裝置(tMAD)製作流程‥‥‥‥‥128 附錄二:PSG中文睡眠問卷‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 133 圖目錄 圖一:顯示正常人睡眠時氣流通過上呼吸道情形‥‥‥‥‥ 46 圖二:經鼻連續正向呼吸道壓力裝置(nCPAP)使用示意圖‥47 圖三:顯示不同口內裝置之設計‥‥‥‥‥‥‥‥‥‥‥ ‥48 圖四:人類及類人猿supra-vocal tract比較示意圖‥‥‥‥49 圖五:黑猩猩至現代人頭顱演化比較示意圖‥‥‥‥‥‥ ‥50 圖六:本實驗所使用下顎可調整式前突裝置(MAD)配戴於口內‥51 圖七:本實驗所使用的tMAD,配戴於口內‥‥‥‥‥‥‥‥‥ ‥52 圖八:舌頭固定器 (tongue retaining device)‥‥‥‥‥‥53 圖九:比較各種阻塞性睡眠呼吸中止症治療的接受程度及治療效果54 圖十:顯示上呼吸道周圍解剖構造‥‥‥‥‥‥‥‥‥‥‥‥ ‥55 圖十一:表示軟顎及舌頭由一個顎舌弓相連接‥‥‥‥‥‥‥ ‥56 圖十二:上左圖及下左圖為受測者上下顎參考模型。上右圖表示上顎模型依據面弓轉移固定於咬合器上。下右圖表示下顎模型依據最大咬合關係或Futar D咬合關係記錄固定於咬合器上‥‥‥‥‥‥‥‥57 圖十三:臨時假牙材料temperon,製作固定於上下顎前牙之間的咬合定位板 (bite index)‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥58 圖十四: 測顱構造座標點與參考線‥‥‥‥‥‥‥‥‥‥‥‥59 圖十五:測顱分析項目-骨性構造(角度) ‥‥‥‥‥‥‥‥‥‥60 圖十六:測顱分析項目-骨性構造(線性距離) ‥‥‥‥‥‥‥‥61 圖十七:測顱分析項目-軟組織構造‥‥‥‥‥‥‥‥‥‥‥‥‥62 圖十八:測顱分析項目-舌骨位置‥‥‥‥‥‥‥‥‥‥‥‥‥‥63 圖十九:測顱分析項目-咽喉空間‥‥‥‥‥‥‥‥‥‥‥‥‥‥64 圖二十:MRI使用t1-mpr-ns-sag模式在上呼吸道的成像‥‥‥‥65 圖二十一:利用Matlab進行上呼吸道3D體積重組‥‥‥‥‥‥‥66 圖二十二:病患A的上呼吸道完整體積矢狀面觀‥‥‥‥‥‥‥‥67 圖二十三:病患B的上呼吸道完整體積矢狀面觀‥‥‥‥‥‥‥‥68 圖二十四:病患C的上呼吸道完整體積矢狀面觀‥‥‥‥‥‥‥69 圖二十五:病患D的上呼吸道完整體積矢狀面觀‥‥‥‥‥‥‥70 圖二十六:病患E的上呼吸道完整體積矢狀面觀‥‥‥‥‥‥‥‥71 圖二十七:病患F的上呼吸道完整體積矢狀面觀‥‥‥‥‥‥‥‥72 圖二十八:ANS-PNS預測因子對於responder的影響效力‥‥‥‥73 圖二十九:PNS-P預測因子對於responder的影響效力‥‥‥‥‥74 圖三十:Overbite預測因子對於responder的影響效力‥‥‥‥‥75 圖三十一:AHI_I預測因子對於responder的影響效力‥‥‥‥‥‥76 圖三十二:ESS_I預測因子對於responder的影響效力‥‥‥‥‥‥77 圖三十三:I_S2預測因子對於responder的影響效力‥‥‥‥‥‥78 圖三十四:I-mixed apnea預測因子對於responder的影響效力‥‥79 圖三十五:流程圖‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥80 圖三十六:I-AHI與△AHI的關係圖‥‥‥‥‥‥‥‥‥‥‥‥‥81 圖三十七:病患D利用MRI作矢狀切面,palatal tongue backing的作用‥‥82 表目錄 表 1:全樣本中男性與女性之人數及比例‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥84 表2:不同類型口內裝置對治療成功與不成功者之比例‥‥‥‥‥‥‥‥‥85 表 3:性別對於治療成功與不成功之比例‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥86 表4:氣喘對於治療成功與不成功之比例‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥87 表5:高血壓對於治療成功與不成功之比例‥‥‥‥‥‥‥‥‥‥‥‥‥‥88 表6 :抽菸對於治療成功與不成功之比例‥‥‥‥‥‥‥‥‥‥‥‥‥‥89 表7:喝酒對於治療成功與不成功之比例‥‥‥‥‥‥‥‥‥‥‥‥‥‥90 表8:全體實驗對象於治療前後PSG data 資料分析表‥‥‥‥‥‥‥‥‥91 表9:全樣本之基礎生理指數表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥92 表10:Responder與Non-responder之基礎生理指數表‥‥‥‥‥‥‥‥‥93 表11:全樣本之測顱分析資料分析表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥94 表12:比較responder及non-responder於測顱分析Shapiro-Wilk test統計表‥95 表13: 比較responder及non-responder於基礎生理指數Shapiro-Wilk test統計表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥96 表14:比較responder及non-responder於治療前PSG資料分析Shapiro-Wilk test統計‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥97 表15:比較responder及non-responder於治療後PSG資料分析Shapiro-Wilk test統計表 ‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥98 表16:比較responder及non-responder於HADS自覺症狀評量指數分析統計‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥99 表17:比較responder及non-responder於自覺症狀評量指數分析統計‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥100 表18:比較responder及non-responder於SF36自覺症狀評量指數分析統計‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥101 表19:比較 responders與non-responders於基礎生理指數之差異‥‥‥102 表20:以成對母體平均數差異檢定測試responder及non-responder在治療前後基礎生理指數改變與p value‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥103 表21:以Wilcoxon Rank Sum test 及Kruskal Wallis test比較 responders與 non-responders 於基礎生理指數之差異‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥104 表22:比較responder及non-responder於測顱分析測量值之差異‥‥‥105 表23:比較 responder及non-responder在治療前與治療後PSG測量值之差異‥107 表24:以成對母體平均數差異檢定測試responder及non-responder在治療前與治療後PSG指數改變與p value‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥108 表25:比較 responder及non-responder在治療前SF36自覺症狀評量指數分析‥109 表26:比較 responder及non-responder在治療後SF36自覺症狀評量指數分析‥110 表27:以成對母體平均數差異檢定測試responder及non-responder在治療前與治療後SF36自覺症狀評量指數改變與p value‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥111 表28:上呼吸道體積的數值‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥112 表29:失敗案例所配戴的口內裝置及相對應的PSG data‥‥‥‥‥‥‥‥113 表30 以逐步選取法進行羅吉斯迴歸模式(Logistic regression model)分析口內裝置治療後為Responder之預測因子‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥114 表31:失敗病患的八項預測因子‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥116 | |
dc.language.iso | zh-TW | |
dc.title | 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 | zh_TW |
dc.title | The success and failure of using mandible andvancing device in treating obstructive sleep apnea patients | en |
dc.type | Thesis | |
dc.date.schoolyear | 98-2 | |
dc.description.degree | 碩士 | |
dc.contributor.oralexamcommittee | 姚宗珍,許明倫 | |
dc.subject.keyword | 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, | zh_TW |
dc.subject.keyword | obstructive sleep apnea,oral appliance,cephalometric analysis,SF-36 questionaire, | en |
dc.relation.page | 143 | |
dc.rights.note | 有償授權 | |
dc.date.accepted | 2010-08-17 | |
dc.contributor.author-college | 牙醫專業學院 | zh_TW |
dc.contributor.author-dept | 臨床牙醫學研究所 | zh_TW |
顯示於系所單位: | 臨床牙醫學研究所 |
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