Alternative approaches to treatment of Central Sleep Apnea.
Alternative approaches to treatment of Central Sleep Apnea.
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DOI：
10.1016/j.jsmc.2013.10.008
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发表时间：
2014-03-01
影响因子：
2.8
通讯作者：
Thomas, Robert Joseph
中科院分区：
文献类型：
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作者：
Thomas, Robert Joseph
治疗低碳酸血症中枢性睡眠呼吸暂停综合征的不同方法反映了驯服过度活跃的呼吸化学反射的困难。由于睡眠碎片化和狭窄的二氧化碳储备或增加的环路增益都是导致疾病的原因，镇静剂（诱导更长的稳定的非快速眼动（NREM）睡眠，减少非快速眼动睡眠中觉醒的不稳定影响）和基于二氧化碳的稳定方法是合乎逻辑的。适应性通气减少了平均过度通气，但可能导致呼吸机-患者不同步，而增加呼气再呼吸间隙（EERS，正压治疗期间的死腔）和CO2操作直接通过将CO2移至呼吸暂停阈值以上来稳定呼吸控制。碳酸酐酶抑制可以提供进一步的辅助益处。对于二氧化碳储备较窄的人来说，普罗文特和温克斯可能不太可能引发中枢性呼吸暂停或周期性呼吸。口腔矫治器可以有意义地减少正压需求，从而使复杂呼吸暂停的治疗成为可能。新的药理学方法可能针对颈动脉体血管细胞兴奋的介质，如气体神经递质之间的平衡。在复杂呼吸暂停患者中，单模式治疗并不总是成功的，可能需要考虑多模式治疗。超越传统评分方法的睡眠呼吸暂停表型是优化管理的关键。
Divergent approaches to treatment of hypocapnic central sleep apnea syndromes reflect the difficulties in taming a hyperactive respiratory chemoreflex. As both sleep fragmentation and a narrow CO2 reserve or increased loop gain drive the disease, sedatives (to induce longer periods of stable non-rapid eye movement (NREM) sleep and reduce the destabilizing effects of arousals in NREM sleep) and CO2-based stabilization approaches are logical. Adaptive ventilation reduces mean hyperventilation yet can induce ventilator-patient dyssynchrony, while enhanced expiratory rebreathing space (EERS, dead space during positive pressure therapy) and CO2 manipulation directly stabilize respiratory control by moving CO2 above the apnea threshold. Carbonic anhydrase inhibition can provide further adjunctive benefits. Provent and Winx may be less likely to trigger central apneas or periodic breathing in those with a narrow CO2 reserve. An oral appliance can meaningfully reduce positive pressure requirements and thus enable treatment of complex apnea. Novel pharmacological approaches may target mediators of carotid body glomus cell excitation, such as the balance between gas neurotransmitters. In complex apnea patients, single mode therapy is not always successful, and multi-modality therapy might need to be considered. Phenotyping of sleep apnea beyond conventional scoring approaches is the key to optimal management.