以主觀及客觀臨床評估偵測兒童阻塞性睡眠呼吸中止

Detection for pediatric obstructive sleep apnea syndrome: Role of objective and subjective measures

康焜泰(Kun-Tai Kang)

指導教授 ： 李永凌

國立臺灣大學/公共衛生學院/流行病學與預防醫學研究所/碩士(2014年)

https://doi.org/10.6342/NTU.2014.00201

摘要

背景 兒童阻塞性睡眠呼吸中止症候群是指在兒童在睡眠中因呼吸道阻塞而導致的呼吸中止。診斷主要是依據臨床病史合併適當的檢查，目前仍以睡眠多項生理檢查為診斷的黃金標準。對兒童進行客觀及主觀的臨床評估可提供臨床醫師決策的參考。
目的 評估客觀及主觀臨床評估在偵測兒童阻塞性睡眠呼吸中止症的診斷能力；並比較客觀評估、主觀評估、及合併主客觀評估偵測兒童阻塞性睡眠呼吸中止症的能力和臨床應用上的差異。
研究設計 橫斷性研究。
研究材料及方法 本研究受試者的年齡層介於2到18歲。客觀的臨床評估包括扁桃腺大小，腺樣體大小，和孩童肥胖的評估：扁桃腺是由耳鼻喉科醫師使用Brodsky分級方法去分級，腺樣體的大小是量測受試者側面的測顱X光片，並以Fujioka方法測定，肥胖是測量受試者的身體質量指數百分位來決定。主觀的臨床評估使用標準化的記錄表格，由照護者填寫受試者相關的症狀。顯著與兒童阻塞性睡眠呼吸中止症有關的客觀評估納入客觀模型，顯著與兒童阻塞性睡眠呼吸中止症有關的主觀評估納入主觀模型，在混合模型中包含了與兒童阻塞性睡眠呼吸中止症有顯著相關性的客觀和主觀臨床評估。兒童阻塞性睡眠呼吸中止症的診斷依據睡眠多項生理檢查的結果加以診斷。客觀模型、主觀模型及混合模型在偵測兒童阻塞性睡眠呼吸中止症的能力是評估模型的配適度(model fit)、鑑別度(discrimination，C指數)、校準度(calibration，Hosmer-Lemeshow檢定)、及重分類(reclassification)的能力。並使用leave-one-out、拔靴法(bootstrap)、以及k-fold方法對模型進行內部驗證(internal validation)。
結果 總共有222名受試者納入本研究。客觀模型的參數包含扁桃腺肥大，腺樣體肥大以及肥胖；而主觀模型的參數包含打鼾的頻率，打鼾的時間，夜晚有驚醒現象，以及照護者發現受試者有呼吸中止現象；混合模型則合併了以上的參數。在模型配適度的部分，經由卡方檢定顯示在客觀模型，主觀模型和混合模型均呈現顯著(P <0.001)。在鑑別度的部分，混合模型的C指數為0.84，顯著的優於客觀模型的C指數0.78 (P=0.0032)及主觀模型的C指數0.72 (P = 0.0001)。在校準度的部分，Hosmer-Lemeshow的檢定結果顯示客觀模型、主觀模型及混合模型均具有足夠的模型合適性(P>0.05)。在重分類的能力方面，相較於客觀模型，混合模型正確地重新分類10.3%的病患(P = 0.044)；另一方面，相較於主觀模型，混合模型正確地重新分類21.9%的病患(P = 0.003)。經由對混合模型的內部驗證顯示模型並未出現明顯過度配適的狀況。
結論 合併主觀和客觀的臨床評估，比起單獨使用客觀評估或主觀評估，在臨床上更能顯著偵測兒童阻塞性睡眠呼吸中止症。本研究的發現提供了相關的理論基礎，即在發展兒童阻塞性睡眠呼吸中止症的篩檢工具時，需要同時合併客觀和主觀的臨床評估去建構此一篩檢工具，以期能達到最大的疾病偵測能力。

關鍵字

腺樣體 ； 兒童 ； 肥胖 ； 扁桃腺 ； 睡眠多項生理檢查 ； 睡眠呼吸中止 ； 症狀評估

並列摘要

Background: Obstructive sleep apnea syndrome (OSAS) is an upper airway disorder. Over-night polysomnography is the “gold standard” for the diagnosis of pediatric OSAS. Information from objective and subjective measures for children with OSAS helps clinicians in decision making.
Purpose: To assess diagnostic abilities of objective measures, subjective measures, and combined objective and subjective measures in detecting pediatric obstructive sleep apnea syndrome, and to compare performance difference and clinical utilities between objective measures, subjective measures, and combined objective and subjective measures for detection of pediatric OSAS.
Study Design: Cross-sectional study.
Methods: Children aged 2-18 years were recruited. Children were assessed objectively for tonsil size, adenoid size, and obesity; tonsils were graded by otolaryngologist using the scheme by Brodsky et al.; adenoid size was measured based on a lateral cephalometric radiographs (Fujioka method); obesity was determined by a measure of body mass index percentile of each child. Subjective measures for symptoms were recorded using a standard sheet. Objective measures significantly correlated with OSAS were put into the objective model, whereas subjective measures into the subjective model. Accordingly, objective and subjective measures significantly correlated with OSAS were served as the combined model. Diagnosis of OSAS was made by polysomnography. Diagnostic performances of models in detecting OSAS were analyzed by model fit, discrimination (C-index), calibration (Hosmer-Lemeshow test), and reclassification. The model was internal validated using the leave-one-out cross-validation, bootstrapping method, and k-fold cross-validation.
Results: In total, 222 children were enrolled. Objective model included tonsil hypertrophy, adenoid hypertrophy, and obesity, whereas subjective model included snoring frequency, snoring duration, awaken, and breathing pause. The chi-square test was significant in the objective model, subjective model, and the combined model (P < 0.001). The C-index was 0.84 for the combined model, which was significantly differed from that in the objective model (0.78, P = 0.0032) and the subjective model (0.72, P = 0.0001). The Hosmer-Lemeshow test showed adequate fit (P > 0.05) for all models. Compared to objective model or subjective model, the combined model correctly reclassified 10.3% (P = 0.044) and 21.9% (P = 0.003) of all subjects. Internal validation of the combined model showed fair model performance and no obvious over-fitting.
Conclusions: Overall performance of combined objective and subjective measures, as compared with objective measures or subjective measures alone, offer incremental utility in detecting OSAS. This finding provides the rationale to combine both objective and subjective measures in developing a screen tool for pediatric OSAS.

並列關鍵字

adenoids ； child ； obesity ； palatine tonsil ； polysomnography ； sleep apnea syndromes ； symptom assessment

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