- 學位論文
以舌支撐下顎前突口內裝置對無法耐受陽壓呼吸器之中重度睡眠呼吸中止症患者的治療成效與預測因子的探討
Effects and predictors of using tongue-backing mandibular advancement device in treating moderate to severe obstructive sleep apnea patients with CPAP intolerance
摘要
目的： 本論文的研究目的，在於針對無法耐受陽壓呼吸器的中重度阻塞型睡眠呼吸中止症為主的患者，以舌支撐下顎前突裝置(tongue backing mandibular advancement device, t-MAD)治療，探討口內裝置在治療上述患者中所扮演的角色，分析其治療成效及預測因子，以期臨床上得以精準預估治療的成功率。 實驗材料與方法： 於西元2011年01月至2014年05月間，至國立台大醫院睡眠中心特別門診就診的病患中，經臨床檢查及PSG測定後，判定為輕度以上之阻塞型睡眠呼吸中止症(睡眠呼吸中止指數apnea-hypopnea index，AHI≧5)者。這些病患都先完成了陽壓呼吸器之壓力測量(CPAP titration)，但卻不適應、無法接受陽壓呼吸器或不能忍受其輸出的高壓，因而轉介至台大醫院牙科部睡眠特別門診接受舌支撐下顎前突口內裝置(t-MAD)治療，實驗對象共71位。 上述患者於治療前先紀錄其年齡、性別、身高、體重等基本資料，並計算身體質量指數(BMI)，並於口內裝置治療後三個月再度至睡眠中心回診，接受PSG之測量。 成功率以治療前睡眠呼吸中止(OSA)的嚴重度：輕度（5≤AHI<15）、中度（15≤AHI<30）、重度（30≤AHI<50）與極重度（AHI≥50）；睡眠呼吸中止指數降低(AHI reduction)的百分比；以及治療後的睡眠呼吸中止指數(AHI)作區分。 不同條件下的成功率定義如下： Criterion 1為：「治療後AHI改善比率大於50％」 Criterion 2為：「治療後AHI改善比率大於50％，且2nd AHI小於15/小時」 Criterion 3為：「治療後AHI改善比率大於50％，且2nd AHI小於10/小時」 Criterion 4為：「治療後AHI改善比率大於50％，且2nd AHI小於5/小時」 實驗結果： t-MAD對於阻塞性睡眠呼吸中止症有顯著地治療效果： (1) 輕度OSA患者之成功率依據criterion 1∼4皆為100％(2/2)；中度OSA之成功率依據criterion 1、2皆為80％(12/15)，依據criterion 3為73.3％(11/15)，依據criterion 4為46.7％(7/15)；重度OSA之成功率依據criterion 1為76%(19/25)，依據criterion 2為68％(17/25)，依據criterion 3為44％(11/25)，依據criterion 4為32％(8/25)；極重度之成功率依據criterion 1為65.5％(19/29)，依據criterion 2為34.5％(10/29)，依據criterion 3為31％(9/29)，依據criterion 4為24.1％(7/29)。 (2) 關於影響口內裝置效果之預測因子，陽壓呼吸器之測量壓力越低、身體質量指數越低者，t-MAD治療後成為responder的機會越高。 總結： 對於中度以下之阻塞型睡眠呼吸中止症患者，配戴t-MAD能夠有效降低呼吸中止指數，是治療阻塞性睡眠呼吸中止症極為有效的方式；然而對重度睡眠呼吸中止的嚴重病患而言，在臨床上根據若干特徵，能有助於治療前病患的篩選以及成功率之評估。
並列摘要
Objectives： Oral appliances have been claimed to be indicated to those OSA patients who can’t tolerate continuous positive airway pressure (CPAP). However, the outcomes, limitation, and indication of such usages have never been documented. The aim of this study was to explore the using of the tongue-backing mandibular advancement device (t-MAD) in treating the above-mentioned OSA patients. Materials and Methods： 71 subjects who had related symptoms and signs, diagnosed as OSAS (AHI≧5) by polysomnography(PSG), were included from Janurary 2011 to May 2014, retrospectively. All of the patients were received CPAP titration first, however, they could not tolerate it. Thus, patients above were transfer to Dental Department of National Taiwan University for tongue-backing mandibular advancement device fabrication. Baseline demographic data were recored, so the BMI were derived. After taking oral appliance treatment for three months , patients then received third PSG at Sleep Center of NTU. Treatment response was classified according to OSA severity, percent of AHI reduction, and residual AHI after treatment.The OSA severity was classified into mild(5≤ AHI<15) ,moderate (15≤AHI <30),severe (30≤AHI<50),and extremely severe(AHI ≥50). The response to t-MAD was defined as criterion 1( ≥ 50% reduction in AHI) ; criterion 2(≥ 50% reduction and residual AHI less than 15/h) ;criterion 3( ≥ 50% reduction in AHI and residual AHI less than 10/h); and criterion 4( ≥ 50% reduction in AHI and residual AHI less than 5/h). Results： t-MAD plays an important role in treating patients of OSA： (1) For the mild OSA patients, the good response occurred in 100%(2/2) according to criterion 1 to 4. For the moderate OSA patients, the good response occurred in 80％(12/15) according to criterion 1 and 2 ; 73.3％ (11/15) according to criterion 3, and 46.7％(7/15) according to criterion 4. For the severe OSA patients, the good response occurred in 76％(19/25) according to criterion 1; 68%(17/25) according to criterion 2 ; 44％ (11/25) according to criterion 3, and 32％(8/25) according to criterion 4. For the extremely severe OSA patients, the good response occurred in 65.9％(19/29) according to criterion 1 ; 34.5％ (10/29) according to criterion 2, 31％(9/29) according to criterion 3,and 24.1%(7/29) according to criterion 4. (2) CPAP titration pressure and BMI were found to be significant predictors of good t-MAD treatment outcome. The lower CPAP pressure and BMI were, the higher chance to become a responder after t-MAD treatment. Conclusion： t-MAD is an effective appliance in treating mild to moderate OSA patients. For the severe ones, certain demographic data and PSG parameters can be utilized in patient selection and outcome assessment.