呼吸控制机制在阻塞性睡眠障碍发病机制中的作用。
Role of respiratory control mechanisms in the pathogenesis of obstructive sleep disorders.
作者信息
Younes Magdy
机构信息
Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada.
出版信息
J Appl Physiol (1985). 2008 Nov;105(5):1389-405. doi: 10.1152/japplphysiol.90408.2008. Epub 2008 Sep 11.
Obstructive sleep disorders develop when the normal reduction in pharyngeal dilator activity at sleep onset occurs in an individual whose pharynx requires a relatively high level of dilator activity to remain sufficiently open. They range from steady snoring, to slowly evolving hypopneas, to fast-recurring obstructive hypopneas and apneas. A fundamental observation is that the polysomnographic picture differs substantially among subjects with the same pharyngeal collapsibility, and even in the same subject at different times, indicating that the type and severity of the disorder is determined to a large extent by the individual's response to the obstruction. The present report reviews the various mechanisms involved in the response to sleep-induced obstructive events. When the obstructive event takes the form of mild-moderate flow limitation, compensation can take place through an increase in the fraction of time spent in inspiration (Ti/Ttot) without any increase in maximum flow (V(MAX)). With more severe obstructions, V(MAX) must increase. Recent data indicate that the obstructed upper airway can reopen reflexly, without arousal, if chemical drive is allowed to reach a threshold (T(ER)) but that this is often preempted by a low arousal threshold. The relation between T(ER) and arousal threshold, as well as the lung-to-carotid circulation time and the rate of rise of chemical drive during the obstructive event, determine the magnitude of ventilatory overshoot at the end of an event and, by extension, whether initial obstructive events will be followed by stable breathing, slow evolving hypopneas with occasional arousals, or repetitive events.
当睡眠开始时咽部扩张肌活动正常减少的情况发生在咽部需要相对较高水平的扩张肌活动才能保持足够开放的个体身上时,就会出现阻塞性睡眠障碍。其范围从持续打鼾到逐渐发展的呼吸浅慢,再到快速反复出现的阻塞性呼吸浅慢和呼吸暂停。一个基本的观察结果是,在具有相同咽部可塌陷性的受试者之间,甚至在同一受试者的不同时间,多导睡眠图表现都有很大差异,这表明该障碍的类型和严重程度在很大程度上取决于个体对阻塞的反应。本报告回顾了对睡眠诱导的阻塞性事件的反应中涉及的各种机制。当阻塞性事件表现为轻度至中度气流受限形式时,可通过增加吸气时间占总时间的比例(Ti/Ttot)来进行代偿,而最大气流(V(MAX))不会增加。对于更严重的阻塞,V(MAX)必须增加。最近的数据表明,如果化学驱动达到阈值(T(ER)),阻塞的上气道可以在无觉醒的情况下反射性重新开放,但这通常会被低觉醒阈值抢先。T(ER)与觉醒阈值之间的关系,以及阻塞性事件期间肺到颈动脉的循环时间和化学驱动的上升速率,决定了事件结束时通气过冲的幅度,进而决定了初始阻塞性事件之后是会出现稳定呼吸、偶尔伴有觉醒的缓慢发展的呼吸浅慢,还是重复性事件。