OCJENA I TUMAČENJE RESPIRATORNIH POREMEĆAJA KRISTINA ZIHERL UKPA GOLNIK

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1 OCJENA I TUMAČENJE RESPIRATORNIH POREMEĆAJA KRISTINA ZIHERL UKPA GOLNIK

2 STRANICE 41-46

3 Sensor Tehnologija aplikacije Prikupljanje i obrada podataka signala Procijena događaja Tumaćenje ocjena Ishod dijagnostike i terapije

4 TRAJANJE RESPIRATORNOG DOGAĐAJA A. Kad smo utvrdili, dali ide za apneu ili hipopneu, duljina događaja se mjeri od nadirja prije prvog daha koji je jasno oslabio do početka prvog daha, kod kojeg se amplituda disanja priblizi osnovnoj B. Ako bazične amplitude disanja ne možemo jasno ocijeniti (i kada postoji velika varijabilnost u amplitudi), događaj završava kada je jasan i stalni porast amplitude disanja, ili ako poslije vezane desaturacije, javlja se resaturacija za najmanje 2%

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6 APNEA Ako padne amplituda više od 90% u odnosu na osnovnu amplitudu Ako traje događaj najmanje 10 s VAŽNO: pad zasićenja je beznačajan

7 APNEA Ako dio respiratornog događaja koji bi inače zadovoljio kriterije za hipopneu, zadovolji kriterij za apneu, ocjenjujejmo cijeli događaj kao apneu

8 OPSTRUKTIVNA APNEA potpuni prekid disanja u trajanju od najmanje 10 sekundi sa očuvanom ili povećanom dišnom naporom tijekom cijelog događaja

9 CENTRALNA APNEA potpuni prekid disanja za najmanje 10 sekundi bez dišnog napora tijekom cijelog događaja

10 MJEŠOVITA APNEA potpuni prestanak disanja u trajanju od najmanje 10 sekundi, počevši bez dišnog napora, u drugoj polovini uspostavi se dišni napor

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12 Ruehland et al, The New Aasm Criteria for Scoring Hypopneas: Impact on the Apnea Hypopnea Index, Sleep 2009

13 HIPOPNEA Ako padne amplituda za više od 30% u odnosu na osnovnu amplitudu Ako traje događaj najmanje 10 s Pad zasićenja najmanje 3%, ili MIKROBUĐENJA

14 HIPOPNEA OPSTRUKTIVNA ILI CENTRALNA? Kategoriziranje opcijsko Važno zbog titracije i kasnijeg tretmana Problem su kompleksne apnee

15 KLASIFIKACIJA HIPOPNEA 1.Hrkanje? 2.Pojačano uravnivanje krivulje protoka zraka flow limitation? 3.Torakoabdominalni paradoks tijekom događaja, ali ne prije događaja? AKO BILOKOJI OPSTRUKTIVNA HIPONEA X AKO NIJEDNA CENTRALNA HIPONEA

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17

18 RERA respiratory effort related arousal Disanje s povećanim dišnim naporom, koji ne iznosi kriterije za hipopnee / apnee, mora trajati najmanje 10 s, a završava s buđenjem

19 1818

20 CHEYNE-STOKESOVO DISANJE OBA KRITERIJA MORAJU BITI ISPUNJENI 1.Najmanje tri uzastopne epizode centralne apnee/hipopnee koje su odvojene jedna od druge krešendo-dekrešendo uzorkom disanja sa duljinom cikla od najmanje 40s (uglavnom 45-90s) 2.Najmanje 5 centralnih apnea/hipopnea po satu vezanih za krešendo/ dekrešendo uzorak disanja tijekom snimanja od najmanje dva sata

21 75s 75s

22 KO IMA NOČNU HIPOVENTILACIJU? PACIENT pco2 budan pco2 spava Promijena pco2 A B C Povećanje pco2 preko 7.3 kpa za 10 min 2. Ako povećanje pco2 1.33kPa med spavanjem, ovisno o stanju u budnosti i prelazi 6.7 kpa za 10 min

23 RESPIRATORNI INDEKSI AHI ODI % sat<90% Prosijećno zasićenje Minimalno zasićenje Pozicijska apneja

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25 AHI vs. ODI Definicija apnee nema veze sa desaturacijama Hipopnee defnirane ili sa desaturacijama ili sa arousals Kod CSA često ODI nižji ODI vrlo dobro korelira sa AHI kot debelih sa OSAS Alveolna hipoventilacija među spavanjem ODI > AHI AHI ODI

26 ZAŠTO JE GRANICA AHI > 5/h?

27 JESU LI SVE PAUZE U DISANJU PATOLOŠKE? OPSTRUKTIVE CENTRALNE - FIZIOLOŠKE Kod uspavanja Poslije buđenja U faznom REMu CENTRALNE PATOLOŠKE Primarna CSA CSA zbog druge bolesti CSB CSA zbog ljekova Primarna CSA novorođenčadi CSA prerano rođenog deteta CSA zbog visoke visine iznad mora CSA zbog PAP terapije

28 Nieto JF, JAMA 2001

29 Punjabi MN et al, PLoS 2009 EFEKT DOZE!

30 ZASIĆENJE S KISIKOM OSAS Hipoksemija v snu

31 OD ČEGA OVISI RAZINA DESATURACIJE? bazična SaO2 u budnošču bazična SaO2 među spavanjem % TST sa apneami i hipopneami trajanje ventilacije među apneami trajanje apnej i hipopnej FVC i ERV Drugih pljučne bolesti Faza spavanja (REM vs. NREM) Tip apnee

32 AHI LEĐA 2X AHI BOK = POLOŽAJNA APNEA

33 AHI>5 CPAP 1. Simptomi dali liječimo CSA? 2. Komorbiditet kardiovaskularni rizik? 3. Razina OSAS 4. Druga motnja spavanja OHS! 5. Obzir do bolesnikovih sklonosti

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