臺灣博碩士論文加值系統

背景: 睡眠呼吸中止症 (obstructive sleep apnea, OSA) 為一常見睡眠呼吸障礙疾病。研究發現環境因子會影響 OSA 的嚴重程度，然是否環境溫度高低為 OSA 之嚴重程度影響因子至今仍尚未明確。目標與假設:本研究擬探討環境溫度對 OSA 嚴重程度之影響。假設環境溫度高低會影響 OSA 患者之呼吸中止指數 (apnea hypopnea index, AHI)，增加交感神經活性，並使睡眠品質下降。材料與方法：12 位 OSA 之參與者將於實驗室進行四個夜晚實驗，包含第一晚的環境適應（主觀舒適溫度）、低溫（Ta 16 ℃）、常溫（Ta 26 ℃）及相對高溫（Ta 30 ℃）之情境，並使用多頻道生理紀錄儀與實驗室自製之雲端血氧機，量測多種睡眠生理參數。並利用溫溼度紀錄儀記錄居家睡眠環境狀態及血氧機推算於居家環境中睡眠呼吸中止症嚴重程度。結果：於實驗室控制環境的狀態下，發現自律神經方面，代表放鬆之副交感神經活性於 Ta 16 ℃ 時較高，且代表警覺之交感神經活性在睡眠第一及第二期於較高溫（Ta 30 ℃）時活性較強；於OSA嚴重程度方面，則發現仰躺姿勢時的 AHI 指數於較高溫（Ta 30 ℃）較高。另發現近身溫度變化和 AHI 參數呈正相關性。而於居家環境不控制環境因子的狀態下，發現睡眠呼吸中止症的嚴重程度與環境的濕度及濕度和溫度的交互作用有關係。結論：本研究發現相較於適溫環境溫度與近身溫度之上升為OSA病程之惡化危險因子，且在較高溫的環境下，代表自律神經活性的交感神經指標的活化及副交感神經的減弱，都反映出自律神經系統的活性於阻塞型睡眠呼吸中止症的嚴重程度與溫度的關係中扮演重要的角色。

Background and Aims: Obstructive sleep apnea (OSA) is a prevalence of sleep breathing disorder. There are different treatment ways, and lifestyle modifications have been tested however the effect is limited. Moreover, the relationship between the sleep environment and OSA severity remains obscure. Aims and Hypotheses: The objective of this study is to investigate if the sleep ambient temperature (Ta) will affect the severity and autonomic nervous system among OSA patients. We hypothesizes that there is a positive correlation with OSA severity and Ta to heightened autonomic activity. Materials and Methods: 12 OSA participants were enrolled in this study. The 7-day sleep diary includes home Ta and apnea-hypopnea index (AHI) will record. Participants would stay in an experimental room four nights, a self-comfortable Ta as the first-night and a relatively cooler Ta (16 ℃), a comfortable Ta (26 ℃) and a warmer Ta (30 ℃) circumstances. The polysomnography and wireless oximeter would evaluate the sleep-related respiratory parameters. ECG signals were further used to analyze the heart rate variability. Results: In the autonomic nerves system, the parasympathetic activity increased in Ta 16 ℃ (p < 0.05); the sympathetic activity arose in Ta 30 ℃ (p < 0.05) among sleep stage N1 and N2. On the other hand, the respiratory data showed Ta 30 ℃ would have higher AHI during supine posture (p < 0.05). Moreover, we found that the near-body temperature (NBT) is highly positive correlation with AHI (r = 0.58, p = 0.025). Conclusions: Compared the Ta and NBT with autonomic nerves system activity and respiratory results, we found OSA severity has a positive correlation with Ta and NBT, and the autonomic nervous system played an important role.

CONTENTS
致謝.....................................i
中文摘要.................................ii
Abstract................................iii
Contents................................iv
Table Index.............................vi
Figure Index............................vii
1. Introduction..........................1
1-1. Obstructive sleep apnea.............1
1-2. Autonomic nervous system and heart rate variability with sleep...................2
1-3. The thermal environment is one of the factors that will influence human sleep...................................................................................3
1-4. The relationship between the Ta and OSA............................................3
1-5. Hypothesis and aims................................................................4
2. Material and Method..................................................................5
2-1. Participants........................5
2-2. Measurements........................5
2-2-1. Subjective evaluations............6
2-2-2. Objective Measurements............7
2-3. Experimental design.................8
2-4. Power spectra analysis..............8
2-5. Sleep stage scoring analysis........9
2-6. Sleep breathing scoring analysis....10
2-7. Statistical analysis................11
3. Results...............................11
3-1 Subjects characteristics.............11
3-2. Effects of three different Ta on ANS during sleep in the lab.......................11
3-3. The effects of 3 different Ta on respiratory parameters during sleep in lab........12
3-4. The relationship between Temperature (Ta and NBT) and AHI in lab...................12
3-5. The relationship between Ta and AHI at home........................................13
4. Discussion...........................................................................13
4-1. The effect of relative humidity....................................................14
4-2. The effect in the sleep posture....................................................14
4-3. The effects of ambient temperature on sleep quality and ANS functions..............15
4-4. The correlation between respiratory parameters and temperature.....................16
5. Conclusion............................18
6. Prospective...........................18
7. Referance.............................19
8. Appendix..............................42

TABLE INDEX

Table 1..................................25
Table 2..................................26
Table 3..................................27
Table 4..................................29
Table 5..................................31

FIGURE INDEX
Figure 1.................................34
Figure 2.................................33
Figure 3.................................35
Figure 4.................................36
Figure 5.................................37
Figure 6.................................38
Figure 7.................................39
Figure 8.................................40
Figure 9.................................41

Association, S. o. P. C. o. t. A. S. D. (1994). Practice parameters for the use of portable recording in the assessment of obstructive sleep apnea. Sleep, 17(4), 372-377.
Berry, R. B., Brooks, R., Gamaldo, C. E., Harding, S. M., Marcus, C., & Vaughn, B. (2012). The AASM manual for the scoring of sleep and associated events. Rules, Terminology and Technical Specifications, Darien, Illinois, American Academy of Sleep Medicine.
Berry, R. B., Budhiraja, R., Gottlieb, D. J., Gozal, D., Iber, C., Kapur, V. K., . . . American Academy of Sleep, M. (2012). Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med, 8(5), 597-619. doi:10.5664/jcsm.2172
Berthomier, C., Drouot, X., Herman-Stoica, M., Berthomier, P., Prado, J., Bokar-Thire, D., . . . d'Ortho, M. P. (2007). Automatic analysis of single-channel sleep EEG: validation in healthy individuals. Sleep, 30(11), 1587-1595.
Buguet, A. (2007). Sleep under extreme environments: effects of heat and cold exposure, altitude, hyperbaric pressure and microgravity in space. J Neurol Sci, 262(1-2), 145-152. doi:10.1016/j.jns.2007.06.040
Buysse, D. J., Reynolds, C. F., 3rd, Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res, 28(2), 193-213.
Cardiology, T. F. o. t. E. S. o. (1996). Heart rate variability, standards of measurement, physiological interpretation, and clinical use. Circulation, 93(5), 1043-1065.
Cartwright, R. D. (1984). Effect of sleep position on sleep apnea severity. Sleep, 7(2), 110-114.
Cassol, C. M., Martinez, D., da Silva, F. A., Fischer, M. K., Lenz Mdo, C., & Bos, A. J. (2012). Is sleep apnea a winter disease?: meteorologic and sleep laboratory evidence collected over 1 decade. Chest, 142(6), 1499-1507. doi:10.1378/chest.11-0493
Chung, F., Yegneswaran, B., Liao, P., Chung, S. A., Vairavanathan, S., Islam, S., . . . Shapiro, C. M. (2008). STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology, 108(5), 812-821. doi:10.1097/ALN.0b013e31816d83e4
Commission, I. T. (2001). Glossary of terms for thermal physiology. III ed. Revised by The Commission for Thermal Physiology of the International Union of Physiological Sciences (IUPS). Jpn. J. Physiol, 28, 1245-1284.
Eckert, D. J., & Malhotra, A. (2008). Pathophysiology of adult obstructive sleep apnea. Proc Am Thorac Soc, 5(2), 144-153. doi:10.1513/pats.200707-114MG
Fanger, P. O. (1970). Thermal comfort. Analysis and applications in environmental engineering. Thermal comfort. Analysis and applications in environmental engineering.
Ibanez, V., Silva, J., & Cauli, O. (2018). A survey on sleep questionnaires and diaries. Sleep Med, 42, 90-96. doi:10.1016/j.sleep.2017.08.026
Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep, 14(6), 540-545.
Kakitsuba, N., & White, M. D. (2014). Effect of change in ambient temperature on core temperature during the daytime. International journal of biometeorology, 58(5), 901-907.
Kario, K., Pickering, T. G., Umeda, Y., Hoshide, S., Hoshide, Y., Morinari, M., . . . Shimada, K. (2003). Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation, 107(10), 1401-1406.
Kim, J., In, K., Kim, J., You, S., Kang, K., Shim, J., . . . Shin, C. (2004). Prevalence of sleep-disordered breathing in middle-aged Korean men and women. Am J Respir Crit Care Med, 170(10), 1108-1113. doi:10.1164/rccm.200404-519OC
Kuo, T. B., & Chan, S. H. (1993). Continuous, on-line, real-time spectral analysis of systemic arterial pressure signals. Am J Physiol, 264(6 Pt 2), H2208-2213. doi:10.1152/ajpheart.1993.264.6.H2208
Kuo, T. B., Hong, C. H., Hsieh, I. T., Lee, G. S., & Yang, C. C. (2014). Effects of cold exposure on autonomic changes during the last rapid eye movement sleep transition and morning blood pressure surge in humans. Sleep Med, 15(8), 986-997. doi:10.1016/j.sleep.2014.03.022
Kuo, T. B., Lai, C. J., Huang, Y. T., & Yang, C. C. (2005). Regression analysis between heart rate variability and baroreflex-related vagus nerve activity in rats. J Cardiovasc Electrophysiol, 16(8), 864-869. doi:10.1111/j.1540-8167.2005.40656.x
Kuo, T. B., Lin, T., Yang, C. C., Li, C. L., Chen, C. F., & Chou, P. (1999). Effect of aging on gender differences in neural control of heart rate. Am J Physiol, 277(6 Pt 2), H2233-2239.
Kuo, T. B., Shaw, F. Z., Lai, C. J., & Yang, C. C. (2008). Asymmetry in sympathetic and vagal activities during sleep-wake transitions. Sleep, 31(3), 311-320.
Kuo, T. B. J., & Yang, C. C. H. (2009). Frequency domain analysis of electrooculogram and its correlation with cardiac sympathetic function. Experimental Neurology, 217(1), 38-45. doi:10.1016/j.expneurol.2009.01.012
Lam, B., Ip, M. S., Tench, E., & Ryan, C. F. (2005). Craniofacial profile in Asian and white subjects with obstructive sleep apnoea. Thorax, 60(6), 504-510. doi:10.1136/thx.2004.031591
Lan, L., Lian, Z. W., & Lin, Y. B. (2016). Comfortably cool bedroom environment during the initial phase of the sleeping period delays the onset of sleep in summer. Building and Environment, 103, 36-43. doi:10.1016/j.buildenv.2016.03.030
Liu, W., Lian, Z., & Liu, Y. (2008). Heart rate variability at different thermal comfort levels. European journal of applied physiology, 103(3), 361-366.
Malliani, A., Pagani, M., Lombardi, F., & Cerutti, S. (1991). Cardiovascular neural regulation explored in the frequency domain. Circulation, 84(2), 482-492.
Merica, H., & Blois, R. (1997). Relationship between the time courses of power in the frequency bands of human sleep EEG. Neurophysiologie Clinique/Clinical Neurophysiology, 27(2), 116-128.
Mo, J. H., Lee, C. H., Rhee, C. S., Yoon, I. Y., & Kim, J. W. (2011). Positional dependency in Asian patients with obstructive sleep apnea and its implication for hypertension. Arch Otolaryngol Head Neck Surg, 137(8), 786-790. doi:10.1001/archoto.2011.122
Netzer, N. C., Stoohs, R. A., Netzer, C. M., Clark, K., & Strohl, K. P. (1999). Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med, 131(7), 485-491.
Okamoto-Mizuno, K., Mizuno, K., Michie, S., Maeda, A., & Iizuka, S. (1999). Effects of humid heat exposure on human sleep stages and body temperature. Sleep, 22(6), 767-773.
Okamoto-Mizuno, K., & Tsuzuki, K. (2010). Effects of season on sleep and skin temperature in the elderly. Int J Biometeorol, 54(4), 401-409. doi:10.1007/s00484-009-0291-7
Okamoto-Mizuno, K., Tsuzuki, K., & Mizuno, K. (2003). Effects of head cooling on human sleep stages and body temperature. Int J Biometeorol, 48(2), 98-102. doi:10.1007/s00484-003-0181-3
Oksenberg, A., & Silverberg, D. S. (1998). The effect of body posture on sleep-related breathing disorders: facts and therapeutic implications. Sleep Med Rev, 2(3), 139-162.
Richard, W., Kox, D., den Herder, C., Laman, M., van Tinteren, H., & de Vries, N. (2006). The role of sleep position in obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol, 263(10), 946-950. doi:10.1007/s00405-006-0090-2
Shapiro, Y., & Epstein, Y. (1984). Environmental physiology and indoor climate—thermoregulation and thermal comfort. Energy and buildings, 7(1), 29-34.
Storms, W. (2008). Allergic rhinitis-induced nasal congestion: its impact on sleep quality. Prim Care Respir J, 17(1), 7-18. doi:10.3132/pcrj.2008.00001
Teerapraipruk, B., Chirakalwasan, N., Simon, R., Hirunwiwatkul, P., Jaimchariyatam, N., Desudchit, T., . . . Wanlapakorn, C. (2012). Clinical and polysomnographic data of positional sleep apnea and its predictors. Sleep Breath, 16(4), 1167-1172. doi:10.1007/s11325-011-0627-5
Tsuzuki, K., Okamoto-Mizuno, K., & Mizuno, K. (2004). Effects of humid heat exposure on sleep, thermoregulation, melatonin, and microclimate. Journal of Thermal Biology, 29(1), 31-36. doi:10.1016/j.jtherbio.2003.10.003
Tsuzuki, K., Okamoto-Mizuno, K., Mizuno, K., & Iwaki, T. (2008). Effects of airflow on body temperatures and sleep stages in a warm humid climate. Int J Biometeorol, 52(4), 261-270. doi:10.1007/s00484-007-0120-9
Udwadia, Z. F., Doshi, A. V., Lonkar, S. G., & Singh, C. I. (2004). Prevalence of sleep-disordered breathing and sleep apnea in middle-aged urban Indian men. Am J Respir Crit Care Med, 169(2), 168-173. doi:10.1164/rccm.200302-265OC
Valham, F., Sahlin, C., Stenlund, H., & Franklin, K. A. (2012). Ambient temperature and obstructive sleep apnea: effects on sleep, sleep apnea, and morning alertness. Sleep, 35(4), 513-517. doi:10.5665/sleep.1736
Weinreich, G., Wessendorf, T. E., Pundt, N., Weinmayr, G., Hennig, F., Moebus, S., . . . Heinz Nixdorf Recall study, g. (2015). Association of short-term ozone and temperature with sleep disordered breathing. Eur Respir J, 46(5), 1361-1369. doi:10.1183/13993003.02255-2014
Won, C., & Guilleminault, C. (2015). Gender differences in sleep disordered breathing: implications for therapy. Expert Rev Respir Med, 9(2), 221-231. doi:10.1586/17476348.2015.1019478
Yang, C. C. H., Shaw, F.-Z., Lai, C. J., Lai, C.-W., & Kuo, T. B. J. (2003). Relationship between electroencephalogram slow-wave magnitude and heart rate variability during sleep in rats. Neuroscience Letters, 336(1), 21-24. doi:https://doi.org/10.1016/S0304-3940(02)01200-4
Young, T., Peppard, P. E., & Gottlieb, D. J. (2002). Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med, 165(9), 1217-1239.
Zanobetti, A., Redline, S., Schwartz, J., Rosen, D., Patel, S., O'Connor, G. T., . . . Gold, D. R. (2010). Associations of PM10 with sleep and sleep-disordered breathing in adults from seven U.S. urban areas. Am J Respir Crit Care Med, 182(6), 819-825. doi:10.1164/rccm.200912-1797OC