臺灣博碩士論文加值系統

前言:阻塞型睡眠呼吸中止症（obstructive sleep apnea, OSA）主要成因為人體在睡眠時化學靈敏度降低及軟組織鬆弛導致上呼吸道塌陷，常見於中年肥胖人口，近年來有越來越多的趨勢。阻塞型睡眠呼吸中止症已被證實為許多心血管疾病、代謝症候群以及神經退化性疾病的危險因子，因此如何早期發現診斷與治療成為非常重要的課題。打鼾為睡眠呼吸中止症中最容易被察覺之症狀，在先前研究中，約有70~95%罹患阻塞型睡眠呼吸中止患者有打鼾現象，而透過報章媒體宣傳，民眾普遍將打鼾與阻塞型睡眠呼吸中止作為連結，但打鼾次數並無標準定義且大多都為他人告知，每人對於鼾聲的靈敏度不同，因此本研究分析與阻塞型睡眠呼吸中止有關之打鼾次數並將其定義為打鼾與否之標準，同時將探討無打鼾阻塞型睡眠呼吸中止症患者的人口分布及其特徵，來讓無打鼾症狀之阻塞型睡眠呼吸中止症潛在患者有所警示。
研究方法：透過回溯性試驗分析2015年一整年度施行睡眠多項生理檢查(Polysomnography, PSG)測試之個案，透過ROC curve分析與阻塞型睡眠呼吸中止症相關之打鼾次數，並將其視為有無打鼾之標準，另外藉此依據分析無打鼾罹患阻塞型睡眠呼吸中止患者之特徵。
研究結果: 總收案數為1264例。平均年齡為49.1±13.6歲，其中70.6％為男性，75.4％的收案者有阻塞性睡眠呼吸暫停。 阻塞型睡眠呼吸中止與打鼾指數的ROC曲線下面積（AUC）為0.791，P <0.01; 最佳切點值≥57.85次/小時，靈敏度和特異性分別為74.6％和72.0％。透過將≥57.85次/小時定義為有打鼾標準，我們發現在有打鼾組別將近有89.10% 為阻塞型睡眠呼吸中止症患者；而在無打鼾者中有242位為阻塞型睡眠呼吸中止患者，約占所有阻塞型睡眠呼吸中止症的25%。透過多元迴歸分析無打鼾阻塞型睡眠呼吸中止個案發現年紀、腰圍、頸圍、身高體重指數(BMI)及男性為其高風險族群。風險比分別為:1.034(P<0.01)、1.097(P<0.01)、1.287(P<0.01)、1.230(P<0.01)、3.249 (P<0.05) 。而分析所有阻塞型睡眠呼吸中止症患者，我們發現女性患者較不以打鼾作為表徵，尤其是中至重度女性患者，達到顯著差異性。
結論：透過本研究，我們發現打鼾次數大於57.85 次/小時即有高度罹患睡眠呼吸中止症之可能，而每增加1次打鼾次數，罹患阻塞型睡眠呼吸中止症的風險增加1.005倍，打鼾次數與阻塞型睡眠呼吸中止症有高度相關性，阻塞型睡眠呼吸中止症女性患者相較於男性，不以打鼾作為表徵。有睡眠障礙個案，儘管沒有打鼾症狀，若年紀較大、高BMI、男性，還是懷疑有罹患睡眠呼吸中止症之可能，建議進行睡眠多項生理檢查或居家睡眠檢測作為評估。

Background: Obstructive sleep apnea (OSA) is a type of sleep-disordered breathing, mainly due to decreased chemical sensitivity during sleep and soft tissue relaxation leading to collapse of the upper airway, which is common in middle-aged obese people.
Snoring is the most easily perceived symptom of sleep apnea. In previous studies, approximately 70 to 95% patients suffer from obstructive sleep apnea are snorers. Through press campaigns in the newspapers, the public linked snoring to obstructive sleep apnea, thus ignoring the possibility of sleep apnea in patients without snoring, leading to the risk of ignoring the disease. This study is a retrospective study. By tracing patients who had undergone polysomnography in 2015, we analyze the polysomnography data to find out what is “the number of snoring that is related to obstructive sleep apnea “and define it as the standard of snoring or non-snoring. In addition, through this analysis, we will look for the characteristics of OSA patients without snoring to alert these patients.

Objective: This study is intended to identify the number of snoring that is related to OSA and is defined as snoring. In addition, this definition is used to identify the characteristics of OSA patients without snoring.
Results: The total number of cases was 1264. The average age of the cases is 49.1±13.6 years old, of which 70.6% are males, and 75.4% of the cases have obstructive sleep apnea. Areas under ROC curves (AUCs) of snoring index for predicting obstructive sleep apnea were 0.791, P <0.05; optimal cutoffs were≧57.85 times/hour with sensitivity and specificity of 74.6% and 72.0%.Through logistic regression analysis, we found that men, higher and BMI are risk factors for non-snorer to get OSA.

Conclusions: We found that the number of snoring was greater than 57.85 times per hour, which was highly probable suffer from obstructive sleep apnea. For each additional snore, the risks of obstructive sleep apnea increased by 1.005 times. Snoring index and obstructive sleep apnea show high correlation. Women do not use snoring as a disease manifestation. There are cases of sleep disorders, although no snoring symptoms, if older, high BMI, male, is recommended to perform polysomnography or home sleep apnea test as an assessment.

目錄
第一章 緒論......................... ............ ................. 1
第一節、 研究背景 ............... ............ ................. 1
第二節、 文獻探討 ............ ............ .................... 3
第三節、 研究動機 ............... ............ ................. 10
第四節、 研究假設及目的.... ......... .... ... ... ................11
第五節、 研究重要性.............. ....... ........ ............. 12
第二章 研究材料與方法......... .................................. 13
第一節、 研究方法 ............... ..... ...........................13
第二節、 資料來源與研究對象 ..................................... 14
第三節、 研究變項 ............................................... 15
第四節、 統計分析 .............................................. ..16
第三章 結果...................................... ................18
第一節、打鼾為診斷阻塞型睡眠呼吸中止症之重要指標........ .. .........18
第二節、不同阻塞型睡眠中止症嚴重度下打鼾與無打鼾人數比例分佈........23
第三節、無打鼾罹患阻塞型睡眠呼吸中止症患者之特徵....................25
第四節、所有阻塞型睡眠呼吸中止症患者有無打鼾個案之差異........ .....27
第四章 討論.............................. ..................... ...29
第一節、打鼾次數與阻塞型睡眠呼吸中止症之相關性......... ............29
第二節、無打鼾阻塞型睡眠呼吸中止症患者比例及特徵....................32
第三節、有阻塞型睡眠呼吸中止症有無打鼾個案差異.... ..... . .. ........33
第四節、研究限制........... ........... ........... ................34
第五章 結論與建議........... ........... ........... ..............35
第六章 參考文獻...................................... ......... ....36


表目錄
表 1-2.1.睡眠呼吸中止症嚴重度分級..................................4
表 2-1.1.收案流程表................................................13
表 3-1.1個案基本資料....................... ......................18
表3-1.2 約登指數下分析最佳切點....................... ............21
表3-1.3收案暨分組流程表... ... ... ... ... ... .. .. ... ... .....21
表3-1.4打鼾及無打鼾之基本生理特徵比較表................. ...... ..22
表3-2.1 在不同阻塞型睡眠呼吸中止症嚴重度下有無打鼾人數比例.. ......23
表3-2.2羅吉斯迴歸分析打鼾次數與罹患阻塞型睡眠呼吸中止症之關係暨打鼾有無與罹患阻塞型睡眠呼吸中止症之關係.. .... .... . .... ... ...... ......24
表3-3.1 無打鼾下有無阻塞型睡眠呼吸中止症個案基本特徵比較...... ....25
表3-3.2 無打鼾者罹患阻塞型睡眠呼吸中止症之危險因子.......... ......26
表3-4.1 所有阻塞型睡眠呼吸中止症有無打鼾個案特徵比較....... ... ...27
表3-4.2比較不同OSA嚴重度下有無打鼾下的男女比例................ ..28

圖目錄
圖1-2.1 打鼾與睡眠呼吸中止相關文宣............................ ....7
圖1-2.2 壓電式震動感測位置.................................... ....9
圖3-1.1打鼾次數與睡眠呼吸中止症之ROC分析... ... ... ... . ... ...20
圖3-2.1 斯皮爾多相關係數分析打鼾次數與呼吸中止-淺呼吸指數之關係...24
圖3-4.1 不同阻塞型睡眠呼吸中止症嚴重度下有無打鼾女性患者比例.. ...28

第六章參考文獻
1.Levitsky MG. Using the pathophysiology of obstructive sleep apnea to teach cardiopulmonary integration. Adv Physiol Educ. 2008;32:196–202.
2.Antic NA, Heeley E, Anderson CS, et al. The Sleep Apnea cardioVascular Endpoints (SAVE) trial: rationale, ethics, design, and progress. Sleep 2015;38:1247-1257
3.Lavie L. Oxidative stress in obstructive sleep apnea and intermittent hypoxia — revisited — the bad ugly and good: implications to the heart and brain. Sleep Med Rev 2015;20:27-45
4.Cadby G, McArdle N, Briffa T, et al. Severity of OSA is an independent predictor
of incident atrial fibrillation hospitalization in a large sleep-clinic cohort.Chest 2015; 148: 945-52.
5.Wang X, Bi Y, Zhang Q, Pan F. Obstructive sleep apnoea and the risk of type 2 diabetes: a meta-analysis of prospective cohort studies Respirology 2013;18:140–146.
6.Sanna A. Obstructive sleep apnoea, motor vehicle accidents, and work performance. Chron Respir Dis2013;10:29–33.
7.Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med 2009;5:573–81.
8.N.R. Netzer, R.A. Stoohs, C.M. Netzer, et al., Using the Berlin questionnaire to identify patients at risk for the sleep apnea syndrome, Ann. Intern. Med. 131 (1999) 485–491
9.F. Chung, B. Yegneswaran, P. Liao, et al., Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients, Anesthesiology 108 (2008) 822–830
10.M.W. Johns, A new method for measuring daytime sleepiness: the Epworth sleepiness scale, Sleep 14 (1991) 540–545
11.Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3): 263–76.
12.Ibrahim AS, Almohammed AA, Allangawi MH, et al. Predictors of obstructive sleep apnea in snorers. Annals of Saudi medicine. 2007;27(6):421-426
13.Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleepdisordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 2015;3:310–8
14.Lugaresi E, Cirignotta F, Coccagna G, Piana C. Some epidemiological data on snoring and cardiocirculatory disturbances. Sleep. 1980;3(3–4): 221–4.
15.Lévy P, Pépin J-L, Tamisier R, Neuder Y, Baguet J-P, Javaheri S. Prevalence and impact of central sleep apnea in heart failure. Sleep Med Clin 2007; 2: 615-21.
16.Morgenthaler TI1, Kagramanov V, Hanak V, Decker PA. Complex sleep apnea syndrome: is it a unique clinical syndrome? Sleep. 2006 Sep;29(9):1203-9.
17.Vishesh K. Kapur, MD, MPH,1 Dennis H. Auckley, MD,2 Susmita Chowdhuri, MD,3 David C. Kuhlmann, MD,4 Reena Mehra, MD, MS,5 Kannan Ramar, MBBS, MD,6 and Christopher G. Harrod, MS Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Mar 15; 13(3): 479–504.
18.Pinna GD1, Robbi E, Pizza F, Taurino AE, Pronzato C, La Rovere MT, Maestri R. Can cardiorespiratory polygraphy replace portable polysomnography in the assessment of sleep-disordered breathing in heart failure patients? Sleep Breath. 2014 Sep;18(3):475-82.
19.Ruehland WR1, Rochford PD, O''Donoghue FJ, Pierce RJ, Singh P, Thornton AT. The new AASM criteria for scoring hypopneas: impact on the apnea hypopnea index. Sleep. 2009 Feb;32(2):150-7.
20.Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med 2005;142:187-97.
21.Danny J. Eckert and Atul Malhotra. Pathophysiology of Adult Obstructive Sleep Apnea. Proc Am Thorac Soc. 2008 Feb 15; 5(2): 144–153.
22.Costa LE, Uchôa CH, Harmon RR, Bortolotto LA, Lorenzi-Filho G, Drager LF. Potential underdiagnosis of obstructive sleep apnoea in the cardiology outpatient setting. Heart 2015;101:1288–92.
23.Yumino D, Redolfi S, Ruttanaumpawan P, et al. Nocturnal rostral fluid shift: a unifying concept for the pathogenesis of obstructive and central sleep apnea in men with heart failure. Circulation. 2010;121:1598–605.
24.Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleepdisordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 2015;3:310–8
25.Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002;165:1217–39.
26.Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med 2009;5:573–81.
27.Phillips CL, McEwen BJ, Morel-Kopp MC, et al. Effects of continuous positive airway pressure on coagulability in obstructive sleep apnoea: a randomised, placebo-controlled crossover study.
28.Loke YK, Brown JW, Kwok CS, Niruban A, Myint PK. Association of obstructive sleep apnea with risk of serious cardiovascular events: a systematic review and meta-analysis Circ Cardiovasc Qual Outcomes 2012; 5: 720-8.
29.Punjabi NM, Shahar E, Redline S, Gottlieb DJ, Givelber R, Resnick HE; Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart HealthStudy.Sleep Heart Health Study Investigators. Am J Epidemiol 2004;160:521–530.
30.Shaw JE, Punjabi NM, Wilding JP, Alberti KG, Zimmet PZ; International Diabetes Federation Taskforce on Epidemiology and Prevention. Sleep disordered breathing and type 2 diabetes: a report from the International Diabetes Federation Taskforce on Epidemiology and Prevention. Diabetes Res Clin Pract 2008;81: 2–12.
31.Iftikhar IH, Hoyos CM, Phillips CL, Magalang UJ. Meta-analyses of the association of sleep apnea with insulin resistance, and the effects of CPAP on HOMA-IR, adiponectin, and visceral adipose fat. J Clin Sleep Med 2015; 11: 475-85.
32.Loke YK, Brown JW, Kwok CS, Niruban A, Myint PK. Association of obstructive sleep apnea with risk of serious cardiovascular events: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2012; 5: 720-8.
33.American Academy of Sleep Medicine. The international classification of sleep disorders, 3rd. ed. Darien, IL: American Academy of Sleep Medicine, 2014.
34.Jing J, Huang T, Cui W, Shen H. Effect on quality of life of continuous positive airway pressure in patients with obstructive sleep apnea syndrome: a meta-analysis. Lung. 2008;186:131
35.Nakano H, Hirayama K, Sadamitsu Y, Toshimitsu A,Fujita H, Shin S, Tanigawa T. Monitoring sound toquantify snoring and sleep apnea severity using a smartphone: proof of concept. J Clin Sleep Med. 2014;10(1): 73–8.
36.Pevernagie, D., Aarts, R. M. and De Meyer, M. The acoustics of snoring. Sleep Med. Rev., 2010, 14: 131–144.
37.Lugaresi E, Cirignotta F, Coccagna G, Piana C. Some epidemiological data on snoring and cardiocirculatory disturbances. Sleep. 1980;3(3–4): 221–4.
38.M. W. J. Armstrong C. L. Wallace J. Marais. The effect of surgery upon the quality of life in snoring patients and their partners: a between‐subjects case‐controlled trial. Clin Otolaryngol.1999.24,510-522
39.Gall, R., Isaac, L., Kryger, M .Quality of life in mild obstructive sleep apnea. Sleep, 16, S59 S61. 1993
40.Lee, S. A., Amis, T. C., Byth, K. et al. Heavy snoring as a cause of carotid artery atherosclerosis. Sleep, 2008, 31: 1207–1213.
41.Ulfberg, J., Carter, N., Talbäck, M. and Edling, C. Excessive daytime sleepiness at work and subjective work performance in the general population and among heavy snorers and patients with obstructive sleep apnea. Chest, 1996, 110: 659–663.
42.Ulfberg, J., Carter, N., Talbäck, M. and Edling, C. Headache, snoring and sleep apnoea. J. Neurol., 1996, 243: 621–625.
43.Nakano H, Hirayama K, Sadamitsu Y, Toshimitsu A, Fujita H, Shin S, Tanigawa T. Monitoring sound to quantify snoring and sleep apnea severity using a smartphone: proof of concept. J Clin Sleep Med. 2014;10(1): 73–8.
44.Christensson E, Franklin KA, Sahlin C, Palm A, Ulfberg J, Eriksson LI, Lindberg E, Hagel E, Jonsson Fagerlund M. Can STOP-Bang and Pulse Oximetry Detect and Exclude Obstructive Sleep Apnea? Anesth Analg. 2018 Sep;127(3):736-743.
45.ERNA S. ARNARDOTTIR, BARDUR ISLEIFSSON , JON S. AGUSTSSON , GUNNAR A. SIGURDSSON , MAGDALENA O. SIGURGUNNARSDOTTIR , GUDJON T. SIGURÐARSON , GUDMUNDUR SAEVARSSON , ATLI T. SVEINBJARNARSON , SVEINBJORN HOSKULDSSON and THORARINN GISLASON. How to measure snoring? A comparison of the microphone, cannula and piezoelectric sensor. J Sleep Res. (2016) 25, 158–168
46.Bloch, K. E., Li, Y., Sackner, M. A. and Russi, E. W. Breathing pattern during sleep disruptive snoring. Eur. Respir. J., 1997, 10: 576–586
47.Hanley JA, McNeil BJ (1982).The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology, 143:29-36.
48.W. J. Youden. Index for rating diagnostic tests. Cancer. 1950 Jan;3(1):32-5.