臺灣博碩士論文加值系統

阻塞性睡眠呼吸中止症(obstructive sleep apnea hypopnea syndrome, OSAHS)，其為睡眠障礙最常見之臨床診斷一般人口中，約有4%的中年男性與2%的中年女性患有睡眠呼吸中止。近年來阻塞性睡眠呼吸中止症已逐漸受到醫界的重視，由於睡眠呼吸中止症會引起心臟血管疾病及交通意外，它潛在影響多數人的身體健康，已是不容忽視的議題。
在治療方面，目前針對睡眠呼吸中止症並無有效藥物可供治療，因此需依賴介入性的治療方式，包括：睡眠時配戴連續陽壓呼吸器(continuous positive airway pressure apparatus, CPAP)、進行耳鼻喉科手術、裝置口腔矯正牙套等，其中陽壓呼吸器是此類患者的黃金標準治療法。使用持續性呼吸道陽壓治療是一種有效的治療方式，並且是對於中度至重度以上的阻塞性睡眠呼吸中止症候群患者，最被廣泛使用的治療方法。
過去許多的研究多著重於阻塞性睡眠呼吸中止症患者的病患衛教、疾病嚴重度、機器及配件設計等因素與持續使用的相關性，較少利用行為模式切入配戴連續陽壓呼吸器順應性之研究 本論文藉由分析健康認知模式Health believed model中的自我效能(Self efficacy)及人格特徵(personality)及瞭解得到疾病造成的嚴重性(perceived severity)進而產生行為(cues of action)使用呼吸器的影響因素。

本論文第一部研究自我效能(Self efficacy)，希望藉由比較初次連續陽壓呼吸道正壓治療前，及治療壓力調整時多功能睡眠檢查生理變化，影響自我效能進而有動機持續使用呼吸道正壓治療， 收集睡眠醫學中心中度以上(apnea-hypopnea index; AHI>15/h)阻塞性睡眠呼吸中止症病患共312名患者進行回朔性分析研究， 依連續陽壓呼吸器繼續使用與否分為接受治療(n=146)與不接受治療(n=166)等二個群組。結果發現整體睡眠時間睡眠效率在兩組有統計學差異，所以在初次連續陽壓呼吸道正壓治療壓力調整時睡得愈好也就是自我效能愈好時， 就有動機持續使用呼吸道正壓治療。

第二部分利用人格特徵Ｄ型與否，提早解暸人格特徵， 是否就是影響接不接受持續性呼吸道正壓治療的因素， 讓臨床醫療人員提早預測順應性， 早些提供其他有效之治療， 避免等待連續陽壓呼吸道正壓治療壓力調整檢查時間之醫療浪費。收集睡眠醫學中心中度以上(apnea-hypopnea index; AHI>15/h)阻塞性睡眠呼吸中止症病患共202名患者進行前瞻性分析研究， 人格特徵Ｄ型與非Ｄ型以1:1比例配對，包括疾病嚴重度、性別、年齡、身體質量指數、頭頸圍及白天嗜睡程度。結果發現人格特徵Ｄ型不影響持續使用呼吸道正壓治療， 反而收入與有無睡眠伴侶影響較大，社會經濟因素反而更為重要。
本論文第三部分想藉由比較容易瞭解的疾病， 讓民眾能容易瞭解得到阻塞性睡眠呼吸中止症疾病造成疾病的嚴重性，藉由分析台灣健保資料庫肝炎與否, 了解肝炎盛行的台灣地區，肝炎與睡眠呼吸中止症的關係，並分析連續陽壓呼吸器是否對肝炎之改善有一定幫助， 分析哪些人比較容易接受連續陽壓呼吸器檢查。 收集自1995至2010年台灣健康保險資料庫中年齡二十歲以上， 共12745人有接受多功能睡眠生理檢查並診斷阻塞性睡眠呼吸中止症， 考慮年齡及性別1:3配對， 共18,516 人無阻塞性睡眠呼吸中止症為控制組， 分析發現不論共病是高血壓、糖尿病、高血脂、心臟衰竭、心房顫動等， 肝炎的發生風險都比控制組高， 使用持續性呼吸道正壓治療可以減低肝炎的發生的趨勢。

結 論
由自我效能、人格特徵及瞭解得到疾病造成的嚴重性三部分研究，使用呼吸器的順應性，可藉由對台灣民眾對肝炎的重視出發，從家人及經濟角度切入, 讓病人能自檢查過程中發現治療效果， 自然順應性就可以增加。

Part I Better Sleep Quality Improves the CPAP Compliance in Patients with OSA
Objectives: An extensive use of continuous positive airway pressure (CPAP) has been shown to have greater clinical benefit for most patients with obstructive Sleep apnea (OSA). Patient compliance remains a major limiting factor to the effectiveness of CPAP. This study sought to determine the potential and quantifiable factors affecting OSA patients to undertake CPAP treatment by comparing the polysomnographic parameters recorded during diagnosis and titration between persistent users and non-users of CPAP.
Methods: Patients with moderate-to-severe OSA attended diagnostic polysomnography (PSG) and CPAP titration at the sleep center of China Medical University Hospital were included for this study. A total of 312 patients were divided to persistent users and non-users of CPAP according to treatment with and without in-home CPAP following titration and a 7-day trial use. Patient characteristics and their polysomnographic parameters were analyzed for comparing sleep efficacy and quality between persistent users and non-users.
Results: Total sleep time, sleep efficiency, and minimum SaO2 were statistically significant different between persistent users and non-users during CPAP titration. The overall sleep quality was also improved among persistent users.
Conclusions: CPAP adherence was associated with longer Total sleep time (TST), better sleep efficiency, lower minimum SaO2, and improved sleep quality during CPAP titration. Appropriate CPAP devices, experienced sleep technicians, and comfortable environment were key elements potentially influencing patients' decision-making of CPAP adoption.

Part 2: Do Personality in OSA patients reduce motivation to purchase CPAP machine.
Objectives: Use of continuous positive airway pressure (CPAP) has been shown to be clinically beneficial for most patients with obstructive sleep apnea hypopnea syndrome (OSAHS). Patient compliance remains a major limiting factor to the effectiveness of CPAP. This study sought to determine the factors that may contribute to the decision of purchasing mechanical ventilation including personality.
Methods: Patients with moderate-to-severe OSAHS who attended diagnostic polysomnography (PSG) and CPAP titration were included in this study. After personality types were determined using a questionnaire, 101 OSAHS patients with Type-D personality were selected and matched at a ratio of 1:1 to OSAHS patients with Non type-D personality. The factors that might affect the decision of purchasing CPAP were analyzed using a conditional logistic regression model .
Results: Characteristic differences were only observed in income and sleep habit with or without a partner between the patients with Type-D and non Type-D personalities. Type-D personality was not significantly associated with the motivation of purchasing a CPAP machine, and EES was the only predicting variable in this study.
Conclusions: CPAP adherence was associated with Type-D personality. More studies using population-based and longitudinal designs with randomly selected OSAS patients are needed to correct the potential bias of participant inclusion and to assess the long term impacts of Type-D personality on health status among OSAS patients.

Part 3
In view of these relevant evidence supporting the association of OSAHS with NAFLD, this study aimed to determine the incidence of NAFLD among OSASH patients, to evaluate whether CPAP treatment contributes to those with these two disorders in a prospective and population-based study in Taiwan, followed-up over a period of 10 years, and to investigate the incidences and effects of comorbidities. To determine whether OSAHS is a risk factor for the development of NAFLD and to compare the relative risks between OSAHS patients with and without CPAP treatment, we measured the hazards ratios (HRs) of NAFLD by using the stratified Cox proportional hazards model adjusting for age, gender, and comorbidities. All data management and calculation of HRs was performed using the SAS System (version 9.3; SAS Institute, Cary, NC). Cumulative incidence was analyzed via the Statistical Package for the Social Sciences (version 10.0; SPSS Inc, Chicago, IL).Our observations from the cohort data suggested that the mechanisms thereby OSAHS increasing the incidence of NALFD are likely associated with the both settings, insulin resistance and intermittent hypoxia (nocturnal hypoxemia). This study also suggests that treatment of OSAHS with CPAP may delay the development or reduce the incidences of NALFD. More evidence is also needed on how to manage comorbidities in OSAHS. Comorbidities not only adds challenges to treatment, but also increases the complexity of patient care, as well as adding to the economic burden of disease. Further interventional studies are required to demonstrate whether CPAP treatment results in diminished severity of NASLD and/or other comorbidities.

綜論 4
目錄 7
1.Better Sleep Quality Improves the CPAP Compliance in Patients with OSA 15
2.Do Personality in OSA patients reduce motivation to purchase CPAP achine 40
3.CPAP Therapy Improved the Risk of Developing NAFLD in Patients with OSASH: A Nationwide Population-Based Cohort Study 63

Contents 1
Abbreviations 18
Introduction 19
Methods 21
Results 24
Discussions 26
Acknowledgement 28
References 29 
List of Table 1
Table 1. Analysis of patient characteristics 34
Table 2. Comparison of baseline characteristic differences between CPAP persistent users and non-users 35
Table 3. Comparison of polysomnographic parameters on the first night between persistent users and non-users of CPAP 36
Table 4. Comparison of polysomnographic parameters during CPAP titration between CPAP persistent users and non-users 37
Table 5. Comparison of sleep quality between CPAP Persistent users and Non-users at diagnosis and during CPAP titration, respectively 38
Table 6. Comparison of sleep quality between diagnosis and CPAP titration for CPAP Persistent users and Non-users) 39
 
Contents 2
Introduction 42
Material and Methods 44
Results 48
Discussion 49
References 52
List of Table 2
Table 1. Characteristics of patients with OSAHS at baseline 56
Table 2. Characteristics of patients with OSAHS at baseline 57
Table 3. Effects of variables on patients’ use of CPAP, analyzed by conditional logistic regression models (adjusted for variables among Type-D and Non Type-D groups) 58
List of Figure 2
Figure 1. Flow diagram of patient progress through phases of the study 55
 
Content 3
Introduction 64
Methods 66
Results 68
Discussion 70
Strengths and limitations 72
Conclusion 72
References 73
List of Table 3
Table 1. Baseline Characteristics of Patients in Non-CPAP, CPAP and CONTROL Cohorts 80
Table 2. Hazard ratios calculated for the relative risks of developing non-alcoholic fatty liver diseases (NAFLD) between the comparative OSAHS cohorts with and without CPAP treatment, adjusted by age and gender 81
Table 3. Hazard ratios of developing non-alcoholic fatty liver diseases (NAFLD) in OSAHS patients without and with CPAP treatment. Adjustments were made for various comorbidities 82

Part 1
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Part 2
1.Gay, P., et al., Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep, 2006. 29(3): 381-401.
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3.Engleman, H.M. and M.R. Wild, Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Medicine Reviews, 2003. 7(1): 81-99.
4.Verse, T., et al., Recent developments in the treatment of obstructive sleep apnea. Am J Respir Med, 2003. 2(2): 157-168.
5.Hoffstein, V., et al., Treatment of obstructive sleep apnea with nasal continuous positive airway pressure. Patient compliance, perception of benefits, and side effects. Am Rev Respir Dis, 1992. 145(4 Pt 1): 841-845.
6.Stepnowsky, C.J., Jr., M.R. Marler, and S. Ancoli-Israel, Determinants of nasal CPAP compliance. Sleep Med, 2002. 3(3): 239-247.
7.Catcheside, P.G., Predictors of continuous positive airway pressure adherence. F1000 Med Rep, 2010. 2.
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17.Elshaug, A.G., et al., An analysis of the evidence-practice continuum: is surgery for obstructive sleep apnoea contraindicated. J Eval Clin Pract, 2007. 13(1): 3-9.
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Part 3
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