肥胖青少年阻塞性睡眠呼吸暂停综合症的上气道塌陷因素分析
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摘要
阻塞性睡眠呼吸暂停综合症（obstructive sleep apnea syndrome, OSAS）是指睡眠状态下反复发生的呼吸节律的停止或呼吸幅度短暂的或持续的降低，并引起明显的低氧血症和高碳酸血症。这些呼吸暂停和低通气是睡眠时相所特有，伴随间歇性低氧经常导致整夜睡眠中短暂的觉醒和睡眠片段化。
儿童OSAS自从上个世纪70年代被提出来以来，其发病率逐年增高，并且被公认为儿科一些疾病的主要原因，可引起心血管系统、神经行为学、生长发育和炎症反应等方面的并发症。然而对于本病发生的病理生理学机制的研究才刚刚处于起步阶段。至今已经确认的四种与儿童OSAS有关的风险因素，包括扁桃体肥大、颅面部畸形、原发性神经肌肉疾病以及肥胖。随着肥胖儿童的增多，肥胖在儿童OSAS发病中的作用更加受到重视。已有报道证实肥胖与婴儿期到儿童期结束的OSAS均有关系，并可以使OSAS发病风险增加四倍。目前大量成人和部分儿童OSAS的研究已经证实限制上气道开放的解剖学因素和导致上气道塌陷性增加的神经因素在本病发生机制中起主导作用。在非肥胖儿童OSAS中，腺样体和扁桃体肥大限制了上气道的面积，是众所周知的原因。研究发现在肥胖儿童OSAS中这种肥大的作用也存在。导致扁桃体腺样体增大的原因可能包括身体增长时激素的改变和与儿童肥胖有关的局部和全身的炎症反应。在成人肥胖OSAS病人，限制气道面积并位于气道周围的软组织，如脂肪垫、软腭、咽侧壁、舌的作用已有报道。然而，在肥胖儿童OSAS病人中，鼻咽气道和上气道周围的软组织的解剖学分析还很少涉及。研究发现并不是所有的肥胖儿童都发生OSAS，在伴有扁桃体和腺样体肥大的肥胖OSAS儿童清醒时上气道不阻塞，因为此时上气道神经肌肉张力高；肥胖儿童OSAS患者经过手术去除解剖因素后，部分患者出现症状的持续存在或复发，这种复发率高于非肥胖OSAS患儿，提示其他的解剖因素或功能因素可能也在肥胖儿童OSAS发病中起作用。导致上气道塌陷性增加的功能机制有神经肌肉张力，组织性质的改变，阻力增加等。成人的研究发现在睡眠状态下，如果没有上气道扩张肌激活的保护作用，即使是非常轻微的吸气负压都会导致气道塌陷，在儿童中发现同样的结果。新近的关于肥胖成人OSAS患者的研究表明肥胖程度和增高的上气道塌陷性有关联，在一定程度上解释了这些患者发生OSAS的倾向性。可以非常合理的推测，在肥胖儿童OSAS患者中也存在这种机制的缺陷。通气驱动功能在成人和儿童OSAS发病中的作用还不甚明了。部分研究表明，患者较对照者之间存在细微异常。因此，可以推测在肥胖OSAS儿童中，像在肥胖OSAS成人一样，通气反应的异常可导致其易患OSAS。
青少年阶段，是儿童期到成人期的过渡阶段，这个成长阶段伴随着重要的睡眠问题。有报道指出青春期前接受扁桃体腺样体手术的OSAS患儿，进入青春期后再度发生此病，并且肥胖在此年龄段儿童中的发生率高于青春期前儿童。然而，目前关于青少年阶段与OSAS发病的关联，以及肥胖对青少年儿童上气道塌陷性的影响机制的研究却很少。因此有必要对此年龄段肥胖OSAS患者进行病理生理学方面的评估。我们预测肥胖青少年儿童发生OSAS的原因在于上气道解剖学结构改变与上气道神经肌肉功能受损密切相关，是二者共同作用的结果。
本研究为病例对照研究，研究对象为12-16岁青少年儿童OSAS患者、肥胖对照儿童和正常体重对照儿童。应用脑电生理学技术、压力-气流反应测定技术、咽部闭合压测定技术、肌肉活性电生理学技术以及核磁共振成像技术，在同一个体上评估了引起上气道塌陷的解剖因素和神经因素，证实在肥胖青少年OSAS患者中，基于上气道解剖结构狭窄基础上的神经肌肉控制功能的缺陷是其主要的病理生理学发病机制；肥胖未发生OSAS青少年的上气道神经反应性在睡眠期补偿性增高，以抵御肥胖带来的解剖因素的狭窄。
研究结果显示：
（1）压力-气流关系曲线斜率在上气道激活状态下，肥胖OSAS组高于肥胖对照组和正常体重对照组(P<0.0005)；上气道低张状态下，肥胖OSAS组和肥胖对照组高于正常体重对照组(P<0.0005和P<0.05)。
（2）咽部闭合压无论在上气道激活状态和低张状态下，肥胖OSAS组均高于肥胖对照组和正常体重对照组(P<0.005和P<0.0005)。
（3）颏舌肌活性-鼻内压关系（EMGgg-PN）曲线斜率在上气道激活状态下，肥胖对照组高于肥胖OSAS组和正常体重对照组(P<0.005和P<0.0005)；在肥胖对照组和正常体重对照组，上气道激活状态下的EMGgg-PN斜率高于低张状态下斜率(P<0.0005和P<0.005)。
（4）肥胖OSAS组扁桃体、腺样体和咽侧壁体积高于肥胖对照组和正常体重对照组(P<0.05，P<0.0005， P<0.02)；肥胖OSAS组和肥胖对照组舌的体积高于正常体重对照组(P<0.05)。
（5）正常体重组在上气道低张和激活状态下，压力-气流曲线斜率（PFR）与咽侧壁体积呈正相关(P<0.05)；上气道激活状态下，PFR斜率与咽侧壁在肥胖OSAS组呈正相关(P<0.02)，而在肥胖对照组呈负相关(P<0.05)。
（6）清醒期，肥胖OSAS组和肥胖对照组对CO2的反应性较正常体重对照组高(P<0.05),经过体重矫正后，三组之间无差别；睡眠期，肥胖OSAS组对CO2的反应性较肥胖对照组和正常体重对照组低，体现在吸入CO2后以下指标的变化较小：分钟通气量（VE, P<0.005)、吸入气流量(Flow, P<0.01)、潮气量(VT, P<0.01)、吸气时间(TI, P<0.05)和VT/TI(P<0.005)。
从以上结果我们可以得出如下结论：
1.睡眠状态下，肥胖OSAS青少年上气道的神经反应性降低，使上气道易于塌陷，引发OSAS。
2．肥胖未发生OSAS的青少年上气道神经反应性补偿性增高，以对抗肥胖带来的上气道解剖结构的狭窄。
3．肥胖可引起上气道周围组织体积增大，限制上气道开放，其中咽侧壁体积增大对上气道解剖结构改变起主要作用，并可使上气道塌陷性增加。
4．睡眠期中枢通气驱动能力下降是肥胖青少年OSAS发生的重要因素之一。
The obstructive sleep apnea syndrome (OSAS) refers to a breathing disordercharacterized by recurrent cessations in breathing rhythm or momentary or sustainedreductions in the breath amplitude, sufficient to cause significant arterial hypoxemia andhypercapnia. These apneas are sleep specific, and commonly associated with sleepfragmentation and intermittent hypoxemia.
The prevalence of OSAS in children has been increasing since it was first described inthe1970s as a clinical entity in children， and is now recognized to be a common cause ofmorbidity in the pediatric population, resulting in cardiovascular, neurobehavioral, growthand inflammatory complications. Despite the high prevalence and significant morbidity ofpediatric OSAS, we are only now beginning to understand its pathophysiology. Four clinicalphenotypes associated with OSAS in children have been recognized since the original reportincluding adenotonsillar hypertrophy, craniofacial malformations and syndromic conditions,primary neuromuscular disorders and obesity. The prevalence of OSAS can be expected toincrease in association with the burgeoning pediatric obesity epidemic. Previous reports haveassociated obesity from ealy infancy to late childrenhood obesity with OSAS. Theprevalence of OSAS in obese children may increase the risk by more than fourfold.Currently, multiple studies about OSAS in adults and children have demonstrated thatanatomic factors restricting the upper airway and neuronal factors increasing thecollapsibility of the upper airway are important mechanistic contributors for OSAS. Innormal weight children, OSAS has associations with adenotonsillar hypertrophy. Suchhypertrophy was reported in obese OSAS children. The hormone change when body growthand local and systematic inflammatory reaction associated with obesity may induceadenotonsillar hypertrophy. It was reported that the soft tissue around upper airway constrictthe area of upper airway in obese adult OSAS, such as fat pad, soft palate, lateral pharyngealwall, tongue. However, little is known about the anatomical analysis for nasal pharynx andsoft tissue around upper airway in obese children with OSAS. However, not all obesechildren suffered from OSAS. There was no obstruction in upper airway during wakefulnessin obese OSAS children with adenotonsillar hypertrophy, because of higher neuromotor toneawake; In some obese OSAS patients, after removal of the anatomical factors by surgery, the symptoms persist or reoccur. This indicates that there must be some other anatomical orfunctional factors contributing the pathophysiological mechanism in obese children withOSAS. The functional factors increasing the collapsibility of upper airway includeneuromuscular tone, changes of tissue characters and increasing of resistance. The adultstudies found mild inspiratory negative pressure can lead the obstruction of upper airwaywithout activation of upper airway dilator muscles, so did the studies in children. Thecorrelation between obesity and the degree of upper airway collapsibility in obese adultswith OSAS indicated the proneness to OSAS in such patients. We can reasonablyhypothesize that there will be such functional deficient in obese children with OSAS. It isnot well understood for the role of ventilatory drive in adult and children. Some studiesshowed there was subtle abnormality between patients and controls. We thereforehypothesize that ventilatory drive abnormality will induce OSAS in obese children similar toadult OSAS.
Adolescence, the transition from childhood to adulthood, is a period of developmentknown to have major sleep issues. It is reported that the symptom in children with OSASunderwent adenotonsillectomy reoccurred when they went into adolescence. In addition, Theprevalence of obesity during this adolescents age is higher that of prepuber stage. However,It remains virtually unstudied in relation to OSAS and the effects of pediatric obesity onupper airway collapsibility. Therefore the pathophysiology of obese adolescents with OSASneeds to be evaluated. Our overall hypothesis is that OSAS develops when a structural loadis acquired by an individual with an underlying impairment of upper airway neuromotorfunction.
This is a matched case-dual control study with a complementary interventionalcomponent. The subjects, aged from12to16, were classified into obese OSAS group, obesecontrol group and lean control group. All subjects will be phenotyped by polysomnography,pressure-flow relationship measurement technology, muscle activity electrophysiology andmagnetic resonance imaging assessment of upper airway, hypercapnic ventilatory responsesand pulmonary function testing. The anatomical and neuromotor tone factors of upperairway will be evaluated in the three groups.
The results showed the following:
(1) In the activated state, the slope of pressure–flow relationship was higher in theobese OSAS compared to obese controls and lean controls (P <0.0005); In the hypotonicstate, the slope of pressure–flow relationship was higher in obese OSAS and obese controls compared to lean controls (P <0.0005, P <0.05respectively).
(2) Pharyngeal closing pressure (Pcrit) was higher in obese OSAS compared to obesecontrols and lean controls (P <0.005, P <0.0005, respectively).
(3) In the activated state, the slope of Genioglossus activity–nasal pressurerelationship (EMGgg–PN) was higher in obese controls compared to obese OSAS and leancontrols (P <0.005, P <0.0005, respectively). The activated slope of EMGgg–PN washigher than the hypotonic slope in obese controls and lean controls (P <0.0005, P <0.005,respectively).
(4) The volumes of tonsils, adenoids and lateral pharyngeal wall were higher in obeseOSAS compared to obese controls and lean controls (P <0.05, P <0.0005, and P <0.02,respectively); the volume of tongue was higher in obese OSAS and obese controls comparedto lean controls (P <0.05).
(5) The relationship between PFR and the volume of lateral pharyngeal wall waspositive in the lean control group both in the activated and hypotonic state (P <0.05); In theactivated state, the relationships were positive (P <0.02) in obese OSAS and negative inobese controls (P <0.05).
(6) During wakefulness, the slopes of hypercapnic ventilatory responses (HCVR) werehigher in obese OSAS and obese controls compared to lean controls, however, no significantdifferences were found in the three groups after controlled for weight; During sleep, theventilatory responses to CO2was lower in the obese OSAS compared to the two controlgroups expressed as the following index: minute ventilation (VE, P <0.005), the inspiratoryfolw (Flow, P <0.01), tidal volume (VT, P <0.01), inspiratory time (TI, P <0.05) and VT/TI(P <0.005).
From the above results, we can draw the following conclusions:
1. The upper airway neuromotor tone was decreased in obese adolescents with OSAS,which increased the collapsibility of upper airway, thus OSAS.
2. Obese adolescents without OSAS had an increased neuromotor tone of upperairway during sleep to compensate the anatomical abnormality.
3. Obesity can increase the volume of the soft tissues around upper airway restrictingthe size of upper airway. The pharyngeal lateral wall may play an important role inthe anatomical fators in the obese adolescents with OSAS and can increase thecollapsibility of upper airway.
4. The central ventilatory drive was blunted during sleep in obese adolescents with OSAS.
儿童OSAS自从上个世纪70年代被提出来以来，其发病率逐年增高，并且被公认为儿科一些疾病的主要原因，可引起心血管系统、神经行为学、生长发育和炎症反应等方面的并发症。然而对于本病发生的病理生理学机制的研究才刚刚处于起步阶段。至今已经确认的四种与儿童OSAS有关的风险因素，包括扁桃体肥大、颅面部畸形、原发性神经肌肉疾病以及肥胖。随着肥胖儿童的增多，肥胖在儿童OSAS发病中的作用更加受到重视。已有报道证实肥胖与婴儿期到儿童期结束的OSAS均有关系，并可以使OSAS发病风险增加四倍。目前大量成人和部分儿童OSAS的研究已经证实限制上气道开放的解剖学因素和导致上气道塌陷性增加的神经因素在本病发生机制中起主导作用。在非肥胖儿童OSAS中，腺样体和扁桃体肥大限制了上气道的面积，是众所周知的原因。研究发现在肥胖儿童OSAS中这种肥大的作用也存在。导致扁桃体腺样体增大的原因可能包括身体增长时激素的改变和与儿童肥胖有关的局部和全身的炎症反应。在成人肥胖OSAS病人，限制气道面积并位于气道周围的软组织，如脂肪垫、软腭、咽侧壁、舌的作用已有报道。然而，在肥胖儿童OSAS病人中，鼻咽气道和上气道周围的软组织的解剖学分析还很少涉及。研究发现并不是所有的肥胖儿童都发生OSAS，在伴有扁桃体和腺样体肥大的肥胖OSAS儿童清醒时上气道不阻塞，因为此时上气道神经肌肉张力高；肥胖儿童OSAS患者经过手术去除解剖因素后，部分患者出现症状的持续存在或复发，这种复发率高于非肥胖OSAS患儿，提示其他的解剖因素或功能因素可能也在肥胖儿童OSAS发病中起作用。导致上气道塌陷性增加的功能机制有神经肌肉张力，组织性质的改变，阻力增加等。成人的研究发现在睡眠状态下，如果没有上气道扩张肌激活的保护作用，即使是非常轻微的吸气负压都会导致气道塌陷，在儿童中发现同样的结果。新近的关于肥胖成人OSAS患者的研究表明肥胖程度和增高的上气道塌陷性有关联，在一定程度上解释了这些患者发生OSAS的倾向性。可以非常合理的推测，在肥胖儿童OSAS患者中也存在这种机制的缺陷。通气驱动功能在成人和儿童OSAS发病中的作用还不甚明了。部分研究表明，患者较对照者之间存在细微异常。因此，可以推测在肥胖OSAS儿童中，像在肥胖OSAS成人一样，通气反应的异常可导致其易患OSAS。
青少年阶段，是儿童期到成人期的过渡阶段，这个成长阶段伴随着重要的睡眠问题。有报道指出青春期前接受扁桃体腺样体手术的OSAS患儿，进入青春期后再度发生此病，并且肥胖在此年龄段儿童中的发生率高于青春期前儿童。然而，目前关于青少年阶段与OSAS发病的关联，以及肥胖对青少年儿童上气道塌陷性的影响机制的研究却很少。因此有必要对此年龄段肥胖OSAS患者进行病理生理学方面的评估。我们预测肥胖青少年儿童发生OSAS的原因在于上气道解剖学结构改变与上气道神经肌肉功能受损密切相关，是二者共同作用的结果。
本研究为病例对照研究，研究对象为12-16岁青少年儿童OSAS患者、肥胖对照儿童和正常体重对照儿童。应用脑电生理学技术、压力-气流反应测定技术、咽部闭合压测定技术、肌肉活性电生理学技术以及核磁共振成像技术，在同一个体上评估了引起上气道塌陷的解剖因素和神经因素，证实在肥胖青少年OSAS患者中，基于上气道解剖结构狭窄基础上的神经肌肉控制功能的缺陷是其主要的病理生理学发病机制；肥胖未发生OSAS青少年的上气道神经反应性在睡眠期补偿性增高，以抵御肥胖带来的解剖因素的狭窄。
研究结果显示：
（1）压力-气流关系曲线斜率在上气道激活状态下，肥胖OSAS组高于肥胖对照组和正常体重对照组(P<0.0005)；上气道低张状态下，肥胖OSAS组和肥胖对照组高于正常体重对照组(P<0.0005和P<0.05)。
（2）咽部闭合压无论在上气道激活状态和低张状态下，肥胖OSAS组均高于肥胖对照组和正常体重对照组(P<0.005和P<0.0005)。
（3）颏舌肌活性-鼻内压关系（EMGgg-PN）曲线斜率在上气道激活状态下，肥胖对照组高于肥胖OSAS组和正常体重对照组(P<0.005和P<0.0005)；在肥胖对照组和正常体重对照组，上气道激活状态下的EMGgg-PN斜率高于低张状态下斜率(P<0.0005和P<0.005)。
（4）肥胖OSAS组扁桃体、腺样体和咽侧壁体积高于肥胖对照组和正常体重对照组(P<0.05，P<0.0005， P<0.02)；肥胖OSAS组和肥胖对照组舌的体积高于正常体重对照组(P<0.05)。
（5）正常体重组在上气道低张和激活状态下，压力-气流曲线斜率（PFR）与咽侧壁体积呈正相关(P<0.05)；上气道激活状态下，PFR斜率与咽侧壁在肥胖OSAS组呈正相关(P<0.02)，而在肥胖对照组呈负相关(P<0.05)。
（6）清醒期，肥胖OSAS组和肥胖对照组对CO2的反应性较正常体重对照组高(P<0.05),经过体重矫正后，三组之间无差别；睡眠期，肥胖OSAS组对CO2的反应性较肥胖对照组和正常体重对照组低，体现在吸入CO2后以下指标的变化较小：分钟通气量（VE, P<0.005)、吸入气流量(Flow, P<0.01)、潮气量(VT, P<0.01)、吸气时间(TI, P<0.05)和VT/TI(P<0.005)。
从以上结果我们可以得出如下结论：
1.睡眠状态下，肥胖OSAS青少年上气道的神经反应性降低，使上气道易于塌陷，引发OSAS。
2．肥胖未发生OSAS的青少年上气道神经反应性补偿性增高，以对抗肥胖带来的上气道解剖结构的狭窄。
3．肥胖可引起上气道周围组织体积增大，限制上气道开放，其中咽侧壁体积增大对上气道解剖结构改变起主要作用，并可使上气道塌陷性增加。
4．睡眠期中枢通气驱动能力下降是肥胖青少年OSAS发生的重要因素之一。
The obstructive sleep apnea syndrome (OSAS) refers to a breathing disordercharacterized by recurrent cessations in breathing rhythm or momentary or sustainedreductions in the breath amplitude, sufficient to cause significant arterial hypoxemia andhypercapnia. These apneas are sleep specific, and commonly associated with sleepfragmentation and intermittent hypoxemia.
The prevalence of OSAS in children has been increasing since it was first described inthe1970s as a clinical entity in children， and is now recognized to be a common cause ofmorbidity in the pediatric population, resulting in cardiovascular, neurobehavioral, growthand inflammatory complications. Despite the high prevalence and significant morbidity ofpediatric OSAS, we are only now beginning to understand its pathophysiology. Four clinicalphenotypes associated with OSAS in children have been recognized since the original reportincluding adenotonsillar hypertrophy, craniofacial malformations and syndromic conditions,primary neuromuscular disorders and obesity. The prevalence of OSAS can be expected toincrease in association with the burgeoning pediatric obesity epidemic. Previous reports haveassociated obesity from ealy infancy to late childrenhood obesity with OSAS. Theprevalence of OSAS in obese children may increase the risk by more than fourfold.Currently, multiple studies about OSAS in adults and children have demonstrated thatanatomic factors restricting the upper airway and neuronal factors increasing thecollapsibility of the upper airway are important mechanistic contributors for OSAS. Innormal weight children, OSAS has associations with adenotonsillar hypertrophy. Suchhypertrophy was reported in obese OSAS children. The hormone change when body growthand local and systematic inflammatory reaction associated with obesity may induceadenotonsillar hypertrophy. It was reported that the soft tissue around upper airway constrictthe area of upper airway in obese adult OSAS, such as fat pad, soft palate, lateral pharyngealwall, tongue. However, little is known about the anatomical analysis for nasal pharynx andsoft tissue around upper airway in obese children with OSAS. However, not all obesechildren suffered from OSAS. There was no obstruction in upper airway during wakefulnessin obese OSAS children with adenotonsillar hypertrophy, because of higher neuromotor toneawake; In some obese OSAS patients, after removal of the anatomical factors by surgery, the symptoms persist or reoccur. This indicates that there must be some other anatomical orfunctional factors contributing the pathophysiological mechanism in obese children withOSAS. The functional factors increasing the collapsibility of upper airway includeneuromuscular tone, changes of tissue characters and increasing of resistance. The adultstudies found mild inspiratory negative pressure can lead the obstruction of upper airwaywithout activation of upper airway dilator muscles, so did the studies in children. Thecorrelation between obesity and the degree of upper airway collapsibility in obese adultswith OSAS indicated the proneness to OSAS in such patients. We can reasonablyhypothesize that there will be such functional deficient in obese children with OSAS. It isnot well understood for the role of ventilatory drive in adult and children. Some studiesshowed there was subtle abnormality between patients and controls. We thereforehypothesize that ventilatory drive abnormality will induce OSAS in obese children similar toadult OSAS.
Adolescence, the transition from childhood to adulthood, is a period of developmentknown to have major sleep issues. It is reported that the symptom in children with OSASunderwent adenotonsillectomy reoccurred when they went into adolescence. In addition, Theprevalence of obesity during this adolescents age is higher that of prepuber stage. However,It remains virtually unstudied in relation to OSAS and the effects of pediatric obesity onupper airway collapsibility. Therefore the pathophysiology of obese adolescents with OSASneeds to be evaluated. Our overall hypothesis is that OSAS develops when a structural loadis acquired by an individual with an underlying impairment of upper airway neuromotorfunction.
This is a matched case-dual control study with a complementary interventionalcomponent. The subjects, aged from12to16, were classified into obese OSAS group, obesecontrol group and lean control group. All subjects will be phenotyped by polysomnography,pressure-flow relationship measurement technology, muscle activity electrophysiology andmagnetic resonance imaging assessment of upper airway, hypercapnic ventilatory responsesand pulmonary function testing. The anatomical and neuromotor tone factors of upperairway will be evaluated in the three groups.
The results showed the following:
(1) In the activated state, the slope of pressure–flow relationship was higher in theobese OSAS compared to obese controls and lean controls (P <0.0005); In the hypotonicstate, the slope of pressure–flow relationship was higher in obese OSAS and obese controls compared to lean controls (P <0.0005, P <0.05respectively).
(2) Pharyngeal closing pressure (Pcrit) was higher in obese OSAS compared to obesecontrols and lean controls (P <0.005, P <0.0005, respectively).
(3) In the activated state, the slope of Genioglossus activity–nasal pressurerelationship (EMGgg–PN) was higher in obese controls compared to obese OSAS and leancontrols (P <0.005, P <0.0005, respectively). The activated slope of EMGgg–PN washigher than the hypotonic slope in obese controls and lean controls (P <0.0005, P <0.005,respectively).
(4) The volumes of tonsils, adenoids and lateral pharyngeal wall were higher in obeseOSAS compared to obese controls and lean controls (P <0.05, P <0.0005, and P <0.02,respectively); the volume of tongue was higher in obese OSAS and obese controls comparedto lean controls (P <0.05).
(5) The relationship between PFR and the volume of lateral pharyngeal wall waspositive in the lean control group both in the activated and hypotonic state (P <0.05); In theactivated state, the relationships were positive (P <0.02) in obese OSAS and negative inobese controls (P <0.05).
(6) During wakefulness, the slopes of hypercapnic ventilatory responses (HCVR) werehigher in obese OSAS and obese controls compared to lean controls, however, no significantdifferences were found in the three groups after controlled for weight; During sleep, theventilatory responses to CO2was lower in the obese OSAS compared to the two controlgroups expressed as the following index: minute ventilation (VE, P <0.005), the inspiratoryfolw (Flow, P <0.01), tidal volume (VT, P <0.01), inspiratory time (TI, P <0.05) and VT/TI(P <0.005).
From the above results, we can draw the following conclusions:
1. The upper airway neuromotor tone was decreased in obese adolescents with OSAS,which increased the collapsibility of upper airway, thus OSAS.
2. Obese adolescents without OSAS had an increased neuromotor tone of upperairway during sleep to compensate the anatomical abnormality.
3. Obesity can increase the volume of the soft tissues around upper airway restrictingthe size of upper airway. The pharyngeal lateral wall may play an important role inthe anatomical fators in the obese adolescents with OSAS and can increase thecollapsibility of upper airway.
4. The central ventilatory drive was blunted during sleep in obese adolescents with OSAS.
引文
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