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小動物耳鼻喉暨臨床睡眠研究室

犬隻睡眠呼吸中止症

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        阻塞型睡眠呼吸中止症(obstructive sleep apnea,簡稱OSA)在人類中是一類常見的睡眠呼吸疾病,在全球有將近十億人罹患。患者會在睡眠時反覆發生動態性的上呼吸道阻塞,導致吸氣時氣流部分或完全無法進入肺部,而有低血氧的狀況。常見的症狀包括大聲且可能忽然停止的鼾聲、睡眠中斷與白天嗜睡,短期可能造成睡眠品質下降與白天精神不濟,長期可能因慢性缺氧及發炎而產生高血壓、心衰竭、糖尿病與認知功能障礙等併發症。阻塞性睡眠呼吸中止症的黃金診斷工具為睡眠多項生理檢查(polysomnography,PSG),而確診者的首選治療方式為持續正壓呼吸器(continuous positive airway pressure,簡稱CPAP)

        近幾年開始,阻塞型睡眠呼吸中止症在犬隻中所帶來的健康與福祉之影響逐漸被重視。然而,現有的獸醫相關文獻大多紀錄短吻犬種(如英國鬥牛犬與查理王小獵犬等)的睡眠呼吸問題,雖與人類的阻塞型睡眠呼吸中止症有許多相似之處,但此類犬種有明顯的阻塞性呼吸道病灶,使其於清醒與睡覺時皆會發生呼吸困難,這與人類病患僅在睡眠時才發生呼吸阻塞有所不同。自2024年起,本研究室開始接獲多起非典型短吻犬種(如吉娃娃博美犬貴賓犬等)因睡眠呼吸問題而就診的病例。其中一些案例的呼吸阻塞症狀亦僅在睡眠期間發生,甚至後續出現昏厥的情形。上述犬隻睡眠呼吸問題的致病機制和臨床表現與人類阻塞型睡眠呼吸中止症之相似性尚不明確,仍需進一步研究釐清。

        阻塞型睡眠呼吸中止症在人醫已有廣泛而深入的研究,但在犬隻卻只有極少的報告描述此疾病,並缺乏臨床診斷的黃金準則。本研究室將探討犬隻阻塞型睡眠呼吸中止症之盛行率和臨床與病生理特徵,並仿造人醫建立非侵入式全身體積描記系統合併多項睡眠生理功能檢查設備作為疾病的診斷工具。我們期望當一個可靠的診斷技術被建立後,將可以提升飼主及獸醫師對於犬隻阻塞型睡眠呼吸中止症之意識,並進而了解此疾病之共病症及治療選擇。

  •         根據人醫文獻,阻塞型睡眠呼吸中止症的病生理機制複雜且涉及多種解剖性與非解剖性因素。首先,患者必有潛在但程度不一的上呼吸道阻塞性病灶(如肥胖、顱顏構造異常或軟組織肥大等),雖然在清醒時可能因適當的神經刺激與肌肉張力得以維持上呼吸道的擴張而無症狀,但當入睡時,呼吸神經與肌肉活性的下降(特別是咽部)將導致上呼吸道塌陷,使潛在的病灶造成動態的阻塞。若病患患有其他可能影響神經與肌肉系統的疾病(如甲狀腺功能低下症),亦可能促使阻塞型睡眠呼吸中止症的發生。

            當患者上呼吸道發生阻塞後,會因氣流無法到達肺部進行有效氣體交換造成血中的二氧化碳濃度上升及氧氣濃度下降,這些變化會刺激呼吸中樞將病患從睡夢中喚醒以適當換氣。病患再度入睡後,上述情形將繼續循環發生。

  •         阻塞型睡眠呼吸中止症在人類病患中有夜間與日間症狀的表現。患者在夜間睡眠時會有大聲且可能忽然停止的鼾聲、頻繁醒來而造成睡眠片斷化、失眠與胃食道逆流等;日間清醒時則可能過度嗜睡、精神不濟、情緒不穩定及注意力不集中等。

            犬隻因睡眠週期與人類不同,無法直接以夜間及日間兩時段描述症狀,不過兩者以睡眠與清醒兩狀態歸納的症狀表現是相似的。另外,犬隻病患可能在醒來後喘氣、咬空氣、咳嗽與舔嘴,有部分病患甚至會發紺、尖叫、步態不穩及昏厥。

  •         在人醫領域,懷疑患有阻塞型睡眠呼吸中止症可先透過多種睡眠問卷初步評估患病風險,欲確診則須轉介睡眠中心進行睡眠多項生理檢查。根據美國睡眠醫學會(American Academy of Sleep Medicine,簡稱AASM)的標準,檢查後計算的呼吸中止低通氣指數(apnea-hypopnea index,簡稱AHI)或呼吸障礙指數(respiratory disturbance index,簡稱RDI)可用來做為阻塞型睡眠呼吸中止症的確診及分級評估。若AHI或RDI為5以上代表患有阻塞型睡眠呼吸中止症。

            目前,犬隻無阻塞型睡眠呼吸中止症確診的黃金診斷工具與診斷標準,大多僅能靠病史或其他設備(如全體積掃描計系統與攜帶式頸圈系統)初步判斷。這些設備的限制為無法確認病患是否真正「入睡」及處在睡眠週期的哪個階段。

  •         由於阻塞型睡眠呼吸中止症為多因子、可能隨時間惡化且可能造成其他共病的疾病,長期且跨領域的治療計畫是相當重要的。人類病患現有的治療選擇包括生活型態調整(如減重)、藥物、手術、口腔裝置、持續性正壓呼吸器與其他潛在疾病的治療。睡覺時配戴的持續正壓呼吸器為其中的首選,不過其引起的不適感導致近50%的使用者在第一個月內即選擇放棄使用。

            有睡眠呼吸問題主訴的犬隻病患若在清醒時亦有明顯上呼吸道阻塞證據(如短吻犬阻塞性呼吸道症候群),大多在接受完上呼吸道矯正手術後即可使症狀消失。針對清醒時已無明顯呼吸困難,與人類阻塞型睡眠呼吸中止症病患症狀更加相似的病患,文獻中紀錄的治療方式主要為針對血清素受體的藥物療法。活化部分血清素受體可增加上呼吸道擴張肌的肌肉張力,而拮抗部分血清素受體則可抑制上呼吸道擴張肌的放鬆,達到減緩上呼吸道在睡眠時塌陷的效果。目前具成功案例的血清素受體藥物包括trazodone與ondansetron在英國鬥牛犬、吉娃娃與巴哥犬的應用。除了藥物治療外,亦有一例查理士王小獵犬使用改造的人類持續正壓呼吸器長期控制睡眠呼吸問題的案例。

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