314.4 📋 章末速記 Summary

314.4.1 🔑 一句話總結

Sleep-disordered breathing 三大類：OSA (1 in 4 adults, airway collapse, obesity #1 RF)、CSA (Cheyne-Stokes in HFrEF, opioid-induced, primary)、hypoventilation (OHS Ch312, CCHS PHOX2B, neuromuscular)；OSA diagnosis = polysomnography (PSG gold standard) or HSAT for uncomplicated；AHI ≥ 5 + symptoms OR ≥ 15；severity mild 5-15 / moderate 15-30 / severe > 30；OSA treatment：weight loss + CPAP gold standard + MAD (mild-moderate) + HGNS (Inspire, STAR 2014) for moderate-severe + CPAP-intolerant + BMI < 32；SURMOUNT-OSA 2024 = tirzepatide ↓ AHI 50% in obese OSA — game-changer；SERVE-HF 2015: ASV NOT for HFrEF + CSR (↑ mortality 28%)；SAVE 2016: CPAP in OSA + CVD = neutral；OSA + AF: 50%+ recurrence post-ablation if untreated。

314.4.2 💊 治療精要

  • lifestyle：weight loss (5-10% → AHI ↓ 25-50%)、avoid alcohol/sedatives、positional therapy
  • CPAP：fixed (8-15 cm H2O typical) or APAP (auto-adjusting)；BiPAP for OHS / complex / comfort
  • MAD (mandibular advancement device)：mild-moderate OSA, CPAP-intolerant
  • HGNS (Inspire)：moderate-severe + CPAP-intolerant + BMI < 32 + non-circumferential collapse + sleep endoscopy guided
  • surgery：UPPP limited、MMA effective select、tracheostomy rare、bariatric surgery for BMI > 35 very effective
  • pharmacotherapy：tirzepatide (SURMOUNT-OSA) for obese OSA、acetazolamide for CSA + altitude、modafinil/solriamfetol for residual sleepiness
  • CSA (HFrEF + CSR)：optimize HF therapy；CPAP modest；ASV CONTRAINDICATED (SERVE-HF)
  • opioid-induced CSA：wean opioid

314.4.3 🎯 盧醫師的考前提醒

  1. AHI severity rules：< 5 normal、5-14 mild、15-29 moderate、≥ 30 severe；diagnostic AHI ≥ 15 OR ≥ 5 + symptoms (sleepiness、snoring、observed apnea、HTN、AF、stroke、HF、DM)
  2. STOP-BANG ≥ 3 = high OSA risk；screening tool；Epworth ≥ 10 = excessive daytime sleepiness
  3. HSAT vs PSG：HSAT for uncomplicated high pretest probability；PSG gold standard for complex, HF, neuromuscular, opioid, comorbidity
  4. CPAP adherence target：≥ 4 hr/night, ≥ 5 nights/week（Medicare standard）；50% suboptimal — major challenge
  5. Inspire HGNS (STAR 2014)：moderate-severe OSA + CPAP-intolerant + BMI < 32 + no complete concentric collapse on DISE；AHI ↓ 68% in trial
  6. SURMOUNT-OSA 2024 (tirzepatide)：obese OSA + AHI ↓ 50%；FDA approval pending；可能改變 OSA practice — game-changer
  7. SERVE-HF 2015：ASV (adaptive servo-ventilation) CONTRAINDICATED in HFrEF + predominant CSR (↑ mortality 28%)；CPAP modest benefit
  8. SAVE 2016：CPAP in OSA + established CVD 沒有 reduce events at population level；個別 compliant users benefit；adherence matters
  9. OSA + AF + ablation：50%+ recurrence if OSA untreated；screen + treat OSA before AF ablation
  10. Cheyne-Stokes 在 HFrEF 約 25% 重度患者：prolonged circulation time + ventilatory instability；optimize HF therapy first；不 routine 用 ASV