优化COPD合并OSA患者稳定期药物方案的前瞻队列研究

Prospective Cohort Study on Optimization of Stable Drug Regimen for COPD Patients with OSA

摘要: 目的：探究COPD稳定期合并OSA患者的预后因素，并对其稳定期药物治疗的优化方案进行探究。方法：本研究连续入选青岛市中心医院2020年1月至2022年12月收治的74例COPD合并OSA患者作为研究对象，并使用家用无创呼吸机通气，由接诊医师按照所在科室日常诊疗习惯进行诊疗。根据患者的用药治疗方案，其中应用布地格福三联吸入气雾剂联合无创呼吸机治疗的患者30例，吸入布地奈德福莫特罗气雾剂二联药物制剂联合无创呼吸机治疗的患者28例，单用口服药物(包括祛痰剂、激素、抗生素、止咳药)联合无创呼吸机治疗的患者16例。比较不同吸入药物患者使用呼吸机参数(吸气压力、呼吸压力)以及使用时长、漏气指数、阻塞指数等情况，吸入三联/二联药物/单用口服药物联合呼吸机治疗方案与急性加重次数、氧合状况和嗜睡量表的关系，COPD-OSA重叠综合征患者的预后多因素分析。结果：1) 吸入三联药物的患者中其呼吸机的吸气压力较吸入二联组患者的吸气压力更低(P < 0.05)。吸入二联药物组的呼吸机使用时长明显小于吸入三联药物组(P < 0.05)。吸入三联药物组患者无创机械通气的夜间呼吸睡眠阻塞指数、无创呼吸机的漏气指数小于吸入二联药物组(P < 0.05)，差异有统计学意义。2) 吸入三联药物联合呼吸机治疗的患者在急性加重次数、氧合状况以及嗜睡程度上要优于吸入二联药物联合呼吸机治疗的患者，差异有统计学意义(P > 0.05)。3) 单用吸入二联药物联合呼吸机治疗的患者和单用口服药物联合呼吸机治疗的患者在氧合状况、急性加重和嗜睡程度差异上无统计学意义(P > 0.05)。4) 吸烟指数、祛痰剂使用、吸入三联药物、呼吸机的应用、口服抗生素、口服激素，是COPD合并OSA患者预后的独立影响因素(OR = 1.852, 0.876, 1.052, 1.774, 0.795, 1.032)。结论：在COPD合并OSA患者的治疗中，吸入二联药物可缩短呼吸机的使用时间，而吸入三联药物可增加COPD合并OSA患者的呼吸机使用时间、降低阻塞指数，从而提高了该类患者呼吸机使用的依从性和舒适度。戒烟、祛痰剂使用、吸入三联药物、呼吸机的应用以及口服抗生素和激素是患者预后的保护性因素，应强化对COPD-OSA重叠综合征患者的药物治疗及呼吸机的有效使用以及临床的随访和督察，提高临床治疗效果及患者的远期预后。

Abstract: Objective: To explore the prognostic factors of COPD patients complicated with OSA in stable period, and to explore the optimal scheme of drug treatment in stable period. Methods: In this study, 74 patients with COPD complicated with OSA admitted to Qingdao Central Hospital from January 2020 to December 2022 were selected as the research object, and were ventilated by home noninvasive ventilator, and the attending physician made diagnosis and treatment according to the daily diagnosis and treatment habits of his department. According to the patients’ medication plan, 30 patients were treated with budgefur combined with noninvasive ventilator, 28 patients were treated with budesonide formoterol combined with noninvasive ventilator, and 16 patients were treated with oral drugs (including expectorants, hormones, antibiotics and cough medicines) combined with noninvasive ventilator. The parameters (inspiratory pressure, respiratory pressure), duration of use, leakage index and obstruction index of patients with different inhaled drugs were compared, and the relationship between the treatment scheme of inhaled triple/combined drugs/single oral drugs combined with ventilator and the number of acute exacerbations, oxygenation status and sleepiness scale was analyzed. The prognosis of patients with COPD-OSA overlap syndrome was analyzed by multivariate analysis. Results: 1) The inspiratory pressure of ventilator in patients who inhaled triple drugs was lower than that in patients who inhaled double drugs (P < 0.05). The duration of ventilator use in the two-drug inhalation group was significantly shorter than that in the three-drug inhalation group (P < 0.05). The nocturnal respiratory and sleep obstruction index of noninvasive mechanical ventilation and the air leakage index of noninvasive ventilator in the triple drug inhalation group were lower than those in the double drug inhalation group (P < 0.05), and the difference was statistically significant. 2) The number of acute exacerbations, oxygenation status and drowsiness of patients treated with inhaled triple drugs combined with ventilator were better than those treated with inhaled double drugs combined with ventilator, and the difference was statistically significant (P > 0.05). 3) There was no significant difference in oxygenation, acute exacerbation and drowsiness between the patients treated with inhaled binary drugs and ventilator alone and those treated with oral drugs and ventilator alone (P > 0.05). 4) Smoking index, use of expectorants, use of inhaled triple drugs, use of ventilators, oral antibiotics and oral hormones are independent influencing factors on the prognosis of COPD patients with OSA (OR = 1.852, 0.876, 1.052, 1.774, 0.795, 1.032). Conclusion: In the treatment of COPD patients with OSA, inhalation of two drugs can shorten the use time of ventilator, while inhalation of three drugs can increase the use time of ventilator in COPD patients with OSA and reduce the obstruction index, thus improving the compliance and comfort of ventilator use in such patients. Quitting smoking, using expectorants, inhaling triple drugs, using ventilators, and taking antibiotics and hormones orally are the protective factors for patients’ prognosis. Therefore, it is necessary to strengthen drug treatment and effective use of ventilators for patients with COPD-OSA overlap syndrome, as well as clinical follow-up and supervision, so as to improve the clinical treatment effect and long-term prognosis of patients.