Uniapnea (obstruktiivinen uniapnea aikuisilla)
Mikä on Käypä hoito -suositus?
Suomalaisen Lääkäriseuran Duodecimin, Suomen Keuhkolääkäriyhdistyksen ja Suomen Unitutkimusseura ry:n asettama työryhmä
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Uniapnea (obstruktiivinen uniapnea aikuisilla)

Käypä hoito
15.6.2017
Suomalaisen Lääkäriseuran Duodecimin, Suomen Keuhkolääkäriyhdistyksen ja Suomen Unitutkimusseura ry:n asettama työryhmä

Opi ja ota käyttöön

Koosteet

Potilaalle

Muut suositukset

 

Miten viitata Käypä hoito -suositukseen? «»1

Keskeinen sanoma

  • Obstruktiivinen uniapnea tarkoittaa hengitysilmavirtauksen rajoittumista tai estymistä, joka johtuu ylähengitysteiden unenaikaisesta ahtautumisesta. Jos toistuviin apneajaksoihin liittyy unen häiriintyminen ja päiväväsymys, puhutaan obstruktiivisesta uniapneaoireyhtymästä.
  • Hoitamaton uniapneaoireyhtymä lisää sympaattisen hermoston aktiivisuutta, sydän- ja verisuonitautien vaaraa, tapaturmavaaraa, terveydenhuoltopalveluiden tarvetta sekä ennenaikaista kuolleisuutta.
  • Kognitiivisen toiminnan ja muistin häiriöt ovat uniapneapotilailla yleisiä. Hoitamaton uniapneaoireyhtymä näyttääkin lisäävän liikenneonnettomuuteen joutumisen vaaraa, kokeepa potilas olevansa väsynyt tai ei.
  • Obstruktiivinen uniapneaoireyhtymä tulisi todeta ja hoitaa nykyistä varhemmin varsinkin nuorilla aikuisilla ja keski-ikäisillä.
  • Hoidon tavoitteena ovat oireiden lievittyminen, työkyvyn säilyttäminen, elämänlaadun parantaminen, liitännäissairauksien ehkäisy ja lievittäminen sekä ennenaikaisen kuolleisuuden estäminen.
  • Uniapneaoireyhtymää voidaan ehkäistä painonhallinnalla ja korjaamalla kasvuiässä uniapnean kannalta epäsuotuisan purennan ja leukasuhteiden kehittymistä oikomishoidolla.
  • Oireyhtymän diagnoosi perustuu anamneesiin, kliiniseen tutkimukseen ja unirekisteröintiin. Väsymyksen aiheuttajina tulee erityisesti ottaa huomioon myös masennus, muut unihäiriöt ja kilpirauhasen vajaatoiminta. Uniapnean oire voi olla myös unettomuus.
  • Liikapainoisen uniapneapotilaan hoitoon kuuluvat aina painonhallinta ja elämäntapaohjaus. Lievässä uniapneassa laihdutus voi olla riittävä hoito.
  • Keskivaikeaa tai vaikeaa uniapneaoireyhtymää hoidetaan ensisijaisesti unen aikana käytettävän ylipainehengityslaitteen (CPAP-laite) avulla.
  • Valikoiduilla potilailla uniapneaoireyhtymää voidaan hoitaa uniapneakiskolla, asentohoidolla tai kirurgisin toimenpitein.

Aiheen rajaus

  • Suosituksessa käsitellään aikuisten obstruktiivista uniapneaoireyhtymää (jäljempänä uniapnea) sen eri muodoissa. Sentraalista uniapneaa ei tässä suosituksessa käsitellä.

Tavoitteet

  • Suosituksen tavoitteena on parantaa uniapnean tunnistamista, hoitoa ja seurantaa sekä ennaltaehkäisyä.

Kohderyhmät

  • Suosituksen kohderyhmänä ovat uniapneapotilaita tutkivat ja hoitavat terveydenhuollon ammattilaiset.

Määritelmiä

  • Aikuisen obstruktiivisella uniapnealla tarkoitetaan toistuvia, vähintään kymmenen sekunnin mittaisia hengityskatkoksia (apnea) tai hengityksen vaimentumia (hypopnea), jotka johtuvat ylähengitysteiden ahtautumisesta unen aikana.
  • Apneoiden ja hypopneoiden keskimääräinen esiintyvyys tuntia kohden ilmaistaan apnea-hypopneaindeksinä (AHI).
  • Osittaisella unenaikaisella ylähengitystieahtaumalla tarkoitetaan pitkiä, yli minuutin kestäviä jaksoja, joissa sisäänhengitysvirtauksen rajoittuminen ei johda hengityskatkokseen tai välittömään havahtumiseen vaan hengitysyritykset, usein kovaääninen kuorsaus ja hiilidioksidipitoisuus lisääntyvät vähitellen.
  • Hengityskatkoksiin liittyy veren happikyllästeisyyden pieneneminen, ja ne päättyvät tavallisesti lyhyisiin tiedostamattomiin havahtumisiin unesta.
  • Kun uniapneaan liittyy oireita (taulukko «Oireiden esiintyvyys uniapneapotilailla. Luvut perustuvat pääosin potilaiden itse ilmoittamiin oireisiin.»1), puhutaan obstruktiivisesta uniapneaoireyhtymästä.
  • Suosituksessa käytettävät lyhenteet esitellään lisätietoaineistossa «Käypä hoito -suosituksessa Uniapnea käytettyjä termejä ja lyhenteitä»4.
Taulukko 1. Oireiden esiintyvyys uniapneapotilailla. Luvut perustuvat pääosin potilaiden itse ilmoittamiin oireisiin.
Oireet Osuus (%) uniapneapotilaista Kirjallisuusviitteet
Yöaikaiset Kuorsaus 70–95 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Unenaikaiset hengityskatkot 75 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Herääminen tukehtumisen tunteeseen 18–31 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Levoton yöuni 50 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Yöhikoilu 50 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Lisääntynyt yöllinen virtsaneritys 28 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Närästys 54–76 «Zanation AM, Senior BA. The relationship between extraesophageal reflux (EER) and obstructive sleep apnea (OSA). Sleep Med Rev 2005;9:453-8 »2
Suun kuivuminen 74 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Kuolaaminen 36 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Unettomuus 28–59, naisilla yleisempi «Lavie P. Insomnia and sleep-disordered breathing. Sleep Med 2007;8 Suppl 4:S21-5 »3
Päiväaikaiset Päiväväsymys naisilla 23–42 «Young T, Palta M, Dempsey J ym. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5 »4, «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
miehillä 15–30
Pakkonukahtelu naisilla 29 «Young T, Palta M, Dempsey J ym. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5 »4
miehillä 23
Aamupäänsärky 18–29 «Loh NK, Dinner DS, Foldvary N ym. Do patients with obstructive sleep apnea wake up with headaches? Arch Intern Med 1999;159:1765-8 »5, «Neau JP, Paquereau J, Bailbe M ym. Relationship between sleep apnoea syndrome, snoring and headaches. Cephalalgia 2002;22:333-9 »6
Muistihäiriöt 66 «Engleman HM, Douglas NJ. Sleep. 4: Sleepiness, cognitive function, and quality of life in obstructive sleep apnoea/hypopnoea syndrome. Thorax 2004;59:618-22 »7, «Flemons WW, Reimer MA. Development of a disease-specific health-related quality of life questionnaire for sleep apnea. Am J Respir Crit Care Med 1998;158:494-503 »8
Keskittymisvaikeudet 78 «Engleman HM, Douglas NJ. Sleep. 4: Sleepiness, cognitive function, and quality of life in obstructive sleep apnoea/hypopnoea syndrome. Thorax 2004;59:618-22 »7, «Flemons WW, Reimer MA. Development of a disease-specific health-related quality of life questionnaire for sleep apnea. Am J Respir Crit Care Med 1998;158:494-503 »8
Mielialahäiriöt 7–70 «Saunamäki T, Jehkonen M. Depression and anxiety in obstructive sleep apnea syndrome: a review. Acta Neurol Scand 2007;116:277-88 »9
Impotenssi, heikentynyt libido 30 «Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. Kirjassa: Principles and Practice of Sleep Medicine. Kryger MH, Roth T, Dement WC (toim.) 3.»1
Yskä 33 «Birring SS, Ing AJ, Chan K ym. Obstructive sleep apnoea: a cause of chronic cough. Cough 2007;3:7 »10, «Lee KK, Birring SS. Cough and sleep. Lung 2010;188 Suppl 1:S91-4 »11

Epidemiologia

Patofysiologia

Uniapnealle altistavat tekijät

Liitännäissairaudet

Sydän- ja verisuonitaudit

Muut liitännäissairaudet

Diagnostiikka

Taulukko 2. Uniapnean kliinisen vaikeusasteen arvioiminen päiväaikaisen uneliaisuuden ja unirekisteröinnin perusteella «Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sl»93, «Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of obstructive sleep apnea. Bloomington (MN). March 2005»94.
Vaikeusaste Uneliaisuus Happikyllästeisyys (%) Apnea-hypopneaindeksi
Lievä Ilmenee vain paikallaan ollessa, ei välttämättä päivittäin, ja aiheuttaa vain vähäistä haittaa sosiaalisessa ja työelämässä SaO2 keskimäärin ≥ 90 ja minimi ≥ 85 5–15
Kohtalainen Päivittäistä, kun aktiivisuus vähäistä ja tilanne vaatii kohtalaista keskittymistä (esimerkiksi autolla ajo, kokoukseen osallistuminen, elokuvien katselu) SaO2 keskimäärin < 90 ja minimi ≥ 70 16–30
Vaikea Päivittäisissä tehtävissä, jotka vaativat aktiivisuutta tai selvää keskittymistä (esimerkiksi autolla ajo, keskustelu, syöminen, kävely).
Aiheuttaa huomattavaa haittaa sosiaalisessa elämässä ja työssä
SaO2 keskimäärin < 90 ja minimi < 70 > 30

Oireet

Kliininen tutkimus

  • Kliinisessä tutkimuksessa kiinnitetään huomiota sydämen ja keuhkojen auskultaatiolöydöksiin, verenpaineeseen, painoindeksiin ja vyötärön ympärykseen. Ks. Käypä hoito -suositus Lihavuus (aikuiset) «Lihavuus (aikuiset)»6. Lisäksi huomiota kiinnitetään erityisesti uniapnealle altistaviin rakenteisiin:
    • nenän tukkoisuuteen (allerginen nuha, polyypit, väliseinän vinous, aikaisemmat traumat)
    • kielen ja risojen kokoon
    • pehmeän suulaen pituuteen ja velttouteen (kitakielekkeen venyttyminen, paksuuntuminen ja uurteisuus ovat usein kuorsauksen merkkejä)
    • kasvojen ja leukojen sekä niiden suhteiden poikkeavuuksiin (kuva «Kasvojen profiilit ja purentasuhde»2 ) ja purentavirheisiin (erityisesti alaleuan pienuus tai retrognatia, alakasvojen hyvin pieni tai suurentunut korkeus, suuret ylipurennat, avopurenta)
    • kaulan rakenteeseen (lyhyt ja paksu kaula).
  • Kognitiivisen suorituskyvyn ja psyykkisen tilanteen arviointi on keskeistä potilaan työ- ja toimintakyvyn kannalta.
  • Epäilyt muista altistavista sairauksista, kuten kilpirauhasen vajaatoiminnasta, reumasta, akromegaliasta tai kyfoskolioosista, kirjataan.
  • Erikoissairaanhoidossa selvitetään tarvittaessa muun muassa seuraavia asioita:
    • Korva-, nenä- ja kurkkutautien erikoislääkärin vastaanotolla nenän, suun, nielun ja kurkunpään tutkimuksilla selvitetään ylähengitysteiden mahdolliset ahtaumakohdat. Nielun ahtautta voi arvioida niin sanotulla Mallampati-luokituksella (kuva «Mallampati-luokitus»1 ). Nenän kautta tehtävä alanielun ja kurkunpään tähystys fiberoskoopin avulla voi antaa lisätietoa etenkin kielenkannan ja velton kurkunkannen (floppy epiglottis) aiheuttamista ahtaumista. Fiberoskopiatutkimus on mahdollista tehdä myös sedatoidulle potilaalle niin, että potilas on makuulla (drug induced sleep endoscopy, DISE).
    • Oikomishoidon erikoishammaslääkäri ja suu- ja leukakirurgi arvioivat tarvittaessa kallorakenteita, leukasuhteita ja purentaa.
    • Erityisesti suurentunut alakasvojen korkeus, kapea kovan suulaen ja nielun takaseinän välinen etäisyys sekä pieni ylähengitysteiden orofaryngeaalinen tilavuus liittynevät uniapneaan «Tietyt kasvojen ja ylähengitysteiden rakenteelliset poikkeavuudet ilmeisesti liittyvät obstruktiiviseen uniapneaan aikuisilla.»B. Ylipainoisilla uniapneapotilailla pään ja leukojen alueen kefalometristen tasojen divergenssi, pään ekstensio ja mahdollisesti kookas kieli ja pehmeä suulaki liittyvät uniapneaan. Ks. lisätietoa lisätietoaineistosta «Ylähengitysteiden tilavuuteen vaikuttavista tekijöistä»23.
    • Kieliluun alhainen sijainti liittyy uniapneaan painoindeksistä riippumatta «Kieliluun alhainen sijainti ilmeisesti liittyy uniapneaan ainakin miehillä.»B.
    • Kliinisen tutkimuksen ja tähystysten lisäksi ylähengitysteiden ahtauttavia tekijöitä voidaan tutkia tarvittaessa kallolateraalikuvalla (2D), kolmiulotteisesti kartiokeilatomografialla (KKTT), tietokonetomografialla ja magneettikuvauksella.

Kliinisneurofysiologiset tutkimukset

Neuropsykologinen tutkimus

  • Kognitiivinen toimintakyky on osalla uniapneapotilaista huonontunut, ja se on yhteydessä työkyvyn heikentymiseen ja lisääntyneeseen onnettomuusriskiin. Neuropsykologisia tutkimuksia tulee harkita etenkin silloin, kun potilaan työ vaatii hyvää tarkkuutta, muistia ja toiminnanohjausta. Kognitiivisia toimintoja arvioitaessa kliininen tutkimus ja anamneesi ovat ensisijaisia. Apuna voidaan käyttää myös kyselytestejä. Muutoksia esiintyy kognitiivisessa prosessointinopeudessa, tarkkaavuuden ylläpitämisessä, toiminnanohjauksessa, uuden oppimisessa ja muistissa, avaruudellisessa hahmottamisessa sekä psykomotorisessa suoriutumisessa. Uniapneapotilaiden kognitiivista toimintakykyä arvioidaan tarvittaessa laajalla neuropsykologisella tutkimuksella osana työkyvyn arviointia ja erotusdiagnostiikkaa. Ks. lisätietoaineisto «Kognitiivisen toimintakyvyn muutokset ja uniapnea»24.

Erotusdiagnostiikka

Lähete erikoissairaanhoitoon ja kiireettömän hoidon kriteerit

  • Kiireettömän lähetteen edellytyksenä on vähintään kaksi seuraavassa lueteltavista oireista «www.terveysportti.fi > Kirjasto > Hoidon perusteet > Keuhkosairaudet ja > Korva-, nenä- ja kurkkutaudit»113 (www.terveysportti.fi > Kirjasto > Hoitoon pääsyn perusteet > Keuhkosairaudet ja > Korva-, nenä- ja kurkkutaudit «http://www.terveysportti.fi/dtk/hpt/koti»3):
    • päiväväsymys
    • poikkeava nukahtelu
    • pitkään jatkunut äänekäs kuorsaus
    • hengityskatkoksia toisen henkilön toteamana
    • aamupäänsärky (unenaikainen hiilidioksidin kertyminen)
    • toistuvat yölliset heräämiset tukehtumisen tunteeseen
    • uniapneaan mahdollisesti liittyvä muistihäiriö tai mielialahäiriö
    • epäily lihavuuteen liittyvästä ventilaatiovajauksesta.
  • Uniapnean tutkimukset on syytä käynnistää kiireellisinä
    • jos oireinen potilas työskentelee erityistä vireyttä vaativassa ammatissa (esim. ammattiautoilijat, veturinkuljettajat, lentäjät tai lennonjohdossa työskentelevät)
    • jos potilaalla on vaikea sydän- ja verisuonitauti
    • jos raskaana olevalla naisella epäillään uniapneaa
    • ennen anestesiassa tehtävää toimenpidettä.
  • Esimerkki uniapneapotilasta tutkittaessa huomioitavista asioista esitetään lisätietoaineistossa «Uniapneapotilasta perusterveydenhuollossa tutkittaessa huomioitavia asioita (keskeiset merkitty lihavoinnilla)»1.
  • Erikoissairaanhoidon ja perusterveydenhuollon työnjako eroaa paikkakunnittain.
  • Yleisperiaatteet lähetteen ohjaamisessa eri erikoisaloille ovat seuraavat (tässä on otettu huomioon, että yöpolygrafia on tehty ennen lähettämistä):
    • Jos yöpolygrafian tulos ei selitä potilaan oireita, muiden sairauksien selvittely on aiheellista.
    • Jos potilas on vähäoireinen ja yöpolygrafiassa havaitaan lievä uniapnea tai osittainen unenaikainen ylähengitystieahtauma, perusterveydenhuollossa hänet ohjataan laihdutus- ja asentohoitoon.
    • Ellei näihin hoitoihin saada riittävää vastetta, potilas lähetetään korva-, nenä- ja kurkkutautien tai suu- ja leukasairauksien klinikkaan (painoindeksi alle 30–35 kg/m2) tai keuhkosairauksien klinikkaan (painoindeksi yli 30–35 kg/m2).
    • Jos yöpolygrafiassa havaitaan keskivaikea tai vaikea uniapnea tai potilas työskentelee erityistä vireyttä vaativassa ammatissa, hänet lähetetään ensisijaisesti keuhkosairauksien klinikkaan.

Hoitomuodot ja hoitovaste

Elintapahoidot

CPAP-hoito

CPAP-hoidon vaikutukset

CPAP-hoidon haittavaikutukset

Taulukko 3. CPAP-hoidon aiheuttamia haittoja ja hoidon onnistumiseen vaikuttavia tekijöitä.
Haitta Kirjallisuusviitteet
Aloitusvaiheessa Pitkäaikaisessa käytössä
Maskiongelmat Ilmavuoto (konjunktiviitti, epämukavuus, melu) «Rolfe I, Olson LG, Saunders NA. Long-term acceptance of continuous positive airway pressure in obstructive sleep apnea. Am Rev Respir Dis 1991;144:1130-3 »147, «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148, «Stauffer JL, Fayter N, MacLurg BJ. Conjunctivitis from nasal CPAP apparatus. Chest 1984;86:802 »149 «Rolfe I, Olson LG, Saunders NA. Long-term acceptance of continuous positive airway pressure in obstructive sleep apnea. Am Rev Respir Dis 1991;144:1130-3 »147, «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148, «Stauffer JL, Fayter N, MacLurg BJ. Conjunctivitis from nasal CPAP apparatus. Chest 1984;86:802 »149
Iho-ongelmat «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148 «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148
Ilmavuoto suusta, suun kuivuminen «Richards GN, Cistulli PA, Ungar RG ym. Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med 1996;154:182-6 »143, «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148 «Richards GN, Cistulli PA, Ungar RG ym. Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med 1996;154:182-6 »143, «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148
Herääminen yöllä «Nino-Murcia G, McCann CC, Bliwise DL ym. Compliance and side effects in sleep apnea patients treated with nasal continuous positive airway pressure. West J Med 1989;150:165-9 »150 «Nino-Murcia G, McCann CC, Bliwise DL ym. Compliance and side effects in sleep apnea patients treated with nasal continuous positive airway pressure. West J Med 1989;150:165-9 »150
Klaustrofobia «Kribbs NB, Pack AI, Kline LR ym. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 1993;147:887-95 »151
Nenäongelmat Nuha tai nenän tukkoisuus «Brander PE, Soirinsuo M, Lohela P. Nasopharyngeal symptoms in patients with obstructive sleep apnea syndrome. Effect of nasal CPAP treatment. Respiration 1999;66:128-35 »139, «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148, «Hoffstein V, Viner S, Mateika S ym. Treatment of obstructive sleep apnea with nasal continuous positive airway pressure. Patient compliance, perception of benefits, and side effects. Am Rev Respir Dis»152 «Brander PE, Soirinsuo M, Lohela P. Nasopharyngeal symptoms in patients with obstructive sleep apnea syndrome. Effect of nasal CPAP treatment. Respiration 1999;66:128-35 »139, «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148, «Hoffstein V, Viner S, Mateika S ym. Treatment of obstructive sleep apnea with nasal continuous positive airway pressure. Patient compliance, perception of benefits, and side effects. Am Rev Respir Dis»152
Nenäverenvuoto, kipu nenässä «Brander PE, Soirinsuo M, Lohela P. Nasopharyngeal symptoms in patients with obstructive sleep apnea syndrome. Effect of nasal CPAP treatment. Respiration 1999;66:128-35 »139, «Strumpf DA, Harrop P, Dobbin J ym. Massive epistaxis from nasal CPAP therapy. Chest 1989;95:1141 »153 «Brander PE, Soirinsuo M, Lohela P. Nasopharyngeal symptoms in patients with obstructive sleep apnea syndrome. Effect of nasal CPAP treatment. Respiration 1999;66:128-35 »139, «Strumpf DA, Harrop P, Dobbin J ym. Massive epistaxis from nasal CPAP therapy. Chest 1989;95:1141 »153
Muut CPAP-laitteen korkea paine «Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev 2003;7:81-99 »145, «Massie CA, McArdle N, Hart RW ym. Comparison between automatic and fixed positive airway pressure therapy in the home. Am J Respir Crit Care Med 2003;167:20-3 »154, «Krieger J. Long-term compliance with nasal continuous positive airway pressure (CPAP) in obstructive sleep apnea patients and nonapneic snorers. Sleep 1992;15:S42-6 »155 «Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev 2003;7:81-99 »145, «Massie CA, McArdle N, Hart RW ym. Comparison between automatic and fixed positive airway pressure therapy in the home. Am J Respir Crit Care Med 2003;167:20-3 »154, «Krieger J. Long-term compliance with nasal continuous positive airway pressure (CPAP) in obstructive sleep apnea patients and nonapneic snorers. Sleep 1992;15:S42-6 »155
Ilman nieleminen, refluksi «Nino-Murcia G, McCann CC, Bliwise DL ym. Compliance and side effects in sleep apnea patients treated with nasal continuous positive airway pressure. West J Med 1989;150:165-9 »150 «Nino-Murcia G, McCann CC, Bliwise DL ym. Compliance and side effects in sleep apnea patients treated with nasal continuous positive airway pressure. West J Med 1989;150:165-9 »150
Motivaatio hoitoon «Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev 2003;7:81-99 »145
Hoidon aiheuttama epämukavuus «Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev 2003;7:81-99 »145
Yleinen sopeutumattomuus hoitoon «Krieger J. Long-term compliance with nasal continuous positive airway pressure (CPAP) in obstructive sleep apnea patients and nonapneic snorers. Sleep 1992;15:S42-6 »155, «Waldhorn RE, Herrick TW, Nguyen MC ym. Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea. Chest 1990;97:33-8 »156, «Rauscher H, Popp W, Wanke T ym. Acceptance of CPAP therapy for sleep apnea. Chest 1991;100:1019-23 »157
Ei vastetta hoitoon «Lojander J, Brander PE, Ammälä K. Nasopharyngeal symptoms and nasal continuous positive airway pressure therapy in obstructive sleep apnoea syndrome. Acta Otolaryngol 1999;119:497-502 »140, «Nino-Murcia G, McCann CC, Bliwise DL ym. Compliance and side effects in sleep apnea patients treated with nasal continuous positive airway pressure. West J Med 1989;150:165-9 »150, «Meslier N, Lebrun T, Grillier-Lanoir V ym. A French survey of 3,225 patients treated with CPAP for obstructive sleep apnoea: benefits, tolerance, compliance and quality of life. Eur Respir J 1998;12:1»158
Puolison häiriintyminen «Pépin JL, Leger P, Veale D ym. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81 »148
Laitteen ääni «Meslier N, Lebrun T, Grillier-Lanoir V ym. A French survey of 3,225 patients treated with CPAP for obstructive sleep apnoea: benefits, tolerance, compliance and quality of life. Eur Respir J 1998;12:1»158

Hoitoon sitoutuminen

Uniapneakisko

Kirurginen hoito

  • Ellei uniapnean konservatiivinen hoito (elintapahoidot, uniapneakisko tai CPAP) ole riittävä, potilas ei siedä hoitoa tai hänellä on merkittäviä uniapnealle altistavia nielun tai kasvojen alueen rakenteellisia tekijöitä, voidaan harkita ylähengitysteiden tai kasvojen alueen kirurgiaa. Leikkaus voidaan kohdistaa yhdelle tasolle (esim. nenä, nielu, pehmeä suulaki, kielen kanta) tai samanaikaisesti usealle eri tasolle (monitasokirurgia).
  • Tutkimusnäyttö leikkauksen vaikutuksista uniapnean hoidossa on puutteellista ja ristiriitaista.
  • Muita leikkaushoitoja kuin lihavuus- ja leukakirurgiaa voidaan käyttää ensisijaisesti normaalipainoisten tai lievästi ylipainoisten potilaiden (painoindeksi alle 30 kg/m2) uniapneassa.

Ylähengitysteiden alueen kirurgia

Leukakirurgia

  • Keskivaikean ja vaikean uniapnean hoitoon voidaan harkita myös leukaosteotomioita.
  • Vaikea purentavirhe on aihe leukaortopediseen hoitoon myös lievässä uniapneassa.
  • Ylä- tai alaleukaa erikseen tai molempia yhdessä voidaan siirtää kirurgisesti eteenpäin, jolloin nielun alueen ilmatila lisääntyy ja unenaikaiset hengityskatkokset saattavat vähentyä. Leukaosteotomioilla voidaan saada paras tulos silloin, kun nielun ahtaumakohta on kielen kannan tasolla alanielun alueella (Fujitan tyyppi III «Uniapnean leikkaushoidoista»36).
  • Pelkästään pehmeän suulaen alueen ahtaumiin leukaosteotomioiden vaikutus on vähäinen. Oikomiskirurgisessa hoidossa olevan potilaan mahdollinen uniapnea tulee diagnosoida ennen leikkausta.
  • Leukaosteotomiaan liittyy yleensä hampaiston oikomishoito kiintein kojein. Oikomiskirurginen hoito purennan ylläpitovaiheineen voi kestää oikomishoidon tarpeen ja laajuuden mukaan jopa useita vuosia. Se toteutetaan oikomishoidon erikoishammaslääkärin ja suu- ja leukakirurgin yhteistyönä.
  • Riittävän radikaalisti toteutettu ylä- ja alaleuan yhtäaikainen siirto eteenpäin saattaa olla obstruktiivisen uniapnean parantava hoito. Leikkauksesta voivat hyötyä etenkin ne konservatiivisessa hoidossa vasteetta jääneet potilaat, joilla on selkeitä uniapnealle altistavia kasvojen, suun ja nielun anatomisia poikkeavuuksia «Ylä- ja alaleukaa eteenpäin tuovat kirurgiset toimenpiteet ovat ilmeisesti tehokkaita obstruktiivisen uniapnean hoidossa.»B.

Lihavuuskirurgia

Hermostimulaattorihoito

Lääkehoito

Ajoterveys ja työkyky

Ajoterveysvaatimukset

Työkyvyn arviointi

Anestesiaa edeltävä arviointi ja hoidon suunnittelu

Seuranta

CPAP-hoito

Muut hoitomuodot

  • Uniapneakiskojen käytön ja ylähengitysteiden tai kasvojen alueen kirurgisten hoitojen tulosta arvioivat hoitavat yksiköt tai erikoislääkärit (asiaan perehtyneet hammaslääkärit tai erikoishammaslääkärit, korva-nenä- ja kurkkutautien erikoislääkärit).
  • Hoitovaste tulee varmistaa objektiivisesti unirekisteröinnillä «Epstein LJ, Kristo D, Strollo PJ Jr ym. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5:263-76 »121, ja tarvittaessa potilas tulee ohjata muuhun hoitoon, jos toivottua vastetta ei ole saavutettu.
  • Uniapneakiskojen pitkäaikaiskäyttäjien seuranta ja tarvittaessa uuden uniapneakiskon valmistus voidaan ohjata avoterveydenhuoltoon asiaan perehtyneiden hammaslääkäreiden vastuulle. Kojeen kuntoa, subjektiivista vaikuttavuutta, potilaan purentaa ja purentaelimen toimintaa olisi syytä seurata vähintään kerran vuodessa tai tarpeen mukaan.

Kuntoutus

  • CPAP-laite luokitellaan lääkinnälliseksi kuntoutusvälineeksi, ja potilas saa sen lainaussopimuksella käyttöönsä ilman kustannuksia. Uniapneakiskoa ei tähän mennessä ole luokiteltu lääkinnällisen kuntoutuksen apuvälineeksi, joten avoterveydenhuollon potilaat joutuvat itse kustantamaan kiskon valmistuksen.
  • Uniapneapotilaiden lääkinnälliseen kuntoutukseen kuuluvat samat toimenpiteet kuin muissakin pitkäaikaissairauksissa. Ks. lisätietoaineisto «Uniapneaa sairastavien kuntoutus»3.
  • Ammatillisen kuntoutuksen toimenpiteitä saatetaan tarvita, jos uniapneapotilas työskentelee poikkeuksellista vireyttä vaativassa ammatissa.
  • Uniapneapotilaiden kuntoutusohjelmien hyödystä ei ole käytettävissä tutkimustietoa.

Kustannukset

Suomalaisen Lääkäriseuran Duodecimin, Suomen Keuhkolääkäriyhdistyksen ja Suomen Unitutkimusseura ry:n asettama työryhmä

Uniapnea (obstruktiivinen uniapnea aikuisilla) -suosituksen historiatiedot «Uniapnea (obstruktiivinen uniapnea aikuisilla), Käypä hoito -suosituksen historiatiedot»44

Puheenjohtaja:

Tarja Saaresranta, LT, dosentti, keuhkosairauksien ja keuhkoallergologian erikoislääkäri, unilääketieteen erityispätevyys, osastonylilääkäri; TYKS Medisiininen toimialue, keuhkosairauksien vastuualue ja Turun yliopisto, keuhkosairausoppi ja kliininen allergologia

Kokoava kirjoittaja:

Ulla Anttalainen, LT, keuhkosairauksien ja allergologian erikoislääkäri; TYKS Medisiininen toimialue, keuhkosairauksien vastuualue

Jäsenet:

Sari-Leena Himanen, LT, dosentti, kliinisen neurofysiologian erikoislääkäri, unilääketieteen erityispätevyys, ylilääkäri, apulaisprofessori; Pirkanmaan sairaanhoitopiiri, Kuvantamiskeskus- ja Apteekkiliikelaitos, Kliinisen neurofysiologian vastuualue ja Tampereen yliopiston lääketieteen ja biotieteiden tiedekunta, fysiologia

Päivi Korhonen, LT, yleislääketieteen professori, yleislääketieteen ja sisätautien erikoislääkäri; Turun yliopisto

Hanna-Riikka Kreivi, LT, keuhkosairauksien ja allergologian erikoislääkäri; HYKS Sydän- ja keuhkokeskus, keuhkosairauksien klinikka, Meilahden sairaala

Jukka Lojander, LT, keuhkosairauksien erikoislääkäri, unilääketieteen erityispätevyys, apulaisylilääkäri; HYKS, Sydän- ja keuhkokeskus, keuhkosairauksien klinikka, Jorvin sairaala

Riitta Pahkala, HLT, dosentti, hampaiston oikomishoidon erikoishammaslääkäri, apulaisylihammaslääkäri; KYS:n suu- ja leukasairauksien klinikka

Markku Partinen, LKT, professori, neurologian dosentti, neurologian erikoislääkäri, unilääketieteen erityispätevyys, tutkimusjohtaja; Helsingin uniklinikka, tutkimuskeskus Vitalmed ja Helsingin yliopiston kliinisten neurotieteiden osasto

Olli Polo, LT, dosentti, keuhkosairauksien erikoislääkäri, unilääketieteen erityispätevyys, ylilääkäri; TAYS:n keuhkosairauksien vastuuyksikkö, Uni- ja hengitysklinikka Unesta, Tampere

Juha Seppä, LKT, dosentti, osastonylilääkäri, korva-, nenä- ja kurkkutautien erikoislääkäri; KYS:n korva-, nenä- ja kurkkutautien klinikka

Arja Tuunainen, LT, biologisen psykiatrian dosentti, kliinisen neurofysiologian ja psykiatrian erikoislääkäri, unilääketieteen erityispätevyys, Käypä hoito -toimittaja

Asiantuntijat:

Pirkko Brander, LKT, dosentti, keuhkosairauksien erikoislääkäri, unilääketieteen erityispätevyys, ylilääkäri, linjajohtaja; HYKS, Sydän- ja keuhkokeskus, keuhkosairauksien linja

Liisa Hiltunen, LT, dosentti, yleislääketieteen erikoislääkäri; Oulun terveyskeskus

Tiia Saunamäki, PsT, neuropsykologian erikoispsykologi; TAYS:n neuroalojen ja kuntoutuksen yksikkö

Sidonnaisuudet

Ulla Anttalainen: Apuraha (Hengityssairauksien tutkimussäätiö, STVYS, TYKS), Luentopalkkio (ResMed Suomi), Korvaukset koulutus – ja kongressikuluista (Boehringer Ingelheim)

Sari-Leena Himanen: Asiantuntijapalkkio (Duodecim Oy), Osakeomistus (Neurotest Tampere OY)

Päivi Korhonen: Asiantuntijapalkkio (Recallmed Oy), Luentopalkkio (AstraZeneca Oy, MSD Oy, Novartis Oy, Novo Nordisk Pharma Oy, Orion Oy)

Hanna-Riikka Kreivi: Korvaukset koulutus – ja kongressikuluista (Leiras, Orion, Philips)

Jukka Lojander: Ei sidonnaisuuksia

Riitta Pahkala: Luentopalkkio (Suomen Hammaslääkäriseura Apollonia)

Markku Partinen: Asiantuntijapalkkio (Jazz Pharmaceuticals, Orion-Pharma)

Olli Polo: Kirjoittajan omistama yritys Unesta Oy jälleenmyy obstruktiivisen uniapnean asentohoitoon tarkoitettua apneavyötä. Kirjoittaja ei ole osallistunut uniapnean asentohoitoa koskevien Käypä hoito -suositusten laadintaan.

Tarja Saaresranta: Apuraha (Hengityssairauksien tutkimussäätiö, Jalmari ja Rauha Ahokkaan säätiö, Paulon säätiö, Suomen Tuberkuloosin vastustamisyhdistyksen säätiö, TYKS-säätiö, Tampereen tuberkuloosisäätiö, Turun yliopistosäätiö, Tyks, VTR-rahoitus, Väinö ja Laina Kiven säätiö), Luentopalkkio (Boehringer Ingelheim, ResMed Finland, Turun kaupunki, Turunmaan Duodecim), Korvaukset koulutus – ja kongressikuluista (ERS:n kongressi 2016, Jazz Pharmaceuticals kliininen lääketutkimus), European Board of Accreditation in Pneumology (EBAP), Member of the MC Nordic Sleep Medicine Accreditation Committee (NOSMAC), Member of the MC

Juha Seppä: Ei sidonnaisuuksia

Arja Tuunainen: Ei sidonnaisuuksia

Kirjallisuusviite

Uniapnea (obstruktiivinen uniapnea aikuisilla) (online). Suomalaisen Lääkäriseuran Duodecimin, Suomen Keuhkolääkäriyhdistyksen ja Suomen Unitutkimusseura ry:n asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim, 2017 (viitattu pp.kk.vvvv). Saatavilla internetissä: www.kaypahoito.fi

Tarkemmat viittausohjeet: «http://www.kaypahoito.fi/web/kh/viittaaminen»7

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Systemaattinen kirjallisuushaku on hoitosuosituksen perusta. Lue lisää artikkelista khk00007

Kirjallisuutta

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