Sleep medicine is a new interdisciplinary subject. In recent years, great progress has been made in basic research and discipline construction. 2007 is an important year in the development history of sleep medicine. The American Medical Examinations Board set up the professional examination of sleep medicine, which marked.
Sleep medicine has become an independent specialty in the field of clinical medicine.
Sleep medicine-a new interdisciplinary subject, people spend about13 of their life in sleep. Like eating and drinking water, sleep is also one of the indispensable basic life activities of human beings. Good sleep is a sign of health, and sleep disorder seriously affects the quality of life and reduces work efficiency. With the accelerated pace of modern life and lifestyle changes, various sleep disorders have increasingly become a prominent medical and public health problem, which has attracted people's attention. According to the International Classification of Sleep Diseases published in 2005, there are more than 90 kinds of sleep diseases caused by external or internal factors, among which the most common ones, such as insomnia and sleep apnea syndrome, have a high prevalence rate in China. Some rare sleep disorders, such as narcolepsy, are gradually recognized. Internationally, after more than 20 years of development, a new interdisciplinary sleep medicine has been formed and gradually developed.
Clinical sleep medicine originated from people's understanding of EEG activity, especially sleep EEG. 1953, American scientists discovered rapid eye movement (REM) sleep and proved that it is related to dreaming. Later, it was found that people sleep periodically all night, and non-rapid eye movement sleep (NREM) includes four stages from shallow to deep and alternate REM sleep. Through the test of EEG and other physiological indexes, we can comprehensively and objectively understand people's sleep structure. In 1960s, sleep research became a hot spot at that time, and the relationship between narcolepsy and abnormal REM sleep was clarified. Sleep apnea syndrome (SAS) has officially become an independent disease, and the international standard atlas of human sleep stages was published in 1968, which has been used ever since. Since then, great progress has been made in the study of sleep mechanism and sleep substances. It is the accumulation of basic research knowledge and the needs of a large number of patients that promote the development of clinical sleep medicine. In the 1970s, Stanford University in the United States used multi-channel physiological recorders to monitor sleep, and established a sleep center, specializing in the diagnosis and treatment of sleep disorders. In the early 1980s, continuous positive airway pressure (CPAP) and uvulopalatoplasty were used to treat sleep apnea, which made a breakthrough in the treatment of sleep apnea syndrome. The past 25 years have become the fastest developing period of sleep medicine in the world. Looking at the development trend of international sleep medicine, it presents the following characteristics.
(1) * * * attaches great importance to it, with high national recognition: the national research plan of 1996 was first published in the United States, and the national research plan of 120 was published again in 2003, guiding the development direction of sleep research.
(2) Sound organizational structure: 1993 The National Sleep Disorder Research Center is set up in the Institute of Cardiopulmonary Hematology of the National Institutes of Health (NIH), which is responsible for research, education, clinical affairs and coordination with other relevant departments in this field. The national sleep research plan was formulated in 1996 and 2003 respectively. On the basis of the American Sleep Association (1987), the American Academy of Sleep Sciences (1999) was established, and the corresponding certification standards and practice norms were formulated to specifically implement the scientific research and education plan. At present, there are more than 5000 members. There are also many special foundations that support scientific research and popular science education activities. Internationally, the International Sleep Research Association (WFSRS) was established in 1987, and its members include Asian Sleep Research Association (ASRS), American Sleep Research Association (AASM), Australian Sleep Research Association (ASA), Canadian Sleep Research Association (CSS), European Sleep Research Association (ESRS), Latin American Sleep Research Association (LASS) and American Sleep Research Association. In order to meet the needs of the development of clinical sleep medicine, it was recently renamed as the International Federation of Sleep Research and Sleep Medicine Associations (WFSRSMS). In order to promote the international exchange of clinical sleep medicine, the World Federation of Sleep Medicine (WASM) was established in 2004. The Asian Sleep Research Association (ASRS) was founded in 1994. Up to now, there are 12 sleep research associations in Asia as members. China Sleep Research Association is one of the sponsors.
(3) Active academic exchanges: Europe and the United States hold annual sleep conferences every year, among which the annual sleep conference in the United States is the largest, with 940 abstracts received in 2004. More than 5000 participants.
(4) The number of academic journals and sleep monographs has increased: With the deepening of sleep research and the progress of clinical medicine, a large number of sleep-related works have been published. Almost all comprehensive academic journals have published a large number of papers related to sleep. The variety of sleep magazines has increased rapidly. Up to 2004, except Sleep (USA) and Journal of Sleep Research (Europe), Sleep and Breathing (Germany), Sleep Medicine (USA), Sleep Medicine Review (France) and Sleep and Biological Rhythm (Japan) were published in recent years. In recent years, a large number of academic monographs on sleep medicine have been published, with incomplete statistics reaching more than 80 kinds.
(5) Multi-disciplinary cooperation, sleep medicine has developed into an independent discipline: after more than 20 years of development, clinical sleep medicine has gradually taken shape and developed into an independent discipline. Mainly manifested in 1, the establishment of an independent certification system, especially in the United States, the qualification examination for sleep doctors and technicians has become necessary, and a more relaxed examination policy will be introduced in 2007. At the end of 2003 and the beginning of 2004, 2,500 professional doctors passed the certification; 2. Professional societies have formed a standardized diagnosis and treatment system through certification and making diagnosis and treatment guidelines; 3. A complete system of continuing education and training has been established. At the end of 2003 and the beginning of 2004, AASM approved 50 continuing education and training projects. The American Thoracic Society also announced the training and skill outline of respiratory physicians engaged in sleep specialty. In addition to the special training courses of academic conferences of professional societies, medical school textbooks such as His Internal Medicine have special courses as compulsory courses for students. 4. In addition to sleep centers, some large hospitals with conditions have also set up independent sleep medicine departments, such as Harvard University and University of Pennsylvania School of Medicine.
In recent years, the development process of international sleep medicine has obviously accelerated, which is highlighted in the following aspects. 1. The World Federation of Sleep Medicine (WASM), with clinical sleep doctors as its main members, was established and its first academic conference was successfully held in Berlin, Germany. International academic organizations that originally focused on basic sleep research, such as the International Federation of Sleep Research Societies (WFSRS), have also been renamed the International Federation of Sleep Research and Sleep Medicine Associations (WFSRSMS). 2. The Theory and Practice of Sleep Medicine, known as the Bible in the field of sleep medicine, was published in the fourth edition, and the International Classification of Sleep Disorders was published in the second edition. These two instructive monographs not only reflect the latest achievements in this field, but also highlight the practical characteristics of clinical medicine. Third, the United States decided to officially become an independent major in sleep medicine, and the National Medical Education Committee included relevant content in the compulsory content of medical students. In 2007, the independent sleep professional examination was formally included in the doctor's practice examination, which changed the mode that was conducted by the American Sleep Medicine Association (AASM) in the past.
3 Pioneers in the Development of Sleep Medicine From the development history of clinical sleep medicine, it can be seen that the great progress in the diagnosis, treatment and research of sleep disordered breathing (SDB) is the most important factor to promote the formation and development of sleep medicine. Mainly due to the following factors: First, SDB is a frequently-occurring and common disease, but it needs to be recognized. The prevalence rate in foreign countries is 24%, and it is not lower than this in China. With the increase of age and weight, the incidence rate will further increase, and the prevalence rate of SDB is comparable to COPD and asthma. Secondly, SDB is a serious disease, which can involve all systems of the whole body and significantly increase the incidence and mortality of complications. Third, SDB can be treated. Especially the application of noninvasive ventilator can completely reverse the pathophysiological changes of SDB, significantly improve the quality of life of patients, improve their prognosis and reduce medical expenses. Other sleep disorders are rare diseases or have no important pathological significance. For example, although the prevalence of insomnia is high, most patients have no serious complications and will not increase the mortality rate. On the contrary, research shows that people with insomnia live a little longer. In foreign sleep centers, SDB patients account for more than 80% of patients, and they are also the main source of income for sleep centers (more than 80%), and the proportion is higher in China. This is why although everyone has a long history in the diagnosis and treatment of insomnia and other sleep diseases, sleep medicine can only develop after understanding SDB and making breakthroughs in its diagnosis and treatment. In the United States, except for a few sleep centers that can diagnose and treat various sleep disorders, most of them are sleep laboratories that only diagnose and treat SDB. With the improvement of people's understanding of the importance of SDB, the position of pulmonary doctors in sleep medicine will become more and more important.
65438+ 0/3 of life is spent in sleep. The relationship between sleep and other diseases and the impact of sleep diseases on health should attract the attention of respiratory doctors. A preliminary survey abroad shows that about 10% and 40% of the patients in the outpatient department of respiratory doctors may be related to SDB. For example, the cause of many patients with chronic pharyngitis may be SDB. The changes of respiratory function and the decrease of ventilation caused by physiological sleep have no important pathological significance in normal people, but for patients with basic respiratory diseases, these changes may accelerate blood gas disorder during the day and induce respiratory failure. After successful evacuation of mechanical ventilation, patients with respiratory failure may have elevated CO2 during sleep and need to be re-intubated, thus leading to evacuation failure. For example, CO2 retention in patients with neuromuscular diseases during the day is often not parallel to the decline of respiratory muscle strength, and the occurrence of respiratory failure may be related to insufficient sleep ventilation; If COPD patients are complicated with severe sleep apnea syndrome (overlap syndrome), their respiratory failure and right heart insufficiency occur early and seriously, and some patients can correct their respiratory failure during the day only by using noninvasive ventilation during sleep. The essence of SDB is a kind of respiratory failure, so it is necessary to deeply understand the sleep respiratory physiology and improve the treatment level of respiratory failure. In addition, non-respiratory sleep disorders may often be complications of some respiratory diseases, such as insomnia caused by theophylline and quinolones, and sleep disorders caused by asthma attacks at night. Because there are few doctors specializing in sleep at present, respiratory doctors often encounter requests for consultation and consultation about SDB and even other non-respiratory sleep disorders. Especially the noninvasive positive pressure ventilator widely used in clinic at present, its invention and perfection depend on the development of sleep respiratory medicine. It is in SDB patients with relatively few systemic complications that they have accumulated rich application experience, and then they are popularized and applied to patients complicated with respiratory failure. In addition, in the clinical practice of sleep respiratory medicine, relevant respiratory therapists have been trained.
The scope of sleep breathing medicine itself is not limited to sleep snoring. SDB has a wide range of diseases, including obstructive sleep apnea syndrome (OSAHS), central sleep apnea syndrome (CSAHS), sleep apnea syndrome, overlap syndrome complicated with COPD, patients with SDB complicated with neuromuscular diseases and patients with Abby Chen's respiratory syndrome complicated with chronic congestive heart failure. In addition to traditional obstructive, mixed and central SA, sleep apnea, upper airway resistance syndrome (UARS) and even airflow limitation caused by partial collapse of upper airway have important pathological significance. Moreover, the above respiratory diseases are interrelated and gradually developing (Figure 1), and become a continuous disease spectrum.
Normal breathing, airflow restriction, snoring, and insufficient ventilation of UARS (insufficient breathing)
Apnea, respiratory failure
SDB can cause multi-system damage, and sleep medicine involves many disciplines. Foreign practitioners in this field mainly come from respiratory, neurology, psychiatry, psychology, otolaryngology, stomatology and so on. This is basically the case in China, but the proportion of otolaryngologists is relatively high, and otolaryngology has also done a lot of work in discipline construction, including the publication of books and the holding of learning classes. Most importantly, the diagnosis and treatment of obstructive sleep apnea syndrome has been included in the Tenth Five-Year Plan of Otolaryngology. From 1995, the composition of medical practitioners certified by the American Sleep Society (AASM) to the changes in the past ten years in 2004, it can be clearly seen that there are more and more sleep doctors who only engage in sleep medicine, and many of them have respiratory professional backgrounds. The proportion of general practitioners in this field has increased. Because most patients come from cardiovascular and geriatric departments, there will be more doctors with these professional backgrounds in the team of sleep medicine in the future, but respiratory doctors have always been the main force of sleep respiratory medicine. With the increasing application of simple screening instruments, the position of non-invasive ventilator in treatment will be further enhanced, and the role of respiratory doctors will become more and more important. At present, the certification and training work in the United States is mainly completed by AASM. Because of the leading position of pulmonary physicians, it is very likely that an independent certification and training system will be established within the respiratory professional society (such as ACCP) in the future, which will be beneficial to the development of the discipline.
How to do a good job in the discipline construction of sleep respiratory medicine? The development of sleep respiratory medicine and the needs of patients provide opportunities for discipline construction. At least in the following aspects: first, the respiratory function of the upper respiratory tract; Second, respiratory regulation and sleep respiratory physiology move from research to clinical application; Third, it provides a guarantee for the popularization and application of noninvasive ventilation technology and respiratory therapists.
In recent years, under the leadership of the Respiratory Society, China has done some work in discipline construction, such as establishing the Sleep Group of the Respiratory Society, organizing nationwide epidemic adjustment, publishing guidelines for diagnosis and treatment, conducting multi-center research on target organ damage, and compiling sleep respiratory medicine. Relevant contents have been included in medical students' textbooks. In the newly established expert training plan, the related knowledge of SDB has been included. However, further efforts are still needed in discipline construction.
(a) Formulate formal training requirements and plans.
(two) the establishment of technician training and certification system.
(3) Set relevant compulsory contents in the continuing education courses for medical students, graduate students majoring in respiratory medicine and residents.
(four) to carry out the certification of sleep centers when conditions are ripe.
refer to
1. Wagner police, Epstein LJ, Kwale PA. Pulmonary physicians in the practice of sleep medicine. I'm a respiratory emergency care doctor. 2005; 172 (11):13578. Chest. 2005; 128:378890. Sleep. 2005; 28: 14967.
2.Strohl KP, et al.: Curriculum and Ability Assessment Tool for Sleep Disorders in Lung Research Training Program. I am. J. Respir。 Critical care medical care. 172: 39 1397
3. Shepard J, Bis D, Cheson A, et al. The History of Sleep Medicine in America. J Clinical Sleep Medicine, 2005 (1):6 183.
National Institutes of Health: National Sleep Disorders Research Program, 2003.