°≈ÿà¡Õ“°“√À¬ÿ¥À“¬„®¢≥–À≈—∫™π`¥Õÿ¥°—Èπ

‡«™ªØ‘ ∫— µ‘ ª √‘ ∑— » πå
§ ≈‘ π‘ °
°≈ÿà¡Õ“°“√À¬ÿ¥À“¬„®¢≥–À≈—∫™π‘¥Õÿ¥°—Èπ
(Obstructive Sleep Apnea Syndrome) ·≈–
‚√§°√¥‰À≈¬âÕπ (Gastroesophageal Reflux Disease)
°≈ÿà¡Õ“°“√À¬ÿ¥À“¬„®¢≥–À≈—∫™π‘¥Õÿ¥°—Èπ (obstructive sleep apnea syndrome :
OSAS) ·≈–‚√§°√¥‰À≈¬âÕπ (gastroesophageal reflux disease : GERD) ‡ªìπ‚√§‡√◊ÈÕ√—ß∑’Ë
æ∫‰¥â∫àÕ¬ ·≈–¡’ªí®®—¬‡ ’ˬß∑’˧≈⓬°—𠇙àπ ºŸâªÉ«¬∑’Ë¡’¿“«–Õâ«π (obesity) ¡’‚Õ°“ ∑’Ë®–
‡ªìπ‚√§∑—Èß 2 π’È¡“°¢÷Èπ πÕ°®“°π—Èπ欓∏‘ √’√«‘∑¬“¢Õß∑—Èß 2 ‚√§π’Ȭ—߇°’ˬ«¢âÕß°—∫°“√Õÿ¥°—Èπ
∑“߇¥‘πÀ“¬„® (airway obstruction) ·≈–°“√Õ—°‡ ∫¢Õ߇¬◊ËÕ∫ÿ∑“߇¥‘πÀ“¬„® (airway
inflammation) ‡À¡◊Õπ°—π ºŸâªÉ«¬ OSAS ¡’Õÿ∫—µ‘°“√≥å¢Õß GERD ∑’ˇ°‘¥√à«¡¥â«¬ Ÿß°«à“
§πª°µ‘Õ¬à“ß¡’π—¬ ”§—≠ ‡™àπ „π°“√»÷°…“Àπ÷Ëß ºŸâªÉ«¬ 21 √“¬ ∑’Ë¡’ªí≠À“¿“«–À“¬„®º‘¥ª°µ‘
¢≥–À≈—∫™π‘¥Õÿ¥°—Èπ (obstructive sleep disordered breathing : OSDB) √âÕ¬≈– 33.3 ¢Õß
ºŸâªÉ«¬∑’Ë¡’ªí≠À“πÕπ°√π ·≈–√âÕ¬≈– 64.3 ¢ÕߺŸâªÉ«¬ OSAS ‡ªìπ GERD ¢≥–‡¥’¬«°—πºŸâªÉ«¬
23 √“¬ ∑’Ë¡’ªí≠À“ OSDB (√âÕ¬≈– 66.7 ¢ÕߺŸâªÉ«¬∑’ËπÕπ°√π ·≈–√âÕ¬≈– 60.7 ¢ÕߺŸâªÉ«¬
OSAS) ‡ªìπ GERD ™π‘¥ laryngopharyngeal reflux (LPR) À√◊Õ‚√§°√¥‰À≈¬âÕπ¢÷Èπ
¡“∑’˧շ≈–°≈àÕ߇ ’¬ß1 πÕ°®“°π—ÈπºŸâªÉ«¬√âÕ¬≈– 90 (26 „π 29 √“¬) ∑’ˇªìπ OSAS æ∫«à“ ¡’
°“√Õ—°‡ ∫¢Õß°≈àÕ߇ ’¬ß (laryngeal inflammation) (¿“æ∑’Ë 1) ®“°°“√µ√«®‚¥¬„™â
reflux finding score ´÷Ë߇¢â“‰¥â°—∫‚√§ LPR ‚¥¬§«“¡√ÿπ·√ߢÕß°≈àÕ߇ ’¬ß∑’ËÕ—°‡ ∫ ¡’§«“¡
—¡æ—π∏å°—∫§«“¡√ÿπ·√ߢÕß OSAS °≈à“«§◊Õ ¬‘Ëߧ«“¡√ÿπ·√ߢÕß‚√§ OSAS ¡“° °Á®–æ∫°“√
Õ—°‡ ∫¢Õß°≈àÕ߇ ’¬ß¡“°2 Õ¬à“߉√°Áµ“¡ §«“¡ —¡æ—π∏å√–À«à“ß 2 ‚√§ „π·ßà¢Õß‚√§Àπ÷Ë߇ªìπ
‡Àµÿ ·≈–∑”„ÀâÕ’°‚√§Àπ÷Ëß´÷Ë߇ªìπº≈µ“¡¡“ ¬—߉¡à™—¥‡®ππ—°.
∫∑§«“¡π’È®–°≈à“«∂÷ߧ«“¡ —¡æ—π∏å√–À«à“ß OSAS ·≈– GERD ´÷Ëßæ∫∫àÕ¬¡“°¢÷Èπ„π™à«ß
ª“√¬– Õ“»π–‡ π æ.∫., √Õß»“ µ√“®“√¬å
“¢“‚√§®¡Ÿ°·≈–‚√§¿Ÿ¡·‘ æâ ¿“§«‘™“‚ µ π“ ‘° ≈“√‘ß´å«∑‘ ¬“
§≥–·æ∑¬»“ µ√å»√‘ √‘ “™æ¬“∫“≈
¡À“«‘∑¬“≈—¬¡À‘¥≈
§≈‘π‘° ªï∑’Ë 30 ©∫—∫∑’Ë 5 情¿“§¡ 2557
303
4-5 ªï∑’˺à“π¡“ ªí®®—¬‡ ’ˬߵàÕ°“√‡°‘¥ GERD ™à«ß
¢≥–πÕπÀ≈—∫ ∑’Ë∑√“∫°—π¥’ ‰¥â·°à À≈Õ¥Õ“À“√¡’
°“√‡§≈◊Ë Õ πµ— « „π°“√°”®— ¥ Õ“À“√·≈–°√¥∑’Ë ≈ ¥≈ß,
√à“ß°“¬¡’°“√º≈‘µπÈ”≈“¬≈¥≈ß ¢≥–∑’˺ŸâªÉ«¬¡’™à«ß∑’Ë
À¬ÿ¥À“¬„® √à“ß°“¬®–欓¬“¡À“¬„®‡¢â“ ‡æ◊ÕË ‡Õ“™π–
∑“߇¥‘πÀ“¬„® à«π∫π∑’˵’∫·§∫ ∑”„À⇰‘¥§«“¡¥—π
‡ªìπ≈∫¢÷Èπ„π∑“߇¥‘πÀ“¬„® à«π∫π ´÷Ëߧ«“¡¥—π∑’Ë
‡ªìπ≈∫¥—ß°≈à“« ®–∑”„Àâ°√¥„π°√–‡æ“–Õ“À“√·≈–
À≈Õ¥Õ“À“√‰À≈¬âÕπ¢÷πÈ ¡“„π∑“߇¥‘πÀ“¬„® à«π∫π
‰¥âßà“¬¢÷Èπ πÕ°®“°π—Èπ™à«ß∑’˺ªŸâ «É ¬¡’¿“«–À¬ÿ¥À“¬„®
¢≥–À≈—∫ ∑”„Àâ intrathoracic pressure ≈¥≈ß ·≈–
transdiaphragmatic pressure ¡’ §à “ Ÿ ß ¢÷È π ´÷Ë ß
§«“¡¥—π∑’Ë Ÿß¢÷Èπ¥—ß°≈à“«¡’º≈µàÕ phrenoesophageal
ligament ´÷ßË ¬÷¥Õ¬Ÿ°à ∫— °≈â“¡‡π◊ÕÈ ÀŸ√¥Ÿ ¢ÕßÀ≈Õ¥Õ“À“√
à«π≈à“ß (lower esophageal sphincter : LES)
(¿“æ∑’Ë 2) °“√‡ª≈’ˬπ·ª≈ߢÕߧ«“¡¥—π∑’ˇ°‘¥¢÷Èπ
´È”‰ª¡“¢≥–À≈—∫ ∑”„Àâ LES ∑”ß“πº‘¥ª°µ‘ ·≈–
¡’°“√§≈“¬µ—«¡“°¢÷Èπ (LES insufficiency) ·≈–
°√–‡æ“–Õ“À“√¡’°“√°”®—¥Õ“À“√·≈–°√¥„π°√–‡æ“–
Õ“À“√‰¥âπâÕ¬≈ß ∑”„Àâ¡’°“√‰À≈¬âÕπ¢Õß°√¥¡“°¢÷Èπ
𔉪 Ÿà GERD.
√’√«‘∑¬“¢Õß°“√πÕπÀ≈—∫
°“√πÕπÀ≈—∫ª√–°Õ∫¥â«¬ rapid-eye-movement (REM) sleep ·≈– non-REM sleep ´÷Ëß™à«ß
non-REM ‡ªìπ™à«ß∑’¡Ë °’ “√‡ª≈’¬Ë π·ª≈ß∑“ß √’√«‘∑¬“
πâ Õ ¬ ‡¡◊Ë Õ ‡ª√’ ¬ ∫‡∑’ ¬ ∫°— ∫ ™à « ß REM ´÷Ë ß ¡’ ° “√
‡ª≈’¬Ë π·ª≈ß∑“ß √’√«‘∑¬“‡°‘¥¢÷πÈ ¡“°3 °“√‡°‘¥ REM
·≈– non-REM „π§πª°µ‘ ®–‡°‘¥ ≈—∫°—π‰ª‡ªìπ
√Õ∫Ê ≈–ª√–¡“≥ 90 π“∑’ ´÷Ëß„π°“√πÕπ 1 §◊π ®–
‡°‘¥ REM ª√–¡“≥ 4-6 √Õ∫ ‚¥¬‡©≈’ˬ®–‡°‘¥ REM
ª√–¡“≥√âÕ¬≈– 25 ¢Õß√–¬–°“√πÕπÀ≈—∫∑—ÈßÀ¡¥3
Electroencephalography (EEG) ¡’≈—°…≥– lowvoltage mixed-frequency ·≈–¡’µ“°√–µÿ°§≈⓬
„π√–¬–µ◊πË ·≈–¡’§«“¡µ÷ßµ—«¢Õß°≈â“¡‡π◊ÕÈ πâÕ¬≈ß¡“°
·≈–¡’§«“¡ —¡æ—π∏å°—∫°“√Ωíπ.
304
°“¬«‘¿“§·≈– √’√«‘∑¬“¢Õß‚√§°√¥‰À≈¬âÕπ
·≈–°“√πÕπÀ≈—∫
À≈Õ¥Õ“À“√¡’ ≈— ° …≥–‡ªì π ∑à Õ ¬“«ª√–¡“≥
20-25 ´¡. ·≈–¡’ LES ªÑÕß°—π‰¡à„Àâ¡’°“√‰À≈¬âÕπ
¢Õß ‘Ëß∑’ËÕ¬Ÿà„π°√–‡æ“–Õ“À“√¢÷Èπ‰ª¬—ßÀ≈Õ¥Õ“À“√
‡¡◊ËÕ¡’°“√‰À≈¬âÕπ¢Õß°√¥À√◊Õ ‘Ëß∑’ËÕ¬Ÿà„π°√–‡æ“–
Õ“À“√¢÷πÈ ‰ª„πÀ≈Õ¥Õ“À“√ ®–‡°‘¥ primary peristalsis ¢ÕßÀ≈Õ¥Õ“À“√¢÷Èπ ‡æ◊Ëՙ૬„π°“√‡§≈◊ËÕπµ—«
¢Õß ‘Ëß∑’ËÕ¬Ÿà„πÀ≈Õ¥Õ“À“√≈߉ª¬—ß°√–‡æ“–Õ“À“√
ºà“π∑“ß°≈‰°°“√°≈◊π (volume clearance) à«π
secondary peristalsis ¢ÕßÀ≈Õ¥Õ“À“√‰¡à§àÕ¬‡°‘¥
·µà®–‡°‘¥ ‡¡◊ÕË ¡’°“√¢¬“¬µ—«¢ÕßÀ≈Õ¥Õ“À“√ secondary peristalsis π’ȇªìπ°≈‰°∑’Ë ”§—≠„π™à«ß°“√πÕπ
À≈—∫ ‡π◊ËÕß®“°¢≥–À≈—∫ °≈‰°°“√°≈◊π‡°‘¥‰¥âπâÕ¬4
πÕ°®“°π—Èπ πÈ”≈“¬·≈– bicarbonate ∑’Ë √â“ߢ÷Èπ®–
™à«¬∑”„Àâ°√¥∑’Ë¢÷Èπ¡“‡ªìπ°≈“ß (acid clearance)
·≈–·√ß‚πâ¡∂à«ß¢Õß‚≈° °Á®–™à«¬∑”„Àâ°“√‰À≈¬âÕπ
°≈—∫¢Õß°√¥·≈– ‘Ëß∑’ËÕ¬Ÿà„π°√–‡æ“–Õ“À“√‡°‘¥¢÷Èπ‰¥â
¬“°À√◊Õ‡°‘¥‰¥âπâÕ¬≈ß.
º≈∑“ß √’√«‘∑¬“¢Õß°“√πÕπÀ≈—∫µàÕ§«“¡∂’Ë
·≈–√–¬–‡«≈“¢Õß°“√‡°‘¥°√¥‰À≈¬âÕπ
®“°°“√»÷°…“æ∫«à“ °√¥‰À≈¬âÕπ “¡“√∂
‡°‘¥‰¥â¢≥–À≈—∫ ·µà‡°‘¥‰¥â∫àÕ¬πâÕ¬°«à“¢≥–ºŸâªÉ«¬
µ◊ËπÀ√◊Õ¢≥–À≈—ß√—∫ª√–∑“πÕ“À“√„À¡àÊ5 ¢≥–À≈—∫
°√¥‰À≈¬â Õ π¡— ° ‡°‘ ¥ „π™à « ß non-REM (‡°‘ ¥ „π
™à«ß REM πâÕ¬¡“°) ·≈–√–¬–‡«≈“„π°“√°”®—¥
°√¥¢≥–À≈— ∫ ®–π“π°«à “ ¢≥–µ◊Ë π6 ®“°°“√»÷°…“
æ∫«à“ „π§πª°µ‘π—Èπ °“√‡°‘¥°“√‰À≈¬âÕπ¢Õß°√¥
¢≥–µ◊Ëπ·≈–¢≥–À≈—∫¡’§«“¡·µ°µà“ß°—π7 °≈à“«§◊Õ
¢≥–µ◊ËπÀ√◊Õ‡«≈“°≈“ß«—π °√¥‰À≈¬âÕπ¡—°‡°‘¥À≈—ß
√—∫ª√–∑“πÕ“À“√ ·≈–°“√°”®—¥°√¥ ¡—°‡°‘¥Õ¬à“ß
√«¥‡√Á« µ√ߢⓡ°—∫¢≥–À≈—∫ °√¥‰À≈¬âÕπ¡—°‡°‘¥
πâÕ¬°«à“ ·≈–°“√°”®—¥°√¥¡—°‡°‘¥™â“°«à“ §”∂“¡∑’Ë
µ“¡¡“ §◊Õ ‡°‘¥Õ–‰√¢÷Èπ¢≥–À≈—∫∑’Ë∑”„Àâ°“√°”®—¥
°√¥≈à“™â“.
§≈‘π‘° ªï∑’Ë 30 ©∫—∫∑’Ë 5 情¿“§¡ 2557
¿“æ∑’Ë 1
¿“æ∑’Ë 2
§≈‘π‘° ªï∑’Ë 30 ©∫—∫∑’Ë 5 情¿“§¡ 2557
305
¿“æ∑’Ë 3
¿“æ∑’Ë 4
306
§≈‘π‘° ªï∑’Ë 30 ©∫—∫∑’Ë 5 情¿“§¡ 2557
¢≥–µ◊Ëπ ‡¡◊ËÕ°√¥‰À≈¬âÕπ¢÷Èπ¡“ —¡º— °—∫‡¬◊ËÕ
∫ÿÀ≈Õ¥Õ“À“√ ®–∑”„À⺪Ÿâ «É ¬¡’Õ“°“√· ∫√âÕπ∫√‘‡«≥
Õ° (heart burn), ¡’°“√º≈‘µπÈ”≈“¬‡æ‘Ë¡¡“°¢÷Èπ,
°√–µÿπâ „À⇰‘¥°“√°≈◊π ·≈–¡’ primary ·≈– secondary
peristalsis ´÷Ëß°≈‰°¥—ß°≈à“«π’È ‡°‘¥¢÷ÈπÕ¬à“ß√«¥‡√Á«
À≈—ß®“°°√¥ —¡º— °—∫‡¬◊ËÕ∫ÿÀ≈Õ¥Õ“À“√ ‡æ◊ËÕ∑”„Àâ¡’
¿“懪ìπ°≈“ß ·≈–°”®—¥°√¥ÕÕ°‰ª„Àâ‡√Á«∑’Ë ÿ¥ ®–
‡ÀÁ π ‰¥â «à “ °“√πÕπÀ≈— ∫ ∑”„Àâ ° ≈‰°¥— ß °≈à “ «‡À≈à “ π’È
(¬°‡«âπ secondary peristalsis) ∑”ß“ππâÕ¬≈ß
À√◊Õ‰¡à∑”ß“π ‡™àπ ¢≥–πÕπÀ≈—∫ ºŸªâ «É ¬®–‰¡à¡Õ’ “°“√
· ∫√âÕπ∫√‘‡«≥Õ° °“√°≈◊π·≈– primary peristalsis
´÷Ë߇ªìπ°≈‰°°“√°”®—¥°√¥°Á®–‡°‘¥¢÷ÈππâÕ¬¡“°8 ‰¡à¡’
°“√º≈‘µπÈ”≈“¬‡æ‘Ë¡¢÷Èπ¢≥–À≈—∫ ‡æ◊ËÕ∑”„Àâ°√¥¡’
¿“懪ìπ°≈“ß9 ¥—ßπ—Èπ®–‡ÀÁπ‰¥â«à“ °“√πÕπÀ≈—∫∑”
„Àâ‡æ‘Ë¡Õ—µ√“‡ ’ˬߢÕߧ«“¡º‘¥ª°µ‘„π°“√°”®—¥°√¥.
°“√À“¬„®‡¢â“-ÕÕ° ∑”„Àâ¡°’ “√‡§≈◊ÕË π‰À«¢Õß
∑√«ßÕ°·≈–™à Õ ß∑â Õ ß ·≈–¡’ ° “√‡ª≈’Ë ¬ π·ª≈ߢÕß
§«“¡¥—π„π™àÕßÕ°·≈–™àÕß∑âÕß ´÷Ëß®–¡’º≈µàÕÀ≈Õ¥
Õ“À“√´÷ËßÕ¬Ÿà„π™àÕßÕ°·≈–™àÕß∑âÕß ∑à“∑“ߢÕߺŸâªÉ«¬
‡™àπ πÕπÀß“¬, πÕπµ–·§ß, π—ËßÀ√◊Õ¬◊π °Á¡’º≈µàÕ
§«“¡¥—π„π™àÕßÕ°·≈–™àÕß∑âÕߥ—ß°≈à“«¥â«¬ ´÷ßË ªí®®—¬
µà“ßÊ ‡À≈à“π’È≈â«π¡’º≈„π°“√°àÕ„À⇰‘¥°“√‰À≈¬âÕπ
¢Õß°√¥¢÷Èπ¡“®“°°√–‡æ“–Õ“À“√ ‚¥¬‡©æ“–¢≥–∑’Ë
°≈â“¡‡π◊ÈÕ‡√’¬∫¢Õß∑“߇¥‘πÕ“À“√¡’°“√§≈“¬µ—« ·≈–
ºŸâªÉ«¬Õ¬Ÿà„π∑à“πÕπÀß“¬.
§«“¡ —¡æ—π∏å√–À«à“ß GERD, OSAS ·≈–
¿“«–Õâ«π
GERD ·≈– OSAS æ∫√à«¡°—π‰¥â∫àÕ¬10-12
OSAS ‡°‘¥®“°∑“߇¥‘πÀ“¬„® à«π∫π ¡’°“√Õÿ¥°—Èπ
∑”„Àâ√–¥—∫ÕÕ°´‘‡®π„π‡≈◊Õ¥µË”≈ß·≈–ºŸâªÉ«¬µ◊Ëπ∫àÕ¬
„π°“√»÷°…“Àπ÷Ëß∑’Ë ”√«®ºŸâªÉ«¬ OSDB ∑’Ë∂Ÿ° àß¡“
µ√«®°“√πÕπÀ≈—∫ (polysomnography : PSG) æ∫
«à“ √âÕ¬≈– 74 ¡’Õ“°“√¢Õß GERD ‡™àπ heart burn
·≈–/À√◊Õ acid regurgitation12 Ing ·≈–§≥–13 ‰¥â„™â
PSG ·≈– 24-hour esophageal pH monitoring
§≈‘π‘° ªï∑’Ë 30 ©∫—∫∑’Ë 5 情¿“§¡ 2557
´÷Ë߇ªìπ gold standard „π°“√«‘π‘®©—¬ OSAS ·≈–
GERD µ“¡≈”¥—∫ æ∫«à“ ºŸâªÉ«¬ OSAS ¡’°“√‰À≈
¬âÕπ°≈—∫¢Õß°√¥µÕπ°≈“ߧ◊π¡“°°«à“ºŸâªÉ«¬∑’ˉ¡à¡’
OSAS ‚¥¬‡©≈’ˬæ∫«à“ ºŸâªÉ«¬ OSAS ¡’ reflux
¡“°°«à“ 100 §√—Èß „π™à«ßπÕπÀ≈—∫ 8 ™—Ë«‚¡ß ‡¡◊ËÕ
‡ª√’¬∫‡∑’¬∫°—∫§πª°µ‘∑’ˉ¡à¡’ OSAS ´÷Ëß¡’ reflux
‡°‘¥¢÷Èπ‡æ’¬ß 23 §√—Èß„π™à«ß‡«≈“¥—ß°≈à“« πÕ°®“°π—Èπ
‡«≈“∑’ËÀ≈Õ¥Õ“À“√„™â„π°“√°”®—¥°√¥·≈–√–¬–‡«≈“
∑’˺ŸâªÉ«¬¡’ pH < 4 „πÀ≈Õ¥Õ“À“√ „πºŸâªÉ«¬ OSAS
®–π“π°«à“ °≈ÿࡧ«∫§ÿ¡∑’ˉ¡à¡’ OSAS Õ¬à“ß¡’π—¬
”§—≠∑“ß ∂‘µ‘ ¢≥–∑’Ë GERD ·≈– OSAS ‡°‘¥√à«¡
°—π ∏√√¡™“µ‘·≈–∑‘»∑“ߢÕߧ«“¡ —¡æ—π∏å√–À«à“ß 2
‚√§π’Ȭ—߉¡à‡ªìπ∑’ˇ¢â“„®Õ¬à“ß·®à¡™—¥ OSAS ∑”„Àâ
‡°‘¥°√¥‰À≈¬âÕπ„π‡«≈“°≈“ߧ◊π‰¥â ‡æ√“–™à«ß∑’˺Ÿâ
ªÉ«¬À¬ÿ¥À“¬„® ®–∑”„À⺟âªÉ«¬µ◊Ëπ∫àÕ¬ (arousal) ¡’
°“√‡§≈◊ËÕπ‰À«¡“°¢÷Èπ ¡’ intrathoracic pressure
∑’Ë≈¥≈ß ·≈–¡’ transdiaphragmatic pressure ∑’Ë
‡æ‘Ë¡¢÷Èπ14 ∂â“°≈‰°¥—ß°≈à“«‡ªìπ®√‘ß °“√‡ª≈’ˬπ·ª≈ß
¢Õß∑—Èß intrathoracic pressure ·≈– transdiaphragmatic pressure µâÕ߇°‘¥°àÕπ∑’Ë®–¡’ reflux ·µà°“√
»÷°…“‚¥¬ Ing ·≈–§≥–13 °≈—∫æ∫«à“ ‡æ’¬ß√âÕ¬≈– 23.7
¢Õß reflux ‡∑à“π—Èπ∑’Ë¡’¿“«–À¬ÿ¥À“¬„®π”¡“°àÕπ
À√◊Õ‡°‘¥¢÷Èπæ√âÕ¡¿“«–À¬ÿ¥À“¬„®.
°≈‰°∑“ß欓∏‘ √’√«‘∑¬“∑’ÕË ∏‘∫“¬§«“¡‡°’¬Ë «¢âÕß
°—π√–À«à“ß 2 ‚√§π’È · ¥ß„Àâ‡ÀÁπ«à“ GERD ∑”„Àâ
OSAS ·¬à≈ß ·≈– OSAS °Á∑”„Àâ GERD ·¬à≈ß15
¢≥–∑’˺ŸâªÉ«¬À¬ÿ¥À“¬„® ®–¡’°“√‡ª≈’ˬπ·ª≈ߢÕß
transdiaphragmatic pressure ∑”„Àâ ° √¥
‰À≈¬âÕπ¢÷Èπ¡“¬—ßÀ≈Õ¥Õ“À“√ ´÷Ëß°“√‡ª≈’ˬπ·ª≈ß
§«“¡¥—π¥—ß°≈à“«∑’ˇ°‘¥´È”Ê °—π √«¡∑—Èß¿“«–µ◊Ëπ∫àÕ¬
®“°°“√¢“¥ÕÕ°´‘‡®π¢≥–À≈—∫ ®–∑”„Àâ phrenoesophageal ligament ·≈– LES ∑”Àπâ“∑’˺‘¥ª°µ‘‰ª
√«¡∑—Èß°“√°”®—¥°√¥‚¥¬À≈Õ¥Õ“À“√™â“≈ß16 ‡°‘¥
GERD µ“¡¡“.
GERD ‡Õß°Á∑”„À⺟âªÉ«¬µ◊Ëπ (arousal) ∫àÕ¬
∑”„ÀâπÕπÀ≈—∫‰¡à π‘∑ Õ“® àߺ≈„Àâ¡’Õ“°“√ßà«ß¡“°
307
‡«≈“°≈“ß«—π ∑”„À⺟âªÉ«¬ OSAS ¡’Õ“°“√·¬à≈ß
·≈–°“√∑’Ë°√¥‰À≈¬âÕπ¢÷Èπ¡“∑’Ë∑“߇¥‘πÀ“¬„® à«π∫π
‚¥¬‡©æ“–¢≥–∑’˺ŸâªÉ«¬πÕπ√“∫ ®–∑”„À⇬◊ËÕ∫ÿ∑“ß
‡¥‘πÀ“¬„® à«π∫π∫«¡·≈–µ’∫·§∫¡“°¢÷Èπ ·≈–∑”„Àâ
OSAS ·¬à≈ß (¿“æ∑’Ë 3) ‚¥¬¡’À≈—°∞“π π—∫ πÿπ
®“°°“√»÷°…“Àπ÷ßË ∑’æË ∫«à“ ‡¥Á°∑’¡Ë ’ nocturnal GERD
®–¡’®”π«π apnea ·≈– hypopnea ‡°‘¥¢÷Èπ„π™à«ß
REM ¡“°°«à“‡¥Á°∑’ˉ¡à¡’ nocturnal GERD.17
§«“¡ —¡æ—π∏å√–À«à“ß GERD ·≈– OSAS ‰¥â
· ¥ß„Àâ‡ÀÁπÕ’° ®“°À≈—°∞“π∑’«Ë “à ∂â“√—°…“ GERD ·≈â«
OSAS ®–¥’¢÷Èπ À√◊Õ°≈—∫°—π ∂â“√—°…“ OSAS ·≈â«
GERD ®–¥’¢÷Èπ ¡’°“√»÷°…“À≈“¬°“√»÷°…“∑’Ë· ¥ß
„Àâ‡ÀÁπ«à“ °“√√—°…“ºŸâªÉ«¬ GERD ¥â«¬ Continuous
Positive Airway Pressure (CPAP) ´÷Ë߇ªìπ°“√
√—°…“¡“µ√∞“π¢Õß OSAS “¡“√∂∑”„ÀâÕ“°“√¢Õß
GERD ¥’¢π÷È ‰¥â ·¡â«“à ºŸªâ «É ¬ GERD π—πÈ ®–‰¡à¡’ OSAS
°Áµ“¡11, 13, 14 ‡™àπ Kerr ·≈–§≥–14 æ∫«à“ À≈—ß„Àâ°“√
√—°…“ºŸâªÉ«¬ GERD ¥â«¬ nasal CPAP §«“¡∂’Ë¢Õß
°“√‡°‘¥°√¥‰À≈¬âÕπ™à«ß°≈“ߧ◊π ·≈–√âÕ¬≈–¢Õß
‡«≈“∑’Ë¡’ pH < 4 „πÀ≈Õ¥Õ“À“√ (®“°√âÕ¬≈– 6.3
‡À≈◊Õ√âÕ¬≈– 0.1) ≈¥πâÕ¬≈ßÕ¬à“ß™—¥‡®π πÕ°®“°
π—ÈπºŸâªÉ«¬ OSAS ∑’Ë„Àâ°“√√—°…“¥â«¬ CPAP ®–∑”„Àâ
sleep-related reflux πâÕ¬≈ßÕ¬à“ß™—¥‡®π11, 13 Green
·≈–§≥–11 »÷°…“ºŸâªÉ«¬ OSAS 331 √“¬ æ∫«à“√âÕ¬
≈– 62 ¡’Õ“°“√¢Õß GERD ‡«≈“°≈“ߧ◊π (‡™àπ
· ∫√âÕπ∫√‘‡«≥Àπâ“Õ°, ¡’°√¥‰À≈¢÷Èπ¡“, ”≈—°)
√âÕ¬≈– 75 ¢ÕߺŸâªÉ«¬ OSAS ∑’Ë„™â CPAP æ∫«à“
§«“¡∂’Ë¢Õß°“√‡°‘¥Õ“°“√°√¥‰À≈¬âÕπ„π‡«≈“°≈“ß
§◊π≈¥≈ß ‚¥¬¡’§«“¡ —¡æ—π∏å√–À«à“ßÕ“°“√¢Õß‚√§
°√¥‰À≈¬âÕπ∑’Ë¥’¢÷Èπ ·≈–§«“¡¥—π¢Õß CPAP ∑’Ë„™â
√—°…“ CPAP Õ“®∑”„ÀâÕ“°“√¢Õß°√¥‰À≈¬âÕπ¥’¢÷Èπ
®“°°“√‡æ‘¡Ë §à“‡©≈’¬Ë ¢Õߧ«“¡¥—π¿“¬„πÀ≈Õ¥Õ“À“√
À√◊Õ‰ª°√–µÿâπªØ‘°‘√‘¬“ reflex ∑”„À⧫“¡µ÷ßµ—«¢Õß
LES ‡æ‘Ë¡¢÷Èπ.14
„π∑“ß°≈—∫°—π °“√√—°…“ GERD ¥â«¬¬“≈¥°√¥
®–∑”„Àâ OSAS ¥’¢÷Èπ18 °“√»÷°…“Àπ÷Ëß ‰¥â»÷°…“º≈
308
¢Õß°“√„Àâ omeprazole ¢π“¥ 20 ¡°. «—π≈– 2 §√—Èß
‡ªìπ√–¬–‡«≈“ 30 «—π „πºŸâªÉ«¬™“¬ 10 √“¬ ∑’ˉ¥â√—∫
°“√«‘π®‘ ©—¬«à“‡ªìπ OSAS ·≈– GERD ‚¥¬ PSG ·≈–
24-hour esophageal pH monitoring µ“¡≈”¥—∫
·≈–‰¡à‰¥â„™â CPAP µ≈Õ¥√–¬–‡«≈“ 30 «—π æ∫«à“
√âÕ¬≈– 31 ¢ÕߺŸâªÉ«¬‡°‘¥ obstructive apnea, hypopnea À√◊Õ respiratory distress πâÕ¬≈ß ·≈–¡’Õ“°“√
OSAS πâÕ¬≈ß18 ∂÷ß·¡â°“√»÷°…“π’ȇªìπ°“√»÷°…“„π
ºŸâªÉ«¬®”π«π‰¡à¡“° ·µà‡ªìπ°“√»÷°…“·√°∑’Ë· ¥ß„Àâ
‡ÀÁπ«à“°“√√—°…“ GERD ¥â«¬¬“≈¥°√¥ “¡“√∂
∑”„Àâ¿“«–À¬ÿ¥À“¬„®¢≥–À≈—∫≈¥≈߉¥â.
πÕ°®“°π—Èπ ¿“«–Õâ«π°Á‡æ‘Ë¡Õ—µ√“‡ ’ˬß∑’Ë∑”„Àâ
‡°‘¥ nocturnal GERD ·≈– OSAS ‰¥â ‡π◊ËÕß®“°
¿“«–Õâ«π∑”„Àâ°“√∑”ß“π¢Õß√–∫∫∑“߇¥‘πÕ“À“√
º‘¥ª°µ‘‰ª ‡™àπ °“√‡§≈◊ËÕπµ—«¢ÕßÀ≈Õ¥Õ“À“√„π
°“√°”®—¥ ‘Ëß∑’ËÕ¬Ÿà„πÀ≈Õ¥Õ“À“√™â“≈ß, ¡’°“√‡æ‘Ë¡¢÷Èπ
¢Õߧ«“¡¥—π¿“¬„π™àÕß∑âÕß, ¡’°“√‡°‘¥‰ â‡≈◊ÕË π°–∫—ß≈¡ (hiatal hernia) (¿“æ∑’Ë 4) √à«¡¥â«¬ ´÷Ëßªí®®—¬
µà“ßÊ ‡À≈à“π’È ®–∑”„Àâ°√¥¡’‚Õ°“ ‰À≈¬âÕπ¢÷Èπ‰ª„π
∑“߇¥‘πÀ“¬„® à«π∫π¡“°¢÷Èπ ¿“«–Õâ«π ®–∑”„Àâ¡’
‰¢¡— π ¡“æÕ°√Õ∫§Õ À√◊ Õ ∑“߇¥‘ π À“¬„® à « π∫π
∑”„Àâ™àÕß§Õ à«πµâπ À√◊Õ∑“߇¥‘πÀ“¬„® à«π∫π·§∫
≈ß ∑”„Àâ‚√§ OSAS ‡ªìπ¡“°¢÷Èπ ∂⓺ŸâªÉ«¬∑’ËÕâ«π
“¡“√∂≈¥πÈ”Àπ—°≈߉¥â ®–™à«¬≈¥‰¢¡—π¥—ß°≈à“«
∑”„Àâ∑“߇¥‘πÀ“¬„® à«π∫π°«â“ߢ÷Èπ ·≈–≈¥§«“¡
¥—π¿“¬„π™àÕß∑âÕß≈ß ∑”„ÀâÕ“°“√¢Õß OSAS ·≈–
GERD ¥’¢π÷È 15 ®“°°“√»÷°…“¢Õß Gislason ·≈–§≥– 19
æ∫«à“ √âÕ¬≈– 4.6 ¢ÕߺŸâªÉ«¬Õ“¬ÿπâÕ¬∑’ˇªìπ GERD
¡’¿“«–Õâ«π√à«¡¥â«¬.
°≈‰°¢Õß°“√‡°‘¥°√¥‰À≈¬âÕπ„πºŸªâ «É ¬ OSAS
¡’°≈‰°À≈“¬°≈‰°∑’ˇ™◊ËÕ«à“∑”„Àâ°√¥‰À≈¬âÕπ
¡“°¢÷Èπ„πºŸâªÉ«¬ OSAS ‡™àπ ¡’ intrathoracic pressure ∑’ˇªìπ≈∫¡“°¢÷Èπ, °“√µ◊Ëπ (arousals) À√◊Õ°“√
‡§≈◊ËÕπ‰À«¢ÕߺŸâªÉ«¬, °“√∑’Ë LES ¡’§«“¡µ÷ßµ—«∑’Ë≈¥
≈ß, °“√∑’Ë ¡’ § «“¡·µ°µà “ ߢÕߧ«“¡¥— π ∑’Ë ¡ “°¢÷È π
§≈‘π‘° ªï∑’Ë 30 ©∫—∫∑’Ë 5 情¿“§¡ 2557
√–À«à“ß°√–‡æ“–Õ“À“√·≈–À≈Õ¥Õ“À“√ à«π≈à“ß ·µà
°≈‰°∑’ˇ™◊ËÕ«à“πà“®–‡ªìπ‰ª‰¥â¡“°∑’Ë ÿ¥ §◊Õ °“√∑’Ë¡’
intrathoracic pressure ∑’ˇªìπ≈∫¡“°¢÷Èπ Graf ·≈–
§≥–20 ‰¥â»÷°…“§«“¡ —¡æ—π∏å√–À«à“ß°√¥∑’ˉÀ≈¬âÕπ
¢÷Èπ¡“ °—∫§«“¡√ÿπ·√ߢÕß OSAS ´÷Ëß∫àß∫Õ°‚¥¬
apnea index ·µà‰¡àæ∫«à“¡’§«“¡ —¡æ—π∏å√–À«à“ß
GERD ·≈– OSAS Heinemann ·≈–§≥–21 æ∫«à“
√âÕ¬≈– 68-76 ¢ÕߺŸâªÉ«¬ OSAS ¡’ GERD ®–‡ÀÁπ«à“
à«π„À≠à¢Õß°“√»÷°…“‡À≈à“π’ȉ¡àæ∫§«“¡ —¡æ—π∏å
√–À«à“ß obstructive respiratory events ·≈–°“√
‡°‘ ¥ °√¥‰À≈¬â Õ π Penzel ·≈–§≥– 22 欓¬“¡
À“§«“¡ —¡æ—π∏å√–À«à“ß®”π«π§√—ßÈ ∑’°Ë √¥‰À≈¬âÕπ¢≥–
ºŸâªÉ«¬ OSAS µ◊Ëπ·≈–À≈—∫ æ∫«à“ √–¬–‡«≈“∑’˺ŸâªÉ«¬
¡’§à“ pH „πÀ≈Õ¥Õ“À“√≈¥≈ß °≈—∫¡“°„π™à«ßµ◊Ëπ
¡“°°«à“™à«ßÀ≈—∫ ·≈–‡æ’¬ß√âÕ¬≈– 71 ¢Õß°√¥∑’ˉÀ≈
¬âÕπ¢÷Èπ¡“√–À«à“ßÀ≈—∫ ¡’ respiratory events π”
¡“°àÕπ ®“°¢âÕ¡Ÿ≈¥—ß°≈à“« OSAS ‰¡àπà“®–∑”„À⇰‘¥
°√¥‰À≈¬âÕπ ‚¥¬°“√‡ª≈’ˬπ·ª≈ß intrathoracic
pressure √–À«à“ß°“√‡°‘¥ respiratory events ·µà
°“√∑’Ë¡’Õÿ∫—µ‘°“√≥å¢Õß GERD ¡“°¢÷Èπ „πºŸâªÉ«¬
OSAS · ¥ß«à“¡’§«“¡ —¡æ—π∏å°—π√–À«à“ß 2 ‚√§π’È
·µà°≈‰°Õ“®®–´—∫´âÕπ¡“°°«à“∑’ˇ√“§‘¥ ·≈–Õ“®
µâÕß°“√°“√»÷°…“‡æ‘Ë¡‡µ‘¡.23
°“√√—°…“
·¡â«à“¬—ß¡’¢âÕ∂°‡∂’¬ß∂÷ߧ«“¡ —¡æ—π∏å√–À«à“ß
GERD ·≈– OSAS ·µà°“√∑’˺ŸâªÉ«¬ OSAS ¡’Õÿ∫—µ‘°“√≥å¢Õß GERD Ÿß (√âÕ¬≈– 53-76) · ¥ß«à“¡’
§«“¡ —¡æ—π∏å°—π∫“ßÕ¬à“ß√–À«à“ß 2 ‚√§π’È ·≈–Õ“®
¡’º≈µàÕ°“√√—°…“ °“√∑’ˉ¡à¡’§«“¡ —¡æ—π∏å√–À«à“ß
§«“¡√ÿπ·√ߢÕß OSAS ·≈– GERD20 ™à«¬∫Õ°«à“
°“√√—°…“§«√¡ÿà߇ªÑ“‰ª∑’˧«“¡√ÿπ·√ß ·≈–°“√¡’Õ¬Ÿà
¢ÕßÕ“°“√ GERD ¡“°°«à“¡ÿà߇ªÑ“‰ª∑’˧«“¡√ÿπ·√ß
¢Õß OSAS ‡¡◊ËÕæ∫«à“ºŸâªÉ«¬‡ªìπ GERD §«√„Àâ°“√
√—°…“‡√Á« ÿ¥ ‡æ√“– GERD ¡’º≈µàÕ°“√πÕπÀ≈—∫
·≈–‚√§ OSAS „π∑“ßµ√ß°—π¢â“¡ ºŸâªÉ«¬ OSAS ∑’Ë
§≈‘π‘° ªï∑’Ë 30 ©∫—∫∑’Ë 5 情¿“§¡ 2557
‰¥â√—∫°“√«‘π‘®©—¬·≈–√—°…“ §«√∂Ÿ°ª√–‡¡‘π«à“ °“√
√—°…“∑—Èß OSAS ·≈– GERD (∂â“¡’√à«¡¥â«¬) ¡’
ª√– ‘∑∏‘¿“æ‡æ’¬ßæÕÀ√◊Õ‰¡à ∂Ⓣ¡à‡æ’¬ßæÕ §«√π”
°“√√—°…“Õ◊Ëπ¡“‡æ‘Ë¡‡µ‘¡ ‡æ◊ËÕ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ¢Õß
°“√√—°…“ ‡™àπ ∂⓺ŸâªÉ«¬¬—߉¡à‰¥â„™â CPAP °Á§«√
·π–π”„À⺪Ÿâ «É ¬„™â ‡æ√“–¡’°“√»÷°…“∑’·Ë ¥ß„Àâ‡ÀÁπ«à“
CPAP “¡“√∂≈¥°√¥‰À≈¬âÕπ∑’Ë¢÷Èπ¡“„πºŸâªÉ«¬
OSAS ‰¥â24,25 ¥—ßπ—Èπª√– ‘∑∏‘¿“æ¢Õß CPAP „π°“√
√—°…“ OSAS „π∑“ßÀπ÷Ëß §◊Õ ≈¥°√¥∑’ˉÀ≈¬âÕπ¢÷Èπ¡“
∑”„Àâ ≈ ¥°“√∫«¡¢Õ߇¬◊Ë Õ ∫ÿ ∑ “߇¥‘ π À“¬„® à « π∫π
∑”„À⺟âªÉ«¬ OSAS ¡’Õ“°“√¥’¢÷Èπ‰¥â Õ¬à“߉√°Áµ“¡
¬—߉¡à¡’°“√»÷°…“«à“ºŸâªÉ«¬ OSAS ·≈–GERD ®–
√—°…“¥â«¬ CPAP Õ¬à“߇¥’¬«‰¥âÀ√◊Õ‰¡à ‚¥¬‰¡àµÕâ ß„™â¬“
À√◊Õ°“√√—°…“Õ◊πË Ê ¢Õß GERD ‡≈¬ ∂⓺Ÿªâ «É ¬ GERD
·≈– OSAS ¡’§«“¡√ÿπ·√ߢÕß‚√§‰¡à¡“°π—° ‡™àπ „™â
CPAP Õ¬à“߇¥’¬«·≈â«∑—ÈßÕ“°“√ GERD ·≈– OSAS
À“¬¥’ ‚¥¬‰¡àµâÕß„™â¬“√—°…“ GERD √à«¡¥â«¬ À√◊Õ
„™â¬“√—°…“ GERD Õ¬Ÿà ·µà¢≥–„™â CPAP “¡“√∂
∂Õ𬓷≈–À¬ÿ¥¬“‰¥â„π∑’Ë ÿ¥ ‚¥¬‰¡à¡’Õ“°“√°≈—∫¡“
‡ªìπÕ’° °Á “¡“√∂„™â CPAP √—°…“‡æ’¬ßÕ¬à“߇¥’¬«
·µà∂⓺ŸâªÉ«¬ GERD ·≈– OSAS ¡’§«“¡√ÿπ·√ߢÕß
‚√§ª“π°≈“ßÀ√◊Õ¡“° °ÁÕ“®µâÕß√—∫ª√–∑“π¬“≈¥°√¥
·≈–/À√◊Õ¬“‡æ‘Ë¡°“√‡§≈◊ËÕπµ—«¢Õß∑“߇¥‘πÕ“À“√„π
°“√°”®—¥°√¥√à«¡¥â«¬ ∂÷ß·¡âÕ“°“√ºŸâªÉ«¬®–§ß∑’Ë
À√◊ÕÀ“¬·≈â«°Áµ“¡.
ºŸâªÉ«¬∫“ß√“¬„™â CPAP ·≈⫉¡à‰¥âº≈ Õ“®‡°‘¥
®“°ºŸâªÉ«¬‰¡à„™â‡§√◊ËÕß CPAP À√◊Õ„™â‰¡àπ“πæÕ26 ®÷ß
§«√µ√«® Õ∫‡√◊ÕË ß§«“¡√à«¡¡◊Õ„π°“√„™â‡§√◊ÕË ß CPAP
π’ȥ⫬ ‚¥¬µ√«® Õ∫¢âÕ¡Ÿ≈®“°‡§√◊ËÕß CPAP ‡æ√“–
‡§√◊ËÕß CPAP ∫“ß√ÿàπ “¡“√∂∫—π∑÷°«—π·≈–√–¬–‡«≈“
„π°“√„™âß“π √«¡∑—Èß§à“§«“¡¥—π‡§√◊ËÕß∑’Ë„™â‰¥â¥â«¬
°“√ºà“µ—¥ºŸâªÉ«¬ OSAS ¡—°®–¡’ª√– ‘∑∏‘¿“æ„π°“√
√—°…“ OSAS ‰¡à¥’π—° À≈—ßºà“µ—¥§«√µ√«® PSG
‡æ◊ËÕª√–‡¡‘πº≈¢Õß°“√√—°…“¥â«¬ ‚¥¬‡©æ“–ºŸâªÉ«¬∑’Ë
¡’πÈ”Àπ—°‡æ‘Ë¡¢÷Èπ À√◊Õ¡’‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥∑’˧ÿ¡
¬“°27 ·≈–ºŸâªÉ«¬∑’ˬ—ߧߡ’Õ“°“√¢Õß OSAS Õ¬Ÿà À√◊Õ
309
Õ“°“√À“¬‰ª·≈â« °≈—∫¡“‡ªìπÕ’° ´÷ßË ‡ªìπ∑’∑Ë √“∫°—π¥’«“à
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