臺灣博碩士論文加值系統

對於放置氣管內管，使用呼吸器的加護病房病人，成功的痰液清除和通氣是一項重要的任務。文獻及臨床經驗皆顯示手動式高度充氣擴肺術可以改善使用呼吸器病人的痰液清除和通氣。然而，很少實證研究支持臨床上常規使用手動式高度充氣擴肺術。本研究目的是驗證手動式高度充氣擴肺術用在急性呼吸衰竭肺擴張不全病人，痰液清除和通氣之成效。
本研究使用控制、隨機、單盲的實驗性研究設計。收案場所在北部某醫學中心的胸腔科加護病房。以隨機決定研究對象進入研究順序的方式，共有28位研究對象完成本研究，實驗組和對照組各14位。實驗組個案接受呼吸器設定型式和手動式高度充氣擴肺術，對照組個案則僅接受呼吸器設定型式。手動式高度充氣擴肺術壓力20cm H2O，每日執行三次，每次20分鐘，共2天。治療效果評值項目共有八項，包括，病患痰液濕/乾比，痰液黏稠度，潮氣容積，最大吸氣壓，動脈血氧分壓/吸入氧濃度，胸部X光影像，動態順應性和淺快呼吸指標。所有研究對象皆每天評值病患痰液濕/乾比、痰液黏稠度、潮氣容積、最大吸氣壓、動態順應性和淺快呼吸指標；每三天評值動脈血氧分壓/吸入氧濃度和胸部X光影像，研究結果如下：
一、痰液清除方面，實驗組病患在痰液黏稠度的得分改變量較對照組進步，達到統計上顯著差異，p值為0.011。兩組病患在濕/乾比的進步程度無顯著差異。
二、通氣方面，實驗組病患在淺快呼吸指標的得分改變量較對照組改善，此項改變量隨著時間遞增，達到統計上顯著差異，在第二天和第三天的p值分別為0.062和0.050。達到統計上顯著差異。兩組病患在潮氣容積、最大吸氣壓、動脈血氧分壓/吸入氧濃度、動態順應性和胸部X光影像的進步程度無顯著差異。
經由本研究顯示實施手動式高度充氣擴肺術可以改善急性呼吸衰竭病人的痰液清除和通氣。

Regarding in the intubated ICU patients receiving mechanical ventilation, successful sputum clearance and ventilation are an important task. The literature and the clinical experience all demonstrated the effect of MH on the patients receiving mechanical ventilation, it may improve sputum clearance and ventilation. However, there are few emperical studues to support its routine use in clinical practice. The purpose of this study was to examine the effectiveness of MH on sputum clearance and ventilation on Atelectasis in Patients With Acute Respiratory Failure.
A controlled, randomized, single blind, experimental design was used. Each patient was assigned a random numder upon entering the research project, which allowed randomly allocation to two groups: experimental group and control group. The sample were collected in the ICU of a Medical Center in northern Taiwan. A total of 28 patients joined the study in two groups, i.e., experimental group and control group, 14 patients in each group. Case from the experimental group received ventilation support and additional manual hyperinflation while cases from the control group were only received ventilation support. Patients in experimental group received the manual hyperinflation at a peak airway pressure of 20 cm H2O once of 20 minutes in 3 times per day for two days.
Outcome measurements were evaluated by noting changes in the patient,s score in dry/wet ratio of sputum, sputum viscosity, tidal volume, maximal respiratory pressure, PaO2/Fio2, upper chest X-ray film, dynamic lung compliance and the index of rapid shallow breathing.
Dry/wet ratio of sputum, sputum viscosity, tidal volume, maximal respiratory pressure, dynamic lung compliance and the index of rapid shallow breathing were assessed every day. PaO2/ Fio2 and upper chest X-ray film were assessed once every three days. Upon giving the conclusions are as follows:
一、For the sputum clearance, patients from the experiment group were significant improvement than those from control group in terms of sputum viscosity(p=0.011);while patients from both group were no significant difference in dry/wet ratio of sputum.
二、For the ventilation, patients from the experimental group were significant improvement than those from control group in terms of the index of rapid shallow breathing on second day and third day(p=0.062,p=0.050); while patients from both groups were no significant difference in terms of tidal volume, maximal respiratory pressure, PaO2/Fio2,dynamic lung compliance and upper chest X-ray film.
This study showed MH improved sputum clearance and ventilation in patients with acute respiratory failure.

指導教授推薦書
口試委員審定書
授權書………………………………………………………………… iii
誌謝………………………………………………………………………iv
中文摘要……………………………………………………………………v
英文摘要…………………………………………………………………vii
目錄…………………………………………………………………………x
圖表目錄…………………………………………………………………xiii
附錄目錄…………………………………………………………………xvi

第一章 緒論……………………………………………………………1
第一節 前言和重要性……………………………………………………1
第二節 研究目的…………………………………………………………5
第三節 研究假設…………………………………………………………5
第四節 名詞解釋…………………………………………………………6
第二章 文獻查證…………………………………………………………8
第一節 呼吸器介紹………………………………………………………8
第二節 呼吸器依賴肺擴張不全原理……………………………………10
第三節 手動式高度充氣擴肺術機轉……………………………………17
第四節 手動式高度充氣擴肺術相關慨念………………………………22
第五節 手動式高度充氣擴肺術和動物實驗相關研究…………………26
第六節 手動式高度充氣擴肺術和肺模型相關研究……………………28
第七節 手動式高度充氣擴肺術和臨床病人相關研究…………………35
第三章 研究方法…………………………………………………………51
第一節 研究架構…………………………………………………………51
第二節 研究設計…………………………………………………………52
第三節 研究對象和研究場所……………………………………………53
第四節 成果測量項目……………………………………………………56
第五節 研究測量工具……………………………………………………60
第六節 研究測量工具的信度……………………………………………62
第七節 手動式高度充氣擴肺術操作步驟………………………………64
第八節 前趨研究（pilot study）…………………………………65
第九節 資料收集過程……………………………………………………68
第十節 資料處理與統計分析……………………………………………71
第四章 研究結果與分析…………………………………………………73
第一節 研究對象基本資料之比較………………………………………79
第二節 各量表前測得分情形……………………………………………82
第三節 各量表所有測量得分情形………………………………………84
第五章 討論……………………………………………………………100
第一節 研究對象的招募與流失………………………………………100
第二節 人口學變項……………………………………………………101
第三節 手動式高度充氣擴肺術對痰液清除的成效…………………102
第四節 手動式高度充氣擴肺術對通氣的成效………………………105
第六章 結論與建議……………………………………………………111
第一節 結論……………………………………………………………111
第二節 護理上的應用…………………………………………………112
第三節 研究限制與建議………………………………………………115
參考文獻…………………………………………………………………118
中文部份…………………………………………………………………118
英文部份…………………………………………………………………119
附錄………………………………………………………………………128

圖表目錄
圖3-1研究架構圖………………………………………………………51
圖3-2手動式高度充氣擴肺術操作流程圖……………………………64
圖3-3資料收集流程圖…………………………………………………70
圖4-1兩組病患在各個研究時間點的人數……………………………73
圖4-2兩組病患痰液濕/乾比平均值的變化趨勢………………………86
圖4-3 兩組病患痰液黏稠度平均值的變化趨勢………………………86
圖4-4兩組病患自發性潮氣容積平均值的變化趨勢…………………89
圖4-5兩組病患最大吸氣壓平均值的變化趨勢………………………90
圖4-6兩組病患PaO2/FiO2平均值的變化趨…………………………90
圖4-7兩組病患動態順應性平均值的變化趨勢………………………90
圖4-8兩組病患淺快呼吸指標平均值的變化趨勢……………………91

表 2-1 手動式高度充氣擴肺術操作歩驟……………………………23
表3-1研究設計…………………………………………………………52
表3-2前趨研究病患基本資料…………………………………………66
表3-3前趨研究病患通氣測量結果……………………………………67
表4-1研究個案流失之原因與人數……………………………………74
表4-2實驗組完成病患與流失病患基本資料分佈情形………………75
表4-3實驗對照組完成病患與流失病患前測痰液清除和通氣比較…………………………………………………………………………76
表4-4對照組完成病患與流失病患基本資料分佈情形………………77
表4-5對照組完成病患與流失病患前測痰液清除和通氣比較………78
表4-6病患基本資料分佈情形一………………………………………80
表4-7 病患基本資料分佈情形二……………………………………81
表4-8 兩組病患前測痰液清除和通氣比較…………………………83
表4-9兩組病患痰液清除比較…………………………………………85
表4-10兩組病患通氣比較……………………………………………89
表4-11兩組病患胸部X光影像改善情形………………………………91
表4-12兩組病患收案以後呼吸器使用總天數情形…………………92
表4-13兩組病患收案以後死亡人數情形………………………………92
表4-14以GEE方法探討兩組病患組間和不同時間的痰液濕/乾比…………………………………………………………………………93
表4-15以GEE方法探討兩組病患組間和不同時間的痰液黏稠度…………………………………………………………………………94
表4-16以GEE方法探討兩組病患組間和不同時間的自發性潮氣容積…………………………………………………………………………97
表4-17 以GEE方法探討兩組病患組間和不同時間的最大吸氣壓…………………………………………………………………………98
表4-18以GEE方法探討兩組病患組間和不同時間的PaO2/FiO…98
表4-19以GEE方法探討兩組病患組間和不同時間的動態順應性............................................ 98
表4-20以GEE方法探討兩組病患組間和不同時間的淺快呼吸指標…………………………………………………………………………98
表4-21兩組病患胸部X光影像改善情形………………………………99

附錄目錄
附錄一 手動式高度充氣擴肺術和動物實驗相關研究………………128
附錄二 手動式高度充氣擴肺術和肺模型相關研究…………………130
附錄三 手動式高度充氣擴肺術和臨床病人相關研究………………134
附錄四 長庚紀念醫院人體試驗倫理委員會同意臨床試驗證明書…………………………………………………………………………141
附錄五 受試者同意書…………………………………………………142
附錄六 個案基本資料表………………………………………………144
附錄七 手動式高度充氣擴肺術痰液清除資料表……………………146

何莉櫻(2005)‧新式呼吸器通氣模式‧臨床醫學,56(4),266-275。
林孟志、蔡玉琴(2004)‧如何安全的使用機械通氣‧臺灣重症醫學,6,167-175。
吳惠東(2005)‧機械呼吸‧當代醫學,32(3),9-15。
吳清平等(2003)‧機械性呼吸的演進‧臺灣重症醫學,5,213-220。
紀崑山、程建祥(2003)‧呼吸器脫離之實證醫學與議定式呼吸器脫離‧臺灣重症醫學,5,39-46。
胡碧瑜(2001)‧呼吸器相關肺損傷‧臨床醫學,48(4),234-238。
郭佑啟(2001)‧呼吸器相關肺炎‧院內感染控制雜誌,11(6),376 -381。
鄭高珍、侯清正、蔡素貞(2005)‧呼吸器導致的肺損傷與肺保護性通氣策略‧中華民國急救加護醫學會雜誌,16(1),1-8。
蔡光超、羅仕錡(1991)．呼吸生理學．台北：藝軒。
謝春美(2001)‧使用呼吸器病人自發性呼吸參數的測量‧臨床醫學,48(4),239-243。
謝雅宜(2001)‧手動式高度充氣擴肺術對呼吸器依賴病人肺泡回復之效用‧私立長庚大學護理研究所碩士論文,未出版,桃園縣。
顧佩芬、高紀惠、郭漢彬(1995)．自發性引流對呼吸道清除成效之探討．長庚護理，6(2),1-12。
Anning, L., Paratz, J., Wong, W., &Wilson, K.(2003). Effect of manual hyperinflation on haemodynamics in an animal model. Physiotherapy Research International,8(3), 155–163.
Baxter, A.D., Allan, J., Bedard, J., Malone-Tucker, S., Slivar, S., Langill, M., Perreault, M., & Jansen, O.(2005). Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia. Canadian Journal of Anesthesia, 52(5), 535-541.
Berney, S., Denehy, L., ＆Pretto, J.(2004). Head-down tilt and manual hyperinflation enhance sputum clearance in patients who are intubated and ventilated.Australian Journal of Physiotherapy,50(1),9-14.
Bruschi, C., Crotti, P., Dacosto, E., Fanfulla, F., Daffonchio, L., & Novellini, R.(2003). Levodropropizine does not affect P0.1 and breathing pattern in healthy volunteers and patients with chronic respiratory impairment . Pulmonary Pharmacology & Therapeutics,16(4), 231-236.
Carmo, M.M., Ferreira, T., Bárbara, C., Lousada, N., & Rendas, A.B.(1999). Control of breathing, respiratory patterns and dyspnoea in patients with congestive heart failure. Pathophysiology,6(2),129-134.
Choi, J.S., & Jones, A.Y.(2005). Effects of manual hyperinflation and suctioning on respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia.Australian Journal of Physiotherapy,51(1),25-30.
Chulay, M., & Graeber, G.M.(1988). Efficacy of a hyperinflation and hyperoxygenation suctioning intervention.Heart & Lung, 17(1),15-22.
Clement, A.J., & Hubsch, S.K.(1968).Chest physiotherapy by the‘bag squeezing’ method:a guide to technique.Physiotherapy,54(10),355-359.
Denehy, L.(1999).The use of manual hyperinflation in airway clearance.European Respiratory Journal,14(4),958-965.
Dreyfuss, D., & Saumon, G. (1998). Ventilator-induced Lung Injury . Lessons from Experimental Studies. American Journal Respiratory Critical Care Medicine,157(1), 294-323.
Duggan, M., & Kavanagh, B.P.(2005). Pulmonary atelectasis:a pathogenic perioperative entity. Anesthesiology,102(4),838-854.
Glass, C., Grap, M.J., Corley, M.C., & Wallace, D.(1993).Nurses’ability to achieve hyperinflation and hyperoxygenation with a manual resuscitation bag during endotracheal suctioning. Heart & Lung,22(2),158-165.
Hila, J., Ellis, E., & Holmes, W.(2002). Feedback withdrawal and changing compliance during manual hyperinflation.Physiotherapy Research International,7(2),53-64.
Hodgson, C., Carroll, S., & Denehy, L.(1999).A survey of manual hyperinflation in Australian hospitals.Australian Journal of Physiotherapy,45(3),185-193.
Hodgson, C., Denehy, L., Ntoumenopoulos, G., Santamaria, J., &Carroll, S.(2000).An investigation of the early effects of manual lung hyperinflation in critically ill patients.Anaesth Intensive Care,28(3),255-261.
Jellema, W.T., Groeneveld, A.B.J., Goudoever, J., Wesseling, K.H., Westerhof, N., Lubbers, M.J., kesecioglu, J., & Lieshout, J.J.(2000).Hemodynamic effects of intermittent manual lung hyperinflation in patients with septic shock.Heart & Lung,29(5),356-366.
Jones, A.Y.M., Hutchinson, R.C., & Oh, T.E.(1992). Effects of bagging and percussion on total static compliance of the respiratory system.Physiotherapy,78(9),661-666.
King, D., & Morrell, A.(1992).A survey on manual hyperinflation as a physiotherapy technique in intensive care units.Physiotherapy,78(1),747-750.
Kumar, V., Abbas, A.K., &Fausto, N. (1999).Robbins and cotran pathologic basis of disease.Philadelphia:Elsevier saunders.
Lachmann, B.(1992).Open up the lung and keep the lung open.Intensive Care Medicine,18,319-321.
Marini, J. J., Pierson,D.J., & Hudson, L.D.(1979).Acute lobar atelectasis:a prospective comparison of fiberoptic bronchoscopy and respiratory therapy.American Review of Respiratory Disease,119,971-978.
Marini, J.J., & Slutsky, A.S. (1998).Physiological basis of ventilatory support.New York：Marcel Dekker.
Marini, J.J., & Slutsky, A.S. (1998).Physiological basis of ventilatory support.New York：Marcel Dekker.
Maxwell, L.,＆Ellis, E.(2002).The effects of three manual hyperinflation techniques on pattern of ventilation in a test lung model .Anaesthesia and Intensive Care,30(3),283-288.
Maxwell, L.,＆Ellis, E.(2003). The effect of circuit type, volume delivered and “rapid release”on flow rates during manual hyperinflation. Australian Journal of Physiotherapy,49(1),31-38.
Maxwell, L., ＆Ellis, E.(2004).The effect on expiratory flow rate of maintaining bag compression during manual hyperinflation.Australian Journal of Physiotherapy,50(1), 47-55.
McCarren, B., & Chow, C.M.(1996). Manual hyperinflation：a description of the technique.Australian Journal of Physiotherapy,42(3),203-208.
McCarren, B., & Chow, C.M.(1998). Description of manual hyperinflation in intubated patients with atelectasis.Physiotherapy Theory and Practice,14,199-210.
Milerad, J., & Sundell, H.W.(1999). Reduced inspiratory drive following laryngeal chemoreflex apnea during hypoxia . Respiration Physiology,116(1), 35-45.
Nunn, J.F.(2000).Nunn’s applied respiratory physiology.(5th).Oxford:Butterworth-Heinemann.
Paratz, J., & Lipman, J. (2006).Manual hyperinflation causes norepinephrine release.Heart & Lung,35(4),262-268.
Paratz, J., Lipman, J., & McAuliffe, M.(2002).Effect of manual hyperinflation on hemodynamics,gas exchange,and respiratory mechanics in ventilated patients.Journal of Intensive Care Medicine,17(6),317-323.
Patman, S., Jenkins, S., &Stiller, K.(2000).Manual hyperinflation-effects on respiratory parameters.Physiotherapy Research International,5(3),157-171.
Pinhu, L., Whitehead, T., Evans, T., & Griffiths, M.(2003).Ventilator-associated lung injury.Lancet,361,332-340.
Porth, C.M. (2005).Pathophysiology concepts of altered health states. Philadelphia:Lippincott Williams&wilkins.
Price, S.A., &Wilson, L.M. (1996).Pathophysiology clinical concepys of disease processes.Louis:Mosby.
Raoof, S., Chowdhrey, N., Raoof, S., Feuerman, M., King, A., Sriraman, R., & Khan, F.A.(1999).Effect of Combined Kinetic Therapy and Percussion Therapy on the Resolution of Atelectasis in Critically Ill Patients.Chest,115,1658-1666.
Ray, R.J., Alexander, C.M., Chen, L., Williams, J., & Marshall, B.E.(1984).Influence of the method of re-expansion of atelectatic lung upon the development of pulmonary edema in dogs.Critical Care Medicine,12(4),364-366.
Redfern, J., Ellis, E., & Holmes, W.(2001).The use of a pressure manometer enhances student physiotherapists’performance during manual hyperinflation.Australian Journal of Physiotherapy,47,121-131.
Robson, W.P.(1998).To bag or not to bag?manual hyperinflation in intensive care.Intensive and Critical Care Nursing,14,239-243.
Rothen, H.U., Sporre, B., Engberg, G., Wegenius, G., &Hedenstierna, G.(1993). Re-expansion of atelectasis during general anaesthesia：a computed tomography study. British Journal of Anaesthesia,71,788-795.
Rothen, H.U., et al.(1995).Prevention of atelectasis during general anaesthesia . Lancet, 345, 1387-1391.
Rusterholz, B., & Ellis, E. (1998). The effect of lung compliance and experience on manual hyperinflation. Australian Journal of Physiotherapy,44(1), 23-28.
Savian, C., Chan, P., & Paratz, J.(2005).The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analgesia,100(4),1112-1116.
Savian, C., Paratz, J., &Davies, A.(2006).Comparison of the effectiveness of manual and ventilator hyperinflation at different levels of positive end-expiratory pressure in artificially ventilated and intubated intensive care patients. Heart & Lung,35(5), 334-341.
Tammeling, G.J., & Quanjer, H.(1983).Contours of breathing2.Boehringer lngelheim:Western Germany.
Tween, W.A., Phua, W.T., Chong, K.Y., Lim, E., & Lee, T.L.(l993).Tidal volume,lung hyperinflation and arterial oxygenation during general anaesthesia.Anaesthesia and Intensive Care,21(6),806-810.
Stone, K.S., Vorst, E.C., Lanham, B., &Zahn, S.(1989).Effects of lung hyperinflation on mean arterial pressure and postsuctioning hypoxemia. Heart & Lung,18(4),377-385.
Vassilakopoulos, T., Roussos, C., & Zakynthinos, S.(1999).Weaning from mechanical ventilation.Journal of Critical Care,14(1), 39-62.
Vlahakis, N.E., & Hubmayr, R.D.(2005).Cellular stress failure in ventilator-injured lungs.American Journal of Respiratory and Critical Care Medicine,171(12),1328-1342.
Webb, A.R., Shapiro, M.J., Singer, M., & Suter, P.M. (1999). Oxford Textbook of Critical Care.(1st).UK: Oxford University Press.
West, J.B., &Mathieu-Costello, O.(1992). Stress Failure of Pulmonary Capillaries: Role in Lung and Heart Disease.The Lancet,340(26),762-767.