臺灣博碩士論文加值系統

目的 本研究旨在探討心臟手術前之個人化運動處方簽訓練，對病患手術後之肺部合併症、心肺運動耐力與生活品質影響。
背景 根據統計指出，心臟疾病是我國十大死因第二位，世界衛生組織亦預估在2020年前，心臟血管疾病病人將會是世界上佔第一名的死亡原因，可見心血管疾病是國內外相當普遍的慢性疾病。對於較嚴重的心臟血管疾病且對保守治療無效的患者而言，心臟手術是一種療效良好的治療選擇，可以明顯改善病患的症狀及往後的死亡率。國外研究發現手術前的個人化運動處方簽訓練能減少肺部合併症並能減少手術後之住院天數。然而國內目前卻沒有針對個人化運動處方簽介入於手術前病患的相關研究。
方法 本研究採取便利取樣，共收集北部某醫學中心即將接受心臟手術之35位病患區分為運動組15人，對照組20人進行研究。研究設計為類實驗設計，對照組接受醫院常規照護，實驗組接受手術前個人化運動處方簽訓練。研究工具包括基本資料問卷、生活品質問卷、手術後肺部合併症與心肺運動測試並以SPSS for windows 17.0 版套裝軟體進行資料處理與分析。
結果 在預防手術後肺部合併症部分顯示：兩組病患間在手術後1-7天胸部X光改變上無顯著差異，在手術移除氣管內管後，使用非侵入性呼吸器中運動組優於對照組(0人 vs. 7人；p=0.012)；手術後第一次下床時間顯示運動組優於對照組(3.26±1.57天 vs. 5.15±3.14天；p=0.041)，在控制變異數後顯示，在「使用非侵入性呼吸器」(p=0.05)與「第一次下床時間」(p=0.041)亦有顯著差異。在氣管插管時間、呼吸器使用時間、鼻胃管放置時間、加護病房停留時間、手術後住院總天數中，兩組間雖在統計學上未達顯著差異，但運動組皆略優於對照組。在心臟手術後心肺運動測試結果顯示：心臟手術前後兩組病患在心肺運動測試皆無顯著差異。所有心臟手術病患手術前最大耗氧量平均為16±5.9ml/kg/min、手術後的最大耗氧量平均為16±4.42ml/kg/min。在無氧閾值部分，所有心臟手術病患手術前無氧閾值平均落於903±296ml/kg/min、手術後無氧閾值平均落於894±285ml/kg/min，兩組手術前後無氧閾值差異顯示：運動組病患有些微提升為1.28±413.4ml/kg/min，但對照組病患卻有降低情形(-16±181ml/kg/min)。兩組研究對象於「最大運動心率」、「休息時血壓」、「最大氧脈」、「最大心率收縮乘積」部分，手術後分數皆略低於手術前；在「休息時心率」部分，兩組手術後皆較手術前高。
在心臟手術生活品質比較結果顯示：研究計畫前，所有心臟手術病患的生活品質顯示，在「生理功能角色受限」、「一般健康」、「活力」、「社會功能」、「情緒角色受限」、「心理健康」等六個次概念及「心理健康層面」得分皆低於50分以下。針對所有心臟手術後的生活品質而言，於「一般健康」(p<0.001)與「活力」(p=0.023)次概念及「生理健康層面」(p=0.008)與「心理健康層面」(p<0.001)兩層面在手術前後改變差異上有統計上的意義。兩組之間在手術前後改變差異得分中，於「一般健康」(p=0.022)與「心理健康層面」(p=0.017)中在統計學上有顯著差異，且運動組優於對照組。
結論 手術前個人化運動處方簽訓練介入結果顯示手術前的低強度的運動訓練可讓病患儘早了解手術復原運動之重要性，亦可縮短病患手術後復原時間並提升手術後生活品質，故建議國內醫療機構應從手術前即建立起可依循的規範與流程，讓心臟手術病患及早開始接受個人化運動處方簽訓練以減少手術後相關合併症的發生，亦可降低因手術後相關併發症產生之醫療成本負擔，協助患者早日恢復生活功能，進而提昇病患之生活品質。並以此研究建立本土實證性的資料，做為未來在設計、推動手術前個人化運動處方簽訓練方案時的指引及介入性研究的參考。

Purpose of study: The purpose of this study is to determine the effect of preoperative individualized exercise prescription on preventing postoperative pulmonary complications, enhancing cardiopulmonary functions and promoting life quality in undergoing cardiac surgery.
Background: According to the statistics, heart disease is the second most common cause of death in our country. The World Health Organization also to state the heart disease will occupy the first cause of death in the world before 2020. As regard to the patients with serious heart disease and those fail to response to conservative treatment. Cardiac surgery is the choice of curative treatment which may improve not only the symptom but also mortality rate. A research conducted in the Netherlands discovers that pre-operation exercise training can decrease the length of hospital stay and reduce pulmonary complications. However, limited evidences are available for our country.
Method: Thirty five pre-cardiac surgery patients were assigned to an exercise group with three to five times in two week before surgery based on the hospital individualized exercise prescription (n=15) or a control group with usual care (n=20). The aims of this study were to identify the effect of individualized exercise prescription’s exercise training on postoperative pulmonary complications, cardiopulmonary function and quality of life after cardiac surgery. Chest X-ray and cardiopulmonary exercise tests and quality of life with the SF-36 were measured at baseline, pre-cardiac surgery (pre-intervention), and and two to four weeks after intervention (follow-up).
Results: After intervention, the mean duration of first time get up and out of bed after operation are 3.26±1.57 and 5.15±3.14 days in the exercise and control group, respectively (p=0.041). After ventilator weaning, no patient uses NIPPV (non-invasive positive pressure ventilator) in the exercise group; however seven patients have history of NIPPV usage in the control group (p=0.05). There are no significant differences between two groups in Chest X-ray, duration of ventilator use, length of ICU stay, duration of antibiotic use and the rate of positive result of sputum culture. But there are shorter duration of ventilator dependence, ICU stay, hospital stay and duration of antibiotics use in the exercise group in comparison to the control group. There are no significant improvement in MVO2, AT (anaerobic threshold), peak oxygen pulse and peak rate pressure product. There is improvement of AT in the exercise group and decreased AT in the control group (1.28±413.4ml/kg/min vs. -16±181ml/kg/min). The mean values of perceived general health of the SF36 are 33±20 and 18±15 in exercise and control group, respectively (p=0.022); whereas the mean values of mental component scale of the SF36 are 17±10 and 9±8, respectively (p=0.017).
Conclusion: Pre-cardiac surgery individualized exercise prescription was beneficial to the patients after cardiac surgery on cardiopulmonary function and quality of life. It may be valuable for their well-being and disease progression and help us to develop an evidence-based pre-operative individualized exercise prescription effectively for cardiac surgery patient.

誌謝 2
論文摘要 i
ABSTRACT iii
第一章 緒論 1
第一節 研究背景和動機 1
第二節 研究目的與問題 2
第二章 文獻探討 3
第一節 心臟手術 3
第二節 手術後肺部合併症及其危險因子 5
第三節 心肺運動耐力 7
第四節 生活品質 8
第五節 個人化運動處方簽 10
第六節 個人化運動處方簽相關研究 13
一、 個人化運動處方簽與手術後肺部合併症及其危險因子 13
二、 個人化運動處方簽與心肺運動耐力 14
三、 個人化運動處方簽與生活品質 15
第七節 總結 16
第三章 研究方法 17
第一節 研究架構 17
第二節 研究假設 17
第三節 名詞界定 18
第四節 研究對象與場所 19
第五節 研究工具及方法 22
第六節 研究步驟 24
第七節 研究倫理考量 26
第八節 資料處理與分析方法 27
第四章 研究結果 29
第一節 心臟手術病患之人口學資料與疾病屬性 29
第二節 心臟手術病患之肺部合併症及其危險因子 34
第四節 心臟手術病患之生活品質 40
第五節 心臟手術病患之基本資料、疾病屬性與肺部合併症及其危險因子、心肺運動測試及生活品質之相關性 44
第五章 討論 61
第一節 個人化運動處方簽訓練對減少心臟手術後肺部合併症及其危險因子之成效 62
第二節 個人化運動處方簽訓練對心臟手術後心肺耐力改變之成效 63
第三節 個人化運動處方簽訓練對心臟手術後生活品質改變之成效 64
第四節 心臟手術病患之基本屬性與肺部合併症及其危險因子、心肺運動耐力與生活品質之間的相關性 66
第六章 結論與建議 69
第一節 結論 69
第二節 應用與建議 70
第三節 研究限制 71
參考文獻 73
中文部分 73
英文部分 75
附錄一 問卷 80
一、個人基本資料 80
二、病歷資料收集 82
三、手術後肺部合併症相關指標 84
四、心肺運動測試(CPET)追蹤紀錄表 84
五、生活品質(SF-36) 85
附錄二 研究問卷使用同意書(SF-36) 90
附錄三 研究計劃審查通知書 91
附錄四 人體試驗計劃同意書 92
附錄五 受試者同意書 93

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