臺灣博碩士論文加值系統

本研究目的在探討慢性呼吸衰竭的病人，接受漸進式和計畫性的呼吸肌力訓練之後，是否能夠改善其預後，以利於成功脫離呼吸器。
此研究設計為前瞻性研究，收集2019年04月至2020年11月期間，因呼吸衰竭呼吸器依賴並入住南部某地區教學醫院呼吸照護病房病人。依據病人及家屬意願，將病人分為接受腹部加壓介入組與觀察組，且在病人及家屬同意之後，經由復健科醫師評估及安排介入腹部加壓訓練。維持3個月的每日復健計畫，包括上肢運動、吐氣誘發訓練及沙袋腹部加壓，每次沙袋加壓訓練半小時，並將沙袋放置於上腹部。訓練期間調整呼吸器設定選擇最適當的壓力輔助程度（pressure support level），以維持潮氣量在每公斤理想體重8毫升的最小壓力支持程度。
總共收集31位病人，接受腹部加壓訓練有17人（54.8%），對照組有14人（45.2%）。比較兩組復健前之臨床特性，介入組之潮氣容積量低於觀察組（214.7±80.57ml vs 302.9±112.98ml; p=0.017）；而兩組預後比較，介入組呼吸器支持壓力參數進步幅度較大，（3.8±1.8cmH2O vs. 1.7±1.1cmH2O; p<0.001），且介入組之潮氣容積有顯著增加（48.89±83.41ml vs. -65.75±145.23ml; p=0.012）、呼吸淺快指數則有下降趨勢（-36.02±77.57breath/min/L vs. 34.33±64.12breath/min/L; p=0.016）；在最大吸氣壓力和最大吐氣壓力，介入組均有明顯增加
（10.45±12.12cmH2O vs. -8.53±10.19cmH2O;p<0.001及6.25±17.34cmH2O vs. -6.22±13.50cmH2O; p=0.046）。介入組之橫膈膜動度及厚度數值大於觀察組(11.99±6.41mm vs. 5.80±5.07mm; p=0.048及 及2.23±0.41mm vs. 1.92±0.19mm; p=0.041)；而呼吸器脫離狀況分析，介入組呼吸器脫離人數佔9人(52.9%)，而觀察組只有1人(7.1%)脫離成功(p=0.008)。
長期呼吸器依賴的病人，給予適當之腹部加壓訓練，可以降低其使用的呼吸器壓力值、增加呼氣肌及吸氣肌的功能，進而提高潮氣容積、降低呼吸速率和呼吸淺快指數，有利於病人呼吸器的脫離，且亦發現橫隔膜厚度、動度和呼吸器脫離率亦會有所改善，所以本研究假設長期呼吸器依賴病人介入腹部沙袋加壓訓練運動與傳統呼吸器脫離方式相比較，是可以提升病人呼吸肌力，進而改善橫膈膜厚度及動度，並提升呼吸器脫離率。

The main aim of the present study is designed to explore the effectiveness of progressive and planned respiratory muscle training on these patients with chronic respiratory failure for successful withdrawal
from the ventilator.
This study is a prospective study from April 2019 to November 2020, we invited the patients intubated ventilator due to respiratory failure in the respiratory care ward of this hospital. After the agreement of patients and/or their families, patients were divided into two groups: one received abdominal compression and another control for observation only. Then, they were evaluated by the thoracic surgeon. The study group received a 3-month daily pulmonary rehabilitation program including upper limbs’ range of motion, chest mobility, and mainly 30 minutes progressive sand-bag on the upper abdomen for diaphragmatic resistant exercise with adjusted best pressure support level of respirator to maintain 8 ml/Kg
tidal volume.
Total 31 patients were involved, 17 (54.8%) received abdominal compression training, and 14 (45.2%) in the control group. Regarding the baseline value of tidal volume, the tidal volume in training group was statistically lower than the control (214.7±80.57ml vs 302.9±112.98ml; p=0.017). Comparing the prognosis of two groups, the training group's ventilator support pressure parameters were improved greatly (3.8±1.8cmH2O vs. 1.7±1.1cmH2O; p<0.001). The tidal volume of training group was markedly increased (48.89 ±83.41ml vs. -65.75±145.23ml; p=0.012). The shallow breathing index declined
(-36.02±77.57breath/min/L vs.34.33±64.12breath/min/L; p=0.016), and the maximum inspiratory pressure and the maximum exhalation pressure were both markedly increased in the training group (10.45±12.12cmH2O vs. -8.53±10.19cmH2O; p<0.001) and (6.25±17.34 cmH2Ovs.
-6.22±13.50cmH2O; p=0.046). The diaphragm mobility value in the training group was greater than that in the control (11.99±6.41mm vs. 5.80±5.07mm; p=0.048) . Similar results were observed in the diaphragm thickness between two groups (2.23±0.41mm vs. 1.92±0.19mm; p=0.041) . A total of 10 patients successfully detached from the ventilator. Among them, 9 patients (52.9%) in the training group were detached from the respirator, while only 1 patient (7.1%) in control group was
successfully detached (p=0.008).
Collectively, abdominal compression training is useful to patients who are dependent on ventilator, due to the reduction in ventilator pressure, increase in the function of expiratory muscles and inspiratory muscles, thereby increasing tidal volume, reducing respiratory rate and shallow breathing index, which is beneficial for the detachment of the patient’s ventilator. The present study also found that the diaphragm thickness, mobility, and ventilator detachment rate were improved by the abdominal sandbag compression training. Therefore, the current study suggested that the abdominal sandbag compression training is benefited to patients with chronic respiratory failure for successful withdrawal from
the ventilator.

目錄
誌謝 I
英文縮寫 II
中文摘要 III
英文摘要 V
壹、 導論 1
一、 呼吸生理學 1
二、 呼吸衰竭定義與發生原因 2
三、 長期呼吸器依賴現況及探討 4
四、 肺部復原之原理與運用 6
五、 健保財政負擔 8
六、 如何突破現況 9
貳、 研究構想 10
一、背景 10
二、目的 11
三、 本研究假設 11
四、 重要性 11
參、 研究材料與方法 12
一、 研究設計及研究對象 12
二、 研究工具 13
三、 統計分析： 19
肆、 研究結果 20
伍、 討論 28
陸、 結論 35
柒、 參考文獻 36
捌、 表 45
表一：病人特性分析(一) 45
表三：呼吸型態之成效分析(每分鐘換氣量) 47
表四：呼吸型態之成效分析(呼吸次數)： 48
表五：呼吸型態之成效分析(潮氣容積值) 49
表六：呼吸肌力強度之成效分析(快淺呼吸指數) 50
表七：呼吸肌力強度之成效分析(最大吸氣壓力) 51
表八：呼吸肌力強度之成效分析(最大吐氣壓力) 52
表九：橫膈膜動度及厚度改善成效 53
表十：呼吸器支持壓力及呼吸器脫離成效分析 54
玖、 圖 55
圖一：收案族群分布圖 55
圖二：組別與時間在快淺呼吸指數之成效 56
圖三：組別與時間在快淺呼吸指數與BASELINE差值之成效 57
圖四：組別與時間在最大吸氣壓力值改善成效 58
圖五：組別與時間在最大吸氣壓力值與BASELINE差值改善成效 59
圖六：組別與時間在最大吐氣壓力值之成效 60
圖七：組別與時間在最大吐氣壓力值與BASELINE差值改善成效 61
圖八：組別與時間在復健前後橫膈膜動度改善成效 62
圖九：組別與時間在復健前後橫膈膜厚度改善成效 63
圖十：組別在復健前後之橫膈膜動度及厚度改善差值成效 64
壹拾、 附錄 65
附錄一：人體試驗委員會臨床試驗/研究核准函(新案)，IRB編號：10801-J01 65
附錄二、呼吸照護病房病人之呼吸復健訓練計畫作業流程 66

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