| 摘要: | 長期呼吸器使用之病患常因活動量減少與肌力減退，增加呼吸器脫離之困難度，造成病患及家屬心理壓力與增加醫護人員的照護負荷。透過肺部復健運動可提升肌肉耐受力，改善活動能力並提高呼吸器成功脫離率。本研究之主要研究目的在於探討呼吸器依賴病患執行肺部復健運動後，四肢肌力及握力的之改善成效，並探討病人屬性與肺部復健運動成效是否為呼吸器成功脫離之相關影響因素。
本研究採用回溯性病歷記錄研究分析，回顧2015至2016年於亞急性呼吸照護病房，呼吸器依賴之整合性照護個案共151位。病患入住單位後，安排適當肺部復健運動，在每天二次1小時的會客時間執行肺部復健運動30分鐘，並於轉入後、每七天及轉出前測試病患四肢肌力與握力，以評估復健運動後成效。肺部復健後的成效評估工具包含肌肉測試量表及手握式測力計（JAMA）。資料收集後，以成對t檢定檢測肺部復健運動前後之四肢肌力與握力差異，以獨立t檢定與卡方檢定比較病患性別、年齡、意識狀態、疾病嚴重度、疾病歸屬、住院天數、肺部復健運動成效在呼吸器脫離成功與呼吸器脫離失敗二組間的差異，並以二元邏輯斯迴歸模式分析呼吸器脫離成功的預測因子。
研究結果顯示呼吸器依賴病患經執行肺部復健運動後，其上肢肌力( p = 0.000 )、下肢肌力( p = 0.000 )及握力( p = 0.000 )均有顯著改善；且呼吸器依賴病患的昏迷指數( p = 0.005)、疾病嚴重度( p = 0.003)、運動前後上肢肌力差距分數( p = 0.000)、運動前後下肢肌力差距分數( p = 0.000)及運動前後握力差距分數( p = 0.016)，在呼吸器脫離成功與呼吸器脫離失敗二組間有顯著差異。進一步以邏輯斯廻歸分析，結果顯示病患的昏迷指數之呼吸器脫離成功勝算比為1.212( p = 0.017)、運動前後下肢肌力差距分數之呼吸器脫離成功勝算比為3.547( p = 0.001)及運動前後握力差距分數之呼吸器脫離成功勝算比為1.327( p = 0.035)，模式解釋力為26.8%，顯示昏迷指數、下肢運動成效與握力運動成效為預測呼吸器脫離是否成功之顯著預測影響因子。
本研究證實呼吸器依賴病患實施肺部復健運動後，能改善四肢肌力及握力，且昏迷指數、下肢肌力和握力的增加可以顯著影響呼吸器成功脫離。早期復健運動訓練對臥床病患有實質幫助，建議加護病房呼吸器依賴病患在急症緩解後，應及早給予肺部復健運動改善四肢肌肉耐力，以能及早成功脫離呼吸器。臨床上，肺部復健運動的執行仍需靠團隊的努力、病患及家屬的堅持，才能達到政策、醫療、病患三贏局面。
The difficulty of weaning from the ventilator for ventilator-dependent patients who suffer from reduced activity and lower muscle strength increases psychological stress of patients and their families. It also increases burdens of medical care professionals. Pulmonary rehabilitation can improve muscle tolerance and physical activity ability to increase the rate of successful ventilator weaning. Therefore, the purpose of this study is to investigate the effectiveness of the muscle strength and grip strength after pulmonary rehabilitation and explore affecting factors of the ventilator weaning successfully.
Data was collected from retrospective medical records and analyzed. We reviewed 151 cases of ventilator-dependent patients in a subacute respiratory care ward at a medical center from January, 2015 to December, 2016. A proper pulmonary rehabilitation was arranged for patients admitted to the ward. The pulmonary rehabilitation was performed for 30 minutes twice daily during the visiting time. The muscle strength and grip strength were evaluated at the time of admission, before the transfer, and once per week to investigate the effectiveness of the pulmonary rehabilitation. Measure tools include a muscle test scale and the hydraulic handgrip dynamometer (JAMAR). The effectiveness of muscle strength and grip strength after the pulmonary rehabilitation were analyzed by the paired t test. Differences among gender, age, consciousness, disease severity, diagnosis, length of hospital stay were analyzed by independent t test and chi square test. Logistic regression was used to predict factors of successful weaning from the ventilator.
Results of this study showed that the ventilator-dependent patients had significant improvement in upper limb strength (p = 0.000), lower limb strength (p = 0.000), and grip strength (p = 0.000) after performing pulmonary rehabilitation exercises. Significant differences of the coma index score (p = 0.005), the disease severity (p = 0.003), the gap score of upper muscle strength (p = 0.000), the gap score of lower limb muscle strength (p = 0.000) and the gap score of grip strength ( p = 0.016) were found between successful ventilator weaning patients and failed ventilator weaning patients. Results of logistic regression showed that the coma index (p = 0.017), the gap score of lower limb muscle strength (p = 0.001) and the gap score of grip strength (p = 0.035) were significant predictive factors of successful ventilator weaning.
This study confirms that pulmonary rehabilitation can significantly improve the muscle strength of the limbs and the grip strength. We suggest that ventilator-dependent patients should implement pulmonary rehabteamilitation earlier. Clinically, the practice of pulmonary rehabilitation still depends on all efforts of the professional teamwork. Patients and their families should cooperate with the healthcare team to achieve a win situation for policy, medical care and health. |
