慢性阻塞性肺部疾病患者之橫膈肌與胸鎖乳突肌在執行吸氣肌負荷測試之肌電活化模式

Activation Patterns of Diaphragm and Sternocleidomastoid Muscle during Threshold Loaded Breathing in Patients with Chronic Obstructive Pulmonary Disease

李建慈(Chien-Tzu Lee)

指導教授 ： 王儷穎

國立臺灣大學/醫學院/物理治療學研究所/碩士(2019年)

https://doi.org/10.6342/NTU201903175

摘要

背景與目的：慢性阻塞性肺部疾病（chronic obstructive pulmonary disease, COPD）的患者常出現呼吸肌無力的現象，而針對此問題，臨床上會介入吸氣肌訓練（inspiratory muscle training, IMT）來改善。過去研究觀察健康成年人在執行吸氣肌訓練時，會使用呼吸輔助肌群（accessory inspiratory muscles），但此現象是否也會發生在慢性阻塞性肺部疾病患者執行吸氣肌訓練時，則尚未有相關研究。因此，本研究目的在探討慢性阻塞性肺疾病患者，在執行30%與50%最大吸氣壓強度之吸氣肌負荷測試時，橫膈肌（diaphragm）與胸鎖乳突肌（sternocleidomastoid, SCM）之肌電活化模式。研究方法：本研究為橫斷面試研究（cross-sectional study），受試者為經胸腔內科確診為慢性阻塞性肺疾病且最大吸氣壓小於60公分水柱。吸氣肌負荷測試以30%及50%最大吸氣壓進行，測試時同步以表面肌電圖分析橫膈肌與胸鎖乳突肌之肌電活化程度及其中位頻率變化。統計以群組化軌跡模式（group-based trajectory modeling, GBTM）將橫膈肌在平緩呼吸與吸氣肌負荷測試的活化度模式分析，再以廣義估計方程式（generalized estimating equation, GEE）檢定在組內與組間相關參數的差異。以多元迴歸（multiple regression analysis）分析與橫膈肌及胸鎖乳突肌負荷測試時肌電活化程度的相關因子。顯著統計意義有效水平標準p值訂為0.05。研究結果：一共30位慢性阻塞性肺疾病合併吸氣肌無力（最大吸氣壓：46.7±13.3公分水柱）患者參與本研究。與平靜吸氣時相比，所有受試者在執行30%與50%最大吸氣壓強度之吸氣肌負荷測試時，橫膈肌與胸鎖乳突肌之肌電活性皆顯著上升（所有p < 0.001），而中位頻率皆顯著下降（所有p < 0.05）。群組化軌跡模式分析顯示橫膈肌在不同吸氣肌負荷測試時呈現低與高兩種不同的活化度模式（低橫膈肌活化組：8位；高橫膈肌活化組：22位）。與高活化組相比，低活化組的橫膈肌在平靜吸氣與執行吸氣肌負荷測試時，肌電活性與中位頻率顯著較低（所有p < 0.05）。多元迴歸分析結果顯示，流速容積比的z分數（z-score of forced expiratory volume in one second to forced vital capacity ratio, FEV1/FVC z-score）、平靜吸氣時的橫膈肌活化程度與中位頻率，與橫膈肌執行吸氣肌負荷測試時的活化度有關；而慢性阻塞性肺疾病嚴重程度（z-score of forced expiratory volume in one second, FEV1 z-score），則與胸鎖乳突肌在執行吸氣肌負荷測試時的活化度有關。結論：吸氣肌無力的慢性阻塞性肺部疾病患者，在執行吸氣肌負荷測試時，橫膈肌與胸鎖乳突肌的肌電活化程度皆會大幅增加，且在執行吸氣肌負荷測試後皆呈現疲勞。在執行吸氣肌負荷測試時，橫膈肌的活化度會取決於其休息時的狀態。臨床上針對吸氣肌無力之慢性阻塞性肺部疾病患者介入吸氣肌訓練時，找到一個不會造成吸氣肌傷害的訓練策略是重要的。

關鍵字

慢性阻塞性肺部疾病 ； 吸氣肌負荷測試 ； 橫膈肌表面肌電圖 ； 胸鎖乳突肌表面肌電圖 ； 群組化軌跡模式

並列摘要

Background and purpose: Inspiratory muscle weakness has been shown in patients with chronic obstructive pulmonary disease (COPD), and inspiratory muscle training (IMT) is commonly applied to these patients. In healthy adults, the accessory inspiratory muscles would be recruited during IMT along with the primary inspiratory muscle. In patients with COPD, the activation patterns of diaphragm and accessory inspiratory muscles during threshold loaded breathing has not been investigated. Therefore, the purpose of this study was to exam diaphragm and sternocleidomastoid (SCM) activation using surface electromyography (EMG) during threshold loaded breathing with intensity of 30% and 50% maximal inspiratory pressure (PImax). Methods: This was a cross-sectional study. Patients with COPD diagnosis and a PImax lower than 60 cmH2O were recruited for the study. Surface EMG was used to measure the activation and the median frequency of diaphragm and SCM during quiet breathing, 30% and 50% PImax of threshold loaded breathing, and the first five minutes of recovery. Group-based trajectory modeling (GBTM) was used to identify diaphragm activation pattern across different breathing conditions. Generalized estimating equation (GEE) was then used to detect within and between differences of parameters among trajectory groups. Multiple regression analysis was used to identify factors associated with diaphragm and SCM activation. Significance p value was set at 0.05. Results: A total of 30 patients (25 males, 5 females) with COPD and a mean PImax of 46.7 (±13.3) cmH2O participated in this study. All patients demonstrated significant increases in diaphragm and SCM activation during 30% and 50% PImax of threshold loaded breathing compared to those of during quiet breathing (all p < 0.001), and the median frequency of diaphragm and SCM significantly decreased after both intensities of threshold loaded breathing (all p < 0.05). GBTM analysis identified two distinct patterns of diaphragm activation in response to threshold loaded breathing: low activation (n= 8) and high activation group (n= 22). Compared to high activation group, diaphragm activation and median frequency during quiet breathing and threshold loaded breathing were significantly lower in the low activation group (p < 0.05). Multiple regression analysis showed that the z-score of forced expiratory volume in one second to forced vital capacity ratio (FEV1/FVC z-score), diaphragm activation and median frequency during quiet breathing were associated with diaphragm activation during threshold loaded breathing, and only disease severity (z-score of forced expiratory volume in one second, FEV1 z-score) was associated with SCM activation during threshold loaded breathing. Conclusions: Diaphragm and SCM were activated to a greater extent in response to threshold loaded breathing in patients with COPD who had inspiratory muscle weakness. Diaphragm and SCM were fatigued after threshold loaded breathing. Furthermore, level of inspiratory muscle activation in response to threshold loaded breathing depended on their resting status. It is of clinical importance to find an optimal training strategy that would provide more benefit than harm when offering IMT for patients with COPD who have inspiratory muscle weakness.

並列關鍵字

Chronic obstructive pulmonary disease ； Threshold loaded breathing ； Surface electromyography of diaphragm ； Surface electromyography of sternocleidomastoid muscle ； Group-based trajectory modeling

參考文獻

1. Adeloye D, Chua S, Lee C, et al. Global and regional estimates of COPD prevalence: Systematic review and meta-analysis. J Glob Health. 2015;5(2):020415.

2. World Health Organization. Global status report on noncommunicable diseases. WHO, 2014

3. Global Initiative for Chronic Obstructive Lung Disease [homepage on the Internet]. Global Strategy for the Diagnosis, Management and Prevention of COPD (2019 Report); 2019. Available from: http://www.goldcopd.org. Accessed June 23, 2019

4. Cheng SL, Chan MC, Wang CC, et al. COPD in Taiwan: a National Epidemiology Survey. Int J Chron Obstruct Pulmon Dis. 2015;10:2459-2467.

5. Hwang SL LY, Guo SE, Chi MH, Chou CT, Lin CM. Prevalence of Chronic Obstructive Pulmonary Disease in Southwestern Taiwan: A Population-Based Study. Int J Respir Pulm Med. 2016;3(2).