探討高齡肺炎住院病人的人口學特性、疾病嚴重度及胸腔物理治療施行療效：病歷回溯分析

台灣衛福部公布肺炎是國人第三大死因，國內高齡者最常見為社區性肺炎，高齡肺炎住院病人是醫療耗用最大族群，相對增加家屬心理與經濟上負荷。老化、失能、長期臥床及慢性疾病導致高齡肺炎病人痰液堆積無法自咳，除用抗生素治療肺炎外，臨床上最常使用胸腔物理治療改善肺功能，但高齡病人對徒手背部叩擊排斥，造成照顧者困擾及執行此措施之困難度。為提升高齡病人對胸腔物理治療的執行度，近年來臨床導入電動震顫拍痰器，但未有研究檢視電動震顫拍痰器使用的效益，故本研究以探討高齡肺炎住院病人的人口學特性、肺炎嚴重度、危險因子指標及胸腔物理治療施行成效為目的。本研究採病歷回溯分析，探討2014至2019年南部某醫學中心高齡肺炎住院病人使用胸腔物理治療醫療的情況。資料收集表內容包括：基本人口學、疾病型態、肺炎嚴重度及危險因子、胸腔物理治療以及醫療成效指標(住院天數、發燒天數、抗生素治療天數和再住院天數)。自高醫體系雲端e病歷資料庫與紙本病歷收集符合納入條件者作資料分析，共收案100人。推論統計採皮爾森積差相關、獨立樣本t檢定、配對 t檢定及卡方檢定。研究結果顯示(1)性別(r = -.20, p = .05)、BMI (r = -.21, p = .04)與入院時肺炎嚴重度達統計上顯著相關，男性(t = 1.99, p = .05)及體重過輕者(t = 2.84, p = .01)肺炎較為嚴重；(2)不論是在入院時或出院前，不同胸腔物理治療的兩組病人之肺炎嚴重度並無顯著組間差異，但在入院時與出院前，各組內肺炎嚴重度是有顯著差異(徒手叩擊組t = 5.05, p < .001；震顫加入組t = 4.03, p < .001)，即不同的胸腔物理治療皆能改善病人肺功能。(3)入院時病人為輕度或中重度肺炎嚴重度，在住院天數(t = -2.57, p = .01)和抗生素使用天數(t = -2.43, p = .02)達統計上顯著差異，但胸腔物理治療組別與醫療成效指標無顯著相關。本研究結果顯示無論是徒手叩擊或是震顫加入的胸腔物理治療都能改善病人肺炎嚴重度，為減少照顧者執行胸腔物理治療的困難度，建議經濟尚可負擔之家屬購置電動震顫拍痰器。本回溯性研究缺乏使用噴霧治療與執行胸腔物理治療的正確性等干擾因子(Confounding factors)的資料，未來在臨床上推廣電動震顫拍痰器需進一步設計實證研究。

關鍵字

高齡肺炎；胸腔物理治療；電動震顫拍痰器；病歷回溯

並列摘要

Pneumonia is the third leading cause of death in Taiwan. Community pneumonia is the most popular in elder population. Elderly inpatients with pneumonia had the highest healthcare expenditure relative to have huge economic and psychological dimension on family members. The elderly patients could not cough out sputum by themselves due to aging, disability, bedridden and chronic diseases. Except using antibiotics to treat pneumonis, chest physiotherapy is the most common clinical application to improve lung function. Elderly patients refused chest percussion to increase the difficulty of chest physiotherapy. In order to complete the chest physiotherapy, vibracare percussor is introduced to bed side in the last fewer years. However, there is no study to examine the effectness of vibracare percussor. The study aims were to explore demographic, pneumonia severity index, risk factors, chest physiotherapy, and indicator of therapeutic effect. This retrospective study used chart review to explore the medical condition of chest physiotherapy in elderly patients with pneumonia in a medical center in South of Taiwan from 2014 to 2019. Data collection included demographic, diseases, pneumonia severity index and risk factors, chest physiotherapy, and indicators of therapeutic effect (length of hospital stay, days of fever, days of antibiotic treatment and rehospitalization). One hundred patients were recruited from Webmail desktop cloud (VMware Horizon) and paper medical records in Kaohsiung Medical University Chung-Ho Memorial Hospital medical system. Pearson correlation, independent t test, paired-t test and chi-squared test were applied by statistical analysis. The results showed(1)that gender (r =-.20, p =.05), and BMI (r =-.21, p=.04) with pneumonia severity index at admissionhad a significant difference.Male (t =1.99, p =.05) and underweight (t =2.84, p =.01) patients tend to be more severity in illness.(2)There was no significant difference in admission and discharge of pneumonia severity index between groups of chest physiotherapy, but had a significant difference between admission and discharge of pneumonia severity index in each group of chest physiotherapy individually (traditional percussion group t=5.05, p <.001；vibracare percussor group t=4.03, p <.001). It was shown that lung function had improved by two groups of chest physiotherapy .(3)There were significant difference in length of hospital stay (t =-2.57, p =.01) and days of antibiotic (t =-2.43, p =.02) therapy between mild and severe level of pneumonia severity index at admission. But there was no significant difference in length of hospital stay and days of antibiotic therapy between two groups of chest physiotherapy. The results stated no matter how to do, the chest physiotherapy can improve the severity of pneumonia in patients effectively. To reduce the performing difficulty of chest physiotherapy, caregiver could buy vibracare percussor. Limitation in this retrospective study was no data of confounding factors such as the application of spray treatment and the exactly performing condition of chest physiotherapy.The effectness of vibracare percussor will need further experimental study.