- 學位論文
胸腔手術後患者介入肺部復原及合併非侵襲呼吸器之成效分析:回溯性研究
Analysis of the clinical effects of pulmonary rehabilitation combined withnon-invasive positive pressure ventilation inpatients after chestsurgery:Retrospective study
摘要
背景與目的: 肺復原運動是多元化的治療方法，包含促進痰液清除、肺部擴張與提高整體肌肉耐力和肌力等治療。已證實可減少疾病的症狀、幫助管理焦慮與提高生活品質。臨床上肺復原運動已運用在外科術後病人，但仍有病患術後因疼痛不敢深呼吸、咳痰，導致痰液滯留及肺擴張不全而變成肺炎，進而延遲胸管拔除，增加住院天數。近幾年來臨床單位開始搭配非侵襲正壓呼吸器(Non-Invasive Positive Pressure Ventilation；NIPPV) 於胸腔手術患者，以促進術後肺部的恢復，期待能盡早拔除胸管，減少住院天數。 研究方法: 本研究為回溯性研究，回溯2015-2017年間進行胸腔手術的病人，利用胸腔外科疾病診斷碼來搜尋高雄醫學大學附設中和紀念醫院電子病歷，收集(1)接受肺部復原(PR)組（2015年1月-2016年7月）。(2)接受肺部復原運動合併使用非侵襲性正壓呼吸器(PR+NIPPV)組（2016年9月-2017年4月）。 結果: 誘發性肺量計(Triflo)的執行，兩組在出院前一天吸球量都約達到900-1200ml，兩組並無顯著差異(P=.86)，在支氣管鏡清除痰液的檢查，PR組開刀後有七個使用支氣管鏡清痰，NIPPV+PR組只有一個使用支氣管鏡清痰，統計分析有顯著差異(P=.03)，在胸外疾病(包含肺部和食道)胸管留置天數，PR組6.64±4.46天，NIPPV+PR組5.74±2.75天，無統計學上的差異(P=.11)。出院後半年內肺塌陷、肺炎而再住院的次數，PR組0.03±0.18，NIPPV+PR組0.02±0.15，兩組統計分析也無統計差異(P=.71)，代表兩組方法對手術後相關疾病的療效也都很好。但只針對肺部疾病(排除食道方面)，NIPPV+PR組比PR組，縮短胸管留置天數1天，NIPPV+PR組平均5.43±2.30天，PR組平均6.62±4.58天，且有達到顯著差異(P=.03)。最後本研究也統計分析住院的天數，NIPPV+PR組平均8.60±4.58天，PR組10.11±6.32天，兩組經分析也是無統計學上的差異(P=.07)。但針對肺部疾病(同樣排除食道方面)，再一次統計分析卻發現，NIPPV+PR組比PR組住院天數更縮短2天，NIPPV+PR組平均7.75±3.36天，PR組平均9.86±6.48天，且明顯有達到顯著差異(P=.01)。 結論: 之前研究證明肺部復原運動針對手術後病人是有很大的幫助，但是此研究發現非侵襲性呼吸器(NIPPV)搭配肺復原(PR)，減少了肺部手術後病人胸管的天數1天，可以縮短肺部手術病人住院天數2天，減少使用支氣管鏡清痰的比例，建議未來研究仍可繼續收案，以提高樣本數增加研究的可信度，而且可以增加問卷調查，讓病人填寫執行非侵襲性呼吸器(NIPPV)後疼痛的分數，以及舒適度，這樣更能客觀的表達出病人的感覺。 總結，臨床除了繼續執行肺部復原運動，更建議手術後應該早期配合介入非侵襲性呼吸器(NIPPV)來幫助的病人，不只是胸腔外科，更可以推廣至其他外科手術的病人。
並列摘要
Background and Purpose: Pulmonary rehabilitation is a comprehensive intervention that helps with sputum clearance, promotes lung expansion, and improves muscular endurance and muscular strength, and it proves effective in relieving symptoms, manage anxiety, and improving quality of life. Despite the fact that pulmonary rehabilitation has been clinically applied to patients after surgery, postoperative pain can prevent deep breathing and coughing and result in sputum retention and atelectasis, thereby causing pneumonia, delaying the removal of the chest tube, and prolonging hospitalization. In recent years, clinical medical practitioners have actively used non-invasive positive pressure ventilation (NIPPV) on patients undergoing thoracic surgery with the aim of speeding postoperative recovery of lung function, reducing the number of days a chest tube is inserted, and shortening the length of stay in hospital. Research Methods: This study is a retrospective study looking into the medical records of patients who underwent thoracic surgery at the Kaohsiung Medical University Chung-Ho Memorial Hospital in 2015-2017. The International Classification of Diseases was adopted to collect the electronic medical records of (1) patients receiving pulmonary rehabilitation (the PR group) (January 2015-July 2016) and (2) patients receiving both pulmonary rehabilitation and non-invasive positive pressure ventilation (the PR+NIPPV group) (September 2016-April 2017). Results: V When using an incentive spirometer (Triflo), both groups reached a flow rate of 900-1,200ml one day before discharge, showing no significant difference (P=.86). A statistically significant difference was observed in the number of patients experiencing sputum clearance by bronchoscopy: seven in the PR group and one in the PR+NIPPV group (P=.03). As for the number of days a chest tube was inserted due to thoracic diseases (including those related to the lungs and esophagus), there was no statistical difference between the two groups (P=.11): 6.64±4.46 days for the PR group and 5.74±2.75 days for the PR+NIPPV group. In addition, the comparison of the number of readmission occurrences within six months of discharge due to lung collapse or pneumonia between the two groups also showed no statistical difference (0.03±0.18 for the PR group and 0.02±0.15 for the PR+NIPPV group; P=.71), indicating that both PR and PR+NIPPV had beneficial effects on postoperative complications. When the data analysis focused only on pulmonary diseases (excluding esophagus-related diseases), the average number of days a chest tube was inserted was 5.43±2.30 for the PR+NIPPV group, one day less than that of the PR group (6.62±4.58 days), and there was a significant difference between the two groups (P=.03). This study also made a statistical analysis of the number of days of hospitalization, finding no statistical different between the PR group (10.11±6.32 days on average) and the PR+NIPPV group (8.60±4.58 days on average) (P=.07). When esophagus-related diseases were excluded from the analysis of the number of days of hospital stay (i.e. focusing only on pulmonary diseases), a statistically significant difference was observed in the VI PR+NIPPV group (7.75±3.36 days on average), two days less than that of the PR group (9.86±6.48 days on average) (P=.01). Conclusion: Previous studies showed that pulmonary rehabilitation provides significant benefits to patients after surgery. This study further found that the combination of pulmonary rehabilitation and non-invasive positive pressure ventilation did help (1) reduce the number of days a chest tube was inserted after pulmonary surgery by one, (2) shorten the hospital days of patients undergoing pulmonary surgery by two, and (3) decrease the use of bronchoscopy to remove sputum. Future research can collect more cases to enhance its credibility by increasing the sample size. Requesting patients to complete a survey questionnaire is another potential tool for an objective assessment of their pain intensity and comfort level after non-invasive positive pressure ventilation. Our research findings suggest that, in addition to pulmonary rehabilitation, non-invasive positive pressure ventilation is highly recommended to patients undergoing all kinds of surgery to aid their recovery.