運用吸氣肌肉訓練於改善慢性阻塞性肺病病人呼吸器脫離成效之實證案例

Effects of Inspiratory Muscle Training on Weaning from Mechanical Ventilation in Patient with Chronic Obstructive Pulmonary Disease: An Evidence-Based Case Report

周怡伶(Yi-Ling Chou) ； 宋怡憓(Yi-Hui Sung) ； 李彩緣(Chai-Yuan Lee)

《台灣專科護理師學刊》 7卷1期 (2020/11) Pp. 51-61

摘要

呼吸器可以延續病人生命，但隨著使用呼吸器的時間延長，對病人的身、心、社會層面將造成壓力與衝擊，尤其是慢性阻塞性肺病病人，不僅呼吸器成功脫離率較低，甚至有較高的死亡率。本文描述為慢性阻塞性肺病急性發作，導致呼吸衰竭併插管治療的53歲男性，病情經治療後逐漸改善，已進行至脫離呼吸器階段。為提升呼吸器脫離率及其照護品質，故探討吸氣肌肉訓練的介入在呼吸器脫離之成效。根據實證的五大步驟進行，以臨床問題形成PICO，其屬於治療型問題，以系統性回顧法搜尋於PubMed、Cochrane Library、Scopus、華藝線上圖書館等資料庫，選取呼吸器重症病人的相關文獻，符合篩選標準及排除重複文獻，以吸氣肌肉訓練介入之實驗性研究經系統性回顧後，再進行統合分析與整理。本系統性回顧納入5篇隨機分派之實驗性研究，共有254位加護病房使用呼吸器病人，經統合分析結果發現吸氣肌肉訓練對呼吸器重症病人能提升呼吸器脫離率，其綜合效量為1.26（95%CI[1.01,1.57]）。根據評讀結果應用，依據個案最大吸氣壓力之20至40%做為起始壓力進行訓練，並每天進行1至2次吸氣肌肉訓練計畫，每週為期5至7天，最終成功脫離呼吸器。因此，對於使用呼吸器重症病人，建議呼吸器已調降至壓力支持模式下，可進行吸氣肌肉訓練計畫，以提升呼吸器脫離率及照護品質。

關鍵字

吸氣肌肉訓練 ； 呼吸器脫離 ； 慢性阻塞性肺病

並列摘要

The ventilation could extend the patient's life, but it also has negative impacts on patient's body, mind and social health. Further, patients with chronic obstructive pulmonary disease have lower mechanical ventilation weaning rate and higher mortality rate. This case report described a 53 years-old intubating patient with respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease. The condition of the patient had improved after receiving a mechanical ventilation weaning program. For better life quality and higher weaning rate from mechanical ventilation, the purpose of this article is to explore the effects of inspiratory muscle training for intubated patients under weaning program. According to the five steps of the evidence-based practice, the therapeutic question has a format that follows the PICO concept. A systematic review was conducted and the databases including: PubMed, Cochrane Library, Scopus, and Airiti Library. Based on the inclusion and exclusion criteria, 5 articles of intervention about inspiratory muscle training addressing relevant randomized controlled trials were extracted for pooling and analysis. All studies contained a total of 254 critically ill patients that received inspiratory muscle training improved mechanical ventilation weaning rate. The meta-analysis showed that effect sizes of 1.26 (95% CI [1.01, 1.57]). According the results of the review, the patient in this case received an inspiratory muscle training program with initial training loads equivalent to 20~40% of a person's maximum inspiratory pressure, once or twice a day, five to seven days per week. The patient successfully weaned from the ventilator eventually. Therefore, critically ill patients who have been adjusted to the pressure-support mode of ventilator could received inspiratory muscle training to improve ventilator weaning rate and care quality.

並列關鍵字

inspiratory muscle training ； weaning from mechanical ventilation ； chronic obstructive pulmonary disease

參考文獻

周昆達、彭殿王（2018）．胸腔病例（三四四）2017慢性阻塞性肺病GOLD診治指引摘要．臨床醫學月刊，81（1），45－51。https://doi.org/10.6666/ClinMed.201801_81(1).0009

蕭逸函、彭殿王（2018）．慢性阻塞性肺病的發炎反應與急性發作之關係．臨床醫學月刊，81（3），128－133。https://doi.org/10.6666/ClinMed.201803_81(3).0024

Bissett, B. M., Leditschke, I. A., Neeman, T., Boots, R., & Paratz, J. (2016). Inspiratory muscle training to enhance recovery from mechanical ventilation: A randomised trial. Thorax, 71(9), 812-819. https://doi.org/10.1136/thoraxjnl-2016-208279

Cader, S. A., de Souza Vale, R. G., Zamora, V. E., Costa, C. H., & Dantas, E. H. M. (2012). Extubation process in bed-ridden elderly intensive care patients receiving inspiratory muscle training: a randomized clinical trial. Clinical Interventions in Aging, 7, 437-443. https://doi.org/10.2147/CIA.S36937

Caruso, P., Denari, S. D., Ruiz, S. A., Bernal, K. G., Manfrin, G. M., Friedrich, C., & Deheinzelin, D. (2005). Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients. Clinics (Sao Paulo, Brazil), 60(6), 479-484. https://doi.org/10.1590/S1807-59322005000600009