慢性阻塞性肺病病人呼吸再訓練指導之成效

The efficacy of respiratory retraining instruction in patients with chronic obstructive pulmonary disease

詹惠雅(Hui-Ya Chan)

指導教授 ： 戴玉慈

國立臺灣大學/醫學院/護理學研究所/博士(2017年)

https://doi.org/10.6342/NTU201700314

摘要

研究目的：本研究旨在探討互動性呼吸再訓練對COPD病人執行呼吸法的學習成效與影響成效之相關因素，期盼研究結果能提供經驗證且符合國內COPD病人學習屬性的呼吸再訓練指導方法。
研究背景：COPD是日漸增加的慢性病，常因伴隨其他病症或急性症狀加重而反覆至急診，甚至需要住院診療。國內外針對COPD病人照護提出許多自我管理相關措施之研究，但鮮少以增進學習動機為主及考量認知功能對COPD指導效果的影響。在住院日數不斷縮減，提供衛教指導的時間也將被限縮的態勢下，臨床護理師除了口頭指導外，也採取書面與影音等多媒體資料幫助病人了解健康照護資訊，隨著科技的進步，不同指導方案持續推陳佈新，然而指導方案對COPD病人造成的學習效果如何，將是值得持續關注的議題。
研究設計：本研究計畫採隨機分配兩組，採前後及追蹤測量之研究設計，實驗組為使用平板電腦提供教練式電腦遊戲的指導，運用激發動機、問答互動遊戲及影片回覆示教等方式，執行系統性指導，控制組則是採用傳統示教指導：以傳統面對面講授與回覆示教方式進行系統性指導。研究資料由不知個案之組別分配的評估者進行資料收集。
研究方法：本研究以入住某教學醫院內科病房，此次住院診斷中有COPD的個案，作為本研究之收案對象，經同意後，在病人出院準備階段進行指導，出院時、出院後1個月與3個月，進行研究資料的收集。兩組研究對象的基本資料將以描述性統計確認兩組對象的基本屬性與分佈情形，男女、有無信仰、是否使用氧氣等類別變項以卡方檢定，年齡、住院天數等連續變項以t檢定進行兩組差異性的確認。結果變項包括1.動機性的成效，及自我效能改變情形；2.學習過程之成效，即呼吸法執行正確性與呼吸法自動練習頻率，與3.進階成效，即生活品質的改變。資料以能處理小樣本與流失資料的廣義估計模式(General estimated equition, GEE)，分析重複測量之改變差異，而實驗組對於以平板電腦學習呼吸法的心得回饋，則以問卷進行調查。
研究結果：經過濾1062位入院具COPD診斷的病人，排除995位因未接受肺功能測試、正參與其他研究或無意願參與本研究的個案後，收案71位病人，以隨機分派方式至實驗組(36位)與控制組(35位)。研究對象大多數為男性(83.1%)，平均年齡71.5±11.4歲，兩組病人的基本資料無顯著差異。在1.動機性的自我效能成效之改變上，兩組病人於出院當下自我效能的測量分數上，實驗組提升的分數與控制組相比有統計上的差異(p=.045)，出院後1個月與3個月的追蹤測量值上，兩組之間則無顯著差異。2.學習過程之成效，即呼吸法執行正確性與呼吸法自動練習頻率的結果，兩組在出院時、出院後1個月與3個月的追蹤測量值均高於入院當時測量值，但兩組之間並無統計上之顯著差異。3.生活品質的改變上，兩組病人在出院後3個月生活品質受到症狀的干擾均較為減少，且呈現統計差異(p=.024)，但兩組之間並無統計上之顯著差異。從實驗組回饋問卷的結果，可發現病人在沒有人協助下，會去使用平板電腦練習呼吸法的得分較其他題項為低(2.58±0.77)。
結 論：針對慢性阻塞性肺病的老年病人，以平板電腦提供指導和以傳統方法提供指導的學習成效並無特別差異，以平板電腦學習的老年病人僅在出院後，對自己呼吸技巧上的自我效能程度略顯優於傳統方法學習者，此結果與本研究的指導僅在於住院期間提供或許相關，有待未來更多有關指導效能為主題的研究進一步探討。

關鍵字

慢性阻塞性肺病 ； 呼吸再訓練 ； 自我效能 ； 生活品質

並列摘要

Aim: The purpose of this study is to examine the effectiveness of a breath-retraining program in patients with Chronic Obstructive Pulmonary Disease (COPD) during and 1- and 3-months after hospitalization.
Background: COPD patients often have unplanned visits to the ER or hospital admissions. The literature has proposed various self-management interventional studies for COPD patients. However, studies rarely consider the effect of COPD instructions that focus on enhancing patients’ motivation. In the era of shortening lengths of hospital stays, the time nurses have to provide patient education is limited. In addition to routine instructional services, for practicality, some nurses may adopt various materials to help patients understand their health care information. Considering technological improvements, there are various novel forms of instruction available to adopt. Therefore, determining the effectiveness of new educational programs for COPD patients is worthy of investigation.
Design: This study was designed as a randomized controlled test and outcomes were measured three times: during, and 1- and 3-months after hospitalization. The included patients were randomized into two groups. The intervention consisted of a media-based interactive teaching program in the experimental group. In addition, systematic teaching by the study nurse was implemented for the control group. A research assistant (evaluator) who was blinded to group allocation measured the outcomes.
Methods: Patients recently admitted to the medical ward of a teaching hospital who had been diagnosed with COPD were invited to participate in this study. After receiving informed consent, we collected data when patients were in the preparation stage of discharge, and 1- and 3-months after hospitalization. Statistical analyses were completed with SPSS 20.0 software. We compared the baseline demographic characteristics of the control and the experimental groups using the chi-square test for categorical variables (gender, religion, oxygen use, etc.) and t-test for continuous variables (age, length of stay, etc). There were three types of outcome measures: (1) motivational outcome: self-efficacy of breathing technique; (2) process outcomes: correct breathing technique and frequency of practice of the breathing technique; and (3) comprehensive outcome: quality of life. All analyses were intent-to-treat analyses using a repeated measures analysis using generalized estimating equations (GEE) to deal with the relatively small sample size and to best account for any missing data. Significant differences were set at p<.05. The feedback on using the tablet computer for learning in the experimental group was also collected by the research assistant.
Results：A total of 1062 admitted patients diagnosed with COPD were screened. The reasons of ineligibility of 995 patients included no pulmonary function test done, being taught a breathing technique in another project, discharged before approach, and refusal to participate. Seventy-one patients with COPD were enrolled and randomly allocated to the experimental (n=36) or the control (n=35) group. The participants were mostly male (83.1%) with an average age of 71.5 (SD=11.4). According to the GEE statistical results, we revealed that immediately after breathing training, the self-efficacy of the experimental group increased a statistically significant amount compared to the control group (β=3.087, p=.045), but there were no differences at 1-month or 3-months post-discharge. Both the experimental and control groups showed statistically significant improvement in process outcomes from baseline at each follow-up (p<.001). Although both groups had significantly improved by 3-months post-training completion (p=.024), GEE analysis showed no statistical difference in the interactions between groups and time. The feedback from the questionnaires showed the scores for the item “even without help, I would like to turn on a tablet computer and learn the breathing technique by myself” (2.58±0.77) were relatively lower than scores for the other items.
Conclusion：Our tablet computer-assisted educational aid did not provide an improvement over the traditional method for teaching breathing techniques to elderly patients with COPD. The results only showed an immediate effect on the self-efficacy of the breathing technique. The elderly did not use the tablet computer actively and the research was conducted without intervention after discharge, which may be a reason why the effect did not last. Further research to evaluate the effectiveness of such a strategy for the elderly is needed in the future.

並列關鍵字

Chronic Obstructive Pumonary Disease(COPD) ； breath retrain ； self-efficacy ； quality of life

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