重度慢性阻塞性肺病患者併發氣胸呼吸照護經驗

Respiratory care of severe chronic obstructive pulmonary disease with secondary spontaneous pneumothorax

楊正旭(Cheng-Hsu Yang) ； 吳佩芝(Pei-Chih Wu) ； 謝佳珍(Chia-Chen Hsieh)

《呼吸治療》 20卷1期 (2021/01) Pp. 41-52

https://doi.org/10.6269/JRT.202101_20(1).0005

摘要

慢性阻塞性肺病（chronic obstructive pulmonary disease ,COPD）屬於氣道慢性發炎之系統性的肺疾，世界衛生組織WHO預測2030年COPD將成為全世界前三大死因之一，COPD除本身即為不容忽視之疾病外，根據統計有高達60.8%的機率會併發自發性氣胸，而COPD與氣胸在嚴重的急性期皆需侵入性的呼吸器支持，並在呼吸器的設定與呼吸照護上皆各有其特殊的策略。當急性病患同時擁有這兩項呼吸疾病時，該如何使用適當之策略與設定，目標維繫病人生命與減少併發症的產生為呼吸照護一大重點。本個案為重度COPD，因COPD急性惡化入院使用藥物治療與氧氣治療後症狀並未改善，並在拒絕使用非侵襲性正壓呼吸器（noninvasive positive pressure ventilation, NIPPV）後，併發自發性氣胸引發呼吸衰竭執行心肺復甦術（cardiopulmonary resuscitation, CPR）轉入加護病房使用呼吸器。藉由外科手術改善氣胸與皮下氣腫症狀後，個案疑似出現CPR後缺氧性腦病變導致呼吸道清除功能失效，經過適當處置後，個案於使用呼吸器第31天成功脫離呼吸器；針對氣胸治療前後的呼吸器設定，該如何評估以減少急性惡化，與疾病穩定期脫離呼吸器的照護策略，並對於COPD惡化初期，呼吸治療照護策略預防病況惡化方法，就上述幾點分享本個案照顧經驗，希冀未來能在呼吸照護上提供臨床人員參考。

關鍵字

慢性阻塞性肺病 ； 氣胸 ； 呼吸器脫離

並列摘要

COPD is a systemic disease with chronic airway inflammation. According to new estimates from the WHO for the year 2020, COPD is predicted to become the third leading cause of death. In patients with severe COPD, 60.8% of patients will develop spontaneous pneumothorax. In the acute stage of severe pneumothorax, these patients need invasive ventilator support, appropriate ventilator settings, and continuous airway care. The primary goals of invasive mechanical ventilation in patients with chronic obstructive pulmonary disease are to prevent complications and decrease mortality. We report a case of a patient with acute exacerbation of COPD (AECOPD). The patient presented with a history of poor response to medications and oxygen therapy. In addition, the patient declined noninvasive positive pressure ventilation. Due to cardiopulmonary arrest and spontaneous pneumothorax, the patient was intubated and transferred to intensive care unit. After surgical intervention, there was significant improvement of the patient's pneumothorax and subcutaneous emphysema. However, there continued to be poor cough function secondary to hypoxic encephalopathy. The patient was successfully weaned from mechanical ventilation and extubated within 31 days after appropriate management. We discuss the ventilation strategy in the early stage of AECOPD, ventilator settings before and after surgery for pneumothorax, evaluation of the patient to prevent disease progression, and the weaning plan when the patient becomes stable.

並列關鍵字

chronic obstructive pulmonary disease ； pneumothorax ； ventilator weaning