運用高流量氧氣鼻導管降低慢性阻塞性肺病個案反覆入院次數之呼吸照護經驗

Using high flow nasal cannula in the respiratory care of readmitted patients with chronic obstructive pulmonary disease

張華倩(Hua-Cian Jhang) ； 周芝菊(Chih-Chu Chou) ； 陳雪莉(Hsueh-Li Chen) ； 柯延昆(Yen-Kun Ko)

《呼吸治療》 21卷1期 (2022/01) Pp. 63-73

https://doi.org/10.6269/JRT.202201_21(1).0006

摘要

當慢性阻塞性肺病（Chronic obstructive pulmonary disease, COPD）發生急性惡化（Acute exacerbation, AE）會導致肺部過度充氣、通氣灌流比值惡化，進而導致低血氧性呼吸衰竭。臨床上常採用非侵襲性正壓呼吸器（Non-invasive positive pressure ventilators, NIPPV）作為輔助治療，其相關合併症為面部損傷、痰液不易排出及幽閉恐懼症等；近年來研究發現使用高流量氧氣鼻導管（High flow nasal cannula, HFNC）作為輔助治療時，相較於NIPPV可降低面部損傷機率並可提升痰液清除功效、增加舒適感。本個案為一名66歲男性，主診斷COPD，無抽菸史、目前職業為鐵路局站長，曾患有右心衰竭、支氣管擴張症等病史。半年內因COPDAE反覆入院三次，其臨床表徵為運動性呼吸困難、呼吸短促、痰液增加等，胸部影像學呈現氣胸、肺氣腫、肺部浸潤增加，動脈血液氣體分析呈現中度低血氧，主要採用藥物及氧氣治療；第二次入院時建議居家使用氧氣，於第三次入院時病況未見改善故而建議使用NIPPV，經評估後採HFNC作為輔助治療其低血氧情形及臨床表徵明顯改善，建議返家長期使用；於後續追蹤個案狀況時，觀察其反覆入院次數明顯降低。此個案為使用HFNC後成功改善臨床表徵並降低反覆入院次數之案例分享；關於長期使用HFNC是否可降低COPDAE反覆入院次數仍需更多研究及文獻證據支持，僅期望此份照護經驗可作為呼吸治療師同仁臨床使用參考。

關鍵字

慢性阻塞性肺病 ； 急性惡化 ； 非侵襲性正壓呼吸器 ； 高流量氧氣鼻導管

並列摘要

Acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) will result in over inflation of the lungs and poor ventilation/perfusion ratio, causing hypoxic respiratory failure. Treatment of acute exacerbation of COPD often resorts to the usage of Non-invasive positive pressure ventilators (NIPPV), but this can be prone to complications like facial injury and sputum removal difficulty. The high flow nasal cannula (HFNC) is a new treatment option; a large diameter nasal cannula provides heated and moistened air in high flow volume, reducing the chance of facial injury, improving sputum removal, and increasing comfort level for the patient. The technique was used mostly on children and infants in the past, with fewer cases on adults. The subject is a 66 years old COPD patient, has no history of smoking and is a railway station chief. The subject had a history of right-sided cardiac failure and bronchiectasis. Subject was re-admitted 3 times in 6 months for COPD AE. The clinical expressions were exertional dyspnea, shortness of breath and increased sputum secretion. Chest imaging showed pulmonary emphysema, over-inflation and pneumothorax. Arterial blood gas analysis indicated intermediate hypoxia. In the first and second readmissions, subject was treated with medication and oxygen therapy; on the 3^(rd) readmission, NIPPV was recommended for the subject. After evaluation, HFNC was used to provide heated and moistened air of high flow volume to wash the upper respiratory dead space, forming positive end-expiratory pressure to promote alveolar ventilation, and reduce work of breathing. After using the HFNC, the subject’s clinical symptoms were successfully improved, and the number of hospital readmissions decreased. It is hoped that the experience from this case will serve as reference for future clinical considerations of respiratory care.

並列關鍵字

Chronic obstructive pulmonary disease(COPD) ； Acute exacerbation(AE) ； Non-invasive positive pressure ventilators(NIPPV) ； High flow nasal cannula (HFNC)