罹患肺部支氣管發育不全之極低出生體重早產兒於學齡前時期之呼吸健康與神經發展

Abstract

研究一： 目的：本研究之目的在探討肺部支氣管發育不全與極低出生體重早產兒(出生體重低於1,500公克)於學齡前時期不良之發展預後之間的關連性。方法：55位極低出生體重早產兒與27位足月兒在達四歲時，以魏氏幼兒智力量表修訂版、兒童動作測驗組、兒童行為檢核表分別評估其智力、動作、與行為的發展。極低出生體重早產兒之肺部支氣管發育不全的嚴重度則依照美國國家衛生研究院訂定的標準評定。結果：罹患重度肺部支氣管發育不全的極低出生體重早產兒於四歲時較同齡未罹患肺部支氣管發育不全、罹患輕度至中度肺部支氣管發育不全的極低出生體重早產兒、以及足月兒呈現較高比例的智力發展遲緩(65% vs. 0%, 10%, 19% and 4%)與動作發展遲緩(53% vs. 9%, 0%, 13% and 4%)(所有p<.05)。行為檢核表的結果則無顯著組間差異。多變項回歸分析結果顯示，肺部支氣管發育不全的嚴重度越高與四歲時較高之動作損傷分數顯著相關(&szlig;=9.4, p=0.01)；母親教育程度較低(&szlig;=-13.4, p=0.02)與罹患嚴重腦部損傷(&szlig;=-18.4, p=0.04)則與四歲時較差之智商顯著相關；而家中兄弟姊妹的人數越多則與四歲時較高之行為問題分數顯著相關(&szlig;=9.4, p=0.03)。結論：美國國家衛生研究院訂定之肺部支氣管發育不全的嚴重度分類能偵測出於四歲時有較高風險會出現認知及動作發展遲緩的極低出生體重早產兒。對於罹患重度肺部支氣管發育不全的極低出生體重早產兒，必須及早提供早期介入服務與親職教育，以改善其預後。 研究二： 目的：透斯氏(Toce)臨床與X光的評分方法可應用於評估早產兒早期的呼吸狀況；然而，有關其預測力的資料仍不足。本研究之目的在於探討以透斯氏的評分方法評估極低出生體重早產兒(出生體重低於1,500公克)出生後早期呼吸狀況對肺部預後的預測力。方法：前瞻性追蹤評估109位極低出生體重早產兒的早期呼吸狀況與肺部預後。早期呼吸狀況於出生後第14與28天以透斯氏方法評估，而肺部預後評估包含：達受孕週數36週時之肺部支氣管發育不全的發生率、達矯正年齡一歲之呼吸罹病情形、以及達四歲時之肺功能(用力呼氣肺活量與第一秒內用力呼氣容積)與6分鐘行走測驗的距離。結果：出生後14與28天時之透斯氏臨床分數對嚴重之肺部支氣管發育不全具高度預測力(正確率為81-82%，陽性概率為3.4-5.6)，而X光分數亦具良好之預測力(正確率為73-75%，陽性概率為2.8-3.3)。至於預測達矯正年齡一歲之呼吸罹病結果顯示，出生後14與28天時之透斯氏臨床分數與X光分數則具中度預測力(正確率為65-70%，陽性概率為2.1-3.9)。此外，較高之14與28天時之透斯氏臨床分數與X光分數與四歲時之較低的用力呼氣肺活量與第一秒內用力呼氣容積(&szlig;=-15.3 to -16.9, R2=0.26-0.31, both p<0.05)，以及較短之6分鐘行走測驗距離(&szlig;=-3.5 to -3.67, R2=0.14-0.17, both p<0.05)顯著相關。結論：透斯氏評分方法為一臨床容易施行於極低出生體重早產兒的早期呼吸狀況評估方法，且在出生後14與28天的評估結果能預測極低出生體重早產兒之短期與長期肺部預後。

Study I: Purpose. The purpose of this study was to examine if bronchopulmonary dysplasia (BPD) was associated with adverse developmental outcomes in very low birth weight (VLBW, birth weight <1,500 g) children at preschool age. Methods. Fifty-five VLBW children and 27 term children were examined for cognitive, motor and behavioral performance at 4 years of age using the Wechsler Preschool and Primary Scale of Intelligence-Revised, the Movement Assessment Battery for Children, and the Child Behavior Checklist/1&frac12;-5 respectively. The severity of BPD was graded according to the consensus definition of American National Institutes of Health (NIH). Results. VLBW children who had severe BPD showed a higher rate of cognitive delay (IQ<70) than VLBW children who had no, mild, or moderate BPD and term children (65% vs. 0%, 10%, 19% and 4%) and so did for motor delay (53% vs. 9%, 0%, 13% and 4%) (all p<0.05). The groups exhibited comparable performance in all domains of behavior, however. Multivariable regression analyses revealed that the severity of BPD was associated with higher motor impairment scores (&szlig;=9.4, p=0.01); a low maternal education (&szlig;=-13.4, p=0.02) and the presence of severe brain damage (&szlig;=-18.4, p=0.04) were associated with lower cognitive scores; a high number of siblings was related to higher behavior problem scores in VLBW children at 4 years of age (&szlig;=9.4, p=0.03). Conclusion. The NIH consensus definition of BPD is useful to identify VLBW children who are at increased risk of cognitive and motor disorder at preschool age. Intervention and parent education are necessary for those children with severe BPD to enhance their developmental outcomes. Study II: Purpose. The Toce clinical and radiographic scoring method is useful for early respiratory assessment in preterm infants; however, the information concerning its predictive values has been limited. This study was therefore aimed to examine the predictability of the Toce method on pulmonary outcomes in very low birth weight (VLBW, birth weight <1,500 g) preterm infants. Methods. One hundred and nine VLBW preterm infants were prospectively administered the Toce method on postnatal 14 and 28 days. Pulmonary outcomes examined included prevalence of bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (PMA), occurrence of respiratory morbidity within 1 year of corrected age (CA), and pulmonary function [i.e., forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1)] and distance traveled during six minutes walk test (6MWT) at 4 years of CA. Results. The predictability of severe BPD at 36 weeks PMA by the clinical score on postnatal day 14 and 28 were high [accuracy= 81-82%, positive likelihood ratio (LR+)= 3.4-5.6] and were good by the radiographic score (accuracy= 73-75%, LR+= 2.8-3.3). The prediction of post-discharge respiratory morbidity was moderate by either the clinical or radiographic score on postnatal day 14 and 28 (accuracy= 65-70%, LR+= 2.1-3.9). Furthermore, a high Toce clinical score on postnatal day 14 and 28 was each associated with a low FVC and FEV1 in pulmonary function test (&szlig;= -15.3 to -16.9, R2= 0.26-0.31, both p<0.05) together with a short distance in 6MWT at 4 years of age (&szlig;= -3.5 to -3.67, R2= 0.14-0.17, both p<0.05). Conclusion. The results indicate that the Toce method is a valid respiratory assessment to predict short- and long-term pulmonary outcomes in VLBW preterm infants.