加護病房使用呼吸器患者接受胸腔物理治療與早期活動之效益探討

Abstract

患者因為有生命威脅的疾病，通常必須住進加護病房接受治療。但時常有很高的風險會併發嚴重的後遺症，像是加護病房後症候群（post intensive care syndrome；PICS）、重症後虛弱症（intensive care unit–acquired weakness；ICU-AW）、身體衰落、精神疾病與生活品質下降。胸腔物理治療是治療重症疾病中的一環，主要可協助像是提升肺功能、減少呼吸器相關肺炎的發生率、促進脫離呼吸器與幫助盡早離開加護病房。此外，早期活動是可以改善重大疾病造成的肌無力情形，本論文的目的為探討胸腔物理治療與早期活動對於使用呼吸器患者的預後影響，並探討周邊肌力對於重症患者後續預後的影響。 本論文主要包含兩個部分。第一個研究為探討胸腔物理治療加上早期活動是否可以降低加護病房患者拔管失敗率。介入組患者接受包括吸氣肌訓練、手壓式過度充氣法、胸廓鬆動術、痰液清除、咳嗽訓練與早期活動。控制組則接受一般護理照護。研究結果發現相較於控制組，介入組患者重插管率顯著較低（8% vs. 16% ; p = 0.01）。本研究結果提供了胸腔物理治療在加護病房所能帶來益處的證據，對於使用呼吸器的患者，胸腔物理治療加上早期活動確實可降低其拔管失敗的風險。第二個研究為探討周邊肌肉力量與加護病房呼吸器使用患者拔管結果的相關性，並追蹤患者後續之功能性行走能力。患者在進行拔管前進行周邊肌力二頭肌（biceps）與股四頭肌（quadriceps）的肌力測量，並分析肌力與拔管結果之相關性。並於患者轉入一般病房後，進行兩分鐘行走測試。結果顯示重插管患者股四頭肌肌力顯著低於未重插管的患者（p = 0.02），患者轉入一般病房後有48%可恢復行走能力，整體死亡率為11%，肱二頭肌肌力與死亡率有顯著相關（r =－0.28, p = 0.04）。 患者從加護病房轉出後，功能上的限制導致活動能力受限及生活品質下降，除了醫療相關方面的支出，往往造成患者與家屬日後需要花費更多後續復原或是臥床照護的成本。因此，本論文提供加護病房介入早期活動及胸腔物理治療效益的相關證據，希望在患者的整合照護上與照護團隊一起安排適當的物理治療介入策略，改善患者因治療或臥床缺乏活動所造成的肌肉無力症狀，進而改善患者預後使其能盡快回復到原來的生活。

Patients with critical illnesses being cared for in ICU often have a life-threatening diseases. However, there is often a high risk of serious sequelae, such as post intensive care syndrome (PICS), intensive care unit-acquired weakness (ICU-AW), physical and cognitive function decline, and reduced quality of life. Chest physiotherapy intervention as part of a multidisciplinary approach to patients with critical illness is integral in promoting lung function, reducing the incidence of ventilator-associated pneumonia, facilitating weaning, and promoting safe and early discharge from ICU. Besides, early mobilization could be an ideal treatment to improve critical illness-related muscle weakness in ICU patients. This dissertation aimed to investigate the effect of chest physiotherapy on patients with ventilator support and explore whether peripheral muscle strength was correlated with functional outcomes in ICU survivors. This dissertation included a series of two studies. The first study investigated whether chest physiotherapy with early mobilization could reduce the extubation failure rate in ICU patients with ventilators. The intervention group was prospectively taken into the chest physiotherapy program. Chest physiotherapy treatment protocol consisted of inspiratory muscle training, manual hyperinflation, chest wall mobilization, secretion removal, cough function training, and early mobilization. The control group received routine nursing chest care and was selected from a retrospective chart review. The results revealed that patients in the intervention group had a significantly lower reintubation rate compared to the control group (8% vs. 16%; p = 0.01). This study indicated that intensive chest physiotherapy with early mobilization could decrease extubation failure in mechanically ventilated patients in ICU. The second study investigated the correlation between peripheral muscle strength and extubation outcome in patients with mechanical ventilation (MV) in ICU and following their prognosis of walking ability. A hand-held dynamometer was used to evaluate the muscle strength of the biceps and quadriceps right before extubation. Besides, after the patients had been transferred from ICU to the general ward, a 2-minute walk test was performed. The results showed that muscle strength of the quadriceps was significantly lower in the extubation failure group compared with the successfully extubated group (p = 0.02). After ICU discharge, ambulation recovery rate in this study was 48%. The overall mortality rate was 11%, with a significant correlation between biceps muscle strength and in-hospital mortality (r =－0.28, p = 0.04). Peripheral muscle strengths may aid predictions of a patient’s prognosis after extubation. In summary, functional limitations after ICU discharge may cause physical activity impairment and a decline in quality of life. Patients who develop these complications may also need more healthcare-related costs, such as extra rehabilitation or long-term medical and nursing care. Therefore, the findings from this dissertation provide evidence for beneficial effects of early mobilization and chest physiotherapy in ICU settings. In the future, appropriate physiotherapy intervention strategies can be arranged in the integrated care of patients in ICU to improve the muscle weakness caused by treatment or prolonged bed rest, which can help patients return to their normal life as soon as possible.