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題名：整體呼吸肌訓練可有效改善慢性阻塞性肺病患者之呼吸功能
作者：徐敏芳
作者(外文)：Min-Fang Hsu
校院名稱：亞洲大學
系所名稱：健康產業管理學系健康管理組
指導教授：蔡仲弘
王俊毅
學位類別：博士
出版日期：2015
主題關鍵詞：慢性阻塞性肺病；呼吸肌訓練；呼吸肌功能；運動耐力；呼吸困難；生活品質；COPD；Respiratory muscle training；Respiratory muscle function；Dyspnea；Exercise tolerance；Quality of life
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背景：慢性阻塞性肺病(Chronic Obstructive Pulmonary Disease, COPD)是常見的慢性呼吸道疾病。其主因是長期抽菸與空氣汙染而導致呼吸功能的失常。其特徵是呼氣時氣流阻塞，產生空氣滯留而使肺過度充氣，造成呼吸肌的衰弱而導致呼吸困難，運動耐力降低，嚴重影響病患的生活品質。如何透過有效的運動訓練以強化患者的呼吸肌功能為一重要的課題。
研究目的：本研究在探討整體呼吸肌訓練對改善COPD患者呼吸肌功能、運動耐力以及健康相關生活品質(health-related quality of life)之成效。
研究方法：本研究為一隨機對照試驗(Randomized Controlled Trial)。以立意取樣(purporsive sampling)選取57位在台灣北部某醫學中心胸腔內科門診以及肺部復原中心就診的COPD患者，依據性別及肺功能嚴重程度分層，隨機分派至實驗組或對照組。所有個案接受相同的12週的橫膈噘嘴呼吸再訓練。實驗組個案又接受12週整體呼吸肌訓練，內容包含上肢運動以及腹肌訓練。訓練頻率為每週三天，每天三次，每次三回合。於基準點、第4、8、及12週進行呼吸肌功能[最大吸氣壓(PImax)、最大呼氣壓(PEmax)、最大自主換氣量(MVV)]、運動耐力(六分鐘走路距離，6-min walking distance, 6MWD)之成效評估，以及於基準點、第12週進行肺功能試驗(FEV1.0, FVC, IC)、肺總容量檢測(TLC)、健康相關生活品質(聖喬治呼吸問卷，St. George's Respiratory Questionnaire,SGRQ)之評估。研究期間每週以電話追蹤並回答個案相關問題，並要求所有個案記錄訓練日誌。以獨立樣本t檢定介入十二週後的成效，並以概似估計方程式(Generalized Estimating Equations, GEE)分析在控制性別、年齡、運動習慣以及疾病嚴重度等變項後，呼吸肌訓練後在不同時間點對COPD患者呼吸肌功能、運動耐力以及COPD評估問卷之成效，顯著水準訂為α＝0.05。
結果：十二週的整體呼吸肌訓練顯著增加最大吸氣壓、最大呼氣壓、最大自主換氣量、六分鐘走路距離，以及顯著降低慢性阻塞性肺疾病評估問卷分數，及聖喬治呼吸問卷各面向的分數(all p<0.05)。最大吸氣壓於介入後四週即有顯著改善，並持續增加到第八(p<0.05)、及十二週(p<0.000)；最大自主換氣量介入後第四週(p<0.05)、及第十二週(p<0.01)均顯著增加；運動耐力(六分鐘走路距離)與慢性阻塞性肺疾病評估問卷得分在介入後第四、八、及十二週皆有顯著改善(p<0.01)，聖喬治呼吸問卷在介入後第十二週有顯著改善(p<0.05)。但介入措施對肺功能各項指標並無顯著的改變。
結論：本研究所設計之整體呼吸肌訓練可以有效的改善COPD患者呼吸肌的功能，增加其運動耐力並提升健康相關之生活品質。本研究所設計的整體呼吸肌訓練可能在臨床實務上值得推廣。
Background: Chronic Obstructive Pulmonary Disease (COPD) is a common chronic respiratory disease. The major risk factors are cigarette smoking and air pollution. COPD is characterized by airflow restriction during expiratory phase as a result of lung hyperinflation which leads to diaphragm muscle weakness and dyspnea. COPD patients often suffer from exercise intolerance which adversely impacts their quality of life. How to improve the functioning of the respiratory muscles through effective training regiments is an important issue for patients with COPD.
Objective: The purpose of this study was to evaluate the effectiveness of a multi-respiratory muscle training program on respiratory muscle functioning, exercise tolerance, and health-related quality of life in patients with COPD.
Methods: We conducted a randomized controlled trial (n=57) and recuited patients from the chest clinic and the pulmonary rehabilitation unit of a medical center in northern Taiwan. Qualified patients were first stratified by sex and severity of disease (per GOLD stage) and then randomly assigned to either the experimental or the control group. All participants received diaphragmatic and pursed-lip breathing retraining. The experimental group further received a 12-week respiratory muscle training (including upper-arm exercise and abdominal muscle training) for 3 times/day, three days/week. We evaluated respiratory muscles functions (PImax, PEmax and MVV), exercise tolerance (6-min walking distance, 6-MWD) and COPD assessment test (CAT) at 0, 4, 8, and 12 weeks and pulmonary function test (FEV1.0, FVC, IC), plethysmography (TLC) and health-related quality of life (St. George’s Respiratory Questionnaire, SGRQ) at 0 and 12 weeks. During the trial, the researcher made weekly follow up check phone calls to each participant to remind their exercise activity and to answer any question related to the training. All patients were requested to keep a training diary. Results were analyzed using the two-sample t-test to evaluate the treatment effect, and Generalized Estimating Equations (GEE) to evaluate the interaction of treatment effect with time on respiratory muscle functions and exercise capacity, adjusted for sex, age, exercise habit and severity of disease. Statistical significance for all analyses was set at p= 0.05.
Results: The 12-week respiratory muscle training significantly improved PImax, PEmax, MVV, 6-MWD, CAT scores according to GEE (all p<0.05) and improved the scores of St. George’s Respiratory Questionnaire according to independent t-test. The intervention significantly improved PImax at week 8 (p<0.05) and 12 (p<0.000), and MVV at week 4 (p<0.05) and 12 (p<0.01). The intervention also significantly imcreased PEmax, 6MWD and CAT scores at all intervals (week 4, 8, and 12) (all p<0.01). However, the intervention did not change pulmonary functional indicators.
Conclusions: Our multi-respiratory muscle training is effective in improving the respiratory muscle function, exercise tolerance, and health-related quality of life for patients with COPD. The value of this multi-respiratory muscle training program in clinical practice derives further investigation.
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