第三章 文獻查證
四、 結 果
(一) 回顧一研究目的: 呼吸訓練介入對腦中風病人之成效
回顧一針對篩選出的二篇文獻進行評析，評析結果整理於表3-3, 3-4及表3-5。
整體而言，二篇文獻的樣本數都少，分組後的各組樣本，最多僅15人，少到10人 一組。納入樣本都屬中風存活期(Britto et al., 2011)或中風後半年(Sutbeyaz et al., 2010) 之居家病人。呼吸訓練方案主要分成二大類: (1)機械輔助加阻力呼吸訓練，所設定 的阻力閾值為最大吸氣壓力(MIP)值的30%~60%。(2)自主式呼吸再訓練，訓練方案 時程都是8周。另改良式Jadad品質量表得分為7及5分，文獻品質理想。
Cochrane偏差風險評估結果(表3-4)顯示，文獻一的各項偏差都呈現低風險；
文獻二部分有較高風險的選樣偏差，結果偵測/測量偏差(detection bias)方面，因文中 說明不完整而無法確認，無法排除可能有此風險。
成效部分，機械輔助加阻力呼吸訓練方案對整體肺功能、吸氣肌功能的改善二 文獻都呈現顯著差異，生活品質(SF-36)、Barthel Index and Functional Ambulation scores一篇文獻達統計顯著差異(Sutbeyaz et al., 2010)，但2011年的另一篇文獻則顯 示生活品質(NHP)及功能實作測試(functional performance)皆未達統計差異 (Britto et al., 2011)。自主式呼吸再訓練方案僅有一篇文獻結果，主要呈現對吐氣肌功能
(PEmax)及部分生活品質變項的顯著改善成效，在Barthel Index及吸氣肌功能(MIP)
改善僅呈現優於前測組內差異效益。
不良反應部分，二篇文獻都未描述。
(二) 回顧二研究目的: 疾病早期自主式呼吸(再)訓練方案發展
基於系統性文獻回顧一之初步發現，並考量急性腦中風後早期階段，病患呼吸 肌力量顯著不足問題。為避免吸氣肌訓練時過度吸氣負荷造成橫膈膜疲憊風險 (Walker et al., 2016)，低成本、自主式呼吸(再)訓練方案成為作者在建構這群病患呼 吸訓練方案的主要核心元素，特別是於 1950 年代中期就被正式命名的蹶嘴式呼吸 (pursed-lips breathing, PLB)法(Fregonezi, Resqueti, & Guell Rous, 2004)，深具改善呼
52
吸功能價值(Dechman & Wilson, 2004; Fregonezi et al., 2004; Gosselink, 2004)，目前 PLB 研究的主要問題是沒有標準的PLB訓練方法，Tiep (2007)強調應建立普及的
PROTOCAL增加其可應用性。
本論文文獻經圖3-2的篩選流程後，共選出29篇文獻進行評析，評析結果整 理列於下頁表3-6。自主呼吸訓練方案內容彙整於表3-7，預計於pilot study時進行 測試。
53
Table 3-3 Characteristics of the Studies Included in Review 1
First
author(Year) Group(n):
age(mean±SD) M/F Attrition rate% Condition Intervention Duration(wk) Control group ( C ) Experimental group ( E )
exercise type, time/ duration/setting
Britto (2011) T(21) 11/10
Stroke onset ≧ 9 month
IMT without the threshold resistance valve
E(11): 56.66±5.56 E: 10.0 MIP<90% IMT threshold device, 30%MIP, 8 weeks C(10): 51.44±15.98 C:18.18 No facial palsy 30min/per time, 5 times/week, home
6 series of 5 minutes each, with a 1-minute rest interval between
series.
Sutbeyaz(2010) T(45) First episode,
IMT(15):
62.8±7.2 7/8 E: 0 Unilateral hemiparesis
IMT with PImax 40% to 60% as tolerance ( 15min /a day, 6 times/week *6 week, home)
Conventional stroke rehabilataion
C: 0 8 weeks
BRT(15):
60.8±6.8 7/8
DB+PLB
15 mim PLB+DB--Rest 5min—air shifting techniques 5min—Rest 5min--Voluntary isocapnoeic hyperpnoea 5 min
1 times / daily * 6 week, home
8 weeks
Conventional stroke rehabilataion
5 C(15):61.9±6.15 7/8
Conventional stroke rehabilataion (five days a week for six weeks)
IMT: Inspiratory muscular training BRT: Breathing retraining
54 Table 3-4 Quality Appraisal of the Studies Included in Review 1
First author (Year)Modified Jadad Quality Scale (0~8) Cochrane's Risk of Bias
Item(scaling): score Item: grade of risk bias(high, low, unclear)
Britto (2011) RA(2): 2 Selection bias: low
Double blind (2): 2 Randon sequence generation: 有說明
Attrition (1): 1 有提及各組流失人數及原因, 未>20% Allocation concealmen分組隱匿: 文中說明適當
Inclusion/Exclusion(1): 1 Performance bias: low
Harmful effect(1):0 Blinding of participants and personnel: yes
Statistics(1): 1 Detection/measurement bias: low
Blinding of outcome assessment: yes Attrition bias: low
Incomplete outcome data Reporting bias: low
Selective outcome reporting: no Others: low 納入/排除條件有說明
Sutbeyaz(2010) RA(2):1 Selection bias: High risk bias
Double blind (2): 0 Randon sequence generation:
Attrition (1): 1 Allocation concealment:
Inclusion/Exclusion(1): 1 Performance bias: low
Harmful effect(1):0 Blinding of participants and personnel:
Statistics(1): 1 Detection/measurement b unclear
Blinding of outcome assessment:
Attrition bias: low
Incomplete outcome data Reporting bias: low
Selective outcome reporting:
Others: low-納入/排除條件有說明
55
Table 3-5 Outcomes of the Studies Included in Review 1 First
author(Year) Intervention Outcome results M-Jadad
score(0~8) Britto (2011) IMT threshold
device, MIP increased after IMT which was greater than control group
7 v.s IME improved after IMTwhich was greater than control group
IMT without the threshold resistance valve
Functional performance after IMT which was no statistically significant differences
QOL after IMT which was no statistically significant differences
Sutbeyaz(2010) IMT
FEV1, FVC, vital capacity, FEF 25–75% and MVV values increased after IMT which were greater than BRT and control groups
BRT(DB+PLB) Conventional stroke
rehabilataion
MIP and PEmax increased after BRT which were greater than baseline.
PEmax increased after BRT which were greater than baseline and control group
PEF increased after BRT which was greater than IMT and control groups.
PImax increased after IMT which were greater than baseline and control groups.
PEmax increased after IMT which were greater than baseline value
5
v.s. Control Conventional stroke rehabilataion
VO2peak increased after IMT which was greater than BRT and control groups Exertional dyspnoea decreased after IMT which was smaller than baseline and control groups.
Barthel Index and Functional Ambulation Categories scores increased after IMT which was greater than baseline and control groups
Barthel Index improved after BRT which was greater than baseline Physical role, general health, and vitality domains of SF-36 improved after IMT which were greater than baseline and control groups.
Emotional role, general health, pain, vitality domains improved after BRT which were greater than baseline and control groups.
IMT: Inspiratory muscular training
MIP or PImax: Maximal inspiratory pressure MEP or PEmax:Maximum expiratory pressure IME: Inspiratory muscular endurance
MVV: Maximum voluntary ventilation values PEF: Peak expiratory flow rate
VO2peak: Peak oxygen consumption
56
表3-6 自主呼吸訓練系統性文獻回顧評析整理—回顧二
作者/年代 研究設計/對象 呼吸訓練措施 測量時間 研究結果 實證等級
(Zakerimoghad am, Tavasoli, Nejad, &
Khoshkesht, 2011)
未隨機雙組前後測 類實驗
住院輕中度COPD E:30
C:30
面對面教導蹶嘴呼吸、橫膈膜 呼吸及有效咳嗽。要求實驗組 執行一天四次連續10天。
其他細節未說明
O1:介入前 O2:10天後
降低疲憊嚴重度(fatigue severity scale):後測實驗組FSS 顯著低於對照組(P=0.001)。
蹶嘴呼吸越多，疲憊改善越顯 著(P=0.001, r= -0.593) 橫膈膜呼吸越多，疲憊改善越 顯著(P=0.001, r= -0.584) 有效咳嗽越多，疲憊改善越顯 著(P=0.006, r= -0.493)
II-2
(Frank J.
Visser, Ramlal, Dekhuijzen, &
Heijdra, 2011)
單組交叉重複測量 設計
GOLD第三四期穩 定病患
32人
2分鐘蹶嘴呼吸,停1分鐘*五次 後，休息五分鐘。再2分鐘蹶 嘴呼吸,停1分鐘*三次，休息五 分鐘。
O1:介入前 O2: PLB時 (吸氣參數) O3:PLB後5 分鐘(吸氣 參數) O4: PLB時 (吐氣參數) O5:PLB後5 分鐘(吐氣 參數)
PLB時，吸氣容積, SPO2 顯著 增加,ETCO(2),呼吸頻率顯著 下降,五分鐘後效益皆下降, 僅 吸氣容積上升仍顯著優於前 測。
II-3
Sutbeyaz(20 10)
RCT
STROKE:第一次中 風,單側偏癱 45人
(居家) PLB+DB訓練, 90min/per time, 6 times/week, 加傳統中風 復健方案,一周五天, 連續六周
O1: 前測 O2: 後測
PLB+DB介入後測最大吸氣壓
(MIP)顯著高於前測、最大吐氣 壓力(PEmax)顯著大於前測值 及控制組;尖峰吐氣流速(PEF) 也顯著高於吸氣肌訓練組及控 制組。介入後後測Barthel
Index 顯著比前測改善,未達
組間差異。生活品質量表的活 力等分量表顯著改善,明顯優 於接受傳統復健的控制組。
I
(Pomidori, Campigotto, Amatya, Bernardi, &
Cogo, 2009)
單組交叉設計 COPD病患 11人
單次瑜珈呼吸:30分鐘 依老師指引於呼吸時依序移動 橫膈、下胸部、上胸部，進行 較深、較慢的呼吸
個案盤腿舒服坐於地板
O1: 自然呼 吸 O2:瑜珈呼 吸執行最後
10分鐘平
呼吸型態顯著比自然呼吸時深 且慢，SaO2%明顯改善。
II-3
57
均數 (Donesky-Cuen
co, Nguyen, Paul, &
Carrieri-Kohlm an, 2009)
隨機化試驗的pilot study
老年COPD個案 29人
樣本接受12周 總計241小時 的瑜珈團體治療+每堂課後 vidotape, 內容主要包括: 瑜珈 擺位(吐氣時柔軟的伸展胸,脊 柱,呼吸輔助肌, 下背等)及
pranayama呼吸。此呼吸強調延
長吐氣時間為吸氣的二倍, 溫 柔吐氣, 吸氣與吐氣間不暫停, 鼻子吸氣(與蹶嘴呼吸型態相 似)。並於吐氣時進行各種瑜珈 擺位
O1:前測 O2:介入結 束時(3個 月)
瑜珈訓練組自陳的 FPI(Functional Performance Inventory)顯著改善；但焦慮狀 態量表, 憂鬱症狀二組差異皆 未達統計差異(p=0.51);
FVC,FEV1差異未達統計意義:
6分鐘走步測驗顯著改善 (P=0.04), 優於常規照護的控 制組, 呼吸困難困擾組間差異 顯著。
I
表3-7 自主呼吸訓練方案內容(蹶嘴式呼吸的行為特徵與目的效益)
呼吸行為特徵 目的或原理 備 註
半張嘴吐氣或 constriction of the lips
增加呼吸道阻力 強調鼻子吸氣
Relaxed expiration (Gosselink, 2004)
放鬆吐氣與用力吐氣相比, 可增加20%的 吐氣量, 降低肺餘量, 使過度充氣情形減少 (Gosselink, 2004)
類似不費力吐氣 (Spahija et al., 2005)
主動延長吐氣
(Gosselink, 2004; Tannheimer, Tannheimer, Thomas,
Engelhardt, & Schmidt, 2009)
改善吐氣及預防呼吸道塌陷
吸2秒: 吐8秒(Tannheimer et al., 2009)
吐氣時間大於吸氣二倍(Reyes Del Paso et al., 2006; F. J. Visser, Ramlal, Dekhuijzen, &
Heijdra, 2010)
吸3秒，吐6秒，停留1秒於吐氣末下一 次吸氣前(Reyes Del Paso et al., 2006)
降低每分鐘呼吸頻率 (Fregonezi et al., 2004; Reyes
增加潮氣容積及每分鐘通氣量(Fregonezi et al., 2004)
類似較慢、較深的 呼吸
58
Del Paso et al., 2006) 每分鐘6次的頻率
(6 bpm)(Reyes Del Paso et al., 2006)
59