一位極重度慢性阻塞性肺疾患者之肺部復健介入整合照護經驗

本個案51歲時被診斷爲GOLD分級之中度(moderate)期慢性阻塞性肺疾患者，於55歲時已進展爲極重度(very severe)並被第一次插管。此次拔管後便開始戒菸及學習呼吸控制技巧，但肺功能持續惡化，故2000~2007年間歷經三次插管。其間除持續使用藥物控制外，於60歲時（2005年）參與至少三個月以上居家手機運動訓練計畫，走路距離及生活品質皆顯著改善。然而一年半後第三次插管後，因持續性高碳酸血症難以脫離呼吸器而作氣切。我們發現此個案，呼吸器使用時間越長，越會加劇其肺過度充張(Hyperinflation)、合倂氣泡性肺氣腫(bullous emphysema)之情形。於呼吸照護中心雖已介入積極清痰，下床走路及四肢肌力訓練之肺部復健，但個案至少仍有半天依賴呼吸器，故仍下轉呼吸照護病房。雖無法有妥善照護者，但病患要求能在家照顧，返家後的確個案居家生活品質有改善，尤其心境安定很多。在此個案長期照護過程，有兩次積極肺部復健介入，一次於能自呼之疾病穩定期、另一次於依賴呼吸器之疾病亞急性期，我們發現兩次皆對病人之日常生活活動及生活品質之心理支持層面有改善。
This case was diagnosis as an patient with Gold moderately severe stage chronic obstructive pulmonary disease (COPD) when he was 51 years old, then he was deteriorated to Gold very severe stage at 55 years old and was first intubated. Afterward he quitted smoking and learn breathing control techniques, but continuing deterioration even persist intensive drug therapy, totally he was performed intubation three times between 2000 and 2007. He entered supervised endurance exercise training program by cell phone in a home setting at least for three months at 60 years old (2005), the outcomes of walking distance and quality of life significantly improved. At two and half years after rehabilitation, he was performed third intubation, difficulty weaning for persist hypercapnia was noted, so he was performed tracheotomy. During this ventilator dependent period, we found that the longer ventilator support, the worse hyperinflation, and then resulted more bullous emphysema change. He was referred to bedside rehabilitation program in respiratory care center, it including intensive airway clearance, out of bed and limbs strengthening exercises. However he had worn ventilator for at least half a day, therefore he was transferred to respiratory care ward. He requested for home care, even the shortage of appropriate caregivers, he got better quality of life specially on emotional components at home setting. In this long term care process, there were two times intensive pulmonary rehabilitation interventions, one was at medical stable stage and he could breathing spontaneously, the other at subacute stage and ventilator dependent, we could found that he gained some improvement in activity of daily living and emotional support during both rehabilitation programs.