| 摘要: | 慢性阻塞性肺疾病急性惡化是一個造成慢性阻塞性肺疾病嚴重程度的關鍵因素，然而，有30 % 以上的慢性阻塞性肺疾病急性惡化的原因仍就不明。胃食道逆流疾病為慢性阻塞性肺病的共病症之一，然而目前相關研究仍相當闕乏。因此本研究針對此特定族群，進行三階段系列性探究。
第一階段以全民健康保險研究資料庫釋出之加值應用資料，以回溯性世代研究法分析1976位慢性阻塞性肺疾病合併胃食道逆流疾病的病人比較3936位沒有胃食道逆流疾病的慢性阻塞性肺疾病人，每位病人我們分別追蹤12個月探討其發生急性惡化的風險機率。研究結果發現在急性惡化的發生率上慢性阻塞性肺疾病合併胃食道逆流疾病及沒有胃食道逆流疾病的兩組發生率分別是每1000人月3.40及 2.32 (p = 0.012)，以存活複回歸分析，校正各相關影響因素後，兩組慢性阻塞性肺疾病急性惡化的風險比為1.48 (95% CI, 1.10 ~ 1.99)，因此可證胃食道逆流疾病為慢性阻塞性肺疾病急性惡化的獨立因子。
第二階段運用質性紮根理論研究法進行一對一深度訪談，深入探究12位經由上消化道內視鏡證實胃食道逆流診斷的慢性阻塞性肺疾病病人其急性惡化之經驗。我們經由訪談資料中建構合併胃食道逆流疾病共病者，在面對慢性阻塞性肺疾病急性惡化的歷程，經驗了「棘手的因應策略」、「模稜不明確的症狀感知」及「不安的經歷」與「疾病控制的無助感」等四個互動類屬，歸納出核心類屬為『模糊不明確症狀處理的奮戰』。
第三階段研究目的在比較走路運動與橫膈呼吸訓練對於慢性阻塞性肺疾合併胃食道逆流症狀病人的影響與成效，我們採用平行隨機控制臨床試驗法，以立意選樣將研究對象38人，以區組隨機分派方法分配為三組，走路運動組13人、橫膈呼吸訓練組12人與控制組13人，進行為期8 週運動介入。結果顯示，介入後單組前後測比較，橫膈呼吸訓練(t = 4.692, p = 0.001)與步行運動(t = 4.827, p < 0.001)皆能改善胃食道逆流症狀；步行運動組在運動耐力(t = -3.065, p = 0.010)與COPD健康相關生活品質(t = 2.242, p < 0.05)亦有顯著的進步，呼吸道症狀對日常生活影響 (t = 2.382, p < 0.05) 也顯著的下降。更進一步的，在控制相關影響變項後，步行運動組在介入後比控制組(參考組)在胃食道逆流症狀惡化分數上減少5.828分並且達到顯著(p < 0.0 5)。本階段研究結果建議，步行運動能有效改善慢性阻塞性肺病合併胃食道逆流病人之胃食道逆流症狀。
經系列性探究研究中，我們建立具有時序性之因果關係推論，驗證胃食道逆流疾病為慢性阻塞性肺疾病急性惡化的風險因子，於臨床照護COPD病人時，應謹慎評估慢性阻塞性肺病病人的胃食道逆流症狀。此外，透過深度訪談了解病人在面對症狀惡化時的模稜不明確的症狀與感受及所採取的因應方式與其困難，最後經過實驗比較，我們建議走路運動能有效改善慢性阻塞性肺病合併胃食道逆患者之胃食道逆流症狀。系列研究結果能使公眾對於共病症病的注意，並提供臨床照護和衛教內涵之擬定方向，提升醫療品質之照護。
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are serious events characterized by high mortality rates. However, the etiology underlying 30 % of AECOPD cannot be identified. Gastroesophageal reflux disease (GERD) is one of comorbid of chronic obstructive pulmonary disease. However, there is a paucity of information regarding with COPD and coexisting GERD’s. Hence, here we propose to conducted three phases of study to gain a better understanding regarding the lives of patients with COPD and GERD.
In the first phase, we used a retrospective population-based cohort design to analyse 1976 COPD subjects with GERD and 3936 COPD subjects without GERD as a comparison group. We individually tracked each subject in this study for 12 months and identified those subjects who experienced an episode of AECOPD.The incidence of AECOPD was 3.40 and 2.32 per 1,000 person-months in individuals with and without GERD, respectively ( p =0.012). Following adjustment for covarious, the stepwise Cox regression analysis revealed that GERD was independently associated with an increased risk of AECOPD (HR=1.48, 95% CI, 1.10 ~ 1.99). We found that gastroesophageal reflux disease (GERD) is an independent risk factor for AECOPD.
The second phase was performed in accordance with the principles of Grounded Theory methodology. Twelve patients with COPD and GERD participated in qualitative interviews aimed at shedding light on the patients’ perspective and better understanding the meaning that patients associate with specific.Four categories of meaning detected include intractable coping strategies, ambiguous symptoms perception, harrowing experience and sense of helplessness in disease management and the core category of this study was struggling to manage ambiguous symptoms.
The third phase of study’s aim was to explore the effectiveness of walking exercise and diaphragmatic training on improving GER symptoms, exercise endurance, and breathing difficulty influence the daily life among COPD patients with comorbid GER symptoms. We conducted parallel random controlled trial methodology with an eight-week intervention.Thirty-eight individuals were block randomized to diaphragmatic training, walking exercise or control groups with 12, 13 or 13 subjects in each group respectively. Following the intervention, one group pre-post analysis indicated that the diaphragmatic training group experienced substantially improved GER symptoms (t = 4.692, p = 0.001). The walking exercise group experienced both decreased GER symptoms(t = 4.827, p < 0.001) and breathing trouble impact on health status (t = 2.382, p < 0.05), moreover experienced improved exercise endurance (t = -3.065, p = 0.010) and health-related quality of life(t = 2.242, p < 0.05). Furthermore, after adjusting for confounding variables, the walking exercise group’sGER symptom value was shown to have decreased by 5.828 points, which was significantly greater than the reference group (p < 0.05).
From the series of study, we demonstrated that GERD is an independent risk factor for AECOPD. Moreover, a better understanding of the symptoms experience will prove useful toward developing interventions aimed at improving patient quality of life. In addition, suggested that walking exercise was more efficiently on the improvement of GER symptoms compared with diaphragmatic training among COPD patient comorbid GER symptoms. Caution should be exercised when assessing GERD symptoms in patients with COPD.An enhanced public awareness about these conditions is necessary, just as a more comprehensive approach to their management. |
