研究目的:
台灣因為醫療之進步、全民健康保險普及以及人口老化，呼吸器依賴患者逐年增加。重大傷病患者的醫療費用占總健保費的26.2％，其中呼吸器依賴患者花費僅次於癌症及洗腎病患。因此本研究擬探討呼吸器依賴病患再插管的影響因子，期望能降低呼吸器依賴病患再插管率，減少再插管的合併症和縮短病患住院天數，降低住院醫療費用以達到多贏的局面。

研究方法:
本研究為回溯性研究，研究對象為屏東某區域教學醫院，收集2005年1月至2010年12月年齡大於17歲且呼吸器使用>21天的病患為研究對象，共計313位。以描述性統計分析、卡方分析及羅吉斯迴歸分析，分別就病患屬性包括性別、年齡、疾病嚴重度(APACH II)、實驗室數據、科別、疾病特質等，來探討呼吸器依賴病患成功脫離呼吸器及再插管之因素。

研究結果:
本研究中成功脫離呼吸器(247位)及再插管(66位)病患平均年齡為72±15 vs. 76±15歲(p=0.092)、疾病嚴重度分數 18±7 vs. 22±8(p<0.001)、鉀離子(K+) 3.8±0.8 vs. 4.2±0.9 mmol/L(p=0.002)、鈣離子(Ca+) 8.0±0.7 vs. 8.6±0.9 mmol/L(p=0.007)、白血球(WBC) 13880±7270 vs. 17720±9540 (p=0.003) 、血紅素(Hb)11.8±2.6 vs. 10.4±1.5 g/dL (p<0.001)、血小板(Platelet) 229240±107270 vs. 288670±120920 (p=0.002)。然而用羅吉斯迴歸分析發現疾病嚴重度(相對危險比1.18；p=0.028)、血紅素(相對危險比0.55；p=0.05)對於病患是否成功脫離呼吸器及再插管最具影響力。由ROC曲線可找出Hb於11.3 g/dL為再插管的風險臨界值。

討論與結論:
本研究發現若年齡每增加1歲，再插管機率增加將近1.2倍；疾病嚴重度每增加1分，再插管機率增加將近1.2倍；而血紅素每增加1 g/dL，再插管機率則降低45%。因此本研究建議臨床醫師若能將此類病患血紅素提昇至高於11.3 g/dL，有可能大幅降低病患再插管之機率。

Goal
Due to the development of medical technology, implementation of national health insurance (NHI) program and population aging, the increasing of ventilator-dependent patients are significant within these years. Patients with the catastrophic illness certification spent about 26.2% NHI medical resource. Oncology, hemodialysis and ventilator-dependent patients were thought to be the most resource utilized ones. The objective of this study was to find the possible risk of reintubation on those ventilator-dependent patients. So, that we may reduce the reintubation rate and shorten their hospital stays.
Method
This study was a retrospective study based on the database of a local teaching hospital. During 2005 and 2010, patients aged older than 17 years old and required more than 3 weeks of mechanical ventilation support were selected. Here were total 313 cases include 247 successful weaning and 66 reintubation. Statistical analysis included descriptive statistic, Chi-square test and logistic regression by SPSS&#174; for windows. Risk factors included their demographic features, acute physiology and chronic health evaluation (APACHE) II scoring system as well as laboratory data.
Results
The ages of successful weaning and reintubation patients were 72±15 vs. 76±15, p=0.092 years old, respectively. APACH II score (17±8 vs. 22±8, p<0.001), BUN (33.2±26 vs. 43.0±33 mg/dL, p=0.033), K+ (3.8±0.8 vs. 4.2±0.9 mmol/L, p=0.002), Ca+ (8.0±0.8 vs. 8.6±0.9 mmol/L, p=0.007), WBC (13880±7270 vs. 17720±9540, p=0.003), Hb (11.8±2.5 g/dL vs. 10.3±1.4 g/dL, p<0.001), Platelet (224400±106310 vs. 284570±119160,p=0.001). However, Logistic regression found two significant factors were APACHE II (odds ratio [OR], 2.97), Hb (OR, 0.701). By means of ROC curves, we derived the critical values of reintubation risk due to Hb as 11.3 g/dL respectively.
Conclusion
Based on the results, we inference that the reintubation risk increases up to 1.2 per unit APACHE II score while decreases 45% per unit Hb. It is suggested that if clinical physician could keep Hb of patients above 11.3 g/dL respectively, the reintubation rate may be significantly reduced.

致謝 I
摘要 II
Abstract III
第一章、緒論 1
第一節、研究背景與重要性 1
第二節、研究動機 1
第三節、研究目的 2
第四節、研究問題與假設 3
第二章、文獻探討 4
第一節、呼吸器依賴的定義及相關研究 4
第二節、呼吸器依賴病患醫療資源耗用之分析 8
第三節、影響呼吸器依賴病患呼吸器再插管之相關研究 11
第四節、全民健康保險呼吸器依賴患者整合性照護前瞻性支付試辦計畫成效之相關研究 15
第三章、研究方法 18
第一節、研究架構 18
第二節、研究設計 19
第三節、研究材料與方法 21
第四章、研究結果 23
第五章、討論 34
第一節、影響呼吸器依賴患者呼吸器脫離及再插管因素探討 34
第二節、呼吸器依賴患者與血色素角色的探討 38
第三節、呼吸器依賴患者資源耗用與政策探討 40
第六章、結論及建議 43
第一節、結論 43
第二節、建議 44
Reference 45
英文部分 45
中文部分 51
表目錄
表2-1國內有關呼吸器依賴病患相關研究整理………… ..……. 6
表2-2國外有關呼吸器依賴病患相關研究整理………….. ……. 7
表2-3國內外有關呼吸器依賴病患醫療資源耗用相關研究整理 … 10
表2-4國內外有關呼吸器依賴病患再插管相關研究整理…… ….. 13
表4-1研究對象基本特徵與實驗室數據的相關性分析…..… ….. 25
表4-2研究對象依科別的相關性分析……………………..… ….. 27
表4-3研究對象依科別區分有無氣切造&#30267;口分析結果……. …….. 27
表4-4研究對象依科別看做氣切造&#30267;口後到呼吸器脫離平均天數和開始使用呼吸器到做氣切造&#30267;口平均天數的相關性分析.… ….. 29
表4-5研究對象依科別區分與成功脫離及再插管病人分析結果…. 30
表4-6研究對象住院天數與費用相關性分析……………… … …. 31
表4-7影響病患再插管因素迴歸分析………..……………… .. . 32
圖目錄
圖2-1重大傷病醫療費用申報概況……………………….. … …. 8
圖2-2老年人口醫療資源耗用情形……………………….. ……. 9
圖2-3呼吸器依賴患者整合性照護試辦計畫流程圖……. ....……16
圖3-1研究架構……. ............................ .....……18
圖3-2個案收案流程. ...................... ...........……20
圖4-1預測成功脫離及再插管的血紅素臨界值ROC曲線… ...……33
圖5-1成功脫離與再插管病患醫療資源耗用與住院天數的比較………………………………………………………………………42

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