| 摘要: | 本研究目的在找出影響國內原發性自發性氣胸病患復發的主要危險因子，並建立一適當之預測氣胸復發之模型，以做為臨床診療指引的依據。資料來源是以病歷回顧並輔以電話查訪之方式，自1995年全民健保實施後至2000年間，由北部、中部及南部二家醫學中心及二家區域醫院選取所有合乎條件之首次單側原發性自發性氣胸病患600例納入研究。經由邏輯斯迴歸分析結果得知，在13個自變項中影響國人原發性自發性氣胸復發的危險因子有身體質量指數(BMI)、氣胸發病時之活動、氣胸的第一次治療方式、職業、抽菸、氣胸發病季節等六項(p<0.05)，而與性別、年齡、家族氣胸史、氣胸症狀、第一次氣胸之病側、x光氣胸大小比例、氣胸合併症等因素無關。由卡方自動互動偵測法結果則可知氣胸的第一次治療方式、病患之職業、年齡、x光氣胸比例及氣胸發作時有無活動等五個危險因子在統計上可以顯著的預測國人自發性氣胸之復發。 在600例樣本中有255例(42.50%)復發，氣胸發作之第一次治療方式是最顯著預測氣胸是否復發的變項。若首次治療為插胸管引流有157例(52.86%)氣胸復發，若採用視訊輔助式胸腔鏡手術治療有41例(20.50%)氣胸復發，行開胸手術治療氣胸的病患則有7例(16.67%)復發，至於以保守觀察方式治療的病患中有50例(81.97%)氣胸復發。因此，氣胸發作時的不同治療方式，所造成的氣胸復發機率亦有差異，其中以開胸手術復發機率最小，再來為胸腔鏡手術、插胸管引流、保守治療等，復發機率由低而高持續增加。 卡方自動互動偵測法以樹狀圖的模式呈現在不同的危險因子組合下自發性氣胸復發的機率，於最後分割出的9個群組中，可看出復發率由12.59% 到97.14%不等，組間變異頗大，這也表示了各個預測變項的不同影響，彼此間的交互作用，以及評估與自發性氣胸復發相關的危險因子的重要性。其中年齡大於18歲的病患若施予VATS治療則復發率為12.59%，是9個組別中氣胸之復發機率最低者；而胸部x光上氣胸比例大於20%，即中度或重度氣胸的病患，若採取保守觀察，復發率高達97.14%，為9組中復發機率最高者。 本研究結果顯示最能影響國內原發性自發性氣胸復發的危險因子，並建立一適當的預測氣胸復發之模型，臨床上若在病患首次發作氣胸時即判斷出其是否屬於未來會復發的高危險群，施予適當的治療，則可以有效的降低疾病復發率及醫療照護成本，達到疾病管理，提高醫療品質的目的。; The objective of this study is to identify the risk factors of recurrence for primary spontaneous pneumothorax in Taiwan and to establish an appropriate model to predict the probability of recurrence in order to assist clinical management. From 1995, the beginning year of national health insurance, to the year of 2000, retrospective data based on chart review and telephone interview were collected from 600 cases of first-time primary spontaneous pneumothorax in two teaching center hospitals and two regional hospitals located at northern, central and southern Taiwan respectively. Data were analyzed using logistic regression and CHAID statistical methods. Among the thirteen independent variables, six risk factors are significantly associated with the recurrence of spontaneous pneumothorax. They are the body mass index, activity during the onset of spontaneous pneumothorax, the first-time treatment modality, occupation, smoking, and the season (p<0.05). Moreover, CHAID method revealed that the first-time treatment modality, occupation, age, size of pneumothorax on the chest X-ray and activity during the onset of spontaneous pneumothorax are the five risk factors to significantly predict the recurrence of spontaneous pneumothorax. Among the 600 patients of this study, 255 (42.5%) patients have recurrence. The first-time treatment modality is the most significant variable. One hundred and fifty-seven patients (52.86%) treated by chest tube for the first time of spontaneous pneumothorax had recurred. Forty-one patients (20.5%) developed recurrent pneumothorax after receiving VATS therapy, while recurrence ensued in 7 patients (16.67%) if thoracotomy procedure was applied. Conservative treatment with observation approach led to recurrence in 50 patients (81.97%). Therefore, the chance of recurrence of pneumothorax varied according to different management strategies with thoracotomy having least rate of recurrence followed increasingly by VATS, chest intubation and conservative measures. The decision tree from the result of CHAID produced nine groups with recurrence rate of pneumothorax ranging from 12.59% to 97.14%. The wide range between the groups also reveals the different impact of individual predictive variables, interactions between them, and importance to evaluate the effect of the risk factors on the recurrence of spontaneous pneumothorax. Patients with chest X-ray finding of more than 20% of pneumothorax and received conservative treatment for their first episode of spontaneous pneumothorax have the highest recurrence rate of 97.14%. Conversely, patients with age more than eighteen years old and treated by VATS had the least recurrence rate of 12.59%. This study identified the risk factors of recurrence of primary spontaneous pneumothorax in Taiwan and provided an appropriate model for prediction of recurrence of pneumothorax. This result could practically he |
