第五章 討論
第三節 結論
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第三節 結論
綜合來說，本研究結果指出OSAS 患者在給予療效回饋後，兩組間的 CPAP 使用情形，雖未能有顯著差異，但在回饋組中流失率較無回饋組少，顯示有給予 療效回饋的OSAS 患者，在後續願意持續使用 CPAP 的比例較高，間接的說明 若能夠提供OSAS 患者在接受 CPAP 治療前後的改變，會使得 OSAS 患者更願 意繼續使用CPAP，進而也能降低未來治療睡眠呼吸中止症併發症的發生及醫療 支出（林律瑋，2009）。此外，患者在使用 CPAP 治療後，無論有無給予療效回 饋，其睡眠品質及嗜睡程度能夠有明顯的改善，對CPAP 的接受程度也明顯的 增加。
從TTM 中行為改變的處理過程來看，個體自身可透過自我再評估（self revaluation）的策略，增加行為改變的動機，而療效的回饋是一種意識的提升
（consciousness raising），透過教育及回饋的方式提升個體做出行為改變，過 去研究從TTM 的角度來看，發現到開始使用 CPAP 後的 1 週至 1 個月的 ESS 狀態，比未開始使用CPAP 前的資料，更能夠有效預測未來 3 個月至 6 個月後 CPAP 的使用狀況（Stepnowsky et al., 2002；Aloia et al., 2005），顯示當患者 開始使用CPAP 後，可運用自我再評估的策略，使自己能夠繼續使用 CPAP，而 從運思期或準備期（preparation）逐漸進入行動期及維持期，本研究在運思期及 準備期增加療效回饋，亦是企圖使患者能更穩定的進入行動期，而結果也顯示有 給予療效回饋的患者比沒有療效回饋的患者更能夠進入下個行為改變的階段，而 不退回上一個的階段。
根據研究結果，提出幾項研究中的限制與未來進一步探討的方向：首先，由 於本研究只選取願意連續使用2 個月 CPAP 的受試者，小樣本的研究可能會使 應該顯著的變項卻不顯著，以致影響研究發現。其次，本研究在客觀測量上僅有 2 個測量時間點，只能看到治療前後的改變，無法瞭解長期療效的改變，建議另 外增加長期追蹤的方式，觀察部分主觀、客觀改變是否有產生變化，以及CPAP
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的療效變化情形，而能更瞭解患者願意進入到維持期的情況。再則，本研究為測 量患者在接受回饋後的瞭解程度，瞭解程度也可能會影響患者接受CPAP 治療 的情況，建議未來研究在療效回饋後增加測量患者對於回饋的瞭解程度，以更進 一步瞭解是否因回饋的接受程度不同而影響CPAP 的使用。此外，本研究僅蒐 集願意使用CPAP 及參與研究的受試者，但確診為 OSAS 的 144 名患者中，願 意使用CPAP 的人數僅有 69 人（正式納入研究 42 人、使用 CPAP 但拒絕研究 者27 人），願意開始使用 CPAP 的比例為 47.9%，未來研究可提高不願意開始 使用CPAP 的患者之動機，例如：提供其他長期使用 CPAP 患者的主觀、客觀 資料，或長期使用CPAP 患者的經驗分享等，讓不願意使用 CPAP 的患者，願 意嘗試使用CPAP。且由於本研究所測量的客觀資料為 PVT 及 HRV 在結果中未 能如預期，除可能因樣本數少的影響外，可能亦受到施測程序上的影響，建議未 來研究需仔細考量施測程序，避免因施測程序所造成的影響。最後，本研究所探 討的部分，在以白天所測得的主客觀功能狀態做為CPAP 療效回饋依據，卻少 了夜間睡眠狀態資料，如：同時使用CPAP 時的 PSG 資料，能更精確的提供 OSAS 患者在夜間使用 CPAP 時，各項睡眠的指標，以提供更多元的療效回饋 資料。
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參考文獻
林律瑋，2009，睡眠呼吸中止症成本推估。台北醫學大學醫務管理學研究所。
陳其昌，2007，運用跨理論模式養成身體活動習慣。運動教育，17，72-80。
吳家碩、蔡宜儒、陳濘宏、楊建銘。（2011）。阻塞性睡眠呼吸中止症患者情緒 狀態與疾病嚴重度的關聯: 探討自主神經系統及嗜睡程度的中介影響。應用 心理研究。50，81-119。
Agrawal S., Sharma S. K., Sreenivas V., & Lakshmy R. (2011). Prevalence of metabolic syndrome in a north Indian hospital-based population with obstructive sleep apnoea. The Indian Journal of Medicial Research, 134(5), 639-644.
Aloia M. S., Di Dio L., Ilniczky N., Perlis M. L., Greenblatt D. W., & Giles D. E.
(2001). Improving compliance with nasal CPAP and vigilance in older adults with OAHS. Sleep Breathing, 5(1), 13-21.
Aloia M. S., Arnedt J. T., Riggs R. L., Hecht J., & Borrelli B. (2004). Clinical management of poor adherence to CPAP: motivational enhancement.
Behavioral Sleep Medicine, 2(4), 205-222.
Aloia M. S., Arnedt J. T., Stepnowsky C., Hecht J., & Borrelli B. (2005).
Predicting treatment adherence in obstructive sleep apnea using
principles of behavior change. Journal of Clinical Sleep Medicine.; 1(4), 346-353.
American Academy of Sleep Medicine. (2005). The international classification of sleep disorders, revised (ICSD-II) (2nd edn ed.): Westchester, IL: AASM.
Andrews J. G., & Oei T. P. (2004). The roles of depression and anxiety in the understanding and treatment of Obstructive Sleep Apnea Syndrome.
Clinical Psychology Review, 24(8), 1031-1049.
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
Antic N. A., Catcheside P., Buchan C., Hensley M., Naughton M.T., Rowland S., et al. (2011). The effect of CPAP in normalizing daytime sleepiness,
quality of life, and neurocognitive function in patients with moderate to severe OSA. Sleep, 34(1), 111-119.
Avlonitou E., Kapsimalis F., Varochakis G., Vardavas C. I. & Behrakis P. (2012).
Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients. Sleep Breath, 16(2), 563-569.
Bakker J., Campbell A., & Neill A. (2010). Randomized Controlled Trial
Comparing Flexible and CPAP Delivery: Effects on Compliance, Objective and Subjective Sleepiness and Vigilance . Sleep, 33(4), 523-529.
Banno K., & Kryger M. H. (2007). Sleep apnea: clinical investigations in humans. Sleep Medicine, 8(4), 400-26.
Barbé F., Mayoralas L. R., Duran J., Masa J. F., Maimó A,. Montserrat J. M., &
et al., (2001). Treatment with continuous positive airway pressure is not effective in patients with sleep apnea but no daytime sleepiness. a randomized, controlled trial. Annals of Internal Medicine, 134(11), 1015-1023.
Barbé F., Durán-Cantolla J., Capote F., de la Peña M., Chiner E., Masa J. F., &
et al. (2010). Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea. American Journal of Respiratory and Critical Care Medicine, 181(7), 718-726.
Barnes M., Houston D., Worsnop C. J., Neill A. M., Mykytyn I. J., Kay A., et al.
(2002). A Randomized Controlled Trial of Continuous Positive Airway Pressure in Mild Obstructive Sleep Apnea. American Journal of Respiratory and Critical Care Medicine, 165(6), 773-780.
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
Bartlett D. (2011). Cognitive behavioral therapy to increase adherence to continuous positive airway. In: M. Perlis, M. Aloia & B. Kuhn (Eds).
Behavioral treatment for sleep disorders (1st ed., pp.211-214). London:
Elsevier Inc.
Basner M., & Dinges D. F. (2011). Maximizing sensitivity of the psychomotor vigilance test (PVT) to sleep loss. Sleep, 34(5), 581-591.
Bawden F. C., Oliveira C. A., & Caramelli P.(2011). Impact of obstructive sleep apnea on cognitive performance. Arquivos de Neuro-Psiquiatria, 69(4), 585-589.
Beebe D. W., Groesz L., Wells C., Nichols A., & McGee K. (2003). The
neuropsychological effects of obstructive sleep apnea: a meta-analysis of norm-referenced and case-controlled data. Sleep, 26(3), 298-307.
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J.
(1989). The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Research, 28, 193-213.
Chen C. W., Yang C. M., & Chen N. H.(2012). Objective versus subjective cognitive functioning in patients with obstructive sleep apnea. The Open Sleep Journal. 5, 33-42.
Chen N. H., Johns M. W., Li H. Y., Chu C. C., Liang S. C,. Shu Y. H., et al.
(2002). Validation of a Chinese version of the Epworth sleepiness scale.
Quality of Life Research, 11, 817-821.
Chen J. Y., Lee Y. L., Tsai W. C., Lee C. H., Chen P. S., Li Y. H. et al. (2011).
Cardiac autonomic functions derived from short-term heart rate variability recordings associated with heart rate recovery after treadmill exercise test in young individuals. Heart Vessels, 26, 282-288.
Cheng J. H., Hua C. C., Chen N. H., Liu Y. C., & Yu C. C. (2011). Autonomic
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
activity difference during CPAP titration in patients with obstructive sleep apnea/hypopnea syndrome with or without hypertension. Chang Gung Medicine Journal, 34(4), 410-417.
Chervin R. D., Theut S., Bassetti C., & Aldrich M. S. (1997). Compliance with nasal CPAP can be improved by simple interventions. Sleep, 20(4), 284-289.
Chuang L. P., Hsu S. C., Lin S. W., Ko W. S., Chen N. H., & Tsai Y. H. (2008).
Prevalence of snoring and witnessed apnea in Taiwanese adults. Chang Gung Medicine Journal, 31(2), 175-181.
Coughlin S. R., Mawdsley L., Mugarza J. A., Calverley P. M., & Wilding J. P.
(2004). Obstructive sleep apnoea is independently associated with an increased prevalence of metabolic syndrome. European Heart Journal, 25(9), 735-741.
Dinges D. F., & Powell J. W. (1985). Microcomputer analysis of performance on a portable, simple visual RT task during sustained operations. Behavior research methods, 17(6), 652-655.
Dray J. & Wade TD.. (2012). Is the transtheoretical model and motivational interviewing approach applicable to the treatment of eating disorders: A review. Clinical Psychology Review. 32(6), 558-565.
Engleman H. M., Asgari-Jirhandeh N., McLeod A. L., Ramsay C. F., Deary I. J.,
& Douglas N. J. (1996). Self-reported use of CPAP and benefits of CPAP therapy: a patient survey. Chest, 109, 1470-1476.
Engleman H. M., & Wild M. R. (2003). Improving CPAP use by patients with the sleep apnoea-hypopnoea syndrome (SAHS). Sleep Medicine Reviews, 7(1),.81-99.
Evers K. E., Paiva A. L., Johnson J. L., Cummins C. O., Prochaska J. O.,
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
Prochaska J. M.,& et al.. (2012). Results of a transtheoretical
model-based alcohol, tobacco and other drug intervention in middle schools. Addictive Behaviors. 37(9), 1009-1018.
Ferguson K. A. & Lowe A. A. (2005). Oral appliances for sleep-disordered breathing. In: M. H. Kryger, T. Roth & W. C. Dement. (2005). Principle and Practice of Sleep Medicine, 4th ed. Philadelphia：Elsevier Saunders.
Ferini-Strambi L,. Baietto C., Di Gioia M. R., Castaldi P., Castronovo C., Zucconi M., & et al. (2003). Cognitive dysfunction in patients with obstructive sleep apnea (OSA): partial reversibility after continuous positive airway pressure (CPAP). Brain Research Bulletin, 61(1), 87-92.
Fuchs F. S., Pittarelli A., Hahn E. G., & Ficker J.H. (2009). Adherence to continuous positive airway pressure therapy for obstructive sleep apnea:
impact of patient education after a longer treatment period. Respiration, 80(1), 32-37.
Gabbay I. E., & Lavie P. (2011). Age- and gender-related characteristics of obstructive sleep apnea. Sleep Breath, 16(2):453-460.
Gilman M.P., Floras J.S., Usui K., Kaneko Y., Leung R.S., & Bradley T.D.
(2008). Continuous positive airway pressure increases heart rate
variability in heart failure patients with obstructive sleep apnoea. Clinical Science (London, England), 114(3), 243-249.
Golbin J. M., Somers V. K., & Caples S. M. (2008). Obstructive sleep apnea, cardiovascular disease, and pulmonary hypertension. Proceedings of the American Thoracic Society, 5, 200-205.
Grandi A. M., Laurita E., Marchesi C., Maresca A. M., Solbiati F., Bernasconi A., et al. (2012). OSA, metabolic syndrome and CPAP: effect on cardiac remodeling in subjects with abdominal obesity. Respiratory Medicine,
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
106(1), 145-152.
Grunstein R. (2005). Continuous positive airway pressure treatment for obstructive sleep apnea-hypopnea syndrome. In: M. H. Kryger, T. Roth &
W. C. Dement. (2005). Principle and Practice of Sleep Medicine, 4th ed.
Philadelphia：Elsevier Saunders.
Haynes P.L. (2005). The role of behavioral sleep medicine in the assessment and treatment of sleep disordered breathing. Clinical Psychology Review, 25(5), 673-705.
Hedner J. Franklin K. A. & Peker Y. (2005). Coronary artery disease and obstructive sleep apnea. In: M. H. Kryger, T. Roth & W. C. Dement. (2005).
Principle and Practice of Sleep Medicine, 4th ed. Philadelphia：Elsevier Saunders.
Horiuchi S., Tsuda A., Watanabe Y., Fukamachi S., & Samejima S.. (2012).
Validity of the six stages of change for exercise. Journal of Health Psychology. 18(4), 518-527.
Iber C., Ancoli-Israel S., Chesson A.,& Quan S. (2007). The AASM Maunal for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications (1st ed.). Illinois: American Academy of Sleep Medicine.
Javaheri S. (2005). Heart failure. In: M. H. Kryger, T. Roth & W. C. Dement.
(2005). Principle and Practice of Sleep Medicine, 4th ed. Philadelphia：
Elsevier Saunders.
Jenkinson C., Davies R. J., Mullins R., & Stradling J. R. (2001). Long‐term benefits in self‐reported health status of nasal continuous positive airway pressure therapy for obstructive sleep apnoea. QJM: An International Journal of Medicine, 94(2), 95-99.
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
Johns M. W. (1991) A new method for measuring daytime sleepiness the Epworth Sleepiness Scale. Sleep, 14(6), 540-545.
Karasulu L,, Epöztürk P, O,, Sökücü S, N,, Dalar L,, & Altin S. (2010).
Improving Heart rate variability in sleep apnea patients: differences in treatment with auto-titrating positive airway pressure (APAP) versus conventional CPAP. Lung, 188(4), 315-320.
Konermann M., Sanner B. M., Vyleta M., Laschewski F., Groetz J., Sturm A.,
&et al. (1998). Use of conventional and self-adjusting nasal continuous positive airway pressure for treatment of severe obstructive sleep apnea syndrome: a comparative study. Chest, 113(3), 714-718.
Krakow B., Ulibarri V., Melendrez D., Kikta S., Togami L., & Haynes P. (2008).
A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP). Journal of Clinical Sleep Medicine., 4(3), 212-222.
Kribbs N. B., Pack A. I., Kline L. R. Smith P. L., Schwartz A. R., Schubert N. M., et al. (1993). Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. American Review of Respiratory Disease, 147, 1162-1168.
Kufoy E., Palma J. A., Lopez J., Alegre M., Urrestarazu E., Artieda J., & Iriarte J. (2012). Changes in the heart rate variability in patients with Obstructive Sleep Apnea and its response to acute CPAP treatment. PLoS One, 7(3), e33769.
Lal C., Strange C., & Bachman D. (2012). Neurocognitive impairment in obstructive sleep apnea. Chest. 141(6), 1601-1610.
Lattimore J. D., Celermajer D. S., & Wilcox I. (2003) Obstructive sleep apnea
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
and cardiovascular disease. Journal of American College Cardiology, 41(9), 1429-1437.
Lavie P., Herer P. & Hoffsstein V. (2000). Obstructive sleep apnoea syndrome as a risk factor for hypertension: population study. BMJ, 320(7233), 479-482.
Lévy P., Bonsignore M. R., & Eckel J. (2009). Sleep, sleep-disordered breathing and metabolic consequences. The European Respiratory Journal, 34(1), 243-260.
Li K. K. & Riley R. W. (2002). Obstructive sleep apnea and maxillomandibular advance. Journal of Oral and Maxillofacial Surgery. 60:526-530.
Lim W., Bardwell W. A., Loredo J. S., Kim E. J., Ancoli-Israel S., Morgan E. E., et al. (2007). Neuropsychological effects of 2-week continuous positive airway pressure treatment and supplemental oxygen in patients with obstructive sleep apnea: a randomized placebo-controlled study. Journal of Clinical Sleep Medicine, 3(4), 380-386.
Malik, M. (1996). Heart rate variability: standards of measurement,
physiclogical interpretation, and clinical use. Circulation, 93, 1043-1065.
Massie C. A., Hart R. W., Peralez K., & Richards G. N. (1999). Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure. Chest, 116(2), 403-408.
Mazza S., Pépin J. L., Naëgelé B., Plante J., Deschaux C., & Lévy P. (2005).
Most obstructive sleep apnoea patients exhibit vigilance and attention deficits on an extended battery of tests. The European Respiratory Journal, 25(1), 75-80.
McArdle N., Devereux G., Heidarnejad H., Engleman H. M., Mackay T. W., &
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
Douglas N.J., (1999). Long-term use of CPAP therapy for sleep
apnea/hypopnea syndrome. American of Journal Respiratory and Critical Care Medicine.;159(4), 1108-1114.
Mehra R., Benjamin E. J., Shahar E., Gottlieb D. J., Nawabit R., Kirchner H. L., et al.(2006). Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. American Journal of
Respiratory and Critical Care Medicine, 173(8), 910-916.
Meslier N., Lebrun T., Grillier-Lanoir V., Rolland N., Henderick C., Sailly J. C.,
& Racineux J. L. (1998). A French survey of 3,225 patients treated with CPAP for obstructive sleep apnoea: benefits, tolerance, compliance and quality of life. European Respiratory Journal, 12(1), 185-192.
McCraty, R., Atkinson, M., Tiller, W. A., Rein, G., & Watkins, A. D. （1995）.
The effects of emotions on short-term power spectrum analysis of heart rate variability. Am J Cardiol, 76, 1083-1093.
Muñoz A., Mayoralas L. R., Barbé F., Pericás J., & Agusti A. G. (2000).
Long-term effects of CPAP on daytime functioning in patients with sleep apnoea syndrome. The European Respiratory Journal. 15(4), 676-681.
Naëgelé B., Thouvard V., Pépin J. L., Lévy P., Bonnet C., Perret J. E., & et al.
(1995). Deficits of cognitive executive functions in patients with sleep apnea syndrome. Sleep, 18(1),43-52.
Naëgelé B., Pépin J. L., Lévy., Bonnet C., Pellat J., & Feuerstein C. (1998).
Cognitive executive dysfunction in patients with obstructive sleep apnea syndrome (OSAS) after CPAP treatment. Sleep, 21(4), 392-397.
Nieto F. J., Young T. B., Lind B. K., Shahar E., Samet J. M., Redline S., et al.
(2000). Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. JAMA, 283(14),
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
1829-1836.
Ng, T. P., Seow, A., & Tan, W. C. (1998). Prevalence of snoring and sleep breathing-related disorders in Chinese, Malay and Indian adults in Singapore. European Respiratory Journal, 12, 198-203.
Olsen S., Smith S. S., Oei T. P., & Douglas J. (2012). Motivational interviewing (MINT) improves continuous positive airway pressure (CPAP) acceptance and adherence: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 80(1), 151-163.
Patel S. R., White D. P., Malhotra A., Stanchina M. L., & Ayas N. T. (2003).
Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a
meta-analysis. Archives of Internal Medical, 163(5), 565-571.
Pieters T., Collard P., Aubert G., Dury M., Delguste P., & Rodenstein D. O.
(1996). Acceptance and long-term compliance with nCPAP in patients with obstructive sleep apnea syndrome. European Respiratory Journal, 9, 939-944.
Pons Y., Ballivet de Régloix S., Maurin O., & Conessa C. (2011). Prevalence of and risk factors for obstructive syndrome apnea. Revue de Laryngologie.
132(2), 89-94.
Powell N. B., Riley R. W. & Gulleminault C. (2005). Durgical management of sleep-disordered breathing. In: M. H. Kryger, T. Roth & W. C. Dement.
(2005). Principle and Practice of Sleep Medicine, 4th ed. Philadelphia：
Elsevier Saunders.
Prochaska J. O., DiClemente C. C., & Norcross J. C.. (1992). In search of how people change. Applications to addictive behaviors. American
Psychologist. 47(9), 1102-1114.
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
Punjabi N. M., Shahar E., Redline S., Gottlieb D. J., Givelber R., Resnick H. E.,
& et al. (2004). Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart Health Study. American journal of Epidemiology, 160(6), 521-530.
Punjabi N. M. & Beamer B. A. (2005). Sleep apnea and metabolic dysdunction.
In: M. H. Kryger, T. Roth & W. C. Dement. (2005). Principle and Practice of Sleep Medicine, 4th ed. Philadelphia：Elsevier Saunders.
Rauscher H., Popp W., Wanke T., & Zwick H. (1991). Acceptance of CPAP Therapy for Sleep Apnea. Chest, 100, 1019-1023.
Richards D., Bartlett D. J., Wong K., Malouff J., &Grunstein R. R. (2007).
Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Sleep, 30(5), 635-640.
Rollnick S. & Miller W. R. (1995). What is Motivational Interviewing?
Behavioural and Cognitive Psychotherapy, 23, 325-334.
Roche F., Court-Fortune I., Pichot V., Duverney D., Costes F, Emonot A., & et al. (1999). Reduced cardiac sympathetic autonomic tone after long-term nasal continuous positive airway pressure in obstructive sleep apnoea syndrome. Clinical Physiology, 19(2), 127-134.
Sánchez A. I., Martínez P., Miró E., Bardwell W. A., Buela-Casal G. (2009).
CPAP and behavioral therapies in patients with obstructive sleep apnea:
effects on daytime sleepiness, mood, and cognitive function. Sleep
effects on daytime sleepiness, mood, and cognitive function. Sleep