氣管內管拔管後的吞嚥效率與安全

Swallow Efficiency and Safety after Endotracheal Extubation

吳崇珮(Chung-Pei Wu) ； 古世基(Shih-Chi Ku) ； 王亭貴(Tyng-Guey Wang) ； 蕭自佑(Tsu-You Hsiao) ； 陳佳慧(Cheryl Chia-Hui Chen)

《台灣醫學》 22卷2期 (2018/03) Pp. 205-210

https://doi.org/10.6320/FJM.201803_22(2).0013

摘要

良好的吞嚥效率(swallow efficiency)與吞嚥安全(swallow safety)是維持正常吞嚥功能的兩大關鍵，然而高達84%接受長期氣管插管(持續氣管插管≧48小時)的重症病患於成功脫離氣管內管後，其吞嚥效率及吞嚥安全受到影響，而出現拔管後吞嚥困難(post-extubation dysphagia，PED)的症狀。氣管內管長期的接觸及壓迫口咽部造成的口咽部組織損傷，使病患的舌肌效能不足，導致吞嚥效率降低，無法恢復正常且安全的經口進食。長期氣管插管同時也鈍化了吞嚥及咳嗽反射，使口咽神經反應遲滯，病患的吞嚥安全因而受到影響，於經口進食時易引發滲入(penetration)或吸入(aspiration)等危險。PED的高盛行率及後續引發的吸入性風險，近年來漸受國內外關注，其症狀持續至出院後的特性也讓PED被歸類為加護症候群(post-intensive care syndromes，PICs)之一。學者們也提出應盡快發展出以PED病生理機轉為依歸的篩檢、評估、及介入方式。有鑒於此，本文以氣管插管拔管後病患的吞嚥效率及吞嚥安全為架構，簡述正常的吞嚥過程、PED的臨床表現及其吸入性危險及歸納出PED兩大病生理機轉：舌肌效能不佳及口咽神經反應遲滯，也期使臨床醫療人員能對PED更為了解，並作為未來建立PED之篩檢、臨床評估指引與介入處理方針之參考。

關鍵字

拔管後吞嚥困難 ； 經口氣管插管 ； 經口進食

並列摘要

Swallow efficiency and safety are two key components for normal swallowing. However, it was reported that up to 84% of long-term intubated patients (i.e. receiving endotracheal intubation over 48 hours) had presented with post-extubation dysphagia (PED) due to its decreased swallowing efficiency and safety. Weak oropharyngeal muscles and delayed neural response are supposed to be the main etiologies of decreased swallowing efficiency and safety, leading to poor oral intake and increased risks of penetration and aspiration. Due to PED’s high prevalence and risks for aspiration, PED has gained much attention worldwide recently. Moreover, its persistence after critical illness until discharge make it be recognized as one of post-intensive care syndromes. Therefore, we used swallow efficiency and safety as main concepts to briefly review the normal swallowing process, prevalence of PED and aspiration, and etiology of PED, including weak oropharyngeal muscles and delayed neural response. By improving the understanding of PED, PED screening, assessment and intervention can be further developed.

並列關鍵字

post-extubation dysphagia ； oral endotracheal intubation ； oral intake

參考文獻

Rofes L, Arreola V, Almirall J, et al: Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterol Res Pract 2011;2011. pii: 818979.

蔡旻璇、吳國湘、蘇涵等: 經口氣管插管於口咽及吞嚥功能的影響。重症醫學雜誌 2012;13:185-9。[ Tsai MS, Wu KS, Su H, et al: Orophayngeal and swallowing functions after prolonged oral endotracheal intubation. Formosan J Med 2012;13:154-89.]

吳崇珮、古世基、王亭貴等：經口氣管插管拔管後吞嚥困難。台灣醫學2016;20:315-21。[Wu CP, Ku SC, Wang TG, et al: Post-extubation dysphagia. Formosan J Med 2016; 20:315-21.]

Macht M, Wimbish T, Clark BJ, et al: Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care 2011;15:1.

Kruser JM, Prescott HC: Dysphagia after acute respiratory distress syndrome. Another lasting legacy of critical illness. Ann Am Thorac Soc 2017;14:307-8.