- 學位論文
呼吸器依賴病人脫離成功影響因素之回溯性研究
Factors of Successful Weaning of Patients With Mechanical Ventilation: a retrospective study
摘要
根據中央健保局2012資料顯示，全台長期使用呼吸器者已達11,573人，龐大的醫療成本，加上呼吸照護病房有70-80%的病人意識不清，因而引起無效醫療及資源浪費的爭議。因此，改善呼吸器依賴患者的預後、預防合併症，使病患脫離呼吸器，降低醫療成本及家屬的負擔已成當務之急。目前有關呼吸器成功脫離之研究，多針對加護病房及呼吸照護中心，甚少有使用呼吸器63天以上之脫離預測因子，且追蹤期間最多1∼2年，無法有效追蹤預後，本研究目的旨在探討影響呼吸照護病房病人成功脫離呼吸器的重要預測指標，提供醫療團對及家屬決策之參考。 本研究以病歷回溯研究方式進行，將北區某區域教學醫院自2005年3月1日至2012年5月28日所有入住呼吸照護病房之病人納入研究，研究對象選取條件為呼吸器使用超過21天者，並追蹤至脫離呼吸器或死亡。彙整文獻後，找出相關影響因素，並蒐集資料，所得資料以採卡方檢定及存活分析檢驗呼吸器成功脫離與否之顯著預測因素，再將疾病嚴重度分三層級（0-19；20-24；≧25）進行存活率分析。 研究結果顯示疾病嚴重度(acute physiology and chronic health evaluation, APACHE Ⅱ)＜20分、動脈血氧分壓（PaO2）>70mmHg、重碳酸氫根（HCO3-）位於22-23.1或32-40.9、血比容積30-45.9%、肌酸酐06-1.4meq/l、鈉離子130-149meq/l、鉀離子3.5-5.4meq/l、平均動脈血壓70-109mmHg、預估腎絲球過濾率≧90ml/min，以及脫離參數中的最大吸氣壓力（maximal inspiration pressure, PiMax）≦-20cmH2O、淺快呼吸指數（rapid shallow breath index, RSBI）＜105、潮器容積（tidal volume, VT）>4ml/kg、自行呼吸次數介於25-34或10-11bpm、呼吸功（work of breathing, WOB）不費力，其呼吸器成功脫離的比例均顯著較高（p < .05）；存活分析結果顯示， APACHEⅡ分數越低（風險比為0.84；95% CI: 0.72~0.98）、使用呼吸器至開氣切的天數越少（風險比為0.97；95% CI: 0.95~0.99 ）、WOB越低（風險比為0.03；95% CI: 0.00∼0.65）、尿素氮與肌酸酐比值越高（風險比為1.05；95% CI: 1.01∼1.09）、感染次數越少（風險比為0.87；95% CI: 0.79∼0.96），則呼吸器脫離成功的機會就越高，建議日後進行APACHEII評估，並參考相關變項來預測長期依賴呼吸器病人之成功脫離與否，進而介入適當之醫療照護處置。 關鍵詞：成功脫離(Successful Weaning)、呼吸照護病房(Respiratory Care Ward)
並列摘要
According to the data from Bureau of National Health Insurance, there were 11,573 people who demand long-term respirators because of respiratory failure. The Huge medical costs, and respiratory care ward with 70-80% of patients with consciousness, and the cost of waste caused an invalid medical controversy. Therefore, improving the prognosis of ventilator-dependent patients and preventing complications will be able to significantly reduce medical expenditures and care burden of their families. However, most research of successful weaning recruited the more severe patients from intensive care unit (ICU) and respiratory care center (RCC), and followed a short period about one to two years only. Rarely use more than 63 days from the ventilator predictors. This study used retrospective study by medical records. Patients were recruited from a respiratory care ward (RCW) of a regional teaching hospital in North Taiwan since March 1, 2005 to May 28, 2012. The selection criteria was patients who used respirator more than 21 days. We collect data and used percentiges of categorical variables and mean and standard deviation of continuous variables for descriptive statistics. Chi-square test was used to examine related factors with successful weaning. Survival analysis and hazard ratio were used to explore significant predictors of successful weaning considering survival times. The results showed that when the patients’ APACHEII score less 20, arterial oxygen partial pressure>70mmHg, HCO3- 22-23.1 or 32-40.9, hematocrit30-45.9%, creatinine 0.6-1.4meq/l, sodium 130-149meq/l, potassium 3.5-5.4meq/l, mean arterial blood pressure 70-109mmHg, estimated glomerular filtration rate≧90ml/min, maximum inspiratory pressure were less than negative 20cmH2O, rapid shallow breathing index less than 105, tidal volume greater than 4ml/kg, spontaneous breathing frequency 25-34 bpm or 10-11 bpm, work of breathing without difficulty,had higher proportion to successfully weaned from the ventilator(p < .05). Survival analysis showed that lower APACHE Ⅱ score (hazard ratio: 0.84；95% CI: 0.72~0.98) , fewer days from ventilator to tracheostomy (hazard ratio: 0.97；95% CI: 0.95~0.99), lower work of breathing (hazard ratio: 0.03；95% CI: 0.00~0.65), fewer number of infections (hazard ratio: 0.87；95% CI: 0.79~0.96), higher serum urea nitrogen and creatinine ratio(hazard ratio: 1.05；95%CI:1.01~1.09) had significant correlation with ventilator weaning success. We suggested that relevant variables could predict successful weaning for long-term ventilator dependent patients and provide appropriate medical care intervention in the future. Keywords:successful weaning , respiratory care ward
參考文獻
延伸閱讀
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