- 學位論文
探討呼吸器脫離指標在延長脫離呼吸器的氣切病人上的預測效應：回溯性研究。
The predictive effect of the predictors of weaning from mechanical ventilation in tracheostomized patients with prolonged weaning: A retrospective study
摘要
背景: 對於急性呼吸衰竭病人使用呼吸器得到呼吸衰竭改善後，脫離呼吸器一直是很重要的臨床議題。其中雖然有大多數的病人能在第一次執行自主呼吸測試即完成脫離呼吸器，但仍有31-40% 的病人無法一次就順利脫離。更進一步，約15%的病人需要嘗試數次，甚至無法脫離而需要長時間使用呼吸器。由於執行氣切相較於使用氣管內管對病人來說具有可以減少呼吸道阻力等好處，而被視為可加速脫離過程的方式之一。同時，使用脫離呼吸器預測指標來評估病人脫離能力，在脫離的過程中更是不可或缺，其中呼吸淺快指標 (Rapid shallow breathing index, RSBI) 較具有預測能力。近年來，有研究探討在使用呼吸器的氣管內管插管病人以不同於以往的脫離呼吸器預測指標，像是修正過的RSBI以及脫離指標 (Weaning index, WI)比傳統的RSBI有更好的預測能力。然而，目前仍無針對延長脫離呼吸器的氣切病人利用修正過的呼吸器預測脫離指標來探討其預測能力的相關研究。 目的: 本研究的目的為使用回溯性研究的方式探討修正過的呼吸器脫離指標在延長脫離呼吸器的氣切病人上的預測效應及適當的閾值。 方法: 以回溯資料的方式，經由關鍵字「氣切」、「使用呼吸器」 針對2013年1月至2017年12月的電子病歷資料庫進行搜索符合納入條件的收案名單後，記錄病人基本資料(含第一天使用呼吸器的APACHE II、開始自主呼吸訓練時的BMI值等)、檢驗報告、開始執行自主呼吸試驗的呼吸器脫離參數等資料後進行統計分析。 結果: 四項脫離預測指標中，以RSBI(閾值≤92、敏感度69%、特異度84%、PPV 90%、NPV 56%、AUC 81.5%)及脫離指標(Weaning index, WI)(閾值≤57.7、敏感度73%、特異度86%、PPV 91%、NPV 60%、AUC 84.5%)的預測脫離成功能力較高。利用多變項迴歸分析後，預測脫離呼吸器的因子中，以年齡、性別、慢性肺阻塞疾病、RSBI、修正過後的RSBI、WI及EI為顯著相關因子。 結論: RSBI及WI在延長脫離的氣切病人上，皆有良好的預測呼吸器脫離的能力。我們可以將本篇研究中的閾值實際應用在脫離延長呼吸器的過程評估中，以決定最佳的脫離時間。
並列摘要
Background：Weaning from mechanical ventilation (MV) is a prominent process in patients with acute respiratory failure when a patient’s underlying cause of respiratory failure begins to reverse or stabilize. Although the majority of patients will wean from MV successfully at the first spontaneous breathing trial (SBT), there are still about 31-40% of patients who will need more than one attempts of SBT. Furthermore, there is about 15% of patients who are prolonged weaning or ventilator dependent. Tracheostomy is an alternative way to promote weaning from MV because of the benefits of decreasing airway resistance and improving patient comfort. Meanwhile, it is crucial to determine the time of weaning from MV by weaning parameters. Rapid shallow breathing index (RSBI) has been thought as an accurate predictor of weaning from MV for decades. In recent years, there are studies that suggest better predictive effects on modified RSBI and weaning index(WI) than the traditional RSBI in orotracheally intubated patients before weaning from MV. To the best of our knowledge, there is no study the predictive effect of the modified predictors of weaning from MV in tracheostomized patients with prolonged weaning. Purpose：To examine the predictive effects of the modified predictors of weaning from MV in tracheostomized patients with prolonged weaning. Methods：This was a retrospective study. The chart database at the intensive care units and respiratory care center (RCC) in a medical center in a 5-year period were collected and analyzed. Weaning parameters, body mass index (BMI), ventilator parameters, arterial blood gas (ABG), and the outcome of weaning from MV were recorded. The thresholds, positive predictive value (PPV), negative predictive value (NPV), specificity and sensitivity of RSBI, modified RSBI, and WI were analyzed. Results：A total of 238 patients were included. 76 (31.9%) patients were successfully weaned. In weaning failure group, patients were older, had lower rates of airway protection, hypercapnic respiratory failure in the reasons of acute respiratory failure, and lower rates of post operation and neurologic in comorbidities. In the indices of weaning from MV, RSBI (threshold ≤ 92, AUC: 81.5%, sensitivity: 69%, specificity: 84%, PPV: 90%, NPV: 56%) and WI (threshold ≤ 57.7, AUC: 84.5%, sensitivity: 73%, specificity: 86%, PPV: 91%, NPV: 60%) had better predictive effects than other indices. Factors found to be associated with weaning outcome were age, gender, presence of COPD as a chronic comorbidity, RSBI, modified RSBI, WI, and EI. Conclusions：In conclusion, both RSBI and WI have better predictive effects than other indices on successful weaning in tracheostomized patients with prolonged weaning. We may apply the threshold values of RSBI and WI found in this study to predict the weaning outcome and determine the ideal weaning steps and timing in this population.