中風後急性／亞急性期吞嚥困難病患鼻胃管拔除之相關因子研究

Factors Associated with Nasogastric Tube Removal in Patients with Post-stroke Dysphagia Following Acute/Subacute Stroke

溫馨喬(Hsin-Chiao Wen) ； 唐浩偉(Hao-Wei Tang) ； 彭昶仁(Chang-Ren Peng) ； 陳冠霖(Kuan-Lin Chen) ； 蕭靜旻(Ching-Min Hsiao) ； 林仲哲(Chung-Che Lin)

《台灣復健醫學雜誌》 43卷4期 (2015/12) Pp. 217-223

https://doi.org/10.6315/2015.43(4)02

摘要

研究目的：中風為造成吞嚥困難(dysphagia)的常見原因之一，而且持續的吞嚥困難和較差的預後及較高的死亡率有關。鼻胃管的置入常用以維持病患的營養和水分補充，但長期的鼻胃管放置會導致許多潛在的併發症如胃食道逆流或吸入性肺炎等。本研究目的在於探討了解本院接受過吞嚥訓練的中風病患，分析其成功移除鼻胃管與否的相關因子，以做為臨床治療中風後吞嚥困難病患之參考。研究方法：本研究採回溯性研究。本研究分析2015年4月1日至2015年12月31日期間因急性／亞急性中風產生的吞嚥障礙，需要部分或完全由鼻胃管灌食並完成至少六次訓練之患者。依照出院前是否能夠移除鼻胃管分為兩組。所分析的變數包含:年齡、性別、中風危險因子、中風型態、相關併發症、訓練次數、美國國衛院腦中風評估表(NIHSS)、巴氏量表(Barthel Index)、改良式Rankin 量表(mRS)、生活功能獨立執行量表(FIM)、簡易心智量表(MMSE)，以及治療前後吞嚥功能評估，其評估工具包括功能性溝通評量表-吞嚥功能(FCMs-swallowing)和功能性口腔進食量表(FOIS)兩種。結果：本研究總共納入113位中風後吞嚥困難的患者，無法移除組有83位而移除組有30位，鼻胃管移除率約為26.5%。兩組比較後發現，無法移除組病患年紀較大(70.5±12.2 vs 65.0±14.9；p=0.048)、過去有中風病史的比例較高(25.3% vs 3.3%；p=0.007)、認知功能較差(MMSE: 12.7±10.1 vs 21.4±9.8；p=0.005)、生活功能獨立程度較低(FIM: 49.4±18.0 vs 65.2±21.3；p=0.002)，且初始的神經學損傷程度也有較嚴重的傾向(NIHSS: 14.0±6.8 vs 11.1±6.3；p=0.059)。兩組病患所接受的總治療次數和吞嚥治療策略在統計上沒有顯著差異。初評的FCMs-swallowing 和FOIS在移除組較高(p=0.000)且治療後的變化量在移除組也顯著較大(p=0.000)。結論：本研究顯示年齡、過去中風病史、認知功能、初始生活功能獨立程度得分、初始的吞嚥功能以及治療後吞嚥功能進步程度為中風後吞嚥困難病患鼻胃管是否能成功移除的相關因子，在臨床上可以提供評估中風病患是否能夠考慮移除鼻胃管之參考。

關鍵字

鼻胃管(nasogastric tube) ； 中風(stroke) ； 吞嚥困難(dysphagia) ； 吞嚥訓練(swallowing training)

並列摘要

Purpose: Stroke is a common cause of dysphagia, and persistent post-stroke dysphagia is associated with a poor outcome and an increased mortality rate. Nasogastric tubes (NGTs) are frequently the recommended method for the safe administration of nutrition and hydration in stroke patients. However, prolonged use of NGTs can lead to complications, such as gastro-esophageal reflux and aspiration pneumonia. The purpose of this study was to determine the factors associated with NGT removal in patients with post-stroke dysphagia. Method: This was a retrospective study. We recruited patients with post-stroke dysphagia who had received feeding either partially or totally via NGT and had accepted swallowing training for at least six times from April 1, 2015 to December 31, 2015. The patients were divided into two groups based on whether their NGT had been removed before discharge from the hospital or not. Demographic characteristics (such as age, sex, risk factors associated with stroke, stroke type, and complications), duration of swallowing training, National Institutes of Health Stroke Scale (NIHSS), Barthel Index, modified Rankin Scale, Functional Independence Measure (FIM), and Mini-Mental Status Examination (MMSE) scores were assessed and analyzed. The Functional Communication Measure Swallowing Subscale (FCMs-swallowing) and Functional Oral Intake Scale (FOIS) were used to evaluate swallowing function. Results: A total of 113 outpatient subjects were recruited, and the NGT removal rate was 26.4%. Patients were classified into either a NGT removal (n = 30) or a non-removal (n = 83) group. Patients in the non-removal group were older (70.5 ± 12.2 vs. 65.0 ± 14.9 years; p = 0.048), were more likely to have had a previous stroke (25.3% vs. 3.3%; p = 0.007), and had poorer cognitive function (MMSE: 12.7 ± 10.1 vs. 21.4 ± 9.8; p = 0.005), lower FIM scores (49.4 ± 18.0 vs. 65.2 ± 21.3; p = 0.002), and a tendency toward higher NIHSS scores (14.0 ± 6.8 vs. 11.1 ± 6.3; p = 0.059). There were no significant differences in the duration and strategy of swallowing training between the two groups. However, the removal group showed better swallowing function on initial evaluation and greater changes in FCMs-swallowing and FOIS scores after treatment (p ＜ 0.001). Conclusion: Among stroke patients who receive NGT, younger age, no previous stroke history, better cognitive function, higher FIM scores, better initial swallowing function, and more improvement after swallowing training were all factors that were associated with a greater chance of NGT removal. Therefore, when deciding whether to remove NGTs in stroke patients, it is important to consider the above mentioned factors.

並列關鍵字

nasogastric tube ； stroke ； dysphagia ； swallowing training

參考文獻

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