護理之家住民肺炎危險因子及專業口腔照護介入對肺炎住院情形與口腔細菌改善成效之探討

Pneumonia risk factors in nursing home residents and their effectiveness of professional oral care intervention on pneumonia status and oral bacteria

江典澄(Tien-Cheng Chiang)

指導教授 ： 林英助

共同指導教授 ： 黃純德(Shun-Te Huang)

高雄醫學大學/口腔醫學院/牙醫學系博士班/博士(2020年)

摘要

背景：肺炎在2016年已上升至台灣十大死因之第三名，同時肺炎好發於長期臥床之機構住民。除了高齡、長期臥床、吞嚥困難、口腔衛生不良之外，口腔細菌伴隨著嗆咳進入氣管或肺部，都被認為是住民發生肺炎的重要危險因子。過去研究指出口腔照護介入能夠改善口腔衛生，但口腔照護的介入對肺炎住院的次數及天數、致病菌種和總菌量的成效仍不清楚。

目的：瞭解住民之基本人口學資料、口腔健康狀況與肺炎病史之相關性，進而探討專業口腔照護介入前後，口腔衛生指數、肺炎住院次數和天數、口腔中肺炎致病菌種分布頻率及總細菌濃度的變化。

方法：經立意取樣收案，以高雄市2間醫院附設護理之家50歲以上住民進行研究調查。先以橫斷式研究進行問卷調查，包括基本人口學資料、治療紀錄，以及牙醫師所進行的口腔健康檢查來收集口腔衛生指數。使用雙樣本t檢定、卡方檢定及費氏精確檢定來分析肺炎病史與基本人口學資料和口腔健康狀況的相關性，使用多變項邏輯斯迴歸來分析肺炎病史之危險因子。介入研究調查採用準實驗設計，專業口腔照護介入共三個月，由口腔衛生學系學生經培訓通過後進行施作，收集資料包括介入前後測之唾液、痰液的採集、口腔健康檢查、肺炎住院狀況等。使用Wilcoxon rank-sum test比較介入組與對照組的平均值之差異，Wilcoxon signed-rank test比較介入前與介入後的平均值之差異，Kruskal-Wallis test比較三組以上樣本的平均值之差異及相關事後檢定post hoc Tukey test。

結果：橫斷式研究中完成收案220位機構住民，其中男性94人，女性126人，平均年齡為80.32 ± 11.36歲。過半住民之意識不清醒 (55%)，大部分住民之日常生活功能完全依賴他人 (72%)，過去三年有肺炎病史者 (40%)，以鼻胃管進食者占大多數 (61%)，口腔清潔頻率一天一次以下者 (45%)。住民平均缺牙顆數高達15.24 ± 10.21顆，且口腔衛生狀況普遍不佳，住民80歲以上有20顆以上功能牙之人數比率僅21.4%。三年內肺炎病史之危險因子有口乾症 (勝算比= 3.47，95% CI = 1.36 – 9.44)、口腔清潔完全依賴他人 (勝算比= 14.70，95% CI = 1.78 – 165.00)、口腔清潔頻率一天一次以下 (勝算比= 3.13，95% CI = 1.29 – 7.99)。分別針對80歲以上住民有20顆或10顆以上功能牙之住民，發現長期臥床6個月以上、口乾症、口腔清潔頻率一天一次以下，都是肺炎的共同危險因子。介入研究中介入組25人，對照組16人，在專業口腔照護介入之後，介入組的牙菌斑指數 (1.66 ± 0.78 vs. 0.94 ± 0.64，p < 0.01)、牙齦指數 (2.36 ± 0.76 vs. 1.65 ± 0.83，p < 0.01)、牙結石指數 (1.52 ± 0.83 vs. 1.08 ± 0.59，p < 0.01)、舌苔指數 (0.96 ± 1.10 vs. 0.16 ± 0.47，p < 0.01)、唾液中金黃色葡萄球菌的分布頻率 (11.11 ± 14.47% vs. 1.74 ± 3.75%，p = 0.02) 和唾液中總細菌濃度 ([4.27 ± 3.65] ×105 vs. [0.75 ± 1.20] ×105，p < 0.01) 都有明顯改善；不過痰液中金黃色葡萄球菌的分布頻率及痰液中細菌濃度則無明顯差異。介入組的肺炎住院次數也在介入後明顯降低 (前vs. 後 = 1.24 ± 1.51 vs. 0.48 ± 0.59，p = 0.01)，尤其是唾液細菌濃度超過中位數的住民。但兩組的肺炎住院天數並沒有統計上顯著差異。

結論：在長照機構住民中，肺炎病史之共同危險因子有口乾症、口腔清潔頻率一天一次以下。此外，專業口腔照護介入可以顯著改善口腔健康、降低唾液中細菌濃度、減少金黃色葡萄球菌的分布以及降低肺炎住院的次數。

關鍵字

長期照護 ； 口腔照護介入 ； 口腔健康狀況 ； 肺炎 ； 金黃色葡萄球菌

並列摘要

Background: Pneumonia is a common and important cause of death in long-term care residents (LTCRs). Oral bacterial infection can cause pneumonia in LTCRs. The professional oral care intervention (POCI) can improve oral health. However, the effectiveness of POCI on the pneumonia development and oral bacteria are not clear in Taiwan LTCRs.

Purpose: Our aims were to explore 1) the correlation between demographic data, oral health, and pneumonia history in LTCRs by cross-sectional study, 2) the effectiveness of POCI on the pneumonia status, bacterial concentration, and distribution of pneumonia pathogen.

Methods: Two nursing homes were selected by purposive sampling. The cross-sectional study was applied to collect the data of a standardized questionnaire and oral health examination. The quasi-experimental study (intervention: 25 LTCRs and controls: 16 LTCRs) was applied to collect the data of oral health examination, pneumonia hospitalization status, salivary and sputum bacterial concentrations, identification of bacterial species before and after the POCI. Statistical analysis was used to determine the risk factors for pneumonia and the effectiveness of POCI.

Results: In the cross-sectional study, a total of 94 males and 126 females with an average age of 80.32 ± 11.36 years were selected into the present study. Most residents were unconscious (55%) and completely dependent on others for their daily life (72%). The majority (61%) who ate by nasogastric tube. The risk factors for pneumonia within three years were dry mouth (odds ratio (OR) = 3.47, 95% CI = 1.36 – 9.44), oral cleaning completely dependent on others (OR = 14.70, 95% CI = 1.78 – 165.00), and oral cleaning  one time per day (OR = 3.13, 95% CI = 1.29 – 7.99). For residents age over 80 and functional teeth number over 10 or 20, common risk factors for pneumonia were bedridden for ≥ 6 months, dry mouth, and oral cleaning  one time per day. After the intervention, the intervention group had significant improvements in plaque index (1.66 ± 0.78 vs. 0.94 ± 0.64, p < 0.01), gingival index (2.36 ± 0.76 vs. 1.65 ± 0.83, p < 0.01), calculus index (1.52 ± 0.83 vs. 1.08 ± 0.59, p < 0.01), tongue coating index (0.96 ± 1.10 vs. 0.16 ± 0.47, p < 0.01), distribution of Staphylococcus aureus in salivary samples (11.11 ± 14.47% vs. 1.74 ± 3.75%, p = 0.02), and salivary bacterial concentration ([4.27 ± 3.65] ×105 vs. [0.75 ± 1.20] ×105, p < 0.01). Sputum bacterial concentration did not significantly differ. The intervention group also had a significantly lower annual frequency of pneumonia hospitalization (before vs. after = 1.24 ± 1.51 vs. 0.48 ± 0.59, p = 0.01), especially in residents whose salivary bacterial concentration exceeded the median. However, the duration of pneumonia hospitalization did not significantly differ between the two groups.

Conclusion: These results suggested that the important risk factors for pneumonia history in LTCRs are dry mouth and oral cleaning  one time per day. After the POCI, oral health, salivary bacterial concentration, annual frequency of pneumonia hospitalization, and the distribution of Staphylococcus aureus in saliva can be improved in LTCRs.

並列關鍵字

Long-term care ； Oral care intervention ； Oral health status ； Pneumonia ； Staphylococcus aureus

參考文獻

1. Ministry of Health and Welfare, R.O.C. Taiwan. Ten leading causes of death in Taiwan. 2017 [Available from: https://dep.mohw.gov.tw/DOS/lp-3352-113.html.

2. Baine WB, Yu W, Summe JP. Epidemiologic trends in the hospitalization of elderly Medicare patients for pneumonia, 1991-1998. Am J Public Health. 2001;91(7):1121-3.

3. 黃純德. 咀嚼吞嚥障礙、吸入性肺炎與口腔衛生不良的三角關係. 護理雜誌. 2020;67(4):14-23.

4. Scannapieco FA, Shay K. Oral health disparities in older adults: oral bacteria, inflammation, and aspiration pneumonia. Dent Clin North Am. 2014;58(4):771-82.

5. World Health Organization. Ageing well must be a global priority. 2014 [Available from: https://www.who.int/news-room/detail/06-11-2014--ageing-well-must-be-a-global-priority.