腦中風病患其咀嚼吞嚥障礙及相關因素之探討

背景：腦中風是台灣十大死亡原因中的第三位，也是導致成人殘疾的主要原因，不僅影響生活自理與工作的能力，也使社會與整個醫療體系付出極大的代價。而咀嚼吞嚥障礙是腦中風病患常見的障礙之一，且伴隨許多併發症，如營養失調、脫水、住院天數增加等；經由食物或分泌物吸入造成的吸入性肺炎，經研究顯示與口咽部咀嚼吞嚥障礙是有相關的。綜觀國內外的研究，多是針對中風後急性期來探討咀嚼吞嚥障礙及其對預後的影響；針對轉入復健期後的病患咀嚼吞嚥障礙的評估應持續進行但這時期的相關研究卻較少。研究目的：瞭解腦中風病患之咀嚼吞嚥狀況、探討影響咀嚼吞嚥功能的相關因素、確立咀嚼吞嚥障礙之預測因子及探討影響腦中風病患預後的相關因素。研究方法：本研究於民國99年5月至民國100年2月於南部某醫學中心之復健科病房進行收案，針對符合條件之病患收集腦中風相關資料、填寫咀嚼吞嚥障礙功能評估問卷，進行反覆性唾液吞嚥試驗法(RSST)與改良式喝水測試(MWST)，咀嚼吞嚥障礙的定義為RSST或MWST任一測試結果不正常。利用JMP 8.0進行資料統計分析，包括描述性統計、t檢定、卡方檢定、與線性/邏輯迴歸分析。結果：本研究有效樣本共100人(平均年齡為59.31±13.71歲)，包含了缺血性與出血性腦中風；經RSST與MWST測試之後，有咀嚼吞嚥障礙者共有52位(53.61%)，結果顯示「年齡、第十對舌咽神經、失語症、構音困難、巴氏量表、流涎、第一次吞口水秒數」等與咀嚼吞嚥障礙有顯著相關；口腔(準備)期異常徵象中「是否可以緊閉嘴唇含水」與「會咀嚼但無法咬碎」；咽喉期異常徵象中「吞嚥後食物是否卡在喉嚨」、「吞嚥後是否有痰液聲出現」、「喝水是否嗆咳」這五種徵象與咀嚼吞嚥障礙有顯著相關。進一步以邏輯迴歸分析結果顯示構音困難與喝水嗆咳為咀嚼吞嚥障礙之重要預測變項。本研究肺炎發生率僅4%，肺炎與咀嚼吞嚥障礙並無顯著性相關；最後以線性迴歸分析探討影響住院天數之因素，結果顯示年齡、第一次吞口水秒數與下肢肢體布朗斯壯動作分期為重要預測變項。結論：中風後的復健期間，仍有53.61%的病患有咀嚼吞嚥障礙的現象，合併咀嚼吞嚥障礙或肺炎的病患則有住院天數延長的傾向，因此針對咀嚼吞嚥障礙給予個別性的飲食調整、餵食技巧姿勢的調整、安全的吞嚥訓練與正確有效的口腔照護，不僅能減少吸入性肺炎的產生及改善預後，也能增進口腔及整體健康與提升病患的生活品質。

關鍵字

腦中風；咀嚼吞嚥障礙；肺炎

並列摘要

Background: In Taiwan, stroke is the third leading cause of death after cancer and heart disease, and is the main cause of adult disability. Stroke not only affects the ability of self-care and work, stroke survivors also produce a great burden to the social and health care systems. Dysphagia is very common after stroke and is linked with malnutrition, dehydration, aspiration pneumonia, and increased length of hospitalization. Aspiration is a sign of severe dysphagia, and refers to abnormal entry of fluid or secretions into the airways. After a patient is transferred to a rehabilitation unit, dysphagia assessment should be monitored continuously. However, little is known about dysphagia reassessment of these patients transferred to rehabilitation units. Study objective: To investigate the related factors to swallowing function among stroke patients with dysphagia, and to examine the impact of dysphagia and its related factors on stroke outcome. Methods: We analyzed patients with stroke admitted to the rehabilitation unit of a medical center in southern Taiwan from May 2010 to February 2011. The procedure included chart review, dysphagia questionnaire, repetitive saliva swallowing test (RSST) and modified water swallowing test (MWST). Dysphagia was defined as either RSST or MWST abnormal. JMP 8.0 was used to perform descriptive statistic, t-test, chi-square test and linear/ logistic regression analysis Results: 100 eligible patients (mean age=59.31±13.71years) with recent ischemic or hemorrhagic stroke were enrolled. On clinical examination 53.61% of the study subjects demonstrated dysphagia. Chi-square analysis showed that age, 10th vagus nerve, aphasia, dysarthria, barthel index, drooling, the duration of swallowing saliva at first time(sec), five abnormal signs(could not close mouth with water, without mastication, food stuck in the throat, obvious sputum sound and choking after swallowing) are all associated with dysphagia (P<0.05). Multiple logistic regression revealed dysarthria and choking are significant variables predicting dysphagia (P<0.05). Four of the subjects (4%) developed pneumonia, but pneumonia is not associated with dysphagia. Finally, multiple linear regression revealed age, the duration of swallowing saliva at first time (sec), lower limb brunnstrom stage were significant variables predicting LOS (P<0.05). Conclusion: This study’s results report that 53.61% of stroke patients in rehabilitation units had dysphagia, and patients with dysphagia or pneumonia tend to have poorer outcome, including increased length of hospitalization. Therefore, individualized treatment with diet modification, feeding skills, swallowing training and maintaining oral hygiene, not only decrease the risk of aspiration and improve outcome, but also can promote oral health and raise quality of life.

並列關鍵字

Stroke ； Dysphagia ； Pneumonia

參考文獻

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