呼吸器依賴病患呼吸器脫離與醫療資源使用影響因子之探討--以某醫學中心呼吸照護中心為例

研究目的近年來醫學科技的發達與進步，各種先進的醫療儀器設備不斷的推陳出新，而使得許多呼吸衰竭的病患得以延續生命，加上人口老化與慢性病的盛行，需要長期依賴呼吸器而生存的病患，亦有逐年增加的趨勢。在臨床使用呼吸器的個案中，約有20- 25%的病患在潛在的問題解決之後，仍無法立即脫離呼吸器，而需長期使用呼吸器，甚至有些個案根本無法脫離呼吸器，而成為呼吸器依賴者。本研究的目的在於希望藉由回溯性的資料整理與統計後，藉以瞭解影響呼吸器依賴病患呼吸器脫離之相關因子，探討此類病患醫療資源使用情形及其相關影響因素，並追蹤病患該次住院於出院後一年的存活情形。希望能藉此建立未來評估呼吸器依賴病患健康照護之可能指標，以及提供健康照護機構擬定病人照護計畫之參考，對於成功脫離機會較高的病患給予積極的訓練；而對於脫離機會較渺茫者，能儘早轉至呼吸照護病房或居家使用呼吸器。以期能有效降低醫療資源的耗費，且能達到較佳的醫療效果。研究方法本研究為回溯性之研究，主要是針對南部某醫學中心，於2006 年1月至2007年12月住進呼吸照護中心之病患為主要研究對象，共計 III 284位。以直線複迴歸分析、對數複迴歸分析與Cox成比例危害分析，探討研究期間病患的人口學特質、使用呼吸器的主要原因、呼吸器脫離相關指數、疾病嚴重度、是否有合併症、是否因脫離失敗再次使用呼吸器、再次使用呼吸器的天數及相關血液生化值，對呼吸器依賴病患呼吸器的脫離、死亡率、當次住院之醫療費用與住院天數的影響。研究結果研究結果顯示，研究期間病患平均年齡為72±15歲，男性病患152 例（53.5%）多於女性，以內科加護病房所轉入的病患居多（57.4%）；使用呼吸器的主要原因以充血性心衰竭（CHF）最多（27.5%），病患疾病嚴重度（APACHE II）平均為16.84±4.23、Charlson Comorbidity Index（CCI，合併症指數）平均為1.95±1.61；有31.3%的病患有作氣切，當次住院出院後一年內的死亡率為55.63%。在線性複迴歸模式中，病患是否因脫離失敗而再次使用呼吸器比較會成為呼吸器依賴患者（P＜0.001）；在影響醫療費用耗用的相關因素中，以是否因呼吸器脫離失敗而再次使用呼吸器影響最大，其次為是否有作氣切（P＜0.001）。以Cox迴歸探討病患該次住院出院後的一年內與存活有關之主要影響因子，結果顯示性別、有合併心臟系統疾病、血中尿素氮值、 APACHE II及因為充血性心衰竭而使用呼吸器皆是影響死亡與否之 IV 重要因子。於影響住院天數相關因素的線性迴歸分析中，結果顯示病患是否有氣切、合併症指數（CCI）、是否因呼吸器脫離失敗而再次使用呼吸器及再次使用呼吸器的天數皆是影響病患住院天數之重要因子，在影響住院天數相關因素中，以再次使用呼吸器的天數影響最大，其次為是否因呼吸器脫離失敗而再次使用呼吸器。結論與建議本研究證實病患其是否作氣切、是否因呼吸器脫離失敗而再次使用呼吸器、合併症指數及再次使用呼吸器的天數，是呼吸器依賴病患其是否能成功脫離呼吸器及減少醫療資源耗用最具影響力之變項，因此建議要為呼吸器依賴病患做呼吸器脫離之準備時，能給於足夠的相關訓練且在疾病病程穩定控制後再進行，如此應可以降低病患死亡率，提高病患呼吸器的脫離率，並進而減少病患住院天數，降低其醫療資源之耗用。

關鍵字

呼吸器依賴；呼吸器脫離死亡率醫療資源

並列摘要

Research Purposes In recent years, with the development and progress of medical technology, there are more and more advanced medical instruments and equipment available, allowing many patients with respiratory failure to survive. Moreover, with population ageing and the prevalence of chronic diseases, the number of long-term ventilator-dependent patients has gradually increased. Clinically, among patients who use ventilators to maintain their life, around 20-25% of them cannot immediately wean from the ventilator after their potential problems have been solved. And among patients with long-term use of ventilators, some individuals even cannot wean from the ventilator and eventually become ventilator-dependent patients. The purposes of this study are to understand the influencing factors of ventilator weaning in ventilator-dependent patients, investigate the utilization of medical resources and its relevant influencing factors for these patients, and track to the survival rate of these patients within a year after hospital discharge by collecting retrospective data and statistics. It is hoped that this study can help construct evaluation indices for the health care of ventilator-dependent patients and provide health care facilities with references for planning the health care of patients, offering more training to patients of higher weaning success rate, and transferring patients of lower weaning success rate to respiratory care wards or sending they home for receiving ventilation at home to effectively reduce the cost of medical resources and achieve better medical effects. Research methods This study is a retrospective study and the research subjects were mainly the patients hospitalized in the respiratory care center in certain medical center in southern Taiwan from January, 2006 to December, 2007. A total of 284 patients were enrolled in this study. Statistical methods such as multiple linear regression analysis, multiple logistic regression analysis, and Cox proportion hazards analysis were used to investigate the influences of demographic profiles of patients, main reasons for using ventilators, relevant indices of ventilator weaning, disease severity, the presence of complications, using ventilators again due to weaning failure, the days of reusing ventilators, and relevant blood biochemical values on the ventilator weaning, mortality, medical expenditure, and the inpatient days of ventilator-dependent patients. VI Research results The research results indicated that the average age of patients was 72±15 years and the number of male patients was 152 (53.5%), which was more than female ones; most of the patients (57.4%) were transferred from the internal intensive care unit; the main reason for using ventilators was mostly (27.5%) congestive heart failure (CHF); the average disease severity of patients (APACHE II) was 16.84±4.23; the average Charlson Comorbidity Index (CCI) was 1.95±1.61; 31.3% patients had received tracheostomy; the mortality of patients after hospital discharge within a year was 55.63%. The multiple linear regression model indicated that patients with weaning failure and using ventilator again had a higher possibility to become ventilator-dependent patients (P<0.001); among the relevant influencing factors for medical expenditure, the most influential factor was using ventilator again due to weaning failure, followed by receiving tracheostomy (P<0.001). The Cox regression analysis was used to investigate the main influencing factors relevant to the survival rate of patients after hospital discharge within a year. The results indicated that gender, presence of cardiac complications, the value of blood urea nitrogen, APACHE II, and using ventilator due to congestive heart failure were all important factors that influenced the mortality of patients. The results of linear regression analysis for analyzing the relevant factors of inpatient days indicated that receiving tracheostomy, Charlson Comorbidity Index (CCI), using ventilators again due to weaning failure, and the days of reusing ventilators were all important factors which influenced the inpatient days of patients. Among the influencing factors of inpatient days, the most influential one was the days of reusing ventilators, followed by using ventilators again due to weaning failure. Conclusions and suggestions The study showed that the receiving tracheostomy, using ventilators again due to weaning failure, Charlson Comorbidity Index, and the days of reusing ventilators were the most influential variables for determining whether ventilator-dependent patients could successfully wean from ventilators and reduce the cost of medical resources. Therefore, to reduce the mortality of patients, increase the weaning success rate, decrease inpatient days, and reduce the cost of medical resources, it is suggested VII that when preparing for weaning ventilator-dependent patients from ventilators, it is necessary to provide patients with enough relevant training and the weaning shall be conducted after patients’ condition is steadily controlled.