神經性呼吸衰竭病患拔管成功預測因子之探討

呼吸衰竭是醫護人員對重症病患進行治療時，常需緊急處理的問題；由於神經系統病症的影響可能使得醫護人員面對部份第二型呼吸衰竭病患(即本研究所稱之「神經性呼吸衰竭病患」)，需考慮欲採行的治療方式對於病患循環系統及神經系統兩者的影響，進而提高了治療上的困難度。本研究的目的為探討神經性呼吸衰竭病患插管治療後拔管成功之預測因子，研究對象為某醫學中心住院插管後使用呼吸器且經過120小時計劃性脫離呼吸器的病患。本研究透過敘述統計、卡方檢定、獨立樣本t檢定描述前述研究對象的資料分布情形並分析各研究變項於拔管成功者與拔管失敗者之間是否存在明顯的差異；之後再將拔管成功者與拔管失敗者之間存在明顯差異的研究變項納入邏輯迴歸分析以瞭解各變項與拔管成功之間是否存在因果。結果顯示研究對象的年齡大於65歲、曾處於通氣不足的狀態、處於手術後的狀態、呼吸器脫離型態、接受簡單脫離、罹患腫瘤、下轉呼吸照護中心(respiratory care center, RCC)、下轉呼吸照護病房(respiratory care ward, RCW)或居家照護、使用氣管造口術固定器、有過量呼吸道分泌物、有上呼吸道阻塞的情形、有氧合失敗的情形、有腦病、再插管和拔管成功與否之間的關聯性達到統計上的顯著性；年齡、自插管至拔管的總時數、插管天數、加護病房(intensive care unit, ICU)留置期間、呼吸照護中心留置期間、住院期間、申報費用、呼吸速率、拔管後呼吸速率、拔管後動脈血液酸鹼度、拔管後動脈二氧化碳壓力、拔管後氧合指數、急性生理及慢性健康評估、治療性介入評分系統、昏迷量表評分、血紅素值、血球容積比及合併症數量等變項在拔管成功者與拔管失敗者之間的差異達到統計上的顯著性(p<0.05)；病患每多留置ICU 一天，病患拔管成功的勝算減少29.1%。本研究推測病患留置ICU天數越長，拔管成功可能性越低的原因，可能由於留置ICU天數越長的病患通常是整體病況較為嚴重者，因而進一步對其呼吸功能造成負面的影響，導致拔管失敗的風險上升。

關鍵字

呼吸衰竭；拔管；成功預測因子；中樞神經系統

並列摘要

Respiratory failure is a problem which needs medical team members to deal with when treating critically ill patients. Because of the influences of neurological diseases or symptoms, physicians facing specific patients with type II respiratory failure (those patients are defined as “patients with neuropathic respiratory failure” in this study) have to think more about the impact of treatments on patients’ circulatory and neurological systems; under the circumstances mentioned above, it turns to be difficult to cure those patients. The aim of this study was to find out the predictors which might predict the extubation success in patients with neuropathic respiratory failure after they were intubated. Participants studied in this study were patients with neuropathic respiratory failure, being intubated in a medical center and attempted to be successfully extubated after planned weaning for 120 hours. The descriptive statistics, chi-squared tests and t tests for independent samples were conducted for describing the distribution of the data of the participants, comparing data of variables of patients being successfully extubated and of patients failing to be extubated to understand if two groups of data of variables were statistically different. Those variables whose data were statistically different between patients being successfully extubated and of patients failing to be extubated were included in the logistic regressional analysis to understand if there was a causal relationship between those variables and extubation success. The results showed that patients being older than 65 year-old, with hypoventilation, post-operation, type of weaning, accepting simple weaning, with tumors, being transferred to respiratory care center (RCC), being transferred to RCW (or hospice), with tracheostomy retainer (TR), with excessive upper airway secretions, with oxygenation failure, with encephalopathy, and being reintubated were statistically associated with extubation success. Variables including age, total hours for intubation, length of stay in intensive care unit (ICU), length of stay in RCC, length of stay in hospital, expenditure in hospital, respiratory rate (RR), RR after being extubated, pH of arterious blood after being extubated, PaCO2 after being extubated, oxygenation index after being extubated, APACHE II score, TISS score, GCS score, measurement of hemoglobin, hematocrit and numbers of comorbidities were statistically different between patients being successfully extubated and patients failing to be extubated. The result of multivariate logistic regression showed that the odds of extubation success would decrease to 70.9% while patients stayed in ICU for one more day each time. It was suggested that the longer the patients had stayed in ICUs, the worse their physical conditions were and the patients’ worse physical conditions might influence their respiratory functions negatively, increasing the risk of extubation failure.

並列關鍵字

respiratory failure ； extubation ； predictors of success ； central nervous system ； CNS

參考文獻

李綺婷(2011)。探討呼吸器依賴病患再插管的影響因子。國立中山大學醫務管理碩士學位學程，高雄市。

Lee, K. & Rincon, F. (2012). Pulmonary complications in patients with severe brain injury. Critical Care Research and Practice, 2012, Article ID 207247, 8 pages. doi: 10.1155/2012/207247

Wendell, L.C., Raser, J., Kasner, S., & Park, S. (2011). Predictors of extubation success in patients with middle cerebral artery acute ischemic stroke. Stroke Research and Treatment, 2011(2011), Article ID 248789, 5 pages. doi: 10.4061/2011/248789

Anderson, C.D., Bartscher, J.F., Scripko, P.D., Biffi, A., Chase, D., Guanci, M., & Greer, D.M. (2010). Neurologic examination and extubation outcome in the neurocritical care unit. Neurocritical Care, 15(3), 490-497. doi: 10.1007/s12028-010-9369-7

Bernard, S.A., Nguyen, V., Cameron, P., Masci, K., Fitzgerald, M., Cooper, D.J., Walker, T., Myles, P., Murray, L., David, Taylor, Smith, K., Patrick, I., Edington, J., Bacon, A., Rosenfeld, J.V., & Judson, R. (2010). Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Annals of Surgery, 252(6), 959-965. doi: 10.1097/SLA.0b013e3181efc15f

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神經性呼吸衰竭病患拔管成功預測因子之探討

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