計劃性拔管成功之呼吸衰竭病人其住院期間的存活分析

Survival Analysis of Respiratory Failure Patients with Planned Successful Extubation during Hospitalization

王娜娜(Na-Na Wang)

指導教授 ： 紀宗呈

長榮大學/健康科學學院/醫學研究所/碩士(2015年)

https://doi.org/10.6833/CJCU.2015.00111

摘要

背景：因手術導致呼吸衰竭的病人通常具有高拔管成功率、低死亡率以及較低的照護成本，但其他插管原因之呼吸衰竭病人，住院期間的存亡及照護成本仍具可探討性。
目的：主要探討非手術治療致呼吸衰竭之病人其住院期間的存亡分析。其次爲影響插管天數的因素探討以及照顧成本的評估。
方法：以病歷回溯性方式,收集南部某教學醫院2010年1月1日至2011
年12月31日於加護病房使用呼吸器，經專責醫師評估病況穩定且執行
計劃性拔管後120小時未再插管之病人的臨床病資1508例。以SPSS 18.0作統計分析，定義統計顯著為p＜0.05。
結果：1508例研究對象，計有簡單脫離組745例；困難脫離組508例；延遲脫離組255例。三組的住院死亡率及照護成本呈逐步遞增；存活率則逐漸遞減。依Multivariate logistic regression model及Cox model作的存活率分析顯示：年齡、APACHEII、ICU天數、拔管後(HR)、呼吸衰竭種類(肺部及胃腸系統)、原始疾病(腎臟及惡性腫瘤)對死亡具有正向淨影響力，死亡危險比高。當病患爲延遲脫離、拔管前(RR、PaCO2、PH)不穩定、拔管後(RR、PaO2)不穩定、高
APACHEII、呼吸衰竭種類(心血管系統)及惡性腫瘤病史者，統計上
插管天數較長。
結論：延遲脫離爲住院死亡率的危險因子之一。相較於困難及容易脫離組，其存活率及成功拔管率較低；死亡率及照護成本較高。當研究對象爲延遲脫離、高APACHEII、惡性腫瘤病史者有較高的住院死亡率及較長的插管天數，此情況之病人若拔管失敗需再插管時，或許尊嚴的安寧照護是另一個不錯的抉擇。

關鍵字

重症加護病房 ； 機械通氣 ； 死亡率 ； 住院期間存活 ； 脫離

並列摘要

BACKGROUND: The patients with postoperative respiratory failure have the higher extubation success rate, lower mortality rate and care costs. However, the survivors and the care costs of the other kind of respiratory failure have the value to be discussed.
OBJECTIVES: The primary outcome measure was discussing the non-surgical patients with respiratory failure , the survival analysis during hospitalization.Secondary outcome measures included discussing the intubation days as well as care cost appraisals.
METHODS: This is a retrospective study.The medical records data was collected from a regional teaching hospital in the south. This retrospective,chart-review study was collected from January 2010 to December 2011. Of 1508 cases who were admitted to the ICU and under mechanical ventilation use. When cases were in a stable condition assessed by the attending physicians, planned extubation was performed for at least 120 hrs without re-intubation. Statistical analyses were conducted on the data by SPSS 18.0 . The level of significance was set at 0.05.
RESULTS: From an initial cohort of 1508 cases. Of these cases the cumulative incidences of simple, difficult, and prolonged weaning were 745, 508, and 255, respectively. Hospital mortality and care costs were increment. Survival rates were decrement. In a multivariate logistic regression model and Cox Model prediction analysis showed that, including older age, APACHII, days of ICU, HR of post-extubation, pulmonary & GI respiratory failure types , history of the Renal or Neoplastic (Malignant) system is related to mortality and have higher risk ratio of mortality. When patients were a case of prolonged weaning, RR or PaCO2 or PH instability of pre-extubation, RR or PaO2 instability of post-extubation, high APACHEII, cardiac type of respiratory failure and Neoplastic (Malignant) past history, they had longer intubation days in statistics.
CONCLUSION: Lower survival and success extubation rate, and higher mortality and care costs had been found in patients with prolonged weaning compared with patients with simple or difficult weaning. Prolonged weaning was identified as an independent risk factor for increased hospital mortality. When the patients with a prolonged weaning, high APACHEII and Neoplastic (Malignant) medical history had higher mortality and longer intubation days. Hospice care was better choice than re-intubation if extubation failed.

並列關鍵字

intensive care unit ； mechanical ventilation ； mortality ； survival during hospitalization ； weaning

參考文獻

3. 李靜怡,陳玉如,翁敏雪等.呼吸器對橫膈膜的影響.重症醫學雜誌 2008；9(3):197.

5. 林珮如,鄭愛琴,陳欽明等.重症患者計劃性拔管成功之現況.台灣呼吸治療 2011;10(2):59-59.

7. 宰翡霙,何厘瑗,王桂芸.計畫性拔管失敗之衝擊及其臨床處置.源遠護理 2007;13:5-14.

4. 沈連喜,洪惠苓,張永源等.影響長期呼吸器依賴病患留置因素與整合式照護之成效分析-以南部某醫學中心爲例.呼吸治療 2011;10(2):97-109.

6. 邱韋欽. APACHEII評估表對中部某醫學中心外科加護病房死亡率之估計與分析.中山醫學大學醫學研究所論文 2008;16.