馬凡氏症候群病患因主動脈剝離合併慢性呼吸衰竭脫離呼吸器之治療經驗

Experience of Weaning from Mechanical Ventilation in a Marfan Syndrome Patient Complicated with Acute Aortic Dissection and Chronic Respiratory Failure

陳秋桂(Chiu-Kuei Chen) ； 蔡美芳(Mei-Fang Tsai) ； 林美瑜(Mei-Yu Lin) ； 劉素卿(Su-Ching Liu) ； 陳富鈞(Fu-Gin Chen)

《北市醫學雜誌》 8卷3期 (2011/09) Pp. 79-87

https://doi.org/10.6200/TCMJ.2011.8.3.09

摘要

一位27歲男性患者因馬凡氏症候群（Marfan Syndrome）合併主動脈剝離及急性心包膜填充，在某醫學中心經緊急手術與三個月的後續治療後，慢性呼吸衰竭仍持續，無法脫離呼吸器。於轉至本院呼吸照護病房住院期間（2010年6月30日至8月12日），醫療團隊評估病患臨床表現及各項理學監測結果後，發現其不利脫離呼吸器的因素主要為：呼吸道清除功能失效（此與無效性的咳嗽且痰量多黏稠有關）、呼吸肌力不足（此與長期臥床，依賴呼吸器，及營養不足有關）、體重低於理想體重（此與營養供應少於身體所需有關）、以及焦慮所誘發的心理生理交互影響。參閱相關文獻的治療經驗後，我們為病患設計了個別化的呼吸治療計畫。以胸腔物理治療及計畫性的呼吸器脫離訓練，病患呼吸道能維持通暢並強化了呼吸肌的力量以脫離呼吸器。在營養狀態方面，藉由正確的評估，並與營養師討論後，我們提供了合宜的飲食計劃、並鼓勵家屬參與改善病人的營養狀態。我們與病患建立良好的互動，鼓勵表達及傾聽內心感受，安排重要家屬適時陪伴，並給予正向鼓勵及情緒支持。在整體的相互配合之下，個案終於在 8月12日成功脫離呼吸器，藉此提供日後各位呼吸治療同仁參考。

關鍵字

馬凡氏症候群 ； 營養狀況 ； 呼吸器脫離

並列摘要

A 27-year-old male with chronic respiratory failure was difficult to wean from mechanical ventilation at 3 months after surgical correction for Marfan syndrome complicated by aortic dissection and cardiac temponade. During his hospitalization (Jun 30, 2011 to Aug 12, 2011) in our respiratory care unit, we evaluated his clinical presentations and data via physiological monitors and found that the main factors acting against the weaning processes were impaired clearance of the respiratory tract (ineffective coughing and a productive sticky sputum), inadequate respiratory muscle power (long term bed-ridden state, mechanical ventilator dependence, and malnutrition related weakness), a body weight lower than the ideal body weight (inadequate nutrition supplement related), and physiopsychological reactions triggered by anxiety. We reviewed the medical references, and individualized the patient’s respiratory care plan. We instituted chest physiotherapy and respiratory training based on our weaning protocols and as a result a patent airway and improved strength of the respiratory muscles were achieved. These helped with the weaning from the mechanical ventilator. After reassessing the patient’s nutrition status with the help of dietitians, we provided him with an improved diet as well as encouraging his family’s participation in this part of the program. We built up a good interaction with the patient by encouraging his emotional expression, listening to his experiences and feelings, arranging timely companionship with his important family members, and offering positive feedback and mental support. These efforts together helped the patient be successfully weaned from mechanical ventilation on Aug 12, 2011. We presented our experiences in treating this complicated case to help others in similar situations in respiratory care units.A 27-year-old male with chronic respiratory failure was difficult to wean from mechanical ventilation at 3 months after surgical correction for Marfan syndrome complicated by aortic dissection and cardiac temponade. During his hospitalization (Jun 30, 2011 to Aug 12, 2011) in our respiratory care unit, we evaluated his clinical presentations and data via physiological monitors and found that the main factors acting against the weaning processes were impaired clearance of the respiratory tract (ineffective coughing and a productive sticky sputum), inadequate respiratory muscle power (long term bed-ridden state, mechanical ventilator dependence, and malnutrition related weakness), a body weight lower than the ideal body weight (inadequate nutrition supplement related), and physiopsychological reactions triggered by anxiety. We reviewed the medical references, and individualized the patient’s respiratory care plan. We instituted chest physiotherapy and respiratory training based on our weaning protocols and as a result a patent airway and improved strength of the respiratory muscles were achieved. These helped with the weaning from the mechanical ventilator. After reassessing the patient’s nutrition status with the help of dietitians, we provided him with an improved diet as well as encouraging his family’s participation in this part of the program. We built up a good interaction with the patient by encouraging his emotional expression, listening to his experiences and feelings, arranging timely companionship with his important family members, and offering positive feedback and mental support. These efforts together helped the patient be successfully weaned from mechanical ventilation on Aug 12, 2011. We presented our experiences in treating this complicated case to help others in similar situations in respiratory care units.

並列關鍵字

Marfan syndrome ； nutrition status ； weaning from mechanical ventilation