口腔吞嚥護理方案於長期氣管插管病患拔管後吞嚥及經口進食狀態之成效

Effects of an Oral Swallowing Care Program on Swallowing and Oral Intake Status in Patients Following Prolonged Endotracheal Intubation

吳崇珮(Chung-Pei Wu)

指導教授 ： 陳佳慧

國立臺灣大學/醫學院/護理學研究所/碩士(2015年)

https://doi.org/10.6342/NTU.2015.10346

摘要

研究背景與目的：
醫療技術發展迅速，接受經口插管合併呼吸器治療的人數節節上升，但經口插管對口咽結構及功能的損傷，易造成吞嚥及進食上的困難，文獻已指出長期經口插管病患(氣管插管 48小時者)於拔管後有吞嚥困難之盛行率高達62%，亟需早期介入且國內缺乏相關介入研究，故本前驅研究旨於發展一個針對氣管內管拔管後中老年病患的口腔吞嚥護理方案，並評估其實際執行之可行性與介入成效。
研究方法：
本研究採雙組前後測（before-and-after intervention）研究設計，自2015年1月10日至10月10日，以台北市某醫學中心內科加護病房插管 48小時且成功拔除氣管內管之中老年病患（ 50歲）為實驗組對象(n=55)，曾有吞嚥困難、中風等神經疾病、口咽結構異常、接受氣切、絕對隔離之病患則予以排除。另外，控制組則由計畫主持人陳佳慧教授之「長期經口插管後病患口腔、吞嚥及營養狀態之變化」研究中篩選出具相同收案條件之個案(n=127)，其收案期間為2013年10月1日至2015年1月10日。所有個案於拔管後48小時內進行基準值前測，於拔管後第7天、第14天測量其口腔健康狀態、舌頭感覺（含輕觸覺、兩點辨識覺、形體辨識覺）、唾液分泌狀況、舌頭力量，並每日追蹤病患之吞嚥(使用台大三階段吞嚥篩檢)及進食狀態(使用功能性經口攝食量表)至拔管後21日。其中實驗組個案於進行基準值前測後即接受為期14天口腔吞嚥護理方案之介入，包含口腔潤濕清潔、唾液腺按摩、口腔運動及吞嚥進食衛教，控制組只接受一般病房常規之臨床照護。
研究結果：
　　病患對口腔吞嚥護理方案之配合度佳，吞嚥進食衛教可達100%，其次為口腔清潔潤濕按摩的97%及口腔運動的67%。實際操作時，平均需花15.6分鐘，研究期間並無造成任何傷害或吸入性危險，安全性佳，故整體而言此方案具可行性。
經過初步地分析，實驗組病患於氣管內管拔管後一週的舌頭力量、唾液分泌、舌頭兩點辨識覺及口腔健康狀況上的成效顯著優於控制組，而拔管後兩週口腔健康狀況上的成效仍顯著優於控制組。另外，兩組在通過台大三階段吞嚥篩檢的天數並無顯著差異，但在恢復至「完全無限制地由口進食」狀態的天數上，在將氣管插管天數控制後，實驗組顯著低於控制組(13.5 7.8天vs. 16.7 6.6天，調整後p值=0.027)。
結論：
口腔吞嚥護理方案對於長期氣管插管病患拔管後部分吞嚥及進食狀態指標有正面效果，但並非所有指標皆有成效。未來還要仰賴增加收案數、進行特定變項之配對及控制後進一步研究方可證實此方案成效。

關鍵字

口腔吞嚥護理方案 ； 長期插管 ； 拔管後吞嚥困難 ； 吞嚥狀態 ； 進食狀態

並列摘要

Background & Objectives:
With rapid growth of medical technology, patients receiving oral endotracheal intubation have increased. Although endotracheal intubation is a life-sustaining procedure, its presence can deteriorate the structure and function of oropharynx, which may contribute to the difficulties in swallowing and subsequent oral intake. Estimated 62% of patients who had been intubated 48 hours will experience post-extubation dysphagia. Intervention is needed but studies are lacking in this regard. Thus, the objective of this pilot trial is to develop and test an Oral Swallowing Care Program (OSCP) for patients aged 50 years and older following prolonged endotracheal intubation.
Method:
A before-and-after with historical control design was used. We enrolled subjects who were over 50 years old and had prolonged ( 48 hours) oral endotracheal intubation as experimental group (n=55) from six medical intensive care units at a medical center in Taipei, Taiwan from January 10th, 2015 to October 10th, 2015. Subjects with prior swallowing difficulties, oropharyngeal structural deficiency, neurological disease, tracheostomy, and absolute quarantine were excluded. Subjects in the control group (n=127) were screened by the same criteria from October 1st, 2013 to January 10th, 2015. All participants were assessed within 48 hours post-extubation for the baseline data. Outcome were assessed on 7th and 14th day post-extubation including tongue strength, salivary secretion, tongue sensation (light touch, two-point discrimination and stereognosis) and oral health status. In addition, Three-Step Swallowing Screen (3-SSS) and Functional Oral Intake Scale (FOIS) were assessed daily 21 days following extubation. OSCP comprised of daily oral care (moisturizing and cleansing of oral cavity and salivary gland massage), oral motor exercise, and intake education was provided to the experimental group for two weeks after extubation while the control group received usual care.
Results:
Participants positively perceived the OSCP with good compliance rates up to 100% for intake education, 97% for daily oral care, and 67% for oral motor exercise. The average time spent for daily OSCP was 15.6 minutes, suggesting that OSCP was clinically feasible. Preliminary analyses indicated that participants received OSCP had better scores (tongue strength, salivary secretion, two-point discrimination, oral health status) by 7th days post-extubation, compared to the controls. By 14th days post-extubation, oral health status was still significantly better for participants received OSCP. Days to pass 3-SSS were not differed between groups. However, days to reach total oral diet with no restrictions were significantly reduced for participants received OSCP (13.5 days vs. 16.7 days, adjusted p=0.027) after adjusted for length of intubation.
Conclusion:
The OSCP demonstrated benefits on some of the variables but not all. However, given the feasibility of OSCP for post-extubated patients, future studies and analyses are required to verify the effects of OSCP.

並列關鍵字

oral swallowing care program ； prolonged intubation ； post-extubation dysphagia ； swallowing status ； oral intake status

參考文獻

中文部份

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