- 學位論文
先天性心臟病嬰兒經口進食困難之現況調查
A Study of Current Status of Oral Feeding Difficulty in Infants with Congenital Heart Disease
摘要
背景：經口進食困難是先天性心臟病嬰兒最常見的問題之一，不僅影響他們的生長與發展，也是令主要照顧者憂慮的議題。隨著醫療技術進步，先天性心臟病嬰兒期存活率提高，因此醫療團隊開始留意他們是否能維持應有的生長與發展，然而經口進食困難問題存在可能會是成長發展的阻礙。過去的研究缺乏針對先天性心臟病嬰兒接受開心手術前後經口進食困難變化情形進行探討，引發研究者欲藉由臨床觀察，了解這群嬰兒經口進食的困難所在及影響因素。 研究目的：本研究目的有二：(1)探討先天性心臟病嬰兒經口進食困難發生類型、時間；(2)了解先天性心臟病嬰兒的基本屬性、先天性心臟病嚴重度、醫療史與經口進食困難之間的關係。 研究方法：採用縱貫式、描述性相關性研究設計，以立意取樣法，觀察於2017年9月至2018年5月在台大兒童醫院接受心臟病手術治療之六個月以下嬰兒。以觀察式評估表、進食過程紀錄單及病歷查詢等方式收集先天性心臟病嬰兒的資料以回答研究問題。使用嬰幼兒經口進食能力評估量表(Early Feeding Skills, EFS)、自擬資料表收集資料。於手術前，以及手術移除氣管內管後每兩天評估經口進食能力，直至病童可完全經口進食或出院為止。以IBM SPSS 21.0套裝軟體進行統計分析：以描述性統計呈現EFS分數、個案基本屬性、進食情形描述，以Wilcoxon Signed Ranks Test、Friedman test等分析在手術前、移除氣管內管第一天、移除氣管內管第三天、出院時這四個時間點，比較嬰幼兒經口進食能力評估量表分數變化，並使用廣義估計方程式(generalized estimating equation, GEE)了解個案於住院期間經口進食能力變化之預測因子。 研究結果：共30人完成研究，平均使用鼻胃管35.67天。整體而言，手術前先天性心臟病嬰兒就有經口進食困難的問題，83.33%嬰兒在進食過程生命徵象不穩定，76.67%嬰兒進食後耐受度不佳。整體而言，嬰幼兒經口進食能力評估量表(EFS)總分在移除氣管內管後進步，特別是在移除氣管內管第三天顯著進步(p < .05)，包含餵食過程維持度(術前平均7.37分進步到平均10.03分，p < .05)、生命徵象穩定度術前平均19.30分進步到平均25.47分， p < .05)、餵食後耐受度(術前平均3.90分進步到平均5.37分， p < .05)。移除鼻胃管當日平均可達到經口進食總量85.82%。嬰兒返家時有24人(80%)返家不需帶鼻胃管，進食能力仍持續增加，其中20人(83.33%) 在EFS總分仍需要一些臨床幫助。經口進食能力總分的GEE 預測模式中，插管天數(β = -8.83, p < .001)、手術類型(β = -3.90, p = .03)、是否接受其他胸廓相關手術者(β = -4.53, p = .04)、時間(β = 0.45, p < .001)呈現顯著。 結論： 本研究旨在了解接受開心手術嬰兒住院期間，於手術前、術後移除氣管內管的經口進食能力變化。研究發現，開心手術能顯著改善血液動力學狀態，有助於提升先天性嬰兒執行消耗體力之日常活動的能力，但長期插管、接受多次手術、感染與否、手術類型皆會對經口進食能力帶來影響，特別是收案對象於出院時口腔及吞嚥協調能力仍未完全恢復。本研究結果發現早期拔管、預防感染對先天性心臟病嬰兒恢復經口進食能力的重要性，未來在臨床上能盡早移除呼吸器、預防術後感染及預防術後導致再次開胸的相關合併症，有助於先天性心臟病嬰兒能恢復經口進食能力。
並列摘要
Background: Due to the advancement of the pediatric cardiology operation, the survival rate of the infants with congenital heart disease (CHD) has been increased. However, the oral feeding difficulty issue has affected the patients’ growth and development. The aim of the research is to investigate the situation including influential factors relevant to the oral feeding ability of CHD infants that need the open heart surgery throughout the period of hospitalization. Purpose: The purpose of this study was: (1) To understand the type of oral feeding difficulty and when would it happen.; (2) To analyze the relationships between the demographic information about the CHD infants, the severity of the CHD and the medical histories of the CHD infants. Methods: This research applied the prospective, longitudinal study with consecutive sampling., by means of purposive sampling approach at the children’s hospital in Taipei, from July, 2017 to May 2018. Further, this research targeted at the CHD infant patients under 6 months that received an open heart surgery. The content of the structured questionnaire includes the Early Feeding Skills Assessment (EFS), observation schedule, and demographic information form. Finally, the SPSS 21.0 was used to conduct the descriptive and inferred statistic analysis. Results: In total, 30 participants were included in this study, the average length of nasogastric tube were 35.67 days. For oral feeding difficulty before the operation, the data shows that the prevalence rate of instability of vital signs was 83.33%, and the prevalence of poor endurance after oral feeding was 76.67%. The total score of EFS improved after extubation, especially it increased significantly (p < .05) on the third day after extubation. The ability of engagement during oral feeding (from 7.37 to 10.03), the stability of vital signs (from 19.3 to 25.45), and also the endurance after oral feeding (from 3.90 to 5.37). The average oral intake was 85.82% of daily intake on the day our participants removed the nasogastric tube. 24 patients (80%) had been discharged without a nasogastric tube, but 20 of them still need some clinical concerns for their oral feeding ability. According to the general estimate equations model, the oral feeding ability measured by the EFS was related to the length of intubation(β = -8.83, p < .001), type of the open heart surgery (β = -3.90, p = .03), whether received other thoracic range operation(β = -4.53, p = .04), and time (β = 0.45, p < .001). Conclusion: Receiving an open heart surgery can improve the cardiac haemodynamics of CHD infants and promote their tolerance of engaging in the daily activities. Also, long-term intubation, receiving multiple operations and infection affected their oral feeding ability, especially the oral-motor skill and the swallowing process of our participants still did not fully recover when discharge from the hospital. The finding of this research emphasized the importance of early extubation, infection prevention, and comorbidity prevention toward the recovery of oral feeding ability in CHD infants.
參考文獻
延伸閱讀
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