臺灣博碩士論文加值系統

胃食道逆流為呼吸器使用合併鼻胃管灌病患常見之健康問題，食道咽喉黏膜常因此產生潰瘍，在拔除氣管內插管後發生喘鳴，影響拔管成效。此外逆流液滲入氣道，引起肺吸入，發生率達40%；若進一步發展成呼吸窘迫症候群，死亡率更高達50%。不但降低呼吸器脫離機會，也增加住院天數和醫療成本。護理若能藉由適當的管灌方式，預防胃食道逆流，將有助於減少其併發症的發生。本研究設計採單盲、前後測、交叉臨床試驗法，研究對象為呼吸疾病使用呼吸器合併鼻胃管灌食病患，一共十位參與，隨機分派於兩組。第一組研究對象於收案後第一天禁食，第二天接受間歇性管灌，第三天禁食，第四天接受持續性管灌。第二組研究對象於收案後第一天禁食，第二天接受持續性管灌，第三天禁食，第四天接受間歇性管灌。兩組病患於第五天至第十八天接受間歇性管灌。研究者於收案後24小時、第二天、第三天、第四天收集病人胃食道酸鹼計(24hr-pH meter)分數，痰量，體溫，有無喘鳴，計算痰液中性球數和吞油脂巨噬細胞數。於第五天至十八天之間病患拔除氣管內管後兩小時及二十四小時測量有無喘鳴。結果顯示：
一、兩組病患接受間歇性管灌後較持續性管灌後，胃食道逆流得分明顯減少，達統計顯著意義。
二、兩組病患接受間歇性管灌後比持續性管灌後，肺吸入指標得分(痰量、痰液吞油脂巨噬細胞數、喘鳴發生頻率)明顯減少，均達統計顯著意義。
三、兩組病患氣管插管拔除後喘鳴發作頻率，與接受間歇性管灌後與連續性管灌後之喘鳴發作頻率改變量成正相關，但未達統計顯著意義。
由此可見，採用間歇性管灌食方式，似乎可以有效減少呼吸器使用合併鼻胃管灌病患胃食道逆流，預防肺吸入合併症的發生。

Patients with ventilator support as well as with nasol-gastric tube feeding often cause gastroesophageal reflux (GE-reflux) syndrome, and induced complicated complication. GE-reflux can cause patient wheezing , pharyngeal mucositis, and difficult to weaning. After reflux, the incident rate of aspiration pneumonia is about 40%. More over developes into adult respiration distress syndrome (ARDS), the motality rate is high up to 50%.
In our investigation, we try to ascertain the efficiency of intermittent nasol-gastric feeding in preventing in GE-reflux patients with ventilator support .A pre-post test with single blind in cross-over was designed. The 10 subjcts suffered from chest diseases with ventilator support were randomized in two groups. Group 1 proceed as following: day 1 NPO, day 2 with intermittent nasol-gastric (NG) feeding, day 3 NPO, day 4 with continuous NG feeding; Group 2 proceed as following: day 1 NPO, day2 with continuos NG feeding, day 3 NPO, day 4 with intermittent NGfeeding. Data collection from day 1 to day 4, included 24hr-pH meter score, sputum, body temperature, wheezing, sputum neutrophil and lipid-ladden macrophage were recorded; during the day 5 to day 18, the frequency of wheezing was assessed at 2 hours and 24 hours after removing endo-treacheal tube.Our conclusions are:
1.Patients with intermittent NG feeding have less GE-reflux scores than those with continuous NG feeding.
2.Patients with intermittent NG feeding have better aspiation sputum index scores,such as sputum、neutrophil、and wheezing incidence.
3.Patients with intermittent NG feeding have less wheezing incidence when
endo-treacheal tube removed.
In our investigation we found that intermitent NG-feeding seems to decrease GE-reflux incidence and prevent severe complications.

中文部份
李旺柞主編．(民80)．1991新編Guyton生理學．台北：合記出版社．
吳德朗．(民87)．赫里遜內科學．台北：合記圖書出版公司．
邱艷芬．(民83)．重症病人腸道營養給法標準之建立．行政院國家科學委員會專題研究計畫成果報告．
英文部份
Bernhard,W.B.,Cottrell,J.E.,Sivakumaran,C.,Patel,K.,Yost,L.,& Turndorf,H.(1979).Adjustment of intracuff pressure to prevent aspiration.Anesthesiology,50,363-366.
Betcher, E.,Seltzer.M.,Slocum,M,(1983).Complication occurring
during enteral nutritional support:A Prospective study .Journary
Parenter Enter Nutrition,7,546.

Bonten,M.J.,Gaillard,C.A.,Hulst,R.,Leeuw,P.W.,Geest,S.,Stobberingh,E.E.,& Soeters,P.B.(1996).Intermittent enteral feeding :the
influence on respiratory and digestive tract colonization in
mechanically ventilated intensive-care-unit patients.Amercan Joural Respiratory Critical Care Medicine 154,(pt 1),394-399.
Bombeck,C.T., Dillard,D.H., & Nyhus,L.M.(1966).Musscular
anatomy of the gastroesophageal junction and role of phrenoesophageal ligament.Annal Surgery.164,645-654.
Cherry,J.,& Margulies,S.I.(1968).Contact ulcer of the larynx
.Laryngoscope,8,1937-1940.
Cogen,R.,& Weinryb,J.(1989).Aspiration pneumonia in nursing home patients fed via gastrostomy tubes.The American Journal of Gastroenterology,84,(12),1509-1512.
Collins,K.A.,Geisinger,K.R.,Wagner,P.H.,Blackburn,K.S.,Washburn,L.K.,& Block,S.M.(1995).The Cytologic evaluation of Lipid-Laden alveolar macrophages as an indicator of aspiration pneumonia in young children.Archcal Pathology Labotory Medical119,229-231.
Dotosn,R.g.,Robinson,R.G.,& Pingleton,S.K.(1994).
Gastroesphageal reflux with Nasogastrictubes .Americal Respiratory Critical Care Medicine ,149,1659-1662.
Elpern,E.H.,Jacobs,E.R.,& Bone,R.C.(1987).Incidence of
aspiration in tracheally intubated adults.Heart andLung,16(5),527-531.
Folkesson ,H .G.,Matthay,M.A.,Hebert,C.A.,& Broaddus,V.C.
(1995).Acid aspiration-induced lung injury in rabbits is mediated by interleukin-8-dependent mechanism.Journal Clinical Investigation,96,107-116.
Goldstein,J.A.(1983).Hydroxychloroquine forasthma.Amercan
Revired Respiratory Disease,128,1100-1101.
Goodwin ,R.S.(1996).Prevention of Aspiration pneumonia:
A research based protocol .Dimensions of Critical Care Nursing ,15,(2),58-73.
Harding,S.M.(1997).Pulmonary abnormalities ingastro-
esophageal reflux disease.Ambulatory Esophageal pH Monitoring:Practical Approach and Clinical Applications (2nd ed.). Media .Pennsylvania .Williams & Wilkins,133-148.149-164.
Ibanez,J.,Penafiel,A.,Raurich,M.R.,Marsw.P.,Jorda,R.,
& Mata,F.(1992).Gastroesophageal refux in intubated patient
receiving enteral nutrition:effect of supine and semire-
cumbent positions.Journal of Parenteral and Enteral Nutrition,
16,(5),419-422.
Kahrilas,P.J., & Gulchin,A.E.(1991).Otolaryngologic manifestations of GERD. Ambulatory Esophageal pH Monitoring:
Practical Approach and Clinical Applications ,(2nd ed.)
Media .Pennsylvania .Williams & Wilkins,133-148.
Kazi,N.,& Mobarhan,S.(1996).Enteral feeding associated
gastroesphageal reflux and aspiration pneumonia:A review.
Nutrition Review,54,(10),324-328.
Kingston,G.W., Phang,P.T.,& Leathley,M.J.(1991).
Increased incidence of nosocomial pneumonia in mechanically ventilated patients with subclinical aspiration.The American Journal of Surgery ,161,589-592.
Kirsch,C.M.,& Sander,A.(1988).Aspiration pneumoniamedical
management.Otolaryngologic Clinics of North America,21,(4),677-
688.
Levi,M.O.,Torres,A.,Ferrer,M.,Piera,C.,Ebiary,M.E.,Bellacasa,J.P.D.L.,& Roisin,R.R.(1995).Semirecumbent position protets from
pulmonary aspiration but not completely from gastroesphageal reflux in mechanically ventilated patients.American Joural Respiratory Critical Care Medicine 152,1387-1390.
McCallum ,R.W.,& Mittal,R.K.(1990) .Gastroesophageal Reflux Disease.Gastroenterology Clinics of North America.N.Y.：W.B.Saunders.
Metheny,N.A.,Eisenberg,P.,& Spies,M.(1986).Aspiration pneumonia in patients fed through nasoenteral tubes.Heart & Lung,15,(3),256-286.
Nagler ,R.,& Spiro, H.M.(1963) .Persistent gastroesophageal reflux induced during prolonged gastric intubation . Nursing England Joural Medicine, 269,495-500.
Norton,J.A.,Ott,L.G.,McClain,C.,Adams,L.,Dempsey,R.J.,Haack,D.(1988).Intolerance to enteral feeding in the brain-injured
patient.Joural Neurosurgery,68,62-66.
Panos,M.Z.,Reilly,H.,Moran,A.,Reilly,T.,Wallis,P.J.
W.,Wears,R.,& Chesner,W.I.(1994).Gut,35,1551-1556.
Rubin,S.A.,WinerMuram,H.T.,& Ellis,J.V.(1995).Diagnosis
imaging of pneumonia and its complications in the critically ill
patient.Clinics in Chest Medicine,16(1),45-59.
Roewer.N.,(1995).Can pulmonary aspiration of gastric contents be prevented by balloon occlusion of the cardia?A study with a new nasogastrictube.(1995). Anesthesia Analgology,80,378-383.
Russell,G.N.,Yam,P.C.I.,&Tran,J.(1996).Gastroesophageal reflux
and tracheobronchial contamination after cardiac surgery : Should a nasogastric tube beroutine? Anesthesia.analgology,83,228-32.
Sands,A.J.(1991).Incidence of pulmonary aspiration in intubated patients reiving enteral nutrition through wide-and narrow-bore nasogastric feeding tubes.Heart & Lung,20,(1),75-80.
Shulman,R.J.,Redel,C.A.,& Stathos,T.H.(1994)Bolus vs
continuous feeding stumulate small intestinal growth and
differentiation newborn piglets. Journal of Parenteral and Enteral Nutrition ,18,19s.
Spray,S.B.,Zuidema,G.D.,& Cameron J.L.(1976).Incidence of aspiration with endotracheal tubes.Heart & Lung,131,701-703.
Taylor,D.R.,Sears,M.R.,& Herbison,G.P.(1992).Regular inhaled
B-agonist in asthma:effects on exacerbation and lung function . Thorax,48,1234-1238.
Torres,A.,Serra-Batlles,J,Ros,E.,Piera,C.,Bellacasa
J.P.,Cobos,A.,Lomena,f.,Rodriquez ,& Roisin,R.(1992).Pulmonary
aspiration of gastric contents in patients receiving mechanical
ventilation:the effect of body position.American Cllege of Physicians,116,(7),540-543.
Treloar D.M.,＆ Stechmiller,J.(1984) .Pulmonary aspiration in tube-fed patients with artificial airways.Heart & Lung ,13,(6),667-671.
Weinstein,D.S.,& Furman,J.(1997).Enteral formulas.Clinical
nutrition:Nutrition Support,32(4),669-683.
Zagola ,G.(1991).Bedside method for placing small bowel feeding tubes in critically ill patients.Chest,100,1643-1646.