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研究生:李坤璋
研究生(外文):Kun-Chang Lee
論文名稱:住院復健期腦中風病人鼻胃管移除與否相關因子分析
論文名稱(外文):Factors associated with removal of nasogastric tube in patients with subacute/chronic stroke
指導教授:季瑋珠季瑋珠引用關係
指導教授(外文):WEI-CHU CHIE
口試委員:杜裕康劉建廷
口試委員(外文):YU-KANG TU
口試日期:2019-07-09
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:流行病學與預防醫學研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2019
畢業學年度:107
語文別:中文
論文頁數:30
中文關鍵詞:吞嚥困難鼻胃管吞嚥訓練腦中風腦出血
DOI:10.6342/NTU201903591
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背景與目標:
吞嚥能力是人類維持生命所需,然而腦中風的病人常合併吞嚥困難而需要使用管路餵食,本研究旨在探討影響鼻胃管移除的相關因子,提供給臨床工作者參考。目的是希望可以盡力矯正可移除因子,找出容易移除失敗的病人,加強訓練以及建議使用較為長期的管路。

方法:
本研究採取病歷回溯性研究,希望找出鼻胃管移除與否的影響因子。納入的條件為從民國民國105年1月1日至民國107年12月31日日因腦中風(包含缺血及出血)入住本院復健科且合併使用鼻胃管的病人,排除的條件為入住時間少於一個禮拜或是中風前已使用鼻胃管的病人。

結果:
比較鼻胃管移除成功以及失敗的變數資料,無法移除組先前日常生活的獨立情況較差(80.28% vs 94.64%;P= 0.02),認知功能中的判斷能力較差(35% vs 89.19%;OR=0.07(0.02-0.22); P<.0001)以及抽象能力較差 (30% vs 62.16%;OR=0.26(0.1-0.67);P=0.0046),有失語症的比例較高(68.18% vs 33.93%;OR=4.17(1.96-8.9);P=0.0002),較差的口腔控制(流涎)(45.71% vs 26.79%;OR=2.3(1.08-)4.9;P=0.03) ,初始布氏動作階段較差(8.29±3.33 vs9.91±3.82;P=0.02) ,初始巴氏量表的分數較低(5.42±11.08 vs 16.79±15.03;P< 0.0001) ,巴氏量表住院期間變化較少(4.68±7.48 vs 14.38±13.08;P< 0.0001) ,住院期間發生肺炎比例較高(22.54% vs 8.93%;OR= 2.97 (1.01-8.69);P=0.04)。

在其他變項的部分,兩組在年齡、性別、身體質量指數、中風型態 (缺血/出血、位置、接受開顱手術與否) 、中風相關危險因子(糖尿病、高血壓、冠狀動脈疾病、高血脂、心房顫動、中風病史、抽菸、喝酒、嚼檳榔) 、社會經濟情況(教育程度,婚姻狀態、有無子女、入住床等、使用語言、住院路徑) 、身體評估(吞嚥反射、布氏動作階段變化)、尿管使用情況、泌尿道感染均沒有顯著差異
運用迴歸分析,可以得到以下方程式
Log(移除與否)=-0.6626 + 0.8207*(認知)-0.7348*(流涎)+0.0584*(入院巴氏量表分數)。利用youden index可以得知最佳切點為Log(移除與否)大於-0.5767,可以達到敏感度84.62%,特異度71.70%。此模型可供臨床工作者參考,來篩選出困難移除的病人。

結論:
先前日常生活的獨立情況、認知功能、失語症、口腔控制(流涎)、初始布氏動作階段、初始巴氏量表的分數、巴氏量表住院期間變化、住院期間是否發生肺炎皆為影響鼻胃管可否移除的相關因子。Log(移除與否)=-0.6626 + 0.8207*(認知)-0.7348*(流涎)+0.0584*(入院巴氏量表分數),此模型可供臨床工作者參考,來篩選出困難移除的病人。
Background and objectives:
Swallowing is vital to sustaining life. However, stroke patients often require tube feeding due to dysphagia. This study aims to investigate the impact factors of the removal of a nasogastric tube for further clinical reference. Our goal is to fix correctable factors, find out patients fail at removal, to strengthen the training and recommend the usage of a permanent tube.
Methods:
This research adopts retrospective study to investigate the factors associated with removal of the nasogastric tube. The inclusion criteria are patients hospitalized in our hospital due to between Jan 1st, 2016 to December 31st, 2018 stroke (including ischemic and hemorrhagic) and combined with nasogastric tube usage, exclusion criteria are hospital stay less than one month or nasogastric tube applied before the stroke.
Results:
Unable to remove group has poor pre-functional status (80.28% vs 94.64%;P= 0.02), poor judgment of cognition (35% vs 89.19%;OR=0.07(0.02-0.22); P<.0001) and poor abstraction of cognition (30% vs 62.16%;OR=0.26(0.1-0.67);P=0.0046), higher aphasia(68.18% vs 33.93%;OR=4.17(1.96-8.9);P=0.0002) , poor oral control (drooling) (45.71% vs 26.79%;OR=2.3(1.08-)4.9;P=0.03) ,lower initial Brunnstrom recovery stage (8.29±3.33 vs9.91±3.82;P=0.02) , lower initial Barthel index (5.42±11.08 vs 16.79±15.03;P< 0.0001) , less change in Barthel index during hospital stay (4.68±7.48 vs 14.38±13.08;P< 0.0001) , high penumonia rate during hospital stay (22.54% vs 8.93%;OR= 2.97 (1.01-8.69);P=0.04) 。
Other variables, two groups has no significant difference in age, sex, BMI, Stroke pattern (ischemic/hemorrhagic、site、craninectomy history) , risk factor about stroke (Diabetes mellius、hypertension、coronary artery disease、hyperlipidemia、atrial fibrillation、previous stroke history、smoking、drikning, chewing betel nut), Socioeconomic situation(educational level、marriage status、whether having children or not、 bed status、language、admission route), physical evaluation (gag reflex、change in Brunnstrom recovery ), whether having Foley using, and urinary tract infection.
The study provides a model by using regression analysis
Log(Remove status) =
-0.6626 +0.8207*(cognition)-0.7348*(drooling)+0.0584*(initial Barthel index). By using Youden index, the most suitable cut-off value is -0.5767 to reach 84.62% sensitivity and 71.70% specificity.
This model can help to screen patients which is difficult in nasogastric tube removal.
Conclusion:
Factors affecting the removal of nasogastric include pre-functional status , cognition , aphasia,oral control (drooling), initial Brunnstrom recovery stage , initial Barthel index , change in Barthel index during hospital stay , penumonia rate during hospital stay. Log(Remove status) =-0.6626+ 0.8207*(cognition) -0.7348*(drooling) +0.0584*(initial Barthel index). This model can help to screen patients which is difficult in nasogastric tube removal.
Key words:dysphagia,nasogastric tube,swallowing trianing, stroke,intracranial hemorrhage
內容綱要(Table of contents)
口試委員會審定書……………………………………………………………… II
誌謝……………………………………………………………………………… III
中文摘要………………………………………………………………………… IV
英文摘要………………………………………………………………………… VI
內容綱要
第一章研究背景…………………………………………………1
第一節: 吞嚥的重要性以及腦中風對吞嚥造成的影響………………………1
第二節: 吞嚥的生理過程………………………………………………………1
第三節: 吞嚥困難的臨床評估以及檢查………………………………………2
第四節: 吞嚥困難的訓練………………………………………………………2
第五節: 吞嚥困難病人灌食的管路選擇………………………………………3
第六節: 腦中風吞嚥困難的預測因子…………………………………………3
第七節: 吞嚥困難能否恢復的預測因子………………………………………3
第二章 研究目的……………………………………………………………………5
第三章: 研究材料與法………………………………………………………………6
第一節: 研究對象選取…………………………………………………………6
第二節: 研究個案變數收集……………………………………………………6
第三節: 統計方法………………………………………………………………6
第四章:結果…………………………………………………………………………8
第一節 收納病人之結果以及人口學資料.……………………………………8
第二節 移除鼻胃管成功與否的變數比較…………………………………….8
第三節 移除鼻胃管成功之預測因子分析……………………………………9
第五章:討論…………………………………………………………………………10
第一節: 綜合結果………………………………………………………………10
第二節: 認知功能和移除鼻胃管的關係………………………………………10
第三節: 失語和移除鼻胃管的關係……………………………………………11
第四節: 巴氏量表分數和移除鼻胃管的關係 …………………………………11
第五節: 流涎和移除鼻胃管的關係…………………………………………12
第六節: 肺炎和移除鼻胃管的關係…………………………………………12
第七節: 先前獨立情況和移除鼻胃管的關係………………………………12
第八節: 布氏動作恢復階段和移除鼻胃管的關係…………………… ……13
第九節: 本研究之限制………………………………………………………13

參考文獻……………………………………………………………14
表格……………………………………………………………18

附錄………………………………………………………………………………. 29
1. Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005;36(12):2756-63. doi: 10.1161/01.STR.0000190056.76543.eb [published Online First: 2005/11/05]
2. Horner J, Massey EW, Brazer SR. Aspiration in bilateral stroke patients. Neurology 1990;40(11):1686-8. [published Online First: 1990/11/01]
3. Braddom RL. Physical Medicine and Rehabilitation E-Book: Elsevier Health Sciences 2010.
4. Kelly BM. DeLisa’s Physical Medicine & Rehabilitation: Principles and Practice. JAMA 2011;306(2):214-15.
5. Ra JY, Hyun JK, Ko KR, et al. Chin tuck for prevention of aspiration: effectiveness and appropriate posture. Dysphagia 2014;29(5):603-9. doi: 10.1007/s00455-014-9551-8 [published Online First: 2014/07/12]
6. Wheeler-Hegland K, Ashford J, Frymark T, et al. Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part II--impact of dysphagia treatment on normal swallow function. Journal of rehabilitation research and development 2009;46(2):185-94. [published Online First: 2009/06/18]
7. Byeon H. Effect of the Masako maneuver and neuromuscular electrical stimulation on the improvement of swallowing function in patients with dysphagia caused by stroke. Journal of physical therapy science 2016;28(7):2069-71. doi: 10.1589/jpts.28.2069 [published Online First: 2016/08/12]
8. Park JS, Hwang NK, Kim HH, et al. Effects of lingual strength training on oropharyngeal muscles in South Korean adults. Journal of oral rehabilitation 2019 doi: 10.1111/joor.12835 [published Online First: 2019/06/18]
9. Britton JE, Lipscomb G, Mohr PD, et al. The use of percutaneous endoscopic gastrostomy (PEG) feeding tubes in patients with neurological disease. Journal of neurology 1997;244(7):431-4. [published Online First: 1997/07/01]
10. Dharmarajan TS, Unnikrishnan D. Tube feeding in the elderly. The technique, complications, and outcome. Postgraduate medicine 2004;115(2):51-4, 58-61. [published Online First: 2004/03/06]
11. Dziewas R, Ritter M, Schilling M, et al. Pneumonia in acute stroke patients fed by nasogastric tube. Journal of neurology, neurosurgery, and psychiatry 2004;75(6):852-6. [published Online First: 2004/05/18]
12. Kadakia SC, Sullivan HO, Starnes E. Percutaneous endoscopic gastrostomy or jejunostomy and the incidence of aspiration in 79 patients. American journal of surgery 1992;164(2):114-8. [published Online First: 1992/08/01]
13. Gordon C, Hewer RL, Wade DT. Dysphagia in acute stroke. British medical journal (Clinical research ed) 1987;295(6595):411-4. [published Online First: 1987/08/15]
14. Veis SL, Logemann JA. Swallowing disorders in persons with cerebrovascular accident. Archives of physical medicine and rehabilitation 1985;66(6):372-5. [published Online First: 1985/06/01]
15. Logemann JA. Approaches to management of disordered swallowing. Bailliere''s clinical gastroenterology 1991;5(2):269-80. [published Online First: 1991/06/01]
16. Ickenstein GW, Hohlig C, Prosiegel M, et al. Prediction of outcome in neurogenic oropharyngeal dysphagia within 72 hours of acute stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 2012;21(7):569-76. doi: 10.1016/j.jstrokecerebrovasdis.2011.01.004 [published Online First: 2011/06/21]
17. Wilkinson TJ, Thomas K, MacGregor S, et al. Tolerance of early diet textures as indicators of recovery from dysphagia after stroke. Dysphagia 2002;17(3):227-32. doi: 10.1007/s00455-002-0060-9 [published Online First: 2002/07/26]
18. 溫馨喬, 唐浩偉, 彭昶仁, et al. 中風後急性/亞急性期吞嚥困難病患鼻胃管拔除之相關因子研究. 台灣復健醫學雜誌 2015;43(4):217-23. doi: 10.6315/2015.43(4)02
19. 王憶華. 探討腦中風合併吞嚥障礙患者影響鼻胃管拔除之相關因素. 高雄醫學大學, 2017.
20. Miller E, Wallis J. Executive function and higher-order cognition: definition and neural substrates. Encyclopedia of neuroscience 2009;4(99-104)
21. Donovan NJ, Kendall DL, Heaton SC, et al. Conceptualizing functional cognition in stroke. Neurorehabilitation and Neural Repair 2008;22(2):122-35.
22. Oto T, Kandori Y, Ohta T, et al. Predicting the chance of weaning dysphagic stroke patients from enteral nutrition: a multivariate logistic modelling study. European journal of physical and rehabilitation medicine 2009;45(3):355-62. [published Online First: 2009/02/25]
23. Ikenaga Y, Nakayama S, Taniguchi H, et al. Factors Predicting Recovery of Oral Intake in Stroke Survivors with Dysphagia in a Convalescent Rehabilitation Ward. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 2017;26(5):1013-19. doi: 10.1016/j.jstrokecerebrovasdis.2016.12.005 [published Online First: 2017/01/22]
24. Kirshner HS. Classical aphasia syndromes. NEUROLOGICAL DISEASE AND THERAPY 1995;33:57-57.
25. Wade D, Hewer RL, David RM, et al. Aphasia after stroke: natural history and associated deficits. Journal of Neurology, Neurosurgery & Psychiatry 1986;49(1):11-16.
26. Yavuzer G, Küçükdeveci A, Arasil T, et al. Rehabilitation of stroke patients: clinical profile and functional outcome. American journal of physical medicine & rehabilitation 2001;80(4):250-55.
27. Kauhanen M, Korpelainen JT, Hiltunen P, et al. Poststroke depression correlates with cognitive impairment and neurological deficits. Stroke 1999;30(9):1875-80. [published Online First: 1999/09/02]
28. Fotiadou D, Northcott S, Chatzidaki A, et al. Aphasia blog talk: How does stroke and aphasia affect a person’s social relationships? Aphasiology 2014;28(11):1281-300.
29. Falsetti P, Acciai C, Palilla R, et al. Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. Journal of Stroke and Cerebrovascular Diseases 2009;18(5):329-35.
30. Lee B, Pyun S-B. Characteristics of cognitive impairment in patients with post-stroke aphasia. Annals of rehabilitation medicine 2014;38(6):759.
31. Sangha H, Lipson D, Foley N, et al. A comparison of the Barthel Index and the Functional Independence Measure as outcome measures in stroke rehabilitation: patterns of disability scale usage in clinical trials. International journal of rehabilitation research Internationale Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de readaptation 2005;28(2):135-9. [published Online First: 2005/05/19]
32. Quinn TJ, Langhorne P, Stott DJ. Barthel index for stroke trials: development, properties, and application. Stroke 2011;42(4):1146-51. doi: 10.1161/strokeaha.110.598540 [published Online First: 2011/03/05]
33. Duffy L, Gajree S, Langhorne P, et al. Reliability (inter-rater agreement) of the Barthel Index for assessment of stroke survivors: systematic review and meta-analysis. Stroke 2013;44(2):462-8. doi: 10.1161/strokeaha.112.678615 [published Online First: 2013/01/10]
34. Ouyang M, Boaden E, Arima H, et al. Dysphagia screening and risks of pneumonia and adverse outcomes after acute stroke: An international multicenter study. International journal of stroke : official journal of the International Stroke Society 2019:1747493019858778. doi: 10.1177/1747493019858778
35. Katzan IL, Cebul RD, Husak SH, et al. The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology 2003;60(4):620-5. doi: 10.1212/01.wnl.0000046586.38284.60 [published Online First: 2003/02/26]
36. 祝旭東, 王淳厚, 謝清麟, et al. 布氏動作恢復量表之信度及同時效度研究. 職能治療學會雜誌 1996;14(1):1-12. doi: 10.6594/jtota.1996.14(1).01
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