臺灣博碩士論文加值系統

本研究主要在探討翻身前口腔分泌物抽吸對肺炎防治及呼吸器脫離成敗之效果。係採實驗性研究設計，經醫院人體試驗倫理委員會審查通過後，在某醫學中心胸腔科加護病房選取符合收案條件的病患為對象，並經說明同意參與研究者方收案。共收案對照組與實驗組各40人。
對照組依常規之護理照護；實驗組，則於執行翻身前給予口腔分泌物抽吸之介入性措施。研究工具包括個案收案紀錄表、個案基本資料及檢驗值登錄表，對實驗組個案進行翻身前口腔分泌物抽吸介入性措施。
資料分析以SPSS 13.0版套裝軟體進行建檔與統計分析，以Chi-square test、independent-t test檢定兩組病患的基本資料及疾病資料之差異性，以Binary Logistic Regression檢視兩組病患之Albumin、CRP值對於呼吸器脫離成敗的預測力，以ROC（Receiver Operating Characteristics）Curves檢視兩組病患之Albumin值與CRP值，預測呼吸器脫離成功的最低標準。
研究結果顯示翻身前執行口腔分泌物抽吸，明顯的有較高之呼吸器脫離率（70% vs. 45%, p=0.02, O.R.=1.6, 95%, CI =1.05~2.32）；及較低的新肺炎之發生率（10％ vs. 30％， p=0.025, O.R.=0.33, 95% CI= 0.12~0.95）。且在較低之Albumin 值（2.5 g/dl vs. 3.0 g/dl），較高之CRP值（2.4 mg/dl vs. 1.7 mg/dl）即可預測拔管成功而進行脫離呼吸器之措施。翻身前執行口腔分泌物抽吸，降低了新肺炎之發生率，與有新肺炎發生病人比較，可縮短停留在RCU之天數10天及使用抗生素天數7天，可減少住院費用。
顯示翻身前執行口腔分泌物抽吸之介入措施，對使用呼吸器病人，可有較高之呼吸器脫離率、較低的新肺炎發生率、可縮短停留在RCU之天數、縮短抗生素使用天數、縮短呼吸器使用天數、減少住院費用。因此值得推廣於照護使用呼吸器的病人，以降低醫療花費並提升照護品質。

Background: Ventilator-associated pneumonia (VAP) is a serious hospital-acquired infection with reported incidence rate of 12.2% and mortality rate of 29.3%. Oral secretion is purported as a media which brings the oropharyngeal pathogens down to the respiratory track.
Purpose: The purpose of this study was to evaluate the effect of removal of oral secretion before body position change on the pneumonia control and ventilator weaning.
Method: It was a randomized clinical trail conducted in respiratory care unit. Adults who were on ventilator for more than 5 days were enrolled and randomly assigned into either experimental or control group. Forty Subjects in experimental group received oral secretion removal with 60-80 mmHg pressure for 10 seconds while 40 subjects in control group received standard RCU care. They were followed-up for 21 days for presence and resolution of pneumonia and weaning from ventilator. The major statistical procedure applied in data process include chi-square, t-test, oneway ANOVA, ROC curve, and logistic regression. A p value of less than .05 was taken as significant.
Results: The result indicated that the experimental group had higher weaning rate (70% vs.45%, p=0.02, O.R.=1.6, 95% CI =1.05~2.32) and lower incidence of new pneumonia (10％ vs. 30％, p=0.025, O.R.=0.33, 95% CI= 0.12~0.95). Subjects in experimental group weaned from ventilator at lower Albumin level (2.5 g/dl vs. 3.0 g/dl) and higher CRP values (2.4 mg/dl vs. 1.7 mg/dl). Patients without developing new pneumonia were 10 days earlier to wean from ventilator and were 7days less on antibiotic therapy. The cost of tube used to remove oral secretion is 0.5 NTD which is much less than the one used to do continuous subglottal suction. Thus
Conclusion: Removal of oral secretion before body position change is a cost-effective procedure in pneumonia control and ventilator weaning for RCU patient.
Recommendation to practice: With the evidence of effective in pneumonia control and ventilator weaning, it is suggested to include the procedure of removal of oral secretion before body position change into nursing routine in taking care of patient with endotreacheal tube.

目錄
致謝---------------------------------------------------------------------------------------------i
中文摘要---------------------------------------------------------------------------------------ii
英文摘要---------------------------------------------------------------------------------------iv
目錄--------------------------------------------------------------------------------------------- v
表目錄------------------------------------------------------------------------------------------ vi
第壹章 緒論------------------------------------------------------------------------------1
第一節 研究動機------------------------- ---------------------------------------------1
第二節 研究問題------------------------------------------------------------------------2
第三節 名詞界定------------------------------------------------------------------------3
第四節 本研究之意義------------------------------------------------------------------3
第貳章 文獻查證---------------------------------------------------------------------------4
第一節 呼吸加護病房病人之特性----------------------------------------------------4
第二節 呼吸器相關肺炎之定義、分類與診斷標準--------------------------------6
第三節 呼吸器相關肺炎之致病菌-----------------------------------------------------8
第四節 呼吸器相關肺炎之危險因子-------------------------------------------------10
第五節 呼吸器相關肺炎對加護病房之病患的影響-------------------------------13
第六節 呼吸器相關肺炎之解決及預防措施----------------------------------------14
第七節 呼吸器相關肺炎處置之相關研究-------------------------------------------15
第叁章 研究方法--------------------------------------------------------------------------17
第一節 研究場所與對象---------------------------------------------------------------17
第二節 研究設計-- ---------------------------------------------------------------------17
第三節 介入性護理措施---------------------------------------------------------------18
第四節 研究工具與測量方法------------------------------------------- -------------18
第五節 資料收集過程------------------------------------------------------ -----------19
第六節 資料分析與統計方法---------------------------------------------------------19
第七節 研究對象的權益保護---------------------------------------------------------20
第八節 研究架構------------------------------------------------------------------------22
第肆章 研究結果--------------------------------------------------------------------------23
第一節 研究對象之基本資料分析---------------------------------------------------23
第二節 研究個案之疾病狀態---------------------------------------------------------24
第三節 對照組呼吸器脫離成敗之區辨因素---------------------------------------26
第四節 口腔分泌物抽吸組呼吸器脫離成敗之區辨因素------------------------28
第五節 預測呼吸器脫離成敗相關因素之分析------------------------------------30
第六節 入RCU時肺炎狀態與脫離呼吸器之相關資料分析--------------------31
第七節 在RCU時發生新肺炎與脫離呼吸器之相關資料分析--------------------33
第伍章 討論--------------------------------------------------------------------------------37
第一節 影響肺炎發生之因素----------------------------------------------------------37
第二節 口腔分泌物抽吸對肺炎防治效果-------------------------------------------37
第三節 口腔分泌物抽吸組影響呼吸器脫離率成功的因素---------------------38
第四節 口腔分泌物抽吸的成本效益分析------------------------------------------40
第陸章 結論與建議-----------------------------------------------------------------------41
第一節 結論-------------------------------------------------------------------------------41
第二節 建議-------------------------------------------------------------------------------41
第三節 研究限制-------------------------------------------------------------------------42
參考資料 -------------------------------------------------------------------------------------43
附錄 ------------------------------------------------------------------------------------------------- 59
附錄一 收案記錄總表---------------------------------------------------------------------59
附錄二 個案收案記錄表------------------------------------------------------------------60
附錄三 痰液菌種分析結果---------------------------------------------------------------------- 61
附錄四 受試者參與研究同意書---------------------------------------------------------62
附錄五 人體試驗委員會同意書---------------------------------------------------------------- 66


圖表目錄
表一 個案基本資料 ---------------------------------------------------------------------53
表二 對照組脫離成功與失敗患者基本資料之比較---------------------------------54
表三 實驗組脫離成功與失敗患者基本資料比較------------------------------------55
表四 預測呼吸器脫離成敗二元邏輯迴歸分析---------------------------------------56
表五 個案入RCU時有無肺炎之基本資料 ------------------------------------------57
表六 個案發生新肺炎之基本資料之比較--------------------------------------------58

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