臺灣博碩士論文加值系統

中文摘要

目的: 探討長期呼吸器依賴患者接早晚期氣切及從不接受氣切者的預後的差別。並分析影響呼吸器脫離率及住院期間死亡率的相關因子。
方法: 本研究為回溯性、觀察性的群體研究，收案對象為彰化基督醫院呼吸照護中心從95年1月1日至97年12月31日共三年之患者，並分為三組，第一組為呼吸衰竭後小於21天內接受氣切的早期氣切組，第二組為呼吸衰竭後大於等於21天以上接受氣切的晚期氣切組。第三組為呼吸衰竭後從未接受氣切的患者。本研究的預後的變異數分別為1.加護病房、呼吸照護中心、總住院天數2.呼吸器使用天數 3.呼吸器脫離率 4.呼吸照護中心、住院期間死亡率5.兩年內的存活率。另外本研究以COX regression 的Hazard Ratio 統計出與呼吸器脫離率及住院期間死亡率有相關性的因子。
結果: 此研究共收案1683名RCC患者，小於21天接受氣切者共403人，大於21天者共328人，從未接受氣切手術組有952人。
其三組的ICU、RCC、總住院天數及呼吸器使用天數以從不開氣切組為最短者，三組總住院天數依組別排序為67±82天、96±89天、59±72天，呼吸器使用天數為52±80天、78±87天、45±68天。但RCC脫離率、RCC存活率、住院期間存活率則以從不開氣切組的最差。然而早期氣切組比晚期氣切組有顯著較佳預後所有的結果(P ﹤0.001)。其三組RCC脫離率分別為60.8%、45.8%、44.7%，三組住院期間的死亡率分別為21.1%、26.15%、39.65%。
結論: 本呼吸照護中心患者，接受氣切後有顯著的提高呼吸器脫離率、降低住院期間的死亡率及提高兩年內存活率。而早期氣切(<21天)患者比晚期氣切(≧21天)患者有顯著較佳的預後影響。
在本研究中的因子分析方面，我們發現有其統計上的意義差別為血尿素氮(BUN)、血清肌酸酐(CREA)、白血球數(WBC)、嗜中性白血球(N-segment)、鎂離子(Mg)、磷離子(P)、可體松值(Cortisol level)及APCHE II score等以上數值較高者其呼吸器脫離率及存活率較差，而相反的Free T4（Thyroxine）游離四碘甲狀腺素、血清白蛋白(Albumin)及血紅素(Hb)及昏迷指數等以上數值較高者其呼吸器脫離率及存活率較佳。另外BMI較高者對脫離呼吸器無影響但其死亡率有較高的傾向。然而，成功脫離呼吸器組在五個月後的存活率較失敗脫離呼吸器組多了40%的勝算。

Objection: To examine the clinical outcomes between these patients receiving early tracheotomy or later tracheostomy or never receiving tracheostomy, who all requiring prolonged mechanical ventilator in respiratory care center. Besides, we also evaluated factors associating with unsuccessful weaning and hospital mortality. These various factors included laboratory data, BMI, type 2 diabetic mellitus, APACHE II score and GCS.
Design: Retrospective cohort analysis
Method: The patients were collected from medical and surgical respiratory care centers during 3 years period between January 2004 and December 2007, which two respiratory care centers were in a medical center in the middle-south of Taiwan. The prediction of the outcomes was ICU days, hospital days, RCC weaning rate, hospital mortality and two years survival rates.
Results: The total 1683 prolong mechanical ventilator patients were enrolled. They were divided into 3 groups according to their tracheostomy timing. The first group was classified as early tracheostomy (within 21 days of ventilator) of 403 patients. The second group was later tracheostomy (after 21 days of ventilator) of 328 patients. The third group was nontracheostomized patients during ventilator of 957 patients. Nontracheosotmized group had shortest days of hospital day and ventilator day. The hospital days of these 3 groups were 67±82 days, 96±89 days, 59±72 days, respectively. Ventilator days were 52±80 days, 78±87 days, 45±68 days, respectively. But RCC weaning rate and hospital mortality were worst in nontracheostomized group. These RCC weaning rates were 60.8%, 45.8%, 44.7%, respectively. Their hospital mortality rates were 21.1%, 26.15%, 39.65%, respectively. However, the early tracheostomy group had better distinguished outcomes (P<0.001) than later tracheostomy group in hospital days, RCC weaning rate and both RCC and hospital mortality rates.
Conclusion: Tracheostomy performed in our RCC patients had better outcomes in weaning rate, hospital survival rate and 2 years survival rate. Moreover, early tracheostomy has significant benefits than later tracheostomy.
These factors associated with unsuccessful weaning during RCC and hospital mortality are elevated WBC, N-segment, BUN level, creatinine, Mg, P, cortisol level, APAPCH-II score, MICU transfer rates and low albumin level, Free T4, Hemoglobin, GCS score. Elevated BMI，serum sodium and long ICU stay associated with hospital mortality. However, our study found after 5 months survival rate, the group of successful weaning ventilator at RCC has 40% higher survival rate compare with unsuccessful weaning group.

壹、導論 1
一、研究背景 1
二、呼吸器依賴整合照護計劃 2
三、長期呼吸器依賴 5
四、脫離呼吸器 7
五、氣切 9
1氣切的歷史. 9
2氣切的適應症 10
3氣切的功能. 10
4氣切的併發症. 11
5氣切的時機. 12
6氣切手術方法. 13
7氣切的移除. 14
8氣切預後文獻參考. 14
六、疾病嚴重度評估系統 17
貳、研究構想 19
一、研究重要性 19
二、研究目的 19
三、本研究的氣切時機的選擇 20
參、研究材料與方法 21
一、收案研究機構 21
二、收案對象 21
三、資料收集 22
四、統計方法 23
五、本呼吸照護中心訓練脫離呼吸器的過程 23
肆、結果 27
ㄧ、研究族群的特性 27
二、研究族群基本特性比較 27
三、研究族群的預後結果 28
四、在呼吸照護中心脫離成功者的特性及預後結果 28
五、在RCC脫離成功者之相關因子分析 29
六、住院期間之存活者之相關因子分析 30
伍、討論 31
一、早期氣切對長期呼吸器依賴患者有較佳的預後影響 31
二、早期氣切對嚴重創傷、腦神意外及重症患者有
較佳的預後影響 32
三、從未接受氣切者卻有較短的呼吸器使用時間及較短的加護
單位住院天數和住院總天數 34
四、氣切不會造成照顧上的負擔 35
五、影響呼吸器脫離率及死亡率的單因子分析 37
六、研究的限制及未來的計劃 39
陸、結論 40
柒、參考文獻 41
一、中文文獻 41
一、英文文獻 42
捌、表 48
表一、氣切與經口氣管內插管優缺點比較 48
表二、描述本研究族群之特性 50
表三、三組之基本特性之比較 51
表四、 主診斷之疾病分類 52
表五、三組之預後之比較 53
表六、在RCC 脫離掉呼吸器的族群基本特性 54
表七、在RCC 脫離掉呼吸器的族群三組特性之比較 54
表八、在RCC 脫離掉呼吸器的族群三組之預後比較 55
表九、比較影響在RCC脫離成功與失敗之因子分析 56
表十、影響脫離失敗之單因子風險分析表一、中文部份 58
表十一、比較影響住院期間死亡之單一因子分析表 59
表十二、影響住院期間死亡之單一因子的風險分析表 60
表十三、近期氣切預後研究文獻比較表 61
玖、圖 63
圖一、研究架構 63
圖二 RCC轉出流程圖 64
圖三、呼吸照護中心脫離呼吸器之流程圖 65
圖四、三組患者兩年內存活圖 67
圖五、三組患者在加護病房的天數 68
圖六、三組患者在呼吸照護中心的天數 69
圖七、三組患者住院總天數 70
圖八、三組患者呼吸器使用天數 71
圖九、脫離呼吸器成功族群之兩年內存活圖 72
圖十、脫離呼吸器成功族群之三組加護病房天數比較 73
圖十一、脫離呼吸器成功族群之三組RCC住院天數比較 74
圖十二、脫離呼吸器成功族群之三組住院總天數比較 75
圖十三、脫離呼吸器成功族群使用呼吸器天數比較 76
圖十四、脫離呼吸器成功與脫離失敗患者在一年內之存活圖
77

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