口腔護理對預防重症病患呼吸器相關肺炎發生之成效探討

Abstract

院內感染肺炎主發生在使用呼吸器之病患，又稱之呼吸器相關肺炎。研究顯示，經由口腔護理減少口腔菌落數、預防吸入可以預防使用呼吸器病患發生肺炎的機會。因此本研究主要在探討口腔護理能否改善外科加護病房病人口腔清潔和呼吸器相關肺炎的發生率。 研究設計採單盲、隨機之臨床試驗(Randomized clinical trials)。將台灣某醫學中心外科加護病房2007年3~11月入住病患，依據使用呼吸器≧48~72小時、未發現肺炎的條件篩選研究對象，在解釋同意後進行收案，隨機分配至實驗與對照兩組，並接受持續7天的口腔護理。實驗組採標準化口腔護理流程，以電動牙刷等方式清潔與潤濕口腔，一天執行兩次每次約20分鐘。對照組部份，則在相同的介入次數與時間，執行具潤濕效果的仿實驗組類口腔護理流程。肺炎發生則依據Clinical Pulmonary Infection Score (CPIS) >6來判定肺炎發生。口腔清潔評量使用Oral Assessment Guide(OAG)與plaque index作兩組在介入措施前後之比較。所得資料以無母數、卡方等統計方式分析，兩組差異檢定P值設定小於0.05。 結果依據44名病患之資料分析，平均年齡60.6±16.1歲，其中有63.6%為男性。在追蹤第九天的累計肺炎發生率，實驗組22.7%較低於對照組的77.8%，顯示兩組之間罹患肺炎達顯著差異(P<0.05)。至於口腔清潔部分，實驗組的清潔狀態不論在OAG或plaque index的得分均達顯著差異，與對照組相比都呈現好轉趨勢。實驗組OAG由16.3±1.9下降到14.9±2.6，而對照組則持平在16.5±1.6與16.6±2.1 (P<0.05)。對照組的Plaque index維持高得分0.74±.13 to 0.75±0.21，然實驗組則是從0.76±0.14降到0.49±0.18 (P<0.05)。 研究結果顯示，對外科加護病房使用呼吸器病患，執行口腔護理可有效改善口腔清潔狀態、預防呼吸器相關肺炎的發生。然而口腔護理如何更有效地在急重症環境執行，還必須仰賴更大型且依據不同研究對象為基礎的進一步研究來探討。

The ventilator-associated pneumonia (VAP) remains to be a major complication for patients who were incubated with ventilators. Most cases are attributed to increased bacteria flora in oropharyngeal secretion and aspiration of those organisms. Evidence exists suggesting that oral care could reduce bacterial flora, prevent aspiration, and subsequently decrease the incidence of VAP for patients with ventilators. This study aims to evaluate the effectiveness of a standardized oral care protocol in improving oral hygiene and reducing the incidence of VAP in a sample of surgical patients at intensive care unit (SICU). This was a single blind, randomized clinical trial. Patients newly admitted to SICU who were under ventilator support for 48~72 hours and without pneumonia present were enrolled during March to November, 2007 from a tertiary medical center in Taiwan. Subjects were randomized into the experimental or control groups and both received a 7 day oral care protocol. For the experimental group (EG), a standardized 20-minute oral care protocol using an electronic toothbrush to clean and moisturize oral cavity twice daily. For the control group (CG), a mimic 20-minute protocol involving moisturizing and attention control was performed for the same intervals. The incidence of VAP defined by the Clinical Pulmonary Infection Score (CPIS) >6 and the oral hygiene measured by the Oral Assessment Guide (OAG) and plague index were compared between the two groups. Variables were compared by the analysis of Fisher exact test, chi-square test, and Mann-whitney U test. A P value < 0.05 was considered significant. Forty-four patients were studied with mean age of 60.6±16.1 years and 63.6% being males. The results showed that the cumulative incidence of VAP was significantly lower in the EG, with 22.7% occurrence in the EG and 77.8% in the CG, both on day 9 (P<0.05). In terms of oral hygiene, subjects in the EG performed significantly better on both OAG scores and plaque index. Specifically, the OAG decreased from 16.3±1.9 to 14.9±2.6 in the EG and remained high from16.5±1.6 to 16.6±2.1 in the CG (P<0.05). The plaque index were decreased from 0.76±0.14 to 0.49±0.18 in the EG and remained high from 0.74±.13 to 0.75±0.21 in the CG (P<0.05). The findings support the effectiveness of an oral care protocol in preventing ventilator-associated pneumonia and improving oral hygiene for patients admitted to SICU with ventilator support. Whether this oral care protocol remains effective and feasible in most critical care settings should be determined in a larger scale study with a diverse population.