住院復健期腦中風病人鼻胃管移除與否相關因子分析

Abstract

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