比較長期經口插管之年輕及老年病人其拔管後吞嚥功能之變化

Abstract

背景：氣管插管是一種維持呼吸道通暢且使用呼吸器提供氧氣的一種快速、侵入性的治療，但口咽部也容易因插管造成結構上及功能上的損傷，進而影響了進食及吞嚥的功能。在插管大於48小時的病人中，拔管後的吞嚥困難盛行率可高達62%，尤其在老年病人及疾病嚴重者，更易影響整體進食狀態。 目的：本研究旨在比較長期經口插管之年輕(20-64歲)及老年( ≥65歲)病人於拔管後其吞嚥及進食功能恢復程度上的差異。 方法：前瞻觀察性研究，收案來源為台北市某醫學中心內科加護病房，且經口插管大於48小時者，若有神經功能疾病、口咽結構異常或氣切等則予以排除。本研究以縱貫性四個時間點收集資料，分別為拔管後四十八小時內、第七天、第十四天及第二十一天。研究工具包括舌肌肉力量評估(舌上舉及唇閉合力量)、重複吞嚥動作測試、台大三階段吞嚥篩檢及進食情況紀錄。 結果：研究納入61位個案，年輕組(25人)平均年齡47.5歲，老年組(36人)平均年齡76.1歲。研究結果顯示，老年病人拔管後吞嚥及進食功能的恢復比年輕病人更慢。在舌肌肉力量方面，老年組的力量皆顯著低於年輕組(含舌上舉力量及唇閉合力量)。重複吞嚥動作測試方面，老年組30秒內唾液吞嚥次數< 3次的比率比年輕組更高(15.0% v.s 20.7%)。台大三階段吞嚥篩檢方面，七成老年組病人於拔管後第11天可喝下>50毫升的水而無嗆咳等情形，年輕組則全數通過。進食情況方面，老年組僅六成(64.3%)的人可完全由口進食(除堅硬食物外；Level 6)，年輕組則有九成，且二組在達成的時間上亦有顯著不同(8.6±6.1天v.s 5.2±3.9天, P=0.06)，廣義估計方程式(GEE)也顯示老年組於21天內進食功能變化上顯著差於年輕組(P<0.001)。 結論：所有吞嚥功能指標皆顯示，拔管後老年病人恢復較年輕病人慢，年輕病人拔管後一週多數已恢復吞嚥功能，但老年病人則延遲至兩週甚至更久。

Background: Endotracheal intubation is life-sustaining procedures but their presence can complicate resumption of oral intake. The prevalence of swallowing dysfunction post-extubation has been reported to occur in between 3% to 62% of those patients intubated longer than 48 hours, particularly for patients who are older and sicker. Purpose: The purpose of this study was to compare levels of swallowing function and oral intake over time in younger (20-64 years) and older medical patients ( ≥65 years) with prolonged oral intubation (>48hours). Methods: A prospective observational study was conducted. Patients with neurological disease, oropharyngeal structural deficiency, and tracheostomy were excluded. Data was assessed within 48 hours, 7th, 14th, and 21st day post-extubation. Swallowing functions were measured by the tongue strength (tongue elevation and lip compression), Repetitive Saliva Swallowing Test (RSST), Three-Step Swallowing Screen (3-SSS), and Functional Oral Intake Scale (FOIS). Results: Sixty one patients were enrolled with 59% (n=36, mean age=76.1 years) being aged 65 years and older and rest of 41% (n=25, mean age=47.5 years) are younger. The recovery of swallowing function and oral intake in older patients was slower compared to younger patients. The tongue strength (both tongue elevation and lip compression) of older patients was constantly significantly lower than that of younger patients. More older patients swallowed saliva <3 times in 30 seconds compared to the younger group (21% vs. 15%). On 11th day post-extubation, while 70% of older patients could swallow >50ml of water without difficulty, all younger patients had done so. For oral intake 21st daypost-extubation, 64.3% of older patients vs. 90% of younger patients tolerated total oral diet with minimal limitation (Level 6). Days to reach the level 6 was also significant longer for older patients (8.6±6.1 days vs. 5.2±3.9 days for younger counterparts, P=0.06). Furthermore the Generalized estimating equations (GEE) indicated that oral intake levels of older patients were significantly worse than younger patients (p<0.001). Conclusion:Older patients had slower recovery on all swallowing functions indicators compared to younger counterparts. For younger patients, swallowing difficulty was uncommon 7th day post-extubation, while one-fifth of older patients had signs and symptoms of swallowing difficulty last for more than 2 weeks post-extubation.