一位肺臟移植術後併發過度動態性呼吸道塌陷病人之加護經驗

Nursing Experience of a Patient in Excessive Dynamic Airway Collapse After Lung Transplant

10.6142/VGHN.202406_41(2).0005

李家語(Chia-Yu Li)；謝秀容(Hsiu-Jung Hsieh)

肺移植 ； 過度動態性呼吸道塌陷 ； 濕化高流量氧氣治療 ； 術後急性譫妄 ； ABCDEF組合照護模式 ； lung transplant ； excessive dynamic airway collapse ； high flow nasal cannula oxygen therapy ； delirium ； ABCDEF bundle care

榮總護理

41卷2期（2024 / 06 / 01）

138 - 146

繁體中文;英文

本文為一位淋巴癌病人骨髓移植後GVHD，導致呼吸衰竭行肺移植術後照護經驗。2021年12月18日至2022年4月18日照護期間運用生、心、靈、社會四大層面評估，以觀察、會談及病歷查閱歸納出低效性呼吸型態、身體活動功能障礙、急性紊亂等健康問題。肺移植術後需大量復健，病人術前長期臥床，身體活動功能障礙加上術後急性紊亂，中斷復健及呼吸訓練，長期氣切併發過度動態性呼吸道塌陷，無法脫離呼吸器，造成治療計畫停擺，此為選案動機。以ABCDEF組合照護模式針對急性紊亂提供照護成功緩解症狀；藉由早期活動及漸進式運動計畫，增進心肺功能，改善身體活動功能障礙；照護期間併發罕見的過度動態性呼吸道塌陷，導致低效性呼吸型態而呼吸訓練屢次失敗，介入濕化高流量氧氣治療及改變姿位，成功脫離呼吸器。藉此案例執行ABCDEF組合照護模式於重症照護，讓家屬參與照護與早期復健，改善病人心肺耐力和譫妄，及運用濕化高流量氧氣，協助罕見的過度動態性呼吸道塌陷症狀，以供同仁參考。

This article describes the nursing care for a patient with excessive dynamic airway collapse after lung transplant. Data regarding the patient's health condition were collected from December 18, 2021, to April 18, 2022, through direct observation, interviews, reviews of medical records, and physical assessment. The author conducted a comprehensive four-facet assessment, encompassing physical, psychological, social, and spiritual dimensions. The three primary health problems identified were acute confusion, impaired physical mobility, and ineffective breathing pattern. After lung transplant, extensive rehabilitation is necessary. However, due to preoperative respiratory failure, the patient had been bedridden for an extended period, which had led to physical activity dysfunction. The onset of delirium after the transplant interrupted postoperative physical therapy and respiratory training. Additionally, long-term intubation was complicated by excessive dynamic airway collapse, resulting in collapse of the respiratory tract and an inability to wean the patient off the respirator, leading to a suspension of the treatment plan. Consequently, the patient experienced substantial psychological and physical postoperative stress, prompting the authors to focus on this case. For acute postoperative delirium, the ABCDEF Bundle offers interventions in pain management, sedation, breathing training, physical activities, and family empowerment and has been found to effectively reduce delirium and enhance patient cognition. After lung transplant, a rehabilitation program involving early mobilization and a gradual exercise program is essential for improving cardiopulmonary function and reducing physical activity dysfunction. The rare complication of long-term intubation due to excessive dynamic airway collapse necessitated continued dependence on the respirator. However, through interventions such as humidified high-flow oxygen therapy and limb strength training to assist with posture changes, the patient was eventually successfully weaned off the respirator. This case demonstrates the efficacy of humidified high-flow oxygen therapy for patients with excessive dynamic airway collapse in facilitating respirator weaning. Furthermore, employing the ABCDEF Bundle in an intensive care setting is recommended to empower families, promote early mobilization, enhance cardiorespiratory function in critically ill patients, and improve the quality of intensive care.

1. 蕭淑芳、蕭季萱、徐紹勛、王亭貴、賴玉玫．(2021)．從術前到術後-急性骨髓性白血病後進行骨髓移植併發移植物對抗宿主疾病接受雙側肺移植個案之物理治療介入成效報告．物理治療，46(2)，119-120。
   連結：
2. DeBolt, C. L., Gao, Y., Sutter, N., Soong, A., Leard, L., Jeffrey, G., Kleinhenz, M. E., Calabrese, D., Greenland, J., Venado, A., Hays, S. R., Shah, R., Kukreja, J., Trinh, B., Kolaitis, N. A., Douglas, V., Diamond, J. M., Smith, P., & Singer, J. (2021). The association of post‐operative delirium with patient‐reported outcomes and mortality after lung transplantation. Clinical Transplantation, 35(5), e14275.
   連結：
3. Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., … Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), 825-873.
   連結：
4. Kako, J., Morita, T., Yamaguchi, T., Kobayashi, M., Sekimoto, A., Kinoshita, H., Ogawa, A., Zenda, S., Uchitomi, Y., Inoguchi, H., & Matsushima, E. (2018). Fan therapy is effective in relieving dyspnea in patients with terminally ill cancer: A parallel-arm, randomized controlled trial. Journal of Pain and Symptom Management, 56(4), 493-500.
   連結：
5. Kheir, F., & Majid, A. (2018). Tracheobronchomalacia and excessive dynamic airway collapse: Medical and surgical treatment. Seminars in Respiratory and Critical Care Medicine, 39(6), 667-673.
   連結：
6. Kim, S. Y., Jeong, S. J., Lee, J. G., Park, M. S., Paik, H. C., Na, S., & Kim, J. (2018). Critical Care after Lung Transplantation. Acute and Critical Care, 33(4), 206-215.
   連結：
7. Liang, S., Chau, J. P. C., Lo, S. H. S., Zhao, J., & Choi, K. C. (2021). Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: A systematic review and meta-analysis. Australian Critical Care, 34(4), 378-387.
   連結：
8. Marra, A., Ely, E. W., Pandharipande, P. P., & Patel, M. B. (2017). The ABCDEF bundle in critical care. Critical Care Clinics, 33(2), 225-243.
   連結：
9. Park, J., Lee, Y. J., Kim, S. J., Park, J. S., Yoon, H. I., Lee, J. H., Lee, C. T.,& Cho, Y. J. (2015). Successful high flow nasal oxygen therapy for excessive dynamic airway collapse: A case report. Tuberculosis and Respiratory Diseases, 78(4), 455-458.
   連結：
10. Song, J. H., Park, J. E., Lee, S. C., Kim, S., Lee, D. H., Kim, E. K., Kim, S. Y., Shin, J. C., Lee, J. G., Paik, H. C. & Park, M. S. (2018). Feasibility of immediate in-intensive care unit pulmonary rehabilitation after lung transplantation: A single center experience. Acute and Critical Care, 33(3), 146-153.
    連結：
11. Spicuzza, L., & Schisano, M. (2020). High-flow nasal cannula oxygen therapy as an emerging option for respiratory failure: The present and the future. Therapeutic Advances in Chronic Disease, 11, 2040622320920106.
    連結：
12. Ulvestad, M., Durheim, M. T., Kongerud, J. S., Lund, M. B., & Edvardsen, E. (2020). Effect of high-intensity training on peak oxygen uptake and muscular strength after lung transplantation: A randomized controlled trial. The Journal of Heart and Lung Transplantation, 39(9), 859-867.
    連結：
13. 行政院衛生福利部(2023，6月30日)．民國111年度死因統計。https://www.mohw.gov.tw/dl-83733-80fb9ab8-ea2d-4e3e-ba06-f70f28aca036.html