呼吸器脫離參數用於預測長期呼吸器使用患者呼吸器脫離及拔管預後之效力

Weaning Parameters for Predicting Weaning and Extubation Outcomes in Long-term Mechanically Ventilated Patients

江佩芙(Pei-Fu Chiang)；江榮人(Jung-Rern Jiang)；顔效禹(Shiao-Yu Yen)；劉曉茜(Hsiao-Chien Liu)；張瀞勻(Ching-Yun Chang)；林姵妏(Pei-Wen Lin)

預氣管內插管拔管 ； 機械通氣 ； 呼吸器脫離 ； 呼吸器脫離參數 ； endotracheal extubation ； mechanical ventilation ； ventilator weaning ； weaning parameters

若瑟醫護雜誌

11卷1期（2017 / 04 / 01）

5 - 16

繁體中文

前言：長期呼吸器依賴的定義為需要呼吸器支持連續超過14 天，在呼吸器脫離過程，拔管失敗是常遇到的狀況，因此，臨床上預測及預防拔管失敗為一個重要的課題。針對長期呼吸器依賴患者成功脫離呼吸器的預測指標探討的文獻不多，此研究目的是探討呼吸脫離參數及一些臨床指標，對連續使用呼吸器超過21 天之長期呼吸器依賴患者成功通過呼吸器脫離訓練及拔管之影響。材料與方法：這是回溯性世代研究，收納超過20 歲長期呼吸器依賴之個案且連續使用呼吸器超過21 天，個案收案時段為8 年，以壓力支持模式及自主呼吸測試的方式嘗試脫離呼吸器，個案分為成功通過呼吸器脫離訓練及失敗組，有氣切之患者通過呼吸脫離訓練後會移除呼吸器，無氣切之患者通過呼吸脫離訓練後進行拔管，之後依照拔管結果，又分為拔管成功組與拔管失敗組，我們進行分析來預測拔管成功之效力。結果：共557 位個案，151 位成功通過呼吸器脫離訓練，其中136 位個案進行拔管，107 位獲得成功拔管。呼吸快淺指標於拔管成功與失敗組無明顯差異，成功拔管組有著稍佳的肺順應性及呼吸道阻力，但用於預測拔管成功的敏感性、特異性結果大致上都不高。結論：對於長期呼吸器使用超過21 天的患者，傳統呼吸器脫離指標無法有效預測成功拔管，在這些患者，針對影響呼吸器脫離及成功拔管因素的全面性評估是至為重要的。

Background: Long-term mechanical ventilator support (LTMV) is defined as more than 14 days of treatment with mechanical ventilation. Extubation failure is one of the most frequently encountered events in the management of mechanically-ventilated patients. Many weaning predictors, used for predicting extubation outcome in patients hospitalized in intensive care unit (ICU), were less addressed for predicting extubation outcome in patients requiring LTMV. This study aimed to determine the effectiveness of using clinical parameters to predict ventilator weaning and extubation outcome in patients requiring LTMV longer than 21 days. Methods: This is a retrospective cohort study with prospective data collection. We recruited patients with a diagnostic coding for respiratory failure requiring LTMV for longer than 21 days over an eight-year period in a single center. All patients were weaned by pressure support weaning mode and spontaneous breathing trials. Patients were divided into successful and unsuccessful groups according to the weaning and extubation outcomes. The cutoff point of the weaning parameters for predicting successful extubation was determined using receiver-operated characteristic curves. The sensitivity and specificity of m-BWAP(Burns weaning assessment program) for predicting successful extubation were calculated. Results: Of the 557 patients included, 151 patient had successful weaning trials. Total 136 patients were extubated, and 107 patient had successful extubation. The patients in the successful weaning group were younger, had a shorter duration of ventilator use, and prominently had surgery as the indication for intubation than the unsuccessful weaning group. The successful weaning group had fewer co-morbidities, higher serum albumin level, better LCs, higher PImax, and lower RSBI than unsuccessful weaning group. But, successful extubation group had slightly better lung compliance and airway resistance. The sensitivity and specificity of the RSBI, lung compliance and airway resistance to predict successful extubation were not satisfied. Conclusions: The traditional weaning parameters are not good predictors for extubation outcome in patients requiring LTMV for longer than 21 days.

1. Combes, A,Costa, MA,Trouillet, JL,Baudot, J,Mokhtari, M,Gibert, C,Chastre, J(2003).Morbidity, mortality, and quality-of-life outcomes of patients requiring ≥14 days of mechanical ventilation.Critical Care Medical,31,1373-1381.
2. Douglas, SL,Daly, BJ,Gordon, N,Brennan, PF(2002).Survival and quality of life: short-termversus long- termventiltor patients.Critical Care Medical,30,2655-2662.
3. Epstein, SK(2002).Extubation.RespiratoryCare,47,483-492.
4. Jiang, JR,Tsai, TH,Jerng, JS,Yu, CJ,Wu, HD,Yang, PC(2004).Ultrasonographic evaluation of liver/spleen movements and extubation outcome.Chest,126,179-185.
5. Jiang, Jung-Rern,Yen, Shiao-Yu,Chien, Jung-Yien,Liu, Hsiao-Chien,Wu, YiLing,Chen, Ching-Hui(2014).Predicting weaning and extubation outcomes in long-term mechanically ventilated patients using the modified Burns Wean Assessment Program scores.Respirology,19,576-582.
6. Jubran, A,Grant, BJ,Duffner, LA,Collins, EG,Lanuza, DM,Hoffman, LA,Tobin, MJ(2013).Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial.JAMA,309,671-677.
7. Macintyre, NR(2012).Macintyre NR. Evidence-based assessments in the ventilator discontinuation process.Respiratory Care,57,1611-1618.
8. McConville, JF,Kress, JP(2012).Weaning patients from the ventilator.New England Journal Medical,367,2233-2239.
9. Ueki, J,De Bruin, PF,Pride, NB(1995).In vivo assessment of diaphragm contraction by ultrasound in normal subjects.Thorax,50,1157-1161.
10. Vassilakopoulos, T,Zakynthinos, S,Roussos, C(1996).Respiratory muscles and weaning failure.Europe Respiratory Journal,9,2383-2400.
11. Verceles, AC,Diaz-Abad, M,GeigerBrown, J,Scharf, SM(2012).Testing the prognostic value of the rapid shallow breathing index in predicting successful weaning in patients requiring prolonged mechanical ventilation.Heart Lung,41(6),546-552.
12. Yang, KL,Tobin, MJ(1991).A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation.New England Journal Medical,324,1445-1450.
13. 吳沼漧,張谷州,黃裕靜,沈連喜,高旭卿,王逸熙,劉世豐,王金洲,林孟志(2015)。APACHE分數系統用來預測呼吸照護中心病患預後。胸腔醫學，30(5)，271-279。
14. 李綺婷,李明杰,陳鼎達,陳志成(2016)。呼吸器依賴病患再插管的影響因子。呼吸治療，15(1)，1-13。
15. 林倡葦,陳濘宏,吳偉芬,顏佑珊,李立夫(2015)。北台灣亞急性呼吸照護病房成功脫離呼吸器的預測指標。胸腔醫學，30(1)，9-17。
16. 林雯淑,黃梓齊,沈伯真,陳亮吾(2015)。加護病房運用 Daily Screen 改善呼吸器脫離率。呼吸治療，14(1)，44-44。

1. 劉介宇,陳俊宇,梁淑媛,尹玓(2021)。影響台灣離島地區插管病人呼吸器脫離之相關因素。榮總護理，38(1)，14-25。