间歇胃管置管鼻饲在脑卒中后吞咽障碍患者中的应用

doi:10.3760/cma.j.issn.1007-1245.2023.12.022

摘要/Abstract

摘要：

目的　探讨间歇性鼻饲联合康复护理在老年脑卒中后吞咽障碍患者中的应用效果。方法　选择2019年7月至2022年6月南阳医学高等专科学校第一附属医院收治的老年脑卒中后吞咽障碍患者86例进行前瞻性研究，按随机数字表法分为两组，各43例，两组患者均实施吞咽功能康复训练。对照组男23例、女20例，年龄（67.49±3.12）岁，病程（26.10±6.54）d，实施持续经鼻胃管置管鼻饲；观察组男21例、女22例，年龄（67.88±3.64）岁，病程（25.76±6.82）d，实施经口间歇胃管置管鼻饲。两组均持续干预4周，比较两组吞咽功能、营养状况［前白蛋白（PA）、转铁蛋白（TRF）、血红蛋白（Hb）和血清白蛋白（ALB）水平］、神经功能、日常生活能力和并发症发生情况。统计学方法采用χ²检验、秩和检验和t检验。结果　观察组干预后洼田饮水试验分级（Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级、Ⅴ级）均优于对照组，差异均有统计学意义（Z=3.19，P<0.05）；观察组干预后吞咽造影检查（VFSS）评分高于对照组［（8.78±0.96）分比（7.02±1.13）分］，差异有统计学意义（t=7.87，P<0.05）；观察组干预后PA水平、Hb、ALB、TRF均高于对照组［（0.38±0.09）g/L比（0.32±0.08）g/L、（145.36±11.65）g/L比（136.42±13.51）g/L、（37.62±4.46）g/L比（33.07±5.41）g/L、（2.48±0.39）g/L比（2.32±0.33）g/L］，差异均有统计学意义（t=3.27、3.29、4.26、2.05，均P<0.05）；观察组干预后美国国家卫生研究院卒中量表（NIHSS）评分低于对照组［（18.84±1.45）分比（24.26±1.78）分］，日常生活能力指数量表（ADL）评分高于对照组［（75.66±5.43）分比（61.54±5.05）分］，差异均有统计学意义（t=15.48、12.49，均P<0.05）；观察组并发症发生率为9.30%（4/43），低于对照组［35.56%（14/43）］，差异有统计学意义（χ²=7.03，P<0.05）。结论　间歇性鼻饲联合康复护理能够减轻老年脑卒中后吞咽障碍患者吞咽障碍程度，改善营养状况，利于提高患者神经功能和日常生活能力，降低并发症发生率，值得推广。

关键词:

脑卒中, 鼻饲, 胃管置管, 康复护理, 吞咽障碍

Abstract:

Objective　To explore the effect of intermittent nasal feeding combined with rehabilitation nursing for elderly patients with dysphagia after stroke. Methods　Eighty-six elderly patients with dysphagia after stroke who were admitted to First Hospital, Nanyang Medical College from July 2019 to June 2022 were selected for the prospective study. The patients were divided into a control group and an observation group by the random number table method, with 43 cases in each group. Both groups received rehabilitation training for swallowing function. The control group [23 males and 20 females; (67.49±3.12) years old; disease course (26.10±6.54) d] carried out continuous nasal feeding through nasogastric tube. The observation group [21 males and 22 females; (67.88±3.64) years old; disease course (25.76±6.82) d] carried out intermittent nasal feeding through oral gastric tube. Both groups received continuous intervention for 4 weeks. The swallowing function, nutritional status [levels of prealbumin (PA), transferrin (TRF), hemoglobin (Hb), and serum albumin (ALB)], neurological function, daily living ability, and incidences of complications were compared between the two groups. χ² test and rank sum test, and t test were applied. Results　The classification of water swallow test after the intervention in the observation group was better than that in the control group, with a statistical difference (Z=3.19, P<0.05). The score of contrast examination of swallowing (VFSS) after the intervention of the observation group was higher than that of the control group [(8.78±0.96) vs. (7.02±1.13)], with a statistical difference (t=7.87, P<0.05). The levels of PA, Hb, ALB, and TRF after the intervention in the observation group were higher than those in the control group [(0.38±0.09) g/L vs. (0.32±0.08) g/L, (145.36±11.65) g/L vs. (136.42±13.51) g/L, (37.62±4.46)g/L vs. (33.07±5.41) g/L, and (2.48±0.39) g/L vs. (2.32±0.33) g/L], with statistical differences (t=3.27, 3.29, 4.26, and 2.05; all P<0.05). The score of the National Institutes of Health Stroke Scale (NIHSS) after the intervention of the observation group was lower than that of the control group [(18.84±1.45) vs. (24.26±1.78)], while the score of the Ability of Daily Living Index (ADL) of the observation group was higher than that of the control group [(75.66±5.43) vs. (61.54±5.05)], with statistical differences (t=15.48 and 12.49; both P<0.05). The incidence of complications in the observation group was lower than that in the control group [9.30% (4/43) vs. 35.56% (14/43)], with a statistical difference (χ²=7.03, P<0.05). Conclusion Intermittent nasal feeding combined with rehabilitation nursing can alleviate the degree of dysphagia in elderly patients with dysphagia after stroke, improve their nutritional status, neurological function, and daily living ability, and decrease the incidence of complications, so it is worthy of promotion.

Key words:

Stroke, Nasal feeding, Gastric tube, Rehabilitation nursing, Nutritional status, Dysphagia

赵梓李寅.

间歇胃管置管鼻饲在脑卒中后吞咽障碍患者中的应用 [J]. 国际医药卫生导报, 2023, 29(12): 1724-1728.

Zhao Zi, Li Yin.

Application of intermittent nasal feeding through gastric tube for patients with dysphagia after stroke [J]. International Medicine and Health Guidance News, 2023, 29(12): 1724-1728.

参考文献

[1] 王芳.舒适护理对吞咽障碍老年鼻饲患者负性情绪和应激反应的影响[J].现代中西医结合杂志,2018,27(29):3297-3299.DOI:10.3969/j.issn.1008-8849.2018.29.034.
[2] 范俐.早期吞咽功能康复锻炼对ACI吞咽障碍患者营养状况及ADL的影响[J].贵州医药,2018,42(11):1352-1353,1358.DOI:10.3969/j.issn.1000-744X.2018.11.031.
[3] 宗敏茹,庞灵,郑兰娥,等.间歇性管饲结合吞咽训练治疗脑卒中气管切开后吞咽障碍的疗效观察[J].中华物理医学与康复杂志,2019,41(12):925-927.DOI:10.3760/cma.j.issn.0254-1424.2019.12.011.
[4] 中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国脑血管疾病分类2015[J].中华神经科杂志,2017,50(3):168-171.DOI:10.3760/cma.j.issn.1006- 7876.2017.03.003.
[5] 武文娟,毕霞,宋磊,等.洼田饮水试验在急性脑卒中后吞咽障碍患者中的应用价值[J].上海交通大学学报(医学版),2016,36(7):1049-1053.DOI:10.3969/j.issn.1674- 8115.2016.07.018.
[6] 曹蓉,许光旭,丁晓晶,等.脑卒中国际功能残疾和健康分类简要核心组合的信度与效度研究[J].中国康复医学杂志,2011,26(8):715-719.DOI:10.3969/j.issn.1001-1242. 2011.08.005.
[7] 巫嘉陵,安中平,王世民,等.脑卒中患者日常生活活动能力量表的信度与效度研究[J].中国现代神经疾病杂志,2009,9(5):464-468.DOI:10.3969/j.issn.1672-6731. 2009. 05. 014.
[8] 何国军,杜亚辉.综合营养干预对脑卒中后吞咽障碍患者营养状况及生活质量的影响[J].中国慢性病预防与控制,2019,27(8):620-623.DOI:10.16386/j.cjpccd.issn.1004- 6194. 2019.08.016.
[9] 周红,栗先增,周金洁.脑卒中并发吞咽障碍患者经胃管营养护理、综合康复训练联合健康教育的预后效果评价[J].中国健康教育,2018,34(6):564-567.DOI:10.16168/j.cnki.issn.1002-9982.2018.06.020.
[10] 杨海燕,喻勇,彭志勇.经口间歇置管注食对在脑卒中后吞咽障碍患者营养摄入的影响[J].中华物理医学与康复杂志,2019,41(12):923-924.DOI:10.3760/cma.j.issn.0254- 1424. 2019.12.010.
[11] 周玉妹,张超,方小群,等.间歇性鼻饲联合吞咽训练对脑卒中吞咽障碍病人的影响[J].护理研究,2019,33(17):2935-2939.DOI:10.12102/j.issn.1009-6493.2019.17.004.
[12] 王秀玲.间歇经口管饲联合康复训练对脑卒中患者吞咽功能及营养状况的影响[J].华南国防医学杂志,2019,33(3):206-208.DOI:10.13730/j.issn.1009-2595.2019.03.015.
[13] 何妮娜,冯霞,刘冬梅,等.间歇性经口至食管管饲法对脑卒中伴吞咽障碍患者吞咽功能、营养状况及长期预后的影响[J].现代中西医结合杂志,2021,30(18):2026-2030.DOI:10.3969/j.issn.1008-8849.2021.18.020.
[14] 潘海英,张楠,赵晶,等.经口间歇管饲联合自拟宣窍利咽汤治疗脑卒中后吞咽障碍的临床疗效[J].中华危重病急救医学,2021,33(5):552-556.DOI:10.3760/cma.j.cn121430- 20200628-00487.
[15] 程姐,张远玲,尤敏,等.基于NRS2002营养评估的康复综合护理对脑卒中后吞咽障碍患者营养状况及预后的影响[J].临床与病理杂志,2020,40(7):1794-1800.DOI:10.3978/j.issn.2095-6959.2020.07.026.
[16] 代欣,魏冰,席家宁.吞咽造影检查联合内镜吞咽检查在脑卒中后吞咽功能评估中的应用价值[J].神经疾病与精神卫生,2018,18(8):548-552.DOI:10.3969/j.issn.1009- 6574.2018.08.004.
[17] 乐琳,郭君,郭钢花,等.间歇口-胃管管饲法对脑卒中后行吞咽障碍治疗患者的影响[J].中国康复医学杂志,2021,36(4):426-430.DOI:10.3969/j.issn.1001-1242.2021.04.007.
[18] 王婷玮,胡瑞萍,邰佳慧,等.经鼻留置胃管与间歇性经口至食管管饲法应用于脑卒中后吞咽障碍患者的临床评价[J].中国康复医学杂志,2022,37(8):1023-1029.DOI:10.3969/j.issn.1001-1242.2022.08.003.
[19] 刘瑶,乔力,刘恒均,等.间歇经口至食管管饲在急性卒中合并吞咽障碍患者中的应用研究[J].中国卒中杂志,2021,16(4):354-359.DOI:10.3969/j.issn.1673-5765. 2021.04.007.
[20] 赵启同,李明霞,张经纬,等.间歇性经口至食管管饲在脑卒中后吞咽障碍患者中的应用进展[J].中国康复,2022,37(10):627-630. DOI:10.3870/zgkf.2022.10.012.
[21] 夏凤,万琴.基于标准吞咽功能评估的分层干预应用于脑卒中吞咽障碍患者中的效果观察[J].国际医药卫生导报,2021,27(18):2872-2875.DOI:10.3760/cma.j.issn.1007- 1245.2021.18.017.
[22] 邱吉艳,赵春艳,徐卓珺.容积-黏度吞咽测试在脑卒中后吞咽功能障碍患者胃管拔管中的应用效果[J].广西医学,2021,43(23):2878-2881.DOI:10.11675/j.issn.0253-4304. 2021.23.23.
[23] 罗冬华,张晓梅,曹猛,等.IDDSI饮食指导在脑卒中吞咽障碍病人中的应用[J].护理研究,2021,35(21):3928-3931.DOI:10.12102/j.issn.1009-6493.2021.21.034.
[24] 李宇辉,张静,王颖颖,等.多学科协作营养管理模式在急性脑卒中伴吞咽障碍患者中的应用效果评价[J].中华临床营养杂志,2021,29(1):14-21.DOI:10.3760/cma.j.cn115822- 20201020-00229.
[25] 王博,袁永学,张庆苏.非经口进食吞咽障碍脑卒中患者预后的相关因素及预测模型[J].中国康复理论与实践,2022,28(4):453-460.DOI:10.3969/j.issn.1006-9771. 2022.04.012.
[26] 司马振奋,龚剑秋,马兰.间歇经口管饲法对脑卒中后吞咽障碍患者营养状况及情绪状态的影响[J].中国康复,2021,36(7):405-408.DOI:10.3870/zgkf.2021.07.005.
[27] Moretti C,Gizzi C.Synchronized nasal intermittent positive pressure ventilation. clin perinatol[J].2021,48(4):745-759.DOI:10.1016/j.clp.2021.07.005.
[28] 张奕玲,汪锐,秦莲花,等.多元化健康教育模式在脑卒中后吞咽障碍患者中的应用效果研究[J].成都医学院学报,2022,17(2):231-234.DOI:10.3969/j.issn.1674-2257. 2022.02.022.
[29] Jennifer maher.Proper oral care can reduce risk of pneumonia[J].Provider Magazine,2019,46(7):33-34.
[30] 陆娟,王蓉,李育平,等.新型鼻饲用具专利技术装置在重症脑卒中患者肠内营养中的应用[J].实用临床医药杂志,2021,25(13):36-39.DOI:10.7619/jcmp.20210393.