陳佳慧Chen, Cheryl Chia-Hui臺灣大學:護理學研究所姚俐音Yao, Li-YinLi-YinYao2010-05-052018-07-072010-05-052018-07-072008U0001-2801200814302900http://ntur.lib.ntu.edu.tw//handle/246246/180323院內感染肺炎主發生在使用呼吸器之病患，又稱之呼吸器相關肺炎。研究顯示，經由口腔護理減少口腔菌落數、預防吸入可以預防使用呼吸器病患發生肺炎的機會。因此本研究主要在探討口腔護理能否改善外科加護病房病人口腔清潔和呼吸器相關肺炎的發生率。究設計採單盲、隨機之臨床試驗(Randomized clinical trials)。將台灣某醫學中心外科加護病房2007年3~11月入住病患，依據使用呼吸器≧48~72小時、未發現肺炎的條件篩選研究對象，在解釋同意後進行收案，隨機分配至實驗與對照兩組，並接受持續7天的口腔護理。實驗組採標準化口腔護理流程，以電動牙刷等方式清潔與潤濕口腔，一天執行兩次每次約20分鐘。對照組部份，則在相同的介入次數與時間，執行具潤濕效果的仿實驗組類口腔護理流程。肺炎發生則依據Clinical Pulmonary Infection Score (CPIS) >6來判定肺炎發生。口腔清潔評量使用Oral Assessment Guide(OAG)與plaque index作兩組在介入措施前後之比較。所得資料以無母數、卡方等統計方式分析，兩組差異檢定P值設定小於0.05。果依據44名病患之資料分析，平均年齡60.6±16.1歲，其中有63.6%為男性。在追蹤第九天的累計肺炎發生率，實驗組22.7%較低於對照組的77.8%，顯示兩組之間罹患肺炎達顯著差異(P<0.05)。至於口腔清潔部分，實驗組的清潔狀態不論在OAG或plaque index的得分均達顯著差異，與對照組相比都呈現好轉趨勢。實驗組OAG由16.3±1.9下降到14.9±2.6，而對照組則持平在16.5±1.6與16.6±2.1 (P<0.05)。對照組的Plaque index維持高得分0.74±.13 to 0.75±0.21，然實驗組則是從0.76±0.14降到0.49±0.18 (P<0.05)。究結果顯示，對外科加護病房使用呼吸器病患，執行口腔護理可有效改善口腔清潔狀態、預防呼吸器相關肺炎的發生。然而口腔護理如何更有效地在急重症環境執行，還必須仰賴更大型且依據不同研究對象為基礎的進一步研究來探討。The ventilator-associated pneumonia (VAP) remains to be a major complication for patients who were incubated with ventilators. Most cases are attributed to increased bacteria flora in oropharyngeal secretion and aspiration of those organisms. Evidence exists suggesting that oral care could reduce bacterial flora, prevent aspiration, and subsequently decrease the incidence of VAP for patients with ventilators. This study aims to evaluate the effectiveness of a standardized oral care protocol in improving oral hygiene and reducing the incidence of VAP in a sample of surgical patients at intensive care unit (SICU).his was a single blind, randomized clinical trial. Patients newly admitted to SICU who were under ventilator support for 48~72 hours and without pneumonia present were enrolled during March to November, 2007 from a tertiary medical center in Taiwan. Subjects were randomized into the experimental or control groups and both received a 7 day oral care protocol. For the experimental group (EG), a standardized 20-minute oral care protocol using an electronic toothbrush to clean and moisturize oral cavity twice daily. For the control group (CG), a mimic 20-minute protocol involving moisturizing and attention control was performed for the same intervals. The incidence of VAP defined by the Clinical Pulmonary Infection Score (CPIS) >6 and the oral hygiene measured by the Oral Assessment Guide (OAG) and plague index were compared between the two groups. Variables were compared by the analysis of Fisher exact test, chi-square test, and Mann-whitney U test. A P value < 0.05 was considered significant.orty-four patients were studied with mean age of 60.6±16.1 years and 63.6% being males. The results showed that the cumulative incidence of VAP was significantly lower in the EG, with 22.7% occurrence in the EG and 77.8% in the CG, both on day 9 (P<0.05). In terms of oral hygiene, subjects in the EG performed significantly better on both OAG scores and plaque index. Specifically, the OAG decreased from 16.3±1.9 to 14.9±2.6 in the EG and remained high from16.5±1.6 to 16.6±2.1 in the CG (P<0.05). The plaque index were decreased from 0.76±0.14 to 0.49±0.18 in the EG and remained high from 0.74±.13 to 0.75±0.21 in the CG (P<0.05). he findings support the effectiveness of an oral care protocol in preventing ventilator-associated pneumonia and improving oral hygiene for patients admitted to SICU with ventilator support. Whether this oral care protocol remains effective and feasible in most critical care settings should be determined in a larger scale study with a diverse population.目 錄試委員會審定書……………………………………………………………… i謝………………………………………………………………………………. ii文摘要…………………………………………………………………………. iii文摘要…………………………………………………………………………. iv容目錄…………………………………………………………………………. vi目錄……………………………………………………………………………. ix 目錄……………………………………………………………………………. xi 容 目 錄一章 緒論…………………………………………………………………….. 1一節 前言………………………………………………….……………… 1二節 研究背景與重要性…………………………………………………. 2三節 研究目的與假設……………………………………………………. 4四節 名詞界定……………………………………………………………. 5二章 文獻查證……………………………………………………………….. 6一節 院內感染肺炎之簡介……………………………….……………… 6二節 VAP診斷方式……………………………………………………… 8三節 住院中腸胃道改變與VAP發生的相關性..……………………… 13四節 住院中呼吸道改變與VAP發生的相關性……………………….. 16五節 預防VAP之實證策略…………………………………………….. 20六節 口腔清潔重要性及執行方式……………………………………… 23三章 研究方法………………………………………………………………. 29一節 研究概念架構……………………………………….……………... 29 二節 研究設計…………………………………………………………… 30三節 研究對象與介入措施..…………………..………………………… 32四節 研究工具..…………………..……………..……………………….. 37五節 資料收集過程………..…………………………………………….. 42六節 資料處理與分析…………………………………………………… 44七節 倫理考量..…………………..……………..……………………….. 46四章 研究結果………………………………………………………………. 49一節 研究對象入住加護病房之基本屬性…………………….………... 50二節 研究對象於措施執行中所接受相關治療之屬性……………….... 51三節 口腔護理介入前、後，研究對象口腔狀況之差異……………… 53四節 口腔護理介入後，研究對象發生肺炎(CPIS>6分)之變化.…….. 62五節 口腔護理介入後，研究對象住院與治療結果…………………… 70五章 討論……………………………………………………………………. 71一節 病患口腔清潔改善成效………………………………….………... 71二節 預防呼吸器相關肺炎的效果…………………………………….... 73三節 尚待量化的口腔護理成效………………………………………… 75四節 口腔護理於加護病房的執行…………………………………….... 76六章 結論與建議……………………………………………………………. 79一節 研究限制與未來研究建議……………………………….………... 79二節 研究貢獻………………………………………………………….... 81三節 未來展望………………………………………………………….... 82考文獻…………………………………………………………………….…… 83錄一 基本資料表 …………………………………………………………… a附錄二 肺炎診斷紀錄表……………………………………………………….. c錄三 口腔評估紀錄表……………………………………………………….. d錄四 口腔護理執行紀錄表………………………………………………….. f錄五 收案醫院回覆公文…………………………………………………….. g錄六 受試者同意書…..…………………………………………………….. h錄七 馬偕醫院人體試驗委員會同意書…………………………………….. j 目 錄3-1 概念架構圖 ………………………………………………………….… 293-2 研究流程圖 …………………………………………………………... 313-3 口腔清潔工具專用盒 ……………………………………….………….. 343-4 電動牙刷刷柄包裝方式…………………………………………………. 343-5 短頭旋轉式電動牙刷 ……………………………………….………….. 353-6 修改潔牙棒為頭之抽吸管………………………………………………. 353-7 執行中氣管內管固定方式………………………………………………. 353-8 口腔護理執行時間示意圖 ………………………………………….… 363-9 臨床肺炎判斷流程圖…………………………………………………… 393-10 評估牙齒選定示意……………..…….………………………………… 413-11 資料收集流程圖……….……………………………………………….. 434-1 收案流程圖………...…………………………………………………….. 474-2 OAG舌頭項3次測驗結果……………………………………………… 544-3 OAG牙齒項3次測驗結果……………………………………………… 554-4 OAG牙齦項3次測驗結果……………………………………………… 554-5 兩組四顆受檢牙齒在基準Plaque score測驗結果..…………………… 574-6 兩組四顆受檢牙齒3~4天Plaque score測驗結果..…………………… 574-7 兩組四顆受檢牙齒7~8天Plaque score測驗結果..…………………… 584-8 兩組受檢牙齒齒面在基準Plaque score測驗結果..…………………… 594-9 兩組受檢牙齒齒面3~4天Plaque score測驗結果..…………………… 594-10 兩組受檢牙齒齒面7~8天Plaque score測驗結果…………………… 604-11 主要結果變項兩組發生肺炎累計比例………………………………... 635-1 清潔前牙齦狀態.………………………………………………………… 725-2 牙齒狀態…………………………………………………………………. 725-3 清潔3~4天後牙齦狀態..…………………………………….………….. 72 目 錄2-1 清潔液優缺點分析表…………………………………………………… 273-1 臨床簡易肺炎感染評量表……………………………………………… 384-1 基本資料分析表………………………………………………………… 504-2 介入執行中相關影響變相分析表……………………………………… 524-3 主要結果變項口腔狀態分析…………………………………………… 614-4 主要結果變項發生肺炎累計分析……………………………………… 634-5 主要結果變項兩組發生肺炎日數比值分析…………………………… 654-6 相關危險比率計算結果……………………….………………………… 664-7 發生肺炎累計結果(以追蹤第九天為例) …………………….………… 664-8 研究過程發生肺炎分析(追蹤九天)…………………….…………….… 684-9 次要結果變項之分析...…….………………………….………………… 70application/pdf2962773 bytesapplication/pdfen-US口腔護理重症病患呼吸器相關肺炎口腔清潔實證策略Oral CareIntensive Care Unit PatientVentilator- Associated PneumoniaOral HygieneEvidence-Based Strategyhttp://ntur.lib.ntu.edu.tw/bitstream/246246/180323/1/ntu-97-R92426011-1.pdf