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1 成人採間歇性鼻胃管灌食後, 不關閉鼻胃管路, 接上引留袋並置放高於枕頭, 以降低吸入性肺炎? Journal Club 引言人 : 王錦雲 2016 年 10 月 11 日

2 Nasogastric Tube Feeding Definition -- Nasogastric tube feeding is defined as the delivery of nutrients from the nasal route into the stomach via a feeding tube. (MOH NURSING CLINICAL PRACTICE GUIDELINES, 2010) Nasogastric feeding is most appropriate when starting EN (McClave, S. A., 2016) Nasal tubes are mainly used for short-term enteral feeding (4-6 wk) and in situations where other methods of enteral feeding are contraindicated. (Blumenstein, I., Shastri, Y. M., Stein, J., 2014)

3 Indication Commissioned by the National Institute for Clinical Excellence,2006

4 Tube-related complications of enteral tube feeding World J Gastroenterol 2014 July 14; 20(26):

5 吸入性肺炎定義指異物或胃內容物, 由口咽吸入氣管, 進入下呼吸道, 導致肺部疾病 ; 如果吸入肺部的物質是無菌的胃酸, 可能會造成急性肺損傷 (acute lung injury ); 如果是含菌的腸胃道液或是夾帶口腔內大量細菌, 就可能造成細菌性肺炎 ( Marik, 2011; Shimada et al., 2010)

7 Background Nasogastric tube feeding may be accompanied by complications. Aspiration is one of the most feared complications of EN. (McClave, s. A, 2009) Thus, it is important for the practitioner to be aware of how to prevent these complications so that nasogastric tube feeding can be administered successfully and safely. Diagnosis of aspiration is difficult without the use of costly procedures; thus, the incidence of this condition is unclear. (American Association of Critical-Care Nurses,2016 ) 要實際預測肺吸入很困難, 所以影像的檢查 ( 胸部 X 光 ) 或是實驗室檢驗 ( 檢測痰液中的胃蛋白酶酸鹼值, 或是添加葡萄糖於食物溶液中, 再檢測痰液是否含糖 ) 以及支氣管鏡檢查, 雖較客觀, 但是臨床要使用這些方法是有困難的 ( 廖呂,2014)

8 Background aspiration is clearly a common problem in acutely ill patients. For example, videofl uoroscopically documented aspiration was reported in 42.6% of 1100 hospitalized adults (25% of the patients were aspirating silently). Reportedly, aspiration pneumonia represents 5% to 15% of pneumonias in the hospitalized population. Because no bedside tests are currently available to detect microaspirations, efforts to prevent or minimize aspiration take on added importance. (American Association of Critical-Care Nurses,2016 )

9 周幸生林玉如實意禎吳麗芬 (2003)

10 胃殘餘量 (gastric residual volumes ) 胃液每天產生的量約 5 公升, 每小時胃排空速度為 232~464cc, 因此當消化不良時, 胃液排空便會減少 (Hurt & McClave,2010) 胃殘餘量與肺吸入沒有正比關係, 但是當胃殘餘量大於 200cc 時, 吸入性肺炎的風險明顯增加 (Metheny et al., 2008)

11 胃殘餘量 (gastric residual volumes ) Feeding intolerance was primarily based on large gastric residual volumes (GRVs) together with other gastrointestinal symptoms. The 2013 Canadian clinical practice guidelines19 indicate that data are insufficient to recommend a specific GRV threshold; guidelines indicate that a GRV between 250 ml and 500 ml is acceptable as a strategy to optimize enteral nutrition in critically ill patients. (American Association of Critical-Care Nurses,2016 )

12 胃殘餘量 (gastric residual volumes ) 美國靜脈和腸道營養學會 (ASPEN) 營養支持指引中建議, 每 4 小時測量一次胃殘餘量, 以胃殘餘量 250cc 做為決定是否暫停灌食的切點 ; 如果胃殘餘量超過 500cc, 則需禁食 (Bankhead et al., 2009)

13 臨床問題 ( 案例 ) 臥床病人採間歇式鼻胃管灌食後, 不慎因咳嗽或抽痰因素, 導致吸入性肺炎

14 臨床問題研究族群 (population) -- 臥床病人介入措施 (Intervention) -- 間歇灌食後不關閉鼻胃管, 並將管路放置高於胃部比較措施 (Comparison) -- 間歇灌食後關閉鼻胃管結果 (Outcomes) -- 造成吸入性肺炎機率 14

15 搜尋結果 - 無證據力佳的相關文獻 NO paper

16 Materials and Methods: Forty eight male rats weighted g were selected in six groups. After anesthesia and tracheal cannulation, received 0.5 ml/kg normal saline, 0.5 ml/kg whole gastric fluid, 0.5 ml/kg pepsin (2.5 μg/ml), 0.5 ml/kg hydrochloric acid (ph=1.5) 0.5 ml/kg bile salts (2.5 μg/ml) injection into their trachea and lungs. In sham group nothing was injected. Iran J Basic Med Sci, Vol. 16, No. 6, Jun 2013

Results: Parenchymal and airways inflammation and fibrosis of bronchi, bronchioles and parenchyma were significantly more in the test groups compared to saline and sham groups (P<0.

19 Results: Parenchymal and airways inflammation and fibrosis of bronchi, bronchioles and parenchyma were significantly more in the test groups compared to saline and sham groups (P<0.001); also inflammation in pepsin and bile salts groups (histopathology scores: 2.87±0.35 and 3.0±0.0 for bronchial, 2.87±0.35 and 2.87±0.35 for bronchioles, 2.87±0.35 and 2.87±0.35 for parenchymal inflammation) were more than hydrochloric acid and gastric fluid groups (1.75±0.46 and 2.5±0.53 for bronchial, 2.0±0.0 and 2.0±0.0 for bronchioles, 2.0±0.0 and 2.0±0.0 for parenchymal inflammation) (P<0.05). The same results were found for fibrosis, so that the fibrosis in pepsin and bile salts groups were more than hydrochloric acid and gastric fluid groups (P<0.05).

20 現況 Bolus feeding can be performed using a 50 ml syringe, either with or without the plunger. If the latter is removed, the syringe can be hung up to allow gravity feeding. 至少 45 ~ 60 度

21 鼻胃管插入及管灌技術標準規範抬高床頭度, 無法坐起者可採右側臥位每一次灌食前, 應測試鼻胃管位置, 輕柔反抽檢查消化情形灌食前胃內殘餘量大於 75mL~200mL, 建議不要再餵食灌食前反抽, 觀察反抽物及空氣量, 排出空氣, 再將反抽物以重力引流方式灌回胃內, 若有未消化之食物, 則應二小時後再反抽看看, 若反抽物仍大於灌食量的一半時應暫緩灌食, 且反抽物仍需灌回胃內, 另有咖啡色液體則予以丟棄灌食液溫度以為宜, 成人每次總灌食量不超過 500ml 將灌食空針抬高 30-45cm 先灌 30ml 的溫開水, 再將食物倒入空針內, 藉重力以緩緩流入或慢慢推入至胃中, 每次灌食時間不可少於分鐘灌食後 30 分鐘內不要立刻平躺翻身及拍痰鼻胃管插入及管灌技術標準規範 S

23 Prevention of Aspiration in Adults (American Association of Critical-Care Nurses,2016 )

24 Actions for Nursing Practice Maintain head-of-bed elevation at an angle of 30º to 45º, unless contraindicated. [level B] Use sedatives as sparingly as feasible [level C] For tube-fed patients, assess feeding tube placement at 4-hour intervals to ensure that the tube has remained in the desired location. [level C] --Encourage obtaining a radiograph to confirm tube position if the tube s position is in doubt

25 Actions for Nursing Practice For patients receiving gastric tube feedings, assess for intolerance to feedings every 4 hours by monitoring GRVs, abdominal discomfort, nausea/vomiting, and abdominal girth/distention. [level C] --If patients are able to communicate, ask if they are experiencing abdominal discomfort or nausea --a. A 60-mL syringe is most suitable for measuring residual volumes; withdraw as much fluid from the tube as possible to make an accurate assessment --b. It is helpful to inject 30 ml of air before attempting to aspirate fluid from flexible, small-diameter tubes

26 Actions for Nursing Practice For tube-fed patients, avoid bolus feedings for those at high risk of aspiration. [level E] -- As indicated earlier, it is better to introduce feedings evenly over a period of hours to minimize the risk for regurgitation and aspiration of gastric contents --Consult with a clinical dietitian and a provider about the best feeding method for individual patients Consult with the patient s provider about obtaining a swallowing assessment before beginning oral feedings for a recently extubated patient who has undergone prolonged intubation. [level C] (American Association of Critical-Care Nurses,2016 )

27 Actions for Nursing Practice Maintain endotracheal cuff pressures at an appropriate level, and ensure that secretions are cleared from above the cuff before it is defl ated. [level B] --The American Thoracic Society recommends that endotracheal tube cuff pressures be maintained at greater than 20 cm H2O to prevent leakage of secretions around the cuff into the lower part of the respiratory tract (American Association of Critical-Care Nurses,2016 )

28 非藥物非侵入性 - 預防鼻胃管灌食導致吸入性肺炎之實證照護措施文獻彙整 ( 廖呂,2014)

29 非藥物非侵入性 - 預防鼻胃管灌食導致吸入性肺炎之實證照護措施文獻彙整 ( 廖呂,2014)

30 結語適量的胃殘留量確定鼻胃管在正確位置適當的病患姿勢口腔衛生和避免食道逆流吸入等照護措施, 皆可減少鼻胃管餵食患者的吸入風險, 達到預防吸入性肺炎的效果

31 討論重點摘要間歇鼻胃管灌食後, 是否同意採不關閉鼻胃管路實際案例分享實施不關閉鼻胃管管路的優點缺點鼻胃管灌食於臨床是很重要的議題, 對於無法使用鼻胃管灌食, 目前國內外之醫療方式, 朝向以 PEG 方式執行, 以減少壓傷吸入性肺炎等合併症由於目前無適合的證據佐證, 建議設計研究, 於加護病房病人試行, 評估其成效

32 臨床運用成人採間歇鼻胃管灌食後, 是否同意採不關閉鼻胃管路, 接上引留袋並置放高於枕頭, 以降低吸入性肺炎? 同意 8 人懷疑 26 人不同意 0 人 32

東吳大學

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