Vitacca Michele, Paneroni Mara, Peroni Roberta, Barbano Luca, Dodaj Valmira, Piaggi Giancarlo, Vanoglio Fabio, Luisa Alberto, Giordano Amerigo, Ceriana Piero
Divisione di Pneumologia Riabilitativa
Divisione di Pneumologia Riabilitativa.
Respir Care. 2014 Dec;59(12):1863-71. doi: 10.4187/respcare.03030. Epub 2014 Sep 2.
The aim of this study was to analyze the effects of a multidisciplinary program carried out in a chronic ventilator facility on disability, autonomy, and nursing needs of patients after a prolonged ICU stay. Secondary outcome measures were survival, weaning rate, chronic ventilator facility stay, and discharge destination.
Multidisciplinary assessment, clinical stabilization, weaning attempts, and a new Disabled Patients Autonomy Planning tool to assess daily care needs were investigated in 240 subjects in a chronic ventilator facility (52 subjects after cardiovascular surgery, 60 subjects with acute respiratory failure, 71 subjects with COPD, and 57 subjects with neurological disease).
At admission, nursing needs, disability, and autonomy differed according to diagnosis (P < .001); weaned subjects had greater nursing needs (P < .001) and disability (P = .0014) than unweaned subjects. During the stay, 13.8% of the subjects died irrespective of diagnosis (P = .12); 47% (P < .001) were weaned with significant differences (P <.007) by diagnosis. In the 207 surviving subjects, nursing needs increased as disability increased (r = 0.59, P < .001) and autonomy decreased (r = -0.66, P < .001); disability and autonomy were inter-related (r = 0.61, P < .001). Oxygen saturation, hypercapnia, dyspnea, disability, autonomy, and nursing needs significantly improved (all, P < .001). Fifty-nine percent of the subjects were discharged home. Subjects discharged to nursing homes presented mainly neurological diseases, being more disabled and less autonomous, with higher nursing needs (all, P < .04). Mechanical ventilation use and tracheostomy increased the probability of being discharged to a nursing home (odds ratio [OR] of 1.84, P = .04; OR 2.47, P = .003, respectively). Mortality was higher in subjects who were ventilated (OR 8.44, P < .001), male (OR 2.64, P = .01), elderly (P < .001), or malnourished (P = .01) and in subjects with low autonomy (P < .001), greater nursing needs (P = .002), and more severe disabilities (P = .04).
A specialized tailored multidisciplinary program in subjects after an ICU stay contributed to recovery from disability, autonomy, and fewer nursing needs irrespective of diagnosis. Subjects discharged to a nursing home were the most severely disabled.
本研究旨在分析在慢性呼吸机治疗机构实施的多学科项目对长期入住重症监护病房（ICU）后患者的残疾状况、自主性及护理需求的影响。次要结局指标为生存率、脱机成功率、在慢性呼吸机治疗机构的住院时间及出院去向。
对一家慢性呼吸机治疗机构的240名患者进行了多学科评估、临床稳定治疗、脱机尝试，并使用一种新的残疾患者自主性规划工具来评估日常护理需求（52名心血管手术后患者、60名急性呼吸衰竭患者、71名慢性阻塞性肺疾病（COPD）患者及57名神经系统疾病患者）。
入院时，护理需求、残疾状况及自主性因诊断不同而存在差异（P <.001）；脱机患者比未脱机患者有更高的护理需求（P <.001）及更严重的残疾状况（P =.0014）。住院期间，13.8%的患者死亡，与诊断无关（P =.12）；47%的患者成功脱机，不同诊断组间存在显著差异（P <.001）（P <.007）。在207名存活患者中，护理需求随残疾程度增加而增加（r = 0.59，P <.001），自主性则降低（r = -0.66，P <.001）；残疾状况与自主性相互关联（r = 0.61，P <.001）。血氧饱和度、高碳酸血症、呼吸困难、残疾状况、自主性及护理需求均有显著改善（均P <.001）。59%的患者出院回家。入住养老院的患者主要患有神经系统疾病，残疾程度更高、自主性更低，护理需求也更高（均P <.04）。使用机械通气及气管切开术增加了入住养老院的可能性（优势比[OR]分别为1.84，P =.04；OR 2.47，P =.003）。接受通气治疗的患者（OR 8.44，P <.001）、男性（OR 2.64，P =.01）、老年人（P <.001）、营养不良患者（P =.01）以及自主性较低（P <.001）、护理需求较高（P =.002）和残疾程度更严重（P =.04）的患者死亡率更高。
针对ICU后患者的专门定制的多学科项目有助于患者从残疾状况中恢复，提高自主性并减少护理需求，与诊断无关。入住养老院的患者残疾程度最为严重。
