School of Nursing, Queensland University of Technology, Caboolture, Queensland, Australia.
Department of Neurology, University Clinic, Tulln, Austria.
Nurs Crit Care. 2018 Mar;23(2):102-107. doi: 10.1111/nicc.12333. Epub 2017 Dec 28.
Post-extubation dysphagia is a condition that is becoming a growing concern. The condition occurs in 3-62% of extubated patients and can be related to mixed aetiologies, such as neuromuscular impairment, critical illness and laryngeal damage. The risk factors for developing dysphagia in critically ill patients are under-diagnosed and perhaps underestimated. Recent studies recommend the implementation of a standardized swallowing screen to prevent aspiration and decrease pneumonia rate and mortality. The aim of this quality improvement initiative was the development of a bedside swallowing screening tool to assess effective swallowing post-endotracheal extubation. Post-extubation dysphagia can result in a delay in re-feeding, with the potential for malnutrition as well as overt and covert aspiration if swallowing is not effectively screened. It is apparent that ICU nurses commence the initial screen for swallowing in the absence of an evidence base of care. A review of current local and international practice guidelines excludes the process of an effective swallowing screen of the extubated patient. Previously, a referral to speech and language therapists would be required to assess swallowing only after an initial review by the ICU medical team. This often leads to delays if the referral is made outside normal working practice, such as weekends or evenings. The initial development of a swallowing screening tool is the first step to promoting a nurse-led/-initiated bedside swallow screening tool that will enhance patient care and patient safety. There is growing body of evidence regarding the incidence of post-extubation dysphagia. Currently, there are very few recognized bedside swallowing screening tools to identify patients at risk. The most serious complication associated with post-extubation dysphagia is aspiration pneumonia, which is the leading cause of nosocomial infection in the critically ill patient.
拔管后吞咽困难是一种日益受到关注的病症。这种情况发生在 3-62%的拔管患者中，可能与多种病因有关，如神经肌肉损伤、重症疾病和喉损伤。重症患者发生吞咽困难的危险因素未得到充分诊断，或许也被低估了。最近的研究建议实施标准化吞咽筛查，以预防误吸、降低肺炎发生率和死亡率。本次质量改进倡议的目的是开发一种床边吞咽筛查工具，以评估气管插管拔管后的有效吞咽能力。拔管后吞咽困难可能导致延迟重新进食，如果吞咽未得到有效筛查，可能导致营养不足以及显性和隐性误吸。显然，在缺乏护理循证依据的情况下，重症监护病房护士开始对吞咽进行初步筛查。对当前本地和国际实践指南的审查排除了对拔管患者进行有效吞咽筛查的过程。以前，只有在重症监护病房医疗团队进行初步审查后，才需要转介言语治疗师来评估吞咽能力。如果在正常工作时间之外（如周末或晚上）进行转介，通常会导致延误。开发吞咽筛查工具是迈出的第一步，旨在促进以护士为主导的床边吞咽筛查工具，以增强患者护理和患者安全。目前，关于拔管后吞咽困难的发生率有越来越多的证据。目前，很少有公认的床边吞咽筛查工具可以识别有风险的患者。与拔管后吞咽困难相关的最严重并发症是吸入性肺炎，这是重症患者医院感染的主要原因。
