使用下巴下壓姿勢是否能改善腦中風病人吞嚥困難The Empirical Application of the Chin-Down Posture in the Improvement of Dysphagia in Stroke Patients

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2020-05-14 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

黃麗靜* 顏秀卉 林雅琪 郭素真 黃秋華

實證知識類別

A 類:實證健康照護綜整

PICO

治療/預防性問題

治療/介入措施

神經醫學 Neurology

科別

  • 臨床指引/實證照護成效 Clinical Guidelines/Evidence Based Outcomes

中文關鍵詞

下巴下壓、腦中風、吞嚥困難

英文關鍵詞

Chin-Down posture dysphagia Stroke patients

機構名稱

奇美醫療財團法人柳營奇美醫院

申請單位

護理部

中文摘要

形成臨床提問:
腦中風因腦部神經受損導致舌頭及咽部動作控制遲緩,約有55%以上病人出現吞嚥障礙之症狀,其中約有25%吞嚥障礙的腦中風病人可由口進食軟質食物,但進食液體時則容易發生嗆咳,因而引發吸入性肺炎之合併症;根據統計,吸入性肺炎為腦中風死亡相關原因之一,其死亡率高達46%,且發生吸入性肺炎機率是無吞嚥障礙之腦中風病人的三倍。醫護人員應確認病人吞嚥障礙程度,並提供個別性進食技巧指導,以降低腦中風吞嚥障礙病人之嗆咳率,進一步避免吸入性肺炎發生之合併症。本文獻系統性回顧目的為:探討下巴下壓姿勢是否能改善腦中風病人吞嚥困難,降低嗆咳率,提升照護品質。
文獻搜尋的方法與分析:
搜尋CEPS華藝中文電子期刊、EMBASE、CINAHL、ProQuest、Pub Med、Cochrane。輸入中英文關鍵字腦中風stroke、下巴下壓chin-down、下巴內縮chin-tuck、吞嚥困難Dysphagia、吞嚥障礙Dysphagic、一般照護usual care;搜尋條件為Humans、adults、English、Mesh term、2014-2018年、布林邏輯。類型為systemic review、meta- analysis、RCT、review article、clinical trial。共計22篇研究文章,排除18篇非實驗性研究文獻與1篇類似臨床實驗方式之文獻,篩選出3篇隨機控制之臨床研究文獻,進行文獻評讀。
文獻的品質評讀:
評讀工具為Critical Appraisal Skills Programme(CASP)進行評讀。Gao and Zhang (2017)研究顯示為Shaker exercise與下巴內縮抗阻力運動(Chin-Tuck Against Resistance, CTAR)於腦梗塞合併吞嚥困難病人較對照組呈現顯著性差異;Park et al. (2018)研究顯示以下巴內縮抗阻力運動(CTAR)於腦中風合併吞嚥困難病人,其功能性吞嚥困難量表(Functional Dysphagia Scale, FDS)與穿透力吸入量表(Penetration-Aspiration Scale, PAS)均有顯著性差異(p<.05);戴等(2018)研究顯示實驗組每天進食至少執行3次下巴下壓(Chin-down)吞嚥動作,其吞嚥問卷積分及吞嚥自我評估量表(Eating Assessment Tool, EAT-10)較控制組達顯著差異(p<.05),嗆咳頻率兩組亦達顯著差異(p<.05);故可做為臨床實務參考。
結論與建議:
運用下巴內縮或下巴下壓姿勢有助於改善吞嚥過程,可降低進食嗆咳頻率;不需耗用過多的成本,且非侵入性,團隊成員皆可執行。但當病人無法坐起或病人意識障礙無法配合、咳嗽反射差,則不建議使用下巴內縮或下巴下壓姿勢。

英文摘要

Ask an answerable question (PICO):
More than 55% of stroke survivors have a clinical problem of difficulty swallowing (dysphagia). Aspiration Pneumonia occurs when foreign materials (food, liquids vomit or saliva) are breathed into the lungs or airways to the lungs; approximately 25% of stroke-related dysphagia can lead to aspiration pneumonia following stroke, and the estimated mortality rate was 46%. The health-care professionals have a role in analyzing the level of dysphagia, providing individual preventative measures to prevent and reducing the incidence of aspirations and pneumonia in stroke patients. This article was conducted a systematic review aiming to identify the empirical application of the chin-down posture in the improvement of dysphagia in stroke patients.
The Method and Analysis of Literature Review:
Electronic databases including, including PubMed Clinical Queries, CINAHL, The Cochrane Library, ProQuest, EMBASE and Airiti library were retrieved for relevant articles. In this systematic review research, keywords included 腦中風stroke、下巴下壓chin-down、下巴內縮chin-tuck、吞嚥困難Dysphagia、吞嚥障礙Dysphagic、一般照護usual care were selected, a total of 22 articles that preliminary the search criteria were extracted. Finally, three randomized controlled trials (RCT) were selected as the final studies after screening the topics and deletions repetitions .
Critical Appraisal:
The Critical Appraisal Skills Programme(CASP, 2014) was used to appraise the quality of the reviewed studies. According to Gao and Zhang (2017), a significant difference between “Shaker exercise” and “Chin-Tuck Against Resistance (CTAR)” in dysphagia following cerebral infarction patients was reported. Chin-Tuck Against Resistance (CTAR) was an effectiveness of dysphagia intervention in in stroke patient with dysphagia, a significant positive correlation was found between Functional Dysphagia Scale (FDS)”and Penetration-Aspiration Scale (PAS)” (p<.05) (Park, et al., 2018). The choking and coughing frequency in the experimental group were decreased after Chin-down swallowing posture intervention (at least 3 times a day), a significant difference was revealed in the swallowing questionnaire and the Eating Assessment Tool (EAT-10) (p< .05).
Conclusions and Recommendations:
The chin-tuck or chin-down postural maneuver, a non-invasive and cost-effective technique, can improve swallowing performance, reduce the chance of choking while eating or drinking. However, it was not recommend for patients with sitting problems, impaired consciousness or poor cough reflex .