探討孟德森吞嚥運動是否能改善腦中風病人吞嚥困難Does Mendelsohn swallowing exercises can improve dysphagia in stroke patients?

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2023-11-21 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

賴珮君 莊情惠 柯貞如*

文章類別

A 類:實證健康照護綜整

問題類型

治療/預防性問題

健康狀況

神經醫學 (Neurology)  

治療/介入措施

臨床護理技術相關措施(Clinical Nursing Skills and Techniques) -

專長類別

神經科學暨肌肉骨骼護理

中文關鍵詞

#腦中風 #吞嚥困難 #孟德森吞嚥運動

英文關鍵詞

#Stroke #dysphagia #Mendelsohn Exercise

機構名稱

衛生福利部草屯療養院

申請單位

個人

中文摘要

形成臨床提問:
腦中風後神經損傷導致口腔期及咽部期吞嚥時間的延遲,喉部上提時間延緩,進而產生吞嚥前期及吞嚥期的障礙(厲等,2022)。根據莊等於(2017)指出,腦中風病人約20%-90%有吞嚥困難情形,因而引發吸入性肺炎,吸入性肺炎為腦中風病人死亡主要原因。醫護人員應確認病人吞嚥障礙程度,提供個別性衛教,降低吞嚥障礙之嗆咳率。本文透過文獻查證,探討孟德森吞嚥運動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電子期刊、CINAHL、 Pub Med、MEDLINE、Cochrane、Nursing & Allied Health Premium-Proquest、EMBASE。輸入關鍵字:P:腦中風Stroke、post-stroke、after stroke、O:吞嚥困難、吞嚥障礙、dysphagia、dysphagic、swallowing disorders、deglutition disorders、I:孟德森吞嚥運動、Mendelsohn Exercise、Mendelsohn maneuver;搜尋條件adults、English、Mesh term、2010-2023年,布林邏輯。類型為SR、meta-analysis、RCT。共計24篇研究文章,排除20篇為不符合PICO及重複記錄,排除2篇類實驗,篩出2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,McCullough et al. (2012)研究,其舌骨最大抬高持續時間(DOHME)和舌骨最大前移的持續時間(DOHMAE)於兩週後有顯著改善上食道括約肌開口持續時間(DOHME):p = .011;DOHMAE:p = .009;結果為DOUESO:p = .472。 其McCullough et al. (2013)研究,治療第一和第二週有顯著差異,舌骨最大前偏移(HMAE):p = 0.05;舌骨最大抬高(HME):p = .01;上食管括約肌開口平均寬度(MWUESO):p =.016。穿透力吸入量表8-point penetration-aspiration (P/A)、口咽殘留物量表(Pyriform Residue),以及吞嚥困難結果和嚴重程度量表(DOSS)數據結果,治療前後大部分都是有顯著差異(p<.05)。故可做為臨床實務參考。
結果、結論與建議:
孟德森吞嚥運動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。但當病人無法坐起或意識障礙無法配合、咳嗽反射差,則不建議使用孟德森吞嚥運動。

英文摘要

Ask an answerable question (PICO):
When nerve innervation is compromised following a stroke, it can result in delayed swallowing times during the oral and pharyngeal phases and a postponement in larynx elevation, potentially leading to challenges in the pre-swallowing and swallowing phases (Li et al., 2022). Dysphagia, affecting 20%-90% of stroke patients, as reported by Zhuang et al., 2017, can predispose individuals to aspiration pneumonia, which is a leading cause of mortality in stroke patients (Chen & Zhuang, 2015). To address these critical issues, healthcare professionals should assess the severity of swallowing disorders in patients, offer personalized health education, and aim to reduce incidents of choking and coughing in individuals with swallowing difficulties. This article conducts a comprehensive literature review to investigate the potential benefits of Mendelsen swallowing exercises in improving dysphagia, lowering coughing rates, and enhancing the overall quality of care for stroke patients.
The Method and Analysis of Literature Review:
To conduct an exhaustive literature search, we explored multiple reputable databases, including CEPS Electronic Journals, CINAHL, PubMed, MEDLINE, Cochrane, Nursing & Allied Health Premium-Proquest, and EMBASE. Our search was guided by a set of carefully chosen keywords: for the Patient (P) category, we utilized 'Stroke,' 'post-stroke,' and 'after stroke'; for the Outcome (O) category, we focused on 'dysphagia,' 'dysphagic,' 'swallowing disorders,' and 'deglutition disorders'; in the Intervention (I) category, our emphasis was on 'Mendelsohn swallowing exercise,' 'Mendelsohn Exercise,' and 'Mendelsohn maneuvers.' We established specific search criteria, including adult populations, articles in English, the use of Mesh terms, publication dates from 2010 to 2023, and the application of Bollinger logic. The types of articles we sought encompassed Systematic Reviews (SR), Meta-Analyses, Randomized Controlled Trials (RCT), Review articles, and clinical trials. In total, we excluded 24 research articles, with 20 not meeting PICO criteria or duplicating records. Additionally, we excluded two similar experiments. Ultimately, two randomized controlled clinical research articles were screened and selected for inclusion in our comprehensive literature review.
Critical Appraisal:
The evaluation tool employed in this study is the Critical Appraisal Skills Program (CASP) evaluation. McCullough et al. (2012) conducted a two-week investigation into the duration of maximum hyoid elevation (DOHME) and the duration of maximum hyoid anterior displacement (DOHMAE). The results revealed significant improvements in the duration of upper esophageal sphincter opening (DOHME, p = .011), DOHMAE (p = .009), while no significant change was observed in DOUESO (p = .472). In a subsequent study by McCullough et al. (2013), a significant difference was found between the first and second weeks of treatment, particularly in the maximum anterior excursion of the hyoid bone (HMAE, p = 0.05), maximum elevation of the hyoid bone (HME, p = .01), and mean width of esophageal sphincter opening (MWUESO, p = .016). The outcomes assessed using the 8-point penetration-aspiration (P/A), Pyriform Residue, and Dysphagia Outcome and Severity Scale (DOSS) demonstrated consistent positive changes before and after treatment, with statistical significance (p < .05). These findings suggest that the CASP evaluation and the associated studies can serve as valuable references for guiding clinical practice.
Results, Conclusions and Recommendations:
The utilization of Mendelsen exercises has been shown to enhance the swallowing process, reducing the incidence of choking and coughing during meals. This approach offers the added advantages of cost-effectiveness, non-invasiveness, and ease of implementation following appropriate teaching. However, it is important to exercise caution and refrain from employing Mendelsen exercises when patients are unable to sit up or cooperate due to impaired consciousness or a compromised cough reflex.