| 摘要: | 研究動機與目的: 在台灣長期使用呼吸器 (prolonged mechanical ventilation, PMV) 之病人持續累積增加中，而長期使用呼吸器之病人實行氣切的比例相對於國外數據是偏低。氣切與長期使用呼吸器病人之相關性持續被探討，許多研究發現氣切執行與否足以影響病人的預後。本研究將探討長期呼吸器依賴患者接受早期氣切與晚期氣切是否影響肺部感染與重返加護病房治療之風險。
研究方法：本研究將採取回溯性世代研究，從全民健康保險研究資料庫(2006-2013健保資料庫全國檔)，針對大於等於18 歲以上呼吸器依賴患者且連續使用呼吸器21天以上，合併氣管內管或氣切管使用(ICD9: 57001B侵襲性呼吸輔助器使用)，並且為第一次入住加護病房之病人。將病人分為兩個組群，包含≦14天內執行氣切與>14天後執行氣切。以傾向分數配對法配對，以減少選擇性偏差，經1: 1配對後，共納入研究對象11,736名。以條件式Cox對比涉險模式探討兩組長期使用呼吸器病人呼吸器相關肺部感染與重返加護病房治療之風險，追蹤病人至2014年底。利用Kaplan-Meier 方法比較兩組在一年內呼吸器相關肺部感染與加護病房重返治療之差異。
研究結果 : 本研究顯示長期使用呼吸器患者從2006至2014執行氣切人數共47485人，87.64%的病患於≦14天內執行氣切，有12.36%的病患於>14天後執行氣切。針對病患配對後，以男性、年長者、共病嚴重度高以及未持有呼吸器以外之重大傷病者占大多數。以條件式Cox對比涉險模式分析結果，以晚期氣切(執行氣切時間>14天)、年長者、投保金額較低、投保地區都市化程度低以及醫學中心之患者產生呼吸器相關肺部感染之風險相對較高。>14天後執行氣切者肺部相關感染之風險為≦14天內執行氣切者之1.32倍(HR=1.32,95% CI:1.06-1.65)。 >14天執行氣切者重返加護病房治療風險為≦14天內執行氣切者的2.14倍(HR=2.14,95% CI:1.58-2.91)。而以晚期氣切(執行氣切時間>14天)、投保金額較低、共病嚴重度高、持有呼吸器以外之重大傷病及醫學中心之患者，其重返加護病房治療之風險相對較高。
結論 : 經早期氣切後相對於晚期氣切可以降低長期使用呼吸器病人呼吸器相關肺部感染，同時也可重返降低加護病房治療之風險，結果可供相關醫療政策之參考。
Motivation and purpose: The number of prolonged mechanical ventilation (PMV)-dependent patients in Taiwan is rising. According to overseas statistics, the proportion of PMV-dependent patients who receive tracheostomy in Taiwan is lower than that in other countries. Research of the correlation between tracheostomy and PMV-dependency is ongoing, with numerous researchers determining that PMV-dependent patients’ prognoses are affected by whether they have received a tracheostomy. This study analyzed the differences in the prognoses of PMV-dependent patients who received early tracheostomies and those who received late tracheostomies. In addition, the researchers analyzed the association between tracheostomies and risk of lung infection and readmission into the intensive care unit (ICU) for further treatment.
Methodology: A retrospective cohort research approach was adopted. The researchers used the National Health Insurance Research Database (NHIRD; 2006–2013 NHIRD National Registry) to collect the data of PMV-dependent patients aged 18 or older who received mechanical ventilation for 21 consecutive days or longer, were intubated with an endotracheal tube (International Classification of Diseases [ICD] 9: 57001B Invasive Mechanical Ventilation), and were admitted to the ICU for the first time. The patients were allocated into two groups at the time of tracheostomy: those that received a tracheostomy within 14 days of intubation and those that received a tracheostomy after 14 days of intubation. A propensity score-matching approach was used to match patients and minimize selective bias. Based on a matching ratio of 1:1, a total of 47,485 patients were recruited in this study. A conditional Cox proportional hazards model was adopted to examine ventilator-associated lung infections across the three groups of PMV-dependent patients as well as patients’ risk of readmission into the ICU for treatment. The study cohort was monitored until the end of 2014. The Kaplan–Meier method was used to compare 1-year lung infection and ICU readmission among the two groups.
Results: This study showed that patients with long-term use of mechanical ventilators were a total of 47,485 people from 2006 to 2014. 87.64% of patients underwent tracheostomy within 14 days, and 12.36% of patients underwent tracheostomy after >14 days. After the patients were matched, the majority patient of the males、the elderly、the high severity of the comorbidity, and the major injuries other than the respiratory dysfunction were predominant. A conditional Cox proportional hazards model was used to analyze the results. Patients who received late tracheostomies (tracheostomy after 14 days of intubation), were of relatively old age, had low insurance salaries, were insured in a low-urbanization region, and received care in medical centers were at relatively high risk of ventilator-associated lung infections. The risk of lung infection among patients who received tracheostomy after 14 days of intubation was 132% higher than among those who received tracheostomy within 14 days of intubation (hazard ratio [HR] = 1.32, 95% confidence interval [CI]: 1.06–1.65). The ICU readmission rate among patients who received tracheostomies after 14 days of intubation was 214% higher than among those who received tracheostomies within 14 days of intubation (HR = 2.14, 95% CI: 1.58–2.91). The ICU readmission rate of patients who received late tracheostomy
(tracheostomy after 14 days of intubation), was highest among those of relatively low insurance salary, with severe comorbidities, with major injuries other than the respiratory dysfunction , and who received care in medical centers.
Conclusion: Compared with late tracheostomies, early tracheostomies were associated with a lower ventilator-associated lung-infection risk for the PMV-dependent patients as well as a lower ICU readmission rate. The findings of this study may serve as a reference for the development of relevant medical policies. |
