齊魯醫(yī)學危重病人的康復(fù)

1、精品醫(yī)學文檔 精品醫(yī)學文檔 精品醫(yī)學文檔 CHAPTER 60第60章ADITI G. SATTI , MELISSA DERR , AND MARY L. FORNEKADITI G. SATTI , MELISSA DERR , AND MARY L. FORNEKRehabilitation in the IntensiveCare UnitCHAPTER OUTLINELearning ObjectivesIntroductionCase Study: Part 1Rehabilitative Issues in the Icu PatientCase Study: Part 2Who

2、le Body RehabilitationInspiratory Muscle TrainingEarly Tracheostomy to Facilitate MobilizationCase Study: Part 3Psychological DysfunctionSpeechSwallowing DysfunctionCase Study: Part 4SleepImplementing an Early Mobility ProgramInitial AssessmenSpecialized Unit Approach to Early MobilityRehabilitation

3、 StrategiesRehabilitation ProgramsSpecial ConsiderationsSummaryReview QuestionsAnswersReferencesAdditional Readings重癥監(jiān)護病人的康復(fù)章節(jié)梗概學習目標前言個案研究：第一部分重癥監(jiān)護病人康復(fù)內(nèi)容個案研究：第二部分整體康復(fù)吸氣力訓(xùn)練保持氣道通暢，早期氣管造口？個案研究：第三部分心理障礙語言障礙吞咽障礙 個案研究：第四部分睡眠障礙實施早期活動方案初始評估t專門早期活動病房？康復(fù)策略康復(fù)程序特別考慮摘要復(fù)習問題答案參考文獻附加讀物LEARNING OBJECTIVESAfter study

4、ing this chapter, you should be able to: Understand the importance of the team approach and the process of care issues, which lead to successful implemention of rehabilitation in the ICU patient. Understand the main neuromuscular, respiratory, and psychological conditions that affect rehabilitation

5、in the ICU. Develop a systematic approach for implementing early mobility of ventilated patients. Execute effective measures to prevent complications in ventilated patients in the ICU.學習目標通過本章節(jié)，你應(yīng)該：理解在重癥監(jiān)護病人康復(fù)實施成功中團隊合作、護理內(nèi)容和護理過程的重要性。理解影響重癥監(jiān)護病人康復(fù)的主要因素：神經(jīng)肌肉、呼吸及心理狀態(tài)。為機械通氣患者制定實施早期活動的系統(tǒng)化的方法。采取有效的措施預(yù)防重癥監(jiān)護

6、室機械通氣患者并發(fā)癥。INTRODUCTION介紹The goal of rehabilitation is to improve physical, psychological,and social function within the constraints of the patients illness. Muscle fatigue and weakness were the major reasons given for patients persistent functional limitation.康復(fù)的主要目的是在病人病情允許的范圍內(nèi)提高患者的身體、心理及社會功能。呼吸機疲

7、勞無力是病人功能持續(xù)受限的原因。下邊左側(cè)The global advancement in ICU care has improved survival of the critically ill patient.This improved survival has led to longer ICU lengths-of-stay and an awareness of the number and diversity of secondary complications. A prolonged ICU stay and chronic critical illness are assoc

8、iated with weakness, deconditioning, decreased function, and quality-of-life. The goal of rehabilitation is to improve physical, psychological, and social function within the constraints of the patients illness. ICU監(jiān)護的全面（全球？）進步提高危重病人的生存率。生存率的提高導(dǎo)致入住ICU時間延長和認知各種各樣的繼發(fā)并發(fā)癥。ICU入住時間延長及慢性危重癥和患者的身體虛弱、不適應(yīng)？、各種

9、功能及生活質(zhì)量降低相關(guān)?？祻?fù)的目的是在病人條件身體允許的范圍內(nèi)？提高患者身體、心理及社會功能。Acute respiratory distress syndrome (ARDS) is a common condition encountered in the ICU and is associated with long term psychological and functional disorders. In a study reviewing 109 survivors of ARDS, muscle fatigue and weakness were the major reaso

10、ns. 第60章 重癥監(jiān)護室病人的康復(fù) 1193CASE STUDY: PART 1 個案研究：第一部分The patient, R.S., was a 54-year-old African American male with history of severe COPD; he was admitted with an acute exacerbation of COPD and hypoxemic respiratory failure. On admission,he was in acute respiratory distress, his respiratory rate wa

11、s 37,pulse 136, blood pressure 100/62, and SpO 2 via pulse oximetry was 82%. On examination, R.S. had an increased work-of-breathing and was using accessory muscles. He had decreased air entry on lung exam. His initial chest X-ray showed hyperinflated lungs. The patient was intubated on admission an

12、d transferred to the ICU. During his stay he was treated with high-dose steroids for his COPD exacerbation and had to be sedated and paralyzed in order to maintain an oxygen saturation above 90% on ventilatory support. As the patient improved, the systemic corticosteroid dose was tapered and the sed

13、ation was weaned. Early in his hospital course, the patient was not a candidate for physical therapy due to his medical instability. At the present time, the patients body is rotated every 2 h by the nurse. Multipodus boots and hand splints were placed on the patient to prevent joint contractures. R

14、.S.是一個54歲的非洲裔美國男性患者，有嚴重的COPD病史。入院時，存在COPD 急性加重和低氧性呼吸衰竭,入院后，患者存在急性呼吸窘迫綜合征，呼吸頻率為37次/分，脈搏為136次/分，血壓為100/62mmHg，經(jīng)皮血氧飽和度為82%，體檢發(fā)現(xiàn)，R.S.呼吸功增加及應(yīng)用輔助呼吸機呼吸，氣體入肺量減少,X線示肺過度膨脹。,病人立即行氣管插管并送往監(jiān)護室，住院期間在應(yīng)用呼吸機輔助通氣時因COPD急性加重應(yīng)用了大量的激素，為了保持血氧飽和度在90%以上，應(yīng)用了鎮(zhèn)靜藥物和肌松藥物,隨著病人病情的改善，系統(tǒng)應(yīng)用激素量減少及鎮(zhèn)靜劑逐漸停用,在他早期的住院時期，這個病人因為它的醫(yī)學不穩(wěn)定性物理療法不作為

15、首選,目前，護士每2小時就給該患者翻一次身。給患者應(yīng)用長筒靴及手夾板以避免關(guān)節(jié)攣縮。given for patients persistent functional limitations. These functional limitations were evident in the lower than predicted distance walked in 6 min.1 Survivors of prolonged ventilation also experienced a marked impairment in their physical quality-of-life,

16、even though their mental health was preserved. 2 There is an increased need for rehabilitation following a stay in the ICU because of the harmful consequences of prolonged bed rest. 急性肺損傷和急性呼吸窘迫綜合征是在ICU中經(jīng)常碰到，它長期的心理和功能紊亂相關(guān)。在回顧一個109個急性呼吸窘迫綜合征存活患者的研究中，呼吸機疲勞及身體虛弱無力是病人持續(xù)性功能障礙主要原因。這些功能限制在預(yù)計6分鐘步行實驗較低的病人中更顯

17、著。機械通氣時間延長的幸存者都經(jīng)歷了生活質(zhì)量的損害，即使他們的身體健康得到康復(fù)，長期臥床會帶來有害結(jié)果，ICU長期住院病人迫切需要康復(fù)。REHABILITATIVE ISSUES IN THE ICU PATIENTICU病人康復(fù)內(nèi)容Muscle atrophy, loss of force generation, and changes in type of muscle fi bers all occur with bed rest. The greatest risk factor for CIM is the use of glucocorticoids and neuromuscul

18、ar blocking agents(see Chap. 58). All patients admitted to the ICU suffer some element of deconditioning related to the need for bed rest and the catabolic nature of the underlying disease. 長期臥床會出現(xiàn)骨骼肌萎縮，無力及骨骼肌纖維類型的改變。危重癥病肌病的最危險的因素是應(yīng)用糖皮質(zhì)激素和神經(jīng)肌肉阻斷劑。所有的入住ICU的病人都會因需要臥床而表現(xiàn)出不適應(yīng)及遭受代謝性質(zhì)的基礎(chǔ)疾病的困擾。在右邊It is not

19、 completely clear why weakness occurs in the ICU. The effects of deconditioning primarily come from studies done on healthy persons placed at bed rest in space programs and low-gravity research. Muscle atrophy, loss of force generation, and changes in type of muscle fibers all occur with bed rest. I

20、t has been found that even short periods of bed rest affect skeletal muscle performance. After 14 and 35 days, muscle force decreases by 15 and 25%, respectively. Thigh and calf muscle volumes also decrease significantly. 3 What happens to skeletal muscle with disuse is also true for the diaphragm.

21、A study that evaluated diaphragm-biopsy specimens from subjects on mechanical ventilation for 1869 h showed atrophy of both slow and fast-twitch muscle fibers. 4 This weakness contributes to an overall decrease in functional status and impairs ventilatory weaning.在ICU中病人身體虛弱的原因上不完全清楚。去條件化的結(jié)果？主要來自空間計

22、劃的健康人群長期臥床及低重力研究。長期臥床會出現(xiàn)骨骼肌萎縮，無力及骨骼肌纖維類型的改變。研究表明，即使短時期臥床也會影響骨骼肌的功能，在臥床14天和35患者中，骨骼肌力量相應(yīng)下降了15%和25%。大腿和腓腸肌容積也顯著下降了。 骨骼肌的廢用同時也發(fā)生在膈肌 。一項評估18-69小時機械通氣患者骨骼肌活檢的研究顯示無論是快或慢收縮纖維存在萎縮情況這種虛弱導(dǎo)致病人功能狀態(tài)的降低及影響患者脫機。Patients in the ICU are also at risk for developing neuromuscular weakness due to ICU treatments used to

23、 treat acute exacerbations of the underlying disease process. The greatest risk factor for critical illness myopathy (CIM) is the use of glucocorticoids and neuromuscular blocking agents (see Chap. 58). It is characterized by flaccid muscle weakness and failure to wean from the ventilator. CIM is us

24、ually reversible over weeks to months, but is associated with a prolonged hospital course.具有基礎(chǔ)疾病的病人在急性加重期在ICU治療中具有很高的發(fā)展為神經(jīng)肌肉無力的可能性。危重癥病肌病的最大危險因素是糖皮質(zhì)激素和神經(jīng)肌肉阻斷劑的應(yīng)用（見58章）。特點是肌肉無力和脫機困難。在數(shù)周到數(shù)月內(nèi)危重癥病肌病通常是可逆的。但是和住院時間增加相關(guān)。Critical illness polyneuropathy (CIP) is another cause of neuromuscular weakness encoun

25、tered in the ICU and may be confused with CIM. The physical findings are similar to those seen in myopathy, but also included sensory nerve dysfunction and decreased deep tendon reflexes; it is associated with severe sepsis.此外，導(dǎo)致神經(jīng)肌肉無力另一重要因素是危重癥病多神經(jīng)病，此病在ICU中很常見且容易和危重癥病肌病相混淆。體格檢查時有很多相似之處，包括感覺神經(jīng)功能障礙及深

26、反射減退，（危重癥病多神經(jīng)?。┖椭匕Y敗血癥相關(guān)。Patients may also develop compressive neuropathies affecting the ulnar and peroneal nerves. Proper positioning and frequent turning may limit the extent of these neuropathies. The remedy for all of these secondary disorders derives from treating the underlying medical conditi

27、ons and intensive rehabilitation.病人可能會發(fā)展為影響尺骨和腓骨神經(jīng)的壓迫性神經(jīng)病，合適的體位和頻繁的轉(zhuǎn)動可能會限制這些神經(jīng)疾病的發(fā)展（范圍）。對所有繼發(fā)功能障礙的治療來源于對基礎(chǔ)醫(yī)療疾病狀況的治療和重癥監(jiān)護病人的康復(fù)。 All patients admitted to the ICU suffer some element of deconditioning related to the need for bed rest and the catabolic nature of the underlying disease prompting admissio

28、n. ICU patients who require sedation, neuromuscular blocking agents, corticosteroids, mechanical ventilation, and suffer from sepsis, shock, and/or renal failure represent patient groups who are at greatest risk for deconditioning; these patients require intensive, multidisciplinary whole body rehab

29、ilitation.所有的入住ICU的病人都會因臥床而遭受不適應(yīng)及基礎(chǔ)疾病所遭受的代謝的困擾。需要鎮(zhèn)靜、神經(jīng)肌肉阻斷劑、糖皮質(zhì)激素及機械通氣、敗血癥、休克或腎臟功能衰竭的病人代表了高度危險人群，需要重癥監(jiān)護，多學科合作的整體康復(fù)。ICU patients are a special population of patients who benefit from early mobility.The ability to sit, stand, and ambulate not only improves their quality-of-life and functional status,

30、but also mitigates the complications of immobility, such as deep venous thrombosis, CASE STUDY: PART 2 個案研究：第2部分R.S. had continued ventilator-dependent respiratory failure. He had a tracheostomy tube placed for comfort and mobility ，Physical therapy was consulted in the ICU. The patient was assessed

31、 daily for any contraindications to physical therapy. The patient at this stage had passive range of motion performed by the nurses three times a day, and the patients bed was put into a sitting position for a minimum of 20 min 3 times a day. The patient had severe weakness and CIM from the use of s

32、ystemic glucocorticoids and neuromuscular blocking agents The patient progressed to sitting in a chair and requested to sit for a minimum of 45 min/day. The patient was unable to wean from the ventilator and was transferred to the ventilator rehab unit (VRU) for further management. The patient met r

33、espiratory and nonrespiratory medical criteria for admission to the VRU tracheostomy, manageable secretions, stable ventilator settings, the presence of a ejunostomy or gastrostomy tubes for nutrition and was medically stable and cooperative. R.S.持續(xù)的呼吸機依賴性呼吸衰竭，他進行了氣管切開并放置了舒適的利于活動的管道.在ICU中接受了物理治療，每天對

34、其有無物理治療的禁忌癥進行評估，護士一天三次對對其進行翻身或者活動。每天患者坐位時間3次，每次20分鐘，患者重度虛弱，因全身應(yīng)用糖皮質(zhì)激素及神經(jīng)肌肉阻斷劑而發(fā)生危重癥病肌病.病人病情進展，要求每天坐在椅子上至少每天45分鐘，病人不能脫機，轉(zhuǎn)入呼吸康復(fù)病房做進一步治療，病人符合機械及非機械通氣的標準入住康復(fù)病房，對其進行氣管造口，分泌物管理，穩(wěn)定的呼吸機以及胃空腸造口保證患者的營養(yǎng)。pulmonary embolism, and decubitus ulcers. The ability to speak and eat also has a benefit on overall psychol

35、ogical well-being. These issues are extremely important and therapy should be instituted as early as feasible when caring for chronically ventilated patients. ICU病人是一種特殊的病人群體，活動能夠提高患者的生活質(zhì)量，而且還能減輕或緩和制動所導(dǎo)致的并發(fā)癥。如，深靜脈血栓形成，肺栓塞，褥瘡，說和吃的能力對心理健康狀態(tài)有益，對慢性需要護理的機械通氣的病人非常重要，應(yīng)該盡早實施（活動）。Many studies have shown that

36、 patients doing arm and leg exercises have an improvement in the strength and endurance of respiratory muscles, decreased shortness of breath, and an improved quality-of-life. Keens et al 5 found that in cystic fibrosis patients undergoing intense upper extremity training, there was a 57% increase i

37、n ventilatory muscle endurance. Clanton et al 6 found that swimmers who did isometric upper extremity training had a 25% increase in mean inspiratory pressure and a 100% increase in ventilatory endurance compared to agematched controls. Estenne et al 7 found that in C5C6 quadriplegic patients, there

38、 was an increased expiratory reserve volume after undergoing 6 weeks of isometric pectoralis major muscle training. These studies have triggered an interest in the incorporation of upper extremity training in rehabilitation programs. 許多研究也已經(jīng)表明患者盡早進行肢體鍛煉能夠提高呼吸肌的力量和耐力，減少呼吸急促的發(fā)生，提高生活質(zhì)量；keen等研究發(fā)現(xiàn)，囊性纖維化病

39、人進行較強烈的（四肢）鍛煉，可以使他們的呼吸肌耐力提高57%， Clanton et al等研究發(fā)現(xiàn)，和相匹配年齡組的人相比，進行同等訓(xùn)練的游泳的（患者）平均吸氣壓升高25%，呼吸機耐力得到100%的提高。Estenne 等發(fā)現(xiàn)，如果C5-C6四肢截癱的病人經(jīng)歷6周的同等胸大肌的訓(xùn)練，那么他們的呼氣末容積就會增加。這些研究激發(fā)大家在上肢訓(xùn)練在康復(fù)過程中的興趣。WHOLE BODY REHABILITATION整體康復(fù)Whole body rehab should be an integral part of the care of a chronically ventilated patien

40、t. Upper limb motor strength correlates inversely with weaning time. 整體康復(fù)訓(xùn)練應(yīng)該成為慢性機械通氣病人治療中的一部分。上肢肌力和脫機長短呈負相關(guān)，。We previously evaluated and reported the efficacy of aggressive whole body rehab in 49 chronically ventilated patients. All patients had been ventilated for at least 14 days and none had neu

41、romuscular disorders. Physical therapy was started on admission to our ventilator rehabilitation unit. The rehab program consisted of trunk control, active and passive extremity resistance training, and inspiratory muscle training (IMT). Deconditioning was assessed daily using a five-point motor sco

42、re looking at strength and range of motion of all muscle groups.Our study showed that patients were initially very weak and debilitated, but had improvement in motor strength after a whole body rehabilitation program. All patients, initially bed bound, were able to sit and stand; and the majority (8

43、1%) were able to ambulate prior to discharge. It can be concluded from our study that whole body rehab should be an integral part of the care of a chronically ventilated patient. 我們先前對49個慢性機械通氣病人進行較強的整體康復(fù)的有效性進行評估和報告，他們都沒有神經(jīng)肌肉功能障礙，都接受了至少14天的機械通氣治療。物理康復(fù)是在在入住呼吸機康復(fù)病房就開始的，康復(fù)過程包括軀干控制，主動或被動的抵抗力訓(xùn)練及吸氣肌的訓(xùn)練（IM

44、T），每天從肌張力和肌肉運動的范圍方面通過5分運動總分對去適應(yīng)進行評估。我們的研究發(fā)現(xiàn)，在初始疲乏無力的患者經(jīng)過整體的康復(fù)訓(xùn)練后運動力量得到了提高。所有的病人初始創(chuàng)傷活動，到能夠坐 或者站立，大部分在出院前能夠自行走動，因此我們得出結(jié)論，整體的康復(fù)訓(xùn)練應(yīng)該成為慢性機械通氣患者的治療的一部分。The study also showed that there was significant correlation between upper limb motor strength and weaning time. This may be due to strengthening of the p

45、ectoralis muscles which_ have both inspiratory and expiratory functions. Past studies in different patient populations have shown an improvement in ventilatory mechanics (increased mean inspiratory pressure and expiratory reserve volume) with pectoralis muscle training. 研究還表明上肢運動張力和脫機時間存在重要的相關(guān)性，這些可能

46、歸因于胸肌的吸氣和呼氣功能的改善，在不同病人的先前的研究中已經(jīng)顯示胸肌訓(xùn)練的病人通氣的改善（包括平均吸氣壓力機呼氣末容積的增加）。Inspiratory Muscle Training 吸氣肌訓(xùn)練Strengthening the respiratory muscles by using IMT to facilitate weaning is also an important part of the rehabilitation program.通過吸氣肌功能訓(xùn)練從而利于病人脫機也是康復(fù)計劃過程中的重要部分。Using IMT to strengthen the respiratory m

47、uscles to facilitate weaning from mechanical ventilation is also an important part of the rehabilitation program.IMT uses devices with different size diameters to provide flow or pressure resistance. An example of an IMT device can be seen in Fig. 60-1 . The training program consists of the regular

48、application of increasingly higher degrees of inspiratory resistance for brief periodsFig. 60-1 of time. In the study by Martin et al, nine out of ten patients undergoing IMT weaned successfully. The studies previously discussed indicate that strengthening of limb skeletal muscles and the respirator

49、y muscles occurs with whole body rehabilitation, but is there an overall improvement in the patients functional independence? In a study looking at functional status,39 patients on prolonged mechanical ventilation were randomized to receive 6 weeks of physical therapy or standard care .Functional in

50、dependence measure was used to assess a patients ability to perform basic activities of daily living. A higher score meant more independence. At the end of 6 weeks, the physical therapy group had a significantly improved functional status compared to the control group that received standard care wit

51、hout dedicated physical therapy. 通過吸氣肌功能訓(xùn)練從而利于病人脫機也是康復(fù)計劃過程中的重要組成部分。應(yīng)用能夠提供不同氣流或壓力阻力的裝置對患者進行呼吸肌功能訓(xùn)練，在圖60-1中，我們可以看到一個呼吸肌訓(xùn)練的裝置。訓(xùn)練包括短期內(nèi)增加高度吸氣阻力的合理應(yīng)用。在Martin 等人的研究中，十分之九的病人通過呼吸肌功能訓(xùn)練成功脫機。先前的研究顯示上肢骨骼肌力及呼吸肌功能隨整體康復(fù)鍛煉的到加強，但是對病人功能的改善是否具有獨立性？在另一項從功能狀態(tài)的研究中. 39個延時脫機的病人隨機接受6周的物理或標準治療。應(yīng)用功能獨立自主量表對病人的基本日常生活活動進行評估。較高的評

52、分意味著著有更多的獨立性，在治療6周后，接受物理治療較單獨應(yīng)用保準治療患者功能狀態(tài)得到較高的改善。Early Tracheostomy to Facilitate Mobilization早期氣管切開利于患者活動Prolonged endotracheal intubation may result in injuries to the mouth, larynx, and trachea. Additionally, there are the risks of self-extubation, tube-malposition,and sinusitis; the physical dis

53、comfort associated with endotracheal intubation leads to the need for increased doses of sedative/ hypnotics and opioids. 長期氣管插管導(dǎo)致對口咽及氣管的損傷。此外，危險因素還有自主拔管，插管位置異常及鼻竇炎，氣管插管所致的身體不適將導(dǎo)致鎮(zhèn)靜/安眠藥物的應(yīng)用劑量增加。Tracheostomy is among the most commonly performed surgical procedures in critically illpatients requiring

54、ventilator support who fail to wean. Prolonged endotracheal intubation CASE STUDY: PART 3While in the ICU, R.S. participated in an aggressive whole body rehabilitation program. An initial therapy assessment was done; the patient progressed from the sitting position in bed to sitting at the edge of t

55、he bed. The therapist assessed response to movement, vital signs, and strength against gravity, trunk control, and balance. The patient then progressed to out of bed to chair and to ambulation. The therapy program also emphasized upper extremity strength to facilitate weaning. The respiratory therap

56、ists were involved during all sessions to assist with the portable ventilator during ambulation and to ensure the patient was comfortable. Vitals signs were monitored throughout and the FiO 2 was adjusted by the therapist to maintain the patients oxygen saturation.在ICU，R.S.參與了較為強烈（激進）的整體康復(fù)過程，對其進行了初始

57、的評估；病人先從在床上坐然后到在床邊坐起。治療學家對其運動、生命體征、對抗重力及軀干控制和平衡進行了評估。然后病人從床邊坐進一步到坐椅子，然后逐漸離床活動。這種治療計劃強調(diào)了上肢肌力在脫機中的重要性。呼吸治療學家參與患者治療的進程保證患者便攜式呼吸機在患者離床活動時的使用，以保證患者的舒適。時刻監(jiān)測患者的生命體征，適時調(diào)整吸入氧濃度以保證患者合適的血氧飽和度。may result in injuries to the mouth, larynx, and trachea. Additionally, there are the risks of self-extubation, tube-ma

58、lposition,and sinusitis; the physical discomfort associated with endotracheal intubation leads to the need for increased doses of sedative/ hypnotics and opioids. The practice of early tracheostomy is controversial because studies demonstrating unequivocal benefit are lacking. Rumbak et al found tha

59、t early tracheostomy (within 48 h) has advantages over delayed tracheostomy in critically ill patients who were predicted to require ventilation for greater than 14 days. Patients with early tracheostomy spent signifi -cantly less time in the ICU, less time on ventilatory support, and had signifi ca

60、ntly lower mortality and ventilator-associated pneumonia rates. Griffi ths et al performed a systematic review of the literature and found that early tracheostomy (07 days after admission to the ICU) resulted in a shorter duration of artifi cial ventilation and length-of-stay in the ICU. Freeman et