孫 燕

圍術(shù)期行呼吸功能鍛煉對(duì)食管癌患者咳嗽排痰及預(yù)后轉(zhuǎn)歸的影響

孫 燕

目的 探討圍術(shù)期行呼吸功能鍛煉對(duì)食管癌患者咳嗽排痰及預(yù)后轉(zhuǎn)歸的影響。方法 選擇我科接受開胸手術(shù)治療的高齡食管癌患者122 例，隨機(jī)分為觀察組62例和對(duì)照組60例。對(duì)照組圍術(shù)期行傳統(tǒng)的呼吸功能鍛煉。觀察組實(shí)施負(fù)荷腹式呼吸功能鍛煉。比較兩組實(shí)施呼吸功能鍛煉后24h咳嗽次數(shù)和排痰量、肺功能的改善情況、術(shù)后肺部并發(fā)癥、胸腔引流管拔管時(shí)間及住院時(shí)間。結(jié)果 觀察組行呼吸功能鍛煉后咳嗽次數(shù)和排痰量顯著少于對(duì)照組,血氧飽和度顯著高于對(duì)照組(P<0.05)。觀察組行呼吸功能鍛煉后呼吸次數(shù)、術(shù)后肺部并發(fā)癥發(fā)生率、胸腔引流管拔管時(shí)間及住院時(shí)間顯著低于對(duì)照組(P<0.05)。結(jié)論 圍術(shù)期行呼吸功能鍛煉對(duì)食管癌患者咳嗽排痰以及預(yù)后轉(zhuǎn)歸有顯著改善作用，有助于改善患者的肺功能，縮短住院時(shí)間和康復(fù)時(shí)間。

食管腫瘤；圍手術(shù)期；呼吸功能鍛煉

目前，中晚期食管癌患者的臨床治療手段以手術(shù)切除為主要選擇[1]。由于開胸手術(shù)對(duì)患側(cè)肺有長(zhǎng)時(shí)間的牽拉和擠壓，易造成患側(cè)肺部損傷，且圍術(shù)期容易造成膈肌損傷和胃膨脹，胸腔積氣、積液，其限制肺的自由膨脹，壓縮肺的有效呼吸面積，造成患者呼吸功能顯著下降[2]。同時(shí)，高齡患者肺和氣道的生理功能均有一定程度降低[3]，故圍術(shù)期呼吸功能鍛煉對(duì)于患者的康復(fù)進(jìn)程和預(yù)后轉(zhuǎn)歸非常重要[4，5]。本研究對(duì)高齡食管癌患者進(jìn)行圍術(shù)期呼吸功能鍛煉，取得了滿意的效果，現(xiàn)報(bào)告如下。

1 資料與方法

1.1 一般資料

選擇2012 年1月～2015年12月在本院接受開胸手術(shù)治療的高齡食管癌患者122 例。納入標(biāo)準(zhǔn)：(1)年齡65～85歲；(2)確診食管癌患者；(3) ASA分級(jí)Ⅰ～Ⅱ級(jí)。(4)患者簽署知情同意書。排除標(biāo)準(zhǔn)：(1)嚴(yán)重的心腦血管等疾病患者；(2)惡性腫瘤患者；(3)精神疾病患者；(4)肝腎功能不全患者。將患者隨機(jī)分為觀察組62例和對(duì)照組60例。對(duì)照組男性40例，女性20 例，平均年齡(66.44±6.29)歲。觀察組男性43例，女性19例，平均年齡(67.18±5.98)歲。兩組一般資料比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，具有可比性。

1.2 方法

對(duì)照組實(shí)施傳統(tǒng)呼吸功能鍛煉。觀察組實(shí)施負(fù)荷腹式呼吸功能鍛煉。呼吸功能鍛煉啟動(dòng)時(shí)間應(yīng)在實(shí)施術(shù)前2周開始。對(duì)于擬行食管癌擴(kuò)大根治術(shù)，且呼吸功能較差的患者，其術(shù)前鍛煉應(yīng)盡可能延長(zhǎng)。術(shù)后鍛煉應(yīng)在手術(shù)結(jié)束后48h內(nèi)開始實(shí)施。參與該呼吸功能鍛煉計(jì)劃的患者必須在術(shù)前已經(jīng)充分訓(xùn)練的基礎(chǔ)上實(shí)施鍛煉，且需要堅(jiān)持鍛煉至康復(fù)為止。

1.2.1 術(shù)前實(shí)施腹式加壓呼吸訓(xùn)練 患者取平臥位或半臥位，雙手置于上腹部或前胸部，讓腹部肌肉松弛。同時(shí)，在患者上腹部置1 個(gè)沙袋，從而增加患者的腹壓。囑患者用鼻吸氣，令其隆起上腹部對(duì)抗所壓沙袋造成的壓力，繼而縮唇呼氣，緩緩下沉上腹部。吸呼比按1：3。鍛煉持續(xù)5min，并且緩慢延長(zhǎng)至2h。沙袋的重量從2 kg 增加至患者無(wú)法耐受為止。

1.2.2 術(shù)后指導(dǎo)患者使用器械實(shí)施呼吸功能鍛煉 患者取端坐位，一手持三球儀呼吸功能鍛煉器，一手扶螺旋管緩慢吸氣，利用空氣將三球儀內(nèi)的球向上方推動(dòng)。每天鍛煉3 次，每次15 min，直至患者感疲勞為止。1.2.3 有效咳嗽訓(xùn)練 囑患者進(jìn)行深吸氣后再屏氣，令其聲門緊閉，使膈肌抬高，讓其胸內(nèi)壓增加，收縮肋間肌后咳嗽，打開聲門，使氣體迅速?zèng)_出。每天鍛煉3 次，每次15min，同時(shí)配合霧化吸入。

1.3 觀察指標(biāo)

比較兩組實(shí)施后血氧飽和度、呼吸次數(shù)、24h咳嗽次數(shù)和排痰量、肺部并發(fā)癥、胸腔引流管拔管時(shí)間及住院時(shí)間。

1.4 統(tǒng)計(jì)學(xué)方法

2 結(jié)果

2.1 兩組呼吸功能鍛煉后咳嗽次數(shù)、排痰量的比較，表1

表1 兩組呼吸功能鍛煉后咳嗽次數(shù)、排痰量的比較±S)

2.2 兩組呼吸功能鍛煉后血氧飽和度及呼吸次數(shù)的比較，表2

表2 兩組呼吸功能鍛煉后血氧飽和度及呼吸次數(shù)的比較±S)

2.3 兩組術(shù)后胸腔引流管拔管時(shí)間及住院時(shí)間的比較，表3

表3 兩組術(shù)后胸腔引流管拔管時(shí)間及住院時(shí)間的比較±S)

2.4 兩組術(shù)后肺部并發(fā)癥發(fā)生率的比較

對(duì)照組發(fā)生肺部并發(fā)癥9例，發(fā)生率為15.0%。觀察組發(fā)生肺部并發(fā)癥2例，發(fā)生率為3.2%，兩組比較差異有統(tǒng)計(jì)學(xué)意義(χ2=5.154,P<0.05)。

3 討論

食管癌手術(shù)雖沒有直接切除患者的肺葉組織，但開胸手術(shù)會(huì)破壞胸廓的完整性，顯著損傷患者的肋間肌，嚴(yán)重影響患側(cè)的肺功能。因此，在圍術(shù)期采取有針對(duì)性的呼吸功能鍛煉，幫助患者術(shù)后24 h內(nèi)盡可能徹底地清除呼吸道內(nèi)的分泌物，確?；颊吆粑劳〞?。本研究結(jié)果顯示，觀察組行呼吸功能鍛煉后咳嗽次數(shù)及排痰量少于對(duì)照組(P<0.05)。

圍術(shù)期應(yīng)實(shí)施沙袋加壓下的負(fù)荷腹式呼吸功能鍛煉，其目的是改變患者的呼吸方式，使腹式呼吸能夠更加有效地彌補(bǔ)胸部存在病變時(shí)胸式呼吸的不足[6,7]。采用加壓式腹式呼吸功能鍛煉措施，能使吸氣肌和呼氣肌都進(jìn)行主動(dòng)收縮。呼吸功能鍛煉中呼氣肌的主動(dòng)收縮可以增強(qiáng)肋間肌、腹肌和膈肌的運(yùn)動(dòng)。該鍛煉方式可協(xié)助患者改善其氣道和肺功能，促進(jìn)以經(jīng)濟(jì)省力的模式進(jìn)行呼吸，從而獲得有效的肺泡通氣與肺部氣體交換[8,9]。本研究結(jié)果顯示，觀察組呼吸次數(shù)顯著少于對(duì)照組，血氧飽和度顯著高于對(duì)照組(P<0.05),表明負(fù)荷腹式呼吸功能鍛煉能有效改善食管癌患者的氣道和肺功能，提高患者的手術(shù)耐受性和預(yù)后轉(zhuǎn)歸的預(yù)期程度。

臨床經(jīng)驗(yàn)表明[10，11]，接受胸部手術(shù)的患者，其本身疾病即對(duì)呼吸有一定影響，加之麻醉和手術(shù)的應(yīng)激損害，多會(huì)誘發(fā)呼吸功能下降。本研究結(jié)果顯示，觀察組術(shù)后并發(fā)癥發(fā)生率、胸腔引流管拔管時(shí)間及住院時(shí)間低于對(duì)照組(P<0.05)，表明正確合理的呼吸功能鍛煉是改善患者圍術(shù)期呼吸功能，減少并發(fā)癥的必要措施之一。傳統(tǒng)的呼吸功能鍛煉方法準(zhǔn)確性和實(shí)際效果均難掌控，患者多因疼痛而難以長(zhǎng)期堅(jiān)持進(jìn)行。呼吸功能鍛煉器和加壓腹式呼吸的新型圍術(shù)期呼吸訓(xùn)練彌補(bǔ)傳統(tǒng)呼吸功能鍛煉方法的弊端，可以顯著減輕術(shù)后疼痛、降低肺部并發(fā)癥發(fā)生率、縮短患者的康復(fù)時(shí)間。

護(hù)理人員應(yīng)對(duì)患者實(shí)施呼吸功能鍛煉的指導(dǎo)，并監(jiān)督鍛煉的時(shí)間、評(píng)估鍛煉的效果。因此，本項(xiàng)措施必須重視護(hù)士的規(guī)范化培訓(xùn)，統(tǒng)一呼吸功能鍛煉的動(dòng)作、程序、技巧和工作原理。此外，研究實(shí)踐表明，該項(xiàng)鍛煉中要特別注意控制吸氣的速度，并且需要將吸呼比調(diào)控在1∶3，同時(shí)不宜操之過(guò)急，防止呼吸肌過(guò)度疲勞的癥狀出現(xiàn)。

綜上所述，食管癌患者圍術(shù)期行呼吸功能鍛煉對(duì)食管癌患者咳嗽排痰以及預(yù)后轉(zhuǎn)歸有顯著改善作用，有助于改善患者的肺功能，縮短住院時(shí)間和康復(fù)時(shí)間。

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The Influence of Respiratory Function Exercise on the Cough and Sputum Discharge and Prognosis of Esophageal Cancer Patients in Operation

SUN Yan

(Songjiang Center Hospital, Shanghai 201600)

Objective To explore the influence of respiratory function exercise on the sputum excretion and prognosis of esophageal cancer patients in operation. Methods 122 cases of elderly patients with esophageal cancer were selected and divided into observation group (62 cases) and control group (60 cases). The patients in the control group were treated with traditional respiratory function exercise during the operative period. The observation group was treated with the method of increasing the load of breathing during the operative period. Compared the number of cough and sputum, the improvement of pulmonary function, postoperative pulmonary complications, chest drainage tube extubation time and length of stay with the 24 hours after the implementation of respiratory function exercise. Results In the observation group, the number of cough and sputum discharge was significantly higher than that of the control group. The blood oxygen saturation of the observation group was significantly higher than that of the control group (P<0.05). The respiratory rate of the observation group was significantly lower than that of the control group (P<0.05). The time and length of hospital stay in the observation group were significantly lower than those in the control group (P<0.05). Conclusion The respiratory function exercise during the operative period of esophageal cancer patients has a significant improvement on the cough and sputum excretion and prognosis of esophageal cancer patients. The measure is helpful in improving the patient's lung function, thereby reducing the length of stay and recovery time.

esophageal neoplasms；perioperative nursing；respiratory functional exercise

10.3969/j.issn.1671-8933.2017.01.009

201600 上海市松江中心醫(yī)院 上海

孫燕，女，本科，護(hù)士

R735.1；R473.6

2016-11-02)