危重病人的康复

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1、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 2Whole Body Rehabilitatio

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

3、tion ProgramsSpecial ConsiderationsSummaryReview QuestionsAnswersReferencesAdditional Readings重症监护病人的康复章节梗概学习目标前言个案研究：第一部分重症监护病人康复内容个案研究：第二部分整体康复吸气力训练保持气道通畅，早期气管造口？个案研究：第三部分心理障碍语言障碍吞咽障碍 个案研究：第四部分睡眠障碍实施早期活动方案初始评估t专门早期活动病房？康复策略康复程序特别考虑摘要复习问题答案参考文献附加读物LEARNING OBJECTIVESAfter studying this chapter, you

4、 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 in the ICU. Develop a

5、 systematic approach for implementing early mobility of ventilated patients. Execute effective measures to prevent complications in ventilated patients in the ICU.学习目标通过本章节，你应该：理解在重症监护病人康复实施成功中团队合作、护理内容和护理过程的重要性。理解影响重症监护病人康复的主要因素：神经肌肉、呼吸及心理状态。为机械通气患者制定实施早期活动的系统化的方法。采取有效的措施预防重症监护室机械通气患者并发症。INTRODUCTI

6、ON介绍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.康复的主要目的是在病人病情允许的范围内提高患者的身体、心理及社会功能。呼吸机疲劳无力是病人功能持续受限的原因。下边左侧T

7、he 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 associated with weakness,

8、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监护的全面（全球？）进步提高危重病人的生存率。生存率的提高导致入住ICU时间延长和认知各种各样的继发并发症。ICU入住时间延长及慢性危重症和患者的身体虚弱、不适应？、各种功能及生活质量降低相关。康复的目的是在病人

9、条件身体允许的范围内？提高患者身体、心理及社会功能。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 reasons. 第60章 重症监护室病人的康复 1

10、193CASE STUDY: PART 1 个案研究：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 was 37,pulse 136, blood

11、 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 and transferred to the

12、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 sedation was weaned. Ear

13、ly 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.S.是一个54岁的非洲裔美国男性患者，有

14、严重的COPD病史。入院时，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综合征，呼吸频率为37次/分，脉搏为136次/分，血压为100/62mmHg，经皮血氧饱和度为82%，体检发现，R.S.呼吸功增加及应用辅助呼吸机呼吸，气体入肺量减少,X线示肺过度膨胀。,病人立即行气管插管并送往监护室，住院期间在应用呼吸机辅助通气时因COPD急性加重应用了大量的激素，为了保持血氧饱和度在90%以上，应用了镇静药物和肌松药物,随着病人病情的改善，系统应用激素量减少及镇静剂逐渐停用,在他早期的住院时期，这个病人因为它的医学不稳定性物理疗法不作为首选,目前，护士每2小时就给该患者翻一次身

15、。给患者应用长筒靴及手夹板以避免关节挛缩。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, even though their men

16、tal 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. 急性肺损伤和急性呼吸窘迫综合征是在ICU中经常碰到，它长期的心理和功能紊乱相关。在回顾一个109个急性呼吸窘迫综合征存活患者的研究中，呼吸机疲劳及身体虚弱无力是病人持续性功能障碍主要原因。这些功能限制在预计6分钟步行实验较低的病人中更显著。机械通气时间延长的幸存者都经历了生活质

17、量的损害，即使他们的身体健康得到康复，长期卧床会带来有害结果，ICU长期住院病人迫切需要康复。REHABILITATIVE ISSUES IN THE ICU PATIENTICU病人康复内容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 neuromuscular blocking agents(se

18、e 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. 长期卧床会出现骨骼肌萎缩，无力及骨骼肌纤维类型的改变。危重症病肌病的最危险的因素是应用糖皮质激素和神经肌肉阻断剂。所有的入住ICU的病人都会因需要卧床而表现出不适应及遭受代谢性质的基础疾病的困扰。在右边It is not completely clear why

19、 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. It has been found that

20、 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. A study that evaluate

21、d 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中病人身体虚弱的原因上不完全清楚。去条件化的结果？主要来自空间计划的健康人群长期卧床及低重力研究。长期卧床

22、会出现骨骼肌萎缩，无力及骨骼肌纤维类型的改变。研究表明，即使短时期卧床也会影响骨骼肌的功能，在卧床14天和35患者中，骨骼肌力量相应下降了15%和25%。大腿和腓肠肌容积也显著下降了。 骨骼肌的废用同时也发生在膈肌 。一项评估18-69小时机械通气患者骨骼肌活检的研究显示无论是快或慢收缩纤维存在萎缩情况这种虚弱导致病人功能状态的降低及影响患者脱机。Patients in the ICU are also at risk for developing neuromuscular weakness due to ICU treatments used to treat acute exacerba

23、tions 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 usually reversible over

24、 weeks to months, but is associated with a prolonged hospital course.具有基础疾病的病人在急性加重期在ICU治疗中具有很高的发展为神经肌肉无力的可能性。危重症病肌病的最大危险因素是糖皮质激素和神经肌肉阻断剂的应用（见58章）。特点是肌肉无力和脱机困难。在数周到数月内危重症病肌病通常是可逆的。但是和住院时间增加相关。Critical illness polyneuropathy (CIP) is another cause of neuromuscular weakness encountered in the ICU and

25、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，导致神经肌肉无力另一重要因素是危重症病多神经病，此病在ICU中很常见且容易和危重症病肌病相混淆。体格检查时有很多相似之处，包括感觉神经功能障碍及深反射减退，（危重症病多神经病）和重症败血症

26、相关。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 conditions and intensive reh

27、abilitation.病人可能会发展为影响尺骨和腓骨神经的压迫性神经病，合适的体位和频繁的转动可能会限制这些神经疾病的发展（范围）。对所有继发功能障碍的治疗来源于对基础医疗疾病状况的治疗和重症监护病人的康复。 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 admission. ICU patients who r

28、equire 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 rehabilitation.所有的入住ICU的病人

29、都会因卧床而遭受不适应及基础疾病所遭受的代谢的困扰。需要镇静、神经肌肉阻断剂、糖皮质激素及机械通气、败血症、休克或肾脏功能衰竭的病人代表了高度危险人群，需要重症监护，多学科合作的整体康复。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, but also mitigates th

30、e complications of immobility, such as deep venous thrombosis, CASE STUDY: PART 2 个案研究：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 daily for any contra

31、indications 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 systemic glucocorticoi

32、ds 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 respiratory and nonres

33、piratory 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.持续的呼吸机依赖性呼吸衰竭，他进行了气管切开并放置了舒适的利于活动的管道.在ICU中接受了物理治疗，每天对其有无物理治疗的禁忌症进行评估，护士一天三

34、次对对其进行翻身或者活动。每天患者坐位时间3次，每次20分钟，患者重度虚弱，因全身应用糖皮质激素及神经肌肉阻断剂而发生危重症病肌病.病人病情进展，要求每天坐在椅子上至少每天45分钟，病人不能脱机，转入呼吸康复病房做进一步治疗，病人符合机械及非机械通气的标准入住康复病房，对其进行气管造口，分泌物管理，稳定的呼吸机以及胃空肠造口保证患者的营养。pulmonary embolism, and decubitus ulcers. The ability to speak and eat also has a benefit on overall psychological well-being. Th

35、ese issues are extremely important and therapy should be instituted as early as feasible when caring for chronically ventilated patients. ICU病人是一种特殊的病人群体，活动能够提高患者的生活质量，而且还能减轻或缓和制动所导致的并发症。如，深静脉血栓形成，肺栓塞，褥疮，说和吃的能力对心理健康状态有益，对慢性需要护理的机械通气的病人非常重要，应该尽早实施（活动）。Many studies have shown that patients doing arm a

36、nd 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 in ventilatory muscle

37、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 was an increased exp

38、iratory 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. 许多研究也已经表明患者尽早进行肢体锻炼能够提高呼吸肌的力量和耐力，减少呼吸急促的发生，提高生活质量；keen等研究发现，囊性纤维化病人进行较强烈的（四肢）锻炼，可以使他们的呼

39、吸肌耐力提高57%， Clanton et al等研究发现，和相匹配年龄组的人相比，进行同等训练的游泳的（患者）平均吸气压升高25%，呼吸机耐力得到100%的提高。Estenne 等发现，如果C5-C6四肢截瘫的病人经历6周的同等胸大肌的训练，那么他们的呼气末容积就会增加。这些研究激发大家在上肢训练在康复过程中的兴趣。WHOLE BODY REHABILITATION整体康复Whole body rehab should be an integral part of the care of a chronically ventilated patient. Upper limb motor s

40、trength correlates inversely with weaning time. 整体康复训练应该成为慢性机械通气病人治疗中的一部分。上肢肌力和脱机长短呈负相关，。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 neuromuscular disorders.

41、 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 score looking at strengt

42、h 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 (81%) were able to ambu

43、late 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. 我们先前对49个慢性机械通气病人进行较强的整体康复的有效性进行评估和报告，他们都没有神经肌肉功能障碍，都接受了至少14天的机械通气治疗。物理康复是在在入住呼吸机康复病房就开始的，康复过程包括躯干控制，主动或被动的抵抗力训练及吸气肌的训练（IMT），每天从肌张力和肌肉运动的范围方面通过

44、5分运动总分对去适应进行评估。我们的研究发现，在初始疲乏无力的患者经过整体的康复训练后运动力量得到了提高。所有的病人初始创伤活动，到能够坐 或者站立，大部分在出院前能够自行走动，因此我们得出结论，整体的康复训练应该成为慢性机械通气患者的治疗的一部分。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 pectoralis muscles whi

45、ch_ 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. 研究还表明上肢运动张力和脱机时间存在重要的相关性，这些可能归因于胸肌的吸气和呼气功能的改善，在不同病

46、人的先前的研究中已经显示胸肌训练的病人通气的改善（包括平均吸气压力机呼气末容积的增加）。Inspiratory Muscle Training 吸气肌训练Strengthening the respiratory muscles by using IMT to facilitate weaning is also an important part of the rehabilitation program.通过吸气肌功能训练从而利于病人脱机也是康复计划过程中的重要部分。Using IMT to strengthen the respiratory muscles to facilitate

47、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 application of increa

48、singly 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 respiratory muscles occurs with

49、 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 independence measure wa

50、s 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 without dedicated physic

51、al therapy. 通过吸气肌功能训练从而利于病人脱机也是康复计划过程中的重要组成部分。应用能够提供不同气流或压力阻力的装置对患者进行呼吸肌功能训练，在图60-1中，我们可以看到一个呼吸肌训练的装置。训练包括短期内增加高度吸气阻力的合理应用。在Martin 等人的研究中，十分之九的病人通过呼吸肌功能训练成功脱机。先前的研究显示上肢骨骼肌力及呼吸肌功能随整体康复锻炼的到加强，但是对病人功能的改善是否具有独立性？在另一项从功能状态的研究中. 39个延时脱机的病人随机接受6周的物理或标准治疗。应用功能独立自主量表对病人的基本日常生活活动进行评估。较高的评分意味着着有更多的独立性，在治疗6周后，接

52、受物理治疗较单独应用保准治疗患者功能状态得到较高的改善。Early Tracheostomy to Facilitate Mobilization早期气管切开利于患者活动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 discomfort associated wi

53、th endotracheal intubation leads to the need for increased doses of sedative/ hypnotics and opioids. 长期气管插管导致对口咽及气管的损伤。此外，危险因素还有自主拔管，插管位置异常及鼻窦炎，气管插管所致的身体不适将导致镇静/安眠药物的应用剂量增加。Tracheostomy is among the most commonly performed surgical procedures in critically illpatients requiring ventilator support wh

54、o 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 the bed. The therapist

55、 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 therapists were involved du

56、ring 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.参与了较为强烈（激进）的整体康复过程，对其进行了初始的评估；病人先从在床上坐然后到在床边坐起。

57、治疗学家对其运动、生命体征、对抗重力及躯干控制和平衡进行了评估。然后病人从床边坐进一步到坐椅子，然后逐渐离床活动。这种治疗计划强调了上肢肌力在脱机中的重要性。呼吸治疗学家参与患者治疗的进程保证患者便携式呼吸机在患者离床活动时的使用，以保证患者的舒适。时刻监测患者的生命体征，适时调整吸入氧浓度以保证患者合适的血氧饱和度。may result in injuries to the mouth, larynx, and trachea. Additionally, there are the risks of self-extubation, tube-malposition,and sinusit

58、is; 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 that early tracheostomy

59、(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 cantly lower mortality

60、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 al performed an obser

61、vational study, which found that the timing of tracheostomy appeared to be signifi cantly associated with the duration of mechanical ventilation,ICU length-of-stay, and hospital length-of-stay, and recommended further study. 脱机失败需要通气支持的危重症病人，气管切开是常用的一种外科方法。长期气管插管导致对口咽及气管的损伤。此外，危险因素还有自主拔管，插管位置异常及鼻窦炎，

62、气管插管所致的身体不适将导致镇静/安眠药物的应用剂量增加。早期气管造口术还存在争议，因为研究还缺乏有益的相应的证据。 Rumbak 等研究发现，对预期气管插管查过14天的患者，在48小时内插管比晚期插管更能获益更大，早期气管造口病人入住ICU时间缩短，通气支持时间缩短，死亡率下降，通气相关肺炎发生率也显著下降 。 Griffi ths 等通过文献系统综述发现在入住ICU早期（0-7天）行气管造口的患者机械通气时间及入住ICU的时间明显缩短。Freeman 等通过观察行研究发现及时的气管造口术能够显著的降低患者机械通气时间，入住ICU的时间及住院总的时间，他们建议更进一步的研究。The over

63、all benefit of a tracheostomy is that it provides improved comfort, mobility, and speech. These functions facilitate rehabilitation and improvement in quality-of-life. 早期气管造口术能够提高患者的舒适度，早日活动及说话的声音质量，这些功能的改善能够使患者更好的康复，提高患者的生活质量It is unclear if early tracheostomy facilitates early mobilization. The se

64、lection of tracheostomy tubes should be individualized for the patient. Small (4 or 6 mm in diameter), cuffless,or metal tubes provide the greatest comfort. Fenestrated tubes may improve voice quality,and cuffed tubes should be used in patients with swallowing dysfunction. 目前尚不清楚早期造口能否使病人早日活动。病人的气管造

65、口术套管的选择应该视病人情况选择个体化方案。小的（直径4或6mm）或者金属套管具有较好的舒适性。具有吞咽功能障碍的病人应选择带窗的套管或者袖珍型套管，这样可以提高患者说话的声音质量。 The overall benefit of a tracheostomy is that it provides improved comfort, mobility, and speech. These functions facilitate rehabilitation and improvement in quality-of-life. 早期气管造口术能够提高患者的舒适度，早日活动及说话的声音质量，这些功能的改善能够使患者更好的康复，提高患者的生活质量。PSYCHOLOGICAL DYSFUNCTION 心理障碍There is a high incidence of