血液透析管路29

1、Evidence-Based Nursing萬芳醫(yī)院戴仲宜 鄧蕙蘭 趙月紅 蘇慧娟 王怡文 翁純瑩 陳可欣比較不同噴霧治療溶液對呼吸道感染病童治療成效之影響報告大綱動機及重要性實證護理五大步驟結(jié)果與討論心得與未來護理方向參考資料Step 1: 整理出一個可以 答復(fù)的問題 Step 2: 尋找文獻證據(jù) Step 3: 嚴(yán)格評讀文獻Step 4: 應(yīng)用於病人身上 Step 5: 對過程進行稽核動機及重要性小兒科病房住院病童以呼吸道疾病佔最多( 50 %)兒童呼吸道生理特徵呼吸道管徑窄小 / 自咳能力有限 / 無法配合治療呼吸道感染住院病童常規(guī)施以噴霧治療( 80 %)噴霧治療目的(Aerosol

2、Therapy) (劉、朱，2002 )軟化分泌物,使呼吸道內(nèi)分泌物溶液排出,促進呼吸道的通暢引發(fā)咳嗽,獲取痰液標(biāo)本經(jīng)由呼吸道給藥本院與其他標(biāo)竿醫(yī)院比較核對醫(yī)囑, 確定稀釋溶液,頻率及時間準(zhǔn)備噴霧器及用物, 測試噴霧功能O2 flow 6-8 l/min,確認霧氣產(chǎn)生核對及準(zhǔn)備病人, 評估呼吸音坐起45-90度, 指導(dǎo)深而慢的呼吸,閉氣,再吐出噴霧吸入治療15分鐘噴霧量減少時, 輕拍噴霧杯, 使杯壁上的藥水掉落再噴出,以免影響劑量紀(jì)錄病童反應(yīng), 評估呼吸音Inhalation流程與其他標(biāo)竿醫(yī)院比較Evidence-Based Clinical Practice Guidelines針對Broc

3、hiolitis呼吸道的照護療法可能有幫忙的餵食前給予噴霧治療 (level D)suction(level D)做了也沒多大用處的CPT(level Ib / Level D)Cool mist therapy (level D)Saline aerosol therapy. (level Ib)本次EBN主要目的審視噴霧治療方式是否影響呼吸道感染病童之治療成效噴霧治療的溶液 / 藥物O2 flow大小flow太大, 發(fā)出聲音造成病童害怕,哭鬧而影響治療噴霧治療的時間 因病童哭鬧,難以配合完整療程噴霧治療的溶液 / 藥物實施實證護理五大步驟Step 1: 整理出一個可以答復(fù)的問題 Step

4、2: 尋找文獻證據(jù) Step 3: 嚴(yán)格評讀文獻Step 4: 應(yīng)用於病人身上 Step 5: 對過程進行稽核Step 1: 臨床問題比較不同噴霧治療溶液對呼吸道感染病童治療成效之影響PatientOutcomeComparision Intervention名詞定義 1噴霧治療 (next)不同溶液蒸餾水 V.S 0.9% 生理食鹽水呼吸道感染病童診斷為pneumonia, Bronchopneumonia(不論感染原)年齡於7歲以下之病童治療成效指痰液稀釋/ 排出 (家屬主訴/ 護理人員觀察)呼吸音改善 (醫(yī)師或護理人員聽診)名詞定義 2氣霧式吸入器(霧化器) ( Jet Nebulize

5、r )原理 (劉、朱，2002 )依白努力定律(Bernoullis priniciple),利用氧氣或壓縮空氣經(jīng)由一個細小管子的噴出口時, 所產(chǎn)生的負壓, 將置於霧化器內(nèi)的藥水打成細小顆粒, 約25 以供吸入霧器治療優(yōu)缺點 (顏, 2001; Uma Maheswari, 2001 )缺點優(yōu)點耗時,所需設(shè)備多昂貴, 攜帶不便易污染嬰兒可使用不需吸入技巧可給高劑量名詞定義 3噴霧治療設(shè)備氧氣導(dǎo)管噴霧杯氧氣面罩73300Nebulizer Bowl83360Jet Nebulizer Bowl93391T Piece103392Mouth Piece1134502Oxygen Tubing 2

6、Metre文獻查證 (1)噴霧治療的理論基礎(chǔ) (黃、張，2002 )使用最低的藥物劑量, 達到組織的治療效果及最低的副作用藥物直接作用到標(biāo)的器官能快速產(chǎn)生作用執(zhí)行噴霧治療時需考慮以最適當(dāng)?shù)乃幬飫┝縼磉_到最正確的治療效果文獻查證 (2)噴霧治療 (Aerosol Therapy) 2適應(yīng)癥(劉、朱，2002 )吸入過乾燥的氣體造成呼吸道濕氣缺乏因為吸入過乾燥的氣體造成鼻黏膜或肺黏膜的脫水, 常見於手術(shù)後的病人因為使用人工氣道, 造成氣體未經(jīng)過鼻腔濕氣缺乏某些本身痰液就很乾的病人,如:慢性支氣管炎文獻查證 (3)噴霧治療 (Aerosol Therapy) 3危險性 (劉、朱，2002 ; Uma

7、 Maheswari, 2001 )原本乾黏的痰,因噴霧吸水膨脹, 造成呼吸道阻塞(Aiwway obstruction)因吸入微小的氣霧粒子造成支氣管痙攣(Bronchospasm)持續(xù)給予噴霧治療時造成呼吸道水分過多(Over hydration) ,尤其嬰兒感染(Infection)使用熱的噴霧治療不慎,導(dǎo)致燙傷(Thermal injury)文獻查證 (4)影響噴霧在肺內(nèi)沉積的主要因素霧氣微粒大小及霧氣輸送進入的量最正確微粒分子為 2um藥物不可預(yù)期的流失年齡小，無法使用口含式吸入器，需使用O2 mask ，經(jīng)鼻孔吸入之藥物易形成不穩(wěn)定的微粒嬰幼兒呼吸道直徑較小，較小的口咽，會使傳送到

8、下氣道的霧氣減少成人口咽可通過35 %的劑量;小孩僅15 % 文獻查證 (6)病童呼吸型態(tài)及疾病的根本變化嬰幼兒呼吸速率較快，藥物沉積在上呼吸道較多霧氣沉積在中心氣道，易造成感染、水腫 、黏液多、 支氣管痙攣、氣道變形 新生兒及幼兒吸入藥物後肺部之分布有許多限制，霧氣傳送的效力及穩(wěn)定性嬰兒 兒童 成人病童本身對噴霧治療的的接受度、 順從性任何年齡層的兒童，吸氣流速常有劇烈改變， 尤其是哭泣的嬰兒，因而減少霧氣到達肺部的量Step 2: 尋找文獻證據(jù) EBMSEARCH FRAMEWORK搜尋實證文獻之架構(gòu)Evidence-based Medicine ReviewNGCPubMedSystem

9、atic Review(National Guide Clearinghouse)MEDLINE全文電子期刊政府研究資料全國碩博士論文館際合作搜尋策略CochraneLibrary尋找證據(jù)文獻之過程 1關(guān)鍵字： aerosol therapy (1篇) 相關(guān)資料 0 篇 nebulizer ( 篇) 相關(guān)資料 0 篇 steam inhalation (6篇) 相關(guān)資料 0 篇尋找證據(jù)文獻之過程 2關(guān)鍵字： aerosol therapy (40篇) 相關(guān)資料 1 篇 nebulizer (40篇) 相關(guān)資料 1 篇 steam inhalation (1篇) 相關(guān)資料 1 篇尋找證據(jù)文獻之過

10、程 3關(guān)鍵字： aerosol therapy (18篇) 相關(guān)資料 3 篇 nebulizer (77篇) 相關(guān)資料 2篇 steam inhalation (1篇) 相關(guān)資料 0 篇MEDLINE尋找證據(jù)文獻之過程 4關(guān)鍵字： aerosol therapy (1268篇) 限制2年 ( 451篇) inhalation (6篇) 相關(guān)資料 0 篇Step 3: 嚴(yán)格評讀文獻The Evidence Pyramid臨床研究證據(jù)等級研究證據(jù)的價值取決於其品質(zhì)及效度評讀文獻的黃金標(biāo)準(zhǔn)中,以雙盲隨機對照臨床試驗得出的結(jié)果為最正確證據(jù)等級實證醫(yī)學(xué)之級別(美國健康照護政策及研究部)-US Agenc

11、y for Health Care Policy and Research Classification (AHCPR, 1992)實證級別描 述I a收集若干較具規(guī)模具有隨機取樣及控制組(randomized controlled trials, RCT)對照所作之實證研究(Mata-analysis)I b至少由一組有良好之隨機化及控制組(RCT)之實驗研究II a有控制組, 但不屬於隨機化II b至少有類似或接近完整之實驗方法(quasi-experimental study)之實證研究III由描述性之實證研究,如:比較方法, 相關(guān)問題之探討, 或個案報告IV由專家會議所發(fā)表之報告或?qū)＜?/p>

12、之意見文獻推薦等級 (Grades of Recommendation of Effectiveness )Develop by JBIGrade AEffectiveness established to a degree that merits applicationGrade BEffectiveness established to a degree that suggests applicationGrade CEffectiveness established to a degree that warrants consideration of applying the findi

13、ngGrade DEffectiveness established to a limited degreeGrade EEffectiveness not established文獻評讀摘要 (1-1)文章主題氣喘孩童的吸入療法作者顏大欽出處臺兒醫(yī)誌 (2001), 42, 50-55文獻評讀摘要 (1-2)內(nèi)容摘要霧化器一般建議設(shè)定(顏大欽, 2001)Gas flow rate: 68 l /min Nebulizing volume: 45 c.c.Slow and deep breathing patternMouth breathing better than nose breat

14、hing文獻等級【IV】 文獻評讀摘要 (2-1)文章主題霧器治療 (Aerosol Therapy)作者劉金蓉 朱家成出處呼吸治療 (2002), 1(1), 81-101文獻評讀摘要 (2-2)內(nèi)容摘要高張溶液的刺激性較高, 對於敏感氣道的病患, 容易引發(fā)支氣管痙攣文獻等級【IV】 文獻評讀摘要 (3-1)文章主題AEROSOL THERAPY作者Uma Maheswari出處Pulmonary & Critical Care Bulletin Vol. VII, No. 3, July 15, 2001文獻評讀摘要 (3-2)內(nèi)容摘要Bland aerosols include heat

15、ed or cooled sterile water and saline.These aerosols are mainly used in treatment of upper airway disease, humidification of the bypassed airway and sputum induction.Size (MMAD u) Site of deposition 100uFiltered by the upper respiratory tract Size (MMAD u) Site of deposition 100uFiltered by the uppe

16、r respiratory tract Size (MMAD u)Site of deposition0.5 - 2uAlveoli2 - 5uBronchi and bronchioles5 - 100uMouth, nose and upper airway 100uFiltered by the upper respiratory tract文獻評讀摘要 (3-3)Higher flow rates cause turbulent flow, aerosol fragmentation and failure of deposition.Higher respiratory rates

17、are associated with higher flow rates and poor aerosol deliveryHence a slow, deep breath with an end inspiratory breath - hold of 5-10 seconds is optimal for aerosol impaction in the bronchi and bronchioles.文獻評讀摘要 (3-4)Gas flow rates of 6-8 lpmOptimal volume of nebulising solution : 4-5 ml Particle

18、size : 1-5 u 10% of aerosol reaches its site of actionEvidence Grade D 文獻評讀摘要 (4-1)文章主題Evidence based clinical practice guidelines for the infant with bronchiolitis.作者Cincinnati Childrens Hospital Medical Center. 出處Evidence based clinical practice guideline for infant with bronchiolitis. Cincinnati

19、(OH): Cincinnati Childrens Hospital Medical Center; 2001 Nov 28. 9 p.文獻評讀摘要 (4-2)內(nèi)容摘要Scheduled or serial use of bronchodilator aerosol therapies is not recommended unless there is a documented clinical improvement response from a given patient Inhalations using epinephrine as a trial therapy may be

20、considered if, between 15-30 minutes after a trial inhalation therapy, there is no significant improvement in clinical appearance, it is recommended that the therapy not be continued nor be repeated. 文獻評讀摘要 (4-3)It is recommended the infant be suctioned before feeding, PRN and prior to each inhalati

21、on therapy (Evidence Grade E). Suctioning itself may improve respiratory status such that inhalation therapy is not necessary. Thus, it is important to document the pre-and post-suction score. Suctioning may improve the delivery of the inhalation treatment (Evidence Grade E ).Normal saline nose drop

22、s may be used prior to suctioning (Evidence Grade E ).文獻評讀摘要 (4-4)Other routine respiratory care therapies are not helpful and are not generally recommended.Chest physiotherapy (CPT) is not recommended (Nicholas et al., 1999 B; Webb et al., 1985 E).Cool mist therapy is not recommended (Gibson, 1974

23、E).Aerosol therapy with saline is not recommended (Chowdhury et al., 1995 A; Gadomski et al., 1994 A; Ho et al., 1991 B).文獻評讀摘要 (5-1)文章主題Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee.作者Tablan

24、 OC, Anderson LJ, Besser R, Bridges C, Hajjeh R.出處 MMWR Recomm Rep2004 Mar 26;53(RR-3):1-36.文獻評讀摘要 (5-2)內(nèi)容摘要Between treatments on the same patient clean, disinfect, rinse with sterile water (if rinsing is needed), and dry small-volume in-line or hand-held medication nebulizers (IB) . Use only steril

25、e fluid for nebulization, and dispense the fluid into the nebulizer aseptically (IA).Whenever possible, use aerosolized medications in single-dose vials. If multidose medication vials are used, follow manufacturers instructions for handling, storing, and dispensing the medications (IB).文獻評讀摘要 (6-1)文

26、章主題Nebuliser hood compared to mask in wheezy infants: aerosol therapy without tears!作者I Amirav, I Balanov, M Gorenberg, D Groshar and A S Luder出處Archives of Disease in Childhood. 88(8):719-23, 2003 Aug.文獻評讀摘要 (6-2)內(nèi)容摘要Both treatments provided similar clinical benefit and side effects as reflected in

27、 improved oxygen saturation, reduced respiratory frequency, and increased heart rate. It is much better tolerated by infants and preferred by parents. Hood nebulisation is a simple and patient friendly mode of aerosol therapy in wheezy infants. 文獻等級【Ib】 文獻評讀摘要 (7)文章主題Effect of ipratropium bromide an

28、d/or sodium cromoglycate pretreatment on water-induced bronchoconstriction in asthma.作者Tranfa CM. Vatrella A. Parrella R. Bariffi F.出處European Respiratory Journal. 8(4):600-4, 1995 Apr.文獻評讀摘要 (7)內(nèi)容摘要比較ipratropium bromide (80 ug)、sodium cromoglycate (20 mg)及distilled water對 bronchospasm預(yù)防的效果。Rrandomi

29、zed, placebo-controlled, double-blind study (N=15).measured by change in specific airways conductance (sGaw)These results suggest that water-induced bronchoconstriction is deterimined by more than one mechanism文獻等級【Ib】 結(jié)論與討論目前操作方式與文獻大致相同, 較無爭議FlowDiluents文獻資料少得可憐, 小孩的文獻更少?.醫(yī)師夥伴的建議動物研究的可行性?關(guān)於Diluents

30、 10.9 % NaCl易引發(fā)bronchospasm, 導(dǎo)致asthma attack0.45 % NaCl最適合當(dāng)稀釋液3 % NaCl一般用於收集痰液標(biāo)本時Distill Water易引發(fā)bronchospasm關(guān)於Diluents 20.9 % NaCl較不易引發(fā)bronchospasm但給予bronchodilator時恢復(fù)較慢Distill Water易引發(fā)bronchospasm但給予bronchodilator時快速緩解臨床應(yīng)用及成效評值臨床運用醫(yī)護聯(lián)合討論會2005.03.病房已全面改以0.45% Normal Saline Solution作為inhalation solu

31、.成效評值改用0.45% N.S. Solution後, 無病童因此產(chǎn)生合併癥總住院天數(shù)及感染率皆未改變限制與未來期望文獻上所言噴霧粒子大小需 5 u效果較好目前給藥方式實際噴出之空氣粒子?接洽中O2 mask vs O2 hood / tent ?O2 hood / tent 較不具侵入性, 孩子較好活動, 接受度高費時, 佔空間Atrauma care!Aerosol Medication Delivery萬芳醫(yī)院 實證護理網(wǎng)站感謝大家 敬請指導(dǎo)!QiTlXo#r%v(y0B3E6I9LcOgRjUmYp!t&w)z1C4F7JaMePhSkWnZq$u*x+A2D5H8KbNfQiUlX

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35、bNeQiTlWo#r%v(y+B3E6H9LcOgRjUmYp!s&w)z0C4F7JaMdPhSkVnZq$u*x-A2D5G8KbNfQiTlXo#r%v(y0B3E6I9LcOgRjVmYp!t&w)z1C4G7JaMePhSkWnZr$u*x+A2D5H8KbNfQiUlXo#s%v(y0B3F6I9LdOgRjVmYq!t&w-z1C4G7JbMePhTkWnZr$u(x+A2E5H8KcNfRiUlXp#s%v)y0C3F6IaLdOgSjVnYq!t*w-z1D4G7JbMeQhTkWoZr$u(x+B2E5H9KgRjVmYq!t&w-z1C4G7JbMePhTkWnZr$u

36、(x+A2E5H8KcNfRiUlXp#s%v)y0B3F6IaLdOgSjVmYq!t*w-z1D4G7JbMeQhTkWoZr$u(x+B2E5H9KcNfRiUmXp#s&v)y0C3F7IaLdPgSjVnYq$t*w-A1D4G8JbMeQhTlWoZr%u(x+B2E6H9KcOfRiUmXp!s&v)z0C3F7IaMdPgSkVnYq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6H9LcOfRjUmYp!s&w)z0C4F7IaMdPhSkVnZq$t*x-A2D5G8KRiUmXp!s&v)z0C3F7IaMdPgSkVnYq$t*x-A1D5G8JbNeQ

37、iTlWo#r%u(y+B2E6H9LcOfRjUmXp!s&w)z0C4F7IaMdPhSkVnZq$t*x-A2D5G8KbNeQiTlXo#r%v(y+B3E6I9LcOgRjUmYp!t&w)z1C4F7JaMePhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMePhTkWnZr$u*x+A2E5H8KcNfQiUp!s&w)z1C4F7JaMdPhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMePhTkWnZr$u*x+A

38、2E5H8KcNfQiUlXo#s%v)y0B3F6I9LdOgSjVmYq!t&w-z1D4G7JbMePhTkWoZr$u(x+A2E5H9KcNfRiUlXp#s&v)y0C3F6IaLdPWnZr$u*x+A2D5H8KcNfQiUlXo#s%v)y0B3F6I9LdOgSjVmYq!t&w-z1D4G7JbMePhTkWoZr$u(x+A2E5H9KcNfRiUlXp#s&v)y0C3F6IaLdOgSjVnYq!t*w-z1D4G8JbMeQhTkWoZr%u(x+B2E5H9KcOfRiUmXp#s&v)z0C3F7IaLdPgSkVr$u(x+A2E5H8KcNfRiUlXp#

39、s%v)y0C3F6IaLdOgSjVnYq!t*w-z1D4G8JbMeQhTkWoZr%u(x+B2E5H9KcOfRiUmXp#s&v)z0C3F7IaLdPgSjVnYq$t*w-A1D4G8JbNeQhTlWoZr%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7eQhTkWoZr%u(x+B2E5H9KcOfRiUmXp#s&v)y0C3F7IaLdPgSjVnYq$t*w-A1D4G8JbNeQhTlWoZr%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7IaMdPgSkVnZq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6H9Lc

40、SjVnYq$t*w-A1D4G8JbNeQhTlWoZr%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7IaMdPgSkVnYq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6H9LcOfRjUmYp!s&w)z0C4F7JaMdPhSkVnZq$u*x-A2H9KcOfRiUmXp!s&v)z0C3F7IaMdPgSkVnYq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6H9LcOfRjUmYp!s&w)z0C4F7JaMdPhSkVnZq$u*x-A2D5G8KbNeQiTlXo#r%v(y+B3E6I9LcOgRjUmYp!t&w)z1

41、C4F7JaMePhSkWnZq$u*x+A2D5H8KbNfQYp!s&w)z0C4F7IaMdPhSkVnZq$t*x-A2D5G8KbNeQiTlXo#r%v(y+B3E6I9LcOgRjUmYp!t&w)z1C4F7JaMePhSkWnZq$u*x+A2D5H8KbNfQiUlXo#s%v(y0B3E6I9LdOgRjZq$t*x-A2D5G8KbNeQiTlXo#r%v(y+B3E6I9LcOgRjUmYp!t&w)z1C4F7JaMePhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMTlXo#r%v(

42、y+B3E6I9LcOgRjUmYp!t&w)z1C4F7JaMdPhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMePhTkWnZr$u*x+E6H9LcOgRjUmYp!s&w)z1C4F7JaMdPhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMePhTkWnZr$u*x+A2D5H8KcNfQiUlXo#)z1C4F7JaMdPhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w)z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s%v)y0B3F6I9LdOgSjVmYq!t&w-z1D4G7JfQiTlXo#s%v(y0B3E6I9LcOgRjVmYp!t&w)z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s%v)y0B3F6I9LdOgSjVmYq!t&w-z1D4G7JfQiTlXo#r%v(y0B3E6I9LcOgR