护士主导的气管插管患者拔管后吞咽障碍管理方案的范围综述

doi:10.3761/j.issn.2096-7446.2025.02.020

摘要/Abstract

摘要：

目的系统分析护士主导的气管插管拔管后吞咽障碍管理方案，为急危重症患者拔管后吞咽困难的预防及管理提供参考。方法根据范围综述的研究规范，系统检索Cochrane Library、PubMed、Embase、Web of Science等英文数据库，中国知网、万方数据库、中国生物医学文献数据库等中文数据库，检索期限为建库至2024年1月31日，筛选拔管后吞咽困难管理相关文献并进行系统综述分析。结果共纳入22篇研究，其中2篇文献内容涉及拔管后吞咽障碍评估与干预两个方面；14篇文献内容仅涉及拔管后吞咽障碍的筛查与评估；6篇文献内容仅涉及拔管后吞咽障碍的预防与干预；拔管后吞咽障碍发生率为3%~54.2%；评估时机多从拔管后2~24 h开始，使用工具包括功能性口服摄入量表、重复性唾液吞咽测试等。部分研究联合多种工具筛查，阳性患者在24 h后接受1~2次复评，再转诊康复科或语言治疗师。预防及干预方法包括口腔运动、代偿策略、呼吸机力量训练、健康教育和冷喷雾治疗，干预多从拔管后24 h开始持续至少10 d或至出院。结论护士主导的吞咽障碍管理具有可行性与安全性，能缩短经口进食等待时间、降低吸入性肺炎风险，并能弥补重症监护单元语言治疗师资源不足。然而，目前缺乏标准的评估与干预方案，评估时机、评估工具及干预方案存在异质性，需要高质量的临床研究为构建综合管理策略提供依据。

关键词: 气管插管, 拔管后吞咽障碍, 吞咽评估, 吞咽康复, 范围综述

Abstract:

Objective To systematically analyze the nurse-led post-extubation dysphagia management program for tracheal intubation，and to provide a reference for the prevention and management of post-extubation dysphagia in patients with acute and critical illness. Methods According to the research specifications of scoping reviews，a systematic search was conducted in English databases including Cochrane Library，PubMed，Embase，Web of Science，and Chinese databases such as CNKI，Wanfang Data，and Chinese Biomedical Literature Database. The search period was from the establishment of the databases to January 31，2024. Relevant literature on the management of post-extubation dysphagia was selected and systematically reviewed. Results A total of 22 studies were included，of which 2 studies were related to the assessment and intervention of post-extubation dysphagia，14 studies related to the screening and assessment of post-extubation dysphagia，6 studies related to the prevention and intervention of post-extubation dysphagia. The prevalence rate of post-extubation dysphagia ranged from 3% to 54.2%，the timing of assessment was mostly started 2-24 h after extubation，and the tools used included Functional Oral Intake Scale，Repetitive Saliva Swallowing Test，etc. Some studies combined multiple tools for screening，and positive patients received 1 or 2 reassessments at 24 h before referral to rehabilitation or speech therapist. Prevention and intervention methods included oral exercises，compensatory strategies，ventilator strength training，health education，and cold spray therapy，with interventions mostly starting 24 h after extubation and continuing for at least 10 d or until discharge. Conclusion Nurse-led dysphagia management is feasible and safe，reduces the waiting time for oral feeding，decreases the risk of aspiration pneumonia，and compensates for the lack of resources for speech therapists in the ICU. However，there is a lack of standardized assessment and intervention protocols，and there is heterogeneity in the timing of assessment，assessment tools，and intervention protocols. High-quality clinical trials are needed to inform the development of comprehensive management strategies.

Key words: Tracheal Intubation, Post-extubation Dysphagia, Swallowing Assessment, Swallowing Rehabilita-tion, Scoping Review

唐佳迎, 郭芝廷, 黄晓霞, 封秀琴. 护士主导的气管插管患者拔管后吞咽障碍管理方案的范围综述[J]. 中华急危重症护理杂志, 2025, 6(2): 240-246.

TANG Jiaying, GUO Zhiting, HUANG Xiaoxia, FENG Xiuqin. The nurse-led management strategies for post-extubation dysphagia in patients with tracheal ventilation：a scoping review[J]. Chinese Journal of Emergency and Critical Care Nursing, 2025, 6(2): 240-246.

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参考文献 32

[1]	黄晓霞, 唐佳迎, 郭芝廷, 等. 气管插管患者拔管后吞咽障碍研究热点的可视化分析[J]. 中华急危重症护理杂志, 2024, 5(2):181-187.
	Huang XX, Tang JY, Guo ZT, et al. Visualization analysis of research hotpots on post-extubation dysphagia in patients with tracheal intubation[J]. Chin J Emerg Crit Care Nurs, 2024, 5(2):181-187.
[2]	Schefold JC, Berger D, Zürcher P, et al. Dysphagia in mecha-nically ventilated ICU patients(DYnAMICS):a prospective ob-servational trial[J]. Crit Care Med, 2017, 45(12):2061-2069. doi: 10.1097/CCM.0000000000002765 pmid: 29023260
[3]	Zuercher P, Moser M, Waskowski J, et al. Dysphagia post-extubation affects long-term mortality in mixed adult ICU patients-data from a large prospective observational study with systematic dysphagia screening[J]. Crit Care Explor, 2022, 4(6):e0714. doi: 10.1097/CCE.0000000000000714 pmid: 35765374
[4]	Demetriou M, Georgiou AM. Perspective on dysphagia screen-ing,assessment methods,and protocols in intensive care units:an opinion article[J]. Front Hum Neurosci, 2024, 18:1375408.
[5]	Brodsky MB, Pandian V, Needham DM. Post-extubation dyspha-gia:a problem needing multidisciplinary efforts[J]. Intensive Care Med, 2020, 46(1):93-96. doi: 10.1007/s00134-019-05865-x pmid: 31768568
[6]	向波, 刘丽萍, 黄萍. 急性肠系膜缺血患者营养支持的范围综述[J]. 中华急危重症护理杂志, 2023, 4(2):119-124.
	Xiang B, Liu LP, Huang P. Nutritional support in patients with acute mesenteric ischemia:a scoping review[J]. Chin J Emerg Crit Care Nurs, 2023, 4(2):119-124.
[7]	Johnson KL, Speirs L, Mitchell A, et al. Validation of a pos-textubation dysphagia screening tool for patients after prolon-ged endotracheal intubation[J]. Am J Crit Care, 2018, 27(2):89-96. doi: 10.4037/ajcc2018483 pmid: 29496764
[8]	Ichibayashi R, Sekiya H, Kaneko K, et al. Use of maximum tongue pressure values to examine the presence of dysphagia after extubation and prevent aspiration pneumonia in elderly emergency patients[J]. J Clin Med, 2022, 11(21):6599.
[9]	Mukdad L, Toppen W, Nguyen S, et al. A targeted swallow screen for the detection of postoperative dysphagia in liver transplant patients[J]. Prog Transplant, 2019, 29(1):4-10. doi: 10.1177/1526924818817035 pmid: 30514164
[10]	Traugott M, Hoepler W, Kitzberger R, et al. Successful treatment of intubation-induced severe neurogenic post-extubation dys-phagia using pharyngeal electrical stimulation in a COVID-19 survivor:a case report[J]. J Med Case Rep, 2021, 15(1):148.
[11]	Ford C, McCormick D, Parkosewich J, et al. Safety and effecti-veness of early oral hydration in patients after cardiothoracic surgery[J]. Am J Crit Care, 2020, 29(4):292-300.
[12]	Siao, Tseng WH, Wang TG, et al. Predicting feeding-tube de-pendence in patients following endotracheal extubation:a two-item swallowing screen[J]. BMC Pulm Med, 2021, 21(1):403.
[13]	Schefold JC, Bäcklund M, Ala-Kokko T, et al. The PhINEST study-Pharyngeal ICU Novel Electrical Stimulation Therapy:study protocol of a prospective,multi-site,randomized,sham-controlled,single-blind(outcome assessor-blinded) study[J]. Medicine, 2020, 99(11):e19503.
[14]	See KC, Peng SY, Phua J, et al. Nurse-performed screening for postextubation dysphagia:a retrospective cohort study in critically ill medical patients[J]. Crit Care, 2016, 20(1):326.
[15]	Miles A, Lee YY, McLellan N, et al. Implementing a systema-tic care pathway for management of dysphagia after cardio-thoracic surgery[J]. Intensive Crit Care Nurs, 2022, 70:103224.
[16]	Ogawa M, Satomi-Kobayashi S, Yoshida N, et al. Impact of frai-lty on postoperative dysphagia in patients undergoing elective cardiovascular surgery[J]. JACC Asia, 2022, 2(1):104-113.
[17]	Omura K, Komine A, Yanagigawa M, et al. Frequency and out-come of post-extubation dysphagia using nurse-performed swa-llowing screening protocol[J]. Nurs Crit Care, 2019, 24(2):70-75.
[18]	Turra GS, Schwartz IVD, Almeida ST, et al. Efficacy of speech therapy in post-intubation patients with oropharyngeal dys-phagia:a randomized controlled trial[J]. Codas, 2021, 33(2):e20190246.
[19]	Siao SF, Ku SC, Tseng WH, et al. Effects of a swallowing and oral-care program on resuming oral feeding and reducing pneumonia in patients following endotracheal extubation:a randomized,open-label,controlled trial[J]. Crit Care, 2023, 27(1):283.
[20]	Wu CP, Xu YJ, Wang TG, et al. Effects of a swallowing and oral care intervention for patients following endotracheal extubation:a pre- and post-intervention study[J]. Crit Care, 2019, 23(1):350.
[21]	Lin R, Chen HY, Chen LL, et al. Effects of a spray-based oropharyngeal moisturising programme for patients following endotracheal extubation after cardiac surgery:a randomised,controlled three-arm trial[J]. Int J Nurs Stud, 2022, 130:104214.
[22]	Bordejé Laguna L, Marcos-Neira P, de Lagrán Zurbano IM, et al. Dysphagia and mechanical ventilation in SARS-COV-2 pneumonia:it’s real[J]. Clin Nutr, 2022, 41(12):2927-2933.
[23]	Hongo T, Yamamoto R, Liu K, et al. Association between tim-ing of speech and language therapy initiation and outcomes among post-extubation dysphagia patients:a multicenter retro-spective cohort study[J]. Crit Care, 2022, 26(1):98.
[24]	Tanaka K, Watanabe K, Kashiwagi H. Association between pos-textubation dysphagia and physical function in survivors of critical illness:a retrospective study[J]. Clin Nutr ESPEN, 2022, 47:147-151. doi: 10.1016/j.clnesp.2021.12.031 pmid: 35063194
[25]	黄师菊, 蔡有弟, 李晓玲, 等. 护士主导的高危科室吞咽障碍患者筛查及分级干预效果评价[J]. 中华护理杂志, 2018, 53(11):1303-1308.
	Huang SJ, Cai YD, Li XL, et al. The effectiveness of screening and grading intervention for dysphagia in high-risk depart-ments in all hospital led by nurses[J]. Chin J Nurs, 2018, 53(11):1303-1308.
[26]	侯芳, 卢智, 高晶, 等. 多学科协作模式在预防ICU获得性吞咽功能障碍中的应用研究[J]. 中国实用护理杂志, 2021, 37(8):599-603.
	Hou F, Lu Z, Gao J, et al. Application of multidisciplinary cooperation model in the prevention of acquired dysphagia in ICU[J]. Chin J Pract Nurs, 2021, 37(8):599-603.
[27]	李俐, 方燕丽, 张冬宁, 等. 吞咽障碍筛查联合吞糊实验在机械通气病人经口进食中的应用研究[J]. 护理研究, 2014, 28(17):2109-2110.
	Li L, Fang YL, Zhang DN, et al. Study on application of swallowing dysfunction screening combined with swallow paste experiments in mechanical ventilation patients eating by mouth[J]. Chin Nurs Res, 2014, 28(17):2109-2110.
[28]	Hou LY, Li Y, Wang JH, et al. Risk factors for post-extubation dysphagia in ICU:a systematic review and meta-analysis[J]. Medicine, 2023, 102(10):e33153.
[29]	Marian T, Dünser M, Citerio G, et al. Are intensive care phy-sicians aware of dysphagia? The MADICU survey results[J]. Intensive Care Med, 2018, 44(6):973-975.
[30]	Zuercher P, Moret CS, Dziewas R, et al. Dysphagia in the in-tensive care unit:epidemiology,mechanisms,and clinical ma-nagement[J]. Crit Care, 2019, 23(1):103.
[31]	Spronk PE, Spronk LEJ, Egerod I, et al. Dysphagia in inten-sive care evaluation(DICE):an international cross-sectional sur-vey[J]. Dysphagia, 2022, 37(6):1451-1460.
[32]	Robbertse A, de Beer A. Perceived barriers to compliance with speech-language therapist dysphagia recommendations of South African nurses[J]. Die Suid Afrikaanse Tydskrif Vir Kommuni-kasieafwykings, 2020, 67(1):e1-e6.