Abstract:

Objective To construct and implement a swallowing disorder assessment and management program for tracheal intubated patients after extubation based on the 4R crisis management theory，providing standardized and scientific interventions for oral feeding. Methods Utilizing the expert meeting method with the 4R crisis management theory framework，a swallowing disorder assessment and management program was developed for post-extubation tracheal intubated patients. A convenience sampling method was employed to select patients with tracheal intubations treated from July to December 2023 in the emergency ICU，central ICU，and cardiovascular surgery ICU of a tertiary hospital in Zhejiang Province.The patients treated from October to December were assigned to an experimental group（n=68），while those treated from July to September were designated as a control group（n=58）. The experimental group received the 4R crisis management-based intervention，whereas the control group received standard ICU assessment and management. Outcomes indicators included the incidence of post-extubation swallowing disorders，time to first oral intake，incidence of aspiration during initial feeding，nasogastric and nasointestinal tube placement duration，incidence of aspiration pneumonia during hospitalization，re-intubation rates，ICU readmission rates，ICU stay duration，and total hospitalization days. Results Of the initially recruited subjects，68 in the experimental group and 54 in the control group were included in the final analysis. After the intervention，the experimental group exhibited significantly lower rates of post-extubation swallowing disorders，shorter time to first liquid oral intake，aspiration incidence during first feeding，shorter durations of nasogastric and nasointestinal tube placement，aspiration pneumonia，ICU readmission compared to the control group（P<0.05）. No significant differences were observed between the groups in time to first regular oral intake，re-intubation rates（P>0.05）. Conclusion The risk management program for dysphagia following tracheal extubation based on the 4R crisis management theory is scientifically robust and safe，offering a valuable reference for clinical assessments and management of swallowing and eating post-extubation in tracheal intubated patients.

Key words: Post-Extubation Dysphagia, 4R Crisis Management Theory, Assessment, Critical Care

摘要：

目的 基于4R危机管理理论构建气管插管患者拔管后吞咽障碍风险管理方案并探讨其应用效果。 方法 以4R危机管理理论为框架，通过专家会议法，构建气管插管患者拔管后吞咽障碍风险管理方案。采用方便抽样法，将2023年7月—12月收治于浙江省某三级甲等医院急诊ICU、中心ICU及心脏大血管外科ICU的气管插管患者作为研究对象，其中2023年10月—12月收治的68例作为试验组，2023年7月—9月收治的58例作为对照组。试验组采用基于4R危机管理理论的气管插管患者拔管后吞咽障碍风险管理方案进行干预，对照组采用ICU常规气道评估与管理。比较两组拔管后吞咽障碍发生率、首次经口进食时间、首次进食过程中误吸发生率、鼻胃管及鼻肠管留置时间、吸入性肺炎发生率、再次气管插管发生率及ICU重返率。 结果 最终试验组纳入68例，对照组54例。干预后，试验组拔管后吞咽障碍发生率、首次经口进流质饮食的时间、首次进食过程中误吸发生率、鼻胃管及鼻肠管留置时间、吸入性肺炎发生率、ICU重返率均低于对照组（均P<0.05）；两组首次经口进普通饮食的时间、再次气管插管发生率比较，差异无统计学意义（P>0.05）。 结论 基于4R危机管理理论的气管插管患者拔管后吞咽障碍风险管理方案具有较好的科学性及安全性，可为临床气管插管患者拔管后的吞咽功能评估与进食管理提供参考。

关键词: 拔管后吞咽障碍, 4R危机管理理论, 评估, 危重病护理