脳出血後の嚥下障害に対する早期介入

昨日紹介した「急性期脳卒中の低栄養：レビュー」で引用されていた日本発の英語論文を紹介します。脳出血後の嚥下障害に対する早期介入に関する後ろ向きコホート研究です。

Hideaki Takahata, Keisuke Tsutsumi, Hiroshi Baba, Izumi Nagata, and Masahiro Yonekura: Early intervention to promote oral feeding in patients with intracerebral hemorrhage: a retrospective cohort study. BMC Neurol. 2011; 11: 6. doi: 10.1186/1471-2377-11-6

下記のHPで全文PDFで見ることができます。

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3034675/pdf/1471-2377-11-6.pdf

脳出血後の嚥下障害に対する早期介入を行うと、経口摂取できる割合が高くなり、呼吸器感染症の合併割合が低くなるという結果です。臨床的にはとても納得できる結果で、それを英語論文として執筆していることは素晴らしいと思います。私にはなかなかできていませんので…。

ただ、小山珠美さんが勤務する東名厚木病院では脳出血に限らず早期経口摂取に挑戦していて、肺炎例でも素晴らしい経口摂取割合を達成しています。東名厚木病院の取り組みを英語論文にできればもっとインパクトのある論文になるのにと感じます。

Background
Stroke is a major cause of dysphagia, but little is known about when and how dysphagic patients should be fed and treated after an acute stroke. The purpose of this study is to establish the feasibility, risks and clinical outcomes of early intensive oral care and a new speech and language therapist/nurse led structured policy for oral feeding in patients with an acute intracerebral hemorrhage (ICH).

Methods
A total of 219 patients with spontaneous ICH who were admitted to our institution from 2004 to 2007 were retrospectively analyzed. An early intervention program for oral feeding, which consisted of intensive oral care and early behavioral interventions, was introduced from April 2005 and fully operational by January 2006. Outcomes were compared between an early intervention group of 129 patients recruited after January 2006 and a historical control group of 90 patients recruited between January 2004 and March 2005. A logistic regression technique was used to adjust for baseline differences between the groups. To analyze time to attain oral feeding, the Kaplan-Meier method and Cox proportional hazard model were used.

Results
The proportion of patients who could tolerate oral feeding was significantly higher in the early intervention group compared with the control group (112/129 (86.8%) vs. 61/90 (67.8%); odds ratio 3.13, 95% CI, 1.59-6.15; P < 0.001). After adjusting for baseline imbalances, the odds ratio was 4.42 (95% CI, 1.81-10.8; P = 0.001). The incidence of chest infection was lower in the early intervention group compared with the control group (27/129 (20.9%) vs. 32/90 (35.6%); odds ratio 0.48, 95% CI, 0.26-0.88; P = 0.016). A log-rank test found a significant difference in nutritional supplementation-free survival between the two groups (hazard ratio 1.94, 95% CI, 1.46-2.71; P < 0.001).

Conclusions
Our data suggest that the techniques can be used safely and possibly with enough benefit to justify a randomized controlled trial. Further investigation is needed to solve the eating problems that are associated with patients recovering from a severe stroke.