脑卒中误吸筛查工具的系统综述

doi:10.3969/j.issn.1006-9771.2020.09.010

《中国康复理论与实践》 ›› 2020, Vol. 26 ›› Issue (9): 1052-1060.doi: 10.3969/j.issn.1006-9771.2020.09.010

脑卒中误吸筛查工具的系统综述

韩春彦¹,赵存¹,王兴蕾^2a,张亚斌¹,苟玲¹,裴菊红¹,田金徽³,豆欣蔓^1,^2b()

1.兰州大学护理学院,甘肃兰州市 730010
2.兰州大学第二医院,a.肝病科；b.护理部,甘肃兰州市 730030
3.兰州大学循证医学中心,甘肃兰州市 730000

收稿日期:2019-05-27 修回日期:2019-07-23 出版日期:2020-09-25 发布日期:2020-09-24
通讯作者: 豆欣蔓 E-mail:dxm1812@163.com
作者简介:韩春彦(1994-),女,汉族,山东济宁市人,硕士研究生,护士,主要研究方向：慢性病管理。|豆欣蔓,女,汉族,甘肃兰州市人,博士,副教授、副主任护师,主要研究方向：慢性病管理。
基金资助:
1.兰州大学第二医院“萃英科技创新”计划项目(CY2017-HL01);2.甘肃省陇原青年创新创业人才团队项目

Aspiration Screening Tools after Stroke: A Systematic Review

HAN Chun-yan¹,ZHAO Cun¹,WANG Xing-lei^2a,ZHANG Ya-bin¹,GOU Ling¹,PEI Ju-hong¹,TIAN Jin-hui³,DOU Xin-man^1,^2b()

1. School of Nursing of Lanzhou University, Lanzhou, Gansu 730010, China
2. a. Department of Hepatology, b. Department of Nursing, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, China
3. Evidence Based Medicine Center of Lanzhou University, Lanzhou, Gansu 730000, China

Received:2019-05-27 Revised:2019-07-23 Published:2020-09-25 Online:2020-09-24
Contact: DOU Xin-man E-mail:dxm1812@163.com
Supported by:
Lanzhou University Second Hospital “Cuiying” Innovation(CY2017-HL01);Gansu Longyuan Youth Innovation Team Project

摘要/Abstract

摘要：

目的系统综述脑卒中患者误吸筛查工具的相关研究。
方法检索PubMed、Cochrane Library、Web of Science、Embase、中国知网、万方数据库、中国生物医学文献数据库从建库至2018年12月有关脑卒中误吸筛查工具的相关文献,2名研究员独立筛选文献,提取数据,分析误吸筛查工具的内容、筛查形式、评分标准、测量学特性。
结果共纳入25项研究,涉及10种误吸筛查工具。分析各误吸筛查工具的内容、筛查形式、评分标准、测量学特性。虽然工具很多,但尚无一致证据支持的工具。
结论医务人员应依据患者的病情、年龄、意识状态、吞咽相关特征,有针对性地选择筛查工具。

关键词: 脑卒中, 误吸, 筛查, 评定, 系统综述

Abstract:

Objective To systematically review the relevant researches on aspiration screening tools for stroke patients.
Methods Literatures aboute stroke aspiration screening tools till December, 2018 were recalled from PubMed, Cochrane Library, Web of Science, EMbase, CNKI, Wanfang Database and China Biomedical Literature Database. Two researchers independently screened the literatures and extracted the basic information, such as the content, screening format, scoring standard and measurement characteristics.
Results A total of 25 studies were included, involving ten aspiration screening tools. The content, screening format, scoring standard and measurement characteristics of the aspiration screening tools were analysed. There was no evidence to support the tools.
Conclusion Tools would be selected according to the patient's condition, age and swallowing related characteristics.

Key words: stroke, aspiration, screening, assessment, systematic review

韩春彦,赵存,王兴蕾,张亚斌,苟玲,裴菊红,田金徽,豆欣蔓. 脑卒中误吸筛查工具的系统综述[J]. 《中国康复理论与实践》, 2020, 26(9): 1052-1060.

HAN Chun-yan,ZHAO Cun,WANG Xing-lei,ZHANG Ya-bin,GOU Ling,PEI Ju-hong,TIAN Jin-hui,DOU Xin-man. Aspiration Screening Tools after Stroke: A Systematic Review[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2020, 26(9): 1052-1060.

图/表 2

表1

纳入研究的具体基本特征"

作者	出版年	国家	n	卒中类型	筛查工具	参考工具	测量特性
Serel等	2017	土耳其	225	脑卒中	EAT-10	VFSS	SS 81.0%,SP 58.0%,PPV 72.0%,NPV 69.0%
Cheney等	2015	美国	360	脑卒中	EAT-10	渗透误吸量表	SS 70.6%,SP 52.7%,PPV 26%,NPV 89%
Rofes等	2014	西班牙	134	脑卒中	EAT-10	VFSS	SS 83%,SP 25%,PPV 52.5%,NPV 59.2%
Warnecke等	2017	德国	121	脑卒中	GUSS	FEES	SS 96.5%,SP 55.8%,PPV 74.3%,NPV 92.3%
Trapl等	2007	澳大利亚	50	急性脑卒中	GUSS	FEES	评价者间信度：kappa = 0.835。治疗师评估(n = 20)：SS 100%,SP 50%,PPV 81%,NPV 100%。护士评估(n = 30)：SS 100%,SP 69%,PPV 74%,NPV 100%
Marian等	2017	德国	50	急性脑卒中	PO	FEES	SS 10%,SP 100%
Wang等	2005	中国	27	脑卒中	PO	VFSS	SS 58.3%,SP 66.7%,PPV 58.3%,NPV 66.7%
Lim等	2001	新加坡	50	急性脑卒中	PO、50 ml WST,以及二者结合	FEES	PO：SS 76.9%,SP 83.3%,PPV 83.3%,NPV 76.9%。 50 ml WST：SS 84.6%,SP 75.0%,PPV 78.6%,NPV 81.8% 二者结合：SS 100%,SP 70.8%,PPV 78.8%,NPV 100%。信度：二者结合kappa = 0.716,氧饱和度测定kappa = 0.601,50 ml水吞咽试验kappa = 0.598
Lindner-Pfleghar等	2017	德国	72	急性脑卒中	SSA	FEES	SS 76%,SP 55.5%,PPV 27.8%,NPV 91.7%
Park等	2014	韩国	395	脑卒中	SSA	GUSS	SS 85.6%,SP 70.6%,PPV 76.4%,NPV 81.5%
孙伟平等	2009	中国	81	急性脑卒中	SSA	FEES	SS 95%,SP 53.7%,PPV 66.7%,NPV 91.7%
Suiter等	2008	美国	229/202/39	左侧/右侧/脑干脑卒中	WST	FEES	左侧：SS 96.3%,SP 41.1%,PPV 17.9%,NPV 98.8%,PLR 1.64,NLR 0.09 右侧：SS 95.8%,SP 38.2%,PPV 17.3%,NPV 为98.6%,PLR 1.55,NLR 0.11 脑干：SS 100.0%,SP 58.1%,PPV 38.1%,NPV 为100.0%,PLR 2.39,NLR 0.00
Garon等	1995	美国	100	脑卒中	WST	VFSS	SS 54%,SP 79%
De Pippo等	1992	美国	44	急性脑卒中	WST	VFSS	SS 76%,SP 59%
Osawa等	2012	日本	111	急性脑卒中	WST	VFSS	5 ml水：SS 52.9%,SP 90.4%,PPV 50.0%,NPV 91.4%。10 ml水：SS 34.8%,SP 93.2%,PPV 81.1%,NPV 57.1%。30 ml水：SS 51.4%,SP 78.9%,PPV 52.9%,NPV 77.9%。60 ml水：SS 55.7%,SP 85.4%,PPV 86.7%,NPV 53.0%。MWST (3 ml水)：SS 55.3%,SP 80.8%,PPV 60.0%,NPV 77.6%
Nishiwaki等	2005	日本	61	急性脑卒中	WST	VFSS	SS 72%,SP 67%
ZHOU等	2011	法国	107	脑卒中	WST	VFSS	SS 87.3%,SP 42.3%,PPV 61.5%,NPV 75.9%,Kappa = 0.29
ZHOU等	2011	法国	107	脑卒中	CPSA	VFSS	SS 50.1%,SP 50%,PPV 87.5%,阴性预测值86.7%,Kappa = 0.30
武文娟等	2016	中国	45	急性脑卒中	WST	VFSS	SS 43.75%,SP 69.23%,PPV 77.78%,NPV 31.03%
Osawa等	2013	日本	50	脑卒中	WST	VFSS	SS 63%,SP 60%
Daniels等	2016	美国	250	脑卒中	RAS	VFSS	SS 93%,SP 43%,PPV 18%,NPV 98%,Kappa = 1.00
孙伟平等	2009	中国	81	急性脑卒中	Any Two试验	FEES	SS 92.5%,SP 31.7%,PPV 56.9%,NPV 81.3%
Warnecke等	2008	德国	100	急性脑卒中	SPT	FEES	第一步：SS 74.1%,SP 100%,PPV 100%,NPV 47.5%。第二步：SS 49.4%,SP 100%,PPV 100%,NPV 31.7%
Ramsey等	2006	英国	189	急性脑卒中	PO	VFSS	降低 ≥ 2%：SS 31%,SP 72%,PPV 51%,NPV 53%。降低 ≥ 5%：SS 7%,SP 97%,PPV 67%,NPV 53%
Edmiaston等	2014	美国	225	急性脑卒中	ASDS	VFSS	SS 95%,SP 50%,PPV 41%,NPV 96%

表1

表2

筛查工具的内容形式及评分标准"

筛查工具	筛查方式	评分标准
EAT-10	10个关于口咽性吞咽困难症状严重程度的问题,每个问题评分0~4分	> 15分存在误吸风险
GUSS	第一部分：保持警惕15 min;能够自主咳嗽;喉功能;吞咽唾液;无口角流水。第二部分：评估吞咽糊状、固体、液体食物后的吞咽表现,每种食物吞咽后观察是否存在吞咽延迟或吞咽、咳嗽、流口水和声音改变4个指标	≥ 14分存在误吸风险
血氧饱和度测定	患者直立5 min,测基线值;行WST,记录吞咽10 ml水期间和吞咽完成后2 min内的最大和最小氧饱和度,测3次,取最高和最低值	下降 ≥ 2%有临床意义
SSA	第1步床旁检查：初步评价意识水平、头部和躯干部控制、唇控制、呼吸方式、声音强弱、自主咳嗽能力、咽反射。若上述指标均正常,第2步WST (5 ml水),观察以下情况：口角流水、吞咽时有喉部运动、吞咽时有反复的喉部运动、咳嗽、哽咽、声音质量,重复3次。如果3次吞咽中有2次及以上正常,则第3步让患者吞咽60 ml水,观察是否能全部饮完、咳嗽、哽咽、声音质量	35~46分为误吸高风险,24~34分为误吸中风险,18~23分为误吸低风险
WST	患者端坐位,连续饮用30 ml、60 ml或90 ml水,观察是否一次性饮完,吞咽完成后是否有呛咳	如果吞咽未完成,或在测试结束后1 min内出现咳嗽、窒息或声音质量改变,则认为存在误吸风险
RAS	非吞咽项目：年龄 ≥ 70岁和构音障碍; 若不符,行吞咽项目：嘱患者通过杯子或吸管一次性饮用5 ml水,观察吞咽期间或吞咽后是否存在任何误吸风险迹象(咳嗽、哽咽、声音改变); 如无,重复上一步骤; 如无,嘱患者通过杯子或吸管不停地饮用90 ml水,直至饮完或告知停止,观察吞咽期间或吞咽后是否存在咳嗽、哽咽、声音改变和/或无法连续饮水	如果任何一项评估为“是”,则停止筛选,认为存在误吸风险
Any Two试验	检查患者有无失音、构音障碍、咽反射异常、自主咳嗽异常;嘱患者吞咽10 ml水,观察饮水后有无呛咳或声音改变	若患者出现的异常征象 ≥ 2项,提示患者存在误吸风险
SPT	将一根薄的导管通过鼻孔插入口咽,其尖端位于绒毛下方。在呼气结束时推注蒸馏水0.4 ml或2.0 ml诱导吞咽反射。评估人员将手指放在患者喉部,通过视觉和手指同时观察特征性喉部向上运动识别吞咽的开始。秒表测量开始注水到吞咽开始的潜伏期	潜伏期 > 3 s,存在误吸风险
ASDS	第一部分：格拉斯哥昏迷量表是否低于13分,是否有面部不对称或面部肌肉无力、舌头不对称或舌肌无力、软腭不对称或无力。第二部分：连续饮水3 Oz3 Oz (约90 ml),1 min后观察喉部残留、咳嗽或声音质量	5个项目中任一项异常,存在误吸风险
CPSA	包括6个条目：不存在非条件反射,12分;软腭反射存在,8分;自愿吞咽,7分;不存在发音困难,6分;存在咽反射,6分;自主声门闭合,3分	> 28分不存在误吸风险;< 14分存在误吸风险;14~28分不确定

表2

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脑卒中误吸筛查工具的系统综述

Aspiration Screening Tools after Stroke: A Systematic Review

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