基于国际健康分类架构构建新型冠状病毒病重症病区配对康复治疗模式及其效果

doi:10.3969/j.issn.1006-9771.2021.04.002

《中国康复理论与实践》 ›› 2021, Vol. 27 ›› Issue (4): 385-393.doi: 10.3969/j.issn.1006-9771.2021.04.002

基于国际健康分类架构构建新型冠状病毒病重症病区配对康复治疗模式及其效果

谭金泽¹,张鸣生²(),曾凡令¹,曾斌¹,邱卓英³()

^1.广东省人民医院（广东省医学科学院），广东省老年医学研究所，广东广州市 510080
^2.深圳大学平湖医院，广东深圳市 518000
^3.中国康复研究中心/中国康复科学所康复信息研究所，北京市 100068

收稿日期:2021-02-11 修回日期:2021-03-17 出版日期:2021-04-25 发布日期:2021-04-20
通讯作者: 张鸣生,邱卓英 E-mail:mszrch@163.com;qiutiger@hotmail.com
作者简介:谭金泽(1994-)，男，汉族，广东佛山市人，治疗师，主要从事神经康复、肺康复及危重症患者的康复治疗|张鸣生，男，汉族，主任医师、教授，博士研究生导师。

Construction and Effect of Partnership Model of Rehabilitation for Patients with COVID-2019 in Critical Wards Using International Health Classifications Framework

Jin-ze TAN¹,Ming-sheng ZHANG²(),Fan-ling ZENG¹,Bin ZENG¹,Zhuo-ying QIU³()

^1.Department of Physical Medicine and Rehabilitation, Guangdong Geriatric Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou, Guangdong 510080, China
^2.Shenzhen University Pinghu Hosipital, Shenzhen, Guangdong 518000, China
^3.China Rehabilitation Research Center/China Institute of Rehabilitation Science, Beijing 100068, China

Received:2021-02-11 Revised:2021-03-17 Published:2021-04-25 Online:2021-04-20
Contact: Ming-sheng ZHANG,Zhuo-ying QIU E-mail:mszrch@163.com;qiutiger@hotmail.com

摘要/Abstract

摘要： 目的

基于国际健康分类架构探讨构建新型冠状病毒病(COVID-19)配对康复治疗模式，并观察其对重症病区COVID-19危重患者的治疗效果。

方法

基于国际健康分类架构建立配对康复治疗模式：两名康复治疗师在危重病房实施康复，一名实施治疗，另一名辅助治疗并进行防疫工作。选择重症病区住院的COVID-19重症肺炎患者11例，采用配对康复治疗模式开展康复治疗。计数治疗安全性行为，观察防疫效果；治疗前后分别采用Borg指数、咳嗽评分、Miller痰液分级和世界卫生组织残疾评定量表(WHODAS) 2.0对患者进行评定。

结果

在实施康复治疗期间，共避免7次感染风险，纠正6项康复治疗风险，治疗师未发生COVID-19感染。治疗1周后，患者Borg指数(P < 0.01)、咳嗽评分(P < 0.05)和WHODAS 2.0评分(P < 0.01)均改善。

结论

基于国际健康分类标准体系，建立适用于重症病区COVID-19配对康复治疗模式，为传染性疾病重症患者康复提供了一种安全和可操作的工作模式。

关键词: 新型冠状病毒病, 团队工作, 配对康复治疗模式, 传染病, 重症康复

Abstract: Objective

To construct a teamwork model, Partnership Rehabilitation Therapy (PRT), for therapists in critical wards for patients with Corona Virus Disease 2019 (COVID-19), and observe its effect.

Methods

PRT had been developed, in which one therapist (main) implementing therapy and another (assistant) monitoring and supporting in the treatment. Eleven COVID-19 patients from infectious critical ward were treated with PRT. The behavior safety of therapists was recorded during the treatment, and the patients were assessed with Borg Index, Cough Score, Miller Sputum Grading and World Health Organization Disability Assessment Schedule (WHODAS) 2.0 before and after treatment.

Results

No physiotherapist was infected by COVID-19. Seven times of infection risks were recorded and avoided, and six times of treatment risks were corrected instantly. All the patients improved in Borg Index (P < 0.01), Cough Score (P < 0.05), Miller Sputum Grading (P = 0.02) and WHODAS 2.0 (P < 0.01) after a 1-week physical therapy.

Conclusion

Based on the Family International Classifications, a teamwork model is established, which provides a safe and practicable way for rehabilitation for COVID-19 patients in critical wards.

Key words: Corona Virus Disease 2019, team work, Partnership Rehabilitation Therapy, infectious disease, ICU rehabilitation

中图分类号:

R511.7

谭金泽,张鸣生,曾凡令,曾斌,邱卓英. 基于国际健康分类架构构建新型冠状病毒病重症病区配对康复治疗模式及其效果[J]. 《中国康复理论与实践》, 2021, 27(4): 385-393.

Jin-ze TAN,Ming-sheng ZHANG,Fan-ling ZENG,Bin ZENG,Zhuo-ying QIU. Construction and Effect of Partnership Model of Rehabilitation for Patients with COVID-2019 in Critical Wards Using International Health Classifications Framework[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2021, 27(4): 385-393.

图/表 6

表1

表2

表3

表4

表5

表6

参考文献 54

1	World Health Organization. Novel Coronavirus disease 2019 (COVID-19) weekly Situation Report [EB/OL]. (2020-08-24). .
2	Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China [J]. Zhonghua Liu Xing Bing Xue Za Zhi, 2020, 41(2): 145-151.
3	国家卫生健康委办公厅. 中国-世界卫生组织新型冠状病毒肺炎(COVID-19)联合考察报告. (2020-02-29). .
4	Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study [J]. Lancet, 2020, 395(10223): 507-513.
5	管汉雄,熊颖, 申楠茜,等. 新型冠状病毒肺炎(COVID-19)临床影像学特征[J]. 放射学实践, 2020, 35(2): 125-130.
	Guan H X, Xiong Y, Shen N Q, et al. Clinical and thin-section CT features of patients with the COVID-19 in Wuhan [J]. Radiol Prac, 2020, 35(2): 125-130.
6	Lei J, Li J, Li X, et al. CT imaging of the 2019 novel coronavirus (2019-nCoV) pneumonia [J]. Radiology, 2020, 295(1): 18.
7	Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome [J]. Lancet Respir Med, 2020, 8(4): 420-422.
8	刘茜,王荣帅,屈国强,等. 新型冠状病毒肺炎死亡尸体系统解剖大体观察报告[J]. 法医学杂志, 2020, 36(1): 19-21.
	Liu Q, Wang R S, Qu G Q, et al. J Forensic Med, 2020, 36(1): 19-21.
9	国家卫生和健康委员会. 关于加强新型冠状病毒感染的肺炎重症病例医疗救治工作的通知.新型冠状病毒感染的肺炎重症、危重症病例诊疗方案(试行)[S]. 国卫医函〔2020〕64.
10	Wiersinga W J, Rhodes A, Cheng A C, et al. Pathophysiology, transmission, diagnosis, and treatment of Coronavirus Disease 2019 (COVID-19) [J]. JAMA,2020, 324(8): 782-793.
11	国家卫生健康委办公厅,国家中医药管理局办公室. 新型冠状病毒肺炎诊疗方案(试行第七版) [S]. 国卫办医函〔2020〕184号.
12	国家卫生健康委办公厅,国家中医药管理局办公室. 新型冠状病毒肺炎诊疗方案(试行第八版) [S]. 国卫办医函〔2020〕680号.
13	World Health Organization. World Health Organization Family International Classifications, WHO-FICs [EB/OL]. [2020-03-20].
14	Zeng B, Chen D, Qiu Z, et al. Expert Consensus on Protocol of Rehabilitation for COVID-19 Patients Using Framework And Approaches of WHO International Family Classifications [J]. Aging Med (Milton), 2020, 3(2): 82-94.
15	邱卓英,李伦,陈迪,等. 基于世界卫生组织国际健康分类家族康复指南研究:理论架构和方法体系[J]. 中国康复理论与实践, 2020, 26(2): 125-135.
	Qiu Z Y, Li L, Chen D, et al. Research on rehabilitation guidelines using World Health Organization Family International Classifications: framework and approaches [J]. Chin J Rehabil Theory Pract, 2020, 26(2): 125-135.
16	Cerniauskaite M, Quintas R, Boldt C, et al. Systematic literature review on ICF from 2001 to 2009: its use, implementation and operationalization [J]. Disabil Rehabil, 2011, 33: 281-309.
17	Pretis M, Kopp-Sixt S, Er-Sabuncuoğlu D M, et al. ICF as a problem solving tool in transdisciplinary teams [J]. Adv Res Psychol, 2020. .
18	World Health Organization. International Classification of Health Interventions (ICHI) [EB/OL]. [2020-03-20]. .
19	中华医学会老年医学分会老年康复学组,中国心理学会康复心理学专业委员会,中国医院协会医疗康复机构管理分会,等. 基于世界卫生组织国际健康分类家族架构的2019冠状病毒病康复方案专家共识[J]. 中国康复理论与实践,2020, 26(10): 1117-1126.
	Chinese Medical Association, China Psychological Society, Chinese Hospital Association, et al. Consensus of Framework and Protocol of Rehabilitation of Coronavirus Disease 2019 Using WHO-FICs [J]. Chin J Rehabil Theory Pract, 2020, 26(10): 1117-1126.
20	国家卫生健康委办公厅,国家医疗保障局办公室. 关于印发新型冠状病毒感染相关ICD代码的通知[A]. 国卫医函〔2020〕58号.
21	World Health Organization. Technical Guidance about Coronavirus disease (COVID-19) [EB/OL]. [2020-03-20]. .
22	World Health Organization. Introduction to ICD-11 Webinar [EB/OL]. (2020-11-09).
23	World Health Organization. Brief Model Disability Survey [EB/OL]. [2020-03-10].
24	国务院新闻办公室. 国务院联防联控机制新闻发布会[Z]. 2020-02-07.
25	Salawu A, Green A, Crooks M G, et al. A proposal for multidisciplinary tele-rehabilitation in the assessment and rehabilitation of COVID-19 survivors [J]. Int J Environ Res Public Health, 2020, 17(13): 4890.
26	Tempest S, McIntyre A. Using the ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation [J]. Disabil Rehabil, 2006, 28(10): 663-667.
27	Negrini S, Grabljevec K, Boldrini P, et al. Up to 2.2 million people experiencing disability suffer collateral damage each day of COVID-19 lockdown in Europe [J]. Eur J Phys Rehabil Med, 2020, 56(3): 361-365.
28	Pan A, Liu L, Wang C, et al. Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China [J]. JAMA, 2020, 323(19): 1915-1923.
29	广东省康复医学科医疗质量控制中心. 广东省新型冠状病毒肺炎疫情防控特殊时期加强康复医疗防护和质控工作的指导意见(第一版)[J]. 广东医学, 2020, 41(4): 325-328.
	Guangdong Rehabilitation Medical Quality Control Center. Guangdong Med J, 2020, 41(4): 325-328.
30	喻鹏铭,何成奇,高强,等. 新型冠状病毒肺炎患者全周期物理治疗操作规范和建议[J]. 中华物理医学与康复杂志,2020, 42(2): 102-104.
	Yu P M, He C Q, Gao Q, et al. Chin J Phys Med Rehabil, 2020, 42(2): 102-104.
31	Pohlman M C, Schweickert W D, Pohlman A S, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation [J]. Crit Care Med, 2010, 38(11): 2089-2094.
32	Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review [J]. Cardiopulmon Phys Ther J, 2012, 23(1): 5-13.
33	张鸣生,郑则广,郭琪. 康复医学丛书:呼吸康复[M]. 北京:人民卫生出版社, 2019.
	Zhang M S, Zheng Z G, Guo Q. Rehabilitation Medicine Series: Respiratory Rehabilitation [M]. Beijing: People's Health Publishing House, 2019.
34	Hodgson C L, Denehy L. Measuring physical function after ICU: one step at a time [J]. Intensive Care Med, 2017, 43(12): 1901-1903.
35	Parry S M, Huang M, Needham D M. Evaluating physical functioning in critical care: considerations for clinical practice and research [J]. Crit Care, 2017, 21(1): 249.
36	Reid J C, Clarke F, Cook D J, et al. Feasibility, reliability, responsiveness, and validity of the patient-reported functional scale for the intensive care unit: a pilot study [J]. J Intensive Care Med, 2020, 35(12): 1396-1404.
37	Menezes K K, Nascimento L R, Ada L, et al. Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review [J]. J Physiother, 2016, 62(3): 138-144.
38	World Health Organization. Clinical management of COVID-19: living guidance. (2021-01-27). .
39	Mccool F D. Global physiology and pathophysiology of cough [J]. Chest, 2006, 129(1): 48S-53S.
40	Choi W, Park J, Kim D, et al. Cough assistance device for patients with glottis dysfunction and/or tracheostomy [J]. J Rehabil Med,2012, 44(4): 351-354.
41	Naraparaju S, Vaishali K, Venkatesan P, et al. A comparison of the Acapella and a threshold inspiratory muscle trainer for sputum clearance in bronchiectasis: a pilot study [J]. Physiother Theory Prac, 2010, 26(6): 353-357.
42	Fink J B. Forced expiratory technique, directed cough, and autogenic drainage [J]. Respir Care, 2007, 52(9): 1210.
43	Volsko T A. Airway clearance therapy: finding the evidence [J]. Respir Care, 2013, 58(10): 1669-1678.
44	Foti G, Cereda M, Sparacino M E, et al. Effects of periodic lung recruitment maneuvers on gas exchange and respiratory mechanics in mechanically ventilated acute respiratory distress syndrome (ARDS) patients [J]. Intensive Care Med, 2000, 26(5): 501-507.
45	Eltorai A E M, Baird G L, Eltorai A S, et al. Effect of an incentive spirometer patient reminder after coronary artery bypass grafting [J]. JAMA Surgery, 2019, 154(7): 579.
46	Gosselink R, Langer D. Recovery from ICU-acquired weakness; do not forget the respiratory muscles [J]. Thorax, 2016, 71(9): 779-780.
47	Gordon B R, Mcdowell C P, Hallgren M, et al. Association of efficacy of resistance exercise training with depressive symptoms [J]. JAMA Psychiatry, 2018, 75(6): 566.
48	Lear S A, Hu W, Rangarajan S, et al. The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-income countries: the PURE study [J]. Lancet, 2017, 390(10113): 2643-2654.
49	Howden E J, Sarma S, Lawley J S, et al. Reversing the cardiac effects of sedentary aging in middle age: a randomized controlled trial: implications for heart failure prevention [J]. Circulation, 2018, 137(15): 1549-1560.
50	Patel K, Straudi S, Yee Sien N, et al. Applying the WHO ICF framework to the outcome measures used in the evaluation of long-term clinical outcomes in coronavirus outbreaks [J]. Int J Environ Res Public Health, 2020, 17(18): 6476.
51	Pinto M, Gimigliano F, de Simone S, et al. Post-acute COVID-19 rehabilitation network proposal: from intensive to extensive and home-based it supported services [J]. Int J Environ Res Public Health, 2020, 17(24): 9335.
52	姜静远,邱卓英,王国祥,等. 世界卫生组织国际健康分类家族在康复中系统应用的方案与路线图[J]. 中国康复理论与实践, 2020, 26(11): 1241-1255.
	Jiang J Y, Qiu Z Y, Wang G X. et al. Systematic Implementation of World Health Organization Family International Classifications in rehabilitation: protocol and roadmap [J]. Chin J Rehabil Theory Pract, 2020, 26(11): 1241-1255.
53	World Health Organization, United Nation Children's Fund. Declaration on Primary Health Care [R]. Astana: Global Conference on Primary Health Care, WHO and UNICEF, 2018.
54	Gimigliano F, Negrini S. The World Health Organization "Rehabilitation 2030—A call for action" [J]. Eur J Phys Rehabil Med, 2017, 53: 155-168.

编码	疾病诊断
U07.1	COVID-19确认携带病毒
U07.2	COVID-19未确认携带病毒
U07.100	2019冠状病毒病
U07.100×001	新型冠状病毒肺炎
U07.100×002	新型冠状病毒感染
U07.100×003	新型冠状病毒肺炎临床诊断病例
Z03.800×001	新型冠状病毒肺炎疑似病例

一级类目	编码	内容	举例
s身体结构	s4301	肺的结构	肺实变，肺痰液积蓄
	s760	躯干的结构	气管切开
	s810	皮肤的结构	长期卧床后压疮，肢体肿胀
b身体功能	b440	呼吸功能	通气或/和换气功能下降
	b445	呼吸肌功能	吸气肌无力，脱机困难
	b450	辅助呼吸功能	咳嗽无效、无力
	b460	与心血管和呼吸功能相关的感觉	呼吸系统本体感觉减退
	b455	运动耐受功能	心肺运动耐力下降，容易疲劳
	b110	意识功能	昏迷等意识障碍
	b265	触觉功能	触觉减退
	b130	能量和驱力功能	患者疲倦，容易乏力
	b730	肌肉力量功能	肌力下降，获得性衰弱
	b152	情感功能	ICU综合征导致焦虑烦躁
d活动和参与	d330	说	气管切开或经口插管无法言语
	d310	交流-接收-口头讯息	无法接收外界信息
	d420	移动自身	手脚束缚无法移动身体
	d410	改变身体的基本姿势	手脚束缚导致无法自己姿势调整
	d520	护理身体各部位	手部束缚导致无法自主完成护理
	d450	步行	长期卧床无法离床运动
	d540	穿着	无法自主完成穿衣动作
	d710	基本人际互动	无法跟外界进行人际交流交往
e环境因素	e250	声音	中心电监护与呼吸机报警
	e310	直系亲属家庭	家属无法探视沟通
	e260	空气质量	密闭的环境
	e115	个人日常生活用的用品和技术	日常生活工具设备不能带进ICU

量表	描述
Borg指数	分0~10级，患者在运动时要求选择最能描述他们呼吸努力程度的等级
咳嗽评分	患者的咳嗽功能分为0~5分，功能分类为非功能咳嗽、弱功能咳嗽和功能性咳嗽
Miller痰液分级	将痰液按黏稠度分级
WHODAS2.0	采用36题版，包括6个维度：认知、活动性、自我照护、与人相处、生活活动和社会参与

编号	脱机困难	咳嗽无力	气道有痰液积蓄	肺不张	肢体乏力	体位转移障碍	步行功能障碍
1	√	√			√	√	√
2	√	√	√		√	√	√
3	√		√		√	√	√
4	√	√	√	√	√	√	√
5					√	√	√
6	√	√					√
7	√	√			√	√	√
8	√	√	√	√	√	√	√
9	√	√			√	√	√
10			√		√	√	√
11	√	√	√		√	√	√

功能障碍	表现	分类	康复措施
脱机困难	呼吸模式异常、肺功能障碍、呼吸急促、PEEP较高，呼吸肌无力	b440呼吸功能 b445呼吸肌功能 b450辅助呼吸功能	腹式呼吸、缩唇呼吸训练、呼吸综合训练
咳嗽无力	咳嗽无效无力，建立人工气道，气道廓清能力较差，气道有痰液积蓄	s760躯干的结构 s4301肺的结构 d330说	有效咳嗽训练、刺激咳嗽训练
气道有痰液积蓄	气道有痰液积蓄,气道廓清能力较差，可自主配合完成咳嗽动作，自主咳嗽较差	s4301肺的结构	主动呼吸循环技术、体位引流、呼气振动训练、运动呼气正压震荡系统
肺不张	气道有痰液积蓄,气道廓清能力较差，可自主配合完成咳嗽动作，自主咳嗽较差	s4301肺的结构 b460与心血管和呼吸功能相关的感觉	徒手肺过度充气技术和激励式呼吸训练器
肢体乏力	肌力不足，肌力减退	b455运动耐受功能 b130精力与驱动力 b760肌肉力量	呼吸操训练、抗阻系统肌力训练
体位转移障碍	长期卧床，坐位平衡障碍，无法自主体位转移	d420移动自身 d410改变身体的基本姿势	翻身训练、摇高床头训练、床边坐位训练
步行功能障碍	站立与步行功能障碍	d450步行 d410改变身体的基本姿势	离床站立训练与步行训练

基于国际健康分类架构构建新型冠状病毒病重症病区配对康复治疗模式及其效果

Construction and Effect of Partnership Model of Rehabilitation for Patients with COVID-2019 in Critical Wards Using International Health Classifications Framework

RichHTML

PDF (PC)

可视化

摘要/Abstract

引用本文

使用本文

图/表 6

参考文献 54

相关文章 2

Metrics

本文评价

推荐阅读 0

编号	脱机困难	咳嗽无力	气道有痰液积蓄	肺不张	肢体乏力	体位转移障碍	步行功能障碍
1	√	√			√	√	√
2	√	√	√		√	√	√
3	√		√		√	√	√
4	√	√	√	√	√	√	√
5					√	√	√
6	√	√					√
7	√	√			√	√	√
8	√	√	√	√	√	√	√
9	√	√			√	√	√
10			√		√	√	√
11	√	√	√		√	√	√

评估指标		治疗前	治疗后	t/χ2值	P值
咳嗽评分		3.45±1.21	4.18±0.75	-3.068	0.012
Borg指数		2.82±1.17	0.82±0.87	10.488	0.001
WHO-DAS2.0		121.64±5.12	101.55±5.34	15.993	0.001
Miller痰液分级(n)	黏稠	10	3	12.769	0.020
	不黏稠	1	8

[1]	刘远文,郑海清,杨敏,胡昔权. 新型冠状病毒病康复初探[J]. 《中国康复理论与实践》, 2020, 26(10): 1237-1240.
[2]	崔尧;李建军;丛芳;周红俊;桑德春;金龙. 一种基于浏览器/服务器结构的综合康复信息系统的设计与初步实现[J]. 《中国康复理论与实践》, 2015, 21(01): 114-116.

编号	脱机困难	咳嗽无力	气道有痰液积蓄	肺不张	肢体乏力	体位转移障碍	步行功能障碍
1	√	√			√	√	√
2	√	√	√		√	√	√
3	√		√		√	√	√
4	√	√	√	√	√	√	√
5					√	√	√
6	√	√					√
7	√	√			√	√	√
8	√	√	√	√	√	√	√
9	√	√			√	√	√
10			√		√	√	√
11	√	√	√		√	√	√

编号	脱机困难	咳嗽无力	气道有痰液积蓄	肺不张	肢体乏力	体位转移障碍	步行功能障碍
1	√	√			√	√	√
2	√	√	√		√	√	√
3	√		√		√	√	√
4	√	√	√	√	√	√	√
5					√	√	√
6	√	√					√
7	√	√			√	√	√
8	√	√	√	√	√	√	√
9	√	√			√	√	√
10			√		√	√	√
11	√	√	√		√	√	√