俯臥通氣治療及其護理

Prone Position and Nursing Care

急性呼吸窘迫症候群（acute respiratory distress syndrome, ARDS）是威脅生命的疾病，因肺部急性炎症反應，病人會有嚴重低血氧及呼吸困難症狀。ARDS的治療包括使用呼吸器輔助換氣、皮質類固醇注射、體外膜氧合治療、吸入一氧化氮以及俯臥等。其中俯臥通氣治療經實證顯示可顯著降低病人死亡率，它是利用俯臥時被壓迫的肺葉減少，獲得血液灌流的肺泡增加，也就是通氣灌流重新分佈，藉以改善氧合狀況。俯臥通氣治療應盡早執行，當呼吸器輔助通氣後12–24小時症狀仍未改善，且氧合指數小於150 mmHg時即可開始進行俯臥治療；但若病人有顱內壓升高、血液動力學不穩定、腹部開放性傷口或懷孕時則不適合執行。採俯臥治療前應固定妥病人身上管路，每次調整姿勢時也應再次檢視所有管路，確保功能順暢沒有扭曲；俯臥過程中注意易受壓部位皮膚是否發生壓力性損傷，可事先予泡棉敷料黏貼保護。藉由此篇文章簡介ARDS的病生理機轉、俯臥通氣治療的原理、適應症、合併症與護理照護事項，期望護理師照護俯臥治療的病人能多一份自信。

Acute respiratory distress syndrome (ARDS) is a life-threatening disease, as acute inflammation in the lungs typically leads to hypoxia and symptoms of dyspnea. The treatment modalities of ARDS include mechanical ventilation, corticosteroid, extracorporeal membranous oxygenation, inhaled nitrogen oxide, and the prone position. Among these, the prone position is supported by evidence showing significantly reduced mortality in patients that adopt this modality. Lying in the prone position reduces atelectatic lung volumes by recruitment of dependent parts and facilitates normal regulation of alveolar ventilation, giving better-matched ventilation perfusion and, thus, improved oxygenation. Lying in the prone position should be initiated as early as possible and may be implemented when there is limited improvement after 12-24 hours under mechanical ventilation and when the PaO2/FiO2 ratio is less than 150 mmHg. However, the prone position may not be appropriate for patients with increased intracranial pressure, hemodynamic instability, an open abdominal wound, or pregnancy. Prior to setting a patient in the prone position, fixation of tubings should be affirmed, and all tubings should be reexamined after each adjustment in position in order to ensure that they are free of twists and function well. In addition, caution should be given to the skin at pressure points to avoid pressure sores and foam dressings may be applied in advance for protection. This article summarizes the pathophysiology of ARDS, the principle of applying the prone position, and related indications, complications, and nursing care in order to give nurses more confidence in caring for patients using the prone position.