頭頸部がんへの化学放射線療法中患者の誤嚥性肺炎発症プロセスの質的検討

Qualitative Study of Factors Relevant to Aspiration Pneumonia in Patients Undergoing Chemoradiotherapy for Head and Neck Cancer

要　旨

　本研究の目的は，頭頸部がんへの化学放射線療法中患者が誤嚥性肺炎発症に至るまでのプロセスを明らかにすることである．37名の診療録および看護記録から，治療，治療に関連した身体症状および看護ケアについてデータ収集を行った．それらを質的記述的に分析し，誤嚥性肺炎発症群と非発症群ごとにカテゴリー関連図を作成し誤嚥性肺炎発症に至るまでの特徴を見い出した．

　誤嚥性肺炎発症群，非発症群ともに〈軟口蓋部，舌辺縁部の口腔粘膜有害事象〉の進行から〈疼痛症状の進行による鎮痛剤の使用〉〈疼痛症状の進行による医療用麻薬の使用〉というプロセスがあった．発症群の特徴として〈疼痛緩和困難による医療用麻薬の重ねての増量〉から〈せん妄発症による意識レベルの低下への対処〉と〈筋弛緩作用薬の使用〉というプロセスがあった．

　以上より，医療用麻薬の使用へ移行する前段階での疼痛コントロールについて重点的に取り組んでいくことが，せん妄の発症予防となり，誤嚥性肺炎発症予防につながると示唆された．

　Aspiration pneumonia is a common complication during the management of head and neck cancer, especially with chemoradiotherapy. Once aspiration pneumonia develops, it can lead to forced interruption of therapy. The purpose of this study was to determine the process of patients undergoing chemoradiotherapy for head and neck cancer until they developed aspiration pneumonia. This was a retrospective study of 37 patients who underwent chemoradiotherapy for head and neck cancer. We collected data on treatment, physical symptoms and nursing care from medical and nursing records. The collected data were analyzed by qualitative description, and a category relation diagram was created for the aspiration pneumonia and control groups to clarify the features in the aspiration pneumonia group. There were six patients in the aspiration pneumonia group and 31 patients in the control group. We found that the processes from the category relation diagram for both groups were: “oral mucosal adverse event in the soft palate and tongue border” to “use of painkillers because of progression of pain symptoms” and “use of medical narcotics because of progression of pain symptoms.” The processes for the aspiration pneumonia group were: “repeated increase in medical narcotics dose due to pain relief,” “dealing with lowering of consciousness level because of onset of delirium” and “use of muscle relaxant agonists.” Patients who had “repeated increase in medical narcotics dose due to pain relief” against pain caused by progression of oral mucosal adverse events required “dealing with lowering of consciousness level because of onset of delirium” and psychotropic drugs used for delirium treatment. “Use of muscle relaxant” caused relaxation of the esophageal sphincter. It was thought that aspiration pneumonia developed. To prevent the occurrence of aspiration pneumonia, it is important to focus on pain control before shifting to the use of medical narcotics to prevent the occurrence of delirium.