脳卒中患者の誤嚥の有無と摂食訓練の適応に関する検討

Study on Aspiration and Swallowing Exercise in Stroke Patients

Ⅰ．はじめに

　近年，摂食・嚥下障害への関心が高まり，病院や施設での取り組みが急速に始まっている。脳卒中では高率に誤嚥を伴うことが知られているが，それに気づかず摂食を行えば，肺炎のみならず，窒息のような生命危機に直面する。特に，咳やむせなどの徴候なしにみられる不顕性誤嚥（silent aspiration: SA)^1）は見過ごされがちであるが，最近は嚥下造影（videofluoroscopy: VF）によって明らかにされるようになった^2，3）。しかし，姿勢や食材，一口量や形態が異なれば，嚥下可能な場合もあるので，嚥下動態を観察評価し，適切な方法を検討することが，誤嚥の予防には重要である。既報^4）にて，これらの誤嚥と身体所見，認知機能，スクリーニングテスト等との関係については報告した。本研究では，嚥下造影検査（VF）で誤嚥を確認できた症例に対して，各々の症例に見合う安全な食材や栄養摂取方法ならびにその退院時の摂食状態について検討した。

Abstract

　We investigated factors for aspiration by videofluoroscopy (VF) and swallowing exercises in stroke patients.　Subjects were 102 stroke patients aged 34-101 years (mean 72.8±13.8 years) including 72 males and 30 females and for whom VF was performed because of suspected swallowing difficulty.　They consisted of 64 patients with cerebral infarction, 33 patients with cerebral hemorrhage, and 5 patients with subarachnoid hemorrhage.　Aspiration was classified into aspiration with choking and silent aspiration (SA) by the presence of a cough reflex.　Eating instructions such as foodstuffs and intake methods and outcome were investigated.　On VF, aspiration with foodstuffs was found in 59 of 102 (57.8%) patients and SA was found in 44 of them (44.1%).　Some patients ate food on the ward in spite of SA in VF.　Such patients were given eating instructions by the judgment of the attending physician, but foodstuffs and intake methods based on the results of VF could be changed in most cases.　As for swallowing training, direct training was conducted only in a few patients in the group that presented overt aspiration in this study.　On the other hand direct training was possible in the majority of patients if foodstuffs and intake methods were handled appropriately in SA.　If these strok patients were approached with attention paid to the forms of foodstuffs and intake method on the basis of detailed evaluation on VF using mimic foodstuffs, eating was possible without aspiration in many cases.

（Received: October 27, 2006, Accepted: March 27, 2007)