— 降低風險 · MEDIUM · SATA —
護理師採取下列哪些措施最能有效預防呼吸器相關肺炎 (VAP)？（選所有適合的）
Which of the following interventions by the nurse would be most effective in preventing ventilator-associated pneumonia (VAP)? (Select all that apply.)
- AKeep the head of the bed elevated at 30-45 degrees✓ 正解將床頭抬高 30-45 度
- BPerform daily sedation vacation to assess readiness to wean✓ 正解每日暫停鎮靜以評估撤機準備情況
- CChange the ventilator circuit daily每日更換呼吸器管路
- DPerform oral care with chlorhexidine every 2-4 hours✓ 正解每 2-4 小時使用氯己定進行口腔護理
- EMaintain cuff pressure at 20-30 cm H2O✓ 正解維持氣囊壓力在 20-30 cm H2O
— Explanation · 中文詳解 —
預防 VAP 的組合式照護包括：床頭抬高以防逆流、每日評估撤機（Sedation vacation）以縮短插管時間、使用氯己定（Chlorhexidine）口腔清潔以減少口咽細菌群落，並維持氣囊壓力以確保密封與減少吸入風險。更換管路則依醫院指引，不需每日更換。
Preventing ventilator-associated pneumonia involves elevating the head of the bed to reduce aspiration, performing daily sedation vacations to facilitate early extubation, maintaining appropriate cuff pressures to prevent microaspiration, and using chlorhexidine for oral care to decrease bacterial colonization. Ventilator circuits should not be changed daily but only when soiled or malfunctioning.
✦ 台美臨床差異
美台皆採用 VAP Bundle 概念，美國強調自動化監測，台灣臨床則更依賴護理人員落實口腔清潔頻率的合規性。