人工气道气囊内压力与误吸量相关性动物实验研究

目的探讨人工气道气囊内压力与误吸的相关性。方法Sheridan气管导管气囊上缘伴行7．0Fr吸痰管，健康杂种犬麻醉后置入内径7．0mm的气管导管，给人工气道气囊充气，选择不同水平囊内压，在气囊上声门下通过伴行的吸痰管注入10mL生理盐水，保留5min，收集剩余液体量，漏出液体量即误吸量，观察比较各囊内压力下误吸量。结果囊内压力在29mmHg时误吸量为0mL，与囊内压力在26mmHg误吸量为（0．48±0．48）mL相比有显著差异P〈0．05。当囊内压力在15mmHg时误吸量为（1．3±1．57）mL，18mmHg时误吸量为（0．8±1．0）mL，22mmHg时误吸量为（0.75±0．8）mL，与囊内压力在26mmHg比较均无显著差异。囊内压力在11mmHg时已出现漏气。结论囊内压力在15-26mmHg时误吸量无显著差异，临床工作中可结合其他因素选择此范围内的压力。     

气囊压力动态变化及预防渗漏的临床研究

目的动态监测气管导管气囊压力,观察不同因素作用下气囊压力的动态变化;探讨气管导管气囊渗漏的机制并指导防渗漏发生。 方法（1）使用压力传感器连接气囊和心电监护仪,动态监测气囊压力的波形变化,并观察呼吸、吸痰、咳嗽、上调呼气末正压通气（PEEP）等情况下气囊压力的变化。（2）将不同型号气管导管插入模拟气管（注射器）内,气囊注气至压力为25~30 cmH₂O（1 cmH₂O=0.098 kPa）;注入含有亚甲基蓝的0.9%NaCl稀释液模拟气囊上分泌物,探讨气管导管气囊渗漏的机制,指导气囊防渗漏的发生。 结果机械通气患者气囊压力随呼吸呈现周期性变化,与平静呼吸时气囊压力相比,吸痰、咳嗽时气囊压力均显著升高,差异有统计学意义[（27.95±2.72）mmHg vs（20.32±2.08）mmHg,t=0.14,P<0.01;（28.68±2.93）mmHg vs （20.32±2.08）mmHg,t=0.03,P<0.01;1 mmHg=0.133 kPa];PEEP增加2 cmH₂O以上时,气囊压力升高至（24.12±2.94）mmHg,差异有统计学意义（t=0.01,P<0.01）;气囊压力不足时,压力波形呈一直线。体外渗漏模拟试验显示,与7号气管导管相比,8号气管导管气囊外径相对气管内径偏大气囊渗漏显著增加,差异有统计学意义（P<0.05）;气囊外径相对气管内径偏小时,气囊上方分泌物沿气囊与气管间隙呈袖套状渗漏。气管导管呈30°~45°倾斜位时,需注意气囊上导管外壁引流管口水平面以下分泌物潴留及渗漏。 结论气管导管气囊压力受多种因素影响而呈现动态变化,需个体化设置并动态监测、实时调整气囊压力。选择与气管相匹配的气管导管型号可降低气囊渗漏的发生。     

老年危重病人人工气道气囊压力监测及护理

[目的 ]探讨人工气道气囊压力监测在老年危重病人气管导管护理中的应用价值。 [方法 ]将 60例建立人工气道的老年危重病人随机分成两组 ,实验组应用PORTEX专用气囊压力监测表注气测压 ,对照组采用传统的手指捏感法注气 ;用呼吸机检查漏气情况 ,并比较两组病人的气囊注气容积、气囊压力及并发症发生率。 [结果 ]实验组气囊压力为 2 .45 2kPa±0 .490kPa时 ,气囊容积为 10 .0mL± 4.7mL ,呼吸机检查不漏气 ;对照组气囊压力为 3 .92 3kPa± 0 .73 6kPa时 ,气囊容积为 15 .0mL± 5 .1mL ,呼吸机检查不漏气。两组病人气管黏膜损伤、气囊破裂发生率比较有统计学意义 (P <0 .0 5 ) ;两组病人误吸、食管气管瘘发生率比较无统计学意义 (P >0 .0 5 )。 [结论 ]建立人工气道的老年危重病人气囊压力维持在1.961kPa～ 2 .942kPa ,能有效避免误吸的发生和气管黏膜的损伤。     

高流量气道湿化结合进食训练对气管切开合并吞咽障碍患者误吸与残留的影响

目的 探索高流量气道湿化对气管切开合并吞咽障碍患者的误吸与残留的影响。 方法 纳入中山大学附属第三医院康复医学科收治的气管切开伴吞咽障碍患者17例,在气管套管处配接高流量湿化仪并抽空气囊,对照条件为气管套管堵管、抽空气囊、充盈气囊的三种状态,在不同状态下给予患者5 ml中稠食物,使用喉镜吞咽功能评估（FEES）对残留和误吸情况进行评估。 结果 17例患者在高流量湿化、气管套管堵管、抽空气囊、充盈气囊四种状态下的渗漏-误吸评分和残留评分差异均有统计学意义(P<0.001)。配接高流量湿化仪时,17例患者的渗漏-误吸评分为（3.2±2.0）分,明显低于另三种状态下的渗漏-误吸评分［气管套管堵管（5.2± 2.3）分、抽空气囊（5.6±2.3）分、充盈气囊（6.0±2.3）分］,差异有统计学意义(P<0.001)。配接高流量湿化仪时,17例患者的残留评分为（2.8±1.1）分,亦明显低于另三种状态下的残留评分［气管套管堵管（3.8±1.2）分、抽空气囊（3.6±1.3）分、充盈气囊（3.9±1.4）分］,差异亦有统计学意义(P<0.001)。 结论 配接高流量湿化仪可以有效改善气管切开患者的吞咽功能状态。     

机械通气病人气管导管的气囊压力与吸气峰压的关系

目的:探讨机械通气时应用最小闭合容量技术注气的气管导管的气囊压力与气道吸气峰压之间的关系。方法:37例用高容低张气囊气管导管插管的机械通气病人,应用最小闭合容量技术注气,并同步测定气囊压力和记录同一时间的气道吸气峰压,用统计学方法分析气囊压力和气道吸气峰压之间的关系。结果:应用最小闭合容量技术注气的气囊压力为13+6 mmHg(4—26 mmHg),气道吸气峰压为23+7 am H2O(15-40 cm H2O);气囊压力与气道吸气峰压之间呈直线正相关(r=0.762,P<0.001,n=37)。结论:应用最小闭合容量技术的气囊压力水平与气道吸气峰压有关,并随后者的增高而增高,当气道吸气峰压较高时,有可能对气管造成缺血性损害。     

带芯多孔口腔吸痰管对机械通气气道的保护作用

目的:探讨使用带芯多孔口腔吸痰管吸痰对机械通气患者气道的保护作用.方法:将80例机械通气患者随机分为观察组(n=41)和对照组(n=39)分别应用带芯多孔口腔吸痰管和传统吸痰管吸痰;比较两组口腔粘膜损伤出血、口咽部和气囊上分泌物滞留量、口腔分泌物细菌培养阳性率.结果:观察组的口腔粘膜损伤出血、口咽部和气管导管气囊上分泌物滞留量、口腔分泌物细菌培养阳性率均明显低于对照组,P<0.05.结论:带芯多孔口腔吸痰管吸痰町减少机械通气患者口腔粘膜损伤出血和气管导管气囊上分泌物滞留量,对气道有一定的保护作用.     

误剪气管导管气囊连接管的补救方法

气管插管是ICU建立人工气道,保持呼吸道通畅,有效进行氧疗或机械通气的主要方式,在护理操作中若不慎将气管导管气囊连接管剪断,会立即导致气囊漏气;病人口、鼻以及气管导管气囊以上的分泌物进入气管内发生呛咳,严重者导致误吸;整个通气环路漏气,呼吸机不能正常工作。常规的处理方法是立即为病人充分吸痰后更换新的气管导管。在更换导管的过程中易出现插管困难、窒息、吸入性肺炎等问题,给病人增加身心痛苦。我们采用以下方法补救,效果较好,介绍如下。     

2种目标气囊压力监测下吸痰对气管插管患者的影响

目的 比较2种目标气囊压力监测下吸痰对气管插管患者的影响.方法 选取我院重症医学科的术后气管插管患者100例,采用随机数字表法分为2组,观察组50例患者入监护室后气囊压力目标监测为25 cmH2O,对照组50例患者入监护室后气囊压力目标监测为30 cmH2O.观察比较2组患者吸痰后最高气囊压、吸痰前后差值、吸痰后气囊压高压时间及气道损伤情况.结果 2组患者吸痰后最高气囊压、吸痰前后差值及气道损伤的比较差异无统计学意义(P>0.05),观察组患者吸痰后气囊压高压时间短于对照组,差异有统计学意义(P<0.05).结论 2种气囊压力监测水平下,吸痰均可导致气囊压力明显升高,但25 cmH2O的低水平气囊压力,患者吸痰后气囊压高压时间较短,可维持较好的气道黏膜毛细血管血流灌注,使气管插管患者有降低气道损伤发生的可能性.     

4种临床因素对人工气道气囊压力的影响

目的探讨吸痰、翻身、口腔护理及吞咽对人工气道气囊压力的影响,为更好地进行气囊管理提供依据。方法应用压力传感器持续监测气囊压力,观察吸痰、翻身、口腔护理过程中气囊压力的变化,记录活动前、活动时、活动后5 min、15 min、30 min的气囊压力值;另外观察吞咽对气囊压力的影响,观察时间点为吞咽前、吞咽时、吞咽后1min、5 min、10 min。结果吸痰时、吸痰后5 min气囊压力高于吸痰前,翻身时、翻身后5 min气囊压力高于翻身前,口腔护理时气囊压力高于口腔护理前,吞咽时气囊压力高于吞咽前,差异均有统计学意义(P0.05)。结论吸痰、翻身、口腔护理、吞咽会导致气囊压力出现短暂性升高,瞬时的压力增高可能会误导医务人员对气囊安全性的判断,建议在此期间不可盲目调整气囊压力,以免增加漏气和误吸的风险。     

经鼻气道内留置吸痰管护理在重症昏迷患者中的应用

目的 观察经鼻气道内留置吸痰管在重症昏迷患者中的应用效果.方法 选取2015年4月至2016年4月本院收治的神经重症昏迷患者120例,按照随机数字表法分为对照组和干预组各60例.对照组给予常规的吸痰护理,干预组留置经鼻气道内留置吸痰管,有痰时及时吸痰.观察并记录两组患者的肺部感染的发生率、神智转清的时间、动脉血气分压的变化.结果 干预组肺部感染的发生率为(4.54%)、神智转清的时间为(4.3±2.5)d,显著低于对照组肺部感染的发生率(13.63%)和神智转清的时间(6.8±4.6)d,差异均有统计学意义(均P<0.05);干预组的血压分压(74.26±11.26)mmHg显著高于对照组的(62.24±10.24)mmHg,二氧化碳分压(46.84±6.28)mmHg显著低于对照组的(49.26±5.47)mmHg,差异均具有统计学意义(均P<0.05).结论 采用经鼻气道内留置吸痰管对神经重症昏迷患者进行吸痰护理,能明显减少并发症的发生,缩短患者苏醒的时间,改善患者的动脉血压分压,值得临床应用.     

The effect of mouth prop on endotracheal tube intracuff pressure in children during dental rehabilitation under general anaesthesia

Although the endotracheal tube (ETT) cuff may be associated with tracheal morbidity, cuffed tubes may reduce the aspiration risk in oral procedures. Dentists must use a mouth prop to facilitate oral visualization and to protect the oral soft tissues during dental rehabilitation under general anaesthesia (DRGA). The aim of this study was to evaluate the effect of mouth prop on endotracheal tube intracuff pressure in children during DRGA. Two-hundred and three ASA I-II patients, <18 years of age (mean: 5.3?±?2.4 years) were included in the prospective observational study whose comprehensive dental treatment was performed under general anaesthesia. Following the induction of general anaesthesia, placement of a cuffed endotracheal tube which was an appropriate size for children was fixed. The intracuff pressure was measured intermittently after the intubation (baseline) (T0), immediately after the mouth prop (T1), 30 min after the mouth prop (T2), after taking out the mouth prop (T3) and just before extubation (T4). The mean intracuff pressure was 28.3?±?2.01 cm H₂O at T0. The mean intracuff pressure significantly increased at T1 (30.8?±?2.7) and T2 (29.6?±?3.7) compared to T0 (P?<?0.001). No significant differences were observed between the duration of the procedure and intracuff pressure or postoperative complications (P?>?0.05). Cough, sore throat and nausea were observed in 4, 1 and 5 patients, respectively. Because a mouth prop may increase the intracuff pressure of ETT, strict measurement and readjustment of cuff pressures should be employed when used in children during DRGA.     

对机械通气患者气管套管气囊压力的临床观察

目的判断机械通气患者气管套管气囊压力和注气量是否合适。方法对30例机械通气老年患者的气管套管气囊压力和注气量的实际值和理想值进行精确测量。结果53.3％的患者气囊实际压力和注气量过高，大于理想值。其中气囊实际注气量大于理想注气量3～5ml，气囊压力超过理想压力2～26cmH2O(0．2～2．6kPa)。结论临床大部分气管套管气囊压力和注气量偏高，应对机械通气患者的气管套管压力和注气量定期进行精确测量和调整，以减少气管套管对气管粘膜的损伤。     

A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement

Cuffed endotracheal tubes are one aspect of airway management designed to ensure safety, yet patients can be at risk for injury from underinflated and overinflated endotracheal cuffs. Tracheal pressures exceeding approximately 48 cm H2O impede capillary blood flow, potentially causing tracheal damage, and pressures below approximately 18 mm Hg may increase the risk of aspiration. There is no standard identified in the literature describing the method of cuff inflation, and nurse anesthetists use various cuff inflation techniques. The purpose of this study was to compare endotracheal cuff pressures obtained by estimation techniques with direct endotracheal cuff pressure measurements. A convenience sample of 40 anesthesia providers (nurse anesthesia students, Certified Registered Nurse Anesthetists, and anesthesiologists) inflated the endotracheal tube cuff using their usual inflation technique. The endotracheal tube cuff pressure was measured with a noninvasive manometer connected to the pilot balloon. Pressures obtained by estimation techniques ranged from 6 to 60 cm H2O (mean = 44.5; SD = 13.07). Analysis revealed that fewer than one third of the anesthesia providers inflated the cuff within an ideal range. No differences were found between level of anesthesia provider and cuff inflation pressures. We conclude that estimation techniques for cuff inflation are inadequate and suggest that direct measurements be used.     

The interaction of subglottic drainage,cuff pressure,and oral care on endotracheal tube fluid leakage: A benchtop study

BackgroundThe types of endotracheal tube, positive end-expiratory pressure (PEEP) level, endotracheal tube cuff pressure level, and nursing activity may influence the occurrence of pulmonary aspiration in ventilated patients with an endotracheal tube, but the evidence on their degree of influence is still inconclusive.AimThe aim of this study was to examine the effect of endotracheal tubes with or without subglottic secretion drainage on fluid leakage across endotracheal tube cuffs under different PEEP levels, different cuff pressures, and with or without oral care.MethodThis was a benchtop study with a multifactorial experimental design using two sets of airway. The two types of endotracheal tubes were tested through 12 scenarios with 240 combinations of different PEEP levels (0, 5, and 10 cmH₂O), endotracheal tube cuff pressures (15 and 25 cmH₂O), and oral care (with or without) using two sets of airway manikins. Each scenario lasted for 30 min, and fluid leakage was measured at the end of each scenario. Generalised Linear Model test was used to analyse fluid leak at 30 min (with and without interaction effect).ResultsA total of 100 cases showed fluid leakage, with more fluid leakage occurring in low cuff pressure (15 cmH₂O), no PEEP, and with oral care. Results of the Generalised Linear Model revealed that endotracheal tubes with subglottic secretion drainage, high PEEP (at 10 cmH₂O), normal cuff pressure (at 25 cmH₂O), and no oral care demonstrated a significant effect in reducing fluid leakage than endotracheal tubes without subglottic secretion drainage, low PEEP (at 5 or 0 cmH₂O), and low cuff pressure (at 15 cmH₂O) (all p < 0.001). However, only the interaction effect of endotracheal tubes with subglottic secretion drainage*high PEEP showed a significant effect on fluid leakage (p < 0.001), with the combination of endotracheal tube*no PEEP producing the greatest volume of fluid leak.ConclusionUsing endotracheal tubes with subglottic secretion drainage, high PEEP, and normal cuff pressure and avoiding excessive endotracheal tube movement during oral care reduced fluid leakage. This study provided strong evidence to inform practice on reducing microaspiration in ventilated patients.     

Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube

Objective This study compared the recently introduced Microcuff endotracheal tube HVLP ICU featuring an ultrathin (7-µm) polyurethane cuff membrane with endotracheal tubes from different manufacturers regarding fluid leakage past the tube cuff.Design In vitro setup.Measurements and results The following endotracheal tubes (ID 7.5 mm) were compared: Mallinckrodt HiLo, Microcuff HVLP ICU, Portex Profile Soft Seal, Rüsch Super Safety Clear, and Sheridan CF. A vertical PVC trachea model (ID 20 mm) was intubated, and cuffs were inflated to 10, 15, 20, 25, 30, and 60 cmH₂O. Colored water (5 ml) was added to the top of the cuff. The amount of leaked fluid past the tube cuff within 5, 10, and 60 min was recorded. Experiments were performed four times using two examples of each tube brand. Fluid leakage past tube cuffs occurred in all conventional endotracheal tubes at cuff pressures from 10 to 60 cmH₂O. In the Microcuff tube cuff pressure fluid leakage was observed within 10 min only at 10 cmH₂O. Results with the Microcuff tube were significantly better than all other tube brands at cuff pressures of 10–30 cmH₂O.Conclusions Within the acceptable upper limit for tracheal cuff pressure (25–30 cmH₂O) the Microcuff endotracheal tube was the only one of the tested tubes to prevent fluid leakage in our in vitro setup. In vivo studies are required to confirm these findings.This study was supported by Microcuff GmbH, Weinheim, Germany, by providing the Microcuff tubes without charge. No financial support was obtained from the manufacturer for the study. Dr. Weiss and Dr. Gerber serve on the Medical Board of Microcuff GmbH for the development of a newly designed pediatric cuffed tracheal tube.     

Assessment of a New Method to Distinguish Esophageal from Tracheal Intubation by Measuring the Endotracheal Cuff Pressure in a Porcine Model

Objectives: With the knowledge of differences in anatomic structures between the trachea and the esophagus, the authors conducted an animal study to evaluate the usefulness of endotracheal cuff pressure in distinguishing endotracheal and esophageal intubations. Methods: Six swine were anesthetized and endotracheally intubated with 7.5-mm cuffed endotracheal tubes. The intubations were confirmed by fiber-optic bronchoscopy. Each pilot balloon was connected to a 10-mL syringe and a manometer via a three-way stopcock. The cuff pressures were measured for each 1-mL incremental filling of air (1–10 mL). After removal of the endotracheal tubes, each swine was then intubated with the same endotracheal tubes into its esophagus. The cuff pressures of the esophageal intubation were measured with the same procedure. The cuff pressures and the pressure–volume relationships in both intubations were compared. Results: The cuff pressure increased significantly in the esophageal intubation in comparison with the endotracheal intubation in all the comparisons from 1 mL to 10 mL (p = 0.028 for all Wilcoxon signed-rank tests). The slope of the pressure–volume curve of the cuff pressure was also significantly higher in the esophageal intubation during the inflation of the cuff on average (0.047 vs. 0.032 cm H₂O/mL; p = 0.001), particularly in the first 5 mL of air inflation. Conclusions: The cuff pressure in the esophageal intubation was significantly higher than that in the endotracheal intubation under the same inflated volume from 1 to 10 mL. This may provide the basis for an adjunctive, simple, rapid, and reliable method to verify endotracheal intubation.     

Non-invasive oscillometric versus invasive arterial blood pressure measurements in critically ill patients: A post hoc analysis of a prospective observational study

PurposeThe aim was to compare non-invasive blood pressure measurements with invasive blood pressure measurements in critically ill patients.MethodsNon-invasive blood pressure was measured via automated brachial cuff oscillometry, and simultaneously the radial arterial catheter-derived measurement was recorded as part of a prospective observational study. Measurements of systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and mean arterial pressure (MAP) were compared using Bland-Altman and error grid analyses.ResultsPaired measurements of blood pressure were available for 736 patients. Observed mean difference (±SD, 95% limits of agreement) between oscillometrically and invasively measured blood pressure was 0.8 mmHg (±15.7 mmHg, −30.2 to 31.7 mmHg) for SAP, −2.9 mmHg (±11.0 mmHg, −24.5 to 18.6 mmHg) for DAP, and −1.0 mmHg (±10.2 mmHg, −21.0 to 18.9 mmHg) for MAP. Error grid analysis showed that the proportions of measurements in risk zones A to E were 78.3%, 20.7%, 1.0%, 0%, and 0.1% for MAP.ConclusionNon-invasive blood pressure measurements using brachial cuff oscillometry showed large limits of agreement compared to invasive measurements in critically ill patients. Error grid analysis showed that measurement differences between oscillometry and the arterial catheter would potentially have triggered at least low-risk treatment decisions in one in five patients.     

神经外科ICU患者胃内容物反流误吸的影响因素分析

目的了解神经外科ICU患者胃内容物反流及误吸的发生率,分析发生误吸的高危因素,为临床及时给予有效护理干预措施,预防误吸发生,减轻误吸并发症提供依据。方法选取某三级甲等医院神经外科ICU机械通气患者进行病情观察,收集年龄、性别、体位、意识状态、胃潴留量、鼻饲管口径、人工气道气囊压力等数据,采集咽喉部分泌物及气管分泌物,进行胃蛋白酶检测。结果观察235例次患者,胃内容物反流的发生率为48.1%,误吸发生率为38.3%。经单因素分析得出不同胃管直径型号、气管插管/气管切型号、鼻饲液泵入速度、胃潴留量、Glasgow评分、气囊压力及是否使用镇静剂患者误吸发生率差异有统计学意义(P0.05或P0.01)。进一步采用Logistic回归分析,患者误吸的影响因素为Glasgow评分、鼻饲液泵入速度、胃潴留量和气囊压力。结论根据胃内容物反流误吸的发生原因,随时观察患者的病情变化,特别注意患者的意识状态和胃潴留量,检测气管插管或气管切开的气囊压力,采取合理的鼻饲液泵入速度,以降低胃内容物反流误吸率。     

气管导管套囊压力术中管理的研究进展

气管导管套囊在机械通气中,可起防止气道漏气,预防呼吸机相关性肺炎的作用。套囊压力管理是气管插管患者气道管理中的一个重要环节。深入了解气管导管套囊压力的影响因素及管理方法,能更好地为气管插管术后套囊相关并发症的防治提供参考。