急诊有创呼吸支持方法的临床研究

目的 观察在急诊抢救危重患者的呼吸阶梯化管理中应用有创呼吸支持方法的效果.方法 总结1994年至2004年中对实施有创呼吸通路方法的292例急诊抢救患者相关临床资料并进行统计分析,比较环甲膜穿刺术、气管切开术、气管穿刺导入气管套管术、气管穿刺旋切术四种有创呼吸支持方法.结果 采用气管切开术203例（69.5%）、气管穿刺导入气管套管术58例（19.8%）、环甲膜穿刺术25例（8.6%）、气管穿刺旋切术6例（2.1%）;使用呼吸机占95例（32.5%）.常规气管切开术常需两个人以上操作,15～30 min完成;气管穿刺导入气管套管术只需单人操作,最快可在90 s以内完成,一般在3～5 min内完成,出血少,损伤小,对生命体征影响小,术中术后并发症少,伤口愈合快.结论 急诊快速建立有创呼吸通路应该视病情紧急程度按时间标准决定选择不同的方法.从速度由快到慢顺序是：环甲膜穿刺术、气管穿刺导入气管套管术、气管穿刺旋切术、气管切开术;从安全可靠性推荐：气管穿刺导入气管套管术、气管穿刺旋切术、气管切开术、环甲膜穿刺术.     

呼吸阶梯化管理在急诊呼吸支持抢救急危重症中的应用价值

目的探讨呼吸阶梯化管理在急诊呼吸支持抢救急危重症救治中的应用价值。方法选取收治的80例急危重症患者作为研究对象,均明确原发疾病并存在不同程度的呼吸衰竭,采用随机数字表法分为观察组与对照组各40例,对照组接受常规急诊抢救与呼吸支持治疗,观察组在常规抢救过程中开展呼吸阶梯化管理,比较两组急救效果及呼吸功能改善情况。结果两组在呼吸支持方面均以复苏体位、导管吸氧、面罩吸氧方式最为多见,观察组呼吸辅助方式主要为联合及跨阶梯方式,而对照组则主要以单一呼吸支持方式为主,观察组气管切开、气管环切率明显低于对照组,而复苏体位方式明显高于对照组(P0.05);观察组平均复苏时间、呼吸平稳时间均低于对照组(P0.05),治疗前两组APACHE II评分无显著差异(P0.05),治疗后观察组APACEH II评分明显低于对照组(P0.05)。结论用呼吸阶梯化管理方法能有效改善急危重症呼吸衰竭患者的呼吸功能,提升急危重症的抢救成功率与急救效果,对改善患者预后结局具有积极意义。     

加湿三通吸氧接头在60例气管切开老年呼吸衰竭病人脱机氧疗中的应用研究

如何为老年呼吸衰竭气管切开脱离呼吸机的病人选择一个安全有效便于临床应用的氧疗方式,是一个有意义的临床护理课题.俞森洋在<老年呼吸衰竭>中报道,在重症监护病房(ICU)老年病人高达50%,其中很多人都因呼吸衰竭需要机械通气,还有报道住入ICU中85岁病人中,82%需要机械通气,需要延长机械通气(10 d)的病人中,大于70岁病人占29%.老年呼吸衰竭的病人建立人工气道使用呼吸机通气后,要想成功脱掉呼吸机,拔除人工气道,采用的人工气道吸氧方式,直接关系到脱机的成功率,抢救成功率.我院ICU为气管切开呼吸衰竭的脱机氧疗老年病人采用自制加湿三通吸氧接头吸氧[2]脱机,取的满意效果,现报告如下.     

长期气管插管并呼吸支持抢救合并呼吸衰竭危重患者48例

1995年 5月以来 ,我院 ICU采用长期气管插管并呼吸支持方法抢救 48例合并呼吸衰竭 (呼衰 )的危重患者 ,报告如下。1　病例与方法1.1　病例 :48例中男 34例 ,女 14例 ;年龄 9～ 6 5岁。肺或食管癌切除术后呼衰 9例 ,颅脑手术后呼衰 11例 ,严重胆系感染、出血性坏死性胰腺炎、肠坏死中毒性休克合并呼衰 13例 ,严重胸、腹、颅及复合伤合并呼衰 15例。抢救时患者均有严重的低氧血症 ,其中 9例心跳、呼吸停止。1.2　插管途径及方法 :41例先经口腔插管 ,3日后考虑短期内不能拔管而改换鼻腔导管 ;7例抢救开始时即作鼻腔插管。鼻腔插管选用美国高…     

不同呼吸支持方式在危重症患者抢救中的价值比较

目的 探讨危重症抢救中呼吸支持的使用率及呼吸支持使用时间和方式与抢救成功率间的关系.方法 对458例接受呼吸支持的危重症患者临床资料进行分层分析,其中心搏、呼吸骤停47例,急性呼吸道阻塞105例,急性呼吸衰竭(呼衰)156例,慢性呼衰150例.分别进行气管插管、气管切开、无创口鼻/面罩通气,统计各组患者不同呼吸支持方式的抢救成功率与疾病、呼吸支持时间的关系.结果 呼吸支持治疗期间死亡117例(25.5%),放弃治疗49例,成功脱离呼吸机292例(63.8%).心搏、呼吸骤停患者复苏及呼吸支持抢救成功率为21.3%(10/47),按病因分类,急性呼吸道阻塞导致的呼衰抢救成功率为82.8%(87/105),急性呼衰的抢救成功率为55.1%(86/156),慢性呼衰合并肺性脑病患者呼吸支持成功率为72.7%(109/150).有创和无创呼吸支持的早期成功率分别为95.0%(57/60)和95.5%(21/22),较早期为81.7%(68/82)和69.0%(20/29),中期为65.6%(63/96)和48.1%(13/27),晚期为44.4%(40/90)和0(0/5),抢救成功率均随抢救开始时间的延迟而显著下降(P均<0.01).结论 呼吸支持的关键是尽早、及时进行有效呼吸支持,人工气道建立的困难和风险是不能早期使用呼吸支持的重要因素.     

心脏介入诊疗术中并发急性心血管事件患者行呼吸阶梯化管理的护理

目的探讨心脏介入诊疗术中并发急性心血管事件患者采用呼吸阶梯化管理的护理效果。方法 2012年1月至2013年12月,南京医科大学第一附属医院心导管室对254例心脏介入诊疗术中发生急性心血管事件患者采用呼吸阶梯化管理,并给予相应的护理措施。结果 237例(93.31%)患者顺利完成手术,安全转至病房;9例(3.54%)患者行气管插管和呼吸机辅助呼吸后转入ICU或CCU进一步治疗;8例(3.15%)患者因原发病危重而死亡。结论心脏介入诊疗术中并发急性心血管事件者经呼吸阶梯化管理及相应的护理,可提高呼吸管理效果,保证手术的顺利完成和提高抢救成功率。     

急诊患者呼吸阶梯的管理

本文通过对急救部近十年(1992年2月至2002年12月)收治的急诊病人进行回顾性临床研究，对呼吸通路进行阶梯管理，以期探讨呼吸通路的阶梯管理方案。     

高流量鼻导管吸氧辅助早产儿呼吸支持的护理

总结39例运用高流量鼻导管吸氧治疗早产儿呼吸衰竭的护理体会。在临床应用高流量鼻导管吸氧过程中,密切观察病情,加强呼吸道管理,保护面部皮肤,及早发现并治疗呼吸衰竭加重症状以避免再次气管插管,积极预防早产儿视网膜病。经治疗及护理,32例患儿成功改用普通鼻导管吸氧,7例患儿改用经鼻塞/鼻罩持续气道正压通气治疗或呼吸机有创机械辅助通气。     

气管插管在急诊抢救中的应用体会

气管插管术是临床急诊抢救过程中心肺复苏的关键，是心脏停搏后抢救成功的关键。尽早为气道梗阻患者实施气管插管，建立有效的呼吸通道，明显降低了患者的死亡率。     

简易呼吸气囊在大咳血窒息患者抢救中的应用

目的 探讨简易呼吸气囊在大咳血窒息患者抢救中的应用价值.方法对26例大咳血患者在常规救治的基础上使用简易呼吸气囊辅助通气,保证供氧的同时进行气道血块清除.结果26例大咳血窒息病例均抢救成功,22例未经气管插管的患者均好转出院,4例经气管插管接呼吸机通气的患者最后成功脱机,好转出院.结论在大咳血窒息的抢救过程中应用简易呼吸气囊辅助通气,可提高SpO2,保证大脑等重要器官的血氧供应,有效预防并发症,提高抢救成功率.其操作容易掌握、便捷、疗效确切,是抢救患者的较好手段,值得在临床推广应用.     

气管切开术的适应证及手术时机的选择

目的探讨气管切开术的适应证及手术时机的选择。方法我院2006年1月至2008年6月行气管切开术268例,所有手术在病房或手术室里进行,其中2例窒息患者先行环甲膜切开,再行常规气管切开。结果 268例气管切开术患者中,72%(193/268)是为了机械通气支持/长时间插管,或吸出下呼吸道分泌物;19.4%(52/268)是辅助头颈部手术;6.0%(16/268)是为了解除上气道阻塞;73.1%(196/268)在病房完成,19.4%(52/268)术前于手术室完成,7.5%(20/268)急诊床旁完成。结论 气管切开术适应证已大大扩展,由过去的仅用于解除上气道阻塞的急诊手术发展为现在的主要用于机械通气支持、吸出下呼吸道分泌物和辅助头颈部手术的常见手术操作,手术时机的选择应恰当。     

环甲膜穿刺置管在胸科术后呼吸道护理中的作用研究

目的探讨环甲膜穿刺在胸科手术后呼吸道护理中的作用。方法采用回顾性研究的方法,比较开展环甲膜穿刺前、后,开胸手术后呼吸衰竭发生率和气管切开率的差异。结果在开展环甲膜穿刺以前,胸科病人手术后呼吸衰竭发生率为4.2%(12/288);开展环甲膜穿刺以后,胸科手术后呼吸衰竭发生率为1.9%(6/310),两组间有显著差异;胸科手术后气管切开率在上述两个时期分别为6.3%(18/288)和2.6%(8/310),两组间也有显著差异。在接受环甲膜穿刺的68例病人中,没有一例发生严重并发症。结论环甲膜穿刺是一种容易掌握、安全性很高的操作,对于促进胸科手术后病人咳嗽、排痰,防止呼吸道分泌物潴留导致的呼吸衰竭有临床应用价值。     

ED hemodialysis for treatment of renal failure emergencies.

Patients with chronic renal failure (CRF) are at risk for unique medical emergencies, many of which require hemodialysis for their definitive treatment. This study describes the use of emergency department (ED) hemodialysis in the management of CRF patients. A retrospective chart review was conducted of patients who underwent ED hemodialysis at a regional dialysis center between April 1994 and September 1996. Data were collected on presenting complaint, ED diagnosis, indication for hemodialysis, ED pharmacologic treatment, ED airway management, cardiovascular stability, and disposition. Fifty episodes of ED hemodialysis were identified in 37 different patients. Presenting complaints included: shortness of breath, 38 (69%); weakness, 8 (15%); chest pain, 3 (5%); and other, 6 (11%). ED diagnoses included: congestive heart failure, 36 (65%); hyperkalemia, 13 (24%); and other, 6 (11%). Indications for hemodialysis included: cardiovascular instability, 33 (38%); respiratory distress, 22 (26%); cardiac monitoring, 16 (19%), timing, 13 (15%); and other, 2 (2%). Predialysis stabilization included: nitroglycerin, 29 (26%); sublingual captopril, 17 (15%); calcium chloride, 13 (11%); sodium bicarbonate, 12 (11%); insulin/dextrose, 11 (10%); none, 12 (11%); and other, 18 (16%). Airway support included: noninvasive pressure support ventilation (NPSV), 9 (18%); and endotracheal intubation, 6 (12%). NPSV was provided with a bilevel positive airway pressure system. Three of the endotracheal intubation patients were weaned to NPSV during dialysis, and all NPSV patients were weaned from respiratory support during their hemodialysis in the ED. Some patients had more than one problem. Sixteen patients (32%) were admitted, while 34 (68%) were discharged, including 3 NPSV patients and 22 initially unstable patients. ED hemodialysis in conjunction with additional medical care is a useful emergency medicine technique that can prevent hospital admission in patients with acute renal emergencies.     

Complications of emergency intubation with and without paralysis

Expert and definitive airway management is fundamental to the practice of emergency medicine. In critically ill patients, rapid sedation and paralysis, also known as rapid-sequence intubation, is used to facilitate endotracheal intubation in order to minimize aspiration, airway trauma, and other complications of airway management. An alternative method of emergent endotracheal intubation, intubation minus paralysis, is performed without the use of neuromuscular blocking agents. The present study compared complications of these two techniques in the emergency setting. Sixty-seven intubations minus paralysis were prospectively compared with 166 rapid-sequence intubations. Complications were greater in number and severity in the nonparalyzed group and included aspiration (15%), airway trauma (28%), and death (3%). None of these difficulties were observed in the rapid-sequence group (P < .0001). These results show that rapid-sequence intubation when compared with intubation minus paralysis significantly reduces complications of emergency airway management and should be made available to emergency physicians trained in its use.     

Management of difficult airways in the field

Establishing an airway is a critical first step in emergency management of comatose patients and those who have suffered head trauma, cardiac arrest, or respiratory failure. The use of succinyl-choline, a paralytic, to assist with intubation is a safe and effective way to help establish an airway under difficult circumstances, in the prehospital setting. It requires excellent intubation skills, a thorough knowledge of the indications and contraindications of its use, and similar knowledge of any other medications employed. Succinylcholine-assisted intubation should never be implemented without close physician monitoring. Therefore, under the auspices of strong medical control, it is an effective way to establish adequate oxygenation and to control ventilation in some of the most critical patients encountered in the field. Additionally, because physical examination alone is not dependable for ensuring proper endotracheal tube placement, an objective confirmatory device such as an end-tidal carbon dioxide detector should be used.     

A Comparison of Trauma Intubations Managed by Anesthesiologists and Emergency Physicians

Although airway management by emergency physicians has become standard for general emergency department (ED) patients, many believe that anesthesiologists should manage the airways of trauma victims. OBJECTIVES: To compare the success and failure rates of trauma intubations performed under the supervision of anesthesiologists and emergency physicians. METHODS: This was a prospective, observational study of consecutive endotracheal intubations (ETIs) of adult trauma patients in a single ED over a 46-month period. All ETIs before November 26, 2000, were supervised by anesthesiologists (34 months), and all ETIs from November 26, 2000, onward were supervised by emergency physicians (12 months). Data regarding clinical presentation, personnel involved, medications used, number of attempts required, and need for cricothyrotomy were collected. Study outcomes were: 1) successful intubation within two attempts, and 2) failure of intubation. Failure was defined as inability to intubate, resulting in successful intubation by another specialist, or cricothyrotomy. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were used to compare results between groups. RESULTS: There were 673 intubations during the study period. Intubation within two attempts was accomplished in 442 of 467 patients (94.6%) managed by anesthesiologists, and in 196 of 206 of patients (95.2%) managed by emergency physicians (OR = 1.109, 95% CI = 0.498 to 2.522). Failure of intubation occurred in 16 of 467 (3.4%) patients managed by anesthesiologists, and in four of 206 (1.9%) patients managed by emergency physicians (OR = 0.558, 95% CI = 0.156 to 1.806). CONCLUSIONS: Emergency physicians can safely manage the airways of trauma patients. Success and failure rates are similar to those of anesthesiologists.     

The role of noninvasive ventilation: CPAP and BiPAP in the treatment of congestive heart failure.

Congestive heart failure (CHF) is a common cause of respiratory failure for which patients seek emergency care. Mechanical ventilation is commonly used in the treatment for severe CHF. Studies have shown that noninvasive ventilation (NIV) methods, such as continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP), are effective in treating CHF and have fewer complications than endotracheal intubation. The use of NIV in the treatment of CHF has been shown to increase oxygenation, improve hemodynamic stability, and decrease the need for intubation. When NIV is chosen for a patient in CHF, the critical care nurse needs to be vigilant in assessing and monitoring these patients, especially those in severe CHF. This article evaluates the differences between the 2 types of NIV, the controversies that may exist, practice issues for the critical care nurse, and any financial considerations.     

Emergency percutaneous tracheostomy is feasable in experienced hands.

One of most stressful situations for a physician occurs when a patient is unable to breathe and endotracheal intubation is not possible. The establishment of an open airway by surgery is indicated only if the physician is unable to do so with an endotracheal tube. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Percutaneous dilatational tracheostomy in experienced hands takes only a few minutes. We describe six patients, including two trauma patients, in whom emergency percutaneous tracheostomy was rapidly and successfully performed under conditions of the imminent loss of airway and inability to intubate the patient. As this procedure is safe and can be performed easily by experienced personnel, we propose its addition to the armamentarium of emergency airway management.     

胸外科肺癌手术后呼吸机应用的护理

目的总结胸外科肺癌患者术后使用呼吸机支持治疗的护理体会。方法对56例肺癌术后使用呼吸机支持治疗的患者,实施包括严密观察生命体征、心理护理、气管插管及切开的护理、口腔护理、肺部并发症的预防护理和褥疮护理等一系列护理措施。结果所有患者术后均保留气管插管进入ICU监护,行呼吸机治疗12～48 h,均顺利脱机,无一例发生相关并发症。结论肺癌术后患者,做好呼吸机支持治疗的护理,加强呼吸道管理是促进术后顺利康复的重要环节。