神经外科患者无支气管镜辅助经皮扩张气管切开术182例临床研究

目的评价神经外科患者无支气管镜辅助行经皮扩张气管切开术的可行性和安全性。方法2002年～2006年182例神经外科患者于首都医科大学附属北京天坛医院ICU行经皮气管切开术。使用导丝扩张钳(GWDF)技术(152例)和经皮旋转扩张(Percutwist)技术(30例)。所有患者均未使用支气管镜辅助。记录手术一般情况及并发症,随访3个月。比较国内外相关资料的差别。结果所有患者均置管成功。GWDF方法操作时间平均约4～5min,Percutwist方法操作时间平均约8.5min,其中熟练者操作约6～7min,欠熟练者操作约10min。并发症发生率为4.95%,常见并发症为切口出血(6例)及切口感染(2例)。发现1例皮下气肿。研究期间未见气胸、气管食管瘘和有症状的气管狭窄等,无与气管切开相关的死亡。结论神经外科患者无支气管镜辅助行经皮扩张气管切开术安全可行,但必须严格掌握适应证并严格进行人员技术培训,认真操作。有条件时应使用支气管镜辅助以进一步降低并发症的发生。     

Standard surgical versus percutaneous dilatational tracheostomy in intensive care patients

OBJECTIVE: The present prospective randomized trial compared surgical tracheostomy (ST) and percutaneous dilatational tracheostomy (PDT) in intensive care unit (ICU) patients in terms of outcomes and complications. METHODS: Between January 2003 and December 2005 tracheostomies were performed on critically ill ICU patients in Medical Faculty Hospital in Prague, with a random allocation of 105 patients for ST and 100 for PDT. RESULTS: The 2 groups did not differ significantly in terms of basic demographic characteristics or length of endotracheal intubation prior to the procedure. Following the procedures, the 2 groups did not differ significantly in terms of the time required for decannulation, decannulated patients or mortalities. Post-mortem examination showed that both groups were similar in terms of placement of the tracheostomy tube. Surgical tracheostomy was found to take longer time to perform than PDT (p<0.001). In terms of early postoperative complications, PDT was associated with a higher rate of postoperative bleeding compared to ST (p=0.0302). CONCLUSION: Percutaneous dilatational tracheostomy is a simpler and faster technique to perform, but is associated with a higher occurrence of early complications, particularly postoperative bleeding.     

Percutaneous dilational tracheostomy: An initial experience in community based teaching hospital

Percutaneous dilational tracheostomy (PDT) is frequently performed in the intensive care unit to prevent the long term complications associated with prolonged endotracheal intubation. Objective: To report the analysis of our experience with percutaneous dilation tracheostomy. Study Design: A prospective documentation of 40 patients who received percutaneous dilational tracheostomy in a multidisciplinary intensive care unit during a 12-month period. Method: The patients demographic, indications of intubation and PDT, time required to perform the procedure, complications and the outcome of these patients in the intensive care unit were noted. Result: Among 425 patients, 40 underwent percutaneous dilational tracheostomy that included 22 females and 18 males with the median age of 35 years. Prolonged ventilatory support was the most common indication for tracheostomy. The average duration of intubation before PDT was 5 days. Median procedure time was 20 minutes. Complications included minor bleeding in two (5%), subcutaneous emphysema with pneumothorax in two patients (5%), tracheal stenosis in three (7.5%), tracheo-esophageal fistula and glottic granuloma in one patient each (2.5%). Among forty patients, 28 (70%) were discharged to the ward, 8 died in intensive care unit and 4 left hospital against medical advice. Conclusion: Percutaneous dilational tracheostomy is a safe, quick and effective way for long term airway management in critically ill patients.     

经皮扩张性气管切开术的临床应用

目的：探讨经皮扩张性气管切开术行气管切开及气道套管插入的方法与效果。方法：在内科ICU病房内，采用一步性扩张气管切开术，对35例患者进行气管切开，同时采用纤维支气管镜对其中l0例患者进行气道内检查。结果：按照操作规程，均完成了气管切开及气管套管的插入，平均操作时间为5．4min．所有患者在带管过程中及拔管后，未发现有气道狭窄的发生，无瘘管或瘘道形成，且创口愈合良好。结论：经皮扩张性气管切开术操作简便易行，值得临床推广使用。     

手术者经验对经皮扩张气管切开术影响的研究

目的:观察手术者经验的积累对经皮扩张气管切开术实施过程、并发症的影响。方法:对2006年6月-2008年12月入住我院ICU的经同一手术者进行经皮扩张气管切开术的24例患者进行研究,分析手术者在不同阶段经皮扩张气管切开术从局部麻醉到插入气管套管的时间、术中出血量、术后发生皮下气肿、气胸等并发症的发生率。结果:全部病例的手术时间为4～18min,平均手术时间为(8.25±3.94)min,术中出血量1～20ml不等,平均出血量为(5.08±4.89)ml,其中前10例的手术时间为(11.5±3.78)min,出血量为(7.2±7.0)ml,后14例的手术时间为(5.93±1.90)min,出血量为(3.57±1.55)ml;术后发生皮下气肿4例,其中3例发生于前10例;不同阶段比较差异具有统计学意义(P<0.05)。所有病例无1例发生气胸、大出血等严重并发症。结论:手术者对技术掌握的熟练程度对手术时间及术中出血、术后皮下气肿等并发症的发生具有明显影响,提示为减少术中、术后的并发症,缩短手术时间,加强对手术者的培训十分重要。     

经皮气管切开术在神经重症患者救治中的效果分析

目的探讨经皮气管切开术（Percuta—neousDilationalTracheostomy,PDT）与传统气管切开术在神经重症患者救治中的优劣。方法回顾2012年2月一2013年2月在我院住院的76例需行气管切开的急性神经重症患者,其中经传统手术气管切开19例,经皮气管切开57例,术前、术后采用美国国立卫生研究院卒中量表（NIHStrokeScale,NIHSs）和格拉斯哥昏迷评分法（GCS,GlasgowComaScale）二种神经评分系统进行神经功能评价,观察比较手术操作时间,出血量、气胸、皮下气肿、气管瘘、食管损伤以及肺部感染等并发症的发生率。结果经皮气管切开_术在手术时间上明显优于传统气管切开术,术中、术后并发症的发生率低于传统气管切开术。结论经皮气管切开术有效快速建立神经重症患者的气道,操作简便、安全,降低呼吸系统感染并发症的发生率。     

经皮扩张气管切开术临床普及应用

目的研究经皮穿刺气管切开术和传统气管切开术的疗效不同。方法对116例危重病人施行经皮穿刺扩张气管切开术。结果经皮扩张气管切开术与传统气管切开术相比,操作时间短,切口小,术中出血少,术后并发症少,切口愈合快,感染率低。结论经皮扩张气管切开术优于传统气管切开术,适合在临床普及应用。     

经皮扩张气管切开术与传统气管切开术在ICU中的应用比较

目的:比较经皮扩张气管切开术与传统气管切开术在ICU中的应用及特点。方法:入住ICU的72例危重患者被随机分为两组,其中经皮扩张气管切开术组(PDT组)41例,同期传统气管切开术组(ST组)31例。对照两组在手术切口大小、手术时间、预后、早期并发症和晚期并发症发生率之间的差异。结果:PDT组的手术时间、切口大小、术中出血、术中低氧血症、切口感染、切口溢痰及并发症的发生率明显低于ST组(P<0.05)。结论:经皮扩张气管切开术与传统气管切开术相比,具有速度快、损伤小、并发症少等优点,值得在ICU中推广应用。     

Audit on tracheostomies performed at the General Intensive Care Unit, Kuala Lumpur Hospital

During a 6-month period from October 2000 to March 2001, we analysed the indications, methods, waiting period and complications following a tracheostomy at the General Intensive Care Unit (GIGU) of Hospital Kuala Lumpur. There were 49 tracheostomies performed during this period. Thirty of them were performed in the GICU using the percutaneous dilatational method while 19 were performed electively in the Operating Theatre (OT) by the ear, nose and throat (ENT) surgeons. The main indications for a tracheostomy were prolonged mechanical ventilation and airway protection for patients with a poor Glasgow Coma Scale. The average waiting time for a tracheostomy after a decision was made to perform one was 1.34 +/- 0.72 days for a percutaneous tracheostomy and 3.72 +/- 2.52 days for a surgical tracheostomy. This difference was statistically significant (p < 0.001). There was excessive bleeding in 3 patients in the percutaneous tracheostomy group and 1 patient in the surgical tracheostomy group. Percutaneous tracheostomy is now the main method of tracheostomy at the GICU in Hospital Kuala Lumpur. Haemorrhage is the most significant complication of this procedure. However the overall complication rate is comparable with that of a surgical tracheostomy.     

第3、4气管软骨环至上中切牙的距离与体表标志的关系及其临床价值

目的研究第3、4气管软骨环至上中切牙的距离与胸骨长度的关系,为经皮扩张气管切开术（PDT）患者外退气管导管提供参考数据。方法第一阶段选择重症医学科行传统气管切开术的患者112例,纤维支气管镜直视下测量第3、4气管软骨环至上中切牙的距离（D）,并以胸骨长度进行一元线性相关分析。第二阶段选择重症医学科气管插管且需行PDT的患者76例,随机分为观察组（A组）和对照组（B组）。A组患者先按第一阶段得出的回归方程计算出D值,然后以D为导向外退气管导管,而B组患者仅凭临床医师经验外退气管导管,待导管尖端退至预定位置后行PDT。观察两组患者手术耗时、一次退管成功率,再次气管插管率的情况。结果112例正常成人胸骨长度15．7-25．1cm,平均（19．3±1．5）cm,D为17．7～23．6cm,平均（18．4±1．6）cm,D与胸骨长度存在显著相关性（r=0．87,P〈0．00。与B组比较,A组患者PDT耗时明显减少[（11．2±1-3）min vs（13．3±1．2）min,P=0．000]。结论胸骨长度预测出的第3、4气管软骨环至上中切牙的个体化距离可以指导PDT患者退管,并减少其手术时间。     

无支气管镜辅助经皮扩张气管切开术的可行性及安全性分析

目的 评价神经外科患者无支气管镜辅助行经皮扩张气管切开术的可行性和安全性.方法 对2005～2010年间,120例入住我院ICU的神经外科患者行经皮气管切开术,术式采用经皮旋转扩张(Percutwist)技术.全部由耳鼻喉科医师完成.本组患者均未使用支气管镜辅助.结果 所有患者均置管成功.操作时间平均约8.5 min,...     

光索辅助微创气管切开术在颌面肿瘤术的应用

目的探讨光索辅助微创气管切开术在颌面肿瘤术的应用价值。方法对25例行颌颈肿瘤根治及远位皮瓣修复术的患者,手术结束时采用盲探气管插管装置的组件光索来辅助定位气管导管头端,将其退至第3气管软骨环处并在第3与第4气管软骨环间行微创气管切开术。结果 25例患者均按上述方法顺利完成手术,操作平均用时为(8.6±1.1)min,术中未发生明显的即刻并发症,术后随访患者均未出现声音嘶哑和明显气道狭窄,也无任何疼痛主诉。采用该方法操作后的气切瘢痕愈合较传统方法平整、美观。结论光索辅助微创气管切开术操作简便,成功率高,手术并发症少,减轻了患者的痛苦,在口腔颌面肿瘤术中有广泛的应用前景。     

经皮扩张气管切开术在ICU中的临床应用价值

目的：通过比较传统开放性气管切开术（OT）和经皮扩张气管切开术（PDT）在ICU中的应用情况来评价PDT的临床应用价值。方法：将84例需要气管切开的危重患者随机分成两组，即传统开放性气管切开组（OT组）和经皮扩张气管切开组（PDT组），各42例。OT组行传统开放性气管切开术，PDT组行经皮气管切开术，观察手术时间、切口大小、术中出血量、伤口愈合时间及术后并发症。结果：PDT组手术时间为（8．35±1．76）min．切El大小为（1．27±0．20）cm，术中出血量为（6．03±1．70）ml，伤口愈合时间为（4．5±0．5）d，明显低于对照组（P〈0．01），术后并发症发生率也低于对照组。结论：经皮扩张气管切开术操作简单，安全快速，出血量少，创伤小，伤口愈合时间快，并发症少，明显优于传统开放性气管切开术，在ICU危重患者抢救中，有广泛的应用价值。     

经皮扩张气管切开术与传统开放气管切开术在重症监护病房应用效果的比较

目的：研究经皮扩张气管切开术与传统开放气管切开术在重症监护病房应用效果。方法：回顾分析我院重症监护病房（ ICU）56例行气管切开患者,其中经皮扩张气管切开术（ PDT）组30例,传统开放气管切开术（ OT）组26例。对两组患者的手术切口、手术时间、术后切口感染、术后出血、皮下气肿进行比较并分析。结果：PDT组比OT组的手术切口小、手术时间短、术中出血少、术后切口感染率低、术后出血发生率低,差异均有统计学意义（P﹤0.05）,皮下气肿的发生率PDT组较OT组低,但差异无统计学意义（P＞0.05）。结论：经皮扩张气管切开术操作简便、快捷、手术时间短、创伤小、出血少、并发症少且轻等特点,是一种安全性、简易度和效价比优于传统开放气管切开术的微创气管切开术。     

开颅术后经皮扩张气管切开术的并发症及防治

目的 探讨开颅术后经皮扩张气管切开术（PDT）并发症的发生原因及其防治措施.方法 回顾分析187例开颅术后行PDT患者的临床资料.结果 11例患者皮下局部有出血,6例患者有气管套管异位,2例有肉芽组织形成,3例有感染,5例皮下气肿.结论 并发症的发生与术者对气管切开术的熟练程度及解剖层次的掌握、术后良好的护理有密切关系.     

经皮扩张气管切开术临床应用研究

目的：研究经皮扩张气管切开术与传统气管切开术2种方法的不同特点。方法：90例气管切开患者,根据手术方式的不同分为A、B两组,A组（48例）行经皮扩张气管切开术,B组（42例）行传统气管切开术,观察并比较两组患者手术时间、切口大小、术中出血量、术后并发症及切口愈合等情况。结果：与传统气管切开术相比,经皮扩张气管切开术操作时间短,切口小,术中出血少,术后并发症少,切口愈合快,感染率低（P〈0．05～0．01）。结论：经皮扩张气管切开术优于传统气管切开术。     

微创气管切开术在神经外科应用体会

目的介绍经皮气管切开术在神经外科的应用经验。方法对32例神经外科病人采用导丝扩张钳法进行经皮气管切开术。结果32例均顺利完成手术，手术时间平均7min，未发生严重并发症及与手术操作有关的死亡。结论经皮气管切开术简单、快速、损伤小，可在神经外科广泛应用。     

徒手急诊动脉测压管引导经鼻气管导管置换

目的观察应用动脉测压管做引导,置换经鼻气管导管的临床效果。方法经鼻气管内插管的病人由于呼吸机报警提示气管导管漏气、或气管导管内痰痂阻塞等原因经常规处理无效,需要再次气管插管。实验组12例患者不使用先拔管再插管的老办法,而是徒手(不借助其他如纤支镜等器械)将引导管插入气管导管内至隆突水平,并拔出原气管导管;将欲更换的气管导管套在引导管外,在引导管引导下将新的气管导管插入气管内,完成换置;对照组为20例患者通过常规先拔管再在纤支镜引导下经鼻气管插管,完成更换。结果实验组及对照组全部32例病例均顺利完成更换经鼻气管导管,术后均未发生与更换导管相关重大并发症,但实验组较对照组在换管过程中病人氧合更加稳定,心率血压变化小,鼻出血、心律失常发生率低,耗时短。结论应用气管导管置换,方法安全、简便易行,可替代传统的先拔管再借助纤支镜引导经鼻气管导管换管的方法。     

经皮扩张气管切开术在ICU的临床观察

目的为ICU危重症患者寻找一种微创、简便、快速的气管切开方法,从而提高抢救的成功率。方法将80例需要气管切开的患者分为两组,分别进行经皮扩张气管切开术(percutaneous dilational tracheostomy,PDT)和传统的开放性气管切开术(surgical tracheostomy,ST),对比两组患者手术时间、切口大小以及手术并发症等情况。结果 PDT组手术时间(8.5±4.2)min、切口长度(1.4±0.2)cm、出血量(5.4±1.6)mL、切口愈合时间(6.5±1.2)d、瘢痕面积(0.4±0.23)cm2与ST组的手术时间(23.4±9.1)min、切口长度(4.5±0.3)cm、出血量(17.1±3.1)mL、切口愈合时间(9.5±2.1)d、瘢痕面积(0.8±0.37)cm2比较,差异均有统计学意义(均P<0.05);手术并发症发生率PDT组(5%)明显小于ST组(30%),P<0.05。结论经皮扩张气管切开术是一种微创的外科气管切开术,对于ICU危重症患者人工气道的建立有很高的应用价值。     

Track your trach: Removal of a fractured tracheostomy tube using a flexible fibreoptic bronchoscope in a patient with severe head injury

Tracheostomy is a common airway procedure for life support in critically ill patients with head injuries. This procedure is safe but also associated with early and late complications. Tube fracture and dislodgement into the tracheobronchial tree leading to airway obstruction is a rare but life-threatening complication after prolonged tracheostomy tube placement. There are very few published reports of tracheostomy tube fracture and dislodgement into tracheobronchial tree in a neurologically injured patient. We report a case of a fractured tracheostomy tube which got impacted in the left main bronchus, in a 41-year-old male patient who had been on prolonged tracheostomy tube after craniotomy and evacuation of subdural hematoma. The distal part of the tracheostomy tube fractured and impacted in the left main bronchus. Fibreoptic bronchoscopy was performed through the oral cavity to extract it, and the anaesthetic management during the period is discussed.