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。

Clinical Studies on 182 Cases of Neurosurgical Patients with Percutaneous Dilative Tracheostomy without the Assistance of Bronchoscopy

Objective To evaluate the feasibility and safety of 182 patients underwent percutaneous tracheotomy using the guide wire dilation forceps(GWDF) techniques and the Percutwist technique without the assistance of bronchoscopy in intensive unit from the year 2002～2006.Methods 182 patients underwent the Percutaneous Dilative Tracheostomy(PDT) in ICU of Tiantan hospital.Most of them are transferred from the neurosurgical department of our hospital.A 3 months' follow-up visit was performed(except the dead cases).The first 152 patients underwent PDT by using the GWDF techniques Kit,and the remaining 30 patients underwent PDT by using the PercuTwist tracheotomy Kit.Results All the cases have a successful cannulation.Non of them was conversed to the conventional open tracheostomy technique.The mean operating duration of GWDF was 4～5 minutes.The mean operating durations of Percutwist was 8.5 minutes,the duration of practician was 6～7 minutes and the duration of unpratician was about 10 minutes in Percutwist technique.Overall,the two most common complications were peristomal hemorrhage in 6 cases and wound infection in 2 cases.1 cases of pneumoderma was found.During the 3 months' follow-up visit,there were no complications of pneumothorax,tracheo-esophageal fistula,symptomatic tracheal stenosis and operating-related death.No symptomatic tracheal stenosis was found.The total complication rate of PDT in our ICU was 4.95%.The total complication rate abroad was 6.23%.11 cases dead form other reasons which was not relate to PDT.The incidence of complications were similar to the relevant domestic and abroad literatures,some complications were even lower than the literatures abroad.The absence of serious complications such as pneumothorax symptomatic tracheal stenosis and pneumomediastinum are attributable to identify the anatomic landmark strictly,ensure the smooth gliding movement of the J guide wire in each step of the operation,never use brute force downward to the trachea.Conclusion The PDT without the assistance of bronchoscopy is feasible and safe.The operator should be careful,obey the contraindication strictly,improve the techniques and skills,never use brute force downward to the trachea.The severe complications of the PDT were not relate to the use or not use of the bronchoscopy.If the PDT kit can be improved to adapt the circumstance of non bronchoscopic assistance,it will be more popular.