老年人工气道重建致气管食管瘘的防治

临床上气管食管瘘多发生于食管癌侵蚀及其手术并发症，气管切开套管置入所致者仅见于个案报道；而人工气道重建是对需要气道管理、急慢性呼吸衰竭老年患者治疗的关键性处理手段，尤其是长时间呼吸机支持者常需行气管切开置入气管套管，在此过程中多种原因可导致气管后壁损伤，形成气管食管瘘，由此可致严重后果。故气管切开套管留置所致气管食管瘘的预防、诊断和处理在临床上日益受到关注。     

等压气囊气切套管在气管切开患者中的应用效果观察

目的 观察等压气囊气切套管在气管切开患者中的应用效果.方法 60例气管切开患者随机分为等压套管组及低压套管组各30例.等压套管组在气管切开后插入Bivona等压气囊气管切开套管,低压套管组在气管切开后插入一次性低压气囊气管套管,两组均给予呼吸机辅助呼吸、气管切开套管内滴入湿化液、吸痰等常规治疗;对两组痰痂堵管、漏气、出血、反流误吸、气道肉芽肿形成、平均机械通气时间、ICU住院天数进行比较.结果 等压套管组机械通气（13.1±3.2）d、住ICU（15.4 ±3.2）d,低压套管组分别为（17.6±7.4）、（19.6±7.4）d,P均＜0.05.等压套管组痰痂堵管、漏气、气道出血、反流误吸、气道肉芽肿分别为10、1、3、1、2例,低压套管组分别为18、12、6、6、7例,P＜0.01或＜0.05.结论 气管切开术后采取Bivona等压气囊气切套管可以有效降低并发症的发生,缩短机械通气时间及ICU住院天数,尤其适用于长期进行机械通气的患者.     

可吸痰式气管切开套管预防呼吸机相关性肺炎的护理观察

目的探讨可吸痰式气管切开套管在呼吸机治疗中对呼吸机相关性肺炎(VAP)发生率的影响。方法将64例行气管切开患者随机分成两组,A组为实验组,B组为对照组,使用可吸痰式气管切开套管,并持续进行气囊上分泌物冲洗吸引,A组使用普通气管切开套管,按常规护理;分析两组呼吸机相关性肺炎(VAP)发生率与呼吸机使用时间。结果A实验组发生呼吸机相关性肺炎(VAP)6例,发生率18.7%,B对照组发生呼吸机相关性肺炎(VAP)14例,发生率43.7%;实验组明显低于对照组(P0.05)。机械通气时间A组平均为120.1±70.5小时,B对照组为190.1±97.7,实验组明显低于对照组(P0.05)。结论机械通气患者应用可吸痰式气管切开套管行气囊上分泌物吸引有利于预防呼吸机相关性肺炎的发生。     

1例气管插管指示气囊损伤后的应急处理

<正>气管插管技术在危重患者抢救中应用十分广泛,而气管插管指示气囊的管理是气管插管管理的重要内容。如果管理不当或操作失误,导致气囊压力过高,会引起呼吸道黏膜损伤,如缺血、溃疡、坏死和炎症,更甚者可导致食管气管瘘;而气囊压力不足则会导致气道漏气,造成潮气量不足、误吸、呼吸机相关性肺炎等严重并发症[1]。我科室收住1名患者,在为患者脱去衣物时损伤指示气囊,积极采取补救措施,避免了重新插管。     

老年气管切开置管并发气管食管瘘

目的探讨老年患者气管切开置管并发气管食管瘘的原因及诊治方法。方法对9例老年气管切开置管并发气管食管瘘的临床资料进行回顾性分析。结果本组病例从套管留置到确诊气管食管瘘的时间平均为30.2±17.9天;临床表现主要有发作性成人呼吸窘迫症(3例),吸入性肺炎(3例);经套管中吸出胃内容物确诊4例,经纤维支气管镜确诊2例,2例误诊为慢性支气管炎,后经胃镜确诊;6例胃管鼻饲饮食,1例行胃造瘘术,1例行胃造瘘 空肠造瘘术;随访3个月,6例死亡。结论老年患者气管切开置管并发气管食管瘘与老年生理特点及疾病因素有关,死亡率高,临床表现缺乏典型性,应积极预防,及时诊断,避免误诊,以适宜的治疗为主。     

气管内加压呼吸引起气管食道瘘1例

为了维持呼吸道畅通、保证氧的供应,常于患者气管切开后选用带气囊的气管套管连接人工呼吸器进行气管内加压呼吸。本文则报告1例因气囊压迫一月左右发生气管食道瘘的病例。女患,30岁。于1983年8月3日因乙型脑炎入院。入院后昏迷加深,很快出现去脑强直并出现痰阻、缺氧、呼吸加快,于8月5日作气管切开,应用人工呼吸器作气管内加压呼吸及青、链霉素常规治疗,并     

气管插管患者气管食管瘘形成的原因及高频喷射通气治疗

气管插管机械通气导致患者气管食管瘘(TEF)者较为罕见,其发病率约为0.5%.本文报道2例呼吸机依赖患者TEF 形成,及其危险因素如下:①插管套囊内压力高是导致TEF 最主要的危险因素.研究表明,当套囊内压力在30cmH_2O 以上时,相应部位气管粘膜的血流量减少,当压力增至50cmH_2O时,血供完全中断.因此气管插管套囊压力高是TEF 形成的主要因素.②低血压状态.血压较低时     

气管食管瘘七例临床诊治经验

长期置入气管套管的患者,由于多种原因导致气管后壁损伤形成瘘管,与食管相通,称为气管食管瘘,严重影响患者的生命质量,甚至危及生命.现将1994-2007年北京安贞医院6例和北京丰台医院1例确诊的气管食管瘘病例诊治情况报道如下.     

气管切开术在心脏外科的应用

【】 目的 探讨心脏外科重症机械通气患者气管切开的时机和并发症及其预防措施。 方法 对36例心外脏科实施的气管切开的患者的临床资料进行总结。 结果 所有患者均存在不同程度的肺部感染,36例重症心脏病患者均为术后机械通气5天以上,长时间应用呼吸机,难以脱机,全部行气管切开术。其中3例出现并发症,4例因多器官功能衰竭死亡。 结论 对于一些重症心脏术后长时间依赖机械通气的患者来说,气管切开术已成为一种有效的治疗辅助措施, 为提高心脏外科的重症患者的治疗质量提供更多帮助。     

气管食管瘘的内镜下治疗

正气管食管瘘(tracheoesophageal fistula,TEF)是指由于先天或后天获得性因素导致食管与气管之间形成瘘管,可以分为气管-食管瘘与支气管-食管瘘。临床上主要表现为反复肺部感染、进食呛咳、阵发性咳嗽、咯血等。TEF根据病因的不同可以分为良、恶性,据文献~([1])报道47%良性TEF是由机械通气导致的,恶性TEF中食管肿瘤占75%。1%机械通气患者当中可能发生TEF,虽然发生率并不     

Late complications of tracheotomy

Complications of tracheotomy are largely preventable. Although some authors cite these complications as indications for prolonged endotracheal intubation to avoid tracheotomy, others believe that the laryngotracheal complications of prolonged endotracheal intubation warrant early tracheotomy. Obviously, unnecessary tracheotomies should not be performed, and the controversy regarding the timing of conversion of endotracheal intubation to tracheotomy is handled in an earlier article in this issue. We feel, however, that a properly performed tracheotomy has a low incidence of complications that are more easily managed than are the complex laryngotracheal complications of prolonged endotracheal intubation. Significant post-tracheotomy tracheal stenosis occurs in 8% of patients and is secondary to an overly large tracheotomy stoma or damage at the tracheostomy tube cuff site. Stoma stenosis can be minimized by not making an overly large tracheal stoma and by prevention of undue leverage on the tracheostomy tube. Cuff stenosis can be minimized by the use of the high-volume low-pressure cuffs with careful prevention of overdistention of the cuff. Bronchoscopic dilatation, laser resection, and Silastic T-tube placement provide control of the airway until definitive surgical resection and reconstruction can be performed safely. Tracheoesophageal fistula is an uncommon but life-threatening complication that can be prevented by avoiding overdistention of the tracheostomy tube cuff and by avoiding the concomitant use of a stiff nasogastric tube. These patients are best managed conservatively until they are able to be weaned from a ventilator. A single-stage repair of both the esophagus and the trachea should then be done. Tracheoinnominate artery fistula can be avoided by correct placement of the tracheostomy stoma through the second and third tracheal rings rather than lower in the trachea and by avoidance of overinflation of tracheostomy tube cuffs.     

Tracheal tear and tension pneumothorax complicating bronchoscopy-guided percutaneous tracheostomy

Percutaneous dilatational tracheostomy (PDT) is a frequently conducted procedure in critically ill patients. Bronchoscopic guidance of PDT is generally recommended to minimize the risk of unintentional tracheal injury. We present a case of tracheal tear and tension pneumothorax, a rare but potentially life-threatening complication, during continuously bronchoscopy-guided PDT. Sealing the large tracheal air fistula with the cuff of an endotracheal tube helped bridge time to definitive surgical repair in our patient. Bronchoscopic guidance may minimize, but cannot completely eliminate, the risk of tracheal injury during PDT.     

Endotracheal tube ignition during the intratracheal laser treatment

We experienced the combustion of the endotracheal tube during a bronchoscopic potassium titanyl phosphate laser resection of an intratracheal metastatic tumor. Some preventive precautions have been reported, however, none of them are absolutely perfect. We report the rare occurrence of tracheal tube ignition, preventive measures and treatment strategies for the resultant airway burn.     

Ventilator-Associated Pneumonia: Update on Etiology,Prevention, and Management

Ventilator-associated pneumonia (VAP) remains one of the most important nosocomial infections in the intensive care unit and has been the focus of much recent research. New evidence on VAP preventive measures includes evidence for the efficacy of changes in endotracheal tube cuff design and materials, drainage of subglottic secretions, saline instillation prior to tracheal suctioning, patient positioning, oral decontamination, aerosolized antibiotics, and probiotic use. In the absence of a clinical reference standard, the diagnosis of VAP remains problematic. Although extensive research on invasive sampling techniques for microbiological confirmation has been conducted, current evidence suggests that endotracheal aspirates are equivalent. Promising new diagnostic methods include non–culture-based microbiological techniques and biomarkers. The treatment of VAP continues to evolve. Shorter antibiotic treatment duration is effective. As well, novel methods of antimicrobial delivery to maximize antibiotic effectiveness and the use of inflammatory biomarkers to guide duration of antibiotic therapy show promise.     

Prevention measures for ventilator-associated pneumonia: a new focus on the endotracheal tube

PURPOSE OF REVIEW: The aim of this article is to analyze the aspects related to the endotracheal tube which may influence the development of ventilator-associated pneumonia and to review the possible measures of prevention. RECENT FINDINGS: The endotracheal tube participates in the pathogenesis of ventilator-associated pneumonia by the elimination of natural defense mechanisms, thereby allowing the entry of bacteria by the aspiration of subglottic secretions or the formation of biofilm on the endotracheal tube. The preventive measures of ventilator-associated pneumonia related to the endotracheal tube include these two mechanisms. It has been suggested that substitution of the endotracheal tube by early tracheostomy may reduce the risk of ventilator-associated pneumonia. SUMMARY: Aspiration of the subglottic secretions seems to be an effective measure with little risk; decontamination or exhaustive control of the sealing of the cuff has not demonstrated a positive risk/benefit balance. The causal relationship between biofilm and ventilator-associated pneumonia has not been clearly established. Treatment of the biofilm with antibiotics, changes in the composition of the endotracheal tube or mechanical cleansing have achieved a reduction or elimination of the biofilm but their effect on the incidence of ventilator-associated pneumonia has not been studied. The benefit of early tracheostomy in reducing ventilator-associated pneumonia is still controversial.     

Massive tracheal necrosis complicating endotracheal intubation

There are significant complications associated with endotracheal intubation. Massive tracheal necrosis secondary to tracheoesophageal space abscess developed in a 71-year-old man during mechanical ventilation. Elevated endotracheal tube cuff pressures, sepsis, hypotension, and other risk factors predispose to this disastrous consequence.     

Automatic regulation of the cuff pressure in endotracheally-intubated patients.

To avoid tracheal wall damage or inadvertent falls of the endotracheal tube cuff pressure (Pcuff) in intubated and mechanically-ventilated patients, the authors devised a simple procedure for automatic and continuous regulation of Pcuff. The procedure, only requiring a simple aquarium air pump and conventional tubing, was first tested at the bench when applied to an intubated and ventilated lung model, including an artificial trachea with an externally-variable section. The clinical performance of the procedure was tested in eight intubated patients, in whom the endotracheal tube cuff was connected to the designed Pcuff regulator during 24 h. The bench test showed that the procedure was able to maintain Pcuff constant, regardless of the changes imposed in the tracheal section. It was also effective in maintaining Pcuff during routine mechanical ventilation. Actual Pcuff recorded over the 24-h period always coincided with the target value within +/-2 cmH2O in all the patients. The procedure devised to maintain endotracheal tube cuff pressure is readily implemented, cheap, easy to operate and can be used regardless of the specific ventilator or tube used. Routine implementation of this procedure may be useful for protecting the trachea from tissue damage and for reducing the risk of ventilator-associated pneumonia.     

The effect of a gas leak around the endotracheal tube on the mean tracheal pressure during mechanical ventilation

Infants requiring mechanical ventilation are usually intubated with uncuffed endotracheal tubes, which permit gas to leak between the tube and the trachea. This gas leak may alter the mean pressure transmitted to the trachea by changing the pattern of airway flow and modifying the resistive behavior of the endotracheal tube. To test this hypothesis, we measured mean tracheal pressure, gas flow through the endotracheal tube, and resistance of the tube in rabbits ventilated with and without a leak. We also studied the effect of the tube size and the pattern of ventilation on these measurements. We found that a leak reduced the mean tracheal pressure by 15 to 21% with respect to the mean proximal airway pressure. This reduction was caused by an increased difference between inspiratory and expiratory flow through the endotracheal tube, and by the mean expiratory resistance of the tube being lower than its mean inspiratory resistance. The rabbits with smaller tubes had lower mean tracheal pressures. A ventilatory pattern of short inspiratory times and high peak pressures was associated with a proportionally greater decrease in mean tracheal pressure caused by the leak. These findings suggest that the mean proximal airway pressure, measured at the ventilator, may overestimate the mean tracheal pressure in the presence of a gas leak around the tube. Furthermore, the decrease in mean tracheal pressure caused by the leak may decrease oxygenation despite a constant mean proximal airway pressure.     

Regulation of airway smooth muscle tone in sleeping dogs.

We examined the influence of sleep state on airway smooth muscle tone in 4 unanesthetized dogs that were trained to sleep in the laboratory. The dogs had been prepared with a permanent side-hole tracheostomy and bilateral cervical vagal loops. During the studies, the dogs breathed through a cuffed endotracheal tube inserted through the tracheostomy. To monitor changes in tracheal smooth muscle tone, we measured the pressure in the water-filled cuff of the endotracheal tube. The technique was validated by examining changes in cuff pressure after administration to the dogs of a series of chemical agents and physiologic stimuli known to constrict or relax tracheobronchial smooth muscle. Sleep state of the dogs was determined by behavioral, electroencephalographic, and electromyographic criteria. During quiet wakefulness, tracheal smooth muscle tone was stable. With the onset and progression of sleep through the nonrapid-eye movement stages, airway smooth muscle tone relaxed (decrease in cuff pressure of 20 to 40 cm H2O), reaching a new steady level during slow-wave sleep. In contrast, during rapid-eye-movement sleep, tracheal smooth muscle tone fluctuated markedly and erratically, as reflected by changes in cuff pressure as large as 90 cm H2O. Partial blockade of the vagus nerves, by cooling the exteriorized cervical vagal loops, decreased or abolished the fluctuations in tracheal smooth muscle tone during rapid-eye-movement sleep at temperatures that did not abolish resting tone, demonstrating that the changes in tone during rapid-eye-movement sleep were related to variability in neural control of airway smooth muscle.     

Effect of cuffed endotracheal tubes on tracheal mucous velocity.

The inflated cuffed endotracheal tube produces a significant depression of tracheal mucous velocity in anesthetized dogs after one hour. This effect occurs with bot low and high compliance cuffs but is not observed with an uncuffed tube. This phenomenon is another factor that must be considered in establishing criteria for the frequency of cuff deflation in patients supported by mechanical ventilators.