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.     

5例机械通气患者炎性气管息肉形成的临床体会

经气管切开后长期行机械通气治疗的患者,气管套管下气管内肉芽肿的形成,发生率很低,如不注意,易引起误诊误治,尤其是老年呼吸衰竭患者,多合并有心脑血管疾病,行机械通气时,出现反复气促或呼吸困难时,通常易考虑到支气管哮喘或心衰,而忽视气道情况,须引起关注,以免贻误治疗。     

纤维支气管镜引导下经鼻气管插管治疗慢性肺心病合并呼吸衰竭37例临床分析

对37例慢性肺心病合并呼吸衰竭急性加重期患者在常规保守治疗无效情况下，行纤维支气管镜引导下经鼻气管插管机械通气治疗，结果为：好转拔管31例，死亡6例。好转率83．8％。存活者带管天数为1-18天，中位数为8天。并发症主要为声音嘶哑，鼻出血，少数病例导管内痰痂形成，插管过程中无一例死亡。认为：通过该法建立人工气道机械通气有助于提高肺心病呼吸衰竭患者的抢救成功率及治疗有效率。     

80岁以上老年人长期气管切开术后并发症的原因分析

目的探讨≥80岁老年患者长期气管切开术后并发症发生的原因及防治措施。方法回顾性分析2004年2月至2011年8月我院收治的≥60岁资料完整的行气管切开术350例患者临床资料,其中就气管切开后带套管较长时间的80例≥80岁老年患者的主要并发症原因及防治进行分析。结果 80例长期带管≥80岁老年患者其并发症最多见为反复肺部感染38例(47.50%),其合并多种致病菌,致病菌以铜绿假单胞菌为主,治疗棘手,是死亡的主要原因。其后依次为拔管困难15例(18.75%)、气管内出血14例(17.50%)、伤口渗血5例(6.25%)、套管堵塞4例(5.00%)、肺大泡3例(3.75%)、气管食管瘘1例(1.25%)。结论≥80岁老年气管切开术后带套管患者由于多种疾病并存,常合并多器官功能不全,凝血机制障碍,长期带管等都是气管切开术后并发症发生的主要危险因素。针对危险因素,做好并发症预防,可延缓患者生命。     

气管切开对机械通气患者镇静剂用量及镇静深度的影响

目的观察气管切开对机械通气患者镇静剂用量及镇静深度的影响。方法对51例ICU长期机械通气并需行气管切开的患者,采用Riker镇静、躁动评分（SAS）评价镇静深度,维持目标镇静深度即SAS3～4分,记录气管切开前后各5d的镇静剂用量和镇静深度及其时间。结果与气管切开前比较,气管切开术后患者的镇静剂用量和过度镇静时间均显著减少（P均〈0．5）。结论气管切开术后可使长期机械通气的患者的镇静剂用量明显减少,过度镇静时间缩短。对ICU长期机械通气的患者宜早期行气管切开术。     

机械通气时气管套管致气管食管瘘的原因分析和预防措施探讨

目的探讨机械通气患者气管切开套管引起气管食管瘘的原因及其预防措施。方法结合5例气管切开套管导致气管食管瘘的机械通气患者临床资料和相关文献复习,详细分析其病因和预防措施。结果机械通气患者发生气管食管瘘与气囊压力过高、气囊压迫时间过长、呼吸机管道重力压迫气管后壁、套管不稳定活动增多、气管切开破坏了气管的结构和稳定性等因素有关,预防措施主要是常规监测气囊内压、避免压力过高、妥善固定气管套管、减轻呼吸机管道对气管后壁的压迫、躁动病人适当镇静等。结论加强机械通气患者人工气道与气囊的管理,能最大限度减轻气管内膜机械性损伤,降低气管食管瘘的发生率。     

脑卒中患者气管切开术的应用研究

目的 探讨脑卒中患者行抢救性气管切开术的临床意义.方法 回顾性分析64例行紧急气管切开术脑卒中患者的临床资料.结果 64例脑卒中患者行抢救性气管切开术无一例术中死亡.4例采用去枕平卧位,60例采用仰卧位.8例术中出现呼吸骤停而行气管插管后再行切开.5例采用双极电凝止血.7例发生并发症(10.8%),术后伤口出血3例、皮下气肿2例、脱管1例及气管内阻塞1例.57例患者原发病好转后拔管,平均带管时间为(13.1±10.6)d,4例因原发病需带管回家,3例术后死于原发病.结论 气管切开术对脑卒中患者抢救生命、减少并发症及促进早日康复有重要意义.     

先天性心脏病合并气管狭窄的保守治疗策略

目的探讨先天性心脏病合并气管狭窄的保守治疗策略及可行性。方法回顾性分析阜外医院2009年1月至2011年12月间收治21例先心病合并气管狭窄的临床资料,对先心病并发上气道狭窄患儿术后采用早拔管策略;中下气道狭窄治疗上兼顾心肺功能调整及气道的管理。结果患儿年龄1～53月;体重4～14kg。术中插管困难发现18例,术后反复脱机困难发现3例。3例术后行纤维支气管镜及CT检查明确狭窄部位。除4例放弃心脏手术治疗外,合并上气道狭窄14例均治愈出院;中、下段狭窄3例中2例治愈出院,1例转外院置气管内支架。结论绝大多数先心病合并的节段性气道狭窄,实施早拔管的保守治疗策略是安全有效的;对合并长段狭窄的患儿在心、肺调整稳定后,仍反复脱机困难者应尽早考虑支架或外科治疗。     

经皮扩张气管切开术的应用观察

临床上对于需要长期机械通气的患者,气管切开术可以有效避免长期气管内插管带来的并发症。临床上多采用常规气管切开术（ST）。近年来,经皮扩张气管切开术（PDT）开始被应用。我们对这两种气管切开术的应用情况进行了对比观察。现将结果报告如下。     

气管插管计划性拔管的护理

机械通气是治疗各种原因所致的呼吸衰竭和手术后呼吸辅助支持必不可少的重要手段。气管插管是机械通气中建立人工气道的方法之一，有经鼻和经口两种。气管插管是侵袭性操作，它破坏了上呼吸道天然的抗菌屏障，易诱发呼吸机相关性肺炎（VAP）及人工气道所致下呼吸道感染等并发症。对于气管插管后的护理一般着重于保持呼吸道通畅、预防感染、预防意外拔管和气道湿化。拔除气管插管是患者病情稳定好转的标志，但是，拔管操作具有潜在的危险性。现将我科2005年1月至2007年9月经鼻进行气管插管抢救各种原因引起呼吸衰竭患者82例的拔管护理报告如下。     

Granulomatoses au cours des déficits immunitaires primitifs de l’adulte

Primary immunodeficiency with granulomatosis in the adulthood mainly concern common variable immunodeficiency (CVID). Hypogammaglobulinemia in the adulthood is usually related to a secondary immunodeficiency. When a patient presents with the association of a hypogammaglobulinemia and a granulomatosis, an opportunistic infection must first be ruled out. For unknown reasons, about 10% of the patients affected by CVID also present with granulomatosis. Lesions usually affect the pulmonary tract or the mediastinum. Half of these patients are also affected by an autoimmune cytopenia. Treatment is not codified. Severe pulmonary complications can occur in about 50% of the patients.     

有创无创呼吸机在呼吸衰竭气管切开患者的临床观察

目的探讨双水平正压通气在呼吸衰竭气管切开患者序贯治疗中应用的价值。方法选择10例呼吸衰竭气管切开机械通气患者,肺部感染基本控制,均有自主呼吸,病情稳定,呼吸机通气模式为压力支持、但撤机困难。应用双水平正压通气无创呼吸机,连接气管切开导管,呼吸支持治疗,观察患者呼吸次数、心率、血压、血气分析指标的变化及预后。结果双水平正压通气无创呼吸机可应用于呼吸衰竭气管切开患者的呼吸支持治疗,患者呼吸次数、心率、血压稳定,PH、PaO2、PaCO2基本维持正常。观察、随访24周,10例患者中7例停用BiPAP,拔除气管导管,封闭气管切开开口。1例BiPAP通气24周,病情稳定。2例因再次感染死亡。结论双水平正压通气可应用于病情稳定,但撤机困难的气管切开呼吸衰竭患者序贯治疗。     

Effect of a One-Way Tracheotomy Speaking Valve on the Incidence of Aspiration in Previously Aspirating Patients with Tracheotomy

The purpose of the present study was to investigate the incidence of aspiration in previously aspirating patients with tracheotomy after use of a one-way tracheotomy tube speaking valve. Twenty consecutive inpatients from the acute care setting of a large urban tertiary care teaching hospital were included. All subjects had objective documentation of aspiration by a fiberoptic endoscopic evaluation of swallowing prior to placement of a one-way tracheotomy speaking valve, from 2 to 7 days of valve use with intelligible speech production, and no surgery to the upper aerodigestive tract except tracheotomy. Results indicated that incidence of aspiration was not affected by use of a one-way tracheotomy speaking valve. These results are in agreement with previous observations that subjects either aspirated or swallowed successfully regardless of tracheotomy tube occlusion status. Also, no significant differences were found between aspiration status and time since tracheotomy, time off ventilator, or duration of valve use. It was concluded that use of a one-way speaking valve provided mostly nondeglutitive benefits and should not be considered to promote successful swallowing for patients with tracheotomy in the acute care setting.     

经皮扩张气管切开术在危重症患者建立人工气道中的应用简

目的 观察经皮扩张气管切开术在危重症患者中的应用价值.方法将我院ICU 38例经皮扩张气管切开术患者（PDT组）,与同期40例用传统气管切开术患者（OT组）进行比较,观察手术时间、术中出血量、手术切口大小、拔管后切口愈合时间及术后并发症.结果 PDT组在手术时间、术中出血量、手术切口大小、切口愈合时间明显优于OT组（P〈0.01 ）.术后并发症比较也明显优于OT组（P〈0.05）.结论 PDT较OT具有操作简单、创伤小、愈合快、并发症少等优势,值得临床推广应用.     

韦格纳肉芽肿病23例临床分析

目的分析韦格纳肉芽肿病(Wegener granulomatosis，WG)的临床和病理特点，提高对本病的认识。方法对23例确诊的WG病人的临床表现、辅助检查及病理特点进行回顾性分析。结果发病年龄20．57岁，平均37．2岁，平均病程5．8个月。首发症状以上呼吸道为主(48％)，可累及多个系统或器官，肺脏受累87％，肾脏受累78%。胞质型抗中性粒细胞胞质抗体(cANCA)阳性率100%，病理表现为坏死性肉芽肿性炎症、炎细胞浸润的血管炎。结论WG的临床表现复杂多样，有多系统或器官病变的症候群，以上、下呼吸道及肾脏受累最多见：病理特点为坏死性肉芽肿和血管炎。     

Tracheotomy Tube Occlusion Status and Aspiration in Early Postsurgical Head and Neck Cancer Patients

The purpose of the present study was to investigate tracheotomy tube occlusion status and prevalence of aspiration utilizing videofluoroscopy. A prospective study was done of 16 consecutive, early, postsurgical head and neck cancer patients with tracheotomy. Selection criteria included the ability to tolerate tracheotomy tube occlusion prior to and during the modified barium swallow procedure, oral and/or pharyngeal surgical resection, no history of neurological disease or stroke, and medical clearance to begin oral feeding. There was 100% agreement among the independent reviewers on ratings of the presence or absence of aspiration. It was found that occlusion status of the tracheotomy tube did not influence the prevalence of aspiration in the immediate postoperative period. No trends were observed when comparing bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and the ratings of aspiration.     

应用BiPAP呼吸机长期进行有创通气的尝试

目的 报告2例BiPAP无创呼吸机经平台呼气阀与气管切开导管相连接进行机械通气病例,分析应用BiPAP呼吸机进行有创通气的可行性.方法 回顾性研究2例呼吸衰竭患者用无创呼吸机经平台呼气阀连接气管切开导管进行机械通气的病例,并复习相关文献.结果 运动神经元病患者经气管切开导管使用BiPAP无创呼吸机获得成功,但肺癌患者...     

Effect of occlusion of a tracheotomy tube on aspiration

The purpose of the present study was to investigate the effect of occlusion of a tracheotomy tube on aspiration utilizing fluoroscopy. Twenty consecutive tracheotomized patients referred for a modified barium swallow were included. Selection criteria were ability to tolerate tracheotomy tube occlusion during the modified barium swallow procedure, no surgery of the upper aerodigestive tract except tracheotomy, and no history of oropharyngeal cancer or stroke. These was 100% agreement among 3 independent reviewers on ratings of the presence or absence of aspiration. It was found that the occlusion status of the tracheotomy tube did not influence the prevalence of aspiration. Nine of 10 (90%) subjects who exhibited aspiration were over 65 years of age ( X=72 years 2 months). No trends were observed for bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and ratings of aspiration.     

深静脉穿刺包行经皮气管切开术在神经重症患者中的应用效果

目的探讨深静脉穿刺包行经皮气管切开术在神经重症患者中的应用效果。 方法选取阜阳市第五人民医院神经外科自2016年12月至2019年10月收治的45例行经皮气管切开的神经重症患者为研究对象,按照使用材料不同分为试验组（23例）与对照组（22例）。试验组使用深静脉穿刺包行经皮气管切开术,对照组使用常规气管切开包行经皮气管切开术。比较2组患者的手术情况、手术费用及术中、术后相关并发症的发生率。 结果2组患者一般情况（性别、年龄、病因及术前GCS评分）比较差异无统计学意义（P>0.05）;试验组手术相关费用[（694±22）元]明显低于对照组[（1402±184）元],差异有统计学意义（t=18.223,P=0.000）;手术情况比较：手术时间、切口大小、术中出血量、导丝弯折率及更改术式发生率比较差异无统计学意义（P>0.05）;2组患者术中、术后并发症（术后渗血、低氧血症、心律失常、皮下气肿、气胸、纵膈气肿、切口感染、切口处溢痰及套管脱出）发生率比较差异无统计学意义（P>0.05）。 结论在熟练掌握常规经皮气管切开术的前提下,神经重症患者应用深静脉穿刺包行经皮气管切开术同样具有创伤小、手术时间短、并发症少等特点,降低手术成本,值得临床推广应用。     

Effects of the Removal of the Tracheotomy Tube on Swallowing During the Fiberoptic Endoscopic Exam of the Swallow (FEES)

This study investigated the effects, if any, that the presence of a tracheotomy tube has on the incidence of laryngeal penetration and aspiration in patients with a known or suspected dysphagia. This was a prospective, repeated-measure design study. A total of 37 consecutive patients with a tracheotomy tube underwent a fiberoptic endoscopic evaluation of swallowing (FEES). Patients were first provided with pureed food boluses with the tracheotomy tube in place. The tracheotomy tube was then removed and the tracheostoma site was covered with gauze and gentle hand pressure was applied. The patients were then evaluated without the tracheotomy tube in place with additional puree. Aspiration status was in agreement with and without the tracheotomy tube in place in 95% (35/37) of the patients. The two patients who demonstrated a different swallowing pattern with regard to aspiration demonstrated aspiration only when the tracheotomy tube was removed. Laryngeal penetration status was in agreement with and without the tracheotomy tube in place in 78% (29/37) of the patients. For the majority of the patients, the removal of the tracheotomy tube made no difference in the incidence of aspiration and/or laryngeal penetration. Results of this study do not support the clinical notion that the patient’s swallowing function will improve once the tracheotomy tube has been removed. Work for this project was completed at Marianjoy Rehabilitation Hospital, Wheaton, Illinois.