人工气管及气管支架材料的应用

背景:以往对中心气道狭窄常采取外科手术治疗,然而,有些患者无法接受,并且手术瘢痕可导致再狭窄.因此,支架置入成为治疗中心气道狭窄的重要手段之一.目的:总结人工气管及气管支架材料在临床中的应用进展.方法:应用计算机检索PubMed数据库及CNKI数据库,在标题和摘要中以"组织工程支架,人工气管,气管支架"或"tissue engineering scaffolds,artificial trachea,trachea scaffolds"为检索词进行检索.根据纳入标准选择22篇文献进行综述.结果与结论:近年来随着组织工程学的兴起和发展,在生物组织工程化气管的研究方面取得了一定的进展,目前已能够以软骨细胞或骨髓间质细胞为种子细胞构建出与自体气管相近的组织工程化气管,而且能够用软骨细胞及上皮细胞构建出带有气管黏膜上皮的复合组织工程化气管,但这些组织工程化气管移植到体内能否长期具有活性、发挥正常的生理功能等还需要进一步的实验验证.     

气管和支气管乳头状瘤临床分析

目的总结气管和支气管乳头状瘤的临床特点及支气管镜下介入治疗情况。方法回顾性分析2012年1月-2018年6月在应急总医院确诊的气管和支气管乳头状瘤的24例患者临床资料,进行分析、总结。16例患者有吸烟史,其中男患者13例;19例良性,5例恶变;9例病变为单发,占37.5%,累及2个及2个以上部位的共15例,占62.5%。喉部受累4例,中央型气道受累21例,二级支气管受累3例。肿瘤可以侵犯多个部位。结果经支气管镜下介入治疗后,气道狭窄程度、气促分级、卡氏评分(KPS)均得到明显改善(P 0.01)。结论气管和支气管乳头状瘤是气道内少见的肿瘤,多为良性病变,可以发生恶变,支气管镜下介入治疗是有效的治疗手段。     

Cancer: new therapies and new approaches to recurring problems

Caring for patients with cancer presents unique challenges to anesthetists. Chemotherapeutic regimens can cause cardiac, pulmonary, and other complications that will influence the anesthesia provider's care. New surgical techniques, including vertebroplasty, vertebrectomy, radiofrequency ablation of the liver, and sentinel node biopsy, present issues related to the surgical techniques and drugs administered. Recurring problems, including tumors of the airway and cardiac tamponade, continue to present challenges for anesthesia providers. Many patients with cancer who undergo surgery not only have acute pain related to the surgical procedure but also have chronic pain that will influence anesthetic and postoperative pain management. This Journal course discusses new therapies and procedures and approaches to recurring problems in cancer care.     

气道肿瘤造成气管狭窄经支气管镜介入治疗的临床疗效研究

目的:回顾性分析探讨肿瘤致气道狭窄的患者经气管介入治疗过程中该法的应用价值,为类似病情治疗提供理论参考。方法:收集76例我院2016年3月—2018年9月收治的气道肿瘤致气道狭窄并接受支气管镜介入治疗的病例资料,分析致使恶性气道狭窄的肿瘤类型成因,并分析评价其治疗前后气道内径、气促分级、治疗效果、术中并发症等临床资料,评估支气管介入治疗方式在该类病情治疗过程中的安全性及有效性。结果:均经病理证实的76例气道狭窄病例中,肺癌71例,肾癌肺转移2例,甲状腺癌气管侵犯3例。经支气管镜介入治疗气道狭窄,治疗前平均气道内径由0.57±0.18mm增至治疗后1.19±0.14mm,平均气道内径增加明显(P<0.05);平均气促分级由3.22±0.48降至治疗后1.52±0.79,气促分级降低明显(P<0.05);治疗总有效率达100%;患者术前平均KPS评分60.42±4.92,术后增至79.31±8.03,差异有统计意义(P<0.05);支气管镜介入治疗术中并发症多为出血、心律失常、一过性血氧低等,术中均得到有效控制。结论:肺癌中腺癌是导致气道狭窄的高发原因;支气管镜介导的手术治疗能直接可解除气道狭窄问题同时辅助其他放化疗,增强治疗效果。     

Airway obstruction due to bilateral giant pulmonary artery aneurysms

Large pulmonary artery aneurysms are rare, but they are associated with significant morbidity and mortality. Significant airway obstruction due to extrinsic compression solely by a pulmonary artery aneurym is an extremely rare occurrence. We present a case of large bilateral pulmonary artery aneurysms causing extrinsic airway compression with collapse of the left primary bronchus in a 51-year-old woman. This is the first report in an adult in which airway compression due solely to the pulmonary artery aneurysm resulted in airway collapse. Furthermore, we describe the use of interventional bronchoscopy with stent placement as a minimally invasive alternative to surgery for treatment of these patients.     

Thoracotomy for tracheal disruption after traumatic intubation: a case report

Tracheal dissection is an uncommon complication of endotracheal intubation. A large source of morbidity and mortality in anesthesia is associated with airway issues. Several airway complications can be avoided or minimized by proper technique and vigilance. Emergency thoracotomy surgery is required in patients who suffer lower tracheal trauma. A tracheal tear poses additional challenges to traditional airway management, demanding vigilant planning and collaboration among the entire operative team. This case report details the airway management strategies employed during an emergent thoracotomy for a patient who suffered tracheal perforation during endotracheal intubation. A discussion of airway anatomy, airway considerations, intubation complications, and one-lung ventilation techniques is provided. Airway management techniques for one-lung ventilation are highly variable, requiring an extensive knowledge of equipment, clinical implications, and technical challenges. It is important for clinicians to be skilled in the use of several airway devices and to be prepared for any unexpected situation such as the case being presented.     

Aortic arch surgery for type B aortic dissection: How far should we go? The value of a hybrid approach

Traditionally, the management of type B aortic dissection has been the domain of the vascular surgeons. Timing and type of intervention still generate debate. We sought to review our early experience with the treatment of this condition based on a hybrid approach following an aortic multi‐disciplinary team meeting involving close cooperation between cardiac surgeons, vascular surgeons, interventional radiologists, vascular anesthetists, and cardiac anesthetists. Four patients (age 41–56 years; 3 males; 1 female) with type B aortic dissection underwent aortic arch surgery through a hybrid approach: one elective procedure consisting of ascending aorta and hemi‐arch replacement with debranching followed by thoracic endovascular aortic repair (TEVAR); one redo procedure requiring aortic arch replacement with hybrid frozen elephant trunk; two acute presentations (aortic arch replacement and debranching followed by TEVAR; AVR with ascending aorta, arch, and proximal descending thoracic aorta replacement with conventional elephant trunk and debranching). Deep hypothermic circulatory arrest was required in three patients. Despite respiratory complications and slightly prolonged postoperative course, all patients survived without onset of stroke, paraplegia, malperfusion, endoleak, or need for re‐exploration. Follow‐up remains satisfactory. Different factors may affect outcome following complex aortic procedures. Nevertheless, close cooperation between cardiac surgeons, vascular surgeons, and interventional radiologists may reduce potential for complications and address aspects that may not be completely within the domain of individual specialists.     

Adult long-segment tracheal stenosis attributable to complete tracheal rings masquerading as asthma

OBJECTIVE: a) To report on an adult patient with congenital long-segment tracheal stenosis from complete tracheal rings complicated by tracheomalacia; b) to highlight the fact that some patients with airway narrowing could be misdiagnosed as having bronchial asthma; and c) to discuss our management with a custom-made tracheostomy tube extending to the carina. DESIGN: Case report. SETTING: A university hospital's 14-bed medical/surgical intensive care unit. PATIENT: A 21-yr-old patient, with a history of what was labeled as asthma, was admitted to the intensive care unit with diabetic ketoacidosis, pneumonia, respiratory failure, and septic shock. INTERVENTIONS: Her therapy included assisted mechanical ventilation through an endotracheal tube. Initially, a size 6.0 endotracheal tube was used. Finally, a custom-made tracheostomy tube extending to the carina was inserted to manage her persistent infantile trachea. MEASUREMENT AND MAIN RESULTS: During 4 months in the intensive care unit, she suffered numerous airway problems from her narrow trachea that were eventually attributed to congenital long-segment tracheal stenosis from complete tracheal rings. Bacterial pneumonia, viral tracheobronchitis, and tracheomalacia complicated her course. Multiple attempts at extubation failed and, after translaryngeal endotracheal tubes and tracheostomy tubes of decreasing size, her airway was managed with a size 5.0 custom-made tracheostomy tube with the tip extending to her carina. She was totally dependent on this tube. CONCLUSION: Airway narrowing may masquerade as asthma. Congenital tracheal stenosis is rare and is associated with a high mortality rate. Complete tracheal rings presenting in adulthood are extremely rare, and we report the first case of long-segment pantracheal stenosis presenting in adulthood. Surgical treatment with tracheoplasty is difficult. A custom-made tracheostomy tube to stent the entire trachea is one management option. Tracheal stenosis should be excluded in patients with a chronic lack of response to therapy for asthma.     

Are patients with obstructive sleep apnea syndrome appropriate candidates for the ambulatory surgical center?

Ambulatory surgery centers (ASCs) provide surgical care for patients not requiring hospital admission for their postoperative care. Obstructive sleep apnea syndrome (OSAS) is a disease process affecting every phase of anesthesia care delivery. The potential complications of OSAS and anesthesia care have been well documented in the preoperative, intraoperative and postoperative phases. Patients with OSAS undergoing procedures at ASCs may be at increased risk because they are discharged to home. The influence of residual anesthetics, analgesia, airway edema, and disruption of sleep cycles may result in significant postoperative apneic events in this patient population. There is a lack of studies regarding the outcomes and management of patients with OSAS in the outpatient and ASC environments. Until there are more studies defining the risk and outlining safe and appropriate care for these patients, it would seem reasonable to remain conservative in our approach because the negative outcomes in this population can be catastrophic.     

Endoscopic laser surgery for subglottic and tracheal stenosis

Seventeen patients with subglottic and tracheal stenosis were treated with laser surgery. Six patients had airway stenosis caused by malignant tumors. Out of 16 patients who required emergency endolaryngeal laser surgery, satisfactory results were achieved in 12, obtaining a sufficient lumen for ventilation. Five cases with airway tumors underwent laser surgery to increase the airway lumen, however, only one patient showed excellent results, with a sufficient airway lumen not being obtained in the others. Airway obstructions due to tumor can be treated satisfactorily by laser surgery, though long-term postoperative follow-up confirmed recurrence of tumor in some cases, which is a problem that must be overcome in the future.     

Contemporary management of peripheral arterial disease: III. Endovascular and surgical management

Traditional indications for invasive treatment in patients with peripheral arterial disease (PAD) have been salvage of a threatened limb or improvement of functional capacity in cases of disabling intermittent claudication, but advances in interventional therapy may be lowering the threshold for these therapies. Percutaneous transluminal angioplasty (PTA), with or without stent placement, is the most common endovascular intervention in patients with occlusive lower extremity PAD. In general, PTA is best suited to cases of short-segment stenosis or large-bore vessels, whereas surgery is best applied to multilevel occlusions involving smaller and more distant vessels. This article reviews endovascular therapy, catheter-based thrombolysis, and surgical revascularization procedures in patients with PAD, with special attention to recommendations from new American College of Cardiology/American Heart Association guidelines.     

Therapeutic cardiac catheterization for congenital heart disease--a new era in pediatric care

In recent years, enormous technological advances have occurred that allow intervention for many congenital heart defects in the pediatric cardiac catheterization laboratory. Therapeutic catheterization procedures, including valvuloplasty, angioplasty, stent implantation, coil embolization, and device occlusion, are employed to treat heart defects in infants and children. This report describes these interventional procedures, outcomes, potential complications, and implications for nursing care.     

COVID-19 respiratory support in the emergency department setting

IntroductionSevere acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), which causes the coronavirus disease 2019 (COVID-19), may result in severe complications, multiorgan dysfunction, acute respiratory failure, and death. SARS-CoV-2 is highly contagious and places healthcare workers at significant risk, especially during aerosol-generating procedures, including airway management.ObjectiveThis narrative review outlines the underlying respiratory pathophysiology of patients with COVID-19 and discusses approaches to airway management in the emergency department (ED) based on current literature.DiscussionPatients presenting with SARS-CoV-2 infection are at high risk for acute respiratory failure requiring airway management. Among hospitalized patients, 10–20% require intensive care unit admission, and 3–10% require intubation and mechanical ventilation. While providing respiratory support for these patients, proper infection control measures, including adherence to personal protective equipment policies, are necessary to prevent nosocomial transmission to healthcare workers. A structured approach to respiratory failure in these patients includes the use of exogenous oxygen via nasal cannula or non-rebreather, as well as titrated high-flow nasal cannula and non-invasive ventilation. This review offers several guiding principles and resources designed to be adapted in conjunction with local workplace policies for patients requiring respiratory support.ConclusionsWhile the fundamental principles of acute respiratory failure management are similar between COVID-19 and non-COVID-19 patients, there are some notable differences, including a focus on provider safety. This review provides an approach to airway management and respiratory support in the patient with COVID-19.     

Role of the interventional pulmonologist in the intensive care unit

Interventional pulmonology is a new field within the pulmonary and critical care medicine specialty with a focus on invasive diagnostic and therapeutic modalities in airway and pleural disorders. The interventional pulmonologist is highly qualified to take a prominent role in the intensive care unit in a consultative fashion to provide assistance with pleural procedures, establishment and care of artificial airways, and management of patients with respiratory failure attributable to structural central airway disorders. The presence of a dedicated operator with advanced skills facilitates access to specialized procedures in an expeditious and safe manner. Clear communication between the interventional pulmonologist and intensivist is vital to ensure a collaborative effort that delivers optimal patient care.     

Cuidados de enfermería al paciente sometido a técnicas de neurointervencionismo endovascular

Vascular interventional radiology (VIR) procedures have increased markedly, partly due to the current healthcare context, which encourages the use of less invasive procedures that reduce pressure on surgery departments and decrease hospital stays. In most patients, these techniques can be carried out in a single intervention. VIR procedures are based on the possibility of gaining access to vascular structures through a catheter inserted percutaneously without the need for open surgery.Due to the complexity of these procedures, hospitalization is required before and after the technique is performed but length of stay is short compared with that associated with surgery. As the health workers closest to patients, nurses must respond to their information needs. The provision of comprehensive nursing care should include all the care required before, during and after the procedure and all aspects related to the quality of the healthcare process. Knowledge of how diagnostic and therapeutic VIR techniques are performed in the neurovascular section is essential. Based on the authors’ experience, the present article aims to provide nurses with knowledge of some neurointerventional procedures (cerebral angiography and embolization of intracranial aneurysms) and of the care provided in RVI rooms.     

Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management,endovascular intervention or open surgery?

Background: Retroperitoneal haematoma is a rare clinical entity with variable aetiology, which is increasing in incidence mainly due to complications related to interventional procedures. There is no general consensus as to the best management plan for patients with retroperitoneal haematoma. Methods: A literature review was undertaken using MEDLINE, all relevant papers on retroperitoneal haemorrhage or haematoma were used. Results: The diagnosis is often delayed as symptoms are nonspecific. Retroperitoneal haematoma should be suspected in patients with significant groin, flank, abdominal, back pain or haemodynamic instability following an interventional procedure. Spontaneous haemorrhage usually occurs in patients who are anticoagulated. Multi‐slice CT and arteriography are important for diagnosis. Most haemodynamically stable patients can be managed with fluid resuscitation, correction of coagulopathy and blood transfusion. Endovascular treatment involving selective intra‐arterial embolisation or the deployment of stent‐grafts over the punctured vessel is attaining an increasingly important role. Open repair of retroperitoneal bleeding vessels should be reserved for cases when there is failure of conservative or endovascular measures to control the bleeding. Open repair is also required if endovascular facilities or expertise is unavailable and in cases where the patient is unstable. If treated inappropriately, the mortality of patients with retroperitoneal haematoma remains high. Conclusion: There is a lack of level I evidence for the best management plans for retroperitoneal haematoma, and evidence is based on small cohort series or isolated case reports. Conservative management should only be reserved for patients who are stable. Interventional radiology with intra‐arterial embolisation or stent‐grafting is the treatment of choice. Open surgery is now rarely required.     

胰十二指肠切除术后晚期出血介入治疗的护理配合

目的 探讨介入治疗胰十二指肠切除术后出血的护理配合,提高护理质量.方法 总结18例胰十二指肠切除术后出血的患者行介入治疗,包括脾动脉栓塞、胃十二指肠动脉残端栓塞、肝动脉栓塞、经导管肠系膜上动脉分支垂体后叶素灌注、肝动脉覆膜支架置入,总结护理配合经验.结果 所有患者共行介入治疗29次,16例患者末次介入治疗后均未再发出血,2例患者血管造影未发现明确出血征象亦未行预防性栓塞治疗,再次开腹后证实为消化道溃疡出血,经手术切除溃疡部位后未再发出血.结论 胰十二指肠切除术后晚期出血患者病情复杂,导管室护师在配合介入医生行栓塞止血时,需要准备物品齐全,加强理论知识,做好预见性护理.     

超声在缺血性脑血管病介入治疗中的诊断价值

目的：探讨彩色多普勒超声（CDI）、经颅多普勒超声（TCD）对缺血性脑血管病的诊断及在脑血管成形支架植入术后随访中的价值，并与全脑数字减影血管造影（DSA）比较。方法：对261例缺血性脑血管病患者行颈部血管听诊、CDI、TCD检查，其中175例加行DSA检查，对有手术指征49例患者行脑血管成形支架植入术并随访。结果：①CDI证实颅外段脑血管狭窄〉50％的患者血管杂音的阳性率高达82％。TCD提示颅内段脑血管狭窄患者血管杂音阳性率达50％。②CDI及TCD示颅外段颈、椎动脉狭窄〉50％的患者中DSA符合率达82％；TCD提示颈内动脉虹吸段或大脉中动脉狭窄〉50％的患者中DSA符合率达98％。③脑血管成形支架植入术后患者CDI可清楚显示支架位置形态及支架内膜增生情况。CDI及TCD在术后监测发现狭窄段血流速度较术前明显降低；而术后支架内再狭窄的发生则表现为血流速度的再度增快。结论：CDI、TCD联合应用对缺血性脑血管病介入治疗前的诊断及术后随访提供了一种可靠的无创性综合检查方法。     

Use of a modified tracheal tube in a child with traumatic bronchial rupture: A case report and review of literature

BACKGROUNDTrauma is one of the leading causes of death in the pediatric population. Bronchial rupture is rare, but there are potentially severe complications. Establishing and maintaining a patent airway is the key issue in patients with bronchial rupture. Here we describe an innovative method for maintaining a patent airway.CASE SUMMARYA 3-year-old boy fell from the seventh floor. Oxygenation worsened rapidly with pulse oxygen saturation decreasing below 60%, as his heart rate dropped. Persistent pneumothorax was observed with insertion of the chest tube. Fiberoptic bronchoscopy was performed, which confirmed the diagnosis of bronchial rupture. A modified tracheal tube was inserted under the guidance of a fiberoptic bronchoscope. Pulse oxygen saturation improved from 60% to 90%. Twelve days after admission, right upper lobectomy was performed using bronchial stump suture by video-assisted thoracic surgery without complications. A follow-up chest radiograph showed good recovery. The child was discharged from hospital three months after admission.CONCLUSIONA modified tracheal tube could be selected to ensure a patent airway and adequate ventilation in patients with bronchial rupture.     

光动力疗法联合气道支架或冷冻治疗恶性中心气道狭窄的效果

目的 探讨光动力疗法联合气道内支架植入或冷冻治疗恶性中心气道狭窄的临床疗效.方法 回顾性分析2009年10月至2019年10月浙江省人民医院因恶性肿瘤引起中心气道狭窄患者45例的临床资料,根据介入治疗方法的不同分为两组,给予光动力治疗后行支架植入的20例患者为支架组,给予冷冻治疗光后行动力治疗的25例患者为冷冻组,比较...