气管导管气囊适当压力持续充气方法减少呼吸机相关性肺炎的探讨

目的:探讨气管导管气囊适当压力持续充盈充气方法减少呼吸机相关性肺炎的效果.方法:将ICU 60例机械通气(48 h以上)患者随机分成两组,实验组、对照组各30例.实验组:气管导管气囊以适当压力持续充盈充气方法;对照组对气管气囊定时(充气-放气-再充气)循环充放气方法观察呼吸机相关性肺炎发生差异.结果:实验组呼吸机相关肺炎发生3例;对照组呼吸机相关肺炎发生13例.差异有显著性统计学意义(P<0.01).结论:气管导管气囊持续保持适当的压力充盈的充气方法可有效减少呼吸机相关肺炎发生.     

气管导管气囊适当压力持续充气方法减少呼吸机相关性肺炎的探讨

目的：探讨气管导管气囊适当压力持续充盈充气方法减少呼吸机相关性肺炎的效果。方法：将ICU60例机械通气（48h以上）患者随机分成两组,实验组、对照组各30例。实验组：气管导管气囊以适当压力持续充盈充气方法;对照组对气管气囊定时（充气一放气一再充气）循环充放气方法观察呼吸机相关性肺炎发生差异。结果：实验组呼吸机相关肺炎发生3例;对照组呼吸机相关肺炎发生13例。差异有显著性统计学意义（P〈0．01）。结论：气管导管气囊持续保持适当的压力充盈的充气方法可有效减少呼吸机相关肺炎发生。     

气管套管气囊实际压力与理想压力的临床意义

为了解老年人机械通气时气囊实际压力与理想压力的关系 ,以便制订合理的注气标准 ,我们用气管套管球囊压力专用测量仪 (Endotest仪 )对机械通气的老年人气管套管、球囊压力进行了精确测量 ,发现实际压力高于理想压力 ,应适当减少 ,以免引起气管黏膜损伤。1　对象和方法1 1　对象　 30例中 ,男 2 8例 ,女 2例 ;年龄 80～ 93岁。气管插管 4例 ,气管切开 2 6例。气管套管应用时间≤ 3个月。1 2　方法　 ( 1)应用Endotest仪对气囊压力和注气量精确测量 ,每项指标取 3次的平均值。 ( 2 )气囊实际压力和气体量 :Luer接头连接充气开口或气管插管…     

维持气管导管合适套囊压方法探讨

全麻气管插管时,导管气囊压力不当可致气管黏膜缺血损伤、术后声嘶、咽喉痛等并发症[1,2]。常用的套囊充气法有：手指捏感法、最小容积阻塞法和套囊充气测压仪（Cuff Pressure Gauge,CPG）充气法。手指捏感法盲目性很大,最小容积     

气管切开患者高压氧舱内吸氧的简便方法

我科自1995年4月至12月于空气加压舱内共治疗24例气管切开及4例气管插管患者，其中男22例，女6例，年龄1～66岁，均为各种原因致脑损伤并深度昏迷者。所有患者呼吸较平稳，均给予气管导管吸氧法。供氧方法：①将一次性硅胶气管导管于气囊充气管根部剪断，尽量减小呼吸道死腔。注意切勿损坏气囊充气管，以备气管导管过细时能将气囊充气，避免漏气。②气管切开患者，应先取下气管套管的内套管，吸氧时将相应型号气管导管插入气管外套管内，用力适度，以不漏气为宜，Y型管衔接在气管导管上。③经口、鼻气管插管患者，将Y型管衔接于气管导管上…     

呼吸机所致肺损伤家兔HSP70和NF-κB表达的意义

目的研究呼吸机所致肺损伤（VILI）炎症反应中热休克蛋白70（HSP70）和核因子-kB（NF-kB）表达的意义，以及加用呼气末正压（PEEP）的影响。方法健康成年新西兰白兔30只，实施麻醉和气管切开术后分别接受不同潮气量（VT）的通气（通气时间均为4h）。随机分为以下三组：PEEP组（VT=40ml/kg，PEEP=3cmH2O,n=12）；ZEEP组（VT=40ml／kg，PEEP=0cmH2O,n=12）；对照组（VT=10ml／kg，n=6），始终以正常条件通气。机械通气开始后4h经颈动脉放血处死动物。在光镜下观察肺组织的病理学改变，Western blot检测家兔肺组织HSP70及NF-kB的表达。结果家兔在致伤机械通气4h后，光镜下可见肺组织有不同程度的损伤；各组肺组织HSP70、NF-kB表达均显著增加，且ZEEP组二者呈负相关。与ZEEP组比较，PEEP组肺组织的病理损伤明显减轻，NF-kB表达明显减少。结论HSP70可通过抑制NF-kB的活性，保护肺组织避免VILI；在机械通气过程中加用PEEP也可通过减少NF-kB的表达减轻肺组织损伤。     

CT在儿童气管支气管X线穿透性异物诊断中的价值

目的：探讨CT在气管及支气管X线穿透性异物的表现及应用价值。方法：回顾性分析50例气管、支气管X线穿透性异物CT表现；所有异物均经临床纤维支气管镜取出证实。结果：气管异物4例，右主支气管异物31例，左主支气管异物15例；CT表现：①异物本身；②局限性支气管阻塞、其下方支气管充气或轻度扩张；③纵隔移位及纵隔“双边”；④胸部“双边”；⑤肺气肿。结论：CT扫描不仅能定位诊断，而且能直接显示异物本身，优于普通X线检查。     

抗哮喘治疗诱发急性肺水肿围术期处理1例

1病例报告患者男,71岁。拟在全麻下行陈旧性硬膜外血肿钻孔引流术。既往有哮喘病史,支气管炎、冠心病、高血压病史10年。心电图检查示,Ⅱ、Ⅲ、aVF异常Q波。患者入室时神清,常规麻醉诱导气管插管,潮气量560ml、气道峰压22cmH2O、SO21.00。10min后气道峰压突然升至30cmH2O,SO2降至0.95,左肺哮鸣音明显。立即在气管导管内喷入沙丁胺醇气雾剂,2min后气道压降至20cmH2O,SO21.00。术中心率、血压平稳,手术历时30min,共输注晶体液700ml,尿量200ml,出血20ml。     

间歇正压及呼气末正压通气对人体眼内压的影响

目的：探讨机械通气对人体眼内压（IOP）的影响,以避免不适当的机械通气对眼的损伤。方法：选择ASAI-II级择期手术患者10例。术前无中枢、心、肺、肝、肾疾患及眼外伤、青光眼等眼部疾病史。采用阻滞麻醉加健忘镇痛气管内插管法。术中间断静注γ-OH维持睡眠。以Drager SA-2型麻醉机行间歇正压通气（IPPV）或不同压力值的呼气末正压通气（PEEP,5cmH2O及10cmH2O）。分别于通气前、通气20min及撤机20min记录监测指标。结果：3种不同通气条件下,中心静脉压（CVP）及IOP在上机20min均比基础值上升（P〈0.01）。IPPV时,IOP从（1.7±0.2）kPa升至（2.0±0.3）kPa,PEEP为5cmH2O及10cmH2O时,IOP分别从（1.8±0.2）kPa升至（2.5±0.2）kPa和（1.9±0.2）kPa升至（2.9±0.3）kPa。3种通气方式间亦有显著差异（P〈0.01）。全部指标在撤机20min时均恢复至基础水平（P〉0.05）。CVP与IOP之间有很好的相关性（R=0.61,P〈0.01）。结论：严重眼外伤,内眼手术要求术后避免高眼压者和青光眼者若需机械通气,最好选用IPPV,必须用PEEP时,呼气末正压勿大于10cmH2O,通气中应监测IOP,避免严重并发症的发生。     

小剂量体外放疗预防兔气管金属支架置入术后再狭窄效果观察北大核心CSCD

目的探讨体外小剂量放疗预防气管金属支架置入术后再狭窄的有效性。方法选用4月龄新西兰大耳白兔32只,体质量2.5~3.0 kg。采用气管切开联合尼龙毛刷刮擦黏膜方法制备良性气管狭窄动物模型。X线透视下置入镍钛合金裸支架。根据生物等效剂量(BED)随机分为20 Gy组、30 Gy组、40 Gy组和对照组,每组8只;20 Gy组以分割剂量7 Gy/d照射2次,30 Gy组以分割剂量7 Gy/d照射3次,40 Gy组以分割剂量8 Gy/d照射3次,每2次照射间歇5 d,对照组不体外放疗。体外放疗后4、8周每组处死4只实验兔,处死前行胸部CT扫描,记录气管狭窄程度。结果气管狭窄模型制作4周,存活30只,2只分别死于肺部感染、气管黏膜水肿所致呼吸衰竭,补做2只均存活;气管狭窄率为42%~85%。体外放疗4、8周平均气管狭窄率,20 Gy组分别为(46.7±4.8)%、(52.9±3.6)%,30 Gy组分别为(36.2±4.7)%、(39.8±4.5)%,40 Gy组分别为(31.9±5.7)%、(34.8±5.2)%;对照组置入气管支架4、8周后平均气管狭窄率为(65.5±2.6)%、(80.7±3.8)%。实验组各组气管平均狭窄率均小于对照组,差异有统计学意义(均P<0.05);20 Gy组气管平均狭窄率大于30 Gy组、40 Gy组,差异有统计学意义(均P<0.05);30 Gy组气管平均狭窄率大于40 Gy组,差异无统计学意义(P>0.05)。40 Gy组1只实验兔体外放疗后死于气管穿孔所致纵隔感染。结论体外放疗可有效抑制气管支架置入术后黏膜肉芽组织增生。推荐应用30 Gy分次照射方案。     

Early radiographic signs of tracheal rupture

Early diagnosis and repair of tracheal rupture are necessary to prevent acute tension pneumothorax, airway obstruction, and chronic tracheal stenosis. Few reliable radiographic signs of tracheal rupture have been proposed. We diagnosed seven cases of tracheal rupture, two related to blunt trauma and five resulting from tracheal intubation. Early radiographic signs included orientation of the distal portion of the endotracheal tube to the right relative to the lumen of the trachea with an overdistended endotracheal balloon cuff, migration of the balloon toward the endotracheal tube tip, and pneumomediastinum and subcutaneous emphysema. In four cases, the overdistended balloon with distal migration preceded the pneumomediastinum by several hours. An overdistended balloon in a patient after tracheal intubation or blunt chest trauma should suggest tracheal rupture.     

Acute tracheobronchial injuries: Impact of imaging on diagnosis and management implications

PURPOSE: To evaluate the role of chest radiography, single-slice CT and 16-row MDCT in the direct evidence of tracheobronchial injuries. METHODS: Patients with acute tracheobronchial injury were identified from the registry of our level 1 trauma center during a 5-year period ending July 2005. Findings at chest radiograph and CT were compared to those shown at bronchoscopy. RESULTS: Eighteen patients with tracheobronchial injury - three patients with cervical trachea injury, eight with thoracic trachea injury and seven with bronchial injury - were identified. Twelve patients had a blunt trauma (67%), six patients had a penetrating (iatrogenic) injury (33%). Chest radiograph directly identified the site of tracheal injury in four cases, showing overdistension of the endotracheal cuff in three cases and displacement of the endotracheal tube in one case. At the level of the bronchi, chest radiograph demonstrated only one injury. CT directly identified the site of tracheal injury in all the cases showing the overdistension of the endotracheal cuff at the level of the thoracic trachea (three cases), posterior herniation of the endotracheal cuff at the thoracic trachea (three cases), lateral endotracheal cuff herniation at the thoracic trachea (one case), tracheal wall discontinuity at the cervical (one case) and at the thoracic trachea (one case) and displacement of endotracheal tube at the cervical trachea (two cases). At the level of the bronchi, CT correctly showed the site of injury in six case including: discontinuity of the left main bronchial wall (two cases), the "fallen lung" sign (one case), right main bronchial wall enlargement (one case), discontinuity of the right middle bronchial wall (two cases). In one case, CT showed just direct "air leak" at the level of the carina suggesting main bronchus injury. This finding was confirmed by bronchoscopy. CONCLUSION: Chest radiograph was helpful for the assessment of iatrogenic tracheal injuries. CT detected the site of blunt tracheobronchial injuries in 94% of the cases. Multiplanar 16-row MDCT reconstructions, were essential for the optimal surgical approach.     

Using CT to diagnose tracheal rupture

OBJECTIVE: A retrospective study was performed to assess CT sensitivity for diagnosing tracheal rupture. Intubated cadaver tracheas were examined to assess endotracheal tube balloon overdistention and deformity and to evaluate the relationship of balloon pressures to tracheal injury. MATERIALS AND METHODS: Neck or chest CT scans of 14 patients with tracheal rupture and 41 control trauma patients with pneumomediastinum but without tracheal injury were reviewed and compared to assess the presence and location of extrapulmonary air, whether direct visualization of tracheal wall disruption was possible, the size and shape of endotracheal tube balloon, signs of transtracheal balloon herniation in intubated patients, and the location of the extratracheal endotracheal tube. Intact and experimentally injured cadaver tracheas were used to evaluate tube balloon pressure and configuration. RESULTS: All 14 patients with tracheal rupture had deep cervical air and pneumomediastinum. Overdistention of the tube balloon occurred in 71% (5/7) of the intubated patients, and balloon herniation occurred in 29% (2/7). Direct tracheal injury was seen in 71% (10/14) of the patients as a wall defect (n = 8) or deformity (n = 2). Overall, CT was 85% sensitive for detecting tracheal injury. Patients with tracheal injury had a significantly lower incidence of pneumothorax (p = 0.01) than did the control group. The CT appearance of balloon herniation through defects in the cadaver tracheas closely mimicked those of patients with tracheal injury. The amount of balloon pressure required to rupture the intubated trachea was extremely high and rupture was difficult to obtain. CONCLUSION: CT can reveal tracheal injury and can be used to select trauma patients with pneumomediastinum for bronchoscopy, leading to early confirmation and treatment.     

The effect of exercise modality on respiratory muscle performance in triathletes.

PURPOSE: The aim of this study was to examine the effects of the cycle-run and run-cycle successions of the triathlon and duathlon, respectively, on respiratory muscle strength and endurance. METHODS: Respiratory muscle strength was assessed by measuring maximal inspiratory (P(Imax)) and expiratory (P(Emax)) pressures. Respiratory muscle endurance was assessed by measuring the time limit (T(lim)). Twelve triathletes participated in a three-trial protocol. The first trial consisted of an incremental cycle test to assess the maximal oxygen uptake (.VO(2max)) of triathletes. Trial 2 consisted of 20 min of cycling followed by 20 min of running (C-R), and trial 3 consisted of 20 min of running followed by 20 min of cycling (R-C). Trials 2 and 3 were performed at the same metabolic intensity (%.VO(2max)). P(Imax) and P(Emax) were measured before and 10 min after C-R and R-C, and 1 min after the post-C-R and post-R-C T(lim) measurements (P(Imax) 1'). T(lim) was measured 1 d before and 30 min after C-R and R-C. RESULTS: The results showed a significant decrease in P(Imax) after C-R (126.7 +/- 4.3 cmH(2)O, P < 0.05) and R-C (123.7 +/- 4.9 cmH(2)O, P < 0.05) compared with the baseline values (130 +/- 3.8 and 129.6 +/- 4.3 cmH(2)O, respectively). P(Imax) 1' showed a significantly greater decrease after R-C versus C-R (111.2 +/- 5.5 cmH(2)O vs 121.2 +/- 3.9 cmH(2O), respectively, P < 0.001). Tlim after C-R (3.3 +/- 0.3 min) and R-C (2.1 +/- 0.3 min) decreased significantly compared with baseline values (4.19 +/- 0.3 min and 4.02 +/- 0.3 min, respectively). However, the Tlim decrease after R-C was significantly greater than after C-R (P < 0.001). CONCLUSION: We concluded that respiratory muscle strength and endurance were less decreased after the cycle-run succession and that cycling induced a greater decrease in respiratory muscle endurance than running.     

CO_2气腹对家兔糖代谢的影响

目的：观察不同压力CO2气腹对家兔糖代谢的影响。方法：健康家兔20只，随机分为4组，每组5只，分别给予1h不同压力的CO2气腹：对照组0mmHg、A组10mmHg、B组15mmHg、C组20mmHg。于气腹前、气腹30min、60min、4h、24h采集股静脉血，测定血糖、胰岛素、C-肽、乳酸。结果：CO2气腹后各组血糖均升高，气腹压力越大，血糖升高的速度越快，峰值越高。对照组、A组胰岛素和C-肽气腹前后无明显变化，B、C组较气腹前明显升高；各组乳酸浓度无明显变化；CO2气腹后胰岛素敏感指数（ISI）在B、C组明显降低，且气腹压力越高，ISI降低越明显。结论：结果表明CO2气腹可引起血糖、胰岛素升高，胰岛素敏感性降低，产生胰岛素抵抗（IR），且程度与CO2气腹压力有关。     

Respiratory muscle training and the performance of a simulated anti-G straining maneuver

INTRODUCTION: Prolonged +G,-exposure eventually decreases a pilot's ability to maintain an effective anti-G straining maneuver (AGSM). Previous studies have implicated the respiratory muscles (RMs) as main contributors to this AGSM-induced fatigue. Thus, this study aimed to investigate if respiratory muscle training (RMT) may be of benefit to improve RM strength, endurance, and performance of the AGSM. METHODS: Subjects (N=14; 27 +/- 5.3 yrs) trained with a commercially available RM trainer for 6 wk, 4 times/wk 20 min per session. Data collection consisted of pulmonary function tests (PFTs) and a RM testing protocol simulating the AGSM. Testing occurred every 2 wk for the duration of RMT, and similarly during the 6-wk control (CON) phase where subjects did not train. The simulated AGSM performance was evaluated through measures of peak respiratory pressures, peak systolic arterial pressure (SAP), mean arterial pressure (MAP), and tidal volumes. RESULTS: Training significantly improved (P < 0.05) RM strength after 6 wk of RMT measured in maximal expiratory pressures (RMT = 207.8 +/- 15.8 cmH2O; CON = 181.3 +/- 13.7 cmH2O) and maximal inspiratory pressures (RMT = -154.7 +/- 8.9 cmH2O; CON = -141.9 +/- 8.5 cmH2O). All other PFTs were unchanged. During performance of the AGSM, only peak expiratory pressure demonstrated an increased performance benefit (RMT = 91.5 +/- 5.9 cmH2O; CON = 82.8 +/- 4.3 cmH2O). Peak inspiratory pressure, SAP, MAP, and tidal volumes remained unchanged. CONCLUSION: Without evident translation of the increased RM strength to performance of the AGSM at +1 Gz, the benefits of RMT for ameliorating AGSM-induced fatigue within the high +G, environment are limited.     

Perforation of the trachea by an endotracheal tube: an autopsy case

An 80-year-old woman was intubated with a spiral endotracheal tube via a tracheal stoma during an arytenoidectomy. After being connected to the ventilator, the victim quickly became cyanosed, showed a decrease in blood pressure, and fell into cardiopulmonary arrest. Despite continuous resuscitation, the victim died. Necropsy found a tracheal perforation located 2.0 cm distal from the tracheal stoma that led to the right pleural space through the mediastinal space. We concluded that the tip of spiral endotracheal tube passed through the membranous part of the trachea into the pleural space and caused a hemopneumothorax followed by blood aspiration and death. Tracheal perforation is a rare, but life-threatening complication following a tracheostomal intubation. The inappropriate use of a tracheal tube stylet, guiding catheter, dilating forceps, and oversize tracheal tube have been demonstrated to cause airway injuries. However, fatal incorrect intubation with a spiral endotracheal tube via a tracheal stoma that resulted in death has not been reported previously.     

The spherical endotracheal tube cuff: A plain radiographic sign of tracheal injury

Tracheobronchial injury is an uncommon event associated with blunt chest trauma. The clinical signs and symptoms as well as plain radiographic findings are usually nonspecific, so a high index of suspicion is required for early detection and optimal management. This report describes a severely traumatized patient whose tracheal inury was suspected when a spherical endotracheal tube cuff was noted on a portable trauma chest radiograph.     

Radiographic detection of esophageal malpositioning of endotracheal tubes

Insertion of an endotracheal tube into the esophagus is an infrequent but life-threatening complication of endotracheal intubation. This complication is difficult to detect on standard, anteroposterior, portable chest radiographs because the incorrectly placed endotracheal tube is usually projected over the tracheal air column. To evaluate the use of chest radiographs to detect the malposition, we performed a two-part study. First, we analyzed the findings on chest radiographs in six patients in whom an endotracheal tube had been inserted in the esophagus, and then we analyzed 328 portable chest radiographs of patients with both endotracheal and nasogastric tubes to determine the best radiographic position for identifying the exact location of an endotracheal tube. The findings in the six patients included projection of the tube lateral to the trachea (five patients), gastric distension (four patients), esophageal air (two patients), and deviation of the trachea by the balloon cuff (one patient). The study of the portable chest radiographs showed that the endotracheal tube position could be identified correctly in 81 (92%) of 88 of the films made with the patient in a 25 degrees right posterior oblique position. The trachea and esophagus were superimposed in 25 (96%) of 26 of the radiographs made with the head turned to the left and with the patient in a 25 degrees left posterior oblique projection. Our results show that by positioning patients for chest radiographs in a 25 degrees right posterior oblique position, the location of endotracheal tubes can be identified accurately.