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。     

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.     

气管插管扩张术联合气管球囊扩张术治疗良性气管狭窄患者的护理

目的总结经纤维支气管镜引导下气管插管扩张术联合气管球囊扩张术治疗良性气管狭窄患者的护理方法。方法回顾性分析2010年4月至2011年9月在广西医科大学第一附属医院呼吸内科行纤维支气管镜引导下气管插管扩张术联合气管球囊扩张术的12例良性气管狭窄患者的临床资料,总结护理方法。结果12例患者术后气管平均直径由术前的（5．7±1．2）mm增加到术后的（12．2士2．1）mm,呼吸困难等症状明显改善。结论术前及术后周到的护理措施和术中默契的医护配合是保证患者安全、有效预防并发症及提高手术成功率的重要环节。     

Pseudomembranous Tracheobronchitis With Severe Tracheal Stenosis and Masked Bronchial Obstruction

BackgroundPseudomembranous tracheobronchitis (PMTB) is a rare condition characterized by the formation of endobronchial pseudomembranes. PMTB overlaps with necrotizing tracheobronchitis or plastic bronchitis. The reported infectious etiology mainly includes invasive aspergillosis. PMTB can cause serious airway obstruction; however, urgent tracheotomy is rarely required.Case ReportA 46-year-old woman was transferred to the emergency department (ED) with a 1-week history of progressive dyspnea and cough that was preceded by fever and sore throat. She was previously healthy except for a 20-year history of mild palmoplantar pustulosis. Stridor was evident. Nasolaryngoscopy performed in the ED revealed severe tracheal stenosis caused primarily by mucosal edema and secondarily by pseudomembranes. Initially, tracheitis was considered the sole cause of dyspnea. Although she underwent urgent tracheotomy to prevent asphyxia, her respiration deteriorated progressively. Bronchoscopy revealed massive pseudomembranes obstructing the bilateral bronchi, which led to the clinical diagnosis of PMTB. Subsequent toilet bronchoscopy markedly improved her ventilation. The causative pathogen was not identified despite extensive work-up, including molecular biological testing. Histopathologic examination of the pseudomembranes revealed fibrin with abundant neutrophils, which was consistent with PMTB. Associated conditions, including immunodeficiency, were not found. Her condition improved with antibiotics and repeated toilet bronchoscopy.Why Should an Emergency Physicians Be Aware of This?PMTB is an important differential diagnosis of airway emergencies. PMTB can present with critical edematous tracheal stenosis and masked bronchial pseudomembranous obstruction. Emergency physicians should include PMTB in the differential diagnosis in adult patients with acute central airway obstruction because it requires prompt multimodal treatment.     

Tracheal stenosis and obliteration above the tracheostoma after percutaneous dilational tracheostomy

Percutaneous dilational tracheotomy (PDT) as opposed to the conventional surgical tracheostomy is a procedure that allows airway control in critically ill patients without surgical exposure of the trachea. Based on the Seldinger technique, dilators are passed along a guiding wire through a small neck incision into the trachea under endoscopic surveillance. This separates the tracheal rings and results in a stoma. As opposed to the regular surgical tracheostoma, a PDT-stoma is not epithelialized. The procedure is cost effective and little time consuming. Considering the increasing number of performed PDTs in the last few years, we feel a need to be aware of possible long-term complications. Thus, in this report, we describe three cases of tracheal stenosis/obliteration after a PDT procedure. In all cases, tracheal narrowing occurred above the level of the stoma. This suggests a procedure-related mechanism, i.e., tracheal ring invagination and the consecutive development of granulation tissue, rather than a mechanism based on the duration of the cannula's placement, which would normally produce the stenosis below the stoma in the area of the cuff. Toward the end of the article, we provide evidence for this hypothesis and thus present a new subset of long-term complications after PDT.     

气道良恶性狭窄镍钛合金支架的介入治疗

目的：评价镍钛合金内支架在治疗气道良恶性狭窄中的安全性以及临床应用价值。材料与方法：在咽喉部黏膜喷雾麻醉或超声雾化吸入麻醉后,对17例气道良恶性器质性狭窄患者,经口直接引入导丝法13例,经麻醉咽喉镜引入导丝法2例,经纤维支气管镜引入导丝法2例,在DSA的X线透视下精确定位,通过气管支架释放器镍钛合金内支架精确置入于气道狭窄处。结果：17例气道良恶性狭窄患者行镍钛合金内支架置放均获成功,放置气管支架17只,支气管支架3只,患者术后呼吸困难,气促症状得到了明显快速的改善,指脉搏氧分压得到提高,未发生意外并发症。结论：镍钛合金内支架治疗气道良恶性狭窄是安全、快速,且非常有效的方法,能改善提高患者的生存质量,具有实际的临床应用价值。     

Extracorporeal membrane oxygenation, extubation, and lung-recruitment maneuvers as rescue therapy in a patient with tracheal dehiscence following slide tracheoplasty

Long-segment congenital tracheal stenosis is characterized by complete tracheal rings. Surgery is required during infancy to optimize outcomes, and the post-surgery complications include mucus plugging, airway trauma, dehiscence at the surgery site, and death. We report a 5-week-old patient who developed a tracheal-wall dehiscence after a slide tracheoplasty. To safeguard against further dehiscence and to protect her one functional lung, we used extracorporeal membrane oxygenation (ECMO). After she was stabilized on veno-arterial ECMO we extubated and continued ECMO for 5 days. On postoperative day 14 we removed the ECMO and transitioned her to high-frequency oscillatory ventilation, and performed slow lung-recruitment maneuvers every 2 hours. This strategy of ECMO with extubation, then high-frequency oscillatory ventilation is a useful rescue therapy in patients with postoperative tracheal dehiscence.     

高龄患者冠状动脉旁路移植术后气管切开的护理经验

目的 探讨高龄患者冠状动脉旁路移植术后气管切开期间的护理经验,提高护理质量。方法 我们对患者给予心理护理,观察气管切口及胸部切口,加强气道湿化和肺部体疗,改善吸痰操作,防止气管软化和狭窄,气管套管的清洁护理。结果 3例患者死于多器官功能衰竭。1例患者出现气道分泌物结痂堵塞,1例有气道内出血。结论 重视心理护理,改善气道,气管套管的护理操作,有效的营养支持有助于患者渡过术后危险期,减少并发症的发生。     

纤维支气管镜直视下有创机械通气中置入金属支架治疗恶性肿瘤致中心气道狭窄的临床应用

目的探讨在机械通气情况下置入气道支架解除恶性肿瘤引起中心气道狭窄的可行性和安全性。方法在机械通气下,将纤维支气管镜和气管插管并行进入气道,在纤维支气管镜直视下经气管插管置入金属气道支架。结果 11例恶性肿瘤引起的中心气道狭窄在机械通气下置入金属气道支架11枚,狭窄解除、呼吸机撤离、操作顺利,缺氧症状缓解。改良英国医学研究学会呼吸困难指数(mMRC)评分、气道压和气道狭窄均改善明显,与支架置入前比较,差异均有统计学意义(P 0.05);动脉血气分析中,动脉血氧分压(PaO_2)和动脉血氧饱和度(SaO_2)升高,动脉血二氧化碳分压(PaCO_2)降低,与支架置入前比较,差异均有统计学意义(P 0.05)。结论在纤维支气管镜直视下,将支架推送器经气管插管置入气道支架治疗中心气道狭窄是可行的、安全的,且近期疗效显著。     

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.     

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.     

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.     

Late complications of tracheostomy

Tracheostomy may be associated with numerous acute, perioperative complications, some of which continue to be relevant well after the placement of the tracheostomy. A number of clinically important unique late complications have been recognized as well, including the formation of granulation tissue, tracheal stenosis, tracheomalacia, tracheoinnominate-artery fistula, tracheoesophageal fistula, ventilator-associated pneumonia, and aspiration. The clinical relevance of these complications is considerable, as their manifestations range from minimally symptomatic to failure to wean from the ventilator (tracheal stenosis) to life-threatening hemorrhage (tracheoinnominate fistula). Treatment modalities vary depending upon the nature of the complication. For the most frequent complication, tracheal stenosis, a multidisciplinary approach utilizing bronchoscopy, laser, airway stents, and tracheal surgery is most effective.     

Postintubation Tracheal Perforation While on Long-Term Steroid Therapy: A Case Report

BackgroundEndotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient's comorbidities, including body habitus and chronic use of certain medications.Case ReportWe report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient's neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful.Why Should an Emergency Physician Be Aware of This?This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management.     

硅酮支架在良性气道狭窄中的临床应用

目的 探讨气道硅酮支架对良性中心气道狭窄的疗效及安全性。方法 收集因良性中心气道狭窄行气道硅酮支架置入术的患者资料共14例次,分析统计围手术期并发症、近期疗效、支架相关并发症和远期疗效等。结果 14例次硅酮支架置入术均成功完成,无严重围手术期并发症,11例次气管狭窄患者血氧饱和度从术前高流量吸氧下平均(86.4±4.8)%改善到术后未吸氧下平均(95.0±2.4)%,术前术后比较,差异有统计学意义(t=-9.42,P=0.000),3例次主支气管狭窄患者的狭窄远端反复感染状况在支架置入后得到控制。14例次患者中,成功取出硅酮支架达到预期疗效11例次,有效率为78.6%(11/14),气道狭窄最窄处平均直径从术前的(5.6±1.1)mm增加到支架取出时的(12.1±2.2)mm,术前术后比较,差异有统计学意义(t=-13.66,P=0.000),支架置入时间199～729 d(中位置入时间352 d,四分位数间距201.5 d)。对6例次狭窄改善的患者进行了随访,1例次复发狭窄,复发狭窄率16.7%(1/6)。支架相关并发症中,肉芽增生发生率71.4%(10/14),声音嘶哑发生率7.1%(1/14),咳痰困难发生率64.3%(9/14),支架移位发生率21.4%(3/14)。结论 气道硅酮支架治疗良性中心气道狭窄,具有良好的近期及远期疗效,安全性较高。     

Laryngoscopic versus intubating LMA guided tracheal intubation by novice users--a manikin study

AIM OF THE STUDY: Airway control is a potentially lifesaving procedure but tracheal intubation by direct laryngoscopy is difficult. This pilot study was conducted to determine whether tracheal intubation was more rapid and the success rate higher using an intubating laryngeal mask airway. MATERIAL AND METHODS: The success rates of 119 medical students without prior airway management experience in ventilating and then intubating the trachea of a Laerdal Airway Management Trainer with two different methods were compared. The methods were bag-mask ventilation (BM-V) followed by laryngoscopic intubation (LG-TI), and intubating laryngeal mask ventilation (ILMA-V) followed by ILMA-guided tracheal intubation (ILMA-TI). After an introductory lecture and demonstration, each student was allowed three attempts to intubate using each method in random order. RESULTS: All participants were successful with BM-V and ILMA-V on the first attempt. Laryngoscopic tracheal intubation was achieved by 60 (50.4%), 31 (26.1%) and 12 (10.1%) participants on the first, second and third attempt, respectively, while 16 (13.4%) failed in all three attempts. In the ILMA-TI group, 107 (90.0%), 10 (8.4%) and 2 (1.6%) succeeded on the first, second and third attempt, respectively. None failed. The intergroup difference is highly significant (p<0.001). Male participants were more successful with LG-TI than female (p<0.01), but not with ILMA-TI. CONCLUSION: Laryngoscopic orotracheal intubation is difficult for the untrained, but all participants were successful with ILMA-TI. These data suggest that alternative devices such as the ILMA should be included in the medical school curriculum for airway management.     

Sonographic visualization of the fetal upper airway.

Laryngeal obstruction is a life-threatening condition which can sometimes be diagnosed by prenatal ultrasound examination. Dilatation of the fetal trachea is an important finding in these cases. Sonographic studies to evaluate the fetal upper airway were performed in 120 consecutive patients. The diameters of the trachea and pharynx were measured and our ability to visualize the trachea and the larynx was evaluated. The diameter of the trachea increased from a mean of 2.4 mm at 18 weeks to 4.6 mm at 38 weeks. The mean diameter of the pharynx increased from 4.4 mm at 18 weeks to 8.8 mm at 38 weeks. The fetal larynx was adequately visualized in 67%) of the cases, while the entire trachea was seen in 47% of the cases. Our success in visualizing the larynx and trachea was best between 20 and 30 weeks' gestation. This study shows that it is possible to obtain excellent views of the fetal airway in a high percentage of cases and reports the range of normal values for tracheal diameter. Early visualization of a diluted trachea may allow better management of a fetus with laryngeal obstruction.     

大气道原发性弥漫性淀粉样变性的多层螺旋CT诊断

目的：探讨大气道原发性弥漫性淀粉样变性的多层螺旋CT表现.方法：收集经病理证实的7例原发性大气道淀粉样变性患者,对多层螺旋CT上病灶的分布、形态,气管支气管壁的厚度、密度及管腔的形态等特征进行回顾性分析.结果：病灶呈连续性,其中1例累及喉及气管,1例累及气管至第1级支气管,1例累及气管至第3级支气管,2例累及气管至第4级支气管,2例累及气管至第5级支气管.大气道表现为软骨环下的管壁围管性增厚,气道厚度为3.2～5.9 mm,中位数为5.5 mm.气道内膜面凹凸不平5例,2例尚光滑.6例气道壁有钙化,且支气管钙化程度较气管明显,钙化呈点状、片状及环状.7例气道腔均有不同程度的狭窄,但仅1例气道有闭塞.结论：大气道原发性弥漫性淀粉样变性的多层螺旋CT表现为气管及大支气管的连续性围管性管壁增厚,内膜面多凹凸不平,管壁可合并钙化,支气管钙化较气管明显.     

Emergency Department Vacuum Extraction of an Obstructing Tracheal Foreign Body Using a Meconium Aspirator and Modified Endotracheal Tube

BackgroundA meconium aspirator is a simple plastic adapter that allows for rapid suctioning of the trachea when attached to an endotracheal tube and a source of continuous negative pressure, as was historically done for suspected neonatal meconium aspiration. Adaptation of this technique for the emergent vacuum extraction of an obstructing tracheal foreign body in an adult has not been previously described.Case ReportWe report the case of a 33-year-old woman with cardiorespiratory arrest after choking on food. Complete tracheal obstruction precluding oxygenation and ventilation due to aspirated chicken was diagnosed by emergency physicians and managed immediately with vacuum extraction using the technique described in this report. No additional airway interventions were necessary and the patient made a full neurologic recovery.Why Should an Emergency Physician Be Aware of This?Vacuum extraction using a meconium aspirator and modified endotracheal tube is a novel and potentially life-saving approach to the emergency management of airway obstruction after choking, especially if the foreign material is below the vocal cords and not amenable to manual extraction with a Magill forceps.     

喉罩与气管插管在小儿全麻气道管理中效果和安全性分析

【目的】比较喉罩与气管插管在小儿全身麻醉气道管理中效果和安全性。【方法】行全身麻醉的患儿120例,随机分为对照组和观察组,每组60例。对照组采用插管通气,观察组采用喉罩通气,比较两组气道管理中的效果和安全性。【结果】观察组置喉罩或插管、拔喉罩或拔管时间点心率（HR）和中心动脉压（MAP）均低于对照组,且差异有显著性（P〈0．01）。观察组副反应发生率低于对照组,且差异有显著性（P〈0．01）。观察组苏醒时间（8．7±4．5）min少于对照组（14．5±5．8）min,且差异有显著性（P〈0．01）。【结论】小儿全身麻醉气道管理中采用喉罩通气对气道损伤小,有利于血流动力学的稳定,且具有苏醒迅速,术后并发症少等优点。