气管支架及人工气管材料的应用

目的:对人工气管及气管支架材料的分类性质及其在气管及支气管狭窄治疗中的应用和并发症的处理进行归纳总结.方法:第一作者应用计算机检索PubMed数据库(http://www.ncbi.nim.nih.gov/PubMed)及CNKI数据库(www.cnki.net/index.htm),在标题中以"人工气管,气管支架,生物复合材料,镍钛合金支架"或"artificial trachea,tracheal stent"为检索词进行检索,选择文章内容与气管支架材料类型,材料特点适应证选择及应用疗效相关,同一领域文献则选择近期发表或发表在权威杂志文章,共纳入10篇文章.结果:高分子聚合物材料人工气管是一种生物型复合式结构,合理地整合了既往无孔型和有孔型人工气管的优点,在防止假体滑脱、移位、漏气、网管裸露塌陷学方面具有明显优势.镍钛合金支架,其独特的网状结构设计,允许金属丝做轴向及冠向运动,因此该支架适用于不规则或表面凸凹不平的气道病变,故广泛用于各种良、恶性气道狭窄的治疗.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、能否发挥正常的生理功能等还需要进一步的实验验证.     

组织工程气管的构成和构建方法

背景:当气管切除长度超过6 cm,因吻合口张力大易产生吻合口瘘,这时需要进行气管重建,但无论是同种异体移植,自体组织移植和人工替代物等方法效果均不理想.组织工程学是近年来的研究热点,气管组织工程学虽然起步较晚,但已经取得一些重要成果,显示出良好的前景.目的:从支架材料、种子细胞、生长因子、立体结构重建、以及临床应用等方面,全面了解组织工程气管的构成和构建方法.方法:以"气管移植(tracheal transplantation),组织工程气管(tissue-engineered trachea)"为检索词,应用计算机检索维普数据库,Pubmed数据库,Elsevier数据库2000/2009有关文章.纳入与组织工程气管的构成和构建方法密切相关的文献,排除重复性研究.结果与结论:共检索到279篇文献,排除无关重复的文献,保留30篇文献进行综述.目前组织工程气管应用的支架材料主要为合成材料,纳米材料被认为是最具潜能的;种子细胞来源有软骨细胞和气管上皮细胞.旋转生物反应器可作为体外构建组织工程化气管软骨的可行的培养方法,生长因子的应用可诱导、加快和增强软骨形成.组织工程气管由于供体组织少,不易发生排斥反应,具有良好的应用前景.但还存在组织工程化气管的质地和延展性、管腔内壁上皮化和组织工程化气管的血管化等问题有待进一步解决.     

间充质干细胞构建组织工程化气管的研究与应用

背景：间充质干细胞诸多特有的良好生物学特性使得其在组织工程化气管研究中成为理想的种子细胞来源。目的：总结间充质干细胞在构建组织工程化气管领域的研究现状、进展、存在的问题及展望。方法：由作者检索PubMed数据库及CNKI数据库1979至2012年,在英文标题和摘要中以＂mesenchymal stem cells,tissue-engineered trachea＂和＂tracheal chondrocytes,tracheal epithelial cells,tracheal vascular endothelial cells＂检索,中文文献检索中以＂间充质干细胞、组织工程化气管、气管软骨细胞、气管上皮细胞和气管血管内皮细胞＂为关键词,选择与组织工程化气管相关的文章,同一领域文献则选择近期发表或发表在权威杂志的文章,共纳入51篇。结果与结论：组织工程化气管种子细胞研究主要包括软骨细胞、上皮细胞和血管内皮细胞。实验已证实,间充质干细胞可定向分化为软骨细胞,细胞因子在诱导间充质干细胞分化为软骨过程中起着关键作用。目前尚未发现合适的诱导因子能特异性诱导间充质干细胞定向分化气管上皮细胞。有研究发现间充质干细胞具有向上皮细胞分化的潜能。间充质干细胞在体内或体外特殊条件下可诱导分化为血管内皮细胞,为间充质干细胞作为种子细胞分化血管内皮细胞应用于组织工程化气管起到借鉴作用。     

组织工程化气管研究：软骨及血供障碍的突破

背景：气管的损伤及缺损在临床上较为常见,临床上难以行气管的端端吻合,需要植入人工气管或组织工程化气管进行修补缺损及完善其功能.植入后组织工程化气管的再血管化、免疫排斥、感染、纤维瘢痕形成及功能恢复情况是目前的研究重点.目的：认识分析近年来国内外组织工程化气管构建过程中种子细胞、支架材料、软骨生成及血管化的研究进展及影响组织工程化气管生长的因素.方法：第一作者应用计算机检索2000年1月至2014年4月PubMed数据库、中国知网全文数据库及谷歌学术有关组织工程化气管的文章,以“Tissue engineering,Tracheal reconstruction,Trachea substitute,Scaffold revascularization,Seed cells,Transforming growth factor”为英文检索词,“组织工程,气管重建,气管替代物支架材料,再血管化,种子细胞,转化生长因子”为中文检索词.共检索到140余篇相关文献,45篇符合纳入标准.结果与结论：组织工程化气管是利用机体的活体组织或者种子干细胞在体外支架材料上进行扩增繁殖,植入病损气管,修补原气管缺损,或者在原位进行诱导缺损端的增殖分化,从而修补缺损并能达到一定功能的技术方法.组织工程化气管的主要影响因素包括种子干细胞、气管支架材料、软骨生成和促进组织工程化气管再生的血管因素及相关生长因子.     

气管支气管内支架材料的评价

目的:评价各种气管支气管支架材料的性能和应用,寻找更加安全有效的气管内支架材料.方法:以"人工气管,气管支架,生物材料"为中文关键词,"trachus,bronchus,stent"为英文关键词,由第一作者应用计算机检索 Pubmed 数据库(http://www.ncbi.nlm.nih.gov/PubMed)及维普数据库(http://www.cqvip.com/)1995-01/2008-10 有关气管支架生物材料的文献,排除重复研究或 Meta 分析类文章.以18篇文献为主重点讨论了气管支气管支架材料的种类及其性能.结果:经检索共查到相关文献50余篇,经阅读标题、摘要、全文后筛选纳入18篇文献进行评价.其中英文文献16篇,中文文献 2 篇.各种材料的气管支架均有其特点,不能完全否定任何一种材质的支架.文献显示目前国内应用最多的为镍钛记忆合金支架,它已被广泛应用于各类原因所致的气管狭窄治疗中,可以被径向拉长,此时直径变细,便于装入导管.释放后又可以自动回复至原直径,顺应性良好,可置于气管各个部位,很好地缓解了气短症状,从而减轻患者的痛苦.结论:人工气管支架近年来发展迅速,金属类支架更是得到了蓬勃的发展.其中镍钛记忆合金支架是目前较为理想的支架材料,它既安全可靠,操作方便又价格适宜,已被广泛地应用于各类气管狭窄的治疗中.     

气管支气管内支架的种类、性能及置入技术

学术背景:气管内支架是目前治疗气道狭窄的重要手段.近年来,随着科学技术的发展,气管内支架的种类不断增多,性能也在不断扩展.根据气道病变的不同,所需内支架的性状和类亦不同.目的:综述近年来国内外气管内支架的最新研究进展,以指导临床正确选择内支架的种类.检索策略:应用计算机检索www.highwire.org 2002-01/2007-11的相关文献,检索词"trachus,bronchus,stent",并限定文章语言种类为English.同时计算机检索中国期刊全文数据库www.cnki.net 2002-01/2007-11的相关文献,检索词"气管,支气管,支架",限定文章语言种类为中文.文献评价:共检索到英文文献363篇,从中选出代表性文章36篇;中文文献101篇,从中选出代表性文章9篇.另有2本专著作为参考.资料综合:①根据材质,气管内支架可分为金属支架和非金属支架两种.根据有无被膜,又分为被膜支架和裸支架.②原则上各种原因引起的大气道狭窄或软化失去手术机会或其他治疗方法无效时,尤是患者处于严重呼吸困难的急症时,均适用于内支架治疗.③良性气管狭窄患者主要放置可回收支架(Z型被膜支架)或硅酮支架,近期内可予取出,慎用Wallstent裸支架或Ultraflex裸支架.恶性病变,如生存期较长的患者首选放置Z型被膜支架,生存期较短的患者可用Ultraflex支架或Wallstent,慎用Gianturco支架.累及隆突的病变可选用"Y"型支架.气道内病变还可与热消融、冷冻等方法结合应用,良性病变慎放支架,恶性病变消融术后可放置放射性粒子支架,以防肿瘤复发.结论:气管内支架置入是一种快速、安全缓解良、恶性气道狭窄的治疗方法.     

复杂中心气道狭窄非计划气管插管内支架置入

目的 初步探讨复杂中心气道狭窄非计划气管插管内支架置入治疗的可行性和疗效.方法 未做计划紧急气管插管的复杂中心气道狭窄患者控制呼吸衰竭后,采取适当的方式放置内支架,然后撤退呼吸机并拔出气管插管.结果 内支架放置均获成功,气道扩张良好,呼吸衰竭控制,呼吸困难改善.结论 复杂中心气道狭窄非计划气管插管内支架置入治疗技术可行,操作简单、安全,近期疗效可靠,可作为特殊情况内支架置入的补充方法.     

组织工程化气管的种子细胞研究

检索Medline、中国期刊网和维普网2000—01／2006—12有关组织工程化气管和种子细胞的研究文章，综述组织工程化气管种子细胞的来源、选择、培养和生长的研究概况。文献显示组织工程化气管与其他气管替代物相比具有明显的优点，它应用的是自体细胞，无免疫原性，具有生物活性，有潜在的生长能力。但在研究过程中至今尚未找到理想的种子细胞的来源。在成体干细胞中，目前虽已能以软骨细胞或骨髓间质干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。     

气管支架及气管支架材料置入治疗

检索中国期刊全文数据库文献,然后对资料进行初审,分析气管支架材料置入在治疗气管狭窄应用中的特点.结果表明治疗气管狭窄支架放置的方法有很多种,不同类型气管狭窄选取置入方式也不尽一样.随着人们对气管狭窄的认识,气管支架置入技术的改进,以及新技术、新方法的出现,气管狭窄行气管支架置入技术的效果越来越确切,相对而言采取传统手术的病例越来越少,而气管支架置入适应证也逐渐放宽,方式也日益增多.镍钛记忆合金支架具有强度高、耐腐蚀、组织相容性好、无毒性、有形状记忆效应等特性.在-10℃时变软,可任意塑形,在30～35℃时复形,是治疗气管狭窄的理想气管支架.     

气管支架治疗气管狭窄26例分析

目的：评价气管支架治疗气管内外肿瘤或其他原因造成气管狭窄的疗效。方法：采用钛镍形状记忆合金支架，在DSA下由纤支镜导引置入。结果：26例均一次性放置成功，呼吸困难立即解除，随诊2～17个月，21例恶性肿瘤致狭窄，至今平均生存126．4天，2例良性狭窄患者气管支架处有肉芽生长。结论：采用气管支架治疗恶性肿瘤所致气道狭窄是十分积极有效的方法．而对良性狭窄则需慎重。     

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。     

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.     

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.     

Rapid progression of tracheal stenosis associated with tracheopathia osteo-chondroplastica

Tracheopathia osteochondroplastica (TPO) is a rare, but increasingly recognised condition in which there is accumulation of calcium phosphate with benign submucous proliferation of cartilage and bone beneath the tracheal mucosa, often with squamous metaplasia of the mucosal columnar epithelium. This condition is usually asymptomatic, but may be slowly progressive, causing haemoptysis, dry cough and dyspnoea. We report a case of TPO in which there was rapid progression of tracheal stenosis such that the size of endotracheal tube that the upper airway would accept changed from 8.00 mm to 3.0 mm during a six-week period. This extreme reduction in airway calibre had not been detected on spirometry nine days prior to his final admission. This is the first report of such rapid progression of tracheal stenosis associated with TPO.     

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.     

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.     

Treatment of tracheal and bronchial tumors and tracheal and bronchial stent placement

Tumors of and trauma to the trachea and bronchi can result in loss of integrity of the airway and death. Once treated primarily with thoracic surgery, these conditions are increasingly being managed with interventional pulmonary procedures outside the operating room but requiring the assistance of anesthetists. These interventional procedures require airway instrumentation, necessitating anesthesia care for ventilation and obtundation of airway reflexes. A thorough preoperative assessment and consultation with the pulmonologist or surgeon performing the procedure are essential for successful completion of the tumor and scar reduction and subsequent stent placement. In addition, anesthetists may care for patients undergoing nonpulmonary surgery who have an existing bronchial or tracheal stent or patients requiring correction of displaced stents. A discussion on the preferred methods for caring for patients in these situations is included.     

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。     

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。     

The role of tracheal tube introducers and stylets in current airway management

Tracheal tube introducers and stylets are highly successful devices for the management of various airway scenarios. Their first-line use is advocated in many difficult airway algorithms. Although they have been used for decades, the shape and design of introducers and stylets as well as their patterns of use are constantly evolving. Our purpose is to provide the clinician with an update on these different devices. We performed a systematic literature search from 2005 until May 2015, without language restrictions. The two authors independently retrieved all studies with the keywords “bougie”, “gum elastic bougie”, “stylet”, “airway management”, “tracheal tube introducer” and “extubation catheter”. Our search did yield mostly observational and retrospective studies with small case numbers. The data was synthesized into a narrative review to provide the clinician with an update on the characteristics, indications and techniques of use as well as the dangers of different intubation aids. Today, numerous tracheal tube introducers and stylets exist with different indications, ranging from general to specific situations. Anesthetists should be familiar with the different devices, their characteristics and indications in order to use the right device at the right time in the right way.