气管穿刺导入气管套管术在ICU中的应用

ICU患者多来自内外科的急危重症患者 ,经常需要建立通畅的气道[1,2 ] 。气管切开是常用的方法 ,但传统的气管切开术需 2人操作 ,在紧急抢救时有其不便之处。我科自 2 0 0 1年 2月至 2 0 0 2年 9月对收住ICU需行气管切开 3 0例采用气管穿刺导入气管套管术。其原理来自于Seldinger的血管穿刺技术 ,被认为与大静脉穿刺的方法相似 ,比大静脉穿刺更容易且出血量少 ,伤口愈合时间短 ,现护理报告如下。1　资料与方法1 1　临床资料　本组 3 0例中男 17例 ,女 13例 ,2 5～ 70岁 ,外科患者 2 1例 ,内科 9例 ;紧急气管穿刺导入气管套管 12例 ,非紧急…     

急诊有创呼吸支持方法的临床研究

目的 观察在急诊抢救危重患者的呼吸阶梯化管理中应用有创呼吸支持方法的效果.方法 总结1994年至2004年中对实施有创呼吸通路方法的292例急诊抢救患者相关临床资料并进行统计分析,比较环甲膜穿刺术、气管切开术、气管穿刺导入气管套管术、气管穿刺旋切术四种有创呼吸支持方法.结果 采用气管切开术203例（69.5%）、气管穿刺导入气管套管术58例（19.8%）、环甲膜穿刺术25例（8.6%）、气管穿刺旋切术6例（2.1%）;使用呼吸机占95例（32.5%）.常规气管切开术常需两个人以上操作,15～30 min完成;气管穿刺导入气管套管术只需单人操作,最快可在90 s以内完成,一般在3～5 min内完成,出血少,损伤小,对生命体征影响小,术中术后并发症少,伤口愈合快.结论 急诊快速建立有创呼吸通路应该视病情紧急程度按时间标准决定选择不同的方法.从速度由快到慢顺序是：环甲膜穿刺术、气管穿刺导入气管套管术、气管穿刺旋切术、气管切开术;从安全可靠性推荐：气管穿刺导入气管套管术、气管穿刺旋切术、气管切开术、环甲膜穿刺术.     

经皮气管穿刺导入气管套管术在ICU中的应用

对2005年以来我院经皮气管穿刺导入气管套管术在ICU中的应用总结如下。 1对象和方法 1．1对象2005年以来我院ICU收治气管插管患者28例，均已行气管插管呼吸机辅助通气。其中经皮气管穿刺导入气管套管12例，男7例，女5例，年龄18～80岁（平均39．5）岁。重症胰腺炎并发呼吸衰竭3例，多发伤致中、高位截瘫4例，格林巴利症1例，急性重度有机磷农药中毒2例 ，     

经皮扩张气管造口术在ICU中的应用

目的探讨经皮扩张气管造口术(PDT)在ICU患者中的应用疗效。方法对58例ICU患者用改良经皮扩张气管造口术器械包行经皮气管切开术,从穿刺针送入导引钢丝,沿钢丝导入专用气管套管到气管内,再拔出气管套管内栓及导丝。结果 58例经皮扩张气管造口术均在5～15分钟顺利完成,出血10～20ml,并发症发生率为3.9%,远低于传统气管切开术(OT)的18.9%。结论经皮扩张气管造口技术是一项操作简便、快速安全、创伤小,并发症发生率低,术后伤口愈合美观的床边施救技术,适合ICU使用。     

气管穿刺导入气管套管术建立气通的护理

我们用气管穿刺导入气管套管建立气道通道 ,通过 4 6例临床实践表明 ,该技术操作简便 ,快速 ,创伤小 ,出血少 ,易掌握 ,成功率高 ,痛苦小 ,为急救患者赢得了时间 ,具有临床推广价值。1　材料和方法1 1　材料　英国ＰＯＲＴＥＸＬＩＭＩＴＥＤ产品。1 2　穿刺方法　局麻下 ,在胸骨上凹上 3～ 4ｃｍ处 ,颈部长度足够时可适当上移。在选择的部位处横行切开皮肤 2ｃｍ ,用有外套管的针具穿抽 2ｍｌ液体 ,与气管呈 4 5°角刺入气管 ,刺入气管指征为回抽有气体溢出 ,然后拔出穿刺针 ,留下外套管。从外套管内送入钢丝 ,病人可有咳嗽反射 ,插入导丝…     

纤支镜引导下经皮气管切开术在重症医学科救治中的临床体会

目的观察纤支镜引导下经皮气管切开术(PDT)在重症医学科急危重症患者救治中的应用疗效。方法重症监护条件下,经气管导管插入纤支镜,穿刺套管针刺入气管内,纤支镜确认引导钢丝进入气管后,拔出套管针,用Ciaglia Blue Rhino(蓝犀牛)扩张器沿导丝充分扩开,气管导管置入气管内,拔出导丝及气管套管内芯,手术成功。结果 28例均操作顺利,手术时间短,出血少,术后无切口渗血、皮下血肿及皮下气肿等并发症。结论 PDT与传统气管切开术相比,具有出血少、操作简单、操作时间短、切口小、定位准确、并发症少的优点。     

ICU护士在经皮穿刺旋转扩张气管切开术中的配合及护理

[目的]介绍气管插管辅助下应用经皮穿刺旋转扩张气管切开术(PDT)的初步经验及ICU护士的配合及护理。[方法]做PDT术的病人先行气管插管术,在第2气管软骨环和第3气管软骨环之间正前方皮肤做1.0cm~1.5cm的横切口,仅切开皮肤,然后将气管插管导管拔出至门齿18cm~20cm处,经气管穿刺针导入套管,经套管置入导引钢丝,用扩张器和特殊尖端带孔的扩张钳顺导丝扩张颈前部组织和气管前壁,沿导丝导入吸痰式气管导管,拔出套管管芯,接上密闭式吸痰管,配合使用人工鼻和呼吸过滤器。[结果]102例病人行PDT术成功率100%,手术平均时间9.8min,均无严重并发症发生。[结论]PDT术用于急危重病人,用时短,操作简单,定位准确,减少术中及术后出血、气胸、皮下气肿以及纵隔气肿等手术初中期并发症,减少了气管狭窄、气管软化、气管内肉芽肿、纵向瘢痕明显等远期并发症,配合严密的术后护理,提高了急危重病人的抢救成功率。     

复尔凯鼻胃管引导逆行气管插管术的临床应用

目的 探讨复尔凯鼻胃管引导逆行气管插管术用于困难气道气管插管的临床应用价值.方法 选取15例困难插管逆行气管插管术的ASAⅠ ～Ⅲ级全麻患者,以18G套管针环甲膜穿刺,经外套管向头端插入深静脉导引钢丝,从口或鼻腔引出,复尔凯鼻胃管涂以润滑油并预先套上气管导管(退放于鼻胃管尾端),将导丝插入胃管前端并从其侧孔引出,轻轻拉住导丝将胃管顺导丝插入气管,插至环甲膜水平时有阻力,从环甲膜处依次拔除导丝和套管,顺胃管将气管导管插入气管.结果 所有患者采用本方法均完成气管插管,成功率100%.插管用时 1.5～2.6 min,平均2.2 min,术后随访未见插管相关并发症.结论 复尔凯鼻胃管引导逆行气管插管术用于困难气管插管,简便易学,损伤较小,效果可靠,插管用时短、成功率高,是临床麻醉中困难气道患者安全可靠的插管方法之一.     

24例经皮穿刺气管置管术病人的护理

经皮穿刺气管置管术因损伤小,操作简便、耗时短而用于临床,有研究表明经皮穿刺气管置管术在操作时间、切口长度、伤口愈合时间三方面显著低于传统气管切开术[1]。我院于2003年8月开展该项目至2005年6月,共完成24例,该技术的开展对护理提出更高的要求,特别是术中的配合和术后护理尤其重要,在此总结护理体会如下。1资料与方法1.1一般资料本组24例,男性18例,女性6例,年龄32~65岁,重症胰腺炎12例,慢性阻塞性肺病(COPD)、呼吸功能衰竭10例,脑梗死1例,脑外伤术后1例,24例病人带气管插管时间为3~7d,因需继续保持人工气道而采取经皮穿刺气管置管术。1.2方法采用PORTEX公司生产的经皮气管切开包。操作如下:检查导管气囊;将病人置于仰卧颈过伸位;选颈前正中线第2~3、3~4环状软骨间隙定位标记作为穿刺点,常规消毒、铺巾,局部麻醉;再选位置做一1.5~2cm水平切口切开皮肤;插入套管穿刺针,进针至有气体抽出,证实进入气管;拔出穿刺针,气管内留置套管,顺套管导入导丝至气管;沿导丝依次用扩张器、扩张钳穿透、扩张开气管前组织及气管壁;将导丝穿过气管造口的管芯,沿导丝将气管造口管置入气管,取走导丝及管芯,布带固...     

气管插管全麻术中胃管置入法

气管插管全麻术中经常遇到胃管未插入胃内或术中临时需要胃肠减压的情况。我们对 38例气管插管全麻术中的患者实施气管导管导入胃管置入法 ,取得满意效果。现介绍如下。方　法　 (1 )成人取 6 5～ 7 0气管导管 ,将导管内外壁均匀涂石蜡油 ;(2 )将胃管前端 50ｃｍ涂石蜡油 ,并试将胃管通过备好的气管导管 ;(3) 3 %麻黄碱 1ｍｌ稀释至 2ｍｌ滴鼻 ,以防鼻粘膜出血 ;(4)先放出患者口腔内气管导管气囊内气体 ,再将气管导管缓慢由鼻腔插入食管 ,以此气管导管为支架 ,将胃管通过气管导管插入。插至咽喉部 ,若插管困难 ,可抬高患者头部 ,使其下颌靠…     

Emergency percutaneous tracheostomy is feasable in experienced hands.

One of most stressful situations for a physician occurs when a patient is unable to breathe and endotracheal intubation is not possible. The establishment of an open airway by surgery is indicated only if the physician is unable to do so with an endotracheal tube. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Percutaneous dilatational tracheostomy in experienced hands takes only a few minutes. We describe six patients, including two trauma patients, in whom emergency percutaneous tracheostomy was rapidly and successfully performed under conditions of the imminent loss of airway and inability to intubate the patient. As this procedure is safe and can be performed easily by experienced personnel, we propose its addition to the armamentarium of emergency airway management.     

经皮气管切开术在重型颅脑损伤中的应用

目的 总结经皮气管切开术在重型颅脑损伤患者中的应用经验。方法 采用导丝扩张钳法行经皮气管切开术，对46例重型颅脑损伤患者的临床资料进行回顾性分析。结果 45例成功，1例改行正规的气管切开术。手术时间平均7．8分钟。5例术中少量渗血，无严重并发症及与手术操作有关的死亡发生。结论 经皮气管切开术具有安全、简单、快速、损伤小的特点，可选择性应用于重型颅脑损伤患者。     

改良经皮扩张气管切开术的临床应用总结

目的观察改良法经皮扩张气管切开术的临床疗效.方法55例患者采用改良法经皮扩张气管切开术,另52例采用经皮扩张气管切开术.结果改良法经皮扩张气管切开术成本仅(216.0±4.4) 元,操作时间(5.0±3.5) min,明显优于经皮扩张气管切开术[(3 011.0±5.3) 元,(10.0±6.9) min],有极显著性差异(t＝23.60、4.76,P均<0.001),而术中出血及愈合时间无显著性差异(P均>0.05).结论改良法经皮扩张气管切开术具有快速、价廉、愈合快及疤痕小的优点,利于急危重患者的抢救,可完全替代标准的外科气管切开及经皮扩张气管切开术,值得临床推广.     

Urgent tracheostomy: four-year experience in a tertiary hospital

BACKGROUND: Urgent airway management is one of the most important responsibilities of otolaryngologists, often requiring a multidisciplinary approach. Urgent surgical airway intervention is indicated when an acute airway obstruction occurs or there are intubation difficulties. In these situations, surgical tracheostomy becomes extremely important.METHODS: We retrospectively studied the patients who underwent surgical tracheostomy from 2011 to 2014 by an otolaryngologist team at the operating theater of the emergency department of a tertiary hospital. Indications, complications and clinical evolution of the patients were reviewed.RESULTS: The study included 56 patients (44 men and 12 women) with a median age of 55 years. The procedure was performed under local anesthesia in 21.4% of the patients. Two (3.6%) patients were subjected to conversion from cricothyrostomy to tracheostomy. Head and neck neoplasm was indicated in 44.6% of the patients, deep neck infection in 19.6%, and bilateral vocal fold paralysis in 10.7%. Stridor was the most frequent signal (51.8%). Of the 56 patients, 15 were transferred to another hospital. Among the other 41 patients, 21 were decannulated (average time: 4 months), and none of them were cancer patients. Complications occurred in 5 (12.2%) patients: hemorrhage in 3, surgical wound infection in 1, and cervico-thoracic subcutaneous emphysema in 1. No death was related to the procedure.CONCLUSION: Urgent tracheostomy is a life-saving procedure for patients with acute airway obstruction or with difficult intubation. It is a safe and effective procedure, with a low complication rate, and should be performed before the patient's clinical status turns into a surgical emergency situation.     

Repeat bedside percutaneous dilational tracheostomy is a safe procedure

OBJECTIVE: Previous tracheostomy has been considered a relative contraindication for percutaneous dilational tracheostomy. The objective of this study was to assess the safety of percutaneous dilational tracheostomy in critically ill patients with a history of previous tracheostomy. DESIGN: Retrospective, single-center case series of all consecutive patients requiring repeat tracheostomy for continued mechanical ventilatory support. SETTING: Intensive care unit of a tertiary-care referral center. SUBJECTS: Fourteen patients (eight female, six male) with a median age of 70 yrs (range, 33-94). All patients had previously undergone tracheostomy. INTERVENTION: Bedside percutaneous dilational tracheostomy. MEASUREMENT AND MAIN RESULTS: Subjects' previous tracheostomies dated back between 10 days and 8 yrs. Present intubation time before percutaneous dilational tracheostomy varied between 4 and 30 days. Bedside percutaneous dilational tracheostomy was performed successfully in all 14 patients by trained pulmonologists and surgeons. Eleven patients received an 8-mm and three received a 7-mm tracheostomy tube. There were no significant periprocedural complications, and no patient required surgical revision. The only postprocedural complication was accidental decannulation in one patient, which was managed with repeat percutaneous dilational tracheostomy. CONCLUSIONS: Trained physicians can safely perform bedside percutaneous dilational tracheostomy after previous tracheostomy. Percutaneous dilational tracheostomy offers an alternative to surgical tracheostomy in this particular patient population and should not be considered contraindicated.     

Pitfalls in percutaneous dilational tracheostomy using the Ciaglia one-step technique

Surgical tracheostomy was first described in 1909. Since then, it has become a standard procedure for patients requiring prolonged mechanical ventilation. More recently, bedside percutaneous tracheostomy has been shown to be as safe and effective as the surgical technique, but with the added advantage of also being technically straightforward and cost-efficient. Partly because of this, percutaneous tracheostomy is now being performed by nonsurgeon intensivists. However, the relative ease of the procedure may mask many potential pitfalls that can result in morbidity. As such, it is important for all intensivists to be familiar with the steps and potential pitfalls of this procedure. This is an evidence-based review of the common pitfalls associated with the Ciaglia one-step percutaneous tracheostomy technique, the method most commonly utilized for percutaneous tracheostomy insertion in the United States.     

Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up

OBJECTIVE: To compare the safety, availability, and long-term sequelae of percutaneous vs. surgical tracheostomy. DESIGN: Prospective, randomized, controlled study. SETTING: Combined medical/surgical intensive care unit in a tertiary referral hospital. PATIENTS: Two hundred critically ill mechanically ventilated patients who required tracheostomy. INTERVENTIONS: Tracheostomy by either percutaneous tracheostomy or surgical tracheostomy performed in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was the aggregate incidence of predefined moderate or severe complications. The secondary outcome measures were the incidence of each of the components of the primary outcome. Long-term follow-up included clinical assessment, flow volume loops, and bronchoscopy. Both groups were well matched for age, gender, admission Acute Physiology and Chronic Health Evaluation II score, period of endotracheal intubation, reason for intubation, and admission diagnosis. There was no statistical difference between groups for the primary outcome. Bleeding requiring surgical intervention occurred in three percutaneous tracheostomy patients and in no surgical tracheostomy patient (p = .2). Postoperative infection (p = .044) and cosmetic sequelae (p = .08) were more common in surgical tracheostomy patients. There was a shorter delay from randomization to percutaneous tracheostomy vs. surgical tracheostomy (p = .006). Long-term follow-up revealed no complications in either group. CONCLUSIONS: Both percutaneous tracheostomies and surgical tracheostomies can be safely performed at the bedside by experienced, skilled practitioners.     

Percutaneous dilational tracheostomy or conventional surgical tracheostomy?

OBJECTIVE: Percutaneous dilational tracheostomy (PDT) is increasingly used in intensive care units (ICU), and it has a low incidence of complications. The aim of this study was to compare the costs, complications, and time consumption of PDT with that of conventional surgical tracheostomy (ST) when both procedures were performed in the ICU. DESIGN: The study was a prospective, randomized trial. SETTING: The procedures were performed routinely in the ICU of Satakunta Central Hospital. PATIENTS: During a 23-month period from December 1995 to November 1997, 30 patients underwent PDT and 26 patients had ST. In one patient, PDT was converted to ST. All patients were receiving ventilation in the ICU, and all tracheostomies were performed at the patient's bedside in the ICU. The Portex percutaneous tracheostomy kit was used for all PDTs. RESULTS: The mean time to perform PDT was 11 mins (SD, 6; range, 2-40), and the mean time to perform ST was 14 mins (SD, 6; range, 3-39). In the PDT group, five patients had moderate bleeding during the procedure. In three patients, the bleeding was resolved with compression; in one patient, it was resolved with ligation of the vessel; and in one patient, it was resolved with electrocoagulation. Bleeding did not cause any complications afterward. In the PDT group, one patient had minimal oozing from the wound edge on the first postoperative day and it was resolved spontaneously. In the ST group, there were no intraprocedural complications. One patient had bleeding from the wound on first postoperative day. The sutures were removed, and the bleeding vessel was ligated. The mean cost (in U. S. dollars) of PDT was $161 (SD, 10.4; range, $159-$219), and the mean cost of ST was $357 (SD, $74; range, $239-$599). The cost of PDT was significantly lower than the cost of ST (p < .001). CONCLUSION: We found that PDT is a cost-effective procedure in critically ill ICU patients. Although we performed ST at the bedside in the ICU to avoid the risks associated with moving critically ill patients to the operating room, we found PDT to be a simple and safe procedure.     

A new simple method for percutaneous tracheostomy: controlled rotating dilation

OBJECTIVE: To describe and introduce a new technique for percutaneous dilational tracheostomy. DESIGN AND SETTING: Open, observational clinical trial in patients requiring an elective tracheostomy in two intensive care units of university hospitals. PATIENTS: Fifty (25/25) consecutive patients requiring an elective tracheostomy above 18 years of age. INTERVENTIONS: Performance of a percutaneous dilational tracheostomy with a specially designed screw-type dilator, using a thread for the dilation procedure. RESULTS: In 50 consecutive patients the new device allowed a quick and safe dilation procedure without any serious bleeding complications or other relevant procedural-related side effects. CONCLUSIONS: The described new percutaneous dilational tracheostomy device (PercuTwist, Rüsch, Kernen, Germany) represents a single-step method with a high degree of control during dilation. So far, it appears to be a safe, quickly performed procedure with a strikingly low incidence of even small bleeding complications, thus offering an interesting new alternative for the performance of a percutaneous tracheostomy.     

Recent developments in percutaneous tracheostomy: improving techniques and expanding roles

PURPOSE OF REVIEW: The purpose of this review is to provide an update of recent developments pertaining to the use of percutaneous tracheostomy. Percutaneous tracheostomy has been established as an alternative to open surgical tracheostomy, but many key questions about the optimal use of this procedure remain unanswered. RECENT FINDINGS: Issues in percutaneous tracheostomy that have been addressed in the recent literature include the optimal method, timing, use of percutaneous tracheostomy in emergencies, safety in high-risk populations, confirmation of tracheal puncture, and outcomes. SUMMARY: Recent literature suggests that percutaneous tracheostomy is safe to use in an expanding population of patients, including patients with airway compromise and thrombocytopenia. Several methods seem to be safe alternatives to that originally described. Capnography has arisen as an alternative to bronchoscopy for confirmation of tracheal puncture. Recent evidence highlights that although tracheostomy may improve short-term outcome, these critically ill patients have a significant long-term risk of poor outcome. This must be taken into consideration when this procedure is offered.