气管切开ppt课件

气管切开术 Tracheotomy,1,Airway management,Successful airway management must begin with a careful, thorough, and rapid evaluation of the airway.Physical examination is a key element in diagnosing upper airway obstruction. Stridor, or noisy respiration, is a hallmark symptom of upper airway obstruction.An accurate history is also critical in evaluating the airway and formulating the best plan to manage it.,2,Nonsurgical measures,Oxygen administration. The first and most important task in nonsurgical airway management is to administer oxygen to relieve hypoxia. Topical decongestants and steroids.Oropharyngeal and nasopharyngeal airways.Translaryngeal intubation.Laryngeal mask airway.,3,Surgical measures,TracheotomyEmergent tracheotomythyrocricotomyPercutaneous tracheotomy,4,定义：切开颈段气管前壁，插入适当的气管套管，建立新的呼吸通道的手术。,The tracheotomy is a procedure that make an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea.,5,Trach History,The Tracheotomy is one of the oldest surgical procedures. The first tracheotomy was performed in Rome in second century B.C.,6,What famous person died of an upper airway obstruction because their M.D. was unwilling to perform his tracheotomy?,7,George Washington toured his estate on horseback in one cold and rainy day in 1799.,The next day he had severe upper airway swelling.,8,Elisha C. Dick,George Washington 1799,12,9,Reasons for Tracheotomy,10,Indications for a tracheotomy,Airway obstructionPulmonary SecretionsVentilationProlonged mechanical ventilationMay assist in weaning from mechanical ventilationPrevention of glottic stenosis/complication of prolonged ett,11,Fixed Airway Obstruction,Tumours of upper aero-digestive tractChronic airway obstruction up to 80% lumenExternal compression by tumourThyroid tumor, massive lymphadenopathyForeign BodyGlottic Stenosis/tracheal stenosisTrauma upper airway,12,Non-Fixed Airway Obstruction,TraumaExpanding neck hematomaMaxillofacial traumaLaryngeal fractureInflammatoryInhalation injuryAnaphylaxis 过敏EpiglottitisLudwigs Angina/Deep Neck space infectionBilateral vocal cord paralysisFiberoptic Intubation can be successful,13,Pulmonary Secretion Clearance,Aspiration / dysphagiaCOPDBronchiectesisStasis of secretionsPoor coughPoor respiratory reserve,14,Ventilation,Neuromuscular disorder affecting respiratory musclesReduced respiratory effortLimited pulmonary reserveCOPD, Scoliosis, bronchiectesisCentral respiratory depression Reduced LOCSevere obstructive sleep apneafailure CPAP,15,Prolonged Intubation,7-10 days ettRisk Factors for Glottic StenosisDiabetesFemaleSize ETT and # ettHemodynamic instabilityIncidence glottic stenosis: 5% over 10 days (Whited 1984),16,Example 1 Subglottic Stenosis,17,Example 3Combined Glottic/Tracheal Stenosis,18,The trachea is a tube that runs from the bottom of the larynx to the chest where it divides into the bronchi，it is a rigid structure formed from rings of cartilage to ensure that the airway always remains open. Its function is to maintain and protect the airway.,19,上 环状软骨 下 胸骨上窝颈段气管 前 皮肤、筋膜、甲状腺峡（24环）， 无名动脉（78环） 后 食管 侧 颈部 A、 V、 N。,20,TracheotomyRelative anatomy,Major blood vessels (carotis, innominate a., jugular veins)Thyroid glandEsophagusLarynxRec.laryngeal nervesCervical spine,21,Isthmus of thyroid gland lies in front of the 2nd-4th ring of the trachea.,22,The innominate artery passes in front of the 7th-8th ring of the trachea,23,Anesthesia,A tracheotomy is most easily performed if the patient is already intubated and general anesthesia has been administrated. If the patient has a tenuous airway with impaired ventilatory status, the tracheotomy should be performed with local anesthesia.,24,1、The patient is placed in the supine position with a shoulder roll to extend the neck, or in semi-upright position when with a tenuous airway.2、anaesthesia：Procain / Lydocain.,operation procedures,25,3、skin incision：longitudinal incision：环状软骨下缘 胸骨上切迹上2cmtransverse incision：环状软骨下约3cm处 Make a incision in the skin of the neck that lies over the trachea. This incision is in the lower part of the neck between the Adams apple and top of the breastbone.,26,4、dissect the soft tissures: the fascial tissue and the neck muscles are separated. 切开气管前筋膜：沿白线正中作锐性切开或钝性分离，用拉钩侧牵两侧胸骨舌骨肌、胸骨甲状肌。,27,5、exposure the trachea:the isthmus of thyroid glandis usually cut down in the middle or pull to the head direction.暴露气管：甲状腺峡部下缘分离组织，向上牵拉暴露34气管环。若峡部较宽可切断、缝扎。,28,6、open the trachea: identify the rings of cartilage that make up the trachea and cuts into the tough walls.切开气管：用尖刀切开第34气管环。,29,注意：气管切开后患者可能突然呼吸停止,呼吸困难，CO2升高，O2下降血中CO2浓度升高刺激呼吸中枢，呼吸加快。血中CO2浓度继续升高抑制中枢。此时，靠颈动脉体化学感受器受缺O2刺激来调节。一旦气管切开，血O2含量增加，颈动脉体刺激消失，CO2对中枢的抑制尚未解除，出现呼吸暂停现象。,30,7、 insert a tracheotomy tube through the opening.安放气管套管：用气管扩张器扩开切口，插入大小适宜的气管套管，并证实无误。,31,32,8、 surgical knot to fix the tube固定套管：缝合套管上方创口。下方创口不予缝合，以免发生皮下气肿。,33,Physiology of Tracheotomy,Neck breathingBypass upper airway and nasal functionLoss of humidification/heat airflowDryness, thick secretionsVoicing possible with speaking valveLoss of smell /reduced tasteLoss glottic closure function for cough,34,Physiology of Tracheotomy Respiration,AdvantagesLower work of breathing (30%) c/w normal airwayFacilitates secretion clearanceAspiration or thick secretionsLess dead space (100 mL)Reduced airway resistanceAssists in patient independence from mechanical ventilationPatient comfort (better than endotracheal tube)Epstein 2005 Respiratory Care,35,Physiology of Tracheotomy Respiration,DisadvantagesTube diameter and shapeincreases turbulent airflow, secretions adhere inside tubeLoss of humidification/heat function of upper airwayCiliary function affectedBiofilm colonizationDiminish cough/loss glottic closureReduce laryngeal elevation during swallowPatient comfort (better no tube at all),36,术后护理1、保持套管通畅2、必要时X线 3、保持适宜的温度和湿度4、预防感染5、防止套管脱出6、拔管试验，48 h,To keep the tracheotomy tube ventilating smoothly. A chest x ray is taken, especially in children, to check whether the tube has become displaced or if complications have occurred. antibiotics to reduce the risk of infection. Humidifying.Avoid accidental decannulation A trial of tracheotomy tube plugging,37,1-5个月 44.0mm 6月1岁 4.54.5 2岁 55.5 35岁 66.0 612岁 76.5 1318岁 87.0 成年女性 97.5 成年男性 108.0,气管套管 tracheotomy tube,38,postoperative complications,皮下气肿 subcutaneous emphysema纵隔气肿 pneumomediastinum气 胸 pneumothorax出 血 bleeding 拔管困难 difficulty in decannulation,39,Complications: innominate artery fistula,40,Keloid (瘢痕疙瘩),41,Decannulation,Goal is to ensure patient can tolerate increased airway resistance/work of breathing and secretion clearance30% increase airway resistance/work of breathing transition from trach breathing to upper airway breathing,42,Decannulation,Indication for tracheotomy has resolved/improvedPatient able to cope with secretionsUpper airway patent - examined if necessaryAppropriate vocal cord functionGood respiratory reserve/overall respiratory statusGag reflex present 作呕反应,43,Decannulation,Stable clinical conditionHemodynamic stabilityAbsence of fever, sepsis infectionAdequate swallowing Maximum expiratory pressure 40 cm H2O,Ceriana et al 2003,44,Decannulation Protocol,Downsize tubeGradually increase corking/cap of trachCorked 24-48 hours before decannulationRemove tracheostomy tubeOcclusive （包扎）dressing for stoma,45,Difficult to Decannulate,Granulation tissueTracheal mucosal edema/supraglottic edemaLaryngeal pathologyGlottic stenosis, cord paralysisPulmonary secretionsIncrease airway resistance not tolerated,46,气管造口术tracheostomy,47,环甲膜切开术thyrocricotomy,对于病情危重，需紧急抢救的喉阻塞病人，可先行环甲膜切开术，待呼吸困难缓解后，再行正规气管切开术。,48,thyrocricotomy,A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening s