气管切开PPT课件.ppt

气管切开术Tracheotomy 1 Airwaymanagement Successfulairwaymanagementmustbeginwithacareful thorough andrapidevaluationoftheairway Physicalexaminationisakeyelementindiagnosingupperairwayobstruction Stridor ornoisyrespiration isahallmarksymptomofupperairwayobstruction Anaccuratehistoryisalsocriticalinevaluatingtheairwayandformulatingthebestplantomanageit 2 Nonsurgicalmeasures Oxygenadministration Thefirstandmostimportanttaskinnonsurgicalairwaymanagementistoadministeroxygentorelievehypoxia Topicaldecongestantsandsteroids Oropharyngealandnasopharyngealairways Translaryngealintubation Laryngealmaskairway 3 Surgicalmeasures TracheotomyEmergenttracheotomythyrocricotomyPercutaneoustracheotomy 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 Thetracheotomyisaprocedurethatmakeanincisionontheanterioraspectoftheneckandopeningadirectairwaythroughanincisioninthetrachea 5 TrachHistory TheTracheotomyisoneoftheoldestsurgicalprocedures ThefirsttracheotomywasperformedinRomeinsecondcenturyB C 6 WhatfamouspersondiedofanupperairwayobstructionbecausetheirM D wasunwillingtoperformhistracheotomy 7 GeorgeWashingtontouredhisestateonhorsebackinonecoldandrainydayin1799 Thenextdayhehadsevereupperairwayswelling 8 ElishaC Dick GeorgeWashington1799 12 9 ReasonsforTracheotomy 10 Indicationsforatracheotomy AirwayobstructionPulmonarySecretionsVentilationProlongedmechanicalventilationMayassistinweaningfrommechanicalventilationPreventionofglotticstenosis complicationofprolongedett 11 FixedAirwayObstruction Tumoursofupperaero digestivetractChronicairwayobstructionupto80 lumenExternalcompressionbytumourThyroidtumor massivelymphadenopathyForeignBodyGlotticStenosis trachealstenosisTraumaupperairway 12 Non FixedAirwayObstruction TraumaExpandingneckhematomaMaxillofacialtraumaLaryngealfractureInflammatoryInhalationinjuryAnaphylaxis过敏EpiglottitisLudwig sAngina DeepNeckspaceinfectionBilateralvocalcordparalysisFiberopticIntubationcanbesuccessful 13 PulmonarySecretionClearance Aspiration dysphagiaCOPDBronchiectesisStasisofsecretionsPoorcoughPoorrespiratoryreserve 14 Ventilation NeuromusculardisorderaffectingrespiratorymusclesReducedrespiratoryeffortLimitedpulmonaryreserveCOPD Scoliosis bronchiectesisCentralrespiratorydepressionReducedLOCSevereobstructivesleepapneafailureCPAP 15 ProlongedIntubation 7 10daysettRiskFactorsforGlotticStenosisDiabetesFemaleSizeETTand ettHemodynamicinstabilityIncidenceglotticstenosis 5 over10days Whited1984 16 Example1SubglotticStenosis 17 Example3CombinedGlottic TrachealStenosis 18 Thetracheaisatubethatrunsfromthebottomofthelarynxtothechestwhereitdividesintothebronchi itisarigidstructureformedfromringsofcartilagetoensurethattheairwayalwaysremainsopen Itsfunctionistomaintainandprotecttheairway 19 上 环状软骨下 胸骨上窝颈段气管前 皮肤 筋膜 甲状腺峡 2 4环 无名动脉 7 8环 后 食管侧 颈部A V N 20 TracheotomyRelativeanatomy Majorbloodvessels carotis innominatea jugularveins ThyroidglandEsophagusLarynxRec laryngealnervesCervicalspine 21 Isthmusofthyroidglandliesinfrontofthe2nd 4thringofthetrachea 22 Theinnominatearterypassesinfrontofthe7th 8thringofthetrachea 23 Anesthesia Atracheotomyismosteasilyperformedifthepatientisalreadyintubatedandgeneralanesthesiahasbeenadministrated Ifthepatienthasatenuousairwaywithimpairedventilatorystatus thetracheotomyshouldbeperformedwithlocalanesthesia 24 1 Thepatientisplacedinthesupinepositionwithashoulderrolltoextendtheneck orinsemi uprightpositionwhenwithatenuousairway 2 anaesthesia Procain Lydocain operationprocedures 25 3 skinincision longitudinalincision 环状软骨下缘 胸骨上切迹上2cmtransverseincision 环状软骨下约3cm处Makeaincisionintheskinoftheneckthatliesoverthetrachea ThisincisionisinthelowerpartoftheneckbetweentheAdam sappleandtopofthebreastbone 26 4 dissectthesofttissures thefascialtissueandtheneckmusclesareseparated 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 exposurethetrachea theisthmusofthyroidglandisusuallycutdowninthemiddleorpulltotheheaddirection 暴露气管 甲状腺峡部下缘分离组织 向上牵拉暴露3 4气管环 若峡部较宽可切断 缝扎 28 6 openthetrachea identifytheringsofcartilagethatmakeupthetracheaandcutsintothetoughwalls 切开气管 用尖刀切开第3 4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 insertatracheotomytubethroughtheopening 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 surgicalknottofixthetube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 PhysiologyofTracheotomy NeckbreathingBypassupperairwayandnasalfunctionLossofhumidification heatairflowDryness thicksecretionsVoicingpossiblewithspeakingvalveLossofsmell reducedtasteLossglotticclosurefunctionforcough 34 PhysiologyofTracheotomyRespiration AdvantagesLowerworkofbreathing 30 c wnormalairwayFacilitatessecretionclearanceAspirationorthicksecretionsLessdeadspace 100mL ReducedairwayresistanceAssistsinpatientindependencefrommechanicalventilationPatientcomfort betterthanendotrachealtube Epstein2005RespiratoryCare 35 PhysiologyofTracheotomyRespiration DisadvantagesTubediameterandshapeincreasesturbulentairflow secretionsadhereinsidetubeLossofhumidification heatfunctionofupperairwayCiliaryfunctionaffectedBiofilmcolonizationDiminishcough lossglotticclosureReducelaryngealelevationduringswallowPatientcomfort betternotubeatall 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 48h Tokeepthetracheotomytubeventilatingsmoothly Achestxrayistaken especiallyinchildren tocheckwhetherthetubehasbecomedisplacedorifcomplicationshaveoccurred antibioticstoreducetheriskofinfection Humidifying AvoidaccidentaldecannulationAtrialoftracheotomytubeplugging 37 1 5个月4 4 0mm6月 1岁4 5 4 52岁5 5 53 5岁6 6 06 12岁7 6 513 18岁8 7 0成年女性9 7 5成年男性10 8 0 气管套管tracheotomytube 38 postoperativecomplications 皮下气肿subcutaneousemphysema纵隔气肿pneumomediastinum气胸pneumothorax出血bleeding拔管困难difficultyindecannulation 39 Complications innominatearteryfistula 40 Keloid 瘢痕疙瘩 41 Decannulation Goalistoensurepatientcantolerateincreasedairwayresistance workofbreathingandsecretionclearance30 increaseairwayresistance workofbreathingtransitionfromtrachbreathingtoupperairwaybreathing 42 Decannulation Indicationfortracheotomyhasresolved improvedPatientabletocopewithsecretionsUpperairwaypatent examinedifnecessaryAppropriatevocalcordfunctionGoodrespiratoryreserve overallrespiratorystatusGagreflexpresent作呕反应 43 Decannulation StableclinicalconditionHemodynamicstabilityAbsenceoffever sepsisinfectionAdequateswallowingMaximumexpiratorypressure 40cmH2O Cerianaetal2003 44 DecannulationProtocol DownsizetubeGraduallyincreasecorking capoftrachCorked24 48hoursbeforedecannulationRemovetracheostomytubeOcclusive 包扎 dressingforstoma 45 DifficulttoDecannulate GranulationtissueTrachealmucosaledema supraglotticedemaLaryngealpathologyGlotticstenosis cordparalysisPulmonarysecretionsIncreaseairwayresistancenottolerated 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 Acricothyrotomyisanincisionmadethroughtheskinandcricothyroidmembranetoestablishapatentairwayduringcertainlife threateningsituations suchasairway