气道管理新进展

SealingOutDoubtAdvancesinAirwayManagement气道管理新进展Disclosure

MarkProcyshyn,RRTistheSeniorRegionalMarketingManagerforCovidien’sRespiratoryDivisioninAsia.Whatarepostoperativepulmonarycomplications?何为术后肺部并发症Whatistheirsignificanceintermsof:Incidence?发生率？Clinicaloutcomes?临床结果？Outline:PostoperativePulmonaryComplications

术后肺部并发症Thesecomplicationsrangefromminor,self-limitedconditionstomajordiseasestateswithsignificantmorbidityandmortality.

这些并发症小至自限性疾病，大至具有较高发病率和死亡率的疾病。Themostcommonlycitedexamplesintheclinicalliteratureare:1

在医学文献中最常见引用的并发症是：Pneumonia肺炎Respiratoryfailure呼吸衰竭Atelectasis肺不张Acuteexacerbationofchroniclungdisease慢性肺部疾病的急性加重OtherprominentexamplesincludeARDS,bronchospasm,tracheobronchitisandperioperativehypoxia.

其他突出的并发症包括：ARDS，支气管痉挛，支气管炎，术中低氧血症1.Arozullahetal.AnnSurg.2000;232(2):242-253.Whatarepostoperativepulmonarycomplications?何为术后肺部并发症Whatistheirsignificanceintermsof:Incidence?发生率？Clinicaloutcomes?Outline:PostoperativePulmonaryComplicationsAreSurprisinglyCommon

术后肺部并发症十分常见SurgicalsiteReportedcomplicationrateStudies,nAAArepair腹主动脉瘤切除术25.5%16Esophagectomy食道切除术18.9%11Abdominalsurgery腹部手术14.2%43Headandnecksurgery头颈部手术10.3%6Hipsurgery髋部手术5.1%5Gynecologic/Urologicprocedures

妇科/泌尿科操作1.8%21.Smetanaetal.AnnInternMed.2006;144:581-95.Summaryofstudiesinvestigatingincidenceofpostoperativepulmonarycomplicationsbysurgicalsite,aspersystematicliteraturereviewin200612006年不同部位外科手术后术后肺部并发症发生率研究的概要Multiplestudiesshowthehighincidenceofpostoperativepulmonarycomplications.多项研究先提示术后肺部并发症的发生率较高。PostoperativePulmonaryComplicationsDeserveEqualAttentionwithPerioperativeCardiacComplications

术后肺部并发症应与术中心脏并发症一样引起重视Retrospectivemulticentercohortstudyof8,930patients60yearsorolderforhipsurgery1针对8930例60岁以上髋部手术患者的多中心回顾性队列研究，1.Lawrenceetal.ArchInternMed.2002.ComplicationIncidence30-daymortality1-yearmortalitySeriouscardiac*严重的心血管疾病2.0%22%36%Seriouspulmonary†严重的肺部疾病2.6%17%44%p-value:->0.05>0.05*DefiniteorprobableMI,emergencycardioversion,pacemakerinsertion,ventricularfibrillation,ventriculartachycardia,hypotensionrequiringvasopressors,sicksinussyndromeorotherconductiondefect,orCPR.†Respiratoryfailureorpneumonia.Nostatisticaldifferencefoundforincidenceormortalityat30daysand1year.30天或1年的发病率或死亡率无显著性差异。InAggregate,PostoperativePulmonaryComplicationsOccurMoreOftenThanCardiac

总体上，术后肺部并发症多于心脏并发症Casecontrolfrom2,291patientsundergoingelectiveabdominalsurgery,excludingatelectasis12291例进行择期腹部手术患者的病例对照研究，除外肺不张ComplicationEstimatedincidence(95%CI)LOS(±SD),p=0.001Pulmonary肺部9.6%(7.2-12.0)22.5(±17)daysCardiac心脏5.7%(3.8-7.7)10.4(±4.5)days1.Lawrenceetal.JGenInternMed.1995;10:671-678.Totalpulmonarycomplicationsoccurrednearlytwiceasoftenandresultedinhospitallengthsofstayovertwiceaslong.总的肺部并发症发生率高一倍，住院天数延长一倍多Pneumonia,inParticular,IsVeryCommoninSurgicalPatients

肺炎，外科患者尤为常见Mostcommonpost-surgicalcomplicationinnoncardiacsurgicalpatients1

非心脏手术患者最常见术后并发症Mostcommoncomplicationintraumapatients2、

外伤患者最常见术后并发症1.Khanetal.JGenInternMed.2006;21:177-180.2.Hemmilaetal.Surgery.2008;144:307-316.Whatarepostoperativepulmonarycomplications?术后并发症Whatistheirsignificanceintermsof:Incidence?Clinicaloutcomes?临床结果？Outline:PostoperativePneumoniaConfersSignificantMortality

术后肺炎导致死亡率增加Aprospectivestudyin155,266surgicalpatientsdemonstrated30-daymortalityratetobe21percentinpatientswithpostoperativepneumoniavs.only2percentwithout(p<0.001).1

一项155,266例外科患者的前瞻性研究证明，术后肺炎患者的30天死亡率为21%，而无术后肺炎患者的死亡率仅为2%(p<0.001)。1Patients>70yearsofagewithpostoperativepneumoniawhosurvivedtheirprimaryadmissionhadatwofoldincreasedriskofdeathatthreeyears.2大于70岁合并术后肺炎的患者出院后三年的死亡率增加一倍。1.Arozullahetal.AnnofInternMed.2001;135:847-857.2.Mankuetal.AnesthAnalg.2003;96:590-594.PostoperativePneumoniaIsAssociatedwithaTenfoldIncreaseinMortalityAfterAbdominalSurgery

术后肺炎导致腹部手术患者死亡率增加十倍OutcomePatientswithHAPPatientswithoutHAPOddsratio95%CIMortality,n1,421(10.7%)7,217(1.2%)9.91(9.34-10.52Impactofhosp-acquiredpneumonia(HAP)duringoriginaladmissionafterabdominalsurgery,n=618,495patients1腹部手术术后医院获得性肺炎的影响1.Thompsonetal.AnnSurg.2006;243:547-552.Summary总结:Readmissionofsurgicalpatientswithpneumoniaisasignificantsourceofincreasedhealthcarecosts.外科患者因肺炎再入院治疗显著增加了医疗费用。Postoperativepulmonarycomplicationsarecommon,expensiveandassociatedwithincreasedmortality.

术后肺部并发症是常见的，昂贵的，增加了死亡率。TheRoleofMicroaspirationinDownstreamComplications

隐性误吸对后续并发症的影响Microaspiration隐性误吸:Microaspirationreferstothemigrationofforeign,supraglotticmaterialpasttheairwaydevice(e.g.ETTcuff)intotherespiratorytract.隐性误吸是指外源性的声门上物质通过导气管装置（如气管插管套囊）进入呼吸道。Pictured:inadvertentmicroaspirationofcontrastmediaafterabariumswallowexaminationinanintubatedpatient图示：一个气管插管患者进行吞钡实验后不慎误吸造影剂ReproducedfromMacraeetal.BrMedJ.1981(ClinResEd);283:1220withpermissionfromBMJPublishingGroupLtd.CuffRedesigninthe1970s

重新设计气管套囊Traditional“redrubber”ETTsrequiredhighpressures(>60cmH2O)toachieveaseal,andwerefrequentlyassociatedwithseveretrachealinjury.1,2

传统气管插管需要高压套囊，且常导致严重气道损伤ThenewETTswithhigh-volume,low-pressure(HVLP)cuffswereintroducedintheearly1970stospecificallyaddressthisissue,achievingclinicalsealsatsaferpressures(<30cmH2O).

新的气管插管具有低压高容量套囊(HVLP)1.KnowelsonGTC,BassetHFM.BrJAnesth.1970;42:834-837.2.SeegobinRD,VanHesseltGL.BMJ.1984;288:965-968.CuffRedesigninthe1970s

上世纪70年代改进套囊Bydesign,HVLPcuff†diametermustbegreaterthanthediameterofthetracheatoensurecontactbetweenthetwo.

新套囊直径大于气管直径Whenproperlysizedcuffsareappropriatelyinflated,theexcesscuffmaterialfoldsontoitself,whichcancreatechannelsthatallowaccumulatedsecretionstopassintothetracheobronchialtree.1-5

当气囊达到合适的体积，多余的套囊折叠，形成通道，使得积蓄在气囊上物质便于进入气道。1.Seegobinetal.CanAnaesthSocJ.1986;33:27327-9. 4.Seegobinetal.BritishMedicalJournal.1984;288:965-968.2.Youngetal.Anaesthesia.1999;54:559-563. 5.Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.3.Pavlinetal.Anesthesiology.1975;42:216-219.†Pictured:amodernhigh-volume,low-pressure(HVLP)ETTcuff,firstintroducedinthe1970s图示：高容低压气管套管(HVLP)在上世纪70年代问世ExcessCuffMaterialFormingFoldsandChannels

多余的套囊材料形成折叠和通道1.Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.CTimageofaninflatedETTcuffinatracheamodel1LEFT:FullcrosssectionofintubatedmodeltracheaRIGHT:EnlargementofregiondemonstratingacufffoldandchannelMicroaspirationIsSurprisinglyCommonintheOperatingRoomwithConventionalHVLPETTs

手术室HVLP气管插管的隐性误吸十分常见“Extensivefoldingofcuffmaterial”containingsecretionsisseenatallcuffpressures(25–100cmH2O).

在任何压力下均可见多余套囊折叠处的含有分泌物Seegobinetal.BrMedJ.1984;288:965-968.“…high-volume,low-pressure(HVLP)cuffswereintroduced....thesehavefailedtodemonstrateeffectivepreventionofleakageinvitroandinvivo.”体内体外实验均不能证实HVLP气管插管能够有效预防渗漏Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.Microaspirationfoundin100percentofgeneralendotrachealanesthetics.

全身麻醉100%存在隐性误吸Seegobinetal.CanAnaesthSocJ.1986;33:273-279.CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential20|MinimizingAspiration避免误吸.

PulmonaryComplications肺部并发症Atelectasis肺不张ARDSCOPDTrachealbronchitis支气管炎VAP呼吸机相关性肺炎TheCausalRelationshipBetweenMicroaspirationandVAPHasBeenWellEstablished1-5

隐性误吸和VAP的因果关系已被证实1.Mahuletal.IntensiveCareMed.1992;18:20-25. 2.Estesetal.IntensiveCareMed.1995;21:365-383. 3.Chastreetal.AmJRespirCritCareMed.2002;165:867-903.4.Sadfaretal.RespiratoryCare.2005;50:725-741.5.Kollefetal.Chest.1999;116:1339-1346.MallinckrodtTM

Hi-LoTMcuffAspiration误吸Tachypnea呼吸急促Severepneumonitis

重症肺炎AcuteRespiratoryDistressSyndrome(ARDS)InfiltrateonCXR渗出Pulmonary1Systemic1Bronchialirritation

支气管刺激Bronchospasm

支气管痉挛Atelectasis肺不张Tracheobronchial1Inflammatory1,21.JandaM,etal.BestPractResClinAnaesthesiol.2006;20:409–427.2.KalinowskiCP,etal.BestPractResClinAnaesthesiol.2004;18:719–737.22

Particle-associatedaspiration微粒性误吸Bacterialinfection细菌感染Acid-associatedaspirationpneumonitis酸性吸入性肺炎Fluidshifts液体重新分布Hemodynamicchanges

血流动力学变化Hypovolemia血容量不足Fever发热Hypoxia缺氧Activationofneutrophils中性粒细胞升高Cytokinerelease

细胞因子释放Increasedthromboxaneandoxygenradicalrelease促凝氧自由基释放AspirationCanCauseLocalandSystemicInjury

误吸可能导致局部和系统损伤MicroaspirationCausingVAPMayBeJusttheTipoftheIceberg

隐性误吸导致的VAP可能只是冰山一角Post-intubationpulmonarycomplications插管后肺部并发症:Pulmonarycomplicationsfollowingintubation插管后肺部并发症VAPUnplannedrespiratoryReadmissions计划外的因肺部疾病而再入院PostoperativePneumonia术后肺炎Respiratoryfailure,

COPDexacerbations,etc.呼吸衰竭，COPD加重CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential24|Thesepulmonarycomplicationsleadto:

这些并发症导致：Daysofmechanicalventilation

机械通气时间延长ICUlengthofstayICU住院天数延长Hospitallengthofstay

总住院天数延长Costofcare

费用增加CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential25|WhatdomostVAPbundlecomponentshaveincommon?大多数VAP治疗的共同点Headofbed(HOB)elevation床头抬高Reducestheincidenceofaspiratinggastriccontents减少胃内容物的误吸Oralcareandchlorhexadinerinse口腔护理Reducebacterialloadoforalsecretions.减少口腔分泌物的细菌量Oralandin-linesuction口腔吸引Reducesthevolumeofaspirates.减少误吸量TheyprimarilyreducetheincidenceofVAPbyaddressingaspiration通过避免误吸减少VAP的发生率CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential26|ReducingPulmonaryComplicationsintheICU减少ICU肺部并发症的发生: Isabout

MinimizingAspiration,andreducingthe

accumulationof

aspirationovertime.避免误吸，减少蓄积CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential27|CurrentSuctionTechnique

目前的吸引技术SubglotticSpaceSubglotticSpace声门下CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential28|CurrentSuctionProtocols目前的吸引流程Oralandin-linesuctioningQ2-Q4

每2-4小时口腔吸引PRN需要时What’shappeninginbetween?那么在这期间发生什么了呢？CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential29|DemonstrationCovidienRespiratory&MonitoringSolutions|March13,2026|Confidential30|Mallinckrodt™EvacProvidessubglotticsecretiondrainagetominimizetheoccurrenceofmicroaspiration

声门下分泌物引流以减少隐性误吸Separatesuctionlumeninwalloftube.CrossSectionSuctionportabovecuffCovidienRespiratory&MonitoringSolutions|March13,2026|Confidential31|SuctionregulatorSuctioncanisterSuctiontubinMallinckrodtEvac™CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential32|SubglotticSecretionDrainage(SSD)

声门下分泌物引流ReductionintheincidenceofVAP减少VAP发生率Delaystheon-setofVAP

延后了VAP的发生时间ReducesICUlengthofstay(LOS)

缩短了ICU住院天数Reducesdurationofmechanicalventilation

缩短了机械通气时间Reducestheuseofantibiotics

减少了抗生素的应用VAPClaimsImprovedOutcomesCovidienRespiratory&MonitoringSolutions|March13,2026|Confidential33|Uniquetaper-shapedcuffGraduallyTapersSoatsomepointMatchesthediameterofthetrachea.在某一点与气管直径吻合Taper-ShapedCuff

梯形套囊CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential34|MinimizingAspiration避免误吸

Summary总结AllVentprotocolsattempttominimizeaspiration

所有的呼吸机流程目的在于避免误吸TheSubglotticspaceremainsunaddressed.声门下空间问题尚未解决TwoETTtechnologiesaddressAspirationSubglotticSecretionDrainage声门下分泌物引流Taperedcufftechnology.梯形套囊CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential35|ClinicalEvidence临床依据7independentclinicalstudies.7个独立临床研究Patientsexpectedtobeintubated>48hrs.

患者插管大于48小时ComparedstandardETTvs.MallinckrodtEvac.

常规气管套管vs.MallinckrodtEvac（声门下分泌物引流）Commonventbundleprecautionsinplace.HOB抬高床头Oralcare口腔护理CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential36|Bouzaetal3943%reductioninVAP呼吸机相关性肺炎发生率降低43%

ICULOSby9.5daysICU住院天数缩短9.5天 MVby4days机械通气时间缩短4天 Reductioninantibioticsby30%抗生素应用减少30%ReductioninABacquisitioncosts$30,000(ITT)CostofEVAC$4,300(ITT)NewClinicalEvidenceForEvac

关于Evac新的临床证据CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential37|SSDclinicallyprovento:ReduceVAP75%呼吸机相关性肺炎发生率降低75%ReduceICUlengthofstayby9.5daysICU住院天数缩短9.5天Shortenthedurationofmechanicalventilationby4days

机械通气时间减缩短4天DelaytheonsetofVAPby6.8daysVAP发生延迟6.8天ReducetheuseofAntibiotics抗生素应用减少30%SSDisagloballyrecognizedintervention,recommendedbytheCDC,ATS,AACN,SHEA,IDSAandtheAHRQ.声门下分泌物引流被全球认可。ClinicalEvidenceSummary临床证据总结

VAPreductionandImprovedpatientoutcomes.

VAP发生率降低，改善患者预后CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential38|EconomicImpact经济影响CurrentstudiesequatethecostofVAP目前相关的研究经费与VAP的治疗费用相当$40,000-$60,000MallinckrodtEvacassociatedwitha75%VAPreduction.MallinckrodtEvac降低VAP发生率75%ReducingevenoneVAPmayresultinsignificantsavings.

减少一个VAP患者也能带来显著的节约

SubglotticSecretionDrainageUsingMallinckrodt™EvacTechnologyImprovesOutcomes

应用MallinckrodtEvac进行声门下分泌物引流能够改善预后ClinicaloutcomeinpatientsreceivingMVfor>48hTheadditionofsubglotticsecretiondrainageimprovedmultipleoutcomes.Bouzaetal.Chest.2008;134:938-946.CovidienRespiratory&MonitoringSolutions|March13,2026|ConfidentialFormerlyTycoHealthcare40|BouzaetalReduceICUlengthofstayby9.5days减少ICU住院天数Reducetheuseofantibioticsby30%减少抗生素应用Shortendurationofmechanicalventilationby4days缩短机械通气时间ImprovedOutcome改善预后Cost花费ICUday$2-3KCostsavingsinBouzaetal$30KMVday$1,5009.5X2,000=$19,000Costsavings=$30,0004X1,500=$6,000Potentialcostsavings潜在的费用的节省Totalpotentialcostsavings=$55,000CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential41|EffectiveImplementationisSimple

有效实施是简单的UsethetubeforallNon-Elective(non-OR)intubations.

在所有非选择性插管患者使用该套管StockICUandFloorcrashcarts在ICU、救护车上常备StockED在急症室常备UseselectivelyinOR

Typically10%ofoverallETTusage.

MicroaspirationMayBeginasSoonas5MinutesAfterCuffInflation

隐性误吸可能在气囊充气后五分钟内发生Resultsandimagefrominternaltesting.CovidienRespiratory&MonitoringSolutions|March13,2026|Confidential43|Reducesmicroaspirationbyatleast90%减少至少90%的隐性误吸ComparedtotheMallinckrodt™Hi-Lo™cuff.

Providesabetterfluidseal

更好地密闭CombinedwithlatestgenerationMallinckrodtEvac™technologyTheNEWTaperGuard™Evaccufftechnology

新的TaperGuard™Evac套囊技术BetterPerformingEndotrachealTubeCuffsMayReduceRisk

更好的气管内导管套囊可以减少风险Hi-LoTMCuffTaperGuardTMCuffThisisthenewTaperGuardTMcuffcomparedtotheHi-LoTMcuff.OikkonenetalreferredtotheHi-LoTMcuffasthebestsealingoftheninetubeshetestedinhisstudy.1TheTaperGuardTMcuffhasbeenshowntoreducemicroaspirationbyanaverageof90percentcomparedtotheHi-LoTMcuff.2

Internalbenchtopcomparison1.Oikkonenetal.Anaesthesia.1997;52:567-569.2.FDA510(k)clearedclaim.TaperGuard™EvacTubeHasan80PercentImprovementinMicroaspirationReductionUnderSuctionvs.Hi-Lo™EvacTube

与Hi-Lo™Evac气管套管比较，TaperGuard™Evac气管套管能够减少80%的隐性误吸InternaltestingofHi-Lo™andTaperGuard™cufftested(90unitseach)inbenchtopsetting.Suctionrateswereequalbetweenthetwotestarms.UseofTaperGuard™EvactuberesultedinlessmicroaspirationcomparedtotheHi-Lo™Evactube.1.Internaltesting,2009.Taper-shapedCuffsAirSealComparedtoCylindrical-shapedCuffs

梯形套囊空气密闭与圆柱形套囊的比较1.Madjdpouretal.EuropeanJournalofAnaesthesiology.2009;26(Supplement45):19AP7-10.Intubatedlungmodel,ventilatedat20and25cmH2Opeakinspiratorypressure(PIP),anesthetizedwith1%sevorane.Leakmeasuredaboveendotrachealcuff.1Taper-shapedcuffwasfoundtoreduceleak.梯形套囊减少渗漏OpinionsVaryRegardingCuffSealingPerformance

对于套囊密闭性能的不同意见ThoughmicroaspirationiswellrecognizedintheICU,itisusuallynotbelievedtoexistoutsidetheICU.隐性误吸也存在于ICU之外“You’regoingofftheassumptionthatmicroaspirationisbad.Noone’sproventhatmicroaspirationisbad.”

Anesthesiologist,Boston

“Intheliteratureyoureadalotmoreabouttheaspirationproblemsthanyouactuallyseeinpractice.”

CRNA,Houston

“Idon’