Modified Percutaneous Dilatational Tracheostomy without Bronchoscopic Guidance Experience of 165 Consecutive Cases

改良式經皮式氣切手術在165病患之經驗

李明璟(Ming-Ching Lee) ； 徐中平(Chung-Ping Hsu) ； 石燕菁(Wen-Ching Shin)

《Formosan Journal of Surgery》 42卷6期 (2009/12) Pp. 321-328

https://doi.org/10.29833/FJS.200912.0004

摘要

經皮式氣切手術在近年來己成爲常見之氣切手術方法之一。目前大多數的研究報告仍建議手術中應實施支氣管鏡檢查，以避免氣管的受傷及手術的併發症。本文目的則是利用改良式經皮式氣切手術的方法，不需術中支氣管鏡檢查及定位來實施這項手術，並統計分析其各項手術併發症。
病例與方法：自2004年06月至2008年12月間，共有165位呼吸衰竭之重症病患接受這項手術（男性110例，女性50例），平均理想體重指數爲22.10±3.81kg/平方公尺，無任何病患因肥胖，甲狀腺腫大或頸部較短而取消此項手術。此改良式經皮式氣切手術之重點在於利用止血鉗及手術醫師之手指來確定氣切插入之定位，並利用原先置入之經口或經鼻氣管內管來保護氣管，避免受傷。
結果：手術時間平均爲6.2±1.6分鐘，各項手術併發症的總發生率爲18.8%，其巾常見的併發症爲氣切造口之感染(13.3%)及滲血(4.2%)，最嚴重的術後併發症爲氣管破裂，其發生率爲0.6%（1/165例），同時並造成此一病患術後死亡。
結論：改良式經皮氣切手術所需的手術時間較短，而各項手術併發症也未增加。因此，我們認爲在只要適當的手術方法輔助下，並不需要輔以術巾支氣管鏡檢查也可以安全地實施經皮氣切手術。

並列摘要

Objectives: The use of percutaneous dilatational tracheostomy (PDT) has become more prevalent over the past decade. While recent studies have advocated intraoperative bronchoscopic guidance during the procedure, the routine use of intraoperative bronchoscopy is still controversial. Herein, we present our experience of percutaneous dilatational tracheostomy without bronchoscopic guidance.
Methods: From July 2004 through December 2008, 165 patients who underwent PDT without bronchoscopic guidance were enrolled. The PDT technique was as follows: (1) subcutaneous tissue was dissected down to the pretracheal fascia until direct visualization of the anterior tracheal wall; (2) a mosquito clamp was used to identify the correct puncture level of the trachea; (3) a fingertip was used to guide the endotracheal (ET) tube, which was withdrawn to the level above the puncture site; (4) the ET tube was pushed forward to prevent posterior tracheal wall injury while introducing a Seldinger wire. All patients' preoperative condition and postoperative outcome were recorded for analysis.
Results: The mean operating time was 6.2±1.6 minutes. One patient (0.6%) died of posterior tracheal wall injury with subsequent tracheal bleeding and tears. Complication occurred in 31 cases (18.8%), including stoma infection in 22 cases (13.3%), stoma oozing in 7 cases (4.2%) and tracheal tear in one case (0.6%).
Conclusions: We have demonstrated that with minimal dissection of the pretracheal fascia, it is possible to perform precise counting of the tracheal rings and advancement of the ET tube. Then, the routine use of bronchoscopic guidance for a safe PDT may not be necessary.

並列關鍵字

percutaneous dilatational tracheostomy ； bronchoscopic guidance