Campanini A, De Vito A, Frassineti S, Vicini C
ENT and Head and Neck Surgery Unit, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy.
Acta Otorhinolaryngol Ital. 2004 Apr;24(2):68-74.
Permanent tracheotomy was the first surgical procedure proposed for the treatment of severe obstructive sleep apnoea syndrome and is still the only surgical option that ensures, even in very severe cases, complete elimination of apnoea and, in turn, clinical remission. Improved knowledge of the causes of obstructive sleep apnoea syndromes and the increasing therapeutic options (instrumental, medical and surgical) have resulted in cases requiring tracheotomy as the only indispensable therapeutic option becoming more rare. At present, the only indications are in very occasional conditions of life-threatening obstructive sleep apnoea syndromes and in patients on whom continuous positive airway pressure is not tolerated or is not effective (severe deoxygenation or hypercapnia, severe respiratory disorder index, severe obstructive sleep apnoea syndrome-related arrhythmias, severe excessive daytime sleepiness, heart diseases or ischaemic encephalopathy exacerbated by obstructive sleep apnoea syndromes, obstructive pneumopathy exacerbated by obstructive sleep apnoea syndromes, severe obstructive sleep apnoea syndromes with few chances of resolution with other surgical procedures or failure of the latter). Moreover, it is the only therapeutic solution in rare nocturnal laryngeal stridor due to multisystemic atrophy (in which obstructive sleep apnoea syndrome is due to nocturnal laryngospasm of neurologic origin). Therapeutic tracheotomy must be permanent (tracheostomy) and, therefore, preferably carried out with a specific technique (skin-lined tracheotomy), able to guarantee greater stability, less risk of granulation tissue, wider opening of the tracheostomy, sufficient reversibility. In our experience, very few patients (10 cases) withsleep disorder breathing have been submitted to skin-lined tracheotomy. Of these, the majority were submitted to surgery for severe apnoea due to nocturnal laryngospasm on account of multisystemic atrophy (n = 7), while only 3 cases of obstructive sleep apnoea syndromes were submitted to skin-lined tracheotomy, i.e., 0.7% of the 424 patients operated on for obstructive sleep apnoea syndrome and 1.7% of the 175 operated on for severe, or very severe, obstructive sleep apnoea syndromes (RDI > 40). Skin-lined tracheotomy was not followed by important complications and expected results were achieved with immediate disappearance of daytime symptoms and considerable improvement in nocturnal apnoea. Besides sleep-related disorders, numerous clinical situations with indications for a permanent tracheotomy may benefit from the skinlined technique, such as severe laryngeal or tracheal stenoses, laryngeal diplegias, miasthenia gravis, lateral amyotrophic sclerosis, intractable aspiration, severe emphysema.
永久性气管切开术是最早被提出用于治疗重度阻塞性睡眠呼吸暂停综合征的外科手术，至今仍是唯一能确保即使在非常严重的病例中也能完全消除呼吸暂停从而实现临床缓解的手术选择。随着对阻塞性睡眠呼吸暂停综合征病因的认识不断提高以及治疗选择（器械治疗、药物治疗和手术治疗）的增加，需要将气管切开术作为唯一必不可少的治疗选择的病例变得越来越少。目前，唯一的适应症是在极个别危及生命的阻塞性睡眠呼吸暂停综合征情况下，以及对持续气道正压通气不耐受或无效的患者（严重脱氧或高碳酸血症、严重呼吸紊乱指数、与严重阻塞性睡眠呼吸暂停综合征相关的心律失常、严重日间过度嗜睡、因阻塞性睡眠呼吸暂停综合征而加重的心脏病或缺血性脑病、因阻塞性睡眠呼吸暂停综合征而加重的阻塞性肺病、其他手术方法解决可能性小或手术失败的严重阻塞性睡眠呼吸暂停综合征）。此外，对于因多系统萎缩导致的罕见夜间喉喘鸣（其中阻塞性睡眠呼吸暂停综合征是由于神经源性夜间喉痉挛引起），这是唯一的治疗方法。治疗性气管切开术必须是永久性的（气管造口术），因此，最好采用一种特定技术（带皮肤衬里的气管切开术）进行，该技术能够保证更高的稳定性、更小的肉芽组织形成风险、更宽的气管造口开口以及足够的可逆性。根据我们的经验，接受带皮肤衬里气管切开术的睡眠呼吸障碍患者非常少（10例）。其中，大多数患者因多系统萎缩导致夜间喉痉挛引起的严重呼吸暂停而接受手术（n = 7），而只有3例阻塞性睡眠呼吸暂停综合征患者接受了带皮肤衬里的气管切开术，即占接受阻塞性睡眠呼吸暂停综合征手术的424例患者的0.7%，以及占接受严重或极重度阻塞性睡眠呼吸暂停综合征（呼吸紊乱指数> 40）手术的175例患者的1.7%。带皮肤衬里的气管切开术未出现严重并发症，且达到了预期效果，日间症状立即消失，夜间呼吸暂停有显著改善。除了与睡眠相关的疾病外，许多有永久性气管切开术适应症的临床情况也可能从带皮肤衬里的技术中受益，如严重的喉或气管狭窄、喉麻痹、重症肌无力、侧索肌萎缩硬化症、顽固性误吸、严重肺气肿。
