Choate Kim, Barbetti Julie, Currey Judy
The Alfred, Commercial Road, Prahran, Victoria 3181, Australia.
Aust Crit Care. 2009 Feb;22(1):8-15. doi: 10.1016/j.aucc.2008.10.002. Epub 2008 Dec 4.
Tracheostomy is a well established and practical approach to airway management for patients requiring extended periods of mechanical ventilation or airway protection. Little evidence is available to guide the process of weaning and optimal timing of tracheostomy tube removal. Thus, decannulation decisions are based on clinical judgement. The aim of this study was to describe decannulation practice and failure rates in patients with tracheostomy following critical illness.
A prospective descriptive study was conducted of consecutive patients who received a tracheostomy at a tertiary metropolitan public hospital intensive care unit (ICU) between March 2002 and December 2006. Data were analysed using descriptive and inferential tests.
Of the 823 decannulation decisions, there were 40 episodes of failed decannulation, a failure rate of 4.8%. These 40 episodes occurred in 35 patients: 31 patients failed once, 3 patients failed twice and 1 patient failed three times. There was no associated mortality. Simple stoma recannulation was required in 25 episodes, with none of these patients readmitted to ICU. Translaryngeal intubation and readmission to ICU took place for the remaining 15 episodes. The primary reason for decannulation failure was sputum retention. Twenty-four patients (60%) failed decannulation within 24h, with 14 of these occurring within 4h.
Clinical assessments coupled with professional judgement to decide the optimal time to remove tracheostomy tubes in patients following critical illness resulted in a failure rate comparable with published data. Although reintubation and readmission to ICU was required in just over one third of failed decannulation episodes, there was no associated mortality or other significant adverse events. Our data suggest nurses need to exercise high levels of clinical vigilance during the first 24h following decannulation, particularly the first 4h to detect early signs of respiratory compromise to avoid adverse outcomes.
气管造口术是一种成熟且实用的气道管理方法，适用于需要长期机械通气或气道保护的患者。目前几乎没有证据可指导撤管过程及气管造口管拔除的最佳时机。因此，拔管决策基于临床判断。本研究的目的是描述危重症患者气管造口术后的拔管实践及失败率。
对2002年3月至2006年12月期间在一家大型都市公立医院重症监护病房（ICU）接受气管造口术的连续患者进行前瞻性描述性研究。使用描述性和推断性检验对数据进行分析。
在823次拔管决策中，有40次拔管失败，失败率为4.8%。这40次失败发生在35名患者中：31名患者失败一次，3名患者失败两次，1名患者失败三次。无相关死亡病例。25次需要简单的造口重新插管，这些患者均未再次入住ICU。其余15次需要经喉插管并再次入住ICU。拔管失败的主要原因是痰液潴留。24名患者（60%）在24小时内拔管失败，其中14例发生在4小时内。
临床评估结合专业判断来决定危重症患者拔除气管造口管的最佳时间，其失败率与已发表数据相当。虽然略超过三分之一的拔管失败病例需要重新插管并再次入住ICU，但无相关死亡或其他重大不良事件。我们的数据表明，护士在拔管后的最初24小时，尤其是最初4小时，需要保持高度的临床警惕性，以检测呼吸功能不全的早期迹象，避免不良后果。
