Marx W H, Ciaglia P, Graniero K D
State University of New York Health Science Center at Syracuse, NY, USA.
Chest. 1996 Sep;110(3):762-6. doi: 10.1378/chest.110.3.762.
The percutaneous dilatational tracheostomy can be performed with a low complication rate if several important technical details are followed. This study delineates our experience and recommends changes in the operative technique.
Patients requiring tracheostomy were selected for percutaneous dilatational tracheostomy based on previously reported criteria. The procedures were performed routinely in the ICU unless there was another reason to transport the patient to the operating room. The patients were monitored with an ECG and pulse oximetry. End-tidal CO2 and ventilator settings were noted by the respiratory therapist. The airway was controlled using the bronchoscope and manually by the respiratory therapist. Adjustments were made in respiratory rate or tidal volume as indicated by an increase in end-tidal CO2.
We report our experience with 254 patients who underwent percutaneous dilatational tracheostomy. We prospectively recorded intraoperative, early, and late complications. From our personal experience of 170 cases previously reported and 84 recent cases, we find that there are several important technical details in performing the procedure that will minimize complications.
(1) Use of a deflated endotracheal tube cuff and increased tidal volume on the ventilator to compensate for lost minute volume and maintain normal PaCO2; (2) an adequate skin incision to more easily palpate and identify the tracheal cartilages; (3) directing the cannula needle caudally to properly identify the tracheal air column; (4) a new ridge on the 8F Teflon guiding catheter to prevent injury to the posterior tracheal wall by the dilators; (5) there is a danger of partially with-drawing the double guide when removing the largest-sized dilators that are usually tightly grasped by the tissues; (6) use of a single cannula flexible tracheostomy tube and a longer tracheostomy tube when indicated; (7) a double swivel connection and flexible tubing to connect the patient to the ventilator to lessen trauma to the stoma; (8) fenestrated tracheostomy tubes allow talking in conscious patients; and (9) use of a disposable end-tidal CO2 monitor and bronchoscope to confirm intratracheal position of the endotracheal tube while performing the procedure and proper placement of the tracheostomy tube on completion of the procedure.
Using these principles, minor complications occurred in 6.5% of the patients and major complications occurred in 1.5% of the patients, with a mortality rate of 0.39%.
如果遵循几个重要的技术细节，经皮扩张气管切开术的并发症发生率可以很低。本研究阐述了我们的经验并建议对手术技术进行改进。
根据先前报道的标准，选择需要气管切开术的患者进行经皮扩张气管切开术。除非有其他原因将患者转运至手术室，否则手术通常在重症监护病房进行。患者通过心电图和脉搏血氧饱和度进行监测。呼吸治疗师记录呼气末二氧化碳分压和呼吸机设置。使用支气管镜并由呼吸治疗师手动控制气道。根据呼气末二氧化碳分压升高情况调整呼吸频率或潮气量。
我们报告了254例行经皮扩张气管切开术患者的经验。我们前瞻性地记录了术中、早期和晚期并发症。根据我们之前报道的170例个人经验和最近的84例病例，我们发现在进行该手术时有几个重要的技术细节可将并发症降至最低。
（1）使用放气的气管内导管套囊并增加呼吸机潮气量以补偿分钟通气量损失并维持正常的动脉血二氧化碳分压；（2）做足够大的皮肤切口以便更轻松地触诊和识别气管软骨；（3）将套管针向尾侧引导以正确识别气管气柱；（4）8F聚四氟乙烯导引导管上有一个新的嵴以防止扩张器损伤气管后壁；（5）在取出通常被组织紧紧夹住的最大尺寸扩张器时，有部分拔出双导丝的风险；（6）必要时使用单套管可弯曲气管切开导管和更长的气管切开导管；（7）使用双旋转接头和可弯曲管道将患者与呼吸机相连以减轻对造口的创伤；（8）带孔气管切开导管可使清醒患者说话；（9）在手术过程中使用一次性呼气末二氧化碳监测仪和支气管镜确认气管内导管的气管内位置，并在手术完成时确认气管切开导管的正确放置。
遵循这些原则，6.5%的患者发生轻微并发症，1.5%的患者发生严重并发症，死亡率为0.39%。
