目的 优化气管切开后导管拔管策略。方法 2016年8月至2018年4月脑损害气管切开术后患者118例,分为早期拔管组(n=74)和传统拔管组(n=44),比较两组拔管成功率、耐受程度,拔管前和拔管后7 d检测患者血生化指标。早期拔管组再分为一次性拔管组(n=37)和先堵管后拔管组(n=37),比较两组拔管成功率。结果 早期拔管组和传统拔管组间拔管成功率无显著性差异(χ2=0.016, P>0.05)。早期拔管组拔管当日耐受性较低(χ2=4.909, P<0.05),拔管7 d、15 d后耐受性无显著性差异(χ2<1.995, P>0.05)。拔管后7 d,患者降钙素原、超敏C反应蛋白和白细胞计数均下降(t>2.680, P<0.05),血红蛋白和白蛋白显著升高(t>11.620, P<0.001)。一次性拔管组与先堵管后拔管组成功率无显著性差异(χ2<2.902, P>0.05)。结论 有良好咳嗽和吞咽功能为拔管成功的决定性因素,其余拔管指征对拔管成功与否无决定性影响,但影响耐受性;拔管对控制患者并发症有利。一次性拔管法有其优势。
Objective To optimize the ways of extubation after tracheotomy.Methods From August, 2016 to April, 2018, 118 patients after tracheotomy for brain injury were divided into early extubation group (n=74) and conventional extubation group (n=44). The success rate and tolerance of extubation were compared, and the biochemical markers of blood were tested before and seven days after extubation. The early extubation group was divided into disposable extubation group (n=37) and occlusion tube-extubation group (n=37), and their success rates of extubation were compared.Results There was no significant difference in success rate between the early extubation group and the conventional extubation group (χ2=0.016, P>0.05). The tolerance was less in the early extubation group on the first day of extubation (χ2=4.909, P<0.05), and it was not different seven days and 15 days after extubation (χ2<1.995, P>0.05). The procalcitonin, hypersensitive C reactive protein and white blood cell count decreased (t>2.680, P<0.05), and hemoglobin and albumin increased seven days after extubation (t>11.620, P<0.001). There was no significant difference in the success rate between the disposable extubation group and the occlusion tube-extubation group (χ2<2.902, P>0.05).Conclusion Satisfactory cough and deglutition reflex are the core indexes of successful extubation, other indications may not influence on the success of extubation but on tolerance. Extubation may benefit to control the complications of tracheotomy. The disposable extubation is more recommended.
[1] 刘大为. 危重病医学ICU主治医生600问[M]. 北京:中国协和医科大学出版社, 2000: 233.
[2] 邱海波. ICU科主治医师手册[M]. 南京:江苏科学技术出版社, 2007: 234.
[3] 刘新民. 外科学[M]. 沈阳:沈阳出版社, 2004: 1209.
[4] 王翰章. 中华口腔医学[M]. 北京:人民卫生出版社, 2001: 3926.
[5] Nakashima H, Yukawa Y, Imagama S, et al.Characterizing the need for tracheostomy placement and decannulation after cervical spinal cord injury[J]. Eur Spine J, 2013, 22(7): 1526-1532.
[6] 卢昌均,安红伟,韦冰心. 神经危重症气管切开患者拔除气管插管影响因素研究[J]. 临床和实验医学杂志, 2014, 13(12): 976-979.
[7] 杨红专,高淑霞,浦一峰. 脑损害气管切开患者康复治疗后拔管成败因素分析[J]. 中国康复医学杂志, 2013, 28(10): 950-951.
[8] 王敏. 气管切开40例改良拔管法效果观察[J]. 齐鲁护理杂志, 2005, 6(11): 618-619.
[9] Christopher KL.Tracheostomy decannulation[J]. Respir Care, 2005, 50(4): 538-541.
[10] Lehn AC, Lettieri J, Grimley R.A case of bilateral lower cranial nerve palsies after base of skull trauma with complex management issues: case report and review of the literature[J]. Neurologist, 2012, 18(3): 152-154.
[11] Choi EH, Jun AY, Shin KY, et al.Traumatic atlanto-occipital dislocation presenting with dysphagia as the chief complaint: a case report[J]. Ann Rehabil Med, 2013, 37(3): 438-442.
[12] Appleby I.Tracheostomy[J]. Anaesth Intensive Care, 2005, 6(7): 220-222.
[13] Kang SW, Shin JC, Park CT, et al.Relationship between inspiratory muscle strength and cough capacity in cervical spinal cord injured patients[J]. Spinal Cord, 2006, 44(4): 242-248.
[14] Bach JR, Saporito LR.Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure–A different approach to weaning[J]. Chest, 1996, 110(6): 1566-1571.
[15] Colonel P, Houze MH, Vert H, et al.Swallowing disorders as a predictor of unsuccessful extubation: a clinical evaluation[J]. Am J Crit Care, 2008, 17(6): 504-510.
[16] Smina M, Salam A, Khamiees M, et al.Cough peak flows and extubation outcoms[J]. Chest, 2003, 124(1): 262-268.
[17] Seymour CW, Martinez A, Christie JD, et al.The outcome of extubation failure in a community hospital intensive care unit:a cohort study[J]. Crit Care, 2004, 8(5): 1-6.
[18] Coplin WM, Pierson DJ, Cooley KD, et al.Implications of extubation delay in brain-injured patients meeting standard weaning criteria[J]. Am J Respir Crit Care Med, 2012, 161(5): 1530-1536.
[19] Hernández G, Ortiz R, Pedrosa A, et al.The indication of tracheotomy conditions the predictors of time to decannulation in critical patients[J]. Med Intensiva, 2012, 36(8): 531-539.
[20] Beard B, Monaco FJ.Tracheostomy discontinuation: impact of tube selection on resistance during tube occlusion[J]. Respir Care, 1993, 38(3): 267-270.
[21] 黄丛萍,倪莹莹,章良翔,等. 持续植物状态气管切开插管两种拔管方式的对照研究[J]. 中国康复医学杂志, 2017, 32(7): 798-801.
[22] 陶冶飞,季勇. 符合气管插管拔管条件的急性脑外伤术后拔管862例临床观察[J]. 交通医学, 2013, 27(6): 635-637.
[23] O'Connor HH, White AC. Tracheostomy decannulation[J]. Respir Care, 2010, 55(8): 1076-1081.
[24] Tanios MA, Nevins ML, Hendra KP, et al.A randomized controlled trial of the role of weaning predictors in clinical decision making[J]. Crit Care Med, 2006, 34(10): 2530-2535.
[25] 朱晶. 气管切开患者气管导管一次性拔除与传统拔管法效果比较[J]. 齐鲁护理杂志, 2013, 19(16): 122-123.
[26] 郝德英. 急性呼吸衰竭患者气管切开术后不同拔管方式的效果比较[J]. 解放军护理杂志, 2009, 26(1): 9-11.
[27] Epstein SK.Anatomy and physiology of tracheostomy[J]. Respir Care, 2005, 50(4): 476-482.
[28] Pierson DJ.Tracheostomy and weaning[J]. Respir Care, 2005, 50(4): 526-533.
[29] Morris LL.Capping a cuffed tracheostomy tube[J]. Crit Care Nurse, 2012, 32(2): 12.
[30] 庞翠华. 气管切开术后拔管和楼口修复方法的探讨[J]. 中国医药指南, 2010, 8(7): 19-21.
[31] 黄芳,伍玉琴. 气管切开患者直接拔管的护理[J]. 中国实用护理杂志, 2011, 27(z2): 146.
[32] 兰冬梅,禤建锋,南进军. 气管切开患者气管导管一次性拔除与传统拔管法的效果比较[J]. 护理实践与研究, 2015, 12(8): 45-46.
[33] 李银玲. 98例气管切开一次性拔管护理体会[J]. 中外医学研究, 2012, 10(31): 83-84.
[34] 李强. 呼吸内镜学[M]. 上海:上海科学技术出版社, 2003: 168-173.
[35] 田勇泉,孙爱华. 耳鼻咽喉–头颈外科学[M]. 6版. 北京:人民卫生出版社, 2004: 241.
