气管切开临床操作【51页】

微量误吸和呼吸机相关性肺炎的关系1-5
细菌，分泌物 (e.g. HCl, bile)
在插管套囊周围的微量误吸
聚集, 肺损伤, & VAP
1. Mahul et al. Intensive Care Med. 1992;18(1):20-25. 2. Estes et al. Intensive Care Med. 1995;21(4):365-383. 3. Safdar et al. Respir Care. 2005;50(6):725-739. 4. Chastre et al. Am J Respir Crit Care Med. 2002;165(7):867-903.
The TaperGuard™ Story 1.0 关于微量误吸
TaperGuard Story 目的
Clinical Evidence
TaperGuard TG EVAC
Clinical Application
Economic Impact
Scientific Platform
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The TaperGuard 套囊技术
渐进封闭锥形套囊技术
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TaperGuard 平台
The TaperGuard 提供两种配置
1. TaperGuard endotracheal tube
for intERNAL USE ONLy
一个基本问题：
微量误吸在OR和ICU中是不是一个普遍 存在，又带来严重并发症的问题？
误吸及微量误吸在OR/ICU
我们知道微量误吸的存在吗？ 误吸后有哪些并发症
有没有文献来证明误吸的确实存在
如何来减少在OR/ICU中的PPC/PIPC发生
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内容
误吸和微量误吸的风险 PIPC/PPC 后果 临床解决方法及相关文献 TaperGuard原理介绍
在使用高容量低压气管导管，微量误吸是普遍的 现象
• “Extensive folding of cuff material” containing secretions is seen at all cuff pressures (25–100 cmH2O).
– Seegobin et al. Br Med J. 1984;288:965-968.
Trachea
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Micro-aspration 微量误吸
为什么误吸和微量误吸会发生？
1. Air Seal. 2. Fluid Seal.
误吸/微量误吸 - 风险因素
▪口/ 口咽
▪呼吸支持设备和附件的污染
▪胃部细菌的过度生长
▪口咽分泌物和胃部内容物
▪受损的黏膜清除
▪气管导管的生物聚结
外因
▪医务人员的传播
▪以前的肺疾病
“口咽腔和胃液的分泌物是主要的细菌进入 肺内的主要通道，也是 误吸/微量误吸发 生的重要原因。
内因
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For Internal Use Only
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• Oikkonen M, Aromaa U 液体渗漏在低压气管套囊的实验 Anaesthesia 1997; 52: 567-569
目前PVC 套囊材料: • 典型的套囊壁的折叠现象
( 所有的高容量低压套囊 ) • 声门下分泌物通过流入气管的通道 • VAP 的主要原因
Cuff
Tube-Shaft
model trachea
5分钟内液体渗漏: 2.4-9.2 mls (4 不同的插管)
• 类似的结果在内部和非印刷的外部研究
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套囊漏气 !
套囊漏气 !
• Young P, Rollinson M, Downward G, Henderson S 液体通过气管导管套囊流入气管内实验 British Journal of Anaesthesia 1997; 78: 557-562
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• 独特的锥形套囊能够在一定位置匹配气管直径大小 .
– 在这点最小化皱褶和通道的存在 – 确保封闭区达到不同插管形状的形状，尺寸大小
– TaperGuard Evac allows for the active removal of secretions from above the cuff for patient’s with a higher risk of aspiration.
– The Evac lumen may be hooked up to wall suction either continuous low or intermittent high, or a syringe may be used periodically to remove secretions from above the cuff.
RIGHT: Enlargement of region
intubated model trachea demonstrating a cuff fold and channel
1. Dullenkopf et al. Intensive Care Med. 2003;29:1849-1853.
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– A Mallinckrodt endotracheal tube with the TaperGuard cuff technology.
2. TaperGuard Evac endotracheal tube:
– A Mallinckrodt endotracheal tube with both the TaperGuard cuff technology and Evac suction lumen.
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微量误吸导致VAP如同冰山一角
Postoperative Pneumonia
Postoperative Pulmonary Complication
Reported complication rate
25.5% 18.9% 14.2% 10.3% 5.1% 1.8%
Smetana et al. Ann Intern Med. 2006;144(8):581-595.
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for intERNAL USE ONLy
Respiratory failure, COPD exacerbations, etc.
Post-intubation pulmonary complications插管后肺部并发症:
肺部并发症可以看成是插管后 所导致的并发症
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for intERNAL USE ONLy
• Only 1% of these microaspiration events were observed, the majority were “silent” microaspiration events.
• Investigator found that microaspiration was on of the most important independent risk factors for pulmonary complications. (p<0.0001)
– Dullenkopf et al. Intensive Care Med. 2003;29:1849-1853.
• Microaspiration found in 100 percent of general endotracheal anesthetics.
– Seegobin et al. Can Anaesth Soc J. 1986;33:273-279.
• “…high-volume, low-pressure (HVLP) cuffs were introduced. ... these have failed to demonstrate effective prevention of leakage in vitro and in vivo.”
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For Internal Use Only
皱褶和通道导致了误吸/微量的发生
CT image of an inflated ETT cuff in a trachea model1
LEFT: Full cross section of
Studies, n 16 11 43 6 5 2
柯惠解决方案
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误吸/微量误吸 防治
外因
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内因
5. Metheny et al. Crit Care Med. 2006;34(4):1007-1015. 6. Kollef et al. Chest. 1999;116(5):1339-1346. 7. Hussain et al. Anaesth Intensive Care 2003;21:272-6.
The problem with the problem
Surgical site AAA repair Esophagectomy Abdominal surgery Head and neck surgery Hip surgery Gynecologic/urologic procedures
误吸/微量误吸 - 风险因素
▪ 声门持续处于开放状态 ▪ 细菌通过分泌物作为载体
迁移进入气管
▪ 分泌物池位置高于气管套囊
▪“口咽腔和胃液的分泌物是主要
的细菌进入肺内的主要通道，也 是误吸/微量误吸发生的重要原因。
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目前大家的习惯是怎么样的 ? Nhomakorabea手指触摸按压测试
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微量误吸在ICU也是普遍被发现的现象，并且 并发VAP的发生
• Metheny el al found evidence of microaspiration in 88.9% of ICU patients even with head of bed elevation and oral care in place.
90％以上的国内医院
手持压力表
在一些医院的日常工作
常见的套囊压力问题
太低 – 套囊封闭
5
10
套囊压力
cmH2O
Microaspiration微量分泌物
. . .?
15
20
25
30
35
40
45
50
关于泄漏实验 • Asai, 2001: Cuff at 40 cmH20; 10 mls fluid in