超声定位纤维支气管镜引导下经皮扩张气管切开术在高呼气末正压患者中的应用

Application of ultrasound and bronchoscopy-guided percutaneous dilatational tracheotomy in mechanically ventilated patients with high positive end expiratory pressure

目的探讨超声定位纤支镜引导下行经皮扩张气管切开术(PDT)在高呼气末正压(PEEP)患者中的应用价值和安全性。方法选取2016年1月至2019年7月绍兴市人民医院收治的61例和绍兴市文理学院附属医院收治的26例行机械通气且需气管切开的患者,其中高PEEP(>10 cmH_(2)O)组38例,低PEEP(≤10 cmH_(2)O)组49例,均行超声定位纤维支气管镜(纤支镜)引导下PDT。观察术前、术后1、24 h患者动脉血气变化,氧合指数(PaO_(2)/FiO_(2))和气管切开相关并发症及预后情况。结果所有患者均一次性穿刺成功,两组均未发生气道后壁损伤、气胸、术后大出血等情况。两组患者术前PEEP、切口溢痰比例比较差异均有统计学意义(均P<0.05),而手术时间、切口大小、术中低氧时间和术中出血量比较差异均无统计学意义(均P>0.05)。两组患者PDT前后各时段PaO_(2)/FiO_(2)、局部皮下气肿率、术后ICU滞留时间比较差异均有统计学意义(均P<0.05);而术后出血事件、切口感染、新发肺部感染率、术后机械通气天数比较差异均无统计学意义(均P>0.05)。结论超声定位纤支镜引导下行PDT对于高PEEP的呼吸衰竭患者安全有效,具有全程可视、创伤小、并发症少的特点,值得在临床上推广应用。

Objective To evaluate the application of ultrasound-and bronchoscopy-guided percutaneous dilatational tracheotomy(PDT)in mechanically ventilated patients with high positive end expiratory pressure(PEEP).Methods Eighty seven mechanically ventilated patients who underwent PDT guided by ultrasound and fiberoptic bronchoscopy were divided into high PEEP group(>10 cmH_(2)O,n=38)and low PEEP group(≤10 cmH_(2)O,n=49).The arterial blood gas and oxygenation index(PaO_(2)/FiO_(2))were observed preoperatively,1 h and 24 h postoperatively.The incidence of complications and prognosis of patients were also observed and compared between two groups.Results The average PEEP was 15.6±4.4 cmH_(2)O in the high PEEP group,and 6.7±3.2 cmH_(2)O in the low PEEP group.There was no significant difference in operation time,incision size,intraoperative hypoxia time and bleeding in the two groups(all P>0.05).No serious complications such as the posterior airway wall injury,pneumothorax and bleeding were occurred in the two groups.There was no significant changes of oxygenation index in both group after operation(all P>0.05).There were no significant differences in bleeding events,incision infection rate,the rate of newly developed pulmonary infection and days of postoperative mechanical ventilation between the two groups(all P>0.05),but the retention time of ICU in high PEEP group was longer than that in low PEEP group(all P<0.05).Conclusion Ultrasound-and bronchoscopy-guided percutaneous dilatational tracheotomy is safe and effective for mechanically ventilated patients with high PEEP in ICU.