气道重建术围术期应用体外膜肺氧合辅助气道管理临床分析

Extracorporeal membrane oxygenation assisted airway management during perioperative period of airway reconstruction

目的 观察气道重建术围术期应用体外膜肺氧合(ECMO)辅助气道管理的效果,探讨其安全性。方法 回顾性分析2017年7月—2023年7月河南省人民医院行气道重建术、围手术期应用静脉-静脉(V-V)ECMO辅助气道管理10例患者的临床资料,其中8例为外伤合并气管/支气管断裂患者,2例为气管中下段肿瘤患者,10例ECMO上机前NYHA心功能Ⅰ~Ⅱ级。记录8例气道创伤患者气道病变位置、Murray肺损伤评分,2例肿瘤患者管腔阻塞情况;记录10例患者ECMO应用情况、手术时间、术中乳酸最高值、术中血氧饱和度最低值、术中停止呼吸机通气者呼吸机暂停时间、ECMO撤机和气管导管拔管情况、ECMO总辅助时间、术后机械通气时间、术后ICU停留时间、总住院时间及术后并发症发生情况。结果 (1)8例气道创伤患者中1例气管中上段断裂,1例左上叶管口处断裂,1例左主支气管断裂,3例右主支气管断裂,2例多节段多部位气道损伤;Murray肺损伤评分均≥3分;7例合并多根多处肋骨骨折;6例术前明确诊断气管/支气管断裂,2例单侧主支气管断裂术前未明确诊断者胸腔闭式引流瓶可见大量气泡随呼吸溢出,可疑气道损伤;8例气管插管后呼吸机难以维持氧合,于ICU建立ECMO。2例肿瘤患者术前CT重建影像示气管中下段肿瘤阻塞管腔>50%,术前建立ECMO。10例患者ECMO上机后氧合均恢复正常。(2)7例患者术中停止呼吸机通气,采用完全ECMO呼吸支持,3例患者术中呼吸机联合ECMO呼吸支持。10例患者手术时间(234.3±73.2)min,术中乳酸最高值(1.4±0.7)mmol/L,术中血氧饱和度最低值(89.3±4.9)%。7例术中停止呼吸机通气者呼吸机暂停时间67.5(0,127.5)min。(3)10例患者手术均成功,术后带气管导管和ECMO返回ICU,ECMO撤机成功、气管导管拔管存活出院。10例ECMO总辅助时间(2.7±1.2)d,术后机械通气时间(4.3±2.0)d,术后ICU停留时间(7.2±2.2)d,总住院时间(24.2±9.5)d。术后发生肺部感染3例,经抗感染治疗后康复;发生左侧声带麻痹1例。结论 气道重建术前充分评估病情,对气管插管后呼吸机难以维持氧合或不能插管的患者应用ECMO有利于维持氧合,促进患者康复,安全性好。

Objective To investigate the efficacy and safety of extracorporeal membrane oxygenation(ECMO)assisted airway management during perioperative period of airway reconstruction.Methods Ten patients were performed airway reconstruction using veno-venous(V-V)ECMO assisted airway management in Henan Provincial People’s Hospital from July,2017to July,2023,and their clinical data were retrospectively analyzed.Among 10patients,8had trauma complicated with tracheal/bronchial rupture,and the other 2had tumors in the middle and lower tracheal segments.The NYHA classification wasⅠ-Ⅱbefore ECMO starting in all patients.The airway lesion location and Murray lung injury score in 8patients,and the lumen obstruction in 2patients were recorded.The application of ECMO,operative time,intraoperative maximal value of lactic acid,minimal value of blood oxygen saturation (SpO_2),intraoperative ventilator pause time,tracheal catheter and ECMO withdrawal,total ECMO assisting time,postoperative mechanical ventilation time,postoperative ICU stay,total hospital stay and postoperative complication were recorded.Results(1)Among 8patients with airway trauma,there were 1case of middle and upper tracheal segment rupture,1case of rupture at the opening of the left upper lobe,1case of left main bronchus rupture,3cases of right main bronchus rupture,and 2cases of multiple segments and multiple tracheal injury;the Murray lung injury score was≥3;7patients were complicated with multiple site and multiple rib fractures;tracheal/bronchial rupture was clearly diagnosed in 6cases before operation,and the other 2patients with unclearly diagnosed lateral main bronchus rupture were suspected airway injury after a large number of bubbles were found in the closed thoracic drainage bottle with respiratory overflow;all 8patients were treated with ECMO in ICU due to low SpO_(2 )after tracheal intubation.The preoperative CT reconstruction showed>50%obstruction in the middle and lower tracheal segments of 2patients with tumors,and were treated with ECMO before operation.All 10patients got normal SpO_2after ECMO application.(2)Mechanical ventilator was paused and replaced by ECMO intraoperatively in 7patients,and 3patients received mechanical ventilator combined with ECMO.The operative time was(234.3±73.2)min,the maximal value of lactic acid was(1.4±0.7)mmol/L,and the minimal value of SpO_(2 )was(89.3±4.9)%.The mechanical ventilator was paused for 67.5(0,127.5)min in 7patients.(3)All 10patients got successful operation and returned to ICU with tracheal catheter and ECMO after operation.The tracheal catheter and ECMO were successfully withdrawn and the patients were discharged alive.The total ECMO assisting time was(2.7±1.2)d,the postoperative mechanical ventilation time was(4.3±2.0)d,the length of postoperative ICU stay was(7.2±2.2)d,and the length of total hospital stay was(24.2±9.5)d.Postoperative pulmonary infection occurred in 3cases,and left vocal cord paralysis occurred in 1case.Conclusions The condition of airway reconstruction should be fully evaluated before operation.ECMO is safe and effective for patients who have difficulty in maintaining normal SpO_2after tracheal intubation or cannot endure tracheal intubation.