颈脊髓损伤气管切开术后拔管指征及延迟、失败原因探讨  

Indications,Causes of Delay and Failure of Decannulation after Tracheostomy in Treatment of Cervical Spinal Cord Injury

作　　者：赵唯[1] 李想[2,3] 张军卫[2,3] 洪毅[2,3] 

机构地区：[1]解放军205医院康复医学科,辽宁锦州121001 [2]首都医科大学康复医学院,北京110000 [3]中国康复研究中心北京博爱医院脊柱外科,北京100068

出　　处：《临床误诊误治》2014年第5期61-63,共3页Clinical Misdiagnosis & Mistherapy

基　　金：首都医学发展科研基金资助(2009-2096)

摘　　要：目的探讨颈脊髓损伤患者气管切开术后拔管指征及延迟、失败的原因。方法对我科收治的63例气管切开颈脊髓损伤患者的临床资料进行回顾,采用自行制定的拔管指征指导选择拔管时机,并分析拔管延迟和失败的原因。结果患者氧合情况、咳痰能力及吞咽能力恢复正常,肺部感染控制,喉镜和支气管镜检查提示无喉头水肿,套管远端无明显气道狭窄,视为拔管指征。54例(85.7%)在伤后3个月内一次性拔管成功,拔管距气管切开时间平均43.2 d。7例拔管延迟,原因包括反复肺部感染3例,气管套管远端肉芽组织增生2例,颈前路手术后喉返神经损伤致饮水呛咳及心理因素各1例。2例拔管失败,其中1例重新插管最终带管出院,另1例因急性呼吸衰竭死亡。结论本研究制定的拔管指征可较安全的指导颈脊髓损伤患者气管切开术后选择拔管时机。反复肺部感染是导致拔管延迟和失败的主要原因。拔管后气管软化塌陷发生率虽较低,但危害大,应引起重视。Objective To investigate the indications,delay and failure causes of decannulation after tracheostomy in treatment of cervical spinal cord injury. Methods Clinical data of 63 patients with cervical spinal cord injury after tracheosto-my was reviewed,and self-designed indications guidance for decannulation was used to choose the time of removing tubes. The delay and failure causes of decannulation were analyzed. Results The patients′oxygenation,expectoration and swallowing a-bilities were recoveried,the pulmonary infection was controlled,and there were no laryngeal edema by laryngoscope and bron-choscopes examinations and no obvious airway constriction in distal cannula. All above conditions were used as decannulation indications. Fifty four patients（85. 7%）underwent removal surgery of the tracheostomy tubes successfully within 3 months af-ter injury. The mean interval between incision of tracheal and decannulation was 43. 2 d. Seven patients（11%）had delayed decannulation,and the causes including repeated pulmonary infection in 3 patients,granulation tissue hyperplasia in distal tra-cheostomy tube in 2 patients,drinking bucking induced by recurrent laryngeal nerve injury after anterior cervical fusion in 1 patient and psychologic factor in 1 patient. Decannulation failure occurred in 2 patients and one received tracheostomy again and was discharged with the tracheostomy tubes,the other one died of acute respiratory failure. Conclusion Self-designed indication for decannulation may guide the time of removing the tracheostomy tubes safely for patients with cervical spinal cord injury after tracheostomy. Repeated pulmonary infection is the main cause of delayed and failed decannulation. Incidence rates of tracheal stenosis and tracheomalacia are low,but the complications may be life threatening,which should be given much more attention.

关 键 词：脊髓损伤 颈 气管切开术 气管插管拔除 

分 类 号：R651.2[医药卫生—外科学]