气管切开与经鼻插管救治重症破伤风致呼吸衰竭患者的疗效比较  

Efficacy comparison of tracheotomy and transnasal intubation in treatment of severe tetanus patients with respiratory failure

作　　者：张齐龙[1] 况卫丰[1] 李航 章玉坤[1] 曾迎春[1] 陶清萍 李明[3] 王传林[3] Zhang Qilong;Kuang Weifeng;Li Hang;Zhang Yukun;Zeng Yingchun;Tao Qingping;Li Ming;Wang Chuanlin(Department of Critical Care,Jiangxi Chest Hospital,Nanchang 300006,China;Department ofDermatology,Changzheng Hospital,Naval Medical University,Shanghai 200003,China;Department ofEmergency/Trauma Center,People's Hospital of Peking University,Beijing 100044,China)

机构地区：[1]江西省胸科医院重症医学科,南昌330006 [2]海军军医大学长征医院皮肤科,上海200003 [3]北京大学人民医院急诊科/创伤救治中心,100044

出　　处：《中华创伤杂志》2021年第1期57-62,共6页Chinese Journal of Trauma

基　　金：国家自然科学基金(2013CB532002)。

摘　　要：目的探讨气管切开与经鼻气管插管人工气道建立在重症破伤风致呼吸衰竭患者救治中的应用效果。方法采用回顾性病例对照研究分析2012年1月至2019年12月江西省胸科医院院收治的92例重症破伤风呼吸衰竭患者临床资料,其中男60例,女32例;年龄23~81岁[(47.5±14.1)岁]。43例行气管切开(气管切开组),49例行经鼻气管插管(经鼻插管组)。比较两组人工气道建立前后血气相关指标(PaO2、PaCO2)、导管留置时间、导管堵塞、气道出血、鼻窦炎、气道狭窄及呼吸机相关性肺炎(VAP)等并发症发生率和预后情况。结果两组人工气道机械通气后的PaO2和PaCO2均较人工气道建立前有明显改善(P<0.01),组间比较差异均无统计学意义(P>0.05)。两组导管留置时间、导管堵塞、气道出血及鼻窦炎相当(P>0.05)。气管切开组拔管后气道狭窄及VAP发生率[12%(5/43)、12%(5/43)]与经鼻插管组[0%(0/49)、31%(15/49)]比较,差异有统计学意义(P<0.05)。气管切开组与经鼻插管组各死亡3例,病死率分别为7%(3/43)和6%(3/49)(P>0.05)。两组生存患者随访3个月,破伤风均获治愈。结论对于重症破伤风呼吸衰竭患者,气管切开与经鼻气管插管两种人工气道类型均可选择。前者虽有气道及组织创伤,但便于机械通气管理,尤其适用于伴有严重抽搐、角弓反张,镇静效果差,需要持续应用肌松剂的患者;后者操作相对无创、简便、快捷,但对VAP的防范及监测需有更高要求。Objective To explore the efficacy of tracheotomy and nasal intubation in airwaysmanagement in treatment of patients with respiratory failure caused by severe tetanus.Methods A respectivecase series study was conducted to analyze the data of 92 patients with respiratory failure caused by severetetanus admitted to Jiangxi Chest Hospital from January 2012 to December 2019.There were 60 malesand 32 females,aged 23-81 years[(47.5±14.l)years].Overall 43 patients underwent tracheotomy(tracheotomy group),and 49 patients underwent nasal intubation(nasal intubation group).The bloodgas relaterd indexes(PaO,,PaCO),catheter retention time,incidence of complications such as airwaybleeding,nasosinusitis,catheter blockage and ventilator-associated pneumonia(VAP),and clinicaloutcome were compared between the two groups.Results After mechanical ventilation,the PaO,andPaCOin both groups wcrc significantly improvcd(P<0.01),with no significant difference between groups(P>0.05).Both groups were sinmilar regarding the catheter indwelling time,catheter blockage,airway bleeding and nasosinusitis(P>0.05).The incidences of VAP and catheter blockage afterextubation in tracheotomy group[12%(5/43),12%(5/43)]were significantly different from those innasal intubation group[0%(0/49),31%(15/49)](P<0.05).There were 3 deaths in each group,with the mortality rate of 7%(3/43)in tracheotomy group and of 6%(3/49)in nasal intubation group(P>0.05).Both groups of live tetanus patients were cured.After 3-month follow-up,the tetanus wascured in the two groups.ConclusionsThe tracheotomy and transnasal tracheal intubation are optionalfor severe tetanus patients with respiratory failure.The former has airway and tissue trauma,but it isconvenient for mechanical ventilation management,especialy indicated for patients with severeconvulsions,angular arch reflexes,poor sedation,and continuous application of muscle relaxants,Nasalintubation is relatively non-invasive,simple and fast method,but the prevention and monitoring of VAPrequires higher requirements.

关 键 词：破伤风 危重病 气管切开术 插管法 气管内 

分 类 号：R633.1[医药卫生—外科学] R563.8[医药卫生—临床医学]