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1、气管切开术 Tracheotomy,1,Airway management,Successful airway management must begin with a careful, thorough, and rapid evaluation of the airway. Physical examination is a key element in diagnosing upper airway obstruction. Stridor, or noisy respiration, is a hallmark symptom of upper airway obstruction.
2、An accurate history is also critical in evaluating the airway and formulating the best plan to manage it.,2,Nonsurgical measures,Oxygen administration. The first and most important task in nonsurgical airway management is to administer oxygen to relieve hypoxia. Topical decongestants and steroids. O
3、ropharyngeal and nasopharyngeal airways. Translaryngeal intubation. Laryngeal mask airway.,3,Surgical measures,Tracheotomy Emergent tracheotomy thyrocricotomy Percutaneous tracheotomy,4,定义：切开颈段气管前壁，插入适当的气管套管，建立新的呼吸通道的手术。,The tracheotomy is a procedure that make an incision on the anterior aspect of
4、the neck and opening a direct airway through an incision in the trachea.,5,Trach History,The Tracheotomy is one of the oldest surgical procedures. The first tracheotomy was performed in Rome in second century B.C,6,What famous person died of an upper airway obstruction because their M.D. was unwilli
5、ng to perform his tracheotomy?,7,George Washington toured his estate on horseback in one cold and rainy day in 1799.,The next day he had severe upper airway swelling.,8,Elisha C. Dick,George Washington 1799,12,9,Reasons for Tracheotomy,10,Indications for a tracheotomy,Airway obstruction Pulmonary Se
6、cretions Ventilation Prolonged mechanical ventilation May assist in weaning from mechanical ventilation Prevention of glottic stenosis/complication of prolonged ett,11,Fixed Airway Obstruction,Tumours of upper aero-digestive tract Chronic airway obstruction up to 80% lumen External compression by tu
7、mour Thyroid tumor, massive lymphadenopathy Foreign Body Glottic Stenosis/tracheal stenosis Trauma upper airway,12,Non-Fixed Airway Obstruction,Trauma Expanding neck hematoma Maxillofacial trauma Laryngeal fracture Inflammatory Inhalation injury Anaphylaxis 过敏 Epiglottitis Ludwigs Angina/Deep Neck s
8、pace infection Bilateral vocal cord paralysisFiberoptic Intubation can be successful,13,Pulmonary Secretion Clearance,Aspiration / dysphagia COPD Bronchiectesis Stasis of secretions Poor cough Poor respiratory reserve,14,Ventilation,Neuromuscular disorder affecting respiratory muscles Reduced respir
9、atory effort Limited pulmonary reserve COPD, Scoliosis, bronchiectesis Central respiratory depression Reduced LOC Severe obstructive sleep apnea failure CPAP,15,Prolonged Intubation,7-10 days ett Risk Factors for Glottic Stenosis Diabetes Female Size ETT and # ett Hemodynamic instability Incidence g
10、lottic stenosis: 5% over 10 days (Whited 1984),16,Example 1 Subglottic Stenosis,17,Example 3 Combined Glottic/Tracheal Stenosis,18,The trachea is a tube that runs from the bottom of the larynx to the chest where it divides into the bronchi，it is a rigid structure formed from rings of cartilage to en
11、sure that the airway always remains open.Its function is to maintain and protect the airway.,19,上 环状软骨 下 胸骨上窝 颈段气管 前 皮肤、筋膜、甲状腺峡（24环）， 无名动脉（78环） 后 食管 侧 颈部 A、 V、 N。,20,Tracheotomy Relative anatomy,Major blood vessels (carotis, innominate a., jugular veins) Thyroid gland Esophagus Larynx Rec.laryngeal
12、nerves Cervical spine,21,Isthmus of thyroid gland lies in front of the 2nd-4th ring of the trachea.,22,The innominate artery passes in front of the 7th-8th ring of the trachea,23,Anesthesia,A tracheotomy is most easily performed if the patient is already intubated and general anesthesia has been adm
13、inistrated. If the patient has a tenuous airway with impaired ventilatory status, the tracheotomy should be performed with local anesthesia.,24,1、The patient is placed in the supine position with a shoulder roll to extend the neck, or in semi-upright position when with a tenuous airway. 2、anaesthesi
14、a：Procain / Lydocain.,operation procedures,25,3、skin incision： longitudinal incision：环状软骨下缘 胸骨上切迹上2cm transverse incision：环状软骨下约3cm处 Make a incision in the skin of the neck that lies over the trachea. This incision is in the lower part of the neck between the Adams apple and top of the breastbone.,2
15、6,4、dissect the soft tissures: the fascial tissue and the neck muscles are separated. 切开气管前筋膜：沿白线正中作锐性切开或钝性分离，用拉钩侧牵两侧胸骨舌骨肌、胸骨甲状肌。,27,5、exposure the trachea: the isthmus of thyroid glandis usually cut down in the middle or pull to the head direction. 暴露气管：甲状腺峡部下缘分离组织，向上牵拉暴露34气管环。若峡部较宽可切断、缝扎。,28,6、ope
16、n the trachea: identify the rings of cartilage that make up the trachea and cuts into the tough walls.切开气管：用尖刀切开第34气管环。,29,注意：气管切开后患者可能突然呼吸停止,呼吸困难，CO2升高，O2下降血中CO2浓度升高刺激呼吸中枢，呼吸加快。 血中CO2浓度继续升高抑制中枢。此时，靠颈动脉体化学感受器受缺O2刺激来调节。一旦气管切开，血O2含量增加，颈动脉体刺激消失，CO2对中枢的抑制尚未解除，出现呼吸暂停现象。,30,7、 insert a tracheotomy tube through the opening. 安放气管套管：用气管扩张器扩开切口，插入大小适宜的气管套管，并证实无误。,31,32,8、 surgical knot to fix the tube 固定套管：缝合套管上方创口。下方创口不予缝合，以免发生皮下气肿。,
