氣管切開(kāi)臨床操作

關(guān)于微量誤吸TheTaperGuard?Story1.0TaperGuardStory目的Covidien|August8,2024forintERNALUSEONLy2|ClinicalEvidenceClinicalApplicationTaperGuardTGEVACEconomicImpactScientificPlatform一個(gè)基本問(wèn)題：微量誤吸在OR和ICU中是不是一個(gè)普遍存在，又帶來(lái)嚴(yán)重并發(fā)癥的問(wèn)題？4|誤吸及微量誤吸在OR/ICU我們知道微量誤吸的存在嗎？誤吸后有哪些并發(fā)癥有沒(méi)有文獻(xiàn)來(lái)證明誤吸的確實(shí)存在如何來(lái)減少在OR/ICU中的PPC/PIPC發(fā)生內(nèi)容誤吸和微量誤吸的風(fēng)險(xiǎn)PIPC/PPC后果臨床解決方法及相關(guān)文獻(xiàn)TaperGuard原理介紹

Covidien|10June2010|6外因內(nèi)因口/口咽

呼吸支持設(shè)備和附件的污染胃部細(xì)菌的過(guò)度生長(zhǎng)口咽分泌物和胃部?jī)?nèi)容物受損的黏膜清除氣管導(dǎo)管的生物聚結(jié)醫(yī)務(wù)人員的傳播以前的肺疾病“口咽腔和胃液的分泌物是主要的細(xì)菌進(jìn)入肺內(nèi)的主要通道，也是

誤吸/微量誤吸發(fā)生的重要原因。誤吸/微量誤吸-風(fēng)險(xiǎn)因素

Covidien|10June2010|7聲門(mén)持續(xù)處于開(kāi)放狀態(tài)細(xì)菌通過(guò)分泌物作為載體遷移進(jìn)入氣管分泌物池位置高于氣管套囊“口咽腔和胃液的分泌物是主要的細(xì)菌進(jìn)入肺內(nèi)的主要通道，也是誤吸/微量誤吸發(fā)生的重要原因。誤吸/微量誤吸-風(fēng)險(xiǎn)因素目前大家的習(xí)慣是怎么樣的?

在一些醫(yī)院的日常工作90％以上的國(guó)內(nèi)醫(yī)院手指觸摸按壓測(cè)試手持壓力表

Covidien|10June2010|9常見(jiàn)的套囊壓力問(wèn)題5101525203530454050套囊壓力cmH2O...?太低– Microaspiration微量分泌物套囊封閉關(guān)于泄漏實(shí)驗(yàn)Asai,2001:Cuffat40cmH20;10mlsfluidinmodeltrachea5分鐘內(nèi)液體滲漏:2.4-9.2mls(4不同的插管)類似的結(jié)果在內(nèi)部和非印刷的外部研究

Covidien|10June2010|10CuffTube-ShaftTrachea套囊漏氣

!YoungP,RollinsonM,DownwardG,

HendersonS

液體通過(guò)氣管導(dǎo)管套囊流入氣管內(nèi)實(shí)驗(yàn)

BritishJournalofAnaesthesia

1997;78:557-562OikkonenM,AromaaU

液體滲漏在低壓氣管套囊的實(shí)驗(yàn)

Anaesthesia

1997;52:567-569目前PVC套囊材料:典型的套囊壁的折疊現(xiàn)象

(所有的高容量低壓套囊)聲門(mén)下分泌物通過(guò)流入氣管的通道VAP的主要原因套囊漏氣

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August8,2024___________11|

August8,2024___________12|Micro-aspration

微量誤吸為什么誤吸和微量誤吸會(huì)發(fā)生？AirSeal.FluidSeal.Covidien|08August2024|ConfidentialForInternalUseOnlyCovidienRespiratory&MonitoringSolutions|08August2024|Confidential15|皺褶和通道導(dǎo)致了誤吸/微量的發(fā)生1.Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.CTimageofaninflatedETTcuffinatracheamodel1LEFT:FullcrosssectionofintubatedmodeltracheaRIGHT:Enlargementofregiondemonstratingacufffoldandchannel微量誤吸和呼吸機(jī)相關(guān)性肺炎的關(guān)系1-51.Mahuletal.IntensiveCareMed.1992;18(1):20-25. 5.Methenyetal.CritCareMed.2006;34(4):1007-1015.2.Estesetal.IntensiveCareMed.1995;21(4):365-383. 6.Kollefetal.Chest.1999;116(5):1339-1346.3.Safdaretal.RespirCare.2005;50(6):725-739. 7.Hussainetal.AnaesthIntensiveCare2003;21:272-6.4.Chastreetal.AmJRespirCritCareMed.2002;165(7):867-903.細(xì)菌，分泌物(e.g.HCl,bile)在插管套囊周圍的微量誤吸聚集,肺損傷,&VAPCovidien|08August2024|ConfidentialForInternalUseOnlyCovidienRespiratory&MonitoringSolutions|08August2024|Confidential18|CovidienRespiratory&MonitoringSolutions|08August2024|Confidential19|CovidienRespiratory&MonitoringSolutions|08August2024|Confidential20|在使用高容量低壓氣管導(dǎo)管，微量誤吸是普遍的現(xiàn)象“Extensivefoldingofcuffmaterial”containingsecretionsisseenatallcuffpressures(25–100cmH2O).Seegobinetal.BrMedJ.1984;288:965-968.“…h(huán)igh-volume,low-pressure(HVLP)cuffswereintroduced....thesehavefailedtodemonstrateeffectivepreventionofleakageinvitroandinvivo.”Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.Microaspirationfoundin100percentofgeneralendotrachealanesthetics.Seegobinetal.CanAnaesthSocJ.1986;33:273-279.CovidienRespiratory&MonitoringSolutions|08August2024|Confidential21|微量誤吸在ICU也是普遍被發(fā)現(xiàn)的現(xiàn)象，并且并發(fā)VAP的發(fā)生Methenyelalfoundevidenceofmicroaspirationin88.9%ofICUpatientsevenwithheadofbedelevationandoralcareinplace.Only1%ofthesemicroaspirationeventswereobserved,themajoritywere“silent”microaspirationevents.Investigatorfoundthatmicroaspirationwasonofthemostimportantindependentriskfactorsforpulmonarycomplications.(p<0.0001)微量誤吸導(dǎo)致VAP如同冰山一角Post-intubationpulmonarycomplications插管后肺部并發(fā)癥:肺部并發(fā)癥可以看成是插管后所導(dǎo)致的并發(fā)癥VAPPostoperativePneumoniaPostoperativePulmonaryComplicationRespiratoryfailure,

COPDexacerbations,etc.Covidien|August8,2024forintERNALUSEONLyTheproblemwiththeproblemSurgicalsiteReportedcomplicationrateStudies,nAAArepair25.5%16Esophagectomy18.9%11Abdominalsurgery14.2%43Headandnecksurgery10.3%6Hipsurgery5.1%5Gynecologic/urologicprocedures1.8%2Smetanaetal.AnnInternMed.2006;144(8):581-595.Covidien|August8,2024forintERNALUSEONLy

Covidien|08August2024|Confidential29|柯惠解決方案

Covidien|10June2010|30

Covidien|10June2010|31誤吸/微量誤吸

防治外因內(nèi)因CovidienRespiratory&MonitoringSolutions|08August2024|Confidential33|TheTaperGuard套囊技術(shù)漸進(jìn)封閉錐形套囊技術(shù)

CovidienRespiratory&MonitoringSolutions|08August2024|Confidential34|TaperGuard平臺(tái)TaperGuardendotrachealtubeAMallinckrodtendotrachealtubewiththeTaperGuardcufftechnology.TaperGuardEvacendotrachealtube:AMallinckrodtendotrachealtubewithboththeTaperGuardcufftechnologyandEvacsuctionlumen.TaperGuardEvacallowsfortheactiveremovalofsecretionsfromabovethecuffforpatient’swithahigherriskofaspiration.TheEvaclumenmaybehookeduptowallsuctioneithercontinuousloworintermittenthigh,orasyringemaybeusedperiodicallytoremovesecretionsfromabovethecuff.TheTaperGuard提供兩種配置CovidienRespiratory&MonitoringSolutions|08August2024|Confidential35|獨(dú)特的錐形套囊能夠在一定位置匹配氣管直徑大小.在這點(diǎn)最小化皺褶和通道的存在確保封閉區(qū)達(dá)到不同插管形狀的形狀，尺寸大小CovidienRespiratory&MonitoringSolutions|08August2024|Confidential36|如何工作？套囊近端:Cuffdiameter>Trachealdiameter

封閉帶:Cuffdiameter=TrachealdiametereliminatingexcesscuffmateriallocallyMallinckrodt?TaperGuard?ETTCovidienRespiratory&MonitoringSolutions|08August2024|Confidential37|關(guān)鍵信息新的TaperGuard?氣插導(dǎo)管有著獨(dú)特的錐形套囊設(shè)計(jì)。這項(xiàng)技術(shù)相比高容量低壓力套囊的桶狀設(shè)計(jì)更能有效提高氣道的封閉性能。TaperGuard套囊是將其套囊近端的直徑設(shè)計(jì)成大于正常成人氣管的直徑。TaperGuard套囊的直徑從近端到遠(yuǎn)端（靠近肺部）逐漸減小，套囊的外形類似于錐體。獨(dú)特的錐形設(shè)計(jì)可以使套囊的直徑從近端至遠(yuǎn)端都契合氣管的直徑。CCI現(xiàn)場(chǎng)動(dòng)物實(shí)驗(yàn)演示在Airwaysworkshop1hrafterTaperguardintubation2hrsCovidienRespiratory&MonitoringSolutions|08August2024|Confidential40|CovidienRespiratory&MonitoringSolutions|08August2024|Confidential41|FDA510批準(zhǔn)CovidienRespiratory&MonitoringSolutions|08August2024|Confidential43|MallinckrodtEvacsignificantlyreducesearlyandlateVAPStatisticallysignificantforearly-onsetandlate-onsetVAP.NosignificantdifferencesindurationofMVorICUmortality.Covidien|August8,2024forintERNALUSEONLyMallinckrodtEvac(HLE)BasicETT(HL)P-valuePatients169164–VAPrate14.8%25.6%0.02Lacheradeetal.AJRCCM2010SubglotticsecretiondrainagewithintegratedsuctionlineSubglotticspaceCovidienRespiratory&MonitoringSolutions|08