颈脊髓损伤气管切开患者的呼吸管理

Respiratory management for patients undergoing tracheotomy after cervical spinal cord injury

中文关键词:  颈脊髓损伤  气管切开术  呼吸功能  护理

英文关键词:Cervical spinal cord injury  Tracheotomy  Respiratory  Nursing care

中文摘要:

  【摘要】 目的：回顾性总结颈脊髓损伤（SCI）气管切开患者护理要点、拔管指征和结果。方法：回顾研究2008年1月～2014 年3月我院收治的92例颈脊髓损伤气管切开患者的呼吸管理过程和转归情况，其中男74例，女18例；年龄41.7±19.2（28～72）岁。随访时间24±8（7～34）个月。护理要点包括鼓励患者自主咳嗽，叩背吸痰，保持气道清洁、湿润、通畅；逐渐辅以振动排痰和呼吸训练。拔管的指征为血气分析结果正常，自行咳嗽排痰，咽反射正常，肺部无炎症表现，无喉头水肿，套管远端无气道狭窄。统计患者气管套管拔出时间和影响因素。结果：92例患者中82例（89.1%）患者一次性拔管成功，伤后3个月内拔管成功患者64例（69.5%），拔管距伤后时间平均44.1±14.2d（11～89d）；伤后3个月后拔管成功患者18例（19.6%），拔管距伤后时间平均138.9±5.5d（125~147d），均反复出现肺部感染。10例（10.9%）患者在随访中拔管失败，其中7例患者因肉芽组织增生致气管狭窄，更换T管后保留气管切开套管直至随访结束；3例患者拔除气切套管后出现气管塌陷，其中2例重新接受气管插管，病情稳定后改用气管切开套管至随访结束，1例因急性呼吸衰竭而死亡。结论：正确的护理和呼吸训练，可以使大部颈脊髓损伤患者气管切开术后度过危险期而顺利拔管。SCI运动平面高、反复肺部感染、气管狭窄和塌陷是导致拔管延迟和失败的主要原因。拔管后气管塌陷发生率虽较低，但危害大，应引起重视。

英文摘要:

  【Abstract】 Objectives: Retrospectively reviewing the rehabilitation of patients suffering from cervical spinal cord injury(SCI) and undergoing tracheotomy, and to summarize the nursing keypoints for managing respiratory function and the indication for tracheotomy and extubation. Methods: Clinical materials of 92 patients with cervical SCI and undergoing tracheotomy who hospitalized from January 2008 to March 2014 were reviewed retrospectively. Including 74 males and 18 females, with an average age of 41.7±19.2(range, 28-72) years old. The follow-up period was 24±8(7-34) months. The necessary nursing care and rehabilitation training skills for respiratory included: encouraging and training for productive cough, keeping the airway wet and unobstructed, starting respiratory training step by step with vibration sputum discarding. The indications of extubation included: normal blood gas, effective voluntary cough, normal pharyngeal reflex, no lung infection, no laryngeal edema and no airway obstruction. Finally, the time span of extubation in each patient was analyzed, and the influencing factors were investigated. Results: 64 of the 92 cases(69.5%) succeeded in extubation at 44.1±14.2 (range, 11-89) days after the onset of injury, while 18 cases(19.6%) experienced delayed extubation at 138.9±5.5(125-147) days due to reccurant lung infection. 10 cases(10.9%) failed in extubation, 7 of them were caused by airway obstruction due to the hypertrophy of granulation tissue and maintained the tracheal tube at the end of the follow-up. The other 3 patients suffered from tracheal collapse after extubation, 2 of the 3 received tracheotomy again and discharged with the tracheal cannula, the rest died of acute respiratory failure． Conclusions: Well planned nursing care and proper respiratory training can help most of patients with cervical SCI and suffering from tracheotomy to remove their tracheal cannula safely in 3 and 4 months． Motor level at C4 or higher, recurrent lung infection, tracheal stenosis or collapse were the main causes of delayed or failed decannulation. The tracheal obstruction and tracheomalacia are rare but threatening life, which should be paid attention．