摘要：
目的 探讨彩色多普勒超声引导下经皮扩张钳扩张气管切开术在头颈部烧伤合并上呼吸道梗阻患者中的应用价值. 方法 2013年7月-2018年6月,笔者单位收治头颈部烧伤合并上呼吸道梗阻患者17例,其中男15例、女2例,年龄19～63岁,均行彩色多普勒超声引导下经皮扩张钳扩张气管切开术.术前采用彩色多普勒超声仪进行气管检查,明确气管情况及气管周围组织器官情况,综合评估确定最佳切开穿刺部位及路径,明确颈前皮肤到气管前壁内膜的距离等.后在彩色多普勒超声实时引导下,行经皮扩张钳扩张气管切开术.观测患者术前气管的位置、形态、内径、管腔内异常情况,气管周围血管及甲状腺的位置异常情况,颈前皮肤到气管前壁内膜的距离;穿刺成功率、手术时间(从皮肤消毒开始至置管成功)、置管成功率;术中出血量、心率、血压、呼吸和经皮血氧饱和度情况;术后是否发生血管/甲状腺损伤、气肿、气胸、窒息、术后大出血、伤口感染等并发症. 结果 (1)术前彩色多普勒超声检查显示:1例患者气管向右偏离颈前正中线13 mm;17例患者颈部软组织均有不同程度的水肿,气管腔内有较多分泌物;3例患者气管由圆形变为椭圆形且前后径变小;1例患者在常规穿刺点上有1条小动脉阻挡;2例患者在第1～3气管软骨环间可见充血肿大的甲状腺峡部遮盖气管;16例患者颈前皮肤到气管前壁内膜的距离为17～33 mm,1例患者颈前皮肤到气管前壁内膜的距离达47 mm.(2)17例患者均一次穿刺成功,穿刺成功率100％;手术时间5～11 min,平均7 min;置管成功率100％.(3)患者术中出血量少,均不超过8 mL;术中经皮血氧饱和度维持在0.90～0.99,心率、血压、呼吸平稳.(4)无一例患者发生血管/甲状腺损伤、气肿、气胸、窒息、术后大出血、伤口感染等并发症. 结论 对头颈部烧伤合并上呼吸道梗阻患者行彩色多普勒超声引导下经皮扩张钳扩张气管切开术不仅快速有效开放气道,而且手术相关的并发症少,有望提高抢救成功率和改善预后,具有很好的应用价值.%Objective To explore the application value of color Doppler ultrasound-guided percutaneous dilational tracheostomy with dilatation forceps in patients with head and neck burns complicated with upper respiratory tract obstruction.Methods From July 2013 to June 2018,17 patients with head and neck burns complicated with upper respiratory tract obstruction,including 15 males and 2 females,aged 19-63 years,were hospitalized in our unit and treated with color Doppler ultrasound-guided percutaneous dilational tracheostomy with dilatation forceps.Before operation,the trachea was examined by color Doppler ultrasonography to specify condition of trachea and peribronchial tissues and organs for comprehensive assessment,so as to confirm optimal incision site of puncture and pathways as well as specify distance from anterior cervical skin to intima of anterior tracheal wall.Then,under real-time guidance of color Doppler ultrasound,percutaneous dilational traeheostomy with dilatation forceps was performed.The position,shape,inner diameter,and intraluminal abnormalities of trachea of patients before operation,abnormal location of peribronchial vessels and thyroid,distance from anterior cervical skin to intima of anterior tracheal wall,success rate of puncture,surgical time (from skin disinfection to successful catheterization),success rate of catheterization,intraoperative blood loss,heart rate,blood pressure,respiration,percutaneous oxygen saturation,and presence or absence of complications such as vascular/thyroid injury,emphysema,pneumothorax,suffocation,postoperative hemorrhea,wound infection after operation were observed and detected.Results (1)Preoperative color Doppler ultrasonography showed that the trachea of one patient deviated from the anterior median line of neck 13 mm to the right;17 patients had edema of different degrees in the cervical soft tissue and more secretions in the trachea;3 patients had the trachea changed from round to oval with reduced anteroposterior diameter;1 patient had a small artery obstruction at the conventional puncture point;2 patients had the trachea covered by the congestive and swollen isthmus of the thyroid between the first and the third tracheal cartilage rings;16 patients had a distance from anterior cervical skin to anterior tracheal wall intima of 17-33 mm,and 1 patient had a distance from anterior cervical skin to anterior tracheal wall intima of 47 mm.(2) Puncture for 17 patients was successful at one time,and success rate of puncture was 100％.The operation time was 5-11 min,with an average of 7 min,and the success rate of catheterization was 100％.(3)Intraoperative blood loss of patients was less,all not exceeding 8 mL.Intraoperative percutaneous oxygen saturation was maintained between 0.90 and 0.99.The heart rate,blood pressure,and respiration were stable.(4) No complications such as vascular/thyroid injury,emphysema,pneumothorax,suffocation,postoperative massive hemorrhage,or wound infection occurred in any patient.Conclusions Applying color Doppler ultrasound-guided percutaneous dilational tracheostomy with dilatation forceps in patients with head and neck burns combined with upper respiratory tract obstruction can not only open up the airway quickly and effectively,but also reduce the complications related to the operation.It is expected to improve the success rate of rescue and improve the prognosis,making it of good application value.
