气管切开术 I：程序和插管

A tracheostomy establishes a patent airway when oral or nasal intubation is not possible, bypasses upper airway obstructions, and simplifies secretion removal. It enables long-term mechanical ventilation, facilitates ventilator weaning, reduces ventilator-dependent days, decreases hospital length of stay, and improves communication for patients with speech difficulties.

Cuffed tubes have an inflated cuff that seals the opening around the tube to prevent air leakage and aspiration, making them essential for patients requiring mechanical ventilation. Cuffless tubes lack this seal and are suitable for long-term tracheostomies without mechanical ventilation, allowing spontaneous breathing without the need for pressurized sealing.

Fenestrated tubes have one or more openings in the shaft that allow patients to breathe spontaneously and speak with the tracheostomy tube in place. Non-fenestrated tubes lack these openings and are used when a complete seal is necessary, such as during mechanical ventilation or when airway protection is the primary goal.

A tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. The outer cannula is the primary tube inserted into the trachea, the inner cannula can be removed for cleaning, and the obturator guides the direction of the outer cannula during placement and must be removed immediately after insertion to keep the airway open.

Nursing care includes regular tracheostomy site assessment, performing sterile dressing changes every 12 to 24 hours, measuring cuff inflation pressure with a cuff manometer at least every 8 hours, and suctioning the tracheostomy tube. Nurses must also ensure patency, provide humidified air to keep secretions thin, and maintain emergency preparedness with spare tubes at the bedside.

Call for help immediately and assess the patient's level of consciousness, ability to breathe, and presence of respiratory distress. Keep a spare tracheostomy tube of the same size and one size smaller at the bedside for prompt reinsertion. Have an obturator readily available to guide the new tube safely into place, and remove it immediately after insertion to maintain airway patency.

The procedure is performed in a sterile environment under local or general anesthesia. An incision is made on the anterior neck extending to the trachea, typically at the second or third cartilaginous ring level. The tracheostomy tube is inserted through the opening and secured around the patient's neck with twill tapes or a Velcro strip, then sutured with a sterile dressing applied.