经皮气管切开术临床操作规范指南样本
重症医学科临床手册气管切开
气管切开操作和配合气管切开术是危重患者常用的手术之一。
相对于外科的气管切开术（ST），经皮扩张气管切开术（PDT）具有在ICU床边进行、耗时短、成本低、对患者创伤小、愈后瘢痕小的优势。
经过我科的不断探索和发展，我们采用了改良的Seldinger技术和纤维支气管镜引导，使经皮扩张气管切开术（PDT）的安全性得到了极大的提高，同时也降低了术后出血和感染的风险。
目前，经皮扩张气管切开术（PDT）已成为我科的特色之一。
ICU中的经皮扩张气管切开术适应症：1、急性呼吸衰竭伴对于预期或已较长时间（定义为机械通气10天或更长）机械通气治疗的患者。
2、呼吸机依赖、困难脱机，需减少镇静、增加舒适度、促成脱机的患者。
3、气道保护性机制受损的患者（例如脊髓麻痹、颅脑损伤、重症肌无力等）。
4、上呼吸道梗阻导致气管插管困难或拔管困难的患者。
ICU中的经皮扩张气管切开术禁忌症：没有绝对禁忌症，但应考虑一些临床情况：1、需要高水平的氧浓度或PEEP（FiO2＞60%或PEEP＞12cmH2O）。
2、凝血功能障碍（血小板＜50，000×109/L或INR＞1.5）。
3、12岁以下儿童、肥胖、颈部手术、甲状腺肿大（肿瘤浸润）、解剖异常（气管异位）。
4、患者临床状况差，预后差。
术前医生准备：1、与家属沟通，签署知情同意书。
2、评估患者凝血功能指标和生命体征及循环状况(术前停用抗凝剂)。
3、床旁评估患者颈部手术部位是否存在穿刺困难、感染、损伤、畸形等，可初步标识出手术位置、并根据患者体型选择合适的气切套管。
4、用物准备：（a）无菌手套、手术衣、铺巾、纱布（b）带气囊及声门下吸引的气管切开套管和小一号的的套管（c）消毒皮肤的消毒液、生理盐水、药碗、润滑无菌石蜡油、无菌钳及利多卡因、（d）PORTEX经皮气管切开套包，内含（手术刀、套管针、注射器、导引钢丝、扩张器、扩张钳）（e）通知护士准备短效肌松药、镇静镇痛药以及根据患者循环状况准备升压或降压药物。
气管切开术临床技术操作规范
气管切开术临床技术操作规范【适应症】1.喉梗阻喉头水肿、急性喉炎、双侧声带麻痹、咽喉部、声带肿瘤、瘢痕狭窄、脓肿、痉挛、畸形而致上呼吸道梗阻者，均可施行气管切开。
2.下呼吸道分泌物阻塞呼吸道诊中枢神经病变（如药物中毒、脑外伤、脑炎、脑溢血及脑梗死等）可致病人咳嗽反射消失，痰液积聚而阻塞呼吸道，气管切开可有助于吸除分泌物及辅助呼吸。
3.各种原因所致的呼吸衰竭严重的慢性阻塞性肺疾患、肺心病、创伤性湿肺、多发性肋骨骨折、呼吸肌麻痹等，气管切开利于行人工机械辅助呼吸亦方便于呼吸道给药及吸除呼吸道分泌物。
【术前准备】1.各种型号的气管套管、管芯及固定套管用的布带。
2.了解病情并作详细的体检，检查咽喉及气管的位置有无畸形及甲状腺肿大、颈部肿块。
3.如情况允许，需要时可行颈部×线摄片以了解气管位置及颈部病变情况。
4.必要时检查患者动脉血气，以评价患者呼吸困难的严重程度。
5.严重呼吸道梗阻者可先施行气管插管以缓解体内缺氧。
【手术方法】1.病人平仰卧位，两肩部间垫以沙袋，头部尽量后伸，以利颈部气管延长且前突，并保持颈部正中位便于手术操作。
2.局部麻醉，以1%利多卡因及0.1%肾上腺素混合液作皮内及皮下浸润麻醉，而范围应包括上至甲状软骨，下至胸骨上凹处的气管前及双侧气管旁的皮下组织（必要时先行全身麻醉及气管内插管，再行气管切开）。
3.常规用颈部正中切口，切开部位以第2-4软骨环为宜，切开皮肤及皮下浅、深筋膜。
用小拉钩拉开切口两侧皮肤，显露颈正中肌白线，切白线，牵向两侧，可见其下方的气管，刀尖刺入气管不应过深，切2—3mm为宜，气管切开后将选好的气管外套管连同套管芯顺势插入气管。
拔出套管芯，此时套管外口有气流冲出可证实套管位于气道内，吸尽气道内积血及痰液，置入内套管，颈前切口如过大可将皮肤缝合1-2针，不可缝合过紧，以防发生血肿及气肿。
4.用两条布带固定外套管颈部，带子固定太紧可影响颈部静脉回流，太松则套管易于滑出，以可伸入3个手指为宜，带子需打外科结，以避免松脱，最后放一块剪开纱布于皮肤及套管之间。
经皮穿刺气管切开术的配合及护理
经皮穿刺气管切开术的配合及护理1方法1.1用物准备：一次性气管切开套管一套,气管切开包,2％利多卡因，1℅肾上腺素,1℅碘伏,氧气,吸引管,吸痰管,呼吸面罩,简易呼吸囊,急救用品等。
1.2操作步骤：患者取仰卧位,肩部垫高,头后仰,充分暴露颈部并使气管位于正中位置。
常规消毒铺巾,2％利多卡因局麻、取第1～2或2～3气管环间为穿刺点。
以穿刺点为中心横切皮肤1～1.5 cm,止血钳分离皮下组织至浅筋膜,用含有5 ml生理盐水的注射器与穿刺套管针沿穿刺点垂直穿刺,落空感后有气泡排出,说明穿刺套管针进入气管内,拔除穿刺针,沿套管针置入导引钢丝8～10 cm至隆突水平,拔除穿刺针套管,沿导引钢丝置入锥形扩张子,顺时针方向旋转扩张,钝性分离肌层至气管穿刺点。
退出扩张子后,Portex扩张钳沿导引钢丝到达气管穿刺点,扩张钳尖端弯曲段与气管垂直,原位打开扩张钳,扩张穿刺部位气管前壁,气体自穿刺部位涌出,改变分离钳角度,使其尖端弯曲段与气管纵轴平行后进一步扩张,沿导引钢丝顺穿刺方向置入相应的气切套管,拔除导引钢丝和气切套管内芯,进一步确认气切套管在位,固定气切套管。
2观察与护理2.1术前健康指导：操作前如患者清醒，应做好解释工作，消除心理顾虑。
手术后患者不能讲话,可以用笔交流，让患者有思想准备，使其配合治疗。
2.2术前给药：术前给予镇静、镇痛,可静脉注射咪唑安定、异丙酚等,使其减轻疼痛。
2.3术中监测：患者的血压、脉搏、脉搏氧饱和度(SpO2)、心电图等,发现异常,如SpO2[1]。
2.5防止局部感染:严格遵守无菌操作,局部每日换药2～3次,有污染及时更换,吸痰时注意无菌操作,避免交叉感染。
2.6预防套管脱出：由于咳嗽、烦躁、皮下气肿、套管过短、体位改变、固定带过松等原因可引起套管移位脱出,应密切观察。
如患者诉胸闷、呼吸困难,使用呼吸机患者气道压力增高,脉搏氧饱和度明显下降,应及时观察导管是否在位。
套管脱出应立即处理,无自主呼吸的患者应闭合伤口,予面罩加压给氧,并立即通知医生。
经皮气切操作图解
定位和消毒
定位：选择合适的气管切开部位， 通常在喉结下方，胸骨上窝上方
切开方式：根据具体情况选择合适 的切开方式，如横切、纵切等
添加标题
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消毒：对切开部位进行严格的消毒， 以减少感染的风险
切开后处理：及时清理呼吸道分泌 物，保持呼吸道通畅
切开和分离
切开：使用手术 刀在气管切开部 位做一个切口
监测生命体征：密切监测患者的生命体征，包括心率、血压、呼吸等，及时发现异常情况并处 理。
预防感染：注意伤口护理，保持伤口清洁干燥，预防感染。
并发症及处理方法
感染：使用抗生素和定期换 药
出血：压迫止血或使用止血 药物
皮下气肿：轻度的可自行吸 收，严重时应立即就医
气管狭窄：定期扩张气管， 严重时可进行手术治疗
套管固定方法三：缝线固定
套管固定方法四：硅胶固定
经皮气切操作案例 分析
案例一：经皮气切在重症肺炎治疗中的应用
患者情况：患者因重症肺炎导致呼吸困难，需进行经皮气切手术 手术过程：医生在患者颈部切开一个小口，插入套管针，建立人工气道 术后护理：定期清洗气道，保持呼吸道通畅，监测患者生命体征 治疗效果：患者呼吸困难得到缓解，肺炎得到有效治疗
汇报人：XX
案例二：经皮气切在COPD急性加重期的应用
患者情况：患者老年男性，长期吸烟史，诊断为COPD急性加重期
操作过程：在床旁进行经皮气切操作，手术过程顺利，无并发症发生
治疗效果：术后患者呼吸困难症状明显改善，血氧饱和度上升 结论：经皮气切在COPD急性加重期中具有较好的应用效果，能够快速改善患者呼吸困难症 状，提高生活质量
优势：操作简便、快速建立人工气 道、减少并发症等
气管切开术参考指南说明书
Tracheostomy Tube Reference GuideBy: Elizabeth Gould BSN, NP-C CORLNENT and Tracheostomy Clinical Nurse SpecialistTable of ContentsGeneral Notes About Trachs………………………………………………….... Page 2 Shiley Flexible Adult Tracheostomy Tube…………………………………....Page 3 Shiley Legacy Adult Tracheostomy Tube………………………………….…Page 4 Shiley Adult Tracheostomy Tube Inner cannulas………………………..…. Page 5 Shiley Fenestrated Tracheostomy Tube………………………………………Page 6 Shiley Single Cannula Tracheostomy Tube.…………………………………. Page 7 Shiley XLT Tracheostomy Tube………………………………………………..Page 8 Portex - Bivona Tracheostomy Tubes…………………………………………Page 9 Portex-Bivona Adjustable Tracheostomy Tubes…………………………….. Page 10 Portex - Bivona Aire-Cuf (vs TTS) Tracheostomy Tube………………..Page 11 Portex - Bivona Fome-Cuf Tracheostomy Tube……………………….…….Page 12 Portex BluSelect and Blue Line Ultra Tracheostomy Tube…………………..P age 13 Portex Regular Tracheostomy Tube…………………………………………… Page 14 Talk Attachment/Suction Aid Trachs ……………………………………….…Page 15 Tracoe Tracheostomy Tube ……………………….………………….……..… Page 16 Blom Singer Tracheostomy Tube……………………………………………… Page 16 Jackson Tracheostomy / LaryngectomyTubes………….……………………Page 17 The information in this document is meant for educational purposes only. Insights from clinical experience are included. Always reference companyspecific instructions and information.Last Updated 11/30/2021General Notes about Trachs:1) There are two different methods for sizing trachs. Understand that sizes amongst brandsare not equivalent…•Jackson sizing is for Shiley regular and Flex trachs only. The size of the trach does not refer to any actual measurement of the trach.•ISO (International Sizing Organization) is used by all other trach manufacturers, and for Shiley XLTs. The size of the trach refers to the inner diameter of the trachWITHOUT the inner cannula.2) Know your cuffs•High Volume Low Pressure (HVLP)•Mid-Range cuffs•High Pressure Low Volume (HPLV)•Fome-cuf•Barrel or cylinder shape cuffs•Round cuffs•Tapered cuffs3) Cuff leaks - Cuff size does not always change with or correspond to trach size. Whenaddressing ventilator leaks check the cuff diameter when inflated (called the “resting diameter”).4) Custom trachs can be made based on bedside measurements or imaging.Shiley Flexible Adult Tracheostomy TubeIndications: Regular/standard adult trach. Uses Jackson sizing.Product Information: Flexible faceplate, 15mm adapter is part of trach, not inner cannula. Inner cannula can be removed to pass scope through smaller trachs and still connect to ventilator/ambu bag. Cap can be worn over inner cannula so inner cannula can be changed to keep trach patent. Increased patient comfort due to the more flexible material of the trach. Improved air flow around deflated cuff. Beveled tip for easier insertion and trach changes, percutaneous insertions. Sizes 4, 5, 6, 7, 8, 9, 10Additional Information: Inner cannula has groove that prevents total finger occlusion. Some patients may not be able to finger occlude enough to produce speech. Also, some patients may not be able to wear a cap or speaking valve with inner cannula in place because the air leak will cause cap/speaking valve to blow off. If this is the case remove the inner cannula temporarily and take measures to prevent obstruction.Cuff: Taperguard Low Volume Low PressureShiley “Legacy” Adult Tracheostomy TubeIndications : Regular/standard adult trach. Uses Jackson sizing.Product Information : Some patients who have used this trach for a long time or have trouble with speechwith the Shiley Flex prefer to stay with the legacy version. See Shiley Flex advantages for comparison of features.Cuff : Barrell-shape High Volume Low PressuresShiley abbreviationsDCT = Disposable (inner cannula) Cuffed Tracheostomy DCFS = Disposable (inner cannula) CufflessDCFN = Disposable (inner cannula) Cuffless Fenestrated DFEN = Disposable (inner cannula) Fenestrated – cuffed LPC – Low Pressure Cuff (softens with body temperature) LGT = Laryngectomy Tube –shorter than a trach tube PERC = Percutaneous tracheostomyOuter diameter of outer cannulaSize Inner cannulainner diameterTypes of Shiley Legacy Adult Tracheostomy Tube Inner CannulasSpare Inner Cannula (SIC) use if totemporarily connect to ventilatorwhile cleaning reusable innercannulaLegacy disposable innercannula (DIC) – Clip lockFenestrated inner cannulaReusable low profile innercannula, does not connect toventilatorReusable Inner Cannula (RIC)– Twist lockFlex disposable inner cannulaShiley Adult Tracheostomy Tube Inner Cannulas continuedFenestrated Tracheostomy TubesIndications : Regular size adult trach placed for speaking. Needs a fenestrated inner cannula to function for speaking purposes.Product Information : Some patients are unable to pass air around regular tracheostomy tubes, so fenestrations can assist with voicing. Not usually first choice for speaking because fenestrations can cause tissue to adhere and bleeding issues. Do not place unless special indication and advanced consultation obtained. Some fenestrated tracheostomy tubes do not come with fenestrated inner cannulas, so they can only be used for voicing without an inner cannula in place.Blue dot indicates inner cannula is reusable. Shiley inner cannulas that twist to lock in place are reusable.Shiley Single Cannula Tracheostomy Tube (always cuffed)Indications: Not generally used anymore, but still stocked in hospital distribution and on emergency carts. Uses ISO sizing meaning the inner diameter of the trach is the same as the size of the trach. Product Information: No inner cannula provides a smaller inner diameter to outer diameter ratio. Can be useful in emergencies for recannulating and ventilation. The size 6 is actually smaller than a regular Shiley size 4, so we place the SCT 6 at bedside in the hospital as a size smaller for regular Shiley 4 trachs for use in emergencies. The larger sizes 8 and above are 89mm and longer, so considered extended length. No inner cannula, material trach is made from easily builds up secretions and can clog off easily. Patients who have this trach should change it and clean is once a week. DO NOT PLACE FOR ANY PROLONGED TIME, NOT ADVISABLE FOR DISCHARGE.Size / SCT = Single Cannula Tracheostomy Outer diameter Inner diameterShiley XLT Tracheostomy TubeIndications : Proximal is used for large necks, Distal to bypass problematic areas in trachea. Uses ISO sizing meaning the inner diameter of the trach without the inner cannula is the same as the size of the trach.Product Information : Longer lengths, different points of flexion.Generally, these are large trachs. Large outer diameters and small inner cannulas Cuff : Round, High Volume Low PressureXLT Proximal or Distal, indicatespart of tube with extended lengthInner Diameter is thesame as trach tube sizeOuter diameterLengthPicture of cuff indicates tube is cuffedPortex - Bivona Tracheostomy TubesIndications : If a longer trach is needed, or a different trach plate is needed due to skin breakdown. The Adjustable length is used temporarily until the appropriate length is determined. Uses ISO sizing meaning the inner diameter of the trach is the same as the size of the trach.Product Information : Low profile flexible trach plate. Longer versions (fixed or adjustable) are available. All three types can come with TTS cuffs or “Aire” cuffs. Longer hyperflex trachs are MRI compatible with caution (need to be secured, see package insert). Can be reprocessed up to 10 times (either autoclave or boiling process to sterilize at home by patient). No inner cannulas.Cuff : Aire- Cuf – round, mid-range. TTS – High Volume High Pressure, water filledThree general types (TTS cuffs pictured – clear pilot balloon)Bivona Adjustable: TTS Extended Adjustable Length Flange, hyperflex reinforced.Bivona Standard: Regular length (no hyperflex reinforcement)Bivona Fixed: TTS Extended Length Fixed Flange, hyperflex reinforcedInternal diameter is same as tube size (some half sizes available inregular length),special orderInternal diameter is same as tube sizeBivona Tight to Shaft Black insertion pin and arrows indicate tube is adjustable length (temporarily used to determine best fit for patient). If not present is fixed length.Diameter of cuffwhen deflatedOutside diameter LengthExtended lengths have clear faceplates, standard lengths have white faceplatesNotes about Adjustable Length Portex-Bivonas•Adjustable trachs are supposed to be used temporarily until the length can be determined. TTS low volume high pressure cuffs can be used because they are indicated for up to two weeks without regular prolonged cuff deflation. TTS can be advantageous for manipulating the length of this trach in the airway.•Adjustable trachs can pose an airway safety issue. Patients dependent on the position of the trach should be monitored in the ICU in most cases. If patient transfers to the floor nursing and RT staff need education on monitoring and maintenance. Adjustable trachs are contraindicated for home or SNF discharge.•The arrows on the trach indicate where the pilot balloon should be rotated. Otherwise the cinch used to keep the length of the trach in place can cause pressure on the balloon and cause cuff pressure issues.•The hash marks on the tube do not indicate the internal length of the trach tube (which would be used for special ordering a fixed length). Subtract 2cm from the length observed externally to determine the internal length.Notes about Tight to Shaft (TTS) versus “Aire” cuff s•TTS “Tight to Shaft” means when deflated, the cuff lays flat against the shaft of the trach tube.This is a high pressure, low volume cuff and should only be used long term if it will regularly be deflated for speaking. Otherwise it is indicated for use less than two weeks. It is also beneficial because it makes trach changes easier, although this is not an indication for long term use in adults.•Bivona TTS cuffs are filled with sterile water, not air. If it is filled with air it will diffuse out. Use minimal leak of minimal occlusive volume techniques for fill amount. If fill amount changes this is an indication that dilation of the traches may be occurring.•“Aire” indicates cuff to be filled with air. Aire cuffs are “mid-range” high volume, low pressure cuffs. Standard cuff pressure is 25mmH20 measured with a manometer. If the silicone cuff is overinflated air will diffuse out.Bivona “Aire-cuf f” Tracheostomy Tubes – Blue pilot balloon)Portex manufacturer, Bivona designPicture of cuff indicating cuffed trach Diameter of cuff when deflatedInner diameter is same astube sizePortex-Bivonas regular length, fixed, and adjustable trachs can all come with TTS or Aire-cuffsIndications : To address or prevent cuff leaks in long term trached/vent dependent patients. Uses ISO sizing meaning the inner diameter of the trach is the same as the size of the trach.Product Information : Places the least pressure on the tracheal wall of any cuff available. Difficult to determine the status of the cuff once it is placed, passively inflates. Requires specialized education for a patient to manage at home and for staff inpatient. DO NOT overinflate, if the cuff breaks in the patient there is no way to deflate the fome part of the cuff. See Trach Resource website for more information (type “Trach in UCD intranet bar).Fome = Fome –cuf trach tubeDiameter of cuffwhen passively expandedInternal diameter is same as tube sizeSyringe with stop cock for tube inflation volumemeasurementFome Cuf, passively expandsPort for cuff deflation and volumemeasurement, never inflated (passively expands)15mmconnector for use with ventilatorWedge to help disconnect 15mmconnector if neededIndications: Regular/standard adult trachProduct Information: Flexible faceplate, 15mm adapter is part of trach, not inner cannula. Inner cannula can be removed to pass scope through smaller trachs and still connect to ventilator/ambu bag. Cap can be worn over inner cannula so inner cannula can be changed to keep trach patent. Clear Faceplate labeling, checkered edging indicated fenestrted trach. Sizes 6, 7, 7.5, 8, 8.5, 9,10.New Portex product line, comes in with fenestrated and SuctionAid optionsCuff: Barrell-shape, High Volume Low Pressure “SOFT-SEAL®tubes”Portex Blue Line Ultra Tracheostomy TubeIndications: Regular/standard adult trachProduct Information:Will be discontinued soon, BluSelect is new product lineCuff: Barrell-shape, High Volume Low PressureIndications: Regular/standard adult trachProduct Information: Generally same as legacy Shiley. Uses ISO sizing for size of trach is the same size as the inner diameter of the trach without the inner cannula. Will be discontinued soon, BluSelect is new product lineCuff: Barrell-shape, High Volume Low PressureColor coded tubes and inner cannulasOrange = 6Green = 7White = 8Blue = 9Yellow = 10Inner cannula inner diameterPortex tracheostomy tubeInternaldiameter issame as tubesizeOuter diameterInner diameter oftrach without innercannulaTrachs with Talk Attachments and Suction Aid•Comes in Portex and Shiley brands. Ports can be used for subglottic suction or as talk attachements. •Talk attachments are used for patients on ventilator (cuff inflated). The attachment opening is just above the cuff. Air can be infused when the cuff is inflated, and adjusted to achieve voicing. Occlude open port with finger for patient to speak.•The suction port is for intermittent or continuous subglottic suction. Can attach to syringe and aspirate manually, or attach to wall suction at 100-120mmHg. Need to occlude open port with finger. For continuous subglottic suction detach open port and connect to wall suction.Talk attachment/Subglottic suction port with open port for finger occlusion Pilot balloons for cuff managementIndications: Regular/standard adult trach.Product Information: Good for speaking, low profile for long term trach patients.Blom-Singer Tracheostomy TubeIndications: Regular/standard adult trach. Long term vent dependent patients, fenestration allows for speech regardless of cuff inflation. Equal size specifications as a Legacy Shiley.Product Information: Speech cannula for ventilator patients with “Flap valve” and “bubble valve.” EVR (exhaled volume reservoir) attachment prevents false low expiratory minute volume alarms. LPV (low profile valve) for patients not on ventilatorIndications: Long term trach patientsProduct Information: Metal is inherently antimicrobial. Can be removed and cleaned easily and often. Patients report less problems with secretions and odor. Come with and without 15mm adapters on inner cannulas, with care used for speaking valves and caps.Jackson Laryngectomy Tube。
气管切开术技术操作规范
气管切开术技术操作规范一、传统气管切开术【适应证】1. 喉阻塞：任何原因引起的3－4度喉阻塞，尤其是病因不能很快解除时，应及时行气管切开术。
2. 下呼吸道阻塞：如昏迷、颅脑病变、神经麻痹、呼吸道烧伤等引起喉肌麻痹，咳嗽反射消失，以致下呼吸道分泌物储留，或呕吐物易进入气管不能咳出，可作气管切开术，通过气管套管便于吸出分泌物，减少呼吸道死腔，改善肺部气体交换。
3. 颈部外伤，为了减少感染，促进伤口愈合；有些头颈部大手术，为了防止血液流入下呼吸道，保持呼吸道通畅，需作预防性气管切开术。
【禁忌证】绝对禁忌证：1. 气管切开部位存在感染。
2. 气管切开部位存在恶性肿瘤。
3. 解剖标志难以辨别。
相对禁忌证：1. 甲状腺增生肥大。
2. 气管切开部位曾行手术（如甲状腺切除术等）。
3. 出凝血功能障碍。
【操作方法及程序】1. 切口：自甲状软骨下缘至胸骨上窝处，沿颈前正中线纵行切开皮肤及皮下组织。
2. 分离颈前肌层：用止血钳沿颈中线作钝性分离，以拉钩将胸骨舌骨肌、胸骨甲状肌用相等力量向两侧牵拉，以保持气管的正中位置，并以手指触摸气管，避免偏离气管或将气管误拉于拉钩内。
3. 暴露气管：甲状腺峡部覆盖于第2－4气管前壁。
若其峡部不宽，在其下缘稍行分离，向上牵拉，便能暴露气管，若峡部过宽，可将其切断，缝扎。
4. 切开气管：分离气管前筋膜，在气管第3－4环切开气管，切勿切断第一环，以防伤及环状软骨而引起喉狭窄。
切口亦勿超过第5环，以免发生出血和气肿。
5. 插入气管套管：用气管扩张器或弯止血钳撑开气管切口，插入已选妥的带管芯的套管，取出管芯，即有分泌物自管口咳出，用吸引器将分泌物吸清。
如无分泌物咳出，可用少许棉花置于管口，视其是否随呼吸飘动，如不飘动，则套管不在气管内，应拔出套管，重新插入。
6. 固定套管：以带子将气管套管的两外缘牢固地缚于颈部，以防脱出；缚带松劲要适度。
7. 缝合：气管套管以上的切口，可以缝合，但不必缝合切口下部，以防气肿。
经皮气管切开术操作步骤
经皮气管切开术操作步骤经皮气管切开术啊，这可是个挺重要的操作呢！咱先说说准备工作吧，就像要去打仗得先把武器弹药准备好一样。
得把各种器械都摆好，什么扩张钳啊、气管套管啊，都得乖乖在那等着。
然后呢，就是确定好切开的位置，这可得看准了，不能有偏差呀，不然那可就麻烦大了。
就好像射箭得瞄得准准的，才能射中靶心嘛。
接下来，就该动手啦！先在皮肤上切个小口，这就像是打开一扇小窗户。
然后呢，用专门的工具慢慢把组织分开，一层一层地，就跟剥洋葱似的，得小心翼翼的。
再之后，就是关键的一步啦，把气管暴露出来。
这时候可得特别小心，不能伤到气管呀，气管可是很重要的呢，就像家里的水管一样，不能随便弄破。
接着就是扩张气管啦，把通道扩大一些，好让气管套管能顺利进去。
这就好比给路拓宽一点，让车能更顺畅地通过。
然后把气管套管放进去，这就像给气管安了个新家一样。
一定要放得稳稳的，不能摇摇晃晃的。
最后呢，固定好气管套管，可不能让它乱跑呀。
这就像给东西打个结，让它稳稳地在那。
哎呀，你说这经皮气管切开术是不是很神奇呀？每一步都得特别仔细，不能有一点马虎。
就好像走钢丝一样，得稳稳当当的，不然一不小心就会出问题呢。
医生们在做这个的时候，那可真是全神贯注，一点都不能分心。
这可不是开玩笑的事儿，每一个细节都关乎着病人的生命安全呢。
所以呀，做这个操作的人都得是高手，技术得过硬。
你想想，如果操作不当，那后果得多严重啊！所以呀，这真的是个很严肃很重要的事情呢。
大家可别小看了这个经皮气管切开术，它可是能在关键时刻救人性命的呀！就像一个隐藏的英雄，平时不显眼，关键时候能发挥大作用。
总之呢，经皮气管切开术是个很专业很精细的操作，每一步都得特别小心谨慎，不能有丝毫差错。
这可真是一门技术活呀！。
经皮扩张气管切开术
02
定期更换气管切开 处的敷料，防止细
菌滋生。
03
观察患者呼吸情况， 如有异常及时通知
医生。
04
指导患者进行深呼 吸和咳嗽，防止痰
液堵塞气管。
05
鼓励患者多喝水， 保持口腔湿润，防
止口干舌燥。
06
定期测量体温，观 察患者有无发热症
状。
07
观察患者有无呼吸 困难、胸闷、气短 等症状，如有异常
及时通知医生。
适应症
01
气管插管困难 或插管时间较
长的患者
02
气管插管无法 维持气道通畅
的患者
03
气管插管无法 提供足够的通
气量的患者
04
气管插管无法 提供足够的氧
合的患者
05
气管插管无法 提供足够的通 气压力的患者
06
气管插管无法 提供足够的通 气时间的患者
07
气管插管无法 提供足够的通 气流量的患者
08
气管插管无法 提供足够的通 气阻力的患者
04
严重感染性 疾病
05
严重神经功 能障碍
06
严重皮肤病 或皮肤损伤
07
严重心理障 碍或精神疾
病
08
严重营养不 良或严重贫
血
09
严重免疫功 能低下或免
疫缺陷
10
严重内分泌 功能紊乱或 内分泌疾病
2
经皮扩张气管切 开术操作步骤
术前准备
评估患者 情况，包 括病情、 年龄、体 重等
准备手术 器械，包 括扩张器、 气管切开 刀、导管 等
手术成功率：评估 手术的成功率，包 括一次成功和二次 手术的成功率
术后并发症：评估 术后可能出现的并 发症，如出血、感 染、气管狭窄等
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经皮气管切开术临床操作规范指南样本
经皮气管切开术（percutaneous tracheostomy）是在Seldinger经皮穿刺插管术基础之上发展起来的一种新的气管切开术，具有简便、快捷、安全、微侵袭等优点，已部分取代正规气管切开术。
经皮气管切开的手术器械和操作方法有几种，下面仅介绍导丝扩张钳法（guide wire dilating forceps），所用器械为一次性Portex成套器械，内有手术刀片、穿刺套管针、注射器、导丝、扩张器、特制的尖端带孔的气管扩张钳及气管套管。
一、手术骤如下：
1、体位及麻醉：同正规气管切开术。
2、切口：在第一和第三气管环之间的正前方皮肤作一长约1.5cm的横行或纵行直切口，皮下组织可用小指或气管扩张钳钝性分离。
3、穿刺：注射器接穿刺套管针并抽吸生理盐水或2%利多卡因5ml，经切口于第一第二或第二第三气管环之间进行穿刺，回抽见气泡，即证实穿刺针在气管内。
拔出针芯，送入穿刺套管。
4、置入导丝：用注射器再次证实穿刺套管位于气管内后，沿穿刺套管送入导丝，抽出穿刺套管。
此时病人多有反射性咳嗽。
皮肤切口穿刺气管经穿刺套管送入导丝
5、扩张气管前壁：先用扩张器沿导丝扩开气管前组织及气管前壁，再用气管扩张钳顺导丝分别扩张气管前组织及气管前壁，拔出扩张钳。
气管前壁扩张后气体可从皮肤切口溢出。
6、放置气管套管：沿导丝将气管套管送入气管，拔出管芯和导丝，吸引管插入气管套管，证实气道通畅后，将球囊充气，最后固定气管套管，包扎伤口，手术完毕。
二、术后处理
气管切开术后处理是否得当，与病人的治疗效果甚至生命都有极大的关系。
若因经验不足或注意不够而处理不当，将造成严重后果。
因此，术后处理非常重要。
1、气管套管要固定牢靠，经常检查系带松紧，以防脱管窒息。
2、气管切开后，上呼吸道丧失对吸入空气过滤、加温和湿化的生理作用，故应湿化空气，防止分泌物干结堵管。
3、严格无菌操作，预防呼吸道感染。
4、随时清除套管内、气管内及口腔内分泌物，保持呼吸道通畅。
5、如原发病已愈、炎症消退、自主呼吸完好、呼吸道分泌物不多，便可考虑拔管。
拔管时间一般在术后一周以上。
拔管前可先试半堵或全堵管口1~3天，如无呼吸困难即可拔管。
拔管后，用蝶形胶布拉紧伤口两侧皮肤，使其封闭，切
口内可不填塞引流物。
外敷纱布，每日或隔日换药一次，一周左右即可痊愈。
拔管后床边仍需备气管切开包，以便病情反复时急救。
拔管困难者可带管出院或延期拔管。
三、术后并发症
1、皮下气肿：是术后最常见的并发症，常与软组织分离过多、气管切口过长或皮肤切口缝合过紧有关。
自气管切口逸出的气体可沿切口进入皮下组织间隙，多发生于颈部，出现颈部增粗，触之有捻发感。
皮下气肿多在一周内消失，不需特殊处理。
2、气胸及纵隔气肿：暴露气管时过于向下分离，损伤胸膜后引起气胸。
右侧胸膜顶位置较高，遇胸膜向上膨出时，应以钝拉钩保护之。
气胸明显，伴呼吸困难者，应行胸腔穿刺抽除积气，必要时作胸腔闭式引流。
过多分离气管前筋膜，气体自气管切口沿气管前筋膜进入纵隔，形成纵隔气肿。
纵隔气肿轻者可自行吸收，积气较多时，可于胸骨上方沿气管前壁向下分离，使空气向上逸出。
3、出血：伤口少量出血，可在伤口内放置明胶海绵，并于气管套管周围填入碘仿纱条压迫止血，或酌情加用止血药物。
若出血较多，应在充分准备下检查伤口，结扎出血点。
4、拔管困难：因手术合并症造成拔管困难的情况不少，而手术后处理不当也是拔管困难的重要原因之一。
如果发生拔管困难，应先检查原因，然后作针对性处理。
一般除引起
严重喉头狭窄外，其他原因引起的拔管困难是可以解决的。