NS Nursing Science 2168-5657 Scientific Research Publishing 10.12677/NS.2024.131007 NS-78891 NS20240100000_71807591.pdf 医药卫生 颈脊髓损伤患者早期气管切开的研究进展 Research Progress of Early Tracheotomy in Patients with Cervical Spinal Cord Injury 彭 娇 1 2 null 铜仁职业技术学院附属医院护理部，贵州 铜仁 05 01 2024 13 01 42 47 © Copyright 2014 by authors and Scientific Research Publishing Inc. 2014 This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

颈髓损伤引起的呼吸系统并发症是患者病情加重甚至死亡的重要原因，而早期气管切开可有效缓解呼吸功能障碍或下呼吸道分泌物潴留引起的呼吸困难。降低气管插管并发症。本文从颈脊髓损伤早期气管切开的定义、流行病学、优点、影响因素及预测工具等几个方面进行综述，以期为未来颈脊髓损伤患者早期气管切开的相关研究及应用提供借鉴。 Respiratory complications caused by cervical spinal cord injury were an important cause of aggravation and even death of patients. Early tracheotomy can effectively alleviate respiratory dysfunction or lower respiratory tract secretion retention caused by dyspnea. Reduce complications of tracheal intubation. This article reviewed the definition, epidemiology, advantages, influencing factors and prediction tools of early tracheotomy in patients with cervical spinal cord injury, in order to provide reference for future research and application of early tracheotomy in patients with cervical spinal cord injury.

 颈脊髓损伤，气管切开，研究进展, Cervical Spinal Cord Injury Tracheotomy Research Progress 摘要

颈髓损伤引起的呼吸系统并发症是患者病情加重甚至死亡的重要原因，而早期气管切开可有效缓解呼吸功能障碍或下呼吸道分泌物潴留引起的呼吸困难。降低气管插管并发症。本文从颈脊髓损伤早期气管切开的定义、流行病学、优点、影响因素及预测工具等几个方面进行综述，以期为未来颈脊髓损伤患者早期气管切开的相关研究及应用提供借鉴。

 关键词

颈脊髓损伤，气管切开，研究进展

 Research Progress of Early Tracheotomy in Patients with Cervical Spinal Cord Injury<sup> </sup>

Jiao Peng

Department of Nursing, Tongren Vocational and Technical College Affiliated Hospital, Tongren Guizhou

Received: Dec. 5th, 2023; accepted: Jan. 3rd, 2024; published: Jan. 10th, 2024

 ABSTRACT

Respiratory complications caused by cervical spinal cord injury were an important cause of aggravation and even death of patients. Early tracheotomy can effectively alleviate respiratory dysfunction or lower respiratory tract secretion retention caused by dyspnea. Reduce complications of tracheal intubation. This article reviewed the definition, epidemiology, advantages, influencing factors and prediction tools of early tracheotomy in patients with cervical spinal cord injury, in order to provide reference for future research and application of early tracheotomy in patients with cervical spinal cord injury.

Keywords:Cervical Spinal Cord Injury, Tracheotomy, Research Progress

Copyright © 2024 by author(s) and beplay安卓登录

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

http://creativecommons.org/licenses/by/4.0/

 1. 引言

脊髓损伤是一种严重的致残性疾病，常见原因为交通事故、坠落伤、暴力或运动伤 [ 1 ] 。世界卫生组织的数据显示，全球每年有25万到50万人遭受脊髓损伤 [ 2 ] ；以颈脊髓损伤(Cervical Spinal Cord Injury, CSCI)最常见，51%~55%的脊髓损伤发生在颈部 [ 3 ] 。CSCI具有发病率高、死亡率高、并发症发生率高、预后差等特点 [ 4 ] 。CSCI可导致多系统功能障碍，其中呼吸系统并发症的发生率为36%~83% [ 5 ] ，是CSCI患者死亡的首要原因 [ 6 ] ，其导致的早期死亡率为5.92%，致残率为50% [ 7 ] 。机械通气技术是治疗和抢救呼吸衰竭最有效的手段，CSCI患者因呼吸肌麻痹及肺有效容量下降，常需要持久机械通气 [ 8 ] 。但口、鼻气管插管常用于紧急处理或短期插管，当患者需要持久机械通气时需做气管切开 [ 9 ] 。因此，本文拟对CSCI患者早期气管切开的相关研究进行综述，以期为后续研究及应用提供借鉴。

 2. 早期气管切开概述

气管切开时机分为早期和晚期，早期气管切开定义为插管后7天内发生，晚期气管切开发生在插管后7天以上；如果患者最初拔管时间超过24小时，但后来需要重新插管，那么气管切开的时机由重新插管的日期决定；如果在24小时内再次插管，则使用初始插管日期 [ 10 ] 。据报道 [ 10 ] ，21%~77%的CSCI患者接受了气管切开术。损伤节段在C5以上完全性脊髓损伤患者气管切开率为81%~83% [ 11 ] 。高度、完全性损伤的患者，机械通气和气管切开术的需要可接近100% [ 12 ] 。

 3. 早期气管切开的优点

早期气管切开可以减少死腔通气和呼吸功，改善通气，减少气管插管并发症，增加患者通气耐受性，促进肺分泌物通畅 [ 9 ] [ 13 ] 。此外，研究证实 [ 14 ] ，患者留置经鼻、口气管插管时间越长，医院获得性肺炎的发生率越高。同时，经口气管插管不能保留较长时间，气管插管8天可导致83%的喉损伤率 [ 15 ] 。而早期气管切开术可以让气道的管理更为便捷，能及时有效清除气道分泌物；可有效缩短机械通气时间、ICU时间及总住院时间，并减少医疗费用及改善预后 [ 16 ] [ 17 ] [ 18 ] [ 19 ] 。机械通气时间的缩短，可以显著降低机械通气治疗过程中废用性萎缩的发生率 [ 20 ] 。此外，研究表明 [ 16 ] [ 21 ] ，在颈椎前路固定前或固定后行气管切开术与颈椎前路手术伤口感染的风险相关性较低。因此，早期气管切开术是安全且有效的。

 4. 影响因素 4.1. 个人因素

史莎等 [ 22 ] 研究表明，CSCI高发年龄为40~69岁，Kim等 [ 23 ] 研究表明40~49岁人群在脊髓损伤患者中所占比例最高。Mu等 [ 24 ] 研究发现，大于60岁的患者行气管切开的比例远高于40~60岁；Lee等 [ 25 ] 、崔怡等 [ 26 ] 发现，大于55岁的CSCI患者行气管切开的比例更高。王严等 [ 27 ] Meta分析发现，年龄、高龄与气管切开无关。另一方面，杜佩红 [ 28 ] 对468例CSCI患者进行研究，发现吸烟与患者行气管切开显著相关，刘瑞端等 [ 29 ] 、孙大卫等 [ 30 ] 、Long PP等 [ 31 ] 研究发现也支持这一结果，而王严等 [ 27 ] Meta分析结果显示，吸烟史与气管切开无关。同时，刘瑞端等 [ 29 ] 研究发现，既往合并呼吸系统疾病可能为CSCI患者气管切开的影响因素。

 4.2. 损伤相关因素

完全性CSCI患者，即ASIA A级(American Spinal Injury Association)行气管切开的概率极高 [ 18 ] 。Higashi等 [ 32 ] 研究发现，ASIA分级越高，行气管切开的概率越大。Wang等 [ 33 ] Meta分析发现，ASI A级和B级是气管切开的危险因素，而C级和D级与气管切开无相关性。Flanagan等 [ 10 ] 研究发现神经损伤平面在C4及以上是导致患者气管切开的危险因素。Jeong等 [ 34 ] 多因素分析结果显示，C5及以上椎体水平损伤是CSCI气管切开的相关因素。刘瑞端等 [ 29 ] 报道了C4及以上或完全性CSCI是其术中气管切开的危险因素，这与孙大卫等 [ 30 ] 研究结果一致。同时，孙大卫等 [ 30 ] 等报道了伴颈椎脱位是CSCI行气管切开的独立危险因素。此外，Lee等 [ 25 ] 研究发现，ISS评分 ≥ 16分可以有效预测气管切开。Long PP等 [ 31 ] 发现颈椎损伤严重程度评分(CSISS) ≥ 7、AIS A级和NLI ≥ C5是影响患者气管切开的危险因素。

 4.3. 其它因素

男性，GCS ≤ 8分是CSCI气管切开的危险因素 [ 33 ] ，同时，车祸伤、院外或急诊插管史是CSCI术后气管切开的重要因素 [ 25 ] [ 35 ] 。还有研究发现 [ 29 ] ，血气分析提示缺氧是CSCI术中气管切开的危险因素。此外，Jeong等 [ 34 ] 认为椎管最大侵占率 ≥ 50%和脊髓内信号改变长度 ≥ 20 mm为气管切开的影像学危险因素指标。

 5. CSCI患者气管切开的预测工具 5.1. 决策树模型

Hou等 [ 36 ] 建立了决策树模型，以ASIA运动评分、严重呼吸道并发症、完全性脊髓损伤和MRI高信号为危险因素；各终止节点的概率值为预测概率。模型的第一个节点是入院时的ASIA运动评分，第二个节点是患者的呼吸并发症和ASIA分级。最后，取术前MRI图像上显示信号变化的颈髓最高节段作为第三个节点。该模型ROC曲线下面积为0.909，敏感度73.7%，准确度89.7%。Lee等 [ 25 ] 以AIS A级为第1节点，以是否有急诊室插管为第2节点，除ASI A级和急诊室插管外，年龄 > 55、C5以上损伤、车祸或ISS评分 > 16分的患者行气管切开术的机会增加，该模型ROC曲线下面积为0.914。Sun DW等 [ 37 ] 以AIS A级和NLI > C5分别为第1和第2节点，兼顾考虑年龄 > 50岁，ISS > 16构建决策树模型，该模型敏感性为0.78，特异性为0.96。

 5.2. 临床评分模型

Scantling等 [ 38 ] 采用多元logistic回归分析方法开发了临床气管切开评分表。评价项目为分别为ISS ≥ 38、C1~C4运动损伤、完全性脊髓损伤或C1~C7脊髓前部损伤，各评分项目均为1分。当总分为0分、1分、2分、3分时行气管切开概率分别为33%、67%、85%、98%，该模型ROC曲线下面积为0.7356。

 5.3. 其他工具

杨铁柱等 [ 35 ] 通过对比ASIA运动和感觉评分、急性生理与慢性健康评分(APACHE II)、ISS、临床肺部感染评分对需行气管切开术的预测价值，结果发现，ASIA运动评分系统预测需气管切开AUC面积最大(0.995)，敏感性最高(0.988)，特异性较高(0.961)，其最佳临界值为13.00分。Long PP等 [ 31 ] 多元逻辑回归模型发现，吸烟史、CSISS ≥ 7、AIS A级和NLI ≥ C5是影响TCSCI患者气管切开的危险因素，其AUC面积为0.858。

 6. 小结

综上所述，CSCI患者早期气管切开具有重要意义，但截至目前，CSCI气管切开的影响因素仍存在争议。已开发的预测工具均可对CSCI患者气管切开病情观察与决策起到一定指导意义，但不能对患者病情进行连续监测和动态评估，不能及时地判断患者的病情变化情况，不具有可解释性。其次，由于国内外相关指标易获得性的差异，现有模型不能完全满足临床实际需要。因此，未来应开展更多大样本、多中心研究明确CSCI患者气管切开的影响因素，并构建易用性和普适性更高的评估预测工具。

 文章引用

彭 娇. 颈脊髓损伤患者早期气管切开的研究进展 Research Progress of Early Tracheotomy in Patients with Cervical Spinal Cord Injury[J]. 护理学, 2024, 13(01): 42-47. https://doi.org/10.12677/NS.2024.131007

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