气管切开临床操作

关于微量误吸TheTaperGuard™Story1.0TaperGuardStory目的Covidien|August8,2024forintERNALUSEONLy2|ClinicalEvidenceClinicalApplicationTaperGuardTGEVACEconomicImpactScientificPlatform一个基本问题：微量误吸在OR和ICU中是不是一个普遍存在，又带来严重并发症的问题？4|误吸及微量误吸在OR/ICU我们知道微量误吸的存在吗？误吸后有哪些并发症有没有文献来证明误吸的确实存在如何来减少在OR/ICU中的PPC/PIPC发生内容误吸和微量误吸的风险PIPC/PPC后果临床解决方法及相关文献TaperGuard原理介绍

Covidien|10June2010|6外因内因口/口咽

呼吸支持设备和附件的污染胃部细菌的过度生长口咽分泌物和胃部内容物受损的黏膜清除气管导管的生物聚结医务人员的传播以前的肺疾病“口咽腔和胃液的分泌物是主要的细菌进入肺内的主要通道，也是

误吸/微量误吸发生的重要原因。误吸/微量误吸-风险因素

Covidien|10June2010|7声门持续处于开放状态细菌通过分泌物作为载体迁移进入气管分泌物池位置高于气管套囊“口咽腔和胃液的分泌物是主要的细菌进入肺内的主要通道，也是误吸/微量误吸发生的重要原因。误吸/微量误吸-风险因素目前大家的习惯是怎么样的?

在一些医院的日常工作90％以上的国内医院手指触摸按压测试手持压力表

Covidien|10June2010|9常见的套囊压力问题5101525203530454050套囊压力cmH2O...?太低– Microaspiration微量分泌物套囊封闭关于泄漏实验Asai,2001:Cuffat40cmH20;10mlsfluidinmodeltrachea5分钟内液体渗漏:2.4-9.2mls(4不同的插管)类似的结果在内部和非印刷的外部研究

Covidien|10June2010|10CuffTube-ShaftTrachea套囊漏气

!YoungP,RollinsonM,DownwardG,

HendersonS

液体通过气管导管套囊流入气管内实验

BritishJournalofAnaesthesia

1997;78:557-562OikkonenM,AromaaU

液体渗漏在低压气管套囊的实验

Anaesthesia

1997;52:567-569目前PVC套囊材料:典型的套囊壁的折叠现象

(所有的高容量低压套囊)声门下分泌物通过流入气管的通道VAP的主要原因套囊漏气

!

August8,2024___________11|

August8,2024___________12|Micro-aspration

微量误吸为什么误吸和微量误吸会发生？AirSeal.FluidSeal.Covidien|08August2024|ConfidentialForInternalUseOnlyCovidienRespiratory&MonitoringSolutions|08August2024|Confidential15|皱褶和通道导致了误吸/微量的发生1.Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.CTimageofaninflatedETTcuffinatracheamodel1LEFT:FullcrosssectionofintubatedmodeltracheaRIGHT:Enlargementofregiondemonstratingacufffoldandchannel微量误吸和呼吸机相关性肺炎的关系1-51.Mahuletal.IntensiveCareMed.1992;18(1):20-25. 5.Methenyetal.CritCareMed.2006;34(4):1007-1015.2.Estesetal.IntensiveCareMed.1995;21(4):365-383. 6.Kollefetal.Chest.1999;116(5):1339-1346.3.Safdaretal.RespirCare.2005;50(6):725-739. 7.Hussainetal.AnaesthIntensiveCare2003;21:272-6.4.Chastreetal.AmJRespirCritCareMed.2002;165(7):867-903.细菌，分泌物(e.g.HCl,bile)在插管套囊周围的微量误吸聚集,肺损伤,&VAPCovidien|08August2024|ConfidentialForInternalUseOnlyCovidienRespiratory&MonitoringSolutions|08August2024|Confidential18|CovidienRespiratory&MonitoringSolutions|08August2024|Confidential19|CovidienRespiratory&MonitoringSolutions|08August2024|Confidential20|在使用高容量低压气管导管，微量误吸是普遍的现象“Extensivefoldingofcuffmaterial”containingsecretionsisseenatallcuffpressures(25–100cmH2O).Seegobinetal.BrMedJ.1984;288:965-968.“…high-volume,low-pressure(HVLP)cuffswereintroduced....thesehavefailedtodemonstrateeffectivepreventionofleakageinvitroandinvivo.”Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.Microaspirationfoundin100percentofgeneralendotrachealanesthetics.Seegobinetal.CanAnaesthSocJ.1986;33:273-279.CovidienRespiratory&MonitoringSolutions|08August2024|Confidential21|微量误吸在ICU也是普遍被发现的现象，并且并发VAP的发生Methenyelalfoundevidenceofmicroaspirationin88.9%ofICUpatientsevenwithheadofbedelevationandoralcareinplace.Only1%ofthesemicroaspirationeventswereobserved,themajoritywere“silent”microaspirationevents.Investigatorfoundthatmicroaspirationwasonofthemostimportantindependentriskfactorsforpulmonarycomplications.(p<0.0001)微量误吸导致VAP如同冰山一角Post-intubationpulmonarycomplications插管后肺部并发症:肺部并发症可以看成是插管后所导致的并发症VAPPostoperativePneumoniaPostoperativePulmonaryComplicationRespiratoryfailure,

COPDexacerbations,etc.Covidien|August8,2024forintERNALUSEONLyTheproblemwiththeproblemSurgicalsiteReportedcomplicationrateStudies,nAAArepair25.5%16Esophagectomy18.9%11Abdominalsurgery14.2%43Headandnecksurgery10.3%6Hipsurgery5.1%5Gynecologic/urologicprocedures1.8%2Smetanaetal.AnnInternMed.2006;144(8):581-595.Covidien|August8,2024forintERNALUSEONLy

Covidien|08August2024|Confidential29|柯惠解决方案

Covidien|10June2010|30

Covidien|10June2010|31误吸/微量误吸

防治外因内因CovidienRespiratory&MonitoringSolutions|08August2024|Confidential33|TheTaperGuard套囊技术渐进封闭锥形套囊技术

CovidienRespiratory&MonitoringSolutions|08August2024|Confidential34|TaperGuard平台TaperGuardendotrachealtubeAMallinckrodtendotrachealtubewiththeTaperGuardcufftechnology.TaperGuardEvacendotrachealtube:AMallinckrodtendotrachealtubewithboththeTaperGuardcufftechnologyandEvacsuctionlumen.TaperGuardEvacallowsfortheactiveremovalofsecretionsfromabovethecuffforpatient’swithahigherriskofaspiration.TheEvaclumenmaybehookeduptowallsuctioneithercontinuousloworintermittenthigh,orasyringemaybeusedperiodicallytoremovesecretionsfromabovethecuff.TheTaperGuard提供两种配置CovidienRespiratory&MonitoringSolutions|08August2024|Confidential35|独特的锥形套囊能够在一定位置匹配气管直径大小.在这点最小化皱褶和通道的存在确保封闭区达到不同插管形状的形状，尺寸大小CovidienRespiratory&MonitoringSolutions|08August2024|Confidential36|如何工作？套囊近端:Cuffdiameter>Trachealdiameter

封闭带:Cuffdiameter=TrachealdiametereliminatingexcesscuffmateriallocallyMallinckrodt™TaperGuard™ETTCovidienRespiratory&MonitoringSolutions|08August2024|Confidential37|关键信息新的TaperGuard™气插导管有着独特的锥形套囊设计。这项技术相比高容量低压力套囊的桶状设计更能有效提高气道的封闭性能。TaperGuard套囊是将其套囊近端的直径设计成大于正常成人气管的直径。TaperGuard套囊的直径从近端到远端（靠近肺部）逐渐减小，套囊的外形类似于锥体。独特的锥形设计可以使套囊的直径从近端至远端都契合气管的直径。CCI现场动物实验演示在Airwaysworkshop1hrafterTaperguardintubation2hrsCovidienRespiratory&MonitoringSolutions|08August2024|Confidential40|CovidienRespiratory&MonitoringSolutions|08August2024|Confidential41|FDA510批准CovidienRespiratory&MonitoringSolutions|08August2024|Confidential43|MallinckrodtEvacsignificantlyreducesearlyandlateVAPStatisticallysignificantforearly-onsetandlate-onsetVAP.NosignificantdifferencesindurationofMVorICUmortality.Covidien|August8,2024forintERNALUSEONLyMallinckrodtEvac(HLE)BasicETT(HL)P-valuePatients169164–VAPrate14.8%25.6%0.02Lacheradeetal.AJRCCM2010SubglotticsecretiondrainagewithintegratedsuctionlineSubglotticspaceCovidienRespiratory&MonitoringSolutions|08