T型支架的应用

nullTracheal Stenosis & T-tube usageTracheal Stenosis & T-tube usagePart I : Case ReportCase I : Brief HistoryCase I : Brief History57 y/o female H/T; CVA(91/3) s/p tracheotomy in 博仁H. Subglottic stenosis(2cm below glottic level)in 亞東H. by rigid bronchoscopy Laryngotracheoplasty and T-tube insertion on 92-3-27 Remove the T-tube on 92-10-02Case I : ProceduresCase I : ProceduresETGA (paralyzed by SCC, then pass a 5.0# ETT from the mouth through the T-tube) Stomaplasty: excision of the granulation tissue around the stoma Pull out the ETT and remove the T-tube, then inserted the ETT from the stoma into trachea Laryngotracheoplasty: excision of the subglottic granulation tissue by rigid bronchoscopy Remove the ETT when the P’t awakedCase II : Brief HistoryCase II : Brief History44 y/o male Pulmonary TB s/p left side pneumonectomy 23 yrs ago (with previous tracheotomy scar) Dyspnea on exertion from 5yrs ago, progressed recently. Bronchoscopy at OPD revealed severe subglottic tracheal stenosis 5cm below vocal cord, then confirmed by CT. 92/3/25 T-tube insertion (by ENT), then discharged on 3/28 92/10/06 T-tube exchange was planned (by Chest) Case II : ProceduresCase II : ProceduresETGA: Induction as usual, but failed to pass by the 7.0# ETT through the T-tube Desaturation!! Mask ventilation but hardly, then change to ventilate the p’t through the T-tube by a ETT connector→successfully ventilated. Exchange the T-tube to low-pressure tracheotomy Intubated again with 6.0# ETT ,passed through successfully after withdraw the low-pressure tube Excision of the granulation tissue around the stoma, and changed a larger T-tube beneath the vocal cord carefully.Tracheal Stenosis & T-tube usageTracheal Stenosis & T-tube usagePart II : Article ReviewTracheal stenosis after long-term endotracheal intubation or tracheostomyTracheal stenosis after long-term endotracheal intubation or tracheostomyIncidence: ~31% Site: Cuff level or stoma level Degree of stenosis: 11~25% in 18% patients, 26~50% in 22% patients, and >50% in 3.7% patients (Walz et al ); but only 3~20% were symptomatic (stenosis>30%) S/S: shortness of breath and either or both inspiratory stridor and expiratory wheeze on exertion ; unresponsive to bronchodilators Diagnosis: plain film, CT, or endoscopy(fiber/rigid) Tracheal stenosis after long-term endotracheal intubation or tracheostomyTracheal stenosis after long-term endotracheal intubation or tracheostomyDifferential diagnosis: Asthma, COPD Pneumonia, CHF… Treatments: Steroids regimens: help release inflammatory Rx Surgical Tx: the mainstay of treatment Rigid bronchoscopy and tracheal dilation with simple balloon or stent (temporary or permanent) Tracheal reconstructionnullFrom:   Norwood: Ann Surg, Volume 232(2).August 2000.233-241 nullMontgomery T-tube tracheal stent Montgomery T-tube tracheal stent 1964, Dr. William W. Montgomery first designed a protype by 2 rigid pieces (stent & tracheostomy) The improved version (1965) was a one-piece flexible silicone stent that possessed greater flexibility and caused minimal tissue reaction Montgomery T-tube tracheal stentMontgomery T-tube tracheal stentA silicone tube that serves as both a tracheal stent and a tracheotomy tube Proximal and distal end of the intraluminal limb; plug for occluding the extraluminal limb Size: OD from 6~16mm Numerous modified models of the T-tube have been produced Ad- & Dis-advantages; applicationsAd- & Dis-advantages; applicationsAdvantages: Preservation of normal respiration and phonation Minimal cough and tissue reaction to the silicone material Decrease the risk of migration owing to the anchored external limb well tolerated by patients (20yrs reported)Disadvantages: The need for a tracheotomy orifice Unpleasant cosmetic appearance of a protruding neck tube T-Y stent: with a long distal intraluminal limb ending in a Y-bifurcation that rests on the main carina and stents the main stem bronchi IndicationsIndicationsMalignant diz: a palliative measurement in malignant peri-tracheal dis. Benign diz: Tracheal stenosis caused by artificial airways Inflammations, relapsing polychondritis, tracheobronchomegaly, tracheomalacia, caustic or irradiation injury and TB infection of trachea… Other situations: A bridge to definitive reconstructive surgery A therapeutic intervention in the postoperative period A definitive treatment when p’t’s poor general condition Contra-indicationsContra-indicationsAnticipated need for prolonged mechanical ventilation in the near future In patients with documented aspiration Relative contra-indication in small inner diameter tubes due to easily obstructionInsertion & RemovementInsertion & RemovementComplicationsComplicationsComplications of T-tubes are rare, with no reported mortality directly related to the T-tube. emphysema following insertion migration requiring removal and reinsertion posterior displacement into the trachea causing acute airway obstruction buildup of dried luminal respiratory secretions airway infection Hemorrhage; formation of granulation tissue prolonged healing of tracheocutaneous fistula aspiration and voice weakening (when proximal end above the vocal cords to stent the subglottic area) Care of the T-tubeCare of the T-tubeThe T-tube should be plugged at all times to preserve phonation and allow normal humidification of air entering the respiratory tree. Clean with 2-3cc NS into lumen 2~3/day, 1/2 hydrogen peroxide for the extraluminal tube & suction in the first 1~2 postoperative weeks. A spare tracheostomy tube in a size selected to fit the tracheotomy orifice should always be within the patient's reach Anesthesia and the T-tubeAnesthesia and the T-tubeMontgomery : an Fogarty (arterial embolectomy catheter) and a ETT tubes from the extra-limb LMA (with the extra-limb plugged) Jet ventilation (with total IVG) from rigid bronchoscope through proximal intra-limb Modified tube (The Hebeler T-tube, contains an internal balloon located in the proximal portion of the intraluminal limb) 6.0mm ETT(#) can pass most T-tubes used in adults if all failed or emergency.Sizes of Endotracheal tubeSizes of Endotracheal tubenull