气道管理新进展.pptx

COVIDIEN,COVIDIEN with Logo and marked brands are trademark of Covidien AG or an affiliate.2008 Covidien.All Rights Reserved.*Proportional Assist and PAV are trademarks of the University of Manitoba,Canada.Used under license by Nellcor Puritan Bennett LLC.Sealing Out DoubtAdvances in Airway Management气道管理新进展 DisclosureMark Procyshyn,RRT is the Senior Regional Marketing Manager for Covidiens Respiratory Division in Asia.What are postoperative pulmonary complications?何为术后肺部并发症What is their significance in terms of:Incidence?发生率？Clinical outcomes?临床结果？Outline:Postoperative Pulmonary Complications术后肺部并发症These complications range from minor,self-limited conditions to major disease states with significant morbidity and mortality.这些并发症小至自限性疾病，大至具有较高发病率和死亡率的疾病。The most commonly cited examples in the clinical literature are:1 在医学文献中最常见引用的并发症是：Pneumonia 肺炎Respiratory failure 呼吸衰竭Atelectasis 肺不张Acute exacerbation of chronic lung disease 慢性肺部疾病的急性加重Other prominent examples include ARDS,bronchospasm,tracheobronchitis and perioperative hypoxia.其他突出的并发症包括：ARDS，支气管痉挛，支气管炎，术中低氧血症1.Arozullah et al.Ann Surg.2000;232(2):242-253.What are postoperative pulmonary complications?何为术后肺部并发症What is their significance in terms of:Incidence?发生率？Clinical outcomes?Outline:Postoperative Pulmonary Complications Are Surprisingly Common术后肺部并发症十分常见Surgical siteReported complication rateStudies,nAAA repair 腹主动脉瘤切除术25.5%16Esophagectomy 食道切除术18.9%11Abdominal surgery 腹部手术14.2%43Head and neck surgery 头颈部手术10.3%6Hip surgery 髋部手术5.1%5Gynecologic/Urologic procedures 妇科/泌尿科操作1.8%21.Smetana et al.Ann Intern Med.2006;144:581-95.Summary of studies investigating incidence of postoperative pulmonary complications by surgical site,as per systematic literature review in 20061 2006年不同部位外科手年不同部位外科手术后术后肺部并发症发生率研究的概要后术后肺部并发症发生率研究的概要Multiple studies show the high incidence of postoperative pulmonary complications.多项研究先提示术后肺部并发症的发生率较高。Postoperative Pulmonary Complications Deserve Equal Attention with Perioperative Cardiac Complications术后肺部并发症应与术中心脏并发症一样引起重视Retrospective multicenter cohort study of 8,930 patients 60 years or older for hip surgery1针对8930例例60岁以上以上髋部手部手术患者的多中心回患者的多中心回顾性性队列研究，列研究，1.Lawrence et al.Arch Intern Med.2002.ComplicationIncidence30-day mortality1-year mortalitySerious cardiac*严重的心血管疾病2.0%22%36%Serious pulmonary严重的肺部疾病2.6%17%44%p-value:-0.05 0.05*Definite or probable MI,emergency cardioversion,pacemaker insertion,ventricular fibrillation,ventricular tachycardia,hypotension requiring vasopressors,sick sinus syndrome or other conduction defect,or CPR.Respiratory failure or pneumonia.No statistical difference found for incidence or mortality at 30 days and 1 year.30天或1年的发病率或死亡率无显著性差异。In Aggregate,Postoperative Pulmonary Complications Occur More Often Than Cardiac总体上，术后肺部并发症多于心脏并发症Case control from 2,291 patients undergoing elective abdominal surgery,excluding atelectasis12291例例进行行择期腹部手期腹部手术患者的病例患者的病例对照研究，除外肺不照研究，除外肺不张ComplicationEstimated incidence(95%CI)LOS(SD),p=0.001Pulmonary肺部9.6%(7.2-12.0)22.5(17)daysCardiac心脏5.7%(3.8-7.7)10.4(4.5)days1.Lawrence et al.J Gen Intern Med.1995;10:671-678.Total pulmonary complications occurred nearly twice as often and resulted in hospital lengths of stay over twice as long.总的肺部并发症发生率高一倍，住院天数延长一倍多Pneumonia,in Particular,Is Very Common in Surgical Patients肺炎，外科患者尤为常见Most common post-surgical complication in noncardiac surgical patients1 非心脏手术患者最常见术后并发症Most common complication in trauma patients2、外伤患者最常见术后并发症1.Khan et al.J Gen Intern Med.2006;21:177-180.2.Hemmila et al.Surgery.2008;144:307-316.What are postoperative pulmonary complications?术后并发症What is their significance in terms of:Incidence?Clinical outcomes?临床结果？Outline:Postoperative Pneumonia Confers Significant Mortality术后肺炎导致死亡率增加A prospective study in 155,266 surgical patients demonstrated 30-day mortality rate to be 21 percent in patients with postoperative pneumonia vs.only 2 percent without(p 0.001).1 一项155,266例外科患者的前瞻性研究证明，术后肺炎患者的30天死亡率为21%，而无术后肺炎患者的死亡率仅为2%(p 70 years of age with postoperative pneumonia who survived their primary admission had a twofold increased risk of death at three years.2 大于70岁合并术后肺炎的患者出院后三年的死亡率增加一倍。1.Arozullah et al.Ann of Intern Med.2001;135:847-857.2.Manku et al.Anesth Analg.2003;96:590-594.Postoperative Pneumonia Is Associated with a Tenfold Increase in Mortality After Abdominal Surgery术后肺炎导致腹部手术患者死亡率增加十倍OutcomePatients with HAPPatients without HAPOdds ratio95%CIMortality,n1,421(10.7%)7,217(1.2%)9.91(9.34-10.52Impact of hosp-acquired pneumonia(HAP)during original admission after abdominal surgery,n=618,495 patients1腹部手腹部手术术后医院后医院获得性肺炎的影响得性肺炎的影响1.Thompson et al.Ann Surg.2006;243:547-552.Summary总结:Readmission of surgical patients with pneumonia is a significant source of increased healthcare costs.外科患者因肺炎再入院治疗显著增加了医疗费用。Postoperative pulmonary complications are common,expensive and associated with increased mortality.术后肺部并发症是常见的，昂贵的，增加了死亡率。The Role of Microaspiration in Downstream Complications隐性误吸对后续并发症的影响Microaspiration 隐性误吸:Microaspiration refers to the migration of foreign,supraglottic material past the airway device(e.g.ETT cuff)into the respiratory tract.隐性误吸是指外源性的声门上物质通过导气管装置（如气管插管套囊）进入呼吸道。Pictured:inadvertent microaspiration of contrast media after a barium swallow examination in an intubated patient图示：一个气管插管患者进行吞钡实验后不慎误吸造影剂Reproduced from Macrae et al.Br Med J.1981(Clin Res Ed);283:1220 with permission from BMJ Publishing Group Ltd.Cuff Redesign in the 1970s重新设计气管套囊Traditional“red rubber”ETTs required high pressures(60 cm H2O)to achieve a seal,and were frequently associated with severe tracheal injury.1,2 传统气管插管需要高压套囊，且常导致严重气道损伤The new ETTs with high-volume,low-pressure(HVLP)cuffs were introduced in the early 1970s to specifically address this issue,achieving clinical seals at safer pressures(48hrs.患者插管大于48小时Compared standard ETT vs.Mallinckrodt Evac.常规气管套管 vs.Mallinckrodt Evac（声门下分泌物引流）Common vent bundle precautions in place.HOB 抬高床头Oral care 口腔护理 Covidien Respiratory&Monitoring Solutions|April 17,2023|Confidential36|Bouza et al3943%reduction in VAP 呼吸机相关性肺炎发生率降低43%ICU LOS by 9.5 days ICU 住院天数缩短9.5天MV by 4 days 机械通气时间缩短4天 Reduction in antibiotics by 30%抗生素应用减少30%Reduction in AB acquisition costs$30,000(ITT)Cost of EVAC$4,300(ITT)New Clinical Evidence For Evac 关于Evac新的临床证据 Covidien Respiratory&Monitoring Solutions|April 17,2023|Confidential37|SSD clinically proven to:Reduce VAP 75%呼吸机相关性肺炎发生率降低75%Reduce ICU length of stay by 9.5 days ICU住院天数缩短9.5天Shorten the duration of mechanical ventilation by 4 days 机械通气时间减缩短4天Delay the onset of VAP by 6.8 days VAP发生延迟6.8天Reduce the use of Antibiotics 抗生素应用减少30%SSD is a globally recognized intervention,recommended by the CDC,ATS,AACN,SHEA,IDSA and the AHRQ.声门下分泌物引流被全球认可。声门下分泌物引流被全球认可。Clinical Evidence Summary 临床证据总结 VAP reduction and Improved patient outcomes.VAP发生率降低，改善患者预后 Covidien Respiratory&Monitoring Solutions|April 17,2023|Confidential38|Economic Impact 经济影响Current studies equate the cost of VAP 目前相关的研究经费与VAP的治疗费用相当$40,000-$60,000Mallinckrodt Evac associated with a 75%VAP reduction.Mallinckrodt Evac降低VAP发生率75%Reducing even one VAP may result in significant savings.减少一个VAP患者也能带来显著的节约 Subglottic Secretion Drainage Using Mallinckrodt Evac Technology Improves Outcomes 应用Mallinckrodt Evac 进行声门下分泌物引流能够改善预后Clinical outcome in patients receiving MV for 48 hThe addition of subglottic secretion drainageimproved multiple outcomes.Bouza et al.Chest.2008;134:938-946.Covidien Respiratory&Monitoring Solutions|April 17,2023|ConfidentialFormerly Tyco Healthcare40|Bouza et alReduce ICU length of stay by 9.5 days减少减少ICU住院天数住院天数Reduce the use of antibiotics by 30%减少抗生素应用减少抗生素应用Shorten duration of mechanical ventilation by 4 days缩短机械通气时间缩短机械通气时间Improved Outcome改善预后Cost 花费ICU day$2-3KCost savings in Bouza et al$30KMV day$1,5009.5 X 2,000=$19,000Cost savings=$30,0004 X 1,500=$6,000Potential cost savings潜在的费用的节省Total potential cost savings=$55,000 Covidien Respiratory&Monitoring Solutions|April 17,2023|Confidential41|Effective Implementation is Simple有效实施是简单的Use the tube for all Non-Elective(non-OR)intubations.在所有非选择性插管患者使用该套管Stock ICU and Floor crash carts 在ICU、救护车上常备Stock ED 在急症室常备Use selectively in OR Typically 10%of overall ETT usage.Microaspiration May Begin as Soon as 5 Minutes After Cuff Inflation 隐性误吸可能在气囊充气后五分钟内发生Results and image from internal testing.Covidien Respiratory&Monitoring Solutions|April 17,2023|Confidential43|Reduces microaspiration by at least 90%减少至少90%的隐性误吸Compared to the Mallinckrodt Hi-Lo cuff.Provides a better fluid seal 更好地密闭Combined with latest generation Mallinckrodt Evac technologyThe NEW TaperGuard Evac cuff technology 新的新的TaperGuard Evac 套囊技术套囊技术Better Performing Endotracheal Tube Cuffs May Reduce Risk 更好的气管内导管套囊可以减少风险Hi-LoTM CuffTaperGuardTM CuffThis is the new TaperGuardTM cuff compared to the Hi-LoTM cuff.Oikkonen et al referred to the Hi-LoTM cuff as the best sealing of the nine tubes he tested in his study.1The TaperGuardTM cuff has been shown to reduce microaspiration by an average of 90 percent compared to the Hi-LoTM cuff.2 Internal benchtop comparison1.Oikkonen et al.Anaesthesia.1997;52:567-569.2.FDA 510(k)cleared claim.TaperGuard Evac Tube Has an 80 Percent Improvement in Microaspiration Reduction Under Suction vs.Hi-Lo Evac Tube与Hi-Lo Evac气管套管比较，TaperGuard Evac气管套管能够减少80%的隐性误吸Internal testing of Hi-Lo and TaperGuard cuff tested(90 units each)in benchtop setting.Suction rates were equal between the two test arms.Use of TaperGuard Evac tube resulted in less microaspiration compared to the Hi-Lo Evac tube.1.Internal testing,2009.Taper-shaped Cuffs Air Seal Compared to Cylindrical-shaped Cuffs梯形套囊空气密闭与圆柱形套囊的比较1.Madjdpour et al.European Journal of Anaesthesiology.2009;26(Supplement 45):19AP7-10.Intubated lung model,ventilated at 20 and 25 cmH2O peak inspiratory pressure(PIP),anesthetized with 1%sevorane.Leak measured above endotracheal cuff.1Taper-shaped cuff was found to reduce leak.梯形套囊减少渗漏Opinions Vary Regarding Cuff Sealing Performance对于套囊密闭性能的不同意见Though microaspiration is well recognized in the ICU,it is usually not believed to exist outside the ICU.隐性误吸也存在于ICU之外“Youre going off the assumption that microaspiration is bad.No ones proven that microaspiration is bad.”Anesthesiologist,Boston“In the literature you read a lot more about the aspiration problems than you actually see in practice.”CRNA,Houston“I dont think we all worry about whether people are aspirating around the tube every time we give a general anesthetic.”Anesthesiologist,Boston Internal Market Research,2009.“It is negligiblenot the microaspirations,but the risk for the patient.”Anesthesiologist,MunichStudies Examining Secretions Above the Cuff Suggest Surprising Volumes May Accumulate套囊上的分泌物的实验研究证实了分泌物的蓄积十分惊人Volumes up to 150 ml were removed per day via intermittent aspiration of subglottic secretions.1 每天有至多有150ml的分泌物从声门下吸引出来Intraoperatively,secretion drainage from the nose and mouth at over 50 ml/hour has been observed in prone patients.2 术中，分泌物从鼻腔和口腔引流，俯卧位患者每小时有50ml分泌物引流出1.Mahul et al.Intensive Care Med.1992;18:20-25.2.Young et al.Br J Anaesth.1997;78:557-562.Covidien Respiratory&Monitoring Solutions|April 17,2023|Confidential49|Economic Impact Summary 经济影响总结Aspiration related pulmonary complications are costly 误吸相关的肺炎并发症的治疗费用巨大Taper-Shaped cuff reduces aspiration 90%.梯形套囊能够减少90%误吸SSD improves patient outcomes.声门下分泌物引流改善患者预后Reduces ICU LOS 减少ICU住院天数Reduces MV 减少机械通气时间May reduce antibiotic usage 减少抗生素的应用A small conversion of basic ETTs,is all that is needed to implement.基本气管插管的小小改变需要广泛实施 Covidien Respiratory&Monitoring Solutions|April 17,2023|Confidential50|Conclusion 结论Minimizing Aspiration is the Key to reducing costly pulmonary complications associated with intubation.避免误吸是减少费用巨大的插管相关肺部并发症的关键SSD and new taper-shaped cuff technology is proven to reduce aspiration in the SGS where current protocols are insufficient SSD和新的梯形套囊技术已被证实能够减少误吸Clinical Evidence proves that SSD with Mallinckrodt Evac reduces VAP,and improves patient outcomes.临床依据证实采用Mallinckrodt Evac 的SSD减少VAP，改善患者预后The Economic Impact of not addressing current holes in practice,is exponentially more costly than the investment in the new technology.无视目前实际操作中的不足可能比研发新技术带来更大的经济消耗