2012 DAS气管导管拔管指南部分翻译

微雨独行

Table 8 Management of post-obstructive pulmonary oedema.

1 Treat the cause: relieve the airway obstruction
2 Administer 100% O2 with full facial CPAP mask. In addition to relieving upper airway obstruction, CPAP may reduce oedema formation by increasing mean intrathoracic pressure and minimise alveolar collapse by increasing functional residual capacity, improving gas exchange and reducing the work of breathing
3 Nurse the patient sitting upright
4 If there is fulminant pulmonary oedema with critical hypoxaemia, tracheal intubation and mechanical ventilation with PEEP are necessary. Less severe hypoxia responds to supplemental oxygen and ? or non-invasive ventilation, or PAP
5 Intravenous opioids may help reduce subjective dyspnoea
6 Chest radiography may exclude other complications of difficult airway management and causes of hypoxia (gastric aspiration, pre-existing infection, pneumothorax, barotrauma, pulmonary collapse)
7 Frank haemoptysis may necessitate direct laryngoscopy and ? or flexible bronchoscopy
8 Diuretics are often administered, but their efficacy is unproven梗阻后肺水肿的处理
1.病因治疗：解除气道梗阻。

2.紧扣面罩，用纯氧持续气道正压通气。CPAP可以减轻上呼吸道梗阻，还可通过增加平均胸腔内压来减轻水肿形成。此外，CPAP可增加功能残气量，改善气体交换，减少呼吸做功，从而减少肺泡萎陷。
3.照顾病人坐直。
4.若急性肺水肿伴极度低氧血症，则需行气管插管，给与呼气末正压机械通气。轻微一点的低氧血症可以给与吸氧和/或无创通气或正压通气。
5.静脉给与阿片类药物或许可以帮助减轻患者的呼吸困难。
6.胸片可以帮助排除其他困难气道管理引起的并发症以及低氧的病因（胃内容物的误吸、术前存在的感染、气胸、气压伤、肺不张）

7.明显的咯血则需直喉镜和/或纤支镜检查。

8.通常会使用利尿剂，但其效果并未得到证实。
Table 1 Factors contributing to reduction in arterial oxygen saturation and depletion of oxygen stores at extubation.

Pathophysiological
Reduced functional residual capacity
Hypoventilation
Diffusion hypoxia
Atelectasis
Ventilation? perfusion mismatch
Problems related to airway reflexes
Shivering
Cardiovascular instability
Neurological dysfunction
Metabolic derangement
Electrolyte disturbances
Airway injury

Pharmacological
Neuromuscular blocking drugs
Opioids
Residual anaesthetic agents

Human & other
factors
Inadequate equipment
Inadequate skilled assistance
Patient position
Access to airway e.g. dressings? gastric
tubes ? rigid fixators
Interruption of oxygen supply during
patient transfer
Communication difficulties
(e.g. language, mental capacity)
Removal of oxygen by agitated or
uncooperative patient
表1 拔管时导致动脉氧饱和度降低和氧储备的减少的因素

病理生理学因素

功能残气量减少

通气不足

弥散障碍引起的缺氧

肺不张

通气/血流比值失调

气道反射相关问题

寒颤

心血管不稳定

神经功能障碍

代谢紊乱

电解质失调

气道损伤



药理学因素

肌松药

阿片类药物

残留的麻醉药物



人为及其他因素

设备不足

缺乏熟练的助手

病人体位

进入气道的途径，如敷料？胃管？僵硬的固定器？
转移病人时妨碍氧供

交流困难（如语言、心智能力、）

病人因烦躁或不合作不吸氧