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Evidence-based guidelines for the use of tracheostomy in critically ill patients Journal of Critical Care 38 (2017) 304–318 Journal of Critical Care 38 (2017) 304–318 気管切開ガイドライン 慈恵ICU勉強会 2017/6/20 関口真利江

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Page 1: Evidence-based guidelines for the use of …Evidence-based guidelines for the use of tracheostomy in critically ill patients Journal of Critical Care 38 (2017) 304–318 Journal of

Evidence-basedguidelinesfortheuseoftracheostomyincriticallyill

patientsJournalofCriticalCare38(2017)304–318

JournalofCriticalCare38(2017)304–318

気管切開ガイドライン慈恵ICU勉強会

2017/6/20関口真利江

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1.Introduction

• 気管切開はICUで広く行われている手技である

• 外科的気管切開(ST)は広く行われてきたが、経皮的気管切開(PT)に関するエビデンスは限られている

Laryngoscope 2008;118:1597–606.

DanMedJ2015;61:3.

AustralianNewZealandintensiveCareSociety.Percutaneousdilatationaltracheos- tomy consensusstatement.[cited201522October].

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2.ガイドライン概要・FEPIMCTI(FederationofSocietiesofCriticalandIntensiveTherapyMedicine)とLACCTIN(theLatinAmericanCriticalCareTrialInvestigatorsNetwork)が作成・29人のteammembers・23のkeyquestion(PICO)をもとに2015年7月までの文献をレビュー

・GRADEapproachによるRecommendation作成・4年ごとにガイドラインを見直す方針

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Literaturegradingandrecommendations

・文献の評価やガイドラインの推奨は

TheGradingofRecommendationsAssessment,DevelopmentandEvaluationsystemに基づく

・エビデンス:gradeA〜D・推奨:grade1,2

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気管切開の選択-相対的禁忌

・凝固異常

・首が短い

・肥満

・甲状腺肥大

・頚部軟部組織感染

・頚部進展困難

・術野の拍動性血管

・局部の悪性初見

・頚部手術や気管切開の既往

・頚部の放射線治療歴

・呼吸器補助が高度に必要

(酸素>70%、呼気陽圧>10cmH2O)

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頚部解剖

解剖学的注意点Jacksonの安全三角内の気管切開時に問題となる血管:・前頸静脈・上・下甲状腺動脈・最下甲状腺動脈・上・中・下甲状腺静脈

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頚部解剖

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3. Tracheostomyvs.prolongedendotrachealintubation

• 3.1.挿管継続より気管切開した方が、喉頭や気管の合併症が減少したり、死亡率が低下するか?

• 挿管継続より早期に気管切開した方が、喉頭や気管の合併症を防いだり、死亡率を低下させたりするという十分なエビデンスはない

• Recommendation:Thereisinsufficientevidencetomakearecommendation.

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・合併症や死亡率のエビデンスがないにも関わらず、

MVの患者の24%が気管切開を経験

・予想される挿管期間で推奨

10日以内:挿管継続21日以上:気管切開

ただし、エビデンスなく、熟練者の意見のみ

・挿管継続と気管切開を比べた研究あるが、

相反する結果である

AmJRespir Crit CareMed2000;161:1450–8.

Chest1989;96:178–80.

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・Objective:挿管継続と早期気管切開を比較・Design :Prospectiverandomizedstudy・Setting :Medicalintensivecareunits・Patients :62patientswithheadinjury

挿管継続群:31人挿管5日目で気切群:31人

・Methods:MV期間、ICU滞在日数、肺炎、死亡率を比較

JTrau- ma2004;57:251–4.

Earlytracheostomyversus,prolongedendotrachealintubationinsevereheadinjury

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Results

・気管切開群の方が、MV日数が有意に少ない(14.5vs.17.5days,P=0.02)

・気管切開群の方が、肺炎診断後のMV日数も有意に少ない

・肺炎や死亡率に有意差認めず

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・Objective:挿管継続 vs.早期気切(挿管4日目)・Design :Prospectiverandomizedstudy・Setting:Medicalintensivecareunits・Patients:18歳以上の123patients

PT、ST群、挿管継続群・primaryendpoint:28日目での死亡率・Methods:MV期間、肺炎、死亡率を比較

RevMalRespir2003;20:411–20.

Astudyofearlytracheostomyinpatientsundergoingprolongedmechanicalventilation

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Results

・Primaryendpoint:28日目での死亡率は2群で差なし

・MV期間、喉頭気管合併症、肺炎に関しても差なし

・Samplesize:468人必要だったが、足りないため研究終了となった

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4.Surgicalvs PT

→STとPTは合併症や死亡率に関して同等であるが、気切孔の感染症に関してはSTの方が高い

Recommendation:感染症を減らすのにPT推奨(Grade1B)

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最新のPTとST比較のmeta-analysis• Objective:PTとSTどちらが/PTではどの方法が優れているか?

• Design:meta-analysis• Setting:RCT(1996-2013)• Patients/Methods:

PTとST :合併症を比較した14のRCT(成人患者973人)PT各手法:合併症を比較した8のRCT(成人患者700人)

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Meta-analysis• CochraneCollaborationReviewManager• 2変数、95%信頼区間• 統計学的異質性、 CochraneQtest、I2 testで評価

• Two-sidedZtest P<0.05で有意な異質性を示すと考えた

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Results

a)術後出血b)難易度c)気切孔の炎症d)感染

でPTとSTを評価

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Resultsa)術後出血:PT <ST

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Resultsb)難易度:PT >ST

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Resultsc)気切孔炎症:PT <ST

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Resultsd)気切孔感染:PT <ST

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Results

PTvs STどちらが好ましいか?• 気切孔の炎症、感染:PT<ST• 術後出血:PT<ST(経喉頭気管切開のRCT1つを除く)

(Fantoni術を除くと有意差なし)

• 処置の速さ、難易度:PT>ST

→PTの方が好ましい

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PTの手法・MDT:Multipledilatortracheostomy・GWDF:guidewiredilatingforceps・TLT:translaryngeal tracheostomy・SSDT:singlestepdilatortracheostomy・RDT:rotationaldilationtracheostomy・BDT:balloondilationtracheostomy

新式

旧式

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PTの手法の中ではどれが好ましいか?MDT,SSDT<GWDFカニューラ挿入困難の割合

術中出血

→術中リスクの点において、PTの中ではMDTとSSDTが好ましい

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5.Earlyvs.latetracheostomy

→気管切開は晩期より早期の方が短期間の死亡率が低い

しかし、長期間の死亡率は差なし

Recommendation:長期間の死亡率低下目的に早期気管切開は推奨しない(Grade1B)

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Earlyvs.latetracheostomy(meta-analysis)

→死亡率に関して、Early/latetracheostomyで相違があるという十分なエビデンスなし

Earlyversuslatetracheostomyforcriticallyillpatients

CochraneDatabaseSyst Rev2015;1:CD007271.

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Aprospective,randomized,studycomparingearlypercutaneous dilational tracheotomytoprolonged

translaryngeal intubation(delayedtracheotomy)incriticallyillmedicalpatients*

・Objective:挿管継続 vs.早期気切(挿管48h以内)・Design :Prospectiverandomizedstudy・Setting:Medicalintensivecareunits・Patients:14日以上MV必要な120人・Methods:ICU滞在日数、MV期間、肺炎などの

合併症、死亡率、自己抜管を比較

Crit CareMed2004;32:1689–94.

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Results

・早期気切群の方が、死亡率、肺炎、自己抜管

が少なかった

・早期気切群の方が、ICU滞在日数、MV期間が少なかった

・挿管継続群の方が、口腔、喉頭への損傷が

大きかった

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・Objective:挿管継続 vs.早期気切(挿管3日以内)・Design :Prospectiverandomizedstudy・Setting:neurological/neurosurgicalICUsof

auniversityhospital・Patients:14日以上MV必要なsevereischemicor

hemorrhagicstrokeの患者60人・primaryoutcome:ICU滞在日数・secondaryoutcomes:diverseaspectsoftheICUcourse

Stroke-RelatedEarlyTracheostomyVersusProlongedOrotracheal IntubationinNeurocritical CareTrial(SETPOINT)ARandomizedPilotTrial

Stroke2013;44:21–8.

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Results

・Primaryoutcome(ICU滞在日数)に違いなし

・早期気切群の方が、セデーション必要量、

ICU死亡率、6ヶ月死亡率が低かった

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→気管切開の早期と晩期で肺炎リスクを減少させる十分なエビデンスがない

Recommendation:肺炎リスク低下目的に早期気管切開は推奨しない(Grade1B)

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→気管切開の早期と晩期でICU滞在時間を減少させる十分なエビデンスがない

Recommendation:ICU滞在時間減少目的に早期気管切開は推奨しない(Grade1B)

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早期気管切開はMV期間を減少させる

Recommendation:早期気管切開はMV期間を減少させるのに推奨される(Grade1B)

MV:mechanicalventilation

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Aprospective,randomized,studycomparingearlypercutaneousdilational tracheotomyto

prolongedtranslaryngeal intubationincriticallyillmedicalpatients*

・Objective:MV患者における早期PTと晩期PTの効果を比較する

・Design :Prospectiverandomizedstudy・Setting:Medicalintensivecareunits・Patients:14日以上呼吸器が必要な患者120人・Methods :早期群(48時間)と晩期群(14-16日)で、

ICU滞在期間、MV期間、肺炎、死亡率、自己抜管、口唇や喉頭の損傷を調べた

CCM:August2004- Volume32- Issue8- pp1689-1694

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Results

死亡率、肺炎、自己抜管、ICU滞在期間、MV期間口唇、喉頭の損傷

→上記いずれも 早期群 <晩期群

MV期間:早期群で9.8日減少(-入院60日)

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現存のエビデンスでは喉頭気管合併症を防ぐのに晩期より早期気管切開を推奨しない

Recommendation:喉頭気管合併症を防ぐ目的に早期気管切開を推奨しない(Grade1B)

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6.Percutaneoustracheostomymethods

生存率や合併症の点で優れたPTの方法があるか?

Recommendation:推奨するPTの方法はない(Grade1B)術者の経験や臨床的見地、実地の研修などを元にPTの方法を決める(Grade2D)

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• DilationPTwithmultipledilators:Ciagliatechnique

• DilationPTwithforceps:Griggstechnique• DilationPTwithasingledilator:CiagliaBlueRhino• RotationalPTorFrova technique:PercuTwist• Translaryngeal PT(TLT):Fantoni technique• DilationPTwithaballoon:CiagliaBlueDolphin

PTの手法

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modifiedCiaglia法(single-stepdilationtechnique)・1990年、太さの異なる複数のダイレーターを用いて気管孔を拡張するCiaglia法が商品化・1999年、その改良版として1本のダイレーターで気管孔を拡張するキットが商品化され、現在最も普及している経皮的気管切開法

Griggs法(guidewiredilatingforcepstechnique)・1990年、Griggsらにより報告され方法で、ガイドワイヤーの通る特殊鉗子で創部を拡張する方法。

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dilator:CiagliaBlueRhino

Ciagliatechnique

Griggstechnique

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CiagliaBlueDolphinPercuTwist

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6.1.1.CiagliatechniquevstheGriggstechnique

Percutaneoustracheostomyincriticallyillpatients:aprospective,randomizedcomparisonoftwotechniques.

Crit CareMed2000;28:3734–9.

・対象:100人 ランダム割付けCiagliatechnique:50人Griggstechnique:50人

・手技所要時間に差なし・難易度:1(容易)〜4

:Griggs>Ciaglia(1.8vs.1.3,respectively,P=.013)・術後2-24h合併症Griggs>Ciaglia

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Comparativeclinicaltrialofprogressivedilatationalandforcepsdilatationaltracheostomy.

IntensiveCareMed2001;27:292–5.

・対象:127人 ランダム割付け

Ciagliatechnique:63人Griggstechnique:64人

・手技所要時間に差なし

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Prospectiverandomizedcomparisonofprogressivedilationalvs.forcepsdilationalpercutaneoustracheostomy.

Anaesth IntensiveCare2006;34:51–4.

・対象:100人 ランダム割付けCiagliatechnique:48人Griggstechnique:52人

・所要時間Griggs<Ciaglia(4vs.7minutes,P=.0005)

・合併症 Griggs<Ciaglia(P =0.01and P =0.08respectively)

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6.1.2.CiagliatechniquevsCiagliaBlueRhino

・Objective:CiagliatechniquevsCiagliaBlueRhino・Design :Prospectiverandomizedstudy・Setting:5months/3ICUsofthehospital(36bedsintotalequippedwithventilator)・Patients:成人患者50人 Ciagliatechnique:25人

CiagliaBlueRhino:25人・Methods:手技時間、手技中の低酸素化、合併症を比較

Anesth Analg 2000;91:882–6.

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患者背景

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Results

・所要時間:CiagliaBlueRhino<Ciaglia

・合併症:差なし

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6.1.3.CiagliaBlueRhinovsPercuTwist

Single-dilatorpercutaneoustracheostomy:acomparisonofPercuTwist andCiagliaBlueRhinotechniques IntensiveCareMed2002;28:1262–6.

・Objective:CiagliaBlueRhinovsPercuTwist・Design :Prospectiverandomizedstudy・Setting:theintensivecareunitsofauniversityhospital・Patients:成人患者70人 CiagliaBlueRhino:35人

PercuTwist :35人・Methods:合併症、難易度を比較

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Results

・合併症:統計学的差なし

・難易度:CiagliaBlueRhino< PercuTwist

バイアスとして考えられるもの

・PercuTwistは比較的新しい手技・CiagliaBlueRhinoの方が慣れている

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6.1.4.Griggstechniquevs.theFantonitechnique

Percutaneoustracheostomy:Prospectivecomparisonofthetranslaryngealtechniqueversustheforcepsdilationaltechniquein100criticallyilladults Crit CareMed2002;30:815–9.

・Objective:Griggstechniquevs.theFantoni technique・Design :Prospectiverandomizedstudy・Setting:Intensivecareunitofamilitaryteachinghospital・Patients:成人患者100人 Griggstechnique:53人

Fantoni technique:47人・Methods:手技時間、合併症を比較

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Results

・合併症:

出血:Griggstechnique>Fantoni techniqueしかし、重大な合併症はFantoni techniqueの方が顕著に多い

・手技時間Griggstechnique<Fantoni technique

著者はGriggstechniqueの方が優れていると結論づけている

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6.1.5.GriggstechniquevsCiagliaBlueRhinotechnique

ComparativeclinicaltrialbetweenCiagliaandGriggstechniquesduringtracheostomyperformedinpatientsadmittedtointensivecareunit

ActaMedIran2012;50:525–9.

・Objective:Griggsvs.CiagliaBlueRhinotechnique・Design :Prospectiverandomizedstudy・Setting::Intensivecareunit・Patients:成人患者100人 Griggstechnique:50人

CiagliaBlueRhinotechnique:50人・Methods:手技時間、合併症を比較

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Results

・Griggsの方が早く行え、皮膚切開も小さい

・CiagliaBlueRhinotechniqueの方がminorbleeding(1-5ml)が多いが、大出血や不整脈は少ない

→CiagliaBlueRhinoはGriggsより、安全に、少ない合併症で行える

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6.1.6.Griggstechniquevs.PercuTwistBedsidepercutaneoustracheostomy:Aprospectiverandomised comparisonofPercuTwistversusGriggs'forcepsdilational tracheostomy

AnaesthIntensiveCare2011;39:209–16.

・Objective:Griggstechniquevs.PercuTwist・Design :Prospectiverandomizedstudy・Setting:Intensivecareunit・Patients:18歳以上の患者87人 Griggstechnique:42人

PercuTwist:45人・Methods:手技時間、合併症,気切前後での血液ガス、

気道内圧、血圧、脈拍を比較

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Results

・手技時間:PercuTwist>Griggstechnique

・合併症:統計学的差なし

→PercuTwistは手技に時間がかかる傾向があるが、Griggstechniqueと同程度に安全に行える

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6.1.7.PercuTwist vs.theGriggstechniquevstheCiagliatechnique

・Objective:PercuTwist vs theGriggstechniquevstheCiagliatechnique

・Design :Prospectiverandomizedstudy・Setting:medical-surgical intensivecareunit・Patients:10日以上挿管130人 PercuTwist :45人

theGriggstechnique:41人theCiagliatechnique:44人

・Methods:手技時間、合併症を比較

EurJAnaesthesiol2007;24:492–7.

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患者背景

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合併症

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Results

・手技時間:PercuTwistが最も短い

・合併症:統計学的差なし

・手技ごとに長所、短所がある

→PercuTwistは合併症も同程度で短時間で施行できる

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WhichPercutaneousTracheostomyMethodIsBetter?ASystematicReview

6.1.8.CiagliaBlueDolphinvs.CiagliaBlueRhinotechniques

Respir Care2014;59:1660–70.

・Objective:CiagliaBlueDolphin,CiagliaBlueRhino,PercuTwist, Griggs,Fantoni, Ciagliaを比較

・Design :SystematicReview・Setting:14randomizedcomparativestudy(1985-2013)(MEDLINE,LILACS,Embase,andCochraneCollaborationdatabasesforRCTs)・Methods:難易度、合併症を比較

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Results

・CiagliaBlueRhinoは難易度は低いが、minorbleedingcomplicationsはわずかに多い

・CiagliaBlueRhinoはやり慣れている傾向

→PTの中で優れた方法はどれか示す結論は出ず

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BrJAnaesth2010;104:728–32.

・Objective:バルーン拡張式気管切開(CiagliaBlueDolphin)はCiagliaの改良法として近年紹介。従来の1step拡張式気管切開(CiagliaBlueRhino)と比較

・Design :Prospectiverandomizedstudy・Setting:2009年1-10月Medicalintensivecareunits・Patients:PT適応の収容18歳以上の患者70人・Methods:気管穿刺時間、気切チューブ留置時間、合併症、

出血量を比較

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Results

・気管穿刺時間、6h後の気管内出血量→CiagliaBlueRhino <CiagliaBlueDolphin・大出血に関しては同等

・CiagliaBlueDolphin:カニューラ挿入が難度高い

・CiagliaBlueDolphinは最近の手法→症例数が限られているエビデンスには、より多くのランダム化studyが必要

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7.Cost

7.1手術室でのSTよりベッドサイドでのPTの方がコストを抑えられるか?

Recommendation:手術室でのSTよりベッドサイドでのPTの方がコストを抑えられる(Grade2C)

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ComparisonofSafetyandCostofPercutaneousversusSurgicalTracheostomy

AmSurg 2001;67:54–60.

・Objective:PTvs.ST・Design :Retrospectivestudy・Setting :intensivecareunitpatientsattheUniversity

ofVirginiaMedicalCenterduringa23-monthperiodbeginningDecember26,1996

・Patients :allventilator-dependentpatients213人PT:74人 ST:139人

・Methods:complications,proceduretime,costを比較

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Results

コスト

・ベッドサイドでのPT:1753ドル・手術室でのST :2604ドル

・しかし、

気管支鏡や合併症治療のコスト含んでおらず

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ComparisonofOpenVersusBedsidePercutaneousDilatationalTracheostomyintheCardiothoracicSurgicalPatient:Outcomesand

FinancialAnalysis

・Objective:PTvs.ST・Design :Retrospectivestudy・Setting:intensivecareunitpatientsduring3years・Patients:心臓手術後4000人のうち、

気管挿管施行した86人 (PT:27人,ST:59人)・Methods:complications,costを比較

AnnThorac Surg 2005;79:1879–85.

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Results

コスト

・PTはSTより1年間で84000ドル低い研究対象の3年間で283000ドル低い

・手術室使用コスト、ICUベッド使用コストを含む

→合併症などの医学的相違はなかったが、コスト面ではPTがSTより低かった

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Aprospective,randomizedstudycomparingpercutaneouswithsurgicaltracheostomyin

criticallyillpatients

・Objective:PTvs ST・Design :Prospectiverandomizedstudy・Setting:Medical,surgical,andcoronaryintensive

careunitsatBarnes-JewishHospital,atertiarycaremedicalcenter

・Patients:80mechanicallyventilatedpatientsrequiringelectivetracheostomy

・Methods:complications,costを比較

Crit CareMed2001;29:926–30.

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Results

・コスト:ベッドサイドでのPT<手術室でのST1569±157ドル 3172±114ドル

・統計学的有意差あり

・物品費と人件費を別に計算しても結果は同じ

・ベッドサイドでのPTの方がコストかからず

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7.2両方ベッドサイドではSTとPTはどちらがコストが良いか?

ベッドサイドでのSTは、手術室使用コストなし→PTよりコストかからずRecommendation:コストのためには推奨しない

(Grade2C)

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8.Additionalequipment:bronchoscopyandUS

8.1PT施行時の気管支鏡使用は合併症のリスクを減らすか?

Recommendation:推奨するには十分なエビデンスがない

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8.2PT施行時/前のエコー使用は合併症のリスクを減らすか?

Recommendation:十分なエビデンスなく推奨しない(Grade1B)解剖的に困難な症例での穿刺の精度向上のためのエコー使用は推奨(Grade1B)

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USでの所見

Sagittalviewoftheneck transversalviewoftheneck.

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・Objective:肥満患者へのUS-guidedPTの有用性と合併症を評価

・Design :Prospective,two-centercohortstudy・Setting:TheICUsatAmiensUniversityHospital

orBeauvaisGeneralHospital・Patients:患者50人(肥満患者(BMI≧30)26人と

非肥満患者24人)・Methods:肥満患者と非肥満患者における合併症

を比較

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合併症について

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患者について

平均BMI: 非肥満患者:34肥満患者:25

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平均所要時間:差なし非肥満患者:10分肥満患者:9分

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合併症の割合に差なししかし、、、80%の患者が肥満以外の難点がなかったため?

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Results

US-guided PT:肥満患者において合併症減少の一助になる

肥満患者の頚部の解剖を把握するのに役立ち、PTの穿刺部位を決めるのに有用

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9.Education

9.1単独で安全に、気管切開を施行するには最低何症例必要か?

Recommendation:推奨するには十分なエビデンスがない

5-10例:theAmericanThoracicSociety,theEuropeanRespiratorySociety

20例:theAmericanCollegeofChestPhysicians

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9.2PT施行に適切な専門者は?Recommendation:適切なトレーニングをすることを推奨(Grade2D)決定から実行までの時間短縮のための制度を推奨(Grade2C)

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7つのstudy:pre-postcohortdesigns(UK,10年間)のmeta-analysis• Objective:Tracheostomyteamsは気管切開手技にかかる時間を減らすか

• Design:systematicreview,meta-analysis• Databases MEDLINE,CINAHL,EMBASE,andAMED.

J Crit Care2013;28:216.e1-216.e10.

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Meta-analysis

• RevMan5.1software(Copenhagen:TheNordicCochraneCentre,TheCochraneCollaboration,2011)

• ランダム効果モデル• 相対危険度、95%信頼区間• 統計学的異質性、I2measureで評価

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各studyにおけるqualityassessmentresult

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経験者の方が気管切開にかかる時間が短い

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speakingvalve使用が増加

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Tracheostomyteams・気管切開所要時間、入院期間、ICU滞在期間を短くする

・speakingvalve使用が増加・合併症に関しては違いを認めず

・気管切開の要望から施行まで平均8日早くなる→しかし、low-qualityevidence

Results

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9.3気管切開の最も良いトレーニングは?

Recommendation:動物やシュミレーター、CTAでトレーニングを推奨(Grade2C)

*CTA: cognitivetaskanalysis

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・Objective:pigmodelvs standardmanikinmodel・Design :Prospectivecrossover study・Setting:呼吸器外科、麻酔科(SecondUniversityofNaples)・Patients:50residents(45 completed)・Methods:4つの項目で評価 (i)realityofskinturgor

(ii)landmarkrecognition(iii)feasibilityoftheprocedure(iv)realityofthemodel(v)preferenceofeachmodel

score(rangingfrom1to4)

InteractCardiovasc Thorac Surg 2015;20:248–53.

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(A)waspreparedtosupportaporcinelaryngo-trachealblock(B) Itwasthencoveredwithathinsponge(C)andwaterprooftape(D)inordertomimictheskin.

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Results・Pigmodelの方がmanikinmodelより、therealityofskinturgor,landmarkrecognition,realityofthemodelに関して良い結果となった

・Feasibilityoftheprocedureに関しては違いなし

→Pigmodelの方が実際の患者に施行する前の練習として好まれる

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10.Usefulnessofthelaryngealmask

10.1ラリンゲルマスクはPTの合併症を減らすのに有効か?

Recommendation:十分なエビデンスなく推奨しない(Grade1B)

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11.Tracheostomyinspecialpatientpopulations

11.1肥満患者への最も良い気管切開は?

Recommendation:推奨するのにST/PTともに十分なエビデンスなし

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11.2熱傷患者への最も良い気管切開は?

Recommendation:禁忌なければ、PT推奨(Grade2D)

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Percutaneousversusconventionaltracheostomyinburnedpatientswithinhalationinjury.

WorldJSurg 2005;29:1571–5.

・Objective:吸入熱傷患者におけるPT群とST群を比較・Design :Retrospectiveanalysis・Setting:Medicalintensivecareunits・Patients:吸入熱傷患者

PT:37人(熱傷による硬化あり:25人)ST:22人(熱傷による硬化あり:17人)

・Methods:PT群とST群で、コスト、合併症、手術時間、呼吸器合感染症を調べた

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Results

合併症に有意差あり

・PT群:周術期合併症なしSTへの変更を余儀なくされた例なし

・ST群:周術期合併症13例(2例:気管硬化、1例:気管瘻 10例:気切孔感染)

手術時間に有意差あり

・PT群:9分・ST群:22分

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コスト

・PT:STの1/5

呼吸器感染症

・PT群:45%・ST群:68%

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熱傷患者への気管切開の適切な時期は?

早期の方が良いとのエビデンスなし

Recommendation:推奨するのに十分なエビデンスなし

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12.Inpatientswithacutespinalinjury,doesearlytracheostomy

急性期脊損患者において、早期気管切開は合併症や死亡率を減少させるか?MV期間や入院期間を短縮させるか?

7日以内の気管切開は合併症、MV期間、入院期間を短縮させる. ST/PT関係なしRecommendation:急性期脊損患者への早期の気管切開を推奨(Grade2D)

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Predictingtheneedfortracheostomyinpatientswithcervicalspinalcordinjury

JTraumaAcuteCareSurg2012;73:880–4.

・Objective:呼吸障害により急性CSCI患者の75%が挿管やMV必要.早期気切は有用か比較

・Design :Retrospectivereview・Setting:LondonHealthScienceCenterfrom1991to2010・Patients:16歳以上の急性CSCI患者66人・Methods:CSCI患者への気管切開の有無、早期気管切開

の影響を、呼吸器合併症、MV期間、入院期間で評価

*CSCI:cervicalspinalcordinjury

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Results

・気管切開群の方が気管切開しない群より呼吸器合併症

が少ない

・早期気管切開群の方が、MV期間が少なく、入院期間が短い

・7日以上MV必要になるのが、・TheInjurySeverityScore>32・CompleteSCI・PAO2/FIO2 ratio<300(MV開始3日)→早期気管切開を推奨

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Tracheostomytimingintraumaticspinalcordinjury

・Objective:MV必要な外傷性CSCI患者への早期/晩期気管切開の有益性と安全性を比較する

・Design :Retrospectivestudy・Setting:Medicalintensivecareunits・Patients:CSCI患者152人(早期群(7日未満で気管開)71人、晩期群(7日以上)81人)(ST83人、PT69人)・Methods:早期と晩期で、合併症、肺炎、死亡率、

MV期間、ICU滞在期間で評価

EurSpineJ2009;18:1452–7.

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Results

・早期気管切開群の方が、MV期間、ICU滞在期間、合併症数(期間肉芽腫、気管硬化)が少ない

一方で、

・MV関連肺炎、死亡率には差なし

→MV管理が見込まれる外傷性CSCI患者は、早期期間切開が推奨される

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好中球減少症患者への気管切開は安全か?

合併症の増加はないが、症例数が少なく推奨するには十分でない

Recommendation:推奨するのに十分なエビデンスなし

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13.Conclusions

• PTはSTと比べ、感染症のリスクが低い• PTは手術室でのSTと比べ、コストが低い(ベッドサイドでのSTとは同程度)• 早期気管切開はMV期間を短くする(肺炎、入院期間、長期死亡率は関係せず)

• US使用は穿刺の正確性を改善する(合併症減少はしない)

• 気管支鏡やラリンジアルマスク使用に関してはエビデンスがない

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私見

・ICUにおいて、気管切開が必要となる患者は多い。当院では、基本的に主科が耳鼻科や外科の場合はST、それ以外はPTとし、PTは気管支鏡、USを使用し、CiagliaBlueRhino法で行っている。

・今回のガイドラインで、推奨するにはエビデンスが十分でない項目もあったが、PTとST各々の利点と欠点を把握することで、今後の治療の一助としたい。

・また、早期気管切開に利点は多いが、研究では挿管2-3日以内を早期としているものが多かった。長期挿管を予測するのは難しく、目安になるものがあれば、より早期に気管切開を施行できるのではないか。