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摘要: 目的 探讨儿童气管切开术的适应证、手术时机及术后处理的变化。方法 回顾性分析2016年1月-2020年12月于复旦大学附属儿科医院就诊并接受气管切开术的95例患儿的住院资料。按原发疾病将所有患儿分为4组，A组：神经肌肉相关疾病36例(37.9%)，B组：先天畸形30例(31.6%)，C组：意外伤害15例(15.8%)，D组：肿瘤疾病14例(14.7%)。结果 A组合并重症肺炎比例最高(47.2%)，呼吸机使用比例最高(97.2%)，平均住院天数最长(84.9 d)，出院时呼吸机依赖比例最高(66.7%)；B组紧急气管切开比例最高(4.2%)，接受气管切开中位年龄最低(2个月)，呼吸机使用率最低(30.0%)；D组死亡率最高(42.9%)，死亡与原发疾病直接相关。对2016—2020年患儿的适应证比例进行逐年比较，A组占比大致呈逐年上升趋势(28.6%、35.0%、38.5%、44.4%、43.5%)，而B组占比逐年下降(57.1%、30.0%、38.5%、33.3%、21.7%)。患儿出院时，带管自主呼吸48例(50.5%)，带管呼吸机维持28例(29.5%)，死亡或自动出院13例(13.7%)，拔管6例(6.3%)。结论 儿童气管切开术的适应证改变，上呼吸道梗阻性疾病占比降低，神经肌肉疾病等复杂慢性疾病占比升高。对于需要长期带管的慢性疾病患儿，早期气管切开有利于气道管理，减少呼吸机依赖，缩短住院时间。Abstract: Objective To disscuss the changes in indications, surgical opportunity and post-operative management of pediatric tracheotomy.Methods Retrospective cohort study of pediatric patients undergoing tracheostomy between January 2016 and December 2020 at Children's Hospital of Fudan University. Ninety-five patients were divided into four groups according to their primary indication. Group A: neuromuscular disease(n=36, 37.9%), Group B: congenital abnormality(n=30, 31.6%), Group C: accidental injury(n=15, 15.8%), Group D: tumor(n=14, 14.7%).Results By the comparison between four groups, children in group A had higher incidence of Severe pneumonia(47.2%), higher usage of mechanical ventilation(97.2%), longer hospitalization days( =84.9 days) and higher rate of Ventilator dependence(66.7%); children in group B had higher rate of emergency surgery(4.2%), lower age(median age 2 months) and lower usage of mechanical ventilation(30.0%); Mortality of the children in group D was the highest(42.9%). In the recent five years, we saw a increasing tendency in the proportion of group A(28.6%, 35.0%, 38.5%, 44.4%, 43.5%), and a decreasing tendency of group B(57.1%, 30.0%, 38.5%, 33.3%, 21.7%). On discharge, 50.5% of children(48 of 95)spontaneously breathe with the tracheos tomy in situ, 29.5% of children(28 of 95)had ventilator-dependence, tracheostomy decannulation was successful in 6.3% of children (6 of 95) and all-cause mortality was 13.7% (13 of 95).Conclusion Most paediatric tracheotomies were performed due to chronic underlying diseases. Pediatric tracheostomy should be considered as a long-term intervention in many children. Earlier tracheotomy can shorten the duration of post-tracheotomy mechanical ventilation in several conditions.
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Key words:
- child /
- tracheotomy /
- indication /
- surgical opportunity
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表 1 4组患儿基本信息及住院资料分析
基本信息 A组 B组 C组 D组 合计 (χ2)F值 P值 例数(%) 36(37.9) 30(31.6) 15(15.8) 14(14.7) 95(100.0) 性别/例(%) 2.285 0.514 男 20(55.6) 17(56.7) 11(73.3) 10(71.4) 58(61.1) 女 16(44.4) 13(43.3) 4(26.7) 4(28.6) 37(38.9) 年龄/月[M(P25，P75)] 54.0
(24.0，84.0)2.0
(1.5，18.0)48.0
(24.0，96.0)36.0
(16.5，144.0)36.0
(8.0，84.0)31.10 < 0.01 年龄段 婴儿期/例(%) 4(13.3) 23(76.7) 1(3.3) 2(6.7) 30(31.6) 幼儿期/例(%) 5(29.4) 5(29.4) 3(17.6) 4(23.5) 17(17.9) 学龄前期/例(%) (55.6) 1(5.6) 5(27.8) 2(11.1) 18(18.9) 学龄期/例(%) (56.7) 1(3.3) 6(20.0) 6(20.0) 30(31.6) 紧急气管切开/例 0 4 0 0 4 术前气管插管通气/例(%) 36(100.0) 11(36.7) 12(80.0) 12(85.7) 70(73.7) 36.31 < 0.01 术前呼吸机使用/例(%) 35(97.2) 9(30.0) 12(80.0) 10(71.4) 66(69.5) 35.90 < 0.01 平均住院天数/d 84.9±46.5 31.2±23.4 39.7±29.3 50.4±46.0 55.7±44.3 7.76 < 0.01 合并肺部感染/例(%) 36(100) 19(63.3) 9(60.0) 9(64.3) 73(76.8) 18.24 < 0.01 肺部感染(重症)/例(%) 17(47.2) 5(16.7) 2(13.3) 3(21.4) 27(28.4) 10.31 < 0.05 出院情况 56.60 < 0.01 拔管/例(%) 0(0) 5(16.7) 0(0) 1(7.1) 6(6.3) 带管自主呼吸/例(%) 10(27.8) 21(70) 12(80.0) 5(35.7) 48(50.5) 带管呼吸机维持/例(%) 24(66.7) 0(0) 2(13.3) 2(14.3) 28(29.5) 死亡或放弃治疗/例(%) 2(5.6) 4(13.3) 1(6.7) 6(42.9) 13(13.7) 
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