目的:比较在最低安全压力下使用不同压力测量方法的圆柱形和圆锥形袖带导管进行气道闭合的有效性,并指导临床应用。
方法:纳入2021年12月至2022年1月广西医科大学肿瘤医院重症监护病房(ICU)24例气管插管患者。对患者袖带上的分泌物进行体外渗漏试验。分离20毫升注射器的针头和柱塞,注射器用粘合剂密封,并彻底填充注射器喷嘴以创建气管模型。连续,圆柱形和圆锥形袖带导管都被插入到模拟气管中,在开始实验之前,将袖带压力校准为20cmH2O(1cmH2O≈0.098kPa)。对患者袖带上分泌物的粘度进行分类(I级为水性声门下分泌物,II级是声门下分泌浓稠,III级为凝胶状声门下分泌),并将相同的粘度分泌物注入导管套中。利用自我控制的方法,通过改进的压力测量方法(间歇压力测量组),最初在圆柱形和圆锥形袖带上进行间歇压力测量,连续测压实验(连续测压组)。记录三种粘度声门下分泌物的泄漏量和不同形状的套囊导管在充气4、6、8小时时的套囊压力测量值。
结果:共抽取了24例气管插管患者在通气过程中保留的180个样本,两组各90个样本,采用不同的压力测量方法,和每组30个不同粘度的保留材料样品。在间歇压力测量组中,在4小时的通货膨胀中,圆柱形袖带上的I级和II级分泌物样本全部漏出,而3个III级分泌物样本也泄漏。对于锥形袖口,28个I级分泌物样本泄漏,只有2个II级分泌物样本泄漏,III级分泌物没有渗漏。在通货膨胀的6小时,所有样品的三种粘度分泌物都在不同形状的袖口上渗漏。随着充气时间的延长,泄漏量逐渐增加。在连续压力测量组中,在4小时的通货膨胀中,圆柱形袖带上的所有I级分泌物样本都泄漏了,而29个二级分泌物样本泄漏,III级分泌物没有渗漏。对于圆锥形袖口,26个I级分泌物样本泄漏,二级和三级分泌物没有渗漏。在通货膨胀的6小时,对于III级的分泌物,圆锥形袖带仍然没有渗漏。随着通货膨胀时间的延长,两组不同形状袖带的声门下分泌物渗漏逐渐增加。在通货膨胀的8小时里,所有样品都经历了泄漏,但与间歇压力测量组相比,连续压力测量组不同形状袖带上的声门下分泌物渗漏明显减少[III级(mL)分泌物渗漏:1.00(0.00,1.25)与2.00(1.00,2.00)在圆柱形袖口上,1.00(0.00,1.00)vs.2.00(2.00,2.00)在圆锥形袖口上,均P<0.01]。连续测压组不同形状袖带在不同充气时间点的测压值在设定范围(20~21cmH2O)内。间歇压力测量组充气4小时时的袖带压力明显低于初始值(cmH2O:18.3±0.6vs.圆柱形袖带中的20.0±0.0,18.4±0.6vs.锥形袖带20.0±0.0,两者P<0.01),随着充气时间的延长,两种异形袖口的袖带压力均呈显着下降趋势。然而,不同形状的套囊导管之间的压力测量值没有统计学上的显著差异.
结论:连续压力监测装置可在最低安全压力下保持圆锥形袖带导管的有效密封。当使用改进的压力测量方法进行间歇压力测量和/或使用圆柱形袖带导管时,目标压力应设定在25-30cmH2O,和袖带压力应定期调整。
OBJECTIVE: To compare the effectiveness of cylindrical-shaped and conical-shaped cuff catheters for airway closure using different pressure measurement methods at the lowest safe pressure and to guide the clinical application.
METHODS: Twenty-four patients with endotracheal intubation admitted to the intensive care unit (ICU) of Guangxi Medical University Cancer Hospital from December 2021 to January 2022 were enrolled. Leakage test in vitro was performed on the secretion on the patients\' cuff. The needle and plunger from 20 mL syringe was separated, the syringe was sealed with adhesive, and the syringe nozzle was filled thoroughly to create a tracheal model. Consecutively, both cylindrical-shaped and conical-shaped cuff catheters were inserted into the simulated
trachea, and the cuff pressure was calibrated to 20 cmH2O (1 cmH2O ≈ 0.098 kPa) before commencing the experiment. The viscosity of the secretion on the patients\' cuff was classified (grade I was watery subglottic secretion, grade II was thick subglottic secretion, grade III was gel-like subglottic secretion), and the same viscosity secretion was injected into the catheter cuff. Utilizing a self-control approach, intermittent pressure measurement was initially conducted on both the cylindrical-shaped and conical-shaped cuff by improved pressure measurement method (intermittent pressure measurement group), followed by continuous pressure measurement experiment (continuous pressure measurement group). The leakage volume of the three viscosity subglottic secretions and the values of cuff pressure measurement of different shaped cuff catheters at 4, 6, 8 hours of inflation were recorded.
RESULTS: A total of 180 retention samples were extracted from 24 patients with tracheal intubation during ventilation, with 90 samples in each of the two groups using different pressure measurement methods, and 30 samples of retention materials with different viscosities in each group. In the intermittent pressure measurement group, at 4 hours of inflation, all samples of secretion with grade I and grade II on cylindrical-shaped cuff leaked, while 3 samples of secretion with grade III also leaked. For conical-shaped cuff, 28 samples of secretion with grade I leaked, only 2 samples of secretion with grade II leaked, and there was no leak for secretion with grade III. At 6 hours of inflation, all samples of the three viscosity secretions on different shaped cuffs leaked. The leakage was gradually increased with the prolongation of inflation time. In the continuous pressure measurement group, at 4 hours of inflation, all samples of secretion with grade I on cylindrical-shaped cuff leaked, while 29 samples of secretion with grade II leaked, and there was no leak for secretion with grade III. For the conical-shaped cuff, 26 samples of secretion with grade I leaked, and there was no leak for secretion with grade II and grade III. At 6 hours of inflation, the conical-shaped cuff still had no leak for secretion with grade III. As the inflation time prolonged, the leakage of subglottic secretion on different shaped cuffs in both groups was gradually increased. At 8 hours of inflation, all samples experienced leakage, but the leakage of subglottic secretion on different shaped cuffs in the continuous pressure measurement group was significantly reduced as compared with the intermittent pressure measurement group [leakage for secretion with grade III (mL): 1.00 (0.00, 1.25) vs. 2.00 (1.00, 2.00) on the cylindrical-shaped cuff, 1.00 (0.00, 1.00) vs. 2.00 (2.00, 2.00) on the conical-shaped cuff, both P < 0.01]. The values of pressure measurement of cuffs with different shapes at different time points of inflation in the continuous pressure measurement group were within the set range (20-21 cmH2O). The cuff pressure at 4 hours of inflation in the intermittent pressure measurement group was significantly lower than the initial value (cmH2O: 18.3±0.6 vs. 20.0±0.0 in the cylindrical-shaped cuff, 18.4±0.6 vs. 20.0±0.0 in the conical-shaped cuff, both P < 0.01), and the cuff pressure in both shaped cuffs showed a significant decrease tendency as inflation time prolonged. However, there was no statistically significant difference in values of pressure measurement between the different shaped cuff catheters.
CONCLUSIONS: Continuous pressure monitoring devices can maintain the effective sealing of conical-shaped cuff catheters at the lowest safe pressure. When using an improved pressure measurement method for intermittent pressure measurement and/or using a cylindrical cuff catheter, the target pressure should be set at 25-30 cmH2O, and the cuff pressure should be adjusted regularly.