氣管內管袖口疝氣之形成導致氣管造口手術時發生氣道阻塞的意外

Airway Obstruction Caused by Endotracheal Tube Cuff Herniation during Creation of Tracheal Stoma

氣管內管袖口疝氣很少發生在低壓力高容積的現代袖口，同時，是導致術中氣道阻塞很少見的原因。一位62歲患下咽癌接受手術的男性，手術中必須建立氣管造口，過程中外科醫師由氣管切開處置入氣管內管取代經口插入的管子，不久便發生單肺換氣的情形，將氣管內管向外置放，並膨脹袖口，之後卻發生了嚴重的氣道阻塞。在與外科醫師合作下，一開始以抽痰管通過氣管內管，並未發現有阻塞現象，最後藉由「袖口放氣測試」而高度懷疑袖口變形，換了新的氣管內管後，果然沒有再發生氣道阻塞。檢視置換下來的氣管內管，發現袖口有一病氣形成。置入過深的氣管內管，加上過度的袖口膨服及手術拉扯是袖口變形的主要成因。藉由文獻回顧，我們探討了袖口病氣形成的可能機轉，並整理有關麻醉中發生氣道阻塞時的鑑別診斷，我們相信「袖口放氣測試」是診斷袖口疝氣的關鍵。這是袖口疝氣首次被報告發生在氣管造口術時，這類手術麻醉醫師無法直接掌控病人的氣道，對於氣道的處理須有更高的警覺。

We report an unusual case of airway obstruction caused by herniation of endotracheal tube (ETT) cuff in a 62- year-old male who underwent surgery for hypopharyngeal carcinoma. During the procedure of creating a tracheal stoma, a new oral ETT was inserted by the surgical team to the lower portion of the trachea through the cut opening to replace the old for ventilation and prevention of soiling of the airway. Upon resumption of surgical manipula-tion, right endobronchial intubation was disclosed. The ETT cuff was therefore repositioned and reinflated, but airway obstruction persisted in spite of tube obstruction being ruled out by successfully passing a suction catheter through the ETT. After deflating the cuff the obstruction was resolved, and ventilation was eased. Thus the ETT was replaced with another new one and careful scrutiny made after the event revealed a herniating cuff due to manufacturing defect. It was conceivable that endobronchial intubation with over-inflation of the tube cuff may cause cuff herniation, particularly when surgical manipulation was active at the adjacency, in spite of the use of a modern tube with low-pressure high-yolume cuff. Performing the 'cuff deflation test” is the simple way to diagnose cuff herniation. Awareness of this condition, especially when anesthesiologists lose direct control of the airway during such procedures is important because undesirable complications can be prevented through quick decision and action.