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[Blue Journal临床医学影像]:支气管镜下鼻咽导管供氧相关的张力性气腹
2017年11月04日 临床影像, 临床话题 暂无评论

Tension Pneumoperitoneum Associated with Nasopharyngeal Catheter Oxygen Delivery during Bronchoscopy

Karim El-Kersh, Hala Karnib

Am J Respir Crit Care Med 2017

Published on 29-June-2017 as 10.1164/rccm.201701-0181IM

A 61-year-old female with chronic lymphocytic leukemia was undergoing bronchoscopy with bronchoalveolar lavage. The patient never smoked and she did not have any underlying chronic gastric disease. The bronchoscopy was performed in supine position under conscious sedation using intravenous midazolam and fentanyl. Due to desaturation on nasal cannula, a 10 French nasopharyngeal oxygen catheter with flow rate of 4L/min was secured in place 4-5 cm from the nostrils. Within two minutes, the patient experienced severe abdominal pain and rapid distension associated with tachycardia, tachypnea, and oxygen desaturation to 60%. Fluoroscopy showed no evidence of pneumothorax but revealed large pneumoperitoneum that was confirmed later by x-ray. (Fig.1) The patient was immediately intubated and underwent emergent exploratory laparotomy, which revealed a gastric rupture that appeared to be acute and it was not associated with any gastric ulcers. (Fig.2) The perforation was repaired and she made a full recovery.

一名61岁女性慢性淋巴细胞白血病患者在支气管镜下接受支气管肺泡灌洗。患者无吸烟史,且没有基础慢性胃病。在静脉咪达唑仑和芬太尼清醒镇静下,患者处于平卧位接受支气管镜检查。由于鼻导管吸氧时氧饱和度下降,因此,留置一根10F的鼻咽吸氧导管,氧流量4 L/min,导管尖端距鼻孔4-5 cm。2分钟内,患者出现严重腹痛及腹胀,伴有心动过速,呼吸频数,氧饱和度下降至60%。透视检查未发现气胸证据,但发现大量气腹,随后X光检查也证实这一诊断(图1)。患者立即气管插管,并接受急诊剖腹探查手术。术中发现急性胃破裂,且未见任何胃溃疡表现(图2)。医生对穿孔进行了修补,患者恢复良好。

Although gastric rupture was previously described in association with the use of nasopharyngeal catheter, tension pneumoperitoneum remains a rare complication.1,2 The mechanism is not fully understood, but sedation can precipitate upper airway obstruction and decrease cricopharyngeal muscle tone leading to passive air suction into the esophagus.2,3 This can be exacerbated by increased negative intrathoracic pressure to overcome obstructed ventilation.3 Furthermore, the catheter location and the oxygen stream may stimulate deglutition reflex with resultant aerophagia.3,4 When stomach distension occurs the lesser curvature is more susceptible to perforation due to its reduced elasticity.2 Needle decompression can be attempted as a bridge for laparotomy in cases that develop tension pneumoperitoneum.5,6 If the decision is made to use nasopharyngeal oxygen catheter during bronchoscopy, it may be a safer practice to insert the catheter through the vocal cords and to confirm intratracheal placement via the bronchoscope prior to initiating oxygen flow. Given its high mortality rate, it is imperative that pneumoperitoneum is identified and addressed immediately.

尽管既往曾报告使用鼻咽导管时出现胃破裂,但张力性气腹仍然是罕见的并发症。发病机制尚不完全清楚,但镇静可导致上气道梗阻,降低环状咽肌张力,导致气体被动进入食道。当患者增加胸腔内负压以克服阻塞通气时,上述情况可加重。而且,导管位置及氧流量可刺激吞咽反射,导致吞入气体。当发生胃胀时,胃小弯因弹性下降更容易发生穿孔。对于发生张力性气腹的患者,在剖腹探查术前,可尝试进行穿刺减压以作为过渡。如果在支气管镜检查时决定使用鼻咽吸氧导管,将导管经声带插入,开始氧疗前通过支气管镜确认导管位于气管内,这样可能更为安全。由于病死率很高,因而必须做到早期鉴别并处理气腹。

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