重症患者の包括的気管切開管理：ICUから病棟まで

気道閉塞に対する治療法であった気管切開は，ポリオ大流行を契機に陽圧換気時の長期気道管理法として確立した。重症患者の生存率向上に伴い，近年，気管切開患者の管理はICU のみならず一般病棟や在宅医療にまで拡大し，長期的なQOLを考慮した包括的管理が求められている。気管カニューレ閉塞や逸脱の予防をはじめとする安全対策は，特に一般病棟では標準化されておらず，喫緊の課題である。気管カニューレ抜去は，行うまでに日数を要するものの，そのアルゴリズムが確立しておらず，急性期病院から転出後にはほとんど行われていないのが現状である。カニューレ未抜去と患者転帰不良との関連が示唆されており，多職種気管切開管理チームに...

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Published in日本集中治療医学会雑誌 Vol. 31; no. 5; pp. 493 - 501
Main Authors 武居, 哲洋, 藤澤, 美智子
Format Journal Article
LanguageJapanese
Published 一般社団法人 日本集中治療医学会 01.09.2024
Online AccessGet full text
ISSN1340-7988
1882-966X
DOI10.3918/jsicm.31_493

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Abstract 気道閉塞に対する治療法であった気管切開は，ポリオ大流行を契機に陽圧換気時の長期気道管理法として確立した。重症患者の生存率向上に伴い，近年，気管切開患者の管理はICU のみならず一般病棟や在宅医療にまで拡大し，長期的なQOLを考慮した包括的管理が求められている。気管カニューレ閉塞や逸脱の予防をはじめとする安全対策は，特に一般病棟では標準化されておらず，喫緊の課題である。気管カニューレ抜去は，行うまでに日数を要するものの，そのアルゴリズムが確立しておらず，急性期病院から転出後にはほとんど行われていないのが現状である。カニューレ未抜去と患者転帰不良との関連が示唆されており，多職種気管切開管理チームによる気管カニューレ抜去戦略の確立や安全対策の啓発は，患者転帰の改善や医療費の削減をもたらす可能性がある。海外でのいくつかの先進的な取り組みを参考に，今後本邦でも気管切開患者の長期的かつ体系的な管理体制を整備することが望まれる。
AbstractList 気道閉塞に対する治療法であった気管切開は，ポリオ大流行を契機に陽圧換気時の長期気道管理法として確立した。重症患者の生存率向上に伴い，近年，気管切開患者の管理はICU のみならず一般病棟や在宅医療にまで拡大し，長期的なQOLを考慮した包括的管理が求められている。気管カニューレ閉塞や逸脱の予防をはじめとする安全対策は，特に一般病棟では標準化されておらず，喫緊の課題である。気管カニューレ抜去は，行うまでに日数を要するものの，そのアルゴリズムが確立しておらず，急性期病院から転出後にはほとんど行われていないのが現状である。カニューレ未抜去と患者転帰不良との関連が示唆されており，多職種気管切開管理チームによる気管カニューレ抜去戦略の確立や安全対策の啓発は，患者転帰の改善や医療費の削減をもたらす可能性がある。海外でのいくつかの先進的な取り組みを参考に，今後本邦でも気管切開患者の長期的かつ体系的な管理体制を整備することが望まれる。
Author 武居, 哲洋
藤澤, 美智子
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  organization: 横浜市立みなと赤十字病院集中治療部
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32) Küchler J, Wojak JF, Smith E, et al. Management of tracheostomized patients after poor grade subarachnoid hemorrhage: Disease related and pulmonary risk factors for failed and delayed decannulation. Clin Neurol Neurosurg 2019;184:105419.
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35) Drendel M, Primov-Fever A, Talmi YP, et al. Outcome of tracheostomy in patients over 85 years old (oldest-old patients). Otolaryngol Head Neck Surg 2009;140:395-7.
16) Martinez GH, Fernandez R, Casado MS, et al. Tracheostomy tube in place at intensive care unit discharge is associated with increased ward mortality. Respir Care 2009;54:1644-52.
39) Ishizaki M, Toyama M, Imura H, et al. Tracheostomy decannulation rates in Japan: a retrospective cohort study using a claims database. Sci Rep 2022;12:19801.
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9) 細川康二，武居哲洋，飯塚悠祐，他．日本の重症ケア病床数と人工呼吸算定 ─病床機能報告の解析─．日集中医誌 2021;28:123-5.
18) Blecha S, Brandl M, Zeman F, et al. Tracheostomy in patients with acute respiratory distress syndrome is not related to quality of life, symptoms of psychiatric disorders or return-to-work: the prospective DACAPO cohort study. Ann Intensive Care 2020;10:52.
36) Weyh A, Davis S, Dolan J, et al. Obese Tracheostomy: A Challenging Path From Surgery to Decannulation. J Oral Maxillofac Surg 2020;78:631-43.
1) Pahor AL. Ear, nose and throat in Ancient Egypt. J Laryngol Otol 1992;106:773-9.
38) 田村暢一朗，野村智子．集中治療室で造設した気管切開術後6か月時点での気管カニューレ抜去率．日救急医会誌 2019;30:26-31.
3) Brendan A. McGrath. Collaborating to improve the safety and quality of care. [cited 2023 Nov 27]. Available from: https://www.tracheostomy.org.uk/who-we-are/collaborate#video
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25) 日本医療安全調査機構医療事故調査・支援センター．医療事故の再発防止に向けた提言第4号 気管切開術後早期の気管切開チューブ逸脱・迷入に係る死亡事例の分析．2018. [cited 2023 Dec 3]. Available from: https://www.medsafe.or.jp/modules/advocacy/index.php?content_id=52
45) 片岡　淳．JSEPTIC簡単アンケート第31回ICUでの気管切開術とその後の管理．Intensivist 2019;11:608-11.
References_xml – reference: 26) McGrath B, ed. Comprehensive tracheostomy care: the national tracheostomy safety project manual. London: BMJ Books; 2014.
– reference: 14) Kluge S, Baumann HJ, Maier C, et al. Tracheostomy in the intensive care unit: a nationwide survey. Anesth Analg 2008;107:1639-43.
– reference: 49) Hyatt RE, Wilcox RE. Extrathoracic airway resistance in man. J Appl Physiol 1961;16:326-30.
– reference: 6) Garrubba M, Turner T, Grieveson C. Multidisciplinary care for tracheostomy patients: a systematic review. Crit Care 2009;13:R177.
– reference: 12) Mehta AB, Syeda SN, Bajpayee L, et al. Trends in Tracheostomy for Mechanically Ventilated Patients in the United States, 1993-2012. Am J Respir Crit Care Med 2015;192:446-54.
– reference: 17) Fernandez R, Bacelar N, Hernandez G, et al. Ward mortality in patients discharged from the ICU with tracheostomy may depend on patient's vulnerability. Intensive Care Med 2008;34:1878-82.
– reference: 36) Weyh A, Davis S, Dolan J, et al. Obese Tracheostomy: A Challenging Path From Surgery to Decannulation. J Oral Maxillofac Surg 2020;78:631-43.
– reference: 24) McGrath BA, Calder N, Laha S, et al. Reduction in harm from tracheostomy-related patient safety incidents following introduction of the National Tracheostomy Safety Project: our experience from two hundred and eighty-seven incidents. Clin Otolaryngol 2013;38:541-5.
– reference: 7) 日本集中治療医学会ICU機能評価委員会．JIPAD年次レポート. [cited 2023 Nov 27]. Available from: https://www.jipad.org/report
– reference: 8) 康永秀生．集中治療室（ICU）病床の占有率に関する分析．令和2年度厚生労働行政推進調査事業費（政策科学総合研究事業）「医師の専門性を考慮した勤務実態を踏まえた需給等に関する研究」分担研究報告書．[cited 2023 Nov 27]. Available from: https://mhlw-grants.niph.go.jp/project/145331
– reference: 32) Küchler J, Wojak JF, Smith E, et al. Management of tracheostomized patients after poor grade subarachnoid hemorrhage: Disease related and pulmonary risk factors for failed and delayed decannulation. Clin Neurol Neurosurg 2019;184:105419.
– reference: 1) Pahor AL. Ear, nose and throat in Ancient Egypt. J Laryngol Otol 1992;106:773-9.
– reference: 31) Schneider H, Hertel F, Kuhn M, et al. Decannulation and Functional Outcome After Tracheostomy in Patients with Severe Stroke (DECAST): A Prospective Observational Study. Neurocrit Care 2017;27:26-34.
– reference: 53) McGrath BA, Wallace S, Lynch J, et al. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. Br J Anaesth 2020;125:e119-29.
– reference: 29) Carrer S, Basilico S, Rossi S, et al. Outcomes of percutaneous tracheostomy. Minerva Anestesiol 2009;75:607-15.
– reference: 54) Ohbe H, Matsui H, Fushimi K, et al. Epidemiology of Chronic Critical Illness in Japan: A Nationwide Inpatient Database Study. Crit Care Med 2021;49:70-8.
– reference: 15) Abe T, Madotto F, Pham T, et al; LUNG-SAFE Investigators and the ESICM Trials Group. Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries. Crit Care 2018;22:195.
– reference: 27) Different types of tracheostomy tubes. McGrath BA, ed. Comprehensive tracheostomy care. London: BMJ Books; 2014. p. 20-7.
– reference: 34) Long SM, Feit NZ, Chern A, et al. Percutaneous and Open Tracheostomy in Patients With COVID-19: The Weill Cornell Experience in New York City. Laryngoscope 2021;131:E2849-56.
– reference: 3) Brendan A. McGrath. Collaborating to improve the safety and quality of care. [cited 2023 Nov 27]. Available from: https://www.tracheostomy.org.uk/who-we-are/collaborate#video
– reference: 9) 細川康二，武居哲洋，飯塚悠祐，他．日本の重症ケア病床数と人工呼吸算定 ─病床機能報告の解析─．日集中医誌 2021;28:123-5.
– reference: 11) Brass P, Hellmich M, Ladra A, et al. Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev 2016;7:CD008045.
– reference: 30) Voelker MT, Wiechmann M, Dietz A, et al. Two-Year Follow-Up After Percutaneous Dilatational Tracheostomy in a Surgical ICU. Respir Care 2017;62:963-9.
– reference: 39) Ishizaki M, Toyama M, Imura H, et al. Tracheostomy decannulation rates in Japan: a retrospective cohort study using a claims database. Sci Rep 2022;12:19801.
– reference: 46) Mussa CC, Gomaa D, Rowley DD, et al. AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting. Respir Care 2021;66:156-9.
– reference: 40) Thomas S, Sauter W, Starrost U, et al. Time to decannulation and associated risk factors in the postacute rehabilitation of critically ill patients with intensive care unit-acquired weakness: a cohort study. Eur J Phys Rehabil Med 2017;53:501-7.
– reference: 52) 藤澤美智子，武居哲洋，永田　功，他．気管切開患者におけるカフ付き複管式スピーチカニューレの側孔開口部留置位置の検討．ICUとCCU 2022;46:367-72.
– reference: 38) 田村暢一朗，野村智子．集中治療室で造設した気管切開術後6か月時点での気管カニューレ抜去率．日救急医会誌 2019;30:26-31.
– reference: 25) 日本医療安全調査機構医療事故調査・支援センター．医療事故の再発防止に向けた提言第4号 気管切開術後早期の気管切開チューブ逸脱・迷入に係る死亡事例の分析．2018. [cited 2023 Dec 3]. Available from: https://www.medsafe.or.jp/modules/advocacy/index.php?content_id=52
– reference: 50) Hernández Martínez G, Rodriguez ML, Vaquero MC, et al. High-Flow Oxygen with Capping or Suctioning for Tracheostomy Decannulation. N Engl J Med 2020;383:1009-17.
– reference: 35) Drendel M, Primov-Fever A, Talmi YP, et al. Outcome of tracheostomy in patients over 85 years old (oldest-old patients). Otolaryngol Head Neck Surg 2009;140:395-7.
– reference: 43) Holmes TR, Cumming BD, Sideris AW, et al. Multidisciplinary Tracheotomy Teams: An Analysis of Patient Outcomes and Resource Allocation. Ear Nose Throat J 2019;98:232-7.
– reference: 5) McGrath BA, Wallace S, Lynch J, et al. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. Br J Anaesth 2020;125:e119-29.
– reference: 23) McGrath BA, Thomas AN. Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency. Postgrad Med J 2010;86:522-5.
– reference: 45) 片岡　淳．JSEPTIC簡単アンケート第31回ICUでの気管切開術とその後の管理．Intensivist 2019;11:608-11.
– reference: 18) Blecha S, Brandl M, Zeman F, et al. Tracheostomy in patients with acute respiratory distress syndrome is not related to quality of life, symptoms of psychiatric disorders or return-to-work: the prospective DACAPO cohort study. Ann Intensive Care 2020;10:52.
– reference: 41) Management of the day-to-day needs of the patient with a tracheostomy and laryngectomy. McGrath BA, ed. Comprehensive tracheostomy care. London: BMJ Books; 2014. p. 28-66.
– reference: 13) Cooper RM. Use and safety of percutaneous tracheostomy in intensive care. Report of a postal survey of ICU practice. Anaesthesia 1998;53:1209-12.
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Snippet 気道閉塞に対する治療法であった気管切開は，ポリオ大流行を契機に陽圧換気時の長期気道管理法として確立した。重症患者の生存率向上に伴い，近年，気管切開患者の管...
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Title 重症患者の包括的気管切開管理：ICUから病棟まで
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