气管切开术在神经重症中的 应用价值

Application Value of Tracheostomy in Neurocritical Care

摘要: 在神经重症医学领域，气管切开术(Tracheostomy)是管理长期机械通气患者、优化气道保护及促进神经康复的关键手段。神经重症患者由于脑干功能受损、意识障碍(格拉斯哥评分(Glasgow coma scale, GCS)持续较低)以及延髓麻痹，常面临气道防御机制丧失、排痰困难及中枢性呼吸衰竭的严峻挑战。随着重症监测技术的进步，气管切开术已从单纯的急救技术演变为包含多学科决策、个体化时机评估及精细化术后管理的综合干预体系。本综述通过梳理现有的学术文献，深入探讨了气管切开术在神经重症患者中的应用现状。重点分析了手术时机、手术方式及临床应用等多个研究方向。分析表明，尽管早期气管切开(通常定义为机械通气后7~10天内)在改善长期神经功能预后(如改良Rankin量表——mRS评分)以及降低死亡率方面尚未显示出显著性的临床改善，但其在缩短机械通气时长、降低呼吸机相关性肺炎(ventilator associated pneumonia, VAP)发生率及优化(intensive care unit, ICU)资源配置方面的优势具有稳健的证据支持。此外，在手术方式上，经皮扩张气管切开术(percutaneous tracheotomy, PDT)因其微创、床旁可操作性及成本效益，已逐渐成为许多中心的首选，但其在困难气道或特定解剖结构患者中的应用仍需谨慎评估。

Abstract: In the field of neurocritical care medicine, tracheostomy is a key method for managing patients on long-term mechanical ventilation, optimizing airway protection, and promoting neurological rehabilitation. Neurocritical patients often face severe challenges such as loss of airway defense mechanisms, difficulty clearing secretions, and central respiratory failure due to brainstem dysfunction, impaired consciousness (persistent decline in Glasgow Coma Scale, GCS), and bulbar paralysis. With advancements in critical care monitoring technologies, tracheostomy has evolved from a purely emergency procedure into a comprehensive intervention system that involves multidisciplinary decision-making, individualized timing assessment, and refined postoperative management. This review summarizes the existing academic literature and delves into the current application of tracheostomy in neurocritical patients. It focuses on analyzing various research directions including timing of surgery, surgical approaches, complications, and clinical applications. The analysis indicates that while early tracheostomy (usually defined as within 7~10 days after initiating mechanical ventilation) has not yet demonstrated significant clinical improvement in long-term neurological outcomes (such as modified Rankin Scale—mRS scores) or reduced mortality, it has robust evidence supporting its advantages in shortening the duration of mechanical ventilation, reducing the incidence of ventilator-associated pneumonia (VAP), and optimizing intensive care unit (ICU) resource allocation. Additionally, in terms of surgical approach, percutaneous dilatational tracheostomy (PDT) has gradually become the preferred choice in many centers due to its minimally invasive nature, bedside feasibility, and cost-effectiveness, although its use in patients with difficult airways or specific anatomical structures still requires careful evaluation.