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    我/我的家人面對呼吸衰竭的狀況時，該接受氣切手術嗎？
    公告日期：106-12-04

    前言        

           礙於國情與民情的因素，雖然氣管造口術相較於延長氣管內管插管使用有較多的優點且較少之合併症發生，還是一直難為普羅大眾於第一時間接受，當中不外乎做了氣切就一輩子難以脫離機器且需要終身臥床的迷思作祟，或是對於鍾愛之親屬身體完整性的維護的取捨。筆者因面臨臨床上述諸多挫折，卻苦於缺乏具有系統性且完整的與病人衛教介紹之題材，故於參照前人經驗筆談及酌以實證證據之提供，希望能給予病人及家屬完整且正確的氣管造口衛教訊息，以利其做出真正對於病況及臨床有幫助的決定。

    疾病簡介

        急性或慢性呼吸衰竭代表呼吸系統的氣體交換，因無法應付人的代謝需求，因而發生的急性生理失去平衡之狀況。嚴重時甚至可能會產生危及生命危險的情境。一般來說急性呼吸衰竭的病人必須用機械通氣支持的方式取代自主呼吸。而機械通氣的途經主要可區分為非侵襲性(如陽壓或雙壓呼吸器)及侵襲性(經氣管內管置入後使用之機械通氣形式)。而臨床工作上常定義使用呼吸器大於3週以上，無法訓練脫離呼吸器成功，或曾經經過拔管嘗試後失敗者，稱之為須長時間呼吸器使用或有潛在脫離困難者8,16,17, 21,26-30,34,37,40,42,43,45-47,50,52,54-56。臨床工作上須長期使用呼吸器的病人建議應考慮建立氣管造口以減少長時間氣管內管插管之合併症產生1,3,4,6-8,16,19-21,25-27,29,31,35,54-56,58。

    醫療選項簡介：

        人工氣道通常是一種緊急處置，當病人出現呼吸困難需進行急救時，通常會先以氣管內插管，輔以呼吸器協助換氣，維持生命並延長治療時機。但非所有病人皆能順利脫離呼吸器，若長期插管會造成口腔、咽喉甚至氣管的損傷，包含表皮黏膜損傷、水腫、牙齒損傷、聲帶麻痺、接觸性肉芽腫、吞嚥困難、氣管軟化、氣管食道瘻管等合併症產生5,13,19。
        為降低經口鼻插管所造成之併發症並改善病人舒適度，醫師會建議儘早執行氣管造口術1-7,16,19-21,23,25-29,31,34,37,40,58，它是一種外科手術，在頸部氣管處，第二、三氣管軟骨間，切開一個暫時性或永久性開口，接著放入一個通氣管（或稱氣切管）以提供病人呼吸及清除痰液之通道。氣管造口術主要有兩種方式：(一)傳統氣管切開手術：在手術室進行，於全身麻醉下，外科醫師在病人頸部第二、三氣管軟骨間，劃開長約2至5公分的傷口，剝離皮下組織後於上述氣管軟骨間，插入氣切管以幫助病人呼吸；(二)經皮氣管切開手術:可在手術室、加護病房，或呼吸照護病房進行。病人在局部麻醉或靜脈注射麻醉下，在病人頸部第二、三氣管軟骨間，劃開長約1至2公分的傷口，於支氣管鏡引導下(視臨床狀況需求安排)，以擴張器與導引裝置將氣切管插入氣管以幫助病人呼吸。與傳統手術相比，經皮氣管切開手術所需手術與麻醉時間較短，傷口較小，出血或傷口感染發生率較低。經由醫師評估病人情形後，方能判斷病人適合接受何種術式6,10,14,15,19, 20,23-27,32,33,37,38,。氣管切開術的常見併發症包括傷口出血、傷口感染。罕見併發症包括氣管狹窄、氣管軟化、氣管破裂、氣管與鄰近構造（例如食道、大血管等）形成瘻管3,5,6,9-13,18-21,26,28,31,44,59。但這些併發症不只是氣管切開術才會發生。長期使用氣管內管的病人，也可能發生這些罕見併發症。此外依病人狀況以及所進行的手術與麻醉，也有不同程度的麻醉相關併發症風險。

    比較項目表：

     

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