复发性多软骨炎患者气管支架移位的气道急诊管理：一例病例报告

文献信息

中文摘要

背景： 复发性多软骨炎（RP）是一种罕见的自身免疫性疾病，以软骨结构反复炎症为特征，常累及气管支气管树。进行性气道受累可导致气管狭窄和气管支气管软化，常需置入气道支架。此类患者的气道管理尤为困难，尤其是在存在支架移位等支架相关并发症时。
病例介绍： 一名71岁男性RP患者，有气管支气管支架置入史，因外伤跌倒后出现呼吸窘迫。因进行性低氧血症需行紧急气管插管。计算机断层扫描（CT）显示气管支架向头侧移位，导致支架腔与自体气道错位。在视频喉镜下实施快速序贯诱导。插管过程中发生明显的胃食管反流。先将7.0 mm气管导管置入，使套囊位于声带水平以降低误吸风险。充分吸引胃内容物后，在可弯曲支气管镜引导下将导管推进至支架腔内。支气管镜检查显示符合气管支气管软化的气道塌陷，并因支架位置异常导致右肺通气受损。尝试重新定位支架未成功。患者随后发生严重肺部感染和急性呼吸窘迫综合征（ARDS），并于两周后死亡。
结论： 气管支架患者的急诊气道管理在技术上具有挑战性，尤其是在存在支架移位时。支气管镜引导对于确保气管导管与支架腔正确对齐至关重要。临床医生应预判气道解剖改变，并做好复杂气道干预的准备。

英文摘要

BACKGROUND: Relapsing polychondritis (RP) is a rare autoimmune disorder characterized by recurrent inflammation of cartilaginous structures, frequently involving the tracheobronchial tree. Progressive airway involvement may result in tracheal stenosis and tracheobronchomalacia, often necessitating airway stent placement. Airway management in these patients is particularly challenging, especially in the presence of stent-related complications such as migration.
CASE PRESENTATION: A 71-year-old man with RP and a history of tracheobronchial stent placement presented with respiratory distress following a traumatic fall. Emergency tracheal intubation was indicated due to progressive hypoxemia. Computed tomography (CT) revealed cephalad migration of the tracheal stent, resulting in misalignment between the stent lumen and the native airway. Rapid sequence induction was performed under video laryngoscopy. During intubation, significant gastroesophageal regurgitation occurred. A 7.0-mm endotracheal tube was initially positioned with the cuff at the level of the vocal cords to reduce the risk of aspiration. After thorough suctioning of gastric contents, the tube was advanced into the stent lumen under flexible bronchoscopic guidance. Bronchoscopy revealed airway collapse consistent with tracheobronchomalacia and impaired ventilation of the right lung due to stent malposition. Attempts to reposition the stent were unsuccessful. The patient subsequently developed severe pulmonary infection and acute respiratory distress syndrome (ARDS) and died two weeks later.
CONCLUSIONS: Emergency airway management in patients with tracheal stents is technically challenging, particularly in the presence of stent migration. Bronchoscopic guidance is essential to ensure proper alignment of the endotracheal tube with the stent lumen. Clinicians should anticipate altered airway anatomy and be prepared for complex airway interventions.