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§ ≈‘ π‘ °

‡«™ªØ‘∫—µ‘ª√‘∑—»πå

ª“√¬– Õ“»π–‡ π æ.∫., √Õß»“ µ√“®“√¬å “¢“‚√§®¡Ÿ°·≈–‚√§¿Ÿ¡‘·æâ ¿“§«‘™“‚ µ π“ ‘° ≈“√‘ß´å«‘∑¬“§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈¡À“«‘∑¬“≈—¬¡À‘¥≈

°“√‡®“–§Õ (Tracheostomy)°“√‡®“–§Õ (tracheostomy) ‡ªìπ«‘∏’Àπ÷Ëß∑’Ë ”§—≠„π°“√§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„® (airway

control) πÕ°‡Àπ◊Õ®“°°“√„ à∑àÕ™à«¬À“¬„® (endotracheal intubation) ÷Ëß°“√§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„®·µà≈–«‘∏’°Á¡’¢âÕ¥’·≈–¢âÕ®”°—¥. ·æ∑¬åµâÕßµ—¥ ‘π„®‡≈◊Õ°«‘∏’§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„®∑’Ë‡À¡“– ¡ ‚¥¬‡©æ“–„π‡«≈“©ÿ°‡©‘π ‡æ◊ËÕ™à«¬™’«‘µºŸâªÉ«¬.

°“√‡®“–§Õ À¡“¬∂÷ß °“√ √â“ß∑“ßµ‘¥µàÕ√–À«à“ßÀ≈Õ¥≈¡ (cervical tracheal) °—∫º‘«Àπ—ß∫√‘‡«≥¥â“πÀπâ“¢Õß≈”§Õ1 ∑”„ÀâÕ“°“» “¡“√∂ºà“π‡¢â“ ŸàªÕ¥ ‚¥¬‰¡àµâÕßºà“π™àÕß®¡Ÿ° ·≈–≈”§Õ à«π∫π ‚¥¬¡’¢âÕ∫àß™’È¥—ßµàÕ‰ªπ’È

1. ‡æ◊ËÕ∫√√‡∑“°“√Õÿ¥°—Èπ„π√–∫∫∑“ß‡¥‘πÀ“¬„® à«π∫π (upper airway obstruction)‰¥â·°à ºŸâªÉ«¬∑’Ë‡ªìπ¡–‡√Áß°≈àÕß‡ ’¬ß À√◊Õ∑àÕ≈¡µ’∫, ºŸâªÉ«¬∑’Ë¡’¿“«–À¬ÿ¥À“¬„®¢≥–À≈—∫™π‘¥√ÿπ·√ß ÷Ëß∑”„ÀâÕ“°“»‰¡à “¡“√∂ºà“π®“°®¡Ÿ°‰ª ŸàªÕ¥‰¥â.

2. ‡æ◊ËÕ„Àâ„™â‡§√◊ËÕß™à«¬À“¬„®‡ªìπ√–¬–‡«≈“π“π (ventilation support) ‰¥â‚¥¬‰¡à¡’º≈¢â“ß‡§’¬ß¢Õß°“√∑’ËµâÕß„ à∑àÕ™à«¬À“¬„®‡ªìπ√–¬–‡«≈“π“π.

3. ‡æ◊ËÕ “¡“√∂¥Ÿ¥‡ ¡À–„πÀ≈Õ¥≈¡‰¥â¥’¢÷Èπ (pulmonary toilet) ‚¥¬‡©æ“–ºŸâªÉ«¬∑’Ë‰¡à√Ÿâ µ‘, ºŸâªÉ«¬∑’Ë¡’°“√µ‘¥‡™◊ÈÕ„πªÕ¥ À√◊ÕºŸâªÉ«¬∑’Ë¡’‡ ¡À–§—Ëß¡“°Ê∑’Ë‰¡à “¡“√∂‰ÕÕÕ°¡“‰¥â¥’.

4. ‡æ◊ËÕ™à«¬ª°ªÑÕß∑“ß‡¥‘πÀ“¬„® à«π≈à“ß (airway protection) „πºŸâªÉ«¬∑’Ë¡’°“√ ”≈—°‡≈◊Õ¥,‡ ¡À– À√◊Õ ‘ËßÕ“‡®’¬π À√◊ÕºŸâªÉ«¬∑’Ë‰¡à “¡“√∂‰Õ‰¥â ‡™àπ ºŸâªÉ«¬Õ—¡æ“µ À√◊Õ ºŸâªÉ«¬∑’Ë‰¡à√Ÿâ µ‘.

∑“ß‡≈◊Õ°„π°“√§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„® πÕ°‡Àπ◊Õ®“°°“√‡®“–§Õ1. °“√„ à∑àÕ™à«¬À“¬„® (endotracheal intubation) °“√„ à∑àÕ™à«¬À“¬„®∑“ßª“°

(orotracheal intubation) À√◊Õ∑“ß®¡Ÿ° (nasotracheal intubation) ‡ªìπ«‘∏’∑’Ë·æ∑¬å§ÿâπ‡§¬·≈– “¡“√∂∑”‰¥â√«¥‡√Á« ‡æ◊ËÕ§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„®¢ÕßºŸâªÉ«¬„π°√≥’©ÿ°‡©‘π ‚¥¬‡≈◊Õ°∑àÕ∑’Ë¡’¢π“¥‡À¡“– ¡ ·≈–∑”®“°«— ¥ÿ∑’Ë‡©◊ËÕ¬ (inert material) ‰¡à√–§“¬‡§◊ÕßµàÕ‡π◊ÈÕ‡¬◊ËÕ‚¥¬√Õ∫.°“√„™â low pressure cuff √«¡∑—Èß°“√‰¡à„Àâ∑àÕ¡’°“√‡§≈◊ËÕπµ—«‰ª¡“¡“°π—° (immobilization

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of tube) ‡ªìπ ‘Ëß ”§—≠∑’Ë®–™à«¬≈¥¿“«–·∑√°´âÕπ®“°°“√„ à∑àÕ™à«¬À“¬„® ‚¥¬‡©æ“– subglotticstenosis ‡«≈“∑’Ë‡À¡“– ¡ ”À√—∫°“√‡ª≈’Ë¬π®“°°“√„ à∑àÕ™à«¬À“¬„® ‡ªìπ°“√‡®“–§Õ ¬—ß‡ªìπ∑’Ë∂°‡∂’¬ß°—π ·≈–§«√æ‘®“√≥“‡ªìπ√“¬Ê ‰ª ÷Ëß¢÷Èπ°—∫À≈“¬ªí®®—¬‰¥â·°à √–¬–‡«≈“¢Õß°“√„ à∑àÕ™à«¬À“¬„®∑’Ëºà“π¡“, ‚√§ª√–®”µ—«¢ÕßºŸâªÉ«¬ ·≈–Õ“°“√ ·≈–§«“¡æ√âÕ¡¢ÕßºŸâªÉ«¬. ‚¥¬∑—Ë«‰ª·≈â« ‡¡◊ËÕºŸâªÉ«¬¡’§«“¡®”‡ªìπ∑’Ë®–µâÕß§“∑àÕ™à«¬À“¬„®¥â«¬¢âÕ∫àß™’È„¥°Áµ“¡‡ªìπ‡«≈“¡“°°«à“ 2 À√◊Õ 3 —ª¥“Àå §«√∑’Ë®–‰¥â√—∫°“√‡®“–§Õ.1-2

2. °“√‡®“– cricothyroid membrane

(cricothyroidotomy) ‡ªìπÀ—µ∂°“√∑’Ë “¡“√∂§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„® à«πµâπ‰¥â„π‡«≈“√«¥‡√Á« ‡æ◊ËÕ™à«¬™’«‘µºŸâªÉ«¬„π¿“«–©ÿ°‡©‘π. „π°√≥’∑’Ë‰¡à “¡“√∂„ à∑àÕ™à«¬À“¬„®‰¥â ·≈–‰¡àæ√âÕ¡∑’Ë®–‡®“–§Õ ‡π◊ËÕß®“°¡’‡«≈“®”°—¥ ·≈–/À√◊ÕÕ¬Ÿà„π ∂“π∑’Ë∑’Ë‰¡à¡’§«“¡æ√âÕ¡¢Õß‡§√◊ËÕß¡◊Õ ‡π◊ËÕß®“° cricothyroid mem-brane (¿“æ∑’Ë 1) ‡ªìπ∫√‘‡«≥∑’Ë‰¡à§àÕ¬¡’À≈Õ¥‡≈◊Õ¥¡“‡≈’È¬ß ∫“ß ·≈–Õ¬Ÿàµ◊Èπ „°≈âº‘«Àπ—ß. °“√„™â‡¢Á¡¢π“¥„À≠à À√◊Õ„™â¡’¥°√’¥„πµ”·Àπàßπ’È “¡“√∂‡¢â“ ŸàÀ≈Õ¥≈¡‰¥âÕ¬à“ß√«¥‡√Á« ‡æ◊ËÕ§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„®.Õ¬à“ß‰√°Áµ“¡ ‡¡◊ËÕºŸâªÉ«¬Õ¬Ÿà„π¿“«–∑’Ëª≈Õ¥¿—¬·≈â«§«√‡ª≈’Ë¬π‡ªìπ°“√‡®“–§Õ ¿“¬„π√–¬–‡«≈“ 24 ™—Ë«‚¡ß‡æ◊ËÕ„Àâ∫ÿ§≈“°√∑“ß°“√·æ∑¬å “¡“√∂¥Ÿ·≈∑“ß‡¥‘πÀ“¬„®¢ÕßºŸâªÉ«¬‰¥âßà“¬ ·≈–≈¥Õÿ∫—µ‘°“√≥å¢Õß°“√‡°‘¥laryngotracheal stenosis.

3. °“√„ à bronchoscope ™π‘¥·¢Áß (rigid

bronchoscopy) ‡ªìπ°“√„™â bronchoscope ™π‘¥·¢Áß∑’Ë¡’≈—°…≥–‡ªìπ∑àÕ°≈«ß·¢Áß Õ¥ºà“π®“°ª“°‰ª Ÿà≈”§Õ °≈àÕß‡ ’¬ß ·≈–‰ª¬—ßÀ≈Õ¥≈¡‡æ◊ËÕ§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„® ÷Ëß§≈â“¬°—∫°“√„ à∑àÕ™à«¬À“¬„® ·µàµà“ß°—πµ√ß∑’Ë„™â«— ¥ÿ™π‘¥·¢Áß ·∑π∑àÕ™à«¬À“¬„® ÷ËßÕàÕπ°«à“. ª√–‚¬™πå¢Õß°“√„™â bronchoscope ™π‘¥·¢Áß §◊Õ “¡“√∂„™â‡∫’¬¥¥—π‡π◊ÈÕ‡¬◊ËÕÕàÕπ À√◊Õ‡π◊ÈÕßÕ°(‡™àπ laryngocele, supraglottic mass) “¡“√∂„™â

∑–≈«ß ·≈–∂à“ß¢¬“¬®ÿ¥µ’∫·§∫„π∑“ß‡¥‘πÀ“¬„® à«π∫π (‡™àπ soft subglottic stenosis, laryngealweb) ‡æ◊ËÕ‡¢â“ Ÿà∑“ß‡¥‘πÀ“¬„® à«π≈à“ß ·≈– “¡“√∂∑”À—µ∂°“√ºà“π bronchoscope ‰¥â (‡™àπ°“√§’∫«— ¥ÿ·ª≈°ª≈Õ¡„πÀ≈Õ¥≈¡). °“√„™â bronchoscope™π‘¥·¢Áß ¡’¢âÕ∫àß™’È‡©æ“–·≈–¡’¢âÕ®”°—¥ §◊Õ‰¡à‰¥â¡’‡§√◊ËÕß¡◊Õπ’ÈÕ¬Ÿà∑—Ë«‰ª √«¡∑—ÈßºŸâ∑’Ë®–∑”À—µ∂°“√π’È®”‡ªìπ®–µâÕß¡’§«“¡™”π“≠·≈–ºà“π°“√Ωñ°Ωπ¡“æÕ ¡§«√.

‡∑§π‘§°“√‡®“–§Õ°“√‡®“–§Õ “¡“√∂∑”‰¥â„π°√≥’©ÿ°‡©‘π À√◊Õ

‡ªìπ elective procedure ¢÷ÈπÕ¬Ÿà°—∫¢âÕ∫àß™’È ·≈– ¿“«–¢ÕßºŸâªÉ«¬ „π°√≥’©ÿ°‡©‘π “¡“√∂∑”‰¥â∑’Ë¢â“ß‡µ’¬ß¢ÕßºŸâªÉ«¬. Õ¬à“ß‰√°Áµ“¡ °“√∑” electivetracheostomy §«√∑”„πÀâÕßºà“µ—¥∑’Ë¡’Õÿª°√≥åæ√âÕ¡ ‡™àπ ‡µ’¬ßºà“µ—¥, ‡§√◊ËÕß¡◊Õ¥Ÿ¥‡≈◊Õ¥ (suction),‡§√◊ËÕß¡◊Õ®’È‰øøÑ“ (electrical cauterization), · ß‰ø∑’Ë‡æ’¬ßæÕ·≈–‡À¡“– ¡ ·≈–¡’ºŸâ™à«¬∑’Ë¡’§«“¡™”π“≠ ‡æ◊ËÕ≈¥Õÿ∫—µ‘°“√≥å¢Õß¿“«–·∑√°´âÕπ®“°À—µ∂°“√π’È

1. «‘∏’√–ß—∫§«“¡√Ÿâ ÷° (anesthesia) °“√‡®“–§Õ∑”‰¥â‚¥¬°“√©’¥¬“™“ (local anesthesia)À√◊Õ¥¡¬“ ≈∫ (general anesthesia) ∑—Èßπ’È¢’ÈπÕ¬Ÿà°—∫¿“«–¢ÕßºŸâªÉ«¬. √“¬∑’Ëºà“µ—¥‚¥¬«‘∏’¥¡¬“ ≈∫ §«√„ÀâºŸâªÉ«¬ß¥πÈ”·≈–Õ“À“√°àÕπ‡®“–§ÕÕ¬à“ßπâÕ¬ 6 ™—Ëß‚¡ß‡æ◊ËÕªÑÕß°—π°“√ ”≈—°Õ“À“√≈ßªÕ¥ ‡«≈“¥¡¬“ ≈∫„π°√≥’ºŸâªÉ«¬‡¥Á° ¡—°®”‡ªìπµâÕß∑”¥â«¬«‘∏’¥¡¬“ ≈∫‚¥¬Õ“»—¬§«“¡√à«¡¡◊Õ®“°«‘ —≠≠’·æ∑¬å ‡æ◊ËÕ„Àâ°“√§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„®ª≈Õ¥¿—¬∑—Èß°àÕπ ¢≥– ·≈–À≈—ß°“√‡®“–§Õ. ºŸâªÉ«¬∫“ß√“¬∑’Ë¡’ªí≠À“∑“ß‡¥‘πÀ“¬„®Õÿ¥°—Èπ©ÿ°‡©‘π (impending airway obstruction)∑’Ë¡’¢âÕ®”°—¥„π°“√„ à∑àÕ™à«¬À“¬„® Õ“®®”‡ªìπµâÕß‡®“–§Õ ‚¥¬„™â¬“™“‡©æ“–∑’Ë §«√·®âß„Àâ«‘ —≠≠’·æ∑¬å√à«¡¥Ÿ·≈ºŸâªÉ«¬„π¢≥–‡®“–§Õ¥â«¬∑ÿ°§√—Èß ·≈–§«√‡µ√’¬¡ bronchoscope ™π‘¥·¢Áß ‡º◊ËÕ‰«â„π°√≥’©ÿ°‡©‘π.

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2. °“√®—¥∑à“ºŸâªÉ«¬ (patient positioning)

∑à“¢ÕßºŸâªÉ«¬∑’Ë‡À¡“– ¡„π°“√‡®“–§Õ §◊Õ∑à“πÕπÀß“¬ (supine position) ·≈–‡Õπ§Õ‰ª∑“ß¥â“πÀ≈—ß(neck extension) ‚¥¬«“ßÀ¡Õπ∑√“¬‰«â„µâ‰À≈à¢Õß

ºŸâªÉ«¬ ‡æ◊ËÕ∑”„Àâ à«π¢ÕßÀ≈Õ¥≈¡∫√‘‡«≥≈”§Õ √«¡∑—Èß anatomical landmarks µà“ßÊ ∫√‘‡«≥π’È‡ÀÁπ‰¥â™—¥·≈–ßà“¬µàÕ°“√∑”À—µ∂°“√. Õ¬à“ß‰√°Á¥’„π∫“ß°√≥’∑’ËºŸâªÉ«¬¡’ªí≠À“∑“ß‡¥‘πÀ“¬„®Õÿ¥°—Èπ©ÿ°‡©‘π

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Õ“®‰¡à “¡“√∂πÕπ√“∫„π∑à“·Àßπ§Õ‰¥â Õ“®®”‡ªìπµâÕß‡®“–§Õ„π∑à“π—ËßÀ√◊Õ ∑à“πÕπ¬°»’√…– Ÿß.

3. ¢—ÈπµÕπ°“√∑” (operative technique)

(¿“æ∑’Ë 2 ·≈– 3)- ‡µ√’¬¡º‘«Àπ—ß∫√‘‡«≥ºà“µ—¥ ‰¥â·°à ∫√‘‡«≥

§Õ à«πÀπâ“ ·≈–Õ° à«π∫π.- §≈”À“ cricoid cartilage ·≈– sternal

notch ·≈–©’¥¬“™“∑’Ë¡’ à«πº ¡¢Õß¬“À¥À≈Õ¥‡≈◊Õ¥(lidocaine with adrenaline) ∫√‘‡«≥∑’Ë®–≈ß¡’¥.

- ”À√—∫ºŸâ„À≠à ≈ß¡’¥„π·π«πÕπ (hori-zontal incision) ª√–¡“≥ 1 §«“¡°«â“ß¢Õßπ‘È«¡◊Õ(one fingerbreadth) µË”°«à“ cricoid cartilage. ”À√—∫‡¥Á° ≈ß¡’¥„π·π«µ—Èß (vertical incision)ª√–¡“≥ 1 ´¡. ‡Àπ◊Õ sternum.

- æ¬“¬“¡À“·π«µ√ß°≈“ß ·≈–·¬° strapmuscles ‰ª∑“ß¥â“π¢â“ß ®–‡ÀÁπµàÕ¡∏—¬√Õ¬¥å ·≈–æ¬“¬“¡¥—πµàÕ¡∏—¬√Õ¬¥å‰ª∑“ß¥â“π∫π ‡æ◊ËÕ‡¢â“À“trachea ·≈–§«∫§ÿ¡‡≈◊Õ¥„ÀâÀ¬ÿ¥ °àÕπ∑’Ë®–≈ß¡’¥∑’Ëtrachea.

- „™â syringe ∫√√®ÿ¬“™“ ∑’Ë¡’‡¢Á¡ªí°≈ß‰ª∑’Ë trachea ·≈â«≈Õß¥Ÿ¥¥Ÿ ∂â“‡ªìπ trachea °Á®–¥Ÿ¥‰¥âÕ“°“» (air) °“√∑”‡™àππ’È‡æ◊ËÕ„Àâ·πà„®«à“Õ«—¬«–∑’Ë®–‡®“–≈ß‰ªπ—Èπ‡ªìπ trachea.

- ”À√—∫ºŸâ„À≠à ≈ß¡’¥∑’Ë trachea (tra-cheal incision) ‡ªìπ√Ÿª U À—«°≈—∫ (invertedU-shaped incision) ∑’Ë tracheal ring ∑’Ë 2 ·≈– 3 ”À√—∫‡¥Á° ≈ß¡’¥∑’Ë trachea „π·π«µ—Èß (verticalincision).

- „™â silk ‡∫Õ√å 2-0 ‡¬Á∫ inverted U-shaped tracheal flap ‡ªìπ stay suture à«π„π‡¥Á°‡¬Á∫ trachea ¥â“π¢â“ß¢Õß vertical incision ∑—Èß 2¢â“ß ‡æ◊ËÕ™à«¬‡ªî¥∑“ß„π°“√„ à tracheostomy tubeπÕ°®“°π—Èπ stay suture ®–™à«¬„Àâ·æ∑¬å„ à tracheo-stomy tube ‡¢â“‰ª‰¥â„À¡à °√≥’∑àÕÀ≈ÿ¥.

- „ à tracheostomy tube ≈ß‰ª„π trachea·≈–¬÷¥ tracheostomy tube ‚¥¬„™â “¬√—¥√Õ∫§Õ„Àâ

·πàπ ‚¥¬„Àâ‡æ’¬ßπ‘È« 1 π‘È«≈Õ¥‰¥â‡∑à“π—Èπ.

°“√‡≈◊Õ° tracheostomy tube°“√‡≈◊Õ° tracheostomy tube ∑’Ë‡À¡“– ¡°—∫

ºŸâªÉ«¬π—Èπ µâÕßæ‘®“√≥“∂÷ßÕ“¬ÿºŸâªÉ«¬ ¢π“¥¢Õßtrachea ¢ÕßºŸâªÉ«¬ «— ¥ÿ∑’Ë„™â∑” tracheostomy tube(æ≈“ µ‘°, ‚≈À–‡ß‘π, ‚≈À–º ¡, ‘≈‘‚§π) √«¡∑—Èß™π‘¥¢Õß∑àÕ«à“‡ªìπ·∫∫¡’ cuff À√◊Õ‰¡à¡’ cuff (noncuff). °“√‡≈◊Õ°¢π“¥¢Õß tracheostomy tube ∑’ËæÕ‡À¡“–°—∫¢π“¥¢Õß trachea ¢ÕßºŸâªÉ«¬ (¿“æ∑’Ë 4)®–™à«¬ªÑÕß°—πÕ—πµ√“¬µàÕ tracheal mucosa ·≈–cartilage ´÷ËßÕ“®°àÕ„Àâ‡°‘¥ tracheal stenosis, tra-cheomalacia ·≈– tracheo-innominate arteryfistula µ“¡¡“ ÷Ëß®–‡ªìπ “‡Àµÿ∑’ËºŸâªÉ«¬‰¡à “¡“√∂∂Õ¥tracheostomy tube ÕÕ°‰¥â (failure of decan-nulation). „πºŸâªÉ«¬‡¥Á°∑’Ë„™â tracheostomy tube¢π“¥‡≈Á° µâÕß√–«—ßªí≠À“‡√◊ËÕß°“√Õÿ¥°—Èπ¢Õß∑àÕ®“°‡ ¡À– ÷Ëß‡°‘¥‰¥â‚¥¬ßà“¬ °“√¥Ÿ·≈∑àÕ∑’Ë∂Ÿ°µâÕß ·≈–‡À¡“– ¡ ‡™àπ °“√¥Ÿ¥‡ ¡À– ‰¡à„Àâ∑àÕµ—π °“√„ÀâπÈ”·≈–§«“¡™◊Èπ∑’ËæÕ‡æ’¬ß (adequate humidification)‡ªìπ ‘Ëß ”§—≠„πºŸâªÉ«¬‡¥Á°. ‡π◊ÈÕ‡¬◊ËÕ∑’ËÕàÕπ∫“ß ·≈–redundant soft tissue ∫√‘‡«≥§Õ¥â“πÀπâ“¢Õß‡¥Á°∑”„Àâ¡’‚Õ°“ ∑’Ë∑àÕ®–À≈ÿ¥ (accidental decannula-tion) ·≈–‡§≈◊ËÕπµ—« (tube displacement) ‰¥â Ÿß°“√‡≈◊Õ° tracheostomy tube ∑’Ë∑”®“°«— ¥ÿÕàÕππÿà¡¬◊¥ À√◊Õ∫‘¥µ—«‰¥â ‡™àπ neonatal À√◊Õ pediatricShileyTM tube √«¡∑—Èß°“√‡¬Á∫ flange ¢Õß tracheo-stomy tube µ‘¥°—∫º‘«Àπ—ß ·≈–‡π◊ÈÕ‡¬◊ËÕÕàÕπ∫√‘‡«≥√Õ∫Ê stoma ®–™à«¬≈¥ªí≠À“π’È‰¥â.

°“√„™â tracheostomy tube ∑’Ë¡’ cuff seal°—∫ tracheal wall π—Èπ¡’ª√–‚¬™πå„πºŸâªÉ«¬∑’Ë®”‡ªìπµâÕß„™â‡§√◊ËÕß™à«¬À“¬„® (respirator) ™à«¬≈¥ªí≠À“°“√ ”≈—° (aspiration) ‡™àπ “¡“√∂ªÑÕß°—π‡≈◊Õ¥∑’ËÕ“®´÷¡®“°¢Õ∫·º≈‡®“–§Õ≈ß‰ª„π trachea À≈—ßºà“µ—¥„À¡àÊ. °“√ blow cuff ‰«âµ≈Õ¥‡«≈“ Õ“®∑”„Àâ

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‡°‘¥ pressure necrosis ∫π tracheal wall ·≈–‡°‘¥ªí≠À“ tracheal stenosis, tracheomalacia, tra-cheoesophageal fistula, tracheo-innominateartery fistula µ“¡¡“‰¥â. ¥—ßπ—Èπ ‡¡◊ËÕÀ¡¥¢âÕ∫àß™’È¢Õß°“√ blow cuff ·≈â« µâÕß deflate cuff À√◊Õ‡ª≈’Ë¬π‡ªìπ tracheostomy tube ™π‘¥‰¡à¡’ cuff‡æ◊ËÕªÑÕß°—π¿“«–·∑√° âÕπ‡À≈à“π’È.

Tracheostomy tube ∫“ß™π‘¥¡’¢π“¥„À≠à‡æ’¬ßæÕ∑’Ë®–¡’∑àÕ 2 ™—Èπ §◊Õ inner and outer can-nula (¿“æ∑’Ë 4) ∑”„Àâ “¡“√∂∂Õ¥ inner cannulaÕÕ° ‡æ◊ËÕ≈â“ß∑”§«“¡ –Õ“¥‰¥â ∑”„Àâßà“¬µàÕ°“√¥Ÿ·≈√—°…“ ·≈–≈¥‚Õ°“ ‡°‘¥°“√Õÿ¥°—Èπ¢Õß∑àÕ®“°‡ ¡À– tracheostomy tube ∑’Ë„™â„π‡¥Á°‡≈Á° ∂Ÿ°®”°—¥¥â«¬¢π“¥ ∑”„Àâ‰¡à “¡“√∂¡’ inner cannula ‰¥â¥—ßπ—Èπ«— ¥ÿ∑’Ë„™â∑”∑àÕµâÕß¡’§«“¡æ‘‡»… ‰¡à∂Ÿ°®—∫‡°“–¥â«¬‡ ¡À–∑’Ë‡Àπ’¬«¢âπ À√◊Õ·Àâß‰¥â‚¥¬ßà“¬.

¢π“¥§«“¡¬“«¢Õß tracheostomy tube‡ªìπ ‘Ëß ”§—≠‡™àπ°—π ∑àÕ∑’Ë¡’¢π“¥¬“«‡°‘π‰ª Õ“®°àÕ„Àâ‡°‘¥ªí≠À“ one lung ventilation „π∑“ß°≈—∫°—π∑àÕ∑’Ë¡’¢π“¥ —Èπ‡°‘π‰ª°Á¡’‚Õ°“ ∑’Ë®–‡≈◊ËÕπÀ≈ÿ¥®“°

trachea ‰¥â‚¥¬ßà“¬. ¥—ßπ—ÈπÀ≈—ß°“√‡®“–§Õ∑ÿ°§√—Èß·æ∑¬åµâÕß¡—Ëπ„®«à“∑àÕÕ¬Ÿà„πµ”·Àπàß∑’Ë‡À¡“– ¡ ¥â«¬°“√øíß‡ ’¬ß breath sound „π∑à“∑’ËºŸâªÉ«¬πÕπÀß“¬·≈–ÀπÿπÀ¡Õπ∑’Ë»’√…–‚¥¬‡Õ“À¡Õπ∑’ËÀπÿπ‰«â∑’Ë‰À≈àºŸâªÉ«¬ÕÕ°®πÀ¡¥·≈â« «à“ª°µ‘¥’·≈–‡∑à“°—π∑—Èß Õß¢â“ßÀ√◊Õ‰¡à. πÕ°®“°π—Èπ §«√∂à“¬¿“æ‡Õ° å‡√¬åªÕ¥À≈—ß‡®“–§Õ∑—π∑’ ‡æ◊ËÕ¬◊π¬—πµ”·Àπàß¢Õßª≈“¬ tra-cheostomy tube ·≈–¥Ÿ«à“¡’¿“«–·∑√° âÕπ®“°°“√‡®“–§Õ¥â«¬À√◊Õ‰¡à „π°√≥’∑’Ë¡’ªí≠À“‡°’Ë¬«°—∫°“√À“¬„®ºà“π tracheostomy tube Õ“®®–µâÕß„™âflexible bronchoscope µ√«®¬◊π¬—πµ”·Àπàß¢Õßª≈“¬ tracheostomy tube Õ’°§√—Èß.

Fenestrated tracheostomy tube (¿“æ∑’Ë 5) ∂Ÿ°ÕÕ°·∫∫„Àâ¡’√Ÿ∫√‘‡«≥ à«π‚§âß¥â“π∫π¢Õß tracheo-stomy tube ‡æ◊ËÕ„ÀâºŸâªÉ«¬ “¡“√∂‡ª≈àß‡ ’¬ß‰¥â ‚¥¬„™âπ‘È«¡◊Õªî¥∑àÕ„π¢≥–À“¬„®ÕÕ° ≈¡À“¬„®ÕÕ°®“°À≈Õ¥≈¡°Á®–ºà“π∑àÕ‰ª¬—ß√Ÿ‡ªî¥∑“ß¥â“π∫π Ÿà°≈àÕß‡ ’¬ßÕÕ°‰ª¬—ß≈”§Õ ºŸâªÉ«¬°Á®– “¡“√∂‡ª≈àß‡ ’¬ß‰¥â‡™àπ„πºŸâªÉ«¬ obstructive sleep apnea ∑’Ë‰¥â√—∫°“√√—°…“¥â«¬°“√‡®“–§Õ ºŸâªÉ«¬¡’ physiologic airway

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obstruction ‡©æ“–‡«≈“πÕπÀ≈—∫‡∑à“π—Èπ „π¢≥–ºŸâªÉ«¬µ◊Ëπ “¡“√∂„™â fenestrated tracheostomy tube‚¥¬ªî¥∑àÕ‰«â„ÀâºŸâªÉ«¬À“¬„®‰¥âµ“¡ª°µ‘ ºà“π√Ÿ∑“ß¥â“π∫π¢Õß∑àÕ ∑”„ÀâºŸâªÉ«¬ “¡“√∂ÕÕ°‡ ’¬ß ◊ËÕ “√°—∫ºŸâÕ◊Ëπ‰¥â ·≈–„™â™’«‘µª√–®”«—π‰¥âµ“¡ª°µ‘ ‡¡◊ËÕ‡¢â“πÕπ®÷ß‡ªî¥∑àÕ∑’Ëªî¥‰«âÕÕ° „ÀâÀ“¬„®‡¢â“ÕÕ°∑“ßtracheostomy tube.

¿“«–·∑√° âÕπ¢≥–ºà“µ—¥ (intraoperativecomplications)

‚¥¬∑—Ë«‰ª·≈â«Õÿ∫—µ‘°“√≥å¢Õß°“√‡°‘¥¿“«–·∑√° âÕπ„π¢≥–ºà“µ—¥ elective tracheostomyπ—ÈππâÕ¬¡“° ∂â“·æ∑¬å™”π“≠·≈–¡’ª√– ∫°“√≥å°√≥’∑’Ë®”‡ªìπµâÕß∑” emergency tracheostomy „π ∂“π°“√≥å√’∫¥à«π ·≈–„π ∂“π∑’Ë∑’Ë‰¡à¡’§«“¡æ√âÕ¡¢Õß‡§√◊ËÕß¡◊Õ ·≈–· ß‰ø °ÁÕ“®∑”„Àâ¡’‚Õ°“ ‡°‘¥¿“«–·∑√° âÕπ®“°°“√‡®“–§Õ‰¥â §◊Õ

1. Hemorrhage ‡≈◊Õ¥Õ“®®–ÕÕ°‰¥â®“°°“√∫“¥‡®Á∫µàÕ anterior jugular vein À√◊Õ ®“°∫√‘‡«≥isthmus ¢ÕßµàÕ¡∏—¬√Õ¬¥å. „π∫“ß°√≥’‡≈◊Õ¥∑’ËÕÕ°¡“°Õ“®‡°‘¥‰¥â®“°°“√∫“¥‡®Á∫µàÕ innominate artery∑’ËÕ“®≈Õ¬ Ÿß¢÷Èπ¡“‡Àπ◊Õ manubrium ‰¥â §«√‡®“–§Õ¥â«¬§«“¡√–¡—¥√–«—ß ‚¥¬¡’§«“¡√Ÿâ∑“ß°“¬«‘¿“§·≈–æ¬“¬“¡‡¢â“·π«°≈“ß‰«â ¢≥–∑”ºà“µ—¥ ®–™à«¬≈¥ªí≠À“‡√◊ËÕß‡≈◊Õ¥ÕÕ°‰¥â.

2. Pneumothorax, pneumomediasti-

num, subcutaneous emphysema °“√„™âocclusive packing ·≈–°“√‡¬Á∫¢Õ∫·º≈√Õ∫ tra-cheostoma ∑’Ë·πàπ®π‡°‘π‰ª Õ“®∑”„Àâ≈¡À“¬„®ÕÕ°√—Ë«‰ª√Õ∫ tracheostoma ·≈–‡´“–‰ªµ“¡‡π◊ÈÕ‡¬◊ËÕÕàÕπ∫√‘‡«≥§Õ¥â“πÀπâ“ ‡°‘¥‡ªìπ subcutane-ous emphysema ‰¥â. „π°√≥’∑’Ë¡’°“√‡≈“–∫√‘‡«≥pretracheal area ‡ªìπ∫√‘‡«≥°«â“ß °ÁÕ“®∑”„Àâ≈¡∑’Ë√—Ë«ÕÕ°¡“ ‡´“–‡¢â“‰ª„π mediastinum (pneu-momediastinum). ¥—ßπ—Èπ°“√‡≈“– pretracheal soft

tissue §«√‡≈“–‡æ’¬ß·§à “¡“√∂≈ß incision ∫π tra-chea ‰¥â‡∑à“π—Èπ ·≈–‰¡à§«√ pack À√◊Õ‡¬Á∫¢Õ∫·º≈‡¢â“À“°—π®π·πàπ ´÷Ëß‰¡à‡æ’¬ß·µà°àÕ„Àâ‡°‘¥ªí≠À“¥—ß°≈à“«¢â“ßµâπ ·µà¬—ß∑”„Àâ°“√„ à∑àÕ‡¢â“‰ª„À¡à „π°√≥’∑’Ë∑àÕÀ≈ÿ¥ À√◊Õ‡§≈◊ËÕπµ—« ∑”‰¥â¥â«¬§«“¡¬“°≈”∫“°„πºŸâªÉ«¬‡¥Á° pleural dome ®–≈Õ¬ Ÿß¢÷Èπ¡“∫√‘‡«≥base of neck ‰¥â. °“√©’°¢“¥¢Õß pleura ∑”„Àâ‡°‘¥ªí≠À“ pneumothorax µ“¡¡“‰¥â.

3. Failure to obtain an airway ºŸâªÉ«¬∑’Ë¡’ªí≠À“∑“ß‡¥‘πÀ“¬„®Õÿ¥°—Èπ©ÿ°‡©‘π ·≈–¡’§«“¡®”‡ªìπ∑’Ë®–µâÕß‰¥â√—∫°“√‡®“–§ÕÕ¬à“ß‡√àß¥à«π‚¥¬„™â¬“™“‡©æ“–∑’Ë ®–°√– —∫°√– à“¬ ‰¡àÕ¬Ÿàπ‘Ëß trachea®–¡’°“√‡§≈◊ËÕπ‰À«¢÷Èπ≈ßµ≈Õ¥‡«≈“ µ“¡®—ßÀ«–°“√À“¬„®∑’Ë·√ß·≈–‡√Á« Õ“®∑”„Àâ°“√‡®“–§Õ ”‡√Á®‰¥â¬“°ª√–°Õ∫°—∫·√ß°¥‡∫’¬¥®“°‡§√◊ËÕß¡◊Õ≈ß‰ª∫π≈”§ÕºŸâªÉ«¬ ®–∑”„ÀâºŸâªÉ«¬¡’§«“¡∑ÿ°¢å∑√¡“π‡æ‘Ë¡¢÷Èπ. °“√§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„®¢ÕßºŸâªÉ«¬„π°√≥’‡™àππ’ÈÕ“®∑”‰¥â‰¡àßà“¬ „π‡«≈“Õ—π®”°—¥ ·≈–ºŸâªÉ«¬¡’‚Õ°“ ‡ ’¬™’«‘µ‰¥â. ¥—ßπ—Èπ§«√§«∫§ÿ¡∑“ß‡¥‘πÀ“¬„®¢ÕßºŸâªÉ«¬„Àâª≈Õ¥¿—¬°àÕπ‡®“–§Õ ‰¡à«à“®–¥â«¬«‘∏’„¥°Áµ“¡ ‡™àπ°“√„ à∑àÕ™à«¬À“¬„® À√◊Õ°“√„™â rigid bronchoscope∂â“¡’‡§√◊ËÕß¡◊Õæ√âÕ¡∑’Ë®–∑”‰¥â ·≈–‰¡à¡’¢âÕÀâ“¡ ·≈–µâÕßÕ“»—¬°“√®—¥∑à“ºŸâªÉ«¬∑’Ë∂Ÿ°µâÕß ·≈–‡§√◊ËÕß¡◊Õ∑’Ëæ√âÕ¡ ‡™àπ ¡’ tracheal hook ∑’Ë§Õ¬¬÷¥‡°’Ë¬«À≈Õ¥≈¡„ÀâÕ¬Ÿàπ‘Ëß ·≈–ºŸâ™à«¬∑’Ëæ√âÕ¡ ·≈–™”π“≠ ÷Ëß®–∑”„Àâ·æ∑¬å “¡“√∂‡®“–§Õ‰¥â ”‡√Á®„π‡«≈“∑’Ë√«¥‡√Á«.

4. Accidental decannulation and im-

proper position of tube º‘«Àπ—ß·≈–‡π◊ÈÕ‡¬◊ËÕ‰¢¡—π∫√‘‡«≥≈”§Õ¢ÕßºŸâªÉ«¬∑’ËÀπ“, °“√‡§≈◊ËÕπ‰À«¢Õß»’√…–‰ª¡“, ∑àÕ∑’Ë¡’¢π“¥ —Èπ‡°‘π‰ª ·≈–°“√ºŸ° “¬√—¥ tracheostomy tube ∑’Ë‰¡à·πàπæÕ ®–∑”„Àâ‡°‘¥°“√‡≈◊ËÕπÀ≈ÿ¥¢Õß∑àÕ®“°À≈Õ¥≈¡‰¥â ´÷ËßÕ“®¡’Õ—πµ√“¬∂÷ß™’«‘µ. ∑àÕ∑’Ë¡’¢π“¥¬“«‡°‘π‰ª ‡¡◊ËÕºŸâªÉ«¬Õ¬Ÿà„π∑à“°â¡»’√…– À≈Õ¥≈¡¡’°“√À¬àÕπµ—«‡µÁ¡∑’Ëª≈“¬¢Õß∑àÕÕ“®Õ¬Ÿà„πµ”·Àπàß∑’Ë‡≈¬ carina ≈ß‰ª„πright main bronchus ‡°‘¥ one lung ventilation

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‰¥â °“√‡≈◊Õ°™π‘¥·≈–¢π“¥∑àÕ∑’Ë‡À¡“– ¡, °“√ºŸ° “¬∑àÕ√—¥√Õ∫≈”§Õ„Àâ·πàπ‡æ’¬ßæÕ·§à 1 π‘È«¡◊Õ Õ¥ºà“π3-4 √«¡∑—Èß°“√µ√«®¬◊π¬—πµ”·Àπàß¢Õß∑àÕÀ≈—ß°“√‡®“–§Õ ¥â«¬°“√øíß‡ ’¬ßÀ“¬„®ºà“π‡¢â“ªÕ¥ ·≈–∂à“¬¿“æ‡Õ° å‡√¬åªÕ¥ ®÷ß‡ªìπ ‘Ëß ”§—≠∑’Ë≈–‡≈¬‰¡à‰¥â.

5. Tracheoesophageal fistula °“√≈ßincision ∫π trachea ∑’Ë¢“¥§«“¡√–¡—¥√–«—ß ‚¥¬‡©æ“–„πºŸâªÉ«¬‡¥Á° ÷Ëß¡’¢π“¥¢Õß trachea ‡≈Á°¡“°ÊÕ“®‡°‘¥°“√∫“¥‡®Á∫µàÕ posterior tracheal wall·≈–∑–≈ÿ‰ª¬—ß esophagus ‰¥â.

6. Pulmonary edema °“√∫√√‡∑“ªí≠À“∑“ß‡¥‘πÀ“¬„®Õÿ¥°—Èπ‡√◊ÈÕ√—ß ¥â«¬°“√‡®“–§Õ Õ“®∑”„Àâintraluminal pressure ¢ÕßÀ≈Õ¥≈¡∑’Ë‡§¬ ŸßÕ¬Ÿà‡ªìπ√–¬–‡«≈“π“π ≈¥≈ßÕ¬à“ß√«¥‡√Á« ·≈–¡’ extravasa-tion ¢Õß¢Õß‡À≈«ºà“π alveolar wall ‡¢â“¡“„πÀ≈Õ¥≈¡®π‡°‘¥ pulmonary edema ‰¥â.

°“√¥Ÿ·≈À≈—ßºà“µ—¥ (postoperative care)1. °“√∂à“¬¿“æ‡Õ°´å‡√¬åªÕ¥ (chest X

ray) ‡æ◊ËÕ¥Ÿµ”·Àπàß¢Õßª≈“¬∑àÕ ·≈–¥Ÿ«à“¡’¿“«–·∑√° âÕπÕ◊ËπÊ ∑’Ë‡°‘¥®“°°“√‡®“–§Õ ‡™àπ pneu-mothorax À√◊Õ‰¡à.

2. Humidification Õ“°“»∑’ËÀ“¬„®ºà“π∑àÕ‡®“–§Õ ®–·Àâß ¢“¥§«“¡™ÿà¡™◊Èπ ¢“¥°“√ª√—∫Õÿ≥À¿Ÿ¡‘·≈–¢“¥°“√°√Õß¥—°ΩÿÉπ≈–ÕÕß ‚¥¬‚æ√ß®¡Ÿ° °“√„Àâ humidified air ºà“π∑“ß tracheal collar ®–™à«¬ªÑÕß°—π°“√‡°‘¥ tracheal dryness, crusting ·≈–mucous plug formation.

3. Pulmonary toilet Õ“°“»∑’Ë·Àâß √«¡∑—Èß°“√√–§“¬‡§◊Õß tracheal mucosa ‡π◊ËÕß®“° tracheo-stomy tube ∑”„Àâ¡’°“√‡æ‘Ë¡ª√‘¡“≥¢Õß‡ ¡À–ª√–°Õ∫°—∫ºŸâªÉ«¬∑’Ë¡’ tracheostomy tube ‰¡à “¡“√∂∑”„Àâ‡°‘¥ subglottic pressure ∑’Ë‡æ’¬ßæÕ∑’Ë®–∑”„Àâ‰Õ¢—∫‡ ¡À–‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ. °“√„Àâ deep tracheal suction ·°àºŸâªÉ«¬ ®–∑”„ÀâºŸâªÉ«¬

√Ÿâ ÷° ∫“¬¢÷Èπ πÕ°®“°π—Èπ§«√°√–µÿâπ„ÀâºŸâªÉ«¬‰Õ∫àÕ¬Ê.

4. Prevention of infection À≈—ß°“√‡®“–§Õ À≈Õ¥≈¡®–¡’∑“ßµ‘¥µàÕ°—∫Õ“°“»¿“¬πÕ°‚¥¬µ√ß‚¥¬‰¡à¡’ ‘Ëß„¥ªÑÕß°—π. ‡ ¡À–∑’Ë‡°‘¥„π∑“ß‡¥‘πÀ“¬„®°Á “¡“√∂ªπ‡ªóôÕπ‰ª∑’Ë·º≈‡®“–§Õ‰¥â‚¥¬µ√ß. °“√„™â‡∑§π‘§ª≈Õ¥‡™◊ÈÕ ·≈–‡§√◊ËÕß¡◊Õ„π°“√¥Ÿ¥‡ ¡À–,°“√ªÑÕß°—π ‘Ëß·ª≈°ª≈Õ¡®“°¿“¬πÕ°‡¢â“‰ª„πÀ≈Õ¥≈¡‚¥¬µ√ß ·≈–°“√¥Ÿ·≈∑”§«“¡ –Õ“¥∫√‘‡«≥·º≈‡®“–§Õ ·≈– stoma ·≈–‡ª≈’Ë¬πºâ“°äÕ ∑ÿ°«—πÕ¬à“ßπâÕ¬«—π≈– 1- 2 §√—Èß À√◊Õ‡¡◊ËÕ‡ªï¬°·©– ®–™à«¬ªÑÕß°—π°“√µ‘¥‡™◊ÈÕ∫√‘‡«≥√Õ∫·º≈‡®“–§Õ·≈–„πÀ≈Õ¥≈¡‰¥â‡ªìπÕ¬à“ß¥’.

5. Maintenance of airway „π™à«ß 48-72™—Ë«‚¡ß·√° À≈—ß°“√‡®“–§Õ ∂◊Õ«à“‡ªìπ™à«ß‡«≈“∑’ËÕ—πµ√“¬1 ‡π◊ËÕß®“°¬—ß‰¡à¡’°“√ √â“ß∑“ß‡™◊ËÕ¡√–À«à“ßtrachea ·≈–º‘«Àπ—ß∫√‘‡«≥≈”§ÕÕ¬à“ß™—¥‡®π ®÷ß‰¡à·π–π”„Àâ‡ª≈’Ë¬π tracheostomy tube „π™à«ß‡«≈“π’È‡æ√“–Õ“®‡ªìπÕ—πµ√“¬‰¥â. Õ¬à“ß‰√°Áµ“¡ ‡¡◊ËÕ‡°‘¥°“√‡≈◊ËÕπÀ≈ÿ¥¢Õß tracheostomy tube ‚¥¬∫—ß‡Õ‘≠ §«√®—¥ºŸâªÉ«¬Õ¬Ÿà„π∑à“πÕπÀß“¬ ·Àßπ§Õ‚¥¬¡’À¡Õπ√Õß„µâ‰À≈à‡À¡◊Õπ∑à“‡µ√’¬¡‡®“–§Õ. ®“°π—Èπ„™â staysutures ∑’Ë‡¬Á∫‰«â‡ªìπµ—«π”∑“ß ·≈–∂à“ß·¬° stomaÕÕ° ‡æ◊ËÕ„ à tracheostomy tube ‡¢â“‰ª„π trachea„À¡à ·≈–‡æ◊ËÕªÑÕß°—π∑àÕÕÿ¥µ—π®“°‡ ¡À–. ∑àÕ 2 ™—Èπ∑’Ë¡’∑—Èß inner and outer cannula §«√≈â“ß innercannula ∑ÿ°Ê 4-6 ™—Ë«‚¡ß ·≈–∑ÿ°§√—Èß ∑’ËºŸâªÉ«¬√Ÿâ ÷°À“¬„®‰¡à –¥«°.

6. Deflating the cuff and decannula-

tion ‡¡◊ËÕÀ¡¥¢âÕ∫àß™’È¢Õß°“√ blow cuff ·≈â«µâÕß deflate cuff À√◊Õ‡ª≈’Ë¬π‡ªìπ tracheostomytube ™π‘¥‰¡à¡’ cuff ‡æ◊ËÕªÑÕß°—π¿“«–·∑√°´âÕπ¥—ß°≈à“«¢â“ßµâπ ‡™àπ À≈—ß‡®“–§Õ„À¡àÊ Õ“®®”‡ªìπµâÕß„™â tracheostomy tube. ™π‘¥æ≈“ µ‘° ÷Ëß¡’cuff Õ¬Ÿà¥â“π¢â“ß ‡æ◊ËÕ¬÷¥„Àâ∑àÕÕ¬Ÿà°—∫∑’Ë ª√–¡“≥ 24™—Ë«‚¡ßÀ≈—ß‡®“–§Õ ·æ∑¬å§«√ deflate cuff ·≈–

387§≈‘π‘° ªï∑’Ë 30 ©∫—∫∑’Ë 6 ¡‘∂ÿπ“¬π 2557

ª√–¡“≥ 72 ™—Ë«‚¡ßÀ≈—ß‡®“–§Õ §«√‡ª≈’Ë¬π‡ªìπ∑àÕ´÷Ëß‰¡à¡’ cuff ÷Ëß¡’∑—Èß™π‘¥æ≈“ µ‘°·≈–‚≈À– ‡π◊ËÕß®“°®–≈â“ß·≈–∑”§«“¡ –Õ“¥‰¥âßà“¬°«à“.

‡¡◊ËÕºŸâªÉ«¬À¡¥¢âÕ∫àß™’È¢Õß°“√„™â tracheo-stomy tube ·≈â« §«√æ‘®“√≥“‡Õ“∑àÕÕÕ°. ‚¥¬∑—Ë«‰ª∂â“‡ªìπ‰ª‰¥â °àÕπ‡Õ“∑àÕÕÕ° ºŸâªÉ«¬§«√‰¥â√—∫°“√ª√–‡¡‘π∑“ß‡¥‘πÀ“¬„® ¥â«¬ direct laryngobronchoscopy°àÕπ «à“æ√âÕ¡∑’Ë®–‡Õ“∑àÕÕÕ°‰¥â‚¥¬ª≈Õ¥¿—¬À√◊Õ‰¡à.®“°π—Èπ®÷ß‡ª≈’Ë¬π‡ªìπ tracheostomy tube ∑’Ë¡’¢π“¥‡≈Á°≈ß ∂â“ºŸâªÉ«¬¬—ß “¡“√∂À“¬„®‰¥â¥’ °Á∑”°“√ªî¥∑àÕ ·≈â«‡ΩÑ“¥ŸÕ“°“√ „π°√≥’∑’ËºŸâªÉ«¬ “¡“√∂ªî¥∑àÕ‰¥â¢â“¡§◊π‚¥¬‰¡à¡’ªí≠À“ ºŸâªÉ«¬®–¡’‚Õ°“ Ÿß∑’Ë®–‡Õ“∑àÕÕÕ°‰¥â ”‡√Á®.

¿“«–·∑√°´âÕπÀ≈—ßºà“µ—¥ (postoperativecomplications)

1. Hemorrhage Õ“®‡°‘¥¢÷Èπ‰¥âÀ≈—ß°“√‡®“–§Õ ‡ªìπ«—πÀ√◊Õ‡¥◊Õπ ‡≈◊Õ¥∑’ËÕÕ°®“° tracheoinnom-inate artery fistula ®–√ÿπ·√ß·≈–∂÷ß·°à™’«‘µ‰¥âµ”·Àπàß∑’Ë‡°‘¥ fistula ¥—ß°≈à“«‰¥â§◊Õ∫√‘‡«≥ cuff·≈–ª≈“¬∑àÕ∑’Ë¡’°“√°¥‡∫’¬¥‰ª∫π anterior tra-cheal wall ‡ªìπ‡«≈“π“π®π‡°‘¥ necrosis ·≈–∑–≈ÿ‰ª∑“ß¥â“πÀπâ“ µ‘¥µàÕ‰ª¬—ß innominate artery‚¥¬‡√‘Ë¡µâπ¡—°®–¡’ sentinel bleeding π”¡“°àÕπ

(≈—°…≥– bright red blood ª√‘¡“≥‰¡à¡“°). ®“°π—Èπ°Á®–µ“¡¡“¥â«¬‡≈◊Õ¥ÕÕ°ª√‘¡“≥¡“° ·≈–√ÿπ·√ß®πºŸâªÉ«¬¡’ hemodynamic change °“√√—°…“‡∫◊ÈÕßµâπ®–µâÕß inflate balloon ¢Õß tracheostomytube À√◊Õ endotracheal tube „Àâµ√ß°—∫µ”·Àπàßfistula ‡æ◊ËÕ„Àâ‡≈◊Õ¥À¬ÿ¥™—Ë«§√“« °àÕπ∑’Ë®–π”ºŸâªÉ«¬‡¢â“ÀâÕßºà“µ—¥©ÿ°‡©‘πµàÕ‰ª.

2. Pneumothorax, pneumomediasti-

num, subcutaneous emphysema.

3. Laryngotracheal lesions °“√°¥∑—∫tracheal mucosa ®“° cuff ‡ªìπ√–¬–‡«≈“π“πÊ,°“√√–§“¬‡§◊Õß tracheal mucosa ®“°ª≈“¬∑àÕ,√–¬–‡«≈“∑’Ë§“∑àÕ‰«â, ™π‘¥«— ¥ÿ∑’Ë„™â∑”∑àÕ ·≈–¢π“¥¢Õß∑àÕ, °“√µ‘¥‡™◊ÈÕ ·≈–°“√µ—¥°√–¥Ÿ°ÕàÕπÕÕ°¡“°‡°‘π‰ª ¡’º≈∑”„Àâ‡°‘¥√Õ¬‚√§‰¥âµ—Èß·µà mucosalulceration, suprastomal granuloma, chondritis,tracheomalacia ®π∂÷ß laryngotracheal stenosis.

4. Tube obstruction

5. Aspiration

6. Wound infection

7. Tracheocutaneous fistula „π°√≥’∑’ËºŸâªÉ«¬‡Õ“∑àÕÕÕ° À≈—ß®“°„ à∑àÕ‡ªìπ√–¬–‡«≈“π“πÕ“®¡’ tracheocutaneous fistula tract ‰¥â ´÷Ëß “¡“√∂√—°…“‰¥â¥â«¬°“√µ—¥ ·≈–‡¬Á∫ªî¥ fistula ¥—ß°≈à“«.

‡Õ° “√Õâ“ßÕ‘ß1. Fagan JJ, Johnson JT, Stool SE, Myers EN.

Tracheostomy. Otolaryngology Self-Instruc-tional Package. American Academy of Otolaryn-gology. Minnesota : Head and Neck SurgeryFoundation, Inc. 1997.

2. Plummer AL, Gracey DR. Consensus confer-ence on artificial airways in patients receiv-ing mechanical ventilation. Chest 1989; 96:178-80.

3. Shott SR. Pedeatric tracheostomy. In : MyerIII CM, Cotton RT, Shott SR : The Pediatric

Airway. Philadelphia, J.B. Lippincott co,1995:151-69.

4. Roger JH. Tracheostomy and decannulation.In : Adam DA, Cinnamond MJ : Volume 6;Pediatric Otolaryngology. Scott-Brownûs Oto-laryngology Sixth edition. Oxford, ButterworthHeinemann, 1997:1-16.

5. Wetmore RF. Tracheotomy. In: Bluestone CD,Stool SE, Kenna MA: Pediatric Otolaryngo-logy Third Edition, Volume II. Philadelphia,W.B. Saunders co, 1996:1425- 40.

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