11-18박명희

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1 대한응급의학회지제 21 권제 2 호 Volume 21, Number 2, April, 2010 원 저 응급의학과의사에의해시행된기관절개술의효과및합병증 서울대학교의과대학응급의학교실 박명희 서길준 권운용 서준석 Effects and Complications of Tracheostomies done by Emergency Physicians Myung Hee Park, M.D., Gil Joon Suh, M.D., Woon Yong Kwon, M.D., Jun Seok Seo, M.D. Purpose: A tracheostomy is an important, life-saving procedure to maintain a patent airway. Our aim was to evaluate the effects and safety of tracheostomies done by emergency physicians. Methods: This was a retrospective study conducted in the emergency intensive care unit (ICU) of a regional emergency medical center. We enrolled consecutive patients who had a tracheostomy in the emergency ICU between November 2004 and September We collected data on demographic characteristics, diagnosis at admission, the indication for a tracheostomy, time from intubation to tracheostomy, weaning success, time from tracheostomy to weaning, hospital stay, survival discharge, and complications. We divided the patients into two groups: the EM group included patients who had a tracheostomy done by an emergency physician; the OL group had it done by an otolaryngologists. We then made between-groups comparisons. Results: One hundred forty six patients were enrolled in this study. Of the 146 patients, 94 were included in the EM group and 52 in the OL group. There was no significant difference in the demographic characteristics except age, diagnosis at admission, indication of tracheostomy, time from intubation to tracheostomy, weaning success, time from tracheostomy to weaning, hospital stay, and survival 책임저자 : 서길준서울특별시종로구연건동 28 서울대학교의과대학응급의학교실 Tel: 02) , Fax: 02) suhgil@snu.ac.kr 접수일 : 2009년 8월 13일, 1차교정일 : 2009년 8월 27일게재승인일 : 2009년 11월 20일 234 discharge between the two groups. There was no significant difference in demographic characteristics? or in the incidence of complications between the two groups. Conclusion: Tracheostomy done by emergency physicians are as effective and safe as ones done by otolaryngologists. Key Words: Tracheostomy, Postoperative complications, Treatment outcome, Emergency medicine, Otolaryngology Department of Emergency Medicine, Seoul National University, College of Medicine, Seoul, Korea 서 기관절개술 (tracheostomy, tracheotomy) 이란, 기관에절개를하여기관튜브 (tracheostomy tube) 를삽입하여호흡이가능하도록유지하는술식으로매우기본적인의학술기중의하나이며기도확보및중증환자의관리에꼭필요한술식이다 1,2). 기관절개술은대표적으로장기간의기도유지를위해기관내삽관이필요한경우와상기도폐쇄등으로인하여기도확보가통상적인방법으로시행되기어려운경우에시행된다 1.3). 기관절개술은중환자실에서장기간의기관내삽관을대체하기위해서많이시행하고있으며환자의생명연장을위해호흡보조장치가필요하다고판단되는경우에는, 사강 (dead space) 을줄이고효과적으로하기도분비물을제거하기위해기관절개술을통한기관튜브로기관내튜브 (endotracheal tube) 를대체한다. 그시행시기에대해서는논란의여지가있으나일반적으로, 2~3주이상기관내삽관을필요로하는환자들은기관절개술을시행받음으로써장기간의기관내삽관에의한많은합병증을예방할수있다 1.4). 기관절개술은호흡보조를위한기도확보및기도내분비물제거뿐만아니라상기도폐쇄, 두부나경부손상등의응급상황에서기도유지를하게해줌으로써생명을구하는술식으로도시행되고있다 2,3). 상기도폐쇄등으로인해기관내삽관이용이하지않은응급 론

2 박명희외 : 응급의학과의사에의해시행된기관절개술의효과및합병증 / 235 환자에게는윤상갑상연골절개술 (cricothyroidotomy) 이우선시행되어야하나이를통해서환자에게적절한양압환기를제공하기어려우며장기간의거치가불안정하여기관절개술로의전환이필요하다 5-7). 기관절개술은비교적안전한시술이지만시술후출혈, 기도폐쇄, 감염, 기흉등여러급성합병증들이보고되고있으며시술로인한사망률이성인의경우 1.1~8.9% 까지보고되고있다 1,8-12). 후기합병증으로는출혈, 상처감염, 기관지-식도누골, 후두마비, 기관협착, 기관연화증, 기관-무명동맥루, 폐렴등이있으며이와같은경우의합병증위험은 65% 까지보고된바가있다 1,10,13). 이처럼기관절개술은기도확보및호흡부전의장애로인해유발된응급상황에서절대적으로필요한시술로응급의학과의사에게반드시필요한술식임에도불구하고시술과관련된합병증, 침습적인시술방법, 기술의불충분한습득, 기관절개술을체계적으로교육받을수있는상황의부재등으로인해아직까지응급의학과의사에의해기관절개술이시행되는경우는매우드물며대부분의경우이비인후과에타과의뢰를통하여시행및관리되고있다. 또한응급의학과의사에의해기관절개술이시행된경우에도이의효과및합병증에대한평가및고찰이이루어진바없다. 이에본연구진은응급의학과전공의의수련과정중기관절개술의기술습득의필요성을인지하여응급중환자실에입원한환자중주진료과가응급의학과인환자에게는응급의학과전공의가응급의학과전문의의지도하에기관절개술을시행및관리하도록하였으며본연구를통해응급중환자실에서응급의학과의사에의해시행된기관절개술과이비인후과의사에의해시행된기관절개술을비교하여응급의학과의사에의해시행된기관절개술의효과및안전성을평가하고자하였다. 대상과방법 1. 연구대상 2004년 11월부터 2008년 9월까지연구대상환자들의의무기록을후향적으로조사하여분석하였다. 모든환자에서기관절개술시행전에환자또는보호자에게시술에대한동의를획득한후시행하였다. 연구기간중응급중환자실에입원한환자중 2~3주이상의호흡보조를위한기도확보가필요거나하기도분비물의배출이어려워기도확보가장기간요구되는경우 (prolonged respiratory support), 응급센터내원시상기도폐쇄등으로인해기관내삽관이용이하지않았던경우 (difficult airway) 의환자들에게기관절개술을시행하였다. 기관절개술시행전모든환자에서경부단순촬영및혈액응고검사 (platelet count, prothrombin time (PT), activated partial thromboplastin time (aptt)) 을확인한후시행하였다. 15세이하의소아환자, 혈액응고장애가교정이되지않은경우, 적극적인치료에동의하지않은경우, 기관절개술시행에동의하지않은경우는본연구에서제외하였다. 대상환자는응급의학과의사에의해기관절개술을시행받은군 (EM) 및이비인후과의사에의해기관절개술을시행받은군 (OL) 으로분류하였다. 2005년 5월 1일이후응급중환자실에입원한환자들중주진료과가응급의학과인환자들은모두응급의학과의사에의해기관절개술을시행받았으며 2006년 4월이전에기관절개술을시행받았거나환자의주진료과가응급의학과가아닌경우이비인후과의사에의해기관절개술을시행받았다. 2. 연구방법응급의학과의사에의한기관절개술은해당기간에응급중환자실에근무중인응급의학과 2년차전공의가 4시간의경부의해부학적구조, 기관절개술시행과정에대한교육및 1회이상의시술참관후시행하였으며반드시경험을갖춘응급의학과전문의의감독하에시행되었다. 기관절개술의방법은외과적기관절개술 (surgical tracheostomy) 을사용하였으며그방법을요악하면다음과같다. 전신마취하에환자의경부를신전 (extension) 하여시술부위를최대한노출시킨후시술부위에국소마취를추가로시행하였다. 흉골상절흔 (suprasternal notch) 과윤상연골 (cricoid cartilage) 사이의경부에횡절개를가한후조심스럽게연부조직을박리하여두번째와세번째기관연골을노출시킨후노출된기관연골을절개하여만든창 (window) 을통해기관튜브를삽입하였다 1,2,14). 동시에전기소작을통해연부조직과기관연골막의출혈을지혈하였다. 시술후기관튜브의이탈, 기도폐쇄여부를확인하기위해인공호흡기를통한양압호흡및호기말이산화탄소분압을즉시적용하여기도내거치및적절한호흡의공급여부를확인하였으며흉부단순촬영을통해기관튜브의위치및기흉, 또는혈흉의유무를관찰하였다. 출혈은시술부위의상처, 기도내분비물의양상, 성대하분비물의양상을 1시간마다관찰하여확인하였다. 합병증이발생하지않으면시술 48시간후첫번째기관튜브의교환을시행하였다. 응급의학과의사에의해기관절개술을시행받은군과이비인후과의사에의해기관절개술을시행받은군의성별및연령, 기관절개술시행사유 (reason), 응급중환자실입원시진단명, 시술전혈액응고기능, 기관내삽관으로부터기관절개술시행까지의시간 [time (Int-Tr)], 기관절개술시행후인공호흡기의이탈 (weaning) 가능여부 (Wn), 기관절개술시행으로부터인공호흡기이탈까지의

3 236 / 대한응급의학회지 : 제 21 권제 2 호 2010 시간 [time (Int-Wn)], 입원기간 (hospital stay), 생존퇴원 (survival discharge) 여부, 입원기간동안발생한출혈, 기도폐쇄, 감염, 기흉, 사망등합병증의발생여부를관찰하여비교분석하였다. 통계는 SPSS ver for windows의카이제곱검정및 student s t-test를사용하였으며 p 값이 0.05 이하일때통계적인의미가있는것으로간주하였다. 결과연구기간중기관절개술은총 146명에서시행되었으며, 응급의학과의사에의해 94명 (64.4%) 에서시행되었 으며이비인후과의사에의해 52명 (35.6%) 에서시행되었다. 응급의학과의사의의해시행된환자의연령이 ±15.17세로이비인후과의사에의해시행된환자보다고령이었다 (p=0.030)(table 1). 응급센터내원시기도확보가어려워시행한응급기관절개술은 146명중 9명 (6.2%) 에서시행되었으며응급의학과의사에의한 94명중 5명 (5.3%), 이비인후과의사에의한 52명중 4명 (7.7%) 에서시행되었다 (Table 1). 응급의학과의사에의해시행된경우에는호흡기계질환으로입원한환자의비율이상대적으로많았으며 (34.0%) 이비인후과의사에의해시행된경우는신경계질환으로입원한환자의비율이상대적으로많았으나 (25.0%) 입원진단명에있어서응급의학과의사에의해기관절개술을시행받은군과이비인 Table 1. Patients characteristics and effects and complications of tracheostomy EM OL Sum N (%) N (%) N (%) Age (yr) 64.39±15.17* 58.33± ±15.82 Male gender 64 (68.1) 37 (71.2) 101 (69.2) Diagnosis Neurological 14 (14.9) 13 (25.0) 027 (18.5) Cardiovascular 30 (31.9) 20 (38.5) 050 (34.2) Respiratory 32 (34.0) 06 (11.5) 038 (26.0) Injury 11 (11.7) 08 (15.4) 019 (13.0) Miscellaneous 7 ( 7.4) 05 ( 9.6) 012 ( 8.2) Reason Prolonged resp support 89 (94.7) 48 (92.3) 137 (93.8) Difficult airway 05 ( 5.3) 4 ( 7.7) 009 ( 6.2) Coagulation Plt (/103) ± ± ± PT (INR) 1.19± ± ±0.25 aptt (sec) 45.09± ± ±20.88 Time [Int-Tr] (days) 11.80± ± ±6.28 Results Weaning success 52 (55.3) 27 (51.9) 079 (54.1) Time [Tr-Wn] (days) 2.73± ± ±2.78 Hospital stay (days) 38.22± ± ±33.73 Survival discharge 71 (75.5) 42 (80.8) 113 (77.4) Complication Bleeding 12 (12.8) 06 (11.5) 018 (12.3) Infection 00 ( 0.0) 01 ( 1.9) 001 ( 0.7) Obstruction 01 ( 1.1) 00 ( 0.0) 001 ( 0.7) Pheumothorax 01 ( 1.1) 00 ( 0.0) 001 ( 0.7) Death 00 ( 0.0) 01 ( 1.9) 001 ( 0.7) Total 14 (14.9) 08 (15.4) 022 (15.1) Sum 94 (64.4) 52 (35.6) 146 (100.0) EM: tracheostomy by residants of emergency medicine, OL: tracheostomy by residants of otolaryngology, Plt: platelet count, PT: prothrombin time, aptt: activated partial thromboplastin time, INR: international normalized ratio, Time [Int-Tr]: time from intubation to tracheostomy, Time [Tr-Wn]: time from tracheostomy to weaning. * p<0.05 vs. OL. Cause of death was tracheo-innominate artery fistula at 14 days post-tracheostomy.

4 박명희외 : 응급의학과의사에의해시행된기관절개술의효과및합병증 / 237 후과의사에의해기관절개술을시행받은양군간에통계적인차이는없었다 (p=0.054). 대부분의환자에서기관내삽관후 2~3주내에기관절개술이시행되었으며기관절개술을시행한환자의 54.1% 가성공적으로인공호흡기에서이탈하였다. 기관내삽관으로부터기관절개술시행까지의시간 [Time (Int-Tr), p=0.579], 기관절개술시행후인공호흡기이탈성공여부 (weaning success, p=0.412) 및기관절개술시행으로부터인공호흡기이탈까지의시간 [time (Tr-Wn), p=0.054], 입원기간 (hospital stay, p=0.362), 생존퇴원여부 (survival discharge, p=0.469) 모두에서응급의학과의사에의해기관절개술을시행받은군과이비인후과의사에의해기관절개술을시행받은양군간에기관절개술의효과에있어유의한차이는없었다 (Table 1). 출혈, 기도폐쇄, 감염, 기흉, 사망등의합병증의발생에있어서도응급의학과의사에의해기관절개술을시행받은군과이비인후과의사에의해기관절개술을시행받은양군간에유의한차이는없었다 (p=0.572)(table 1)(Fig. 1). 시술후출혈이 146명중 18명 (12.3%) 로가장많았으며응급의학과의사에의한경우와이비인후과의사에의해시행된경우간의차이는없었다 (p=0.526)(table 1). 대부분의출혈은보존적인처치를통해대부분 1~2일내에지혈되었다. 이비인후과의사에의해기관절개술을시행받은군에서 1명 (0.7%) 은사망에이르는다량의출혈이발생하였다 (Table 1)(Fig. 1). 사망환자는심정지로본원응급실내원하여심폐소생술후자발순환이회복되어응급중환자실에입원하여소생술후치료를시행중인환자였으며장기간의호흡보조를위해이비인후과에의뢰하여기관절개술을시행하였다. 인공호흡기이탈후일반병동으로전동하였으나, 시술 2주후기관튜브로다량출혈이발 생하여사망하였다. 다량출혈의원인은기관-무명동맥루 (tracheo-innominate artery fistula) 로추정된다. 기도폐쇄가발생한 1명 (0.7%) 은심폐소생술후자발순환이회복되어응급중환자실에입원하여장기간의호흡보조를위해응급의학과의사에의해기관절개술을시행받았던환자였다. 기관튜브삽입후인공호흡기를연결하였으나적절한양압환기가제공되지못하였으며즉시기관튜브교환을시행한후에적절한호흡이이루어졌다. 피떡 (blood clot) 에의한기관튜브폐쇄가원인으로추정된다. 상처부위의감염은이비인후과의사에의해기관절개술을시행받은군에서 1명 (0.7%) 발생하였다. 경막외출혈로인한의식저하로본원응급실에내원한환자로수술후장기간의호흡보조를위해기관절개술을시행하였다. 시술후 4일에기관튜브주변의피부의홍반성변화 (erythematous change) 를보이면서염증성조직및미란이관찰되었으며잦은국소소독및거즈교환을통해호전되었다. 이외에도상기도폐쇄로내원한환자에서기관내삽관에실패하여윤상갑상연골절제술을시행한후응급의학과의사에의해응급기관절개술시행한환자에서소량의피하기종및기흉이발생한 1명 (0.7%) 이있었으며산소투여만으로호전되었다. 대상환자들은평균 40일간의입원기간동안후기합병증의발생여부를관찰하였으나기관지-식도누공, 후두마비, 기관협착, 기관연화증의발생은두군모두에서관찰되지않았다. 고찰연구결과응급의학과의사에의한기관절개술은이비인 A B Fig. 1. Complications of tracheostomy. (A) Tracheostomy by residents of emergency medicine, (B) Tracheostomy by residents of otolaryngology

5 238 / 대한응급의학회지 : 제 21 권제 2 호 2010 후과의사에의한기관절개술과비교할때효과및합병증에있어서차이를보이지않았다. 이는체계화된교육과함께경험많은응급의학과전문의의지도및감독이이루어진다면응급의학과의사에의해기관절개술이적절하고안전하게시행될수있음을시사한다. 기관절개술의표준방법은외과적기관절개술로수술장에서하는것이원칙이나외과적기관절개술을위해중환자를수술장으로이송하는경우이동자체가위험을수반하고있으며최근에는중환자실에서도흔히이루어지며안전하게할수있다는보고가있다 4,15,16). 외과적기관절개술외에도경피적확장기관절개술 (percutaneous dilatational tracheostomy) 이최근여러연구에서제시되고있다. 경피적확장기관절개술은침상에서곧시행할수있고시술방법을배우기쉬운장점이있으나응급기관절개술, 두경부종양, 소아갑상선종대등의해부학적변화가있는경우및출혈경향이있는환자는상대적금기로알려져있다 17,18). 본연구에서는일반적인외과적기관절개술을주로시행하였으며응급센터내원시상기도폐쇄로인해기관내삽관이용이하지않았던경우에는응급기관절개술을시행하였다. 일반적인외과적기관절개술방법은혈관구조물및갑상선등주위조직에대한손상을줄이며술후반흔을최소화하기위해흉골상절흔과윤상연골사이에횡절개를가한후노출된두번째와세번째기관연골을절개하여만든창 (window) 을통해기관튜브를삽입한다 1,2,14). 이와달리응급기관절개술은안면및후두외상에의해구강및비강으로의기관내삽관이어렵거나외상으로인한출혈로인해상기도폐쇄로기관절개를할시간이없거나기관내삽관을시도할수없을경우응급으로시행하며, 흉골상절흔과갑상연골및윤상연골사이에종절개를가한후기관튜브로기도를확보한다. 이는혈관구조물및갑상선과같은해부학적구조물에대한고려없이이루어질수있기때문에다량의출혈이발생할수있으며윤상연골및기관손상을유발할수있다는단점이있다 19,20). 기관절개술과관련된합병증은시술 1주이내에발생하는조기합병증과 1주이후에발생하는후기합병증으로구분할수있는데, 조기합병증으로는출혈, 감염, 기흉, 저혈압, 기관절개튜브의기관주변으로의이탈, 기도폐쇄, 시술실패등이있으며후기합병증으로는출혈, 상처감염, 기관지-식도누공, 후두마비, 기관협착, 기관연화증, 기관-무명동맥루, 폐렴등이있다 1,8,10,13). 조기합병증중가장많이발생하는것으로알려진기관절개술후출혈의빈도는보고자에따라크게차이를보여 % 로알려져있다 8,12,21,22). 본연구에서출혈의합병증은 146명중 18명 (12.3%) 으로기존연구들과큰차이를보이지않았으며응급의학과의사에의해시행된경우와이비인후과의사에의해시행된경우간에차이는없었다. 전갑상정맥과갑상선피막표면의소정맥, 피하연부조직내의소혈관들이출 혈의가장많은원인이며, 기관절개술후 24시간이내에발생하는출혈은대개수술시의지혈이불완전했거나환자의기침등으로혈압이상승하는경우및혈액응고장애에기인하며대개거즈팩킹 (packing) 만으로도지혈된다고보고되고있다 1,4). 그러나시술 2~3주이내에발생할수있는기관 - 무명동맥류에의한출혈의발생빈도는 1% 미만이지만다량출혈이발생할수있으며매우치명적이며수술적조치가취해져도사망률은 70~100% 까지보고되고있다 10,12). 기관절개술후기흉의빈도는다른연구에서는 0.7~5% 까지로보고된바있으며본연구에서는 146명중 1명 (0.7%) 에서발생하였다 8,9,23). 기흉이생기는기전은절개를할때박리를너무깊이하여직접흉막을손상시켜서발생되기도하며, 절개후삽입한기관튜브가정상위치에있지않고이탈되어있는상태에서피하기종이생길수있는데이를확인하지않고기계호흡또는양압환기를할때종격동기흉이발생하고이것이흉강내로터질경우기흉이발생하게된다 9). 특히환자의목이짧고굵은경우박리되는연부조직이깊게절개되며이때기관절개관이연부조직으로이탈되어삽입될확률이높아져기흉등의합병증이발생하기쉽다. 기흉이생겼을때인지하지못하고방치될경우긴장성기흉으로사망할수있기때문에반드시기관절개술후에는흉부단순촬영을하여확인해야한다 24). 기관절개술후상처부위의감염은드물며그치료또한국소적인상처소독만필요하다고알려져있다 1). 기관절개술후기도폐쇄는점액질 (mucus), 피떡 (blood clot) 에의한기관튜브폐쇄, 기관튜브끝의기관벽인접, 기관주변으로의삽관등에의해서발생한다 1). 후기합병증중수주에서수개월후에발생하는후기출혈은기관연골염증, 기관절개구육아조직및기관-무명동맥류에기인하며, 후기출혈의 70% 는술후 3주이내에발생한다. 기관절개술후기관협착의빈도는약 1~2% 이며협착부위는기관절개구 (stoma) 주변과기관튜브의커프 (cuff) 부위및기관튜브의끝 (tip) 부위이다. 그발생기전은압력에의한괴사로점막의얕은미란이생기기시작하여연골부로침습하게되고세균감염이동반되면서기관염의형태로진행된후섬유성반흔조직에의한협착을남기면서치유되는것으로알려져있다 1,10). 기관-식도누공은그발생빈도가 1% 미만으로드물지만사망률이 80% 까지보고되고있다. 기관절개술후장기간의인공호흡기치료중기관튜브커프를과도하게팽창시킨경우그압력으로인해기관후벽의미란및비위관 (nasogastric tube) 접촉으로인해근접한기관및식도를손상시켜발생한다 1,10). 본연구는후향적관찰연구이며이로인한몇가지제한점이있다. 첫째, 시술자간의차이를배제할수없다는점이다. 응급의학과전공의에의해기관절개술이시행될경우모든환자에서응급중환자실을전담하는 1인의응급의학과전문의가항상시술보조자로참여함으로써시술자에따른

6 박명희외 : 응급의학과의사에의해시행된기관절개술의효과및합병증 / 239 차이를줄이고자하였으나 30명이상의전공의가시술을시행하였으며이로인해시술자에따른효과및합병증발생의차이를따로분석할수는없었다. 둘째, 기관절개술을시행받은환자들의비만도, 목길이, 두께등의해부학적차이를평가하지못했다. 보고에따라차이가있으나일부연구에서는목이짧고굵거나비만인환자및갑상선크기가큰환자의경우시술이어려우며합병증의발생도증가할수있음이보고되고있으나전향적으로자료를수집하지못하여본연구에서는응급의학과의사에의해기관절개술을시행받은군과이비인후과의사에의해시행받은군간의해부학적인차이를평가할수없었다 25,26). 셋째, 응급중환자실특성상장기체류가어려워기관절개술을시행받은환자들은대부분안정기간을거친후타중환자실또는타원으로전원되어지속적인치료를받았다. 본연구에서는본원에입원기간동안발생한합병증만관찰하였으며퇴원한환자또는타원으로전원된환자를추적하지못하였다. 이로인해평균 40일이내에발생한합병증들의발생여부는확인할수있었으나퇴원후수개월후또는기관튜브제거후발생할수있는기관지-식도누공, 후두마비, 기관협착, 기관연화증등후기합병증발생여부를확인하지못하였다. 이러한제한점의극복을위해여러응급센터의응급의학과와의협조하에전향적인다기관연구가필요할것으로사료된다. 결 응급의학과의사에의해시행된기관절개술과이비인후과의사에의해시행된기관절개술간의효과및합병증의발생에차이는없었다. 본연구결과는기도확보에필수적인술식인기관절개술을효과적으로습득할수있는체계적인수련프로그램의개발과더불어응급의학과전문의의적절한교육및지도감독이이루어진다면응급의학과의사에의해기관절개술이효과적이고안전하게시행될수있음을시사한다. 론 참고문헌 01. De Leyn P, Bedert L, Delcroix M, Depuydt P, Lauwers G, Sokolov Y, et al. Tracheotomy: clinical review and guidelines. Eur J Cardiothorac Surg 2007;32: Upadhyay A, Maurer J, Turner J, Tiszenkel H, Rosengart T. Elective bedside tracheostomy in the intensive care unit. J Am Coll Surg 1996;183: Heffner JE. Medical indications for tracheotomy. Chest 1989;96: Pogue MD, Pecaro BC. Safety and efficiency of elective tracheostomy performed in the intensive care unit. J Oral Maxillofac Surg 1995;53: Kress TD, Balasubramaniam S. Cricothyroidotomy. Ann Emerg Med 1982;11: Helm M, Gries A, Mutzbauer T. Surgical approach in difficult airway management. Best Pract Res Clin Anaesthesiol 2005;19: Heidegger T, Gerig HJ, Henderson JJ. Strategies and algorithms for management of the difficult airway. Best Pract Res Clin Anaesthesiol 2005;19: Durbin CG Jr. Early complications of tracheostomy. Respir Care 2005;50: Heffner JE, Miller KS, Sahn SA. Tracheostomy in the intensive care unit. Part 2: Complications. Chest 1986;90: Epstein SK. Late complications of tracheostomy. Respir Care 2005;50: Carey JP, Stemmer EA, Connolly JE. Fatal complications of tracheostomy. Rev Surg 1970;27: Goldenberg D, Ari EG, Golz A, Danino J, Netzer A, Joachims HZ. Tracheotomy complications: a retrospective study of 1130 cases. Otolaryngol Head Neck Surg 2000;123: Francois B, Clavel M, Desachy A, Puyraud S, Roustan J, Vignon P. Complications of tracheostomy performed in the ICU: subthyroid tracheostomy vs surgical cricothyroidotomy. Chest 2003;123: Heffner JE, Miller KS, Sahn SA. Tracheostomy in the intensive care unit. Part 1: Indications, technique, management. Chest 1986;90: Perfeito JA, Mata CA, Forte V, Carnaghi M, Tamura N, Leao LE. Tracheostomy in the ICU: is it worthwhile?. J Bras Pneumol 2007;33: Plummer AL, Gracey DR. Consensus conference on artificial airways in patients receiving mechanical ventilation. Chest 1989;96: Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 2006;10:R Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985;87: Bonanno FG. Techniques for emergency tracheostomy. Injury 2008;39: Golden GT, Fox JW, Edlich RF, Edgerton MT. Emergency tracheostomy. Am J Surg 1976;131: Skaggs JA, Cogbill CL. Tracheostomy: management, mortality, complications. Am Surg 1969;35: Glas WW, King OJ Jr, Lui A. Complications of tracheostomy. Arch Surg 1962;85:56-63.

7 240 / 대한응급의학회지 : 제 21 권제 2 호 Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981;70: Yoon HY, Oh SU, Park JG, Sin TR, Park SM. A case of tracheostomy induced bilateral tension pneumothorax. Tuberc Respir Dis 2007;62: Tabaee A, Geng E, Lin J, Kakoullis S, McDonald B, Rodriguez H, et al. Impact of neck length on the safety of percutaneous and surgical tracheotomy: a prospective, randomized study. Laryngoscope 2005;115: Nowak K, Szyfter W. In the case of difficult tracheotomy. Otolaryngol Pol 2008;62:11-5.

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