清醒气管插管气道局部麻醉技术的研究进展

对于术前评估为困难气道的患者应当采用清醒镇静表面麻醉下实施气管插管。实施清醒气管插管的关键技术是完善的气道局部麻醉。清醒气管插管是麻醉科医师必须掌握的技能之一。本文通过回顾近十年的文献,旨为麻醉科医师提供清醒气管插管气道局部麻醉技术相关理论参考。     

Flexible fibreoptic intubation

Flexible fibreoptic intubation offers options of airway control in awake and asleep patients, in cases with limited or absent mouth opening and complex anatomy. It may be used as a first choice or a rescue technique. Despite its limitations, for example in situations with significant airway blood or secretions, and airway obstruction, it is a valuable core skill for every anaesthetist.     

Flexible fibre-optic intubation

Flexible fibre-optic intubation offers options of airway control in awake and asleep patients, in cases with limited or absent mouth opening and complex anatomy. It may be used as a first choice or a rescue technique. Despite its limitations, e.g. in situations with significant airway blood or secretions, and airway obstruction, it is a valuable core skill for every anaesthetist.     

Fibreoptic intubation

A flexible fibreoptic scope can be used to facilitate tracheal intubation in both awake and asleep patients, in those with limited or absent mouth opening and complex anatomy. It may be used as a first choice for airway management or as a rescue technique. Despite its potential limitations, e.g. in situations with significant blood or secretions in the airway, fibreoptic intubation remains an invaluable core skill for every anaesthetist. Awake tracheal intubation must be considered in the presence of predictors of difficult airway management.     

Anesthesia of a patient with an obstructing tracheal mass: a new way to manage the airway

A case of upper airway obstruction due to thyroid tumor requiring surgery is presented. Successful establishment of an open tracheal airway was achieved by the insertion of an endotracheal stent and was followed 10 days later by tracheal resection and anastomosis.     

Flexible fibre-optic intubation

Flexible fibre-optic intubation has been practised for 40 years. It is an enormously useful skill, but it is not always the most appropriate tactic to deploy. The great advantage of flexible endoscopy is that the passage of an endoscope is acceptable to conscious patients, so that a tracheal tube can be placed easily when face-mask ventilation or direct laryngoscopy is likely to be difficult. The best position for the endoscopist is by the patient’s side (whether the patient is conscious or not) and the patient should be semi-sitting when possible. Disorientation because of premature entry is the most frequent source of difficulty in the authors’ experience. ‘Railroading’ the tracheal tube can also cause difficulty. In the authors’ experience flexible reinforced tubes are the easiest to use, and it is vital to refrain from pushing the tube – it must be advanced gently while being constantly rotated. Lidocaine in generous doses (< 9 mg/kg) is used for topical anaesthesia, but can cause airway obstruction as a result of glottic irritation. It must be applied cautiously. There are several successful methods of sedation available, with remifentanil infusion probably being the most popular in the UK at present.     

Light-guided intubation via the intubating laryngeal mask using a prototype illuminated flexible catheter. Clinical experience in 400 patients

BACKGROUND: The transillumination of the soft tissues of the neck using lighted stylets has been used as an aid for tracheal intubation. We evaluated the efficacy and safety of a prototype illuminated flexible catheter to facilitate light-guided intubation through the intubating laryngeal mask. METHODS: The illuminated flexible catheter consists of a completely flexible thin plastic catheter with a bulb attached to its distal end. The device was placed into a silicone tracheal tube in such a way that the bulb was adjusted at the distal end of the tracheal tube. The tracheal tube preloaded with the device was inserted through the intubating laryngeal mask and, by observing the glow on the neck, was advanced into the trachea. We report our experience with light-guided intubation through the intubating laryngeal mask in 400 ASA grade 1-3 patients undergoing general anaesthesia. RESULTS: The intubating laryngeal mask was inserted successfully in all patients. The overall intubating success rate was 99.8% (399/400); in 367 (91.8%) cases at the first attempt, in 28 (7%) at the second, in 4 (1%) at the third and in one case (0.2%) at the fifth attempt. There were 27 patients with potentially difficult airways. All these cases were intubated successfully; in 23 of 27 (85.2%) at the first attempt, in 3 of 27 (11.1%) at the second and one of 27 patients (3.7%) at the third attempt. CONCLUSION: We conclude that the use of the illuminated flexible catheter facilitates the intubation through the intubating laryngeal mask. The suggested light-guided intubating method proved to be a simple, safe and effective technique.     

Fibreoptic-guided tracheal intubation through i-gel® and LMA® ProtectorTM supraglottic airway devices - a randomised comparison

Fibreoptic-guided tracheal intubation using a supraglottic airway device as a conduit is a technique that can be used in anticipated and unanticipated difficult airway management. Although the i-gel^® supraglottic airway device has been examined for this purpose, the LMA^® Protector^TM, a recently introduced second-generation supraglottic airway device, has not been evaluated for this use in clinical trials. This prospective, randomised clinical trial compared fibreoptic-guided tracheal intubation via i-gel and LMA Protector supraglottic airway devices in two UK hospitals. Patients who were ASA physical status 1 or 2 and undergoing elective surgery requiring tracheal intubation were recruited to the study. A block randomisation list was generated for each study site. The primary outcome measure was time to successful tracheal intubation and secondary outcomes were tracheal intubation success rate, glottic view through flexible fibrescope, ease of tracheal intubation using operator visual analogue score, supraglottic airway device insertion time and insertion success rate. Ninety patients were randomly allocated to each device, and final data analysis was carried out for 92 patients in the i-gel group and 86 patients in the LMA Protector group. Mean (SD) tracheal intubation time in the i-gel and LMA Protector groups were 54.3 (13.8) s and 52.0 (13.0) s, respectively (p = 0.240). There were no significant differences in tracheal intubation success rate, glottic view and ease of tracheal intubation between the two groups. This study demonstrates that the LMA Protector supraglottic airway device is comparable to the i-gel supraglottic airway device as a conduit for fibreoptic-guided tracheal intubation.     

新型气管插管器具发展的新特点

背景自上世纪40年代Macintosh和Miller喉镜片问世以来,各种新的气管插管器具被商业性推广。目的综述与目前临床实践相关的新型气管插管器具。内容重点阐述新型气管插管器具与传统直接喉镜性能的比较、新型气管插管器具的并发症、新型气管插管器具在清醒气管插管方法中的应用以及新型气管插管器具气管插管失败的预测等。趋向在预知的和未预知的困难气管插管或者气管插管失败的情况下,应用新型气管插管器具可获得极高的气管插管成功率。然而更重要的是,操作者应用各种新型气管插管器具的经验和技能是保证其在不同临床情况下成功应用的关键。     

Cisto hidático na medula cervical complicada por via aérea difícil com potencial risco de vida: relato de caso

Hydatid cyst in the cervical region is an extremely rare condition that can create challenges for anesthesiologists. Timely recognition of difficult airway and preparing the management plan is crucial to avoid life‐threatening complications such as hypoxic brain damage. We describe a case of difficult airway management in a patient with massive cervical hydatid cyst. We used a low‐dose ketamine‐propofol sedation and lidocaine spray for local oropharyngeal anesthesia. Muscular relaxants were not used, and spontaneous breathing was maintained during intubation. Recognition, assessment, and perioperative planning are essential for difficult airway management in patients with cervical hydatid cyst.     

瑞芬太尼在纤维支气管镜清醒气管插管中的应用进展

背景 困难气道患者的围术期气道管理是临床麻醉关注的热点问题.纤维支气管镜清醒气管插管(awake fibreoptic intubation,AFO1)技术是处理预见性困难气道的公认方法.然而实施AFOI的难点在于给患者提供充分镇静、镇痛的同时,又要保证患者有效的自主通气功能.瑞芬太尼作为一种较理想的麻醉性镇痛药,一定剂量下能有效抑制气管插管的应激反应,故已有用于AFOI的报道. 目的 概述及评价瑞芬太尼在AFOI中的有效性及安全性,为临床应用和进一步研究提供参考. 内容 分析瑞芬太尼用于AFOI的剂量对机体的影响、不同给药方案的优劣以及在特殊患者中的应用. 趋向 瑞芬太尼在AFOI中的应用具有诸多优势,但最佳方案仍需进一步临床研究.     

Anesthetic management of a patient with Hallermann-Streiff syndrome

Key words  airway management - difficult intubation - Hallermann-Streiff syndrome     

广东省困难气道处理清醒插管现状调查及分析

目的 对广东省部分二级以上医疗机构困难气道管理清醒插管技术的现状进行调查,为改进和完善气道管理提供参考. 方法 采用邮寄调查问卷的方法,对全省66家医院进行调查,按照医院等级分为三甲和二甲两组.问卷内容包括困难气道时麻醉方式的选择,是否常规沟通,是否准备鼻腔、收缩鼻腔的药物,是否应用抗胆碱药物,常用哪种抗胆碱药物,表面麻醉药物的种类,表面麻醉的工具,是否做环甲膜穿刺表面麻醉,常用的镇痛镇静药物,在镇痛镇静药物的基础上是否复合表面麻醉等.以医院等级为分组变量,采用校正x2检验进行分析比较. 结果 选择清醒表面麻醉插管处理者分别为三甲30％,二甲18％(P＜0.01),镇静镇痛慢诱导插管处理者三甲28％、二甲23％,清醒插管前会与患者充分沟通的比例均仅为53％,经口不做鼻腔准备的三甲为13％、二甲为23％(P＜0.01).常规使用抗胆碱药物的三甲为36％、二甲为22％(P＜0.01),选择2％利多卡因溶液做表面麻醉的三甲为46％、二甲为34％(P＜0.01).镇静镇痛慢诱导插管时,选用丙泊酚复合芬太尼诱导的最多,三甲为20％,二甲为28％(P＜0.05). 结论 清醒表面麻醉插管应用率不高,清醒插管的各种准备措施不足,对于清醒镇静下的气道管理仍需不断改善.