可视喉罩CTrach在颈椎手术中的临床应用研究

目的评估新型可视喉罩CTrach在颈椎病手术中的应用价值。方法80例颈椎手术行全身麻醉者采用CTrach喉罩系统置入通气，并引导气管插管，记录喉罩置入所需时间、喉罩通气的成功率、气管导管首次插入的成功率、总的成功率、喉罩直视下声门显露的比率以及从喉罩置入到气管导管成功插入所需的时间。结果所有患者均可置入喉罩，其中2例通气效果不满意；喉罩通气满意者78例中有5例首次插管未成功。除2例喉罩通气效果不满意和3例3次试插未成功外，其余75例最后都可以在CTrach喉罩引导下完成气管导管的插入，从开始操作到完成置入气管导管的平均时间为192s（156—273s）。结论CTrach喉罩系统可以在直视下进行调整，暴露喉头的位置，提高插管的成功率，避免一些不必要的损伤，在颈椎手术的气道管理中具有一定的应用价值。     

经Cookgas气管插管型喉罩视可尼喉镜引导全麻患者气管插管的可行性

经典喉罩管腔较小,只能使用内径小于6.0 mm的气管导管,且插管成功后喉罩退出困难,因而引导气管插管的使用范围有限。经典插管型喉罩虽然管腔较大,但其通气导管为硬质导管,无法使用各种纤维硬镜和各种可视管芯引导气管插管。而Cookgas气管插管型喉罩（CILA）是一种新型插管型喉罩,是用于引导气管插管和困难气管插管的有效工具。视可尼喉镜（SOS）是目前广泛应用于气管插管和困难气管插管的光导纤维硬镜，但能否采用SOS经CILA引导气管插管尚需进一步探讨。本研究拟评价SOS经CILA引导全麻患者气管插管的可行性，为临床应用提供参考。     

可视喉罩与可视喉镜用于困难气管插管的比较

目的 比较可视喉罩和可视喉镜用于困难气管插管患者的效果。

方法 选择气管插管全麻手术患者90例,男27例,女63例,年龄18～64岁,BMI<30 kg/m²,ASA Ⅰ或Ⅱ级,根据术前简化气道风险指数（SARI）筛选困难气管插管患者（SARI评分≥3分）。采用随机数字表法将患者分为两组：可视喉罩组（S组）和可视喉镜组（C组）,每组45例。S组使用可视喉罩引导气管插管,C组使用可视喉镜完成气管插管。记录声门暴露分级、声门暴露时间、气管插管时间、总插管时间、插管成功例数,插管前、插管即刻、插管后3 min和拔管前、拔管即刻、拔管后3 min的HR和MAP、术后插管并发症（声音嘶哑、咽喉痛）的发生情况。

结果 与C组比较,S组声门暴露时间［Ｓ组（18.2±7.6）s vs C组（14.1±2.8）s］明显延长（P＜0.05）,S组插管即刻和拔管即刻HR明显减慢,MAP明显降低（P＜0.05）。两组声门暴露分级、气管插管时间、总插管时间、插管成功率和术后插管并发症发生率差异无统计学意义。

结论 在困难气管插管的患者中,使用可视喉罩与可视喉镜均能快速有效地完成气管插管,与可视喉镜比较,使用可视喉罩声门暴露时间延长,插管与拔管即刻血流动力学波动幅度较小。     

困难气道时两种经插管型喉罩引导气管插管方法的疗效比较

气管插管型喉罩通气道（ILMA）是一种为引导盲探气管插管而特殊设计的新型喉罩通气道。不仅具有普通型喉罩通气道（LMA）的特性,还可引导气管导管进行盲探插管。本文报道本院使用的两种经ILMA引导气管插管方法在处理困难气道的临床效果。     

喉罩及插管型喉罩的进展

喉罩作为“无法通气、无法插管”困难气道的急救方法之一,无需扭曲气道以暴露声门,即可独立通气。它的曲线造型又可辅助盲插或纤维支气管镜引导下气管插管,适用于常规和困难气道。近年来有不少改进,插管型喉罩有更好的插管特性,可明显降低插管困难及失败率,更利于临床使用。     

喉罩及插管型喉罩的进展

喉罩作为“无法通气、无法插管”困难气道的急救方法之一,无需扭曲气道以暴露声门,即可独立通气。它的曲线造型又可辅助盲插或纤维支气管镜引导下气管插管,适用于常规和困难气道。近年来有不少改进,插管型喉罩有更好的插管特性,可明显降低插管困难及失败率,更利于临床使用。     

声门上通气装置引导气管插管的临床应用进展

声门上通气装置（SAD）在院前急救、常规麻醉及困难气道的开放、维持氧合等方面发挥着重要作用,同时也为引导气管插管提供了一个可行方式。在日常麻醉及手术室外治疗或抢救中,保持气道通畅和充分氧合是气道管理的关键。困难插管发生率约4.5%～7.5%,困难气道管理仍是麻醉管理中的重中之重。在困难插管发生时,先可放置SAD,后经SAD盲探或在可视设备辅助下行气管插管,迅速建立气道、提高首次插管成功率、减少插管过程中气道损伤。本文着重介绍不同种类可引导气管插管的SAD的临床应用进展。     

Cookgas气管插管型喉罩在其他插管方法失败患者中的应用

Cookgas气管插管型喉罩(Cookgas intubating laryngeal airway,CILA,Mercury医疗公司,美国)是一种新型插管型喉罩,具备了经典喉罩管壁柔软和Fastrach插管型喉罩引导插管简单、喉罩退出容易双重特点,是处理困难气道的良好选择.经CILA可以盲探完成气管插管,也可以辅助多种纤维软镜和硬镜完成插管,成功率较高[1,2].     

Fastrach 喉罩辅助纤维支气管镜引导气管插管的效果

临床上纤维支气管镜(纤支镜)引导气管插管时,因目镜小,镜干柔软易弯曲,而不易找到声门.Fastrach喉罩为气管插管型喉罩[1],还配有特制的加强型气管导管和退喉罩管蕊,弧度近90度,前倾角约30度,容易置入;罩体中央带有会厌提升板,提升会厌时,前端罩口与声门近似呈直线,罩体还能有效隔离口腔分泌物,有利于纤支镜操作.     

气道压力法判断喉罩位置的临床观察

喉罩是一种置于声门外、介于面罩与气管导管之间的一种通气工具,临床上已广泛应用.通常多采用听诊咽喉部是否漏气判断喉罩置入位置是否合理,至今尚缺乏直观的量化指标.本研究旨在通过观察喉罩置入前、后气道峰压差值,判断喉罩置入位置是否合理的可行性.     

严重气道狭窄患者气管内治疗的麻醉管理

目的：探讨严重气道狭窄患者气管内治疗的麻醉管理方法。方法：10例不同原因气道狭窄患者分别进行狭窄气道内支架置入术、支架或异物取出术或气管造口处“T”管置入术,分别于全身麻醉下采用气管插管、喉罩及高频喷射等不同的保障气道及通气的方法。结果：经气管导管或喉罩支气管镜下定位气道内支架成功放置7例;感染气管支架或异物取出失败各1例,但均清除部分坏死组织,解除部分气道梗阻;经气管导管手控呼吸及高频喷射通气下“T”型硅胶管成功放置1例。结论：严重气道狭窄患者气管内治疗的麻醉管理关键在于保障气道内操作时的气道通畅。气管插管、喉罩及高频喷射等可灵活应用于不同的病例,其选择主要取决于气道梗阻的部位、严重程度及治疗方法,医护人员的通力协作也是成功的保障之一,经喉罩通气下行气管内操作为可行的方法之一。     

Fiberoptic techniques

Fiberoptic intubation of the spontaneously breathing patient is the gold standard and technique of choice for the elective management of a difficult airway. In the hands of the properly trained and experienced user, it is also an excellent 'plan B' alternative when direct laryngoscopy unexpectedly fails. Fiberscope-assisted intubation through an endoscopy face mask, laryngeal mask airway or intubating laryngeal mask airway secures ventilation and oxygenation, and permits endotracheal intubation in airway emergency situations. Portable fiberscopes can be used in remote settings, increasing patient safety. This review discusses current fiberoptic intubation techniques and their applications in the management of both the anticipated and unanticipated difficult airway.     

全身麻醉诱导后经多功能插管型喉罩盲探气管插管的临床观察

目的 观察全身麻醉患者经多功能插管型喉罩盲探行气管插管的可行性及安全性. 方法 选择ASA分级Ⅰ、Ⅱ级,年龄18～77岁择期行全身麻醉下手术的患者100例.麻醉诱导使用芬太尼4μg/kg、丙泊酚1.5～2.0 mg/kg、罗库溴铵0.6 mg/kg,诱导后先置入多功能插管型喉罩,通气行纤维支气管镜检查并定位后,经喉罩盲探插入配套的鹰嘴气管导管,观察放置喉罩及气管插管的次数和时间,记录诱导前、放置喉罩前后、气管插管前后的BP和HR.结果 置入喉罩和气管插管均1～2次成功,置入喉罩时间平均(11.0±3.2)s,气管插管时间平均(10.5±6.2)s,插管成功退出喉罩后即刻SBP、DBP和HR与诱导前比较,差异均无统计学意义(P＞0.05). 结论 经多功能插管型喉罩盲探气管插管,安全、快捷、有效,患者舒适、刺激小,比经典的插管型喉罩盲探插管更具有优势.     

可弯曲喉罩在患儿气道管理中的应用进展

可弯曲喉罩是患儿麻醉领域常用的气道管理工具,其具有可曲折、抗压缩的长通气端导管,固定方便且可充分暴露手术视野,不妨碍外科操作。患儿舌体大、声门高等解剖因素增加了可弯曲喉罩置入及对位的难度,可弯曲喉罩较低的密封压也增加了术中喉罩漏气及反流误吸的风险。本文就可弯曲喉罩在患儿气道管理中的临床应用进展作一综述,为优化围术期气道管理提供思路,以提高手术安全性并减少术后并发症。     

An alternative method to intubate with laryngeal mask and see-through-bougie

BACKGROUND: Different ways of managing the difficult airway is an important issue for the anaesthetist. We have investigated a technique with a see-through-bougie and laryngeal mask for intubation. METHODS: We report our experience with intubation of 30 patients using a see-through-bougie guided through a laryngeal mask with a fibreoptic bronchoscope. The bougie is then used as a guidance for a tracheal tube. RESULTS: In 29 of the 30 investigated patients, this method could be used. In one patient the method had to be abandoned because of a tortuous trachea. Seventeen patients were intubated within 2 min, 11 between 2 and 5 min and 1 required 10 min. The time was mainly dependent on the endoscopic experience of the anaesthetist. No patient sustained arterial desaturation. CONCLUSION: We conclude that intubation using a see-through-bougie and a laryngeal mask is a valuable method in the difficult intubation situation, when a temporary airway can be achieved with laryngeal mask, since it permits continuous ventilation and visual control throughout the procedure.     

A French survey of paediatric airway management use in tonsillectomy and appendicectomy

BACKGROUND: There are no epidemiological data describing tracheal intubation and laryngeal mask airway (LMATM) use in paediatric anaesthesia. This analysis focused on the factors leading to the indication for an airway management procedure, i.e. tracheal intubation and laryngeal mask airway vs face mask during general anaesthesia for tonsillectomy and appendicectomy. METHODS: The data were recorded in the French survey of Practical Anaesthesia performed in 1996. Two main types of surgical procedures were selected: tonsillectomy and appendicectomy because of the number of patients and the need to use an invasive airway management technique. RESULTS: During a 1-year period, 627 anaesthetics for appendicectomy and 653 anaesthetics for tonsillectomy were recorded in the sample under consideration. Tracheal intubation or laryngeal mask airway was undertaken in 66% of tonsillectomies and 84% of appendicectomies. Univariate analysis showed that tracheal intubation/laryngeal mask were used significantly more often in older children, with long duration of anaesthesia, in nonambulatory procedures and in procedures performed at an academic centre. When these variables were included in a multivariate analysis, the duration of anaesthesia over 30 min was a factor linked to the use of tracheal intubation/laryngeal mask airway for the two types of surgery (P < 0.0001). For tonsillectomy, inpatients were 2.9 times more likely to be intubated (or have an laryngeal mask airway) than were outpatients. For appendicectomy, older children were 3.4 times more likely to be intubated (or have an laryngeal mask airway) than younger children. CONCLUSIONS: This large French survey shows that the use of tracheal intubation/laryngeal mask airway in this country is primarily related to a predicted long duration of anaesthesia.     

Intubating laryngeal mask for airway management in lateral decubitus state: comparative study of right and left lateral positions

Background. The intubating laryngeal mask has been used forthe emergency management of the airway in patients placed inthe lateral decubitus position. We have conducted this prospectivestudy to compare the feasibility of placement of an intubatinglaryngeal mask and blind tracheal intubation guided by the intubatinglaryngeal mask in patients placed in the right and the leftlateral positions. Methods. A total of 82 adults of both sexes with normal airways,scheduled for cholecystectomy, were allocated randomly to beplaced in either the right (n=41) or left (n=41) lateral positionfor the insertion of an intubating laryngeal mask and blindtracheal intubation guided by the intubating laryngeal maskunder balanced general anaesthesia. A sequence of standard manoeuvreswas performed after each failed attempt at intubating laryngealmask placement and intubation. Results. The intubating laryngeal mask was placed in all patientsat the first attempt. Ventilation of the lungs through the intubatinglaryngeal mask was possible in 40 patients (97.5%) from eachgroup after the first attempt at insertion (P=1). Followingadjustments, adequate ventilation could be achieved in all patients.The first attempt success rates of blind tracheal intubationwere 85.3% (35/41) and 87.8% (36/41) in the right and left lateralgroups, respectively (P=1). The remaining patients from bothgroups (except for one patient in the left lateral group whohad a failed intubation) were intubated at the second attempt. Conclusion. Insertion of the intubating laryngeal mask and blindtracheal intubation through it in the lateral position is feasiblein patients with normal airways. These procedures have a highand comparable success rate when patients are placed in theright and left lateral positions.     

Craniodiaphyseal dysplasia; another cause of difficult intubation

A nine-year-old boy with craniodiaphyseal dysplasia (CDD) presented for mandibular reduction. Patients with CDD present problems to the anaesthetist, specifically difficulties with airway management and tracheal intubation. This child was managed using laryngeal mask airway (LMA) guided fibreoptic intubation. Spontaneous respiration was maintained throughout intubation, following which ventilation was controlled and anaesthesia was provided using nitrous oxide, isoflurane and fentanyl. The perioperative management is described.     

Die Kehlkopfmaske – ein wertvolles Instrument bei erschwerter kindlicher Intubation Anästhesiologisches Management bei Vorliegen eines Pierre-Robin-Syndroms

In cases of craniofacial and mandibulofacial malformations, which are mostly treated during childhood, difficult intubation conditions must generally be expected. In such cases, the laryngeal mask airway (LMA) an alternative instrument for use in endotracheal intubation is a new aid for ventilation. In certain instances, it can be used alone to induce general anaesthesia. Reports of endotracheal intubation by means of the LMA in adults have also been published. Case report. In our case, a 6-year-old boy with Pierre-Robin syndrome (triad: micrognathia, broad palatoschisis, glossoptosis) needed dental resetting. After induction of anaesthesia in this very cooperative boy with thiopentone and fluothane and relaxation with succinylcholine, it was not possible to examine the hypopharynx by laryngoscopy preparatory to nasal intubation as usual. Repeated blind attempts at nasal intubation (again with spontaneous breathing) failed, as did the attempt at fibreoptic bronchoscopic intubation, because of the narrow anatomical conditions. Finally, a laryngeal mask airway (LMA; size 2) was introduced, and as a result of this ventilation was achieved. However, endotracheal intubation was required for performance of the surgical resetting. With the fibreoptic bronchoscope, we could verify the central position of the LMA over the glottis. A tracheal tube (size 4) was inserted across the laryngeal airway without optic control. The tube connector was disconnected and a normal guide inserted into the tube to remove the LMA. The dental resetting was also performed by oral intubation. Conclusion. Therefore, the LMA is not only a ventilation aid, but also a valuable tool in difficult intubation conditions. In our opinion, it is necessary to provide this tool in every anaesthetic unit.     

喉罩用于隆胸手术患者气道管理的效果

[摘要]目的观察喉罩通气全凭静脉麻醉用于隆胸术的临床效果。方法选择ASAI～Ⅱ级女性隆胸手术患者40例,年龄23—42岁;体重45—67kg;随机分为气管内插管组（A组,n=20）与喉罩组（B组,n=20）两组,A组静脉注射芬太尼0．2mg、丙泊酚2．0—2．5mg／kg、阿曲库铵0．15mg／kg诱导,插入气管导管;B组静脉注射芬太尼0．1mg、丙泊酚2．0～2．5mg／kg诱导,插入普通型喉罩,两组均接麻醉机行IPPV模式控制呼吸,两组均以微量泵持续泵入丙泊酚6～9tLg／（kg·min）,瑞芬太尼0．1—0．15μg/（kg·min）维持麻醉,A组间断静脉注射阿曲库铵,手术结束前10min停止用药,待受术者呼之能应,呼吸良好时拔除气管导管或喉罩。观察记录两组患者气管内插管和喉罩置入时间及置人情况、监测病人麻醉前（11D）、插管（插喉罩）后即刻（T1）、分离胸部肌肉时（他）、植入假体时（T3）、喉罩和气管导管拔除后即刻（T4）时的MAP、HR及SpO：的变化、通气状态以及操作时及术后的相关不良反应。结果A组1次成功完成气管内插管率与B组1次成功置入喉罩率无显著性差异（P〉0．05）;A组诱导时芬太尼用量显著多于B组（P〈0．05）;A组气管内插管后即刻（T1）以及拔管后即刻（rr4）的MAP及HR较诱导前显著升高（P〈0．05）,分离胸部肌肉时（T2）与植入假体时（T3）SBP、DBP、MAP和HR值均低于麻醉前,而B组T1、T2、T3时均较诱导前低（P〈0．05）;T4与诱导前相比无明显差异（P〉0．05）。A组插管时发生口腔粘膜出血及术后发生咽喉疼痛及呛咳的患者明显多于B组（P〈0．05）。结论与气管内插管全麻相比,喉罩通气全凭静脉麻醉施行隆胸手术,麻醉效果更满意、循环更稳定、并发症更少,术后恢复更舒适。