气管插管困难的处理

气管内插管是保持上呼吸道通畅的最可靠手段，是临床麻醉中的一个重要组成部分，它不仅广泛用于麻醉实施，而且在危重病人呼吸循环的抢救复苏及治疗中发挥重要作用。在与麻醉有关的死亡病例中，大约30％是由于困难呼吸道管理不当造成的。随着麻醉技术的开展，临床上气管内插管的应用越来越广泛。困难气管插管的发生率有时高达3％，是麻醉医生常遇到的问题。困难气管插管是指气道因解剖异常或病理改变而导致在普通喉镜直视下3次不能将气管导管顺利插入气管内或插管时间超过10min。一些病人体征明显，麻醉前容易引起重视，但有些病人外表似乎正常，仍有可能给插管带来意想不到的困难，若插管前未能料及，并且处理不当，则有死亡的潜在危险。现将气管插管困难及处理综述如下：     

加强管用于颈椎骨折手术患者气管插管的体会

目的：观察加强型气管导管用于颈椎骨折手术患者气管插管的实际效果。方法选择在笔者所在医院择期行颈椎前路或后路减压手术的患者40例,按随机数字表法分为两组,观察组采用加强型气管导管,对照组采用普通气管导管,采用管芯法气管插管。比较两组一次插管成功率和术后6 h内咽喉痛的发生率。结果观察组一次插管成功率95%,对照组一次插管成功率70%;术后6 h内咽喉痛的发生率观察组为10%,对照组为30%。结论加强型气管导管用于颈椎骨折手术患者气管插管一次插管成功率高,术后咽喉痛发生率低,具有明显的优势。     

中心静脉置管临床应用及并发症防治分析

外周导入中心静脉置管是指采用引导针经外周静脉穿刺，将一根由硅胶材料制成、标有刻度、能放射显影的心静脉导管插入并使其顶端位于上或下腔静脉内的深静脉管置入术。近年来，在临床上广泛用于长期禁食需静脉营养治疗病人、危重病人的抢救和肿瘤化疗的病人。此法操作简单，创伤少，血管定位准确，但也存在一定的并发症。为减少和避免并发症的发生，现将我院应用中心静脉置管的护理及其并发症的防治，总结报告如下。     

我国介入放射学新进展

本从影像学设备，支架技术，导管栓塞技术，基因治疗等几个方面阐述介入技术的最新成果；计算机控制的显示技术，造影剂长距离自动跟踪技术（步进技术）及三维血管成像等新技术已被广泛应用在数字减影血管造影机上，CT透视引导介入穿刺正逐渐在临床应用，介入MRI基本处于研究阶段；内支架及导管栓塞技术应用领域越来越广泛，可部分取代外科手术；用介入放射学方法进行基因治疗前景令人鼓舞；介入放射学的发展和普遍应用。现已成为同内科，外科并列的三大诊疗技术之一，在新的世纪里，介入放射学将进入快速发展阶段。     

麻醉机快速充氧连接气管镜在小儿气管异物取出术中的应用

目的总结麻醉机快速充氧连接气管镜在小儿气管异物取出术中应用的经验。方法15例行气管异物取出的患儿经快速诱导面罩加压通气经口腔于声门置入气管镜用麻醉机高频喷射充氧控制通气，氯安酮或丙泊酚复合肌松荆维持麻醉，术中严密监测SPO2。术毕停滴麻醉药，病人洁醒后拔管。结果14例取出异物，1例未取出；无一例发生屏气、呛咳。患儿均于停麻醉药30min内清醒。睁眼，吞咽反射、自主呼吸恢复良好，吸空气时SPO2维持在93％以上，拔管后均未发生喉痉挛及喉头水肿，术后也未发生缺氧。结论经快速诱导面罩加压通气后置入气管镜用麻醉机高频喷射充气控制通气用于气道异物取出术，声门暴露良好便于气管镜的插入，术中不发生屏气、呛咳，病人苏醒快。术后并发症少。不失为一种比较实用的方法，但术中及术后均需加强监测，尤其是SPO2。     

国产镍钛合金气管支架治疗恶性气道狭窄的临床应用

目的评价应用国产镍钛合金气管支架治疗恶性气道狭窄的临床效果。方法11例恶性气道狭窄患者(其中肺癌6例、食管癌晚期伴气管旁淋巴结转移合并气道狭窄5例),其中男性7例,女性4例,年龄46～62岁。术前常规行高千伏胸部X线摄片和CT检查,明确气道狭窄的部位、形态及范围。在X线透视下将多功能导管沿导丝经声门进入气管并越过狭窄段,更换超硬导丝并将导丝留置于狭窄段远端,撤除导管,沿导丝通过置入器置入气管支架。结果11例患者成功置入气管支架。随即所有患者呼吸困难症状明显改善。全部病例均无严重并发症。结论气管支架置入术是治疗恶性气道狭窄的有效方法。     

1 MHz腔内射频加热辐射器在体模和犬颈段食管中的热场分布

目的 在肌肉等效体模及Beagle犬颈段食管中测定ZRL—Ⅱ型食管腔内加热辐射器的温度分布，探讨其热场分布能否满足食管癌加热治疗的临床需要。方法 ①在肌肉等效体模中测定ZRL—Ⅱ型食管腔内射频加热辐射器的温度分布，②Beagle犬用氯胺酮麻醉、固定。将腔内加热辐射器插入食管腔内，加热45min后分层解剖犬的颈部，同时测量食管外壁、气管、食管周围软组织中的温度。结果 ①在肌肉等效体模中距离导管囊表面1cm的环形体内的温度在43．2℃～43．6℃之间；在距离导管囊表面2cm的环形体内的温度在42．6℃～43．3℃之间，在距离导管囊表面3cm的环形体内的温度在42．6℃～42．8℃之间。②测得Beagle犬颈段食管腔内和外壁的温度为43．5℃，气管内为38．0℃，主动脉旁38．0℃，距食管外壁1cm处的软组织温度为40-3℃，距食管外壁2cm处的软组织温度为39．0℃，而颈部皮下的温度是37．5℃。结论 ①ZRL-Ⅱ型射频食管腔内加热辐射器的热场分布满足临床食管腔内加热的需要，②体模测定与活体动物测定，热场分布存在一定差异，需进一步研究。     

气管切开术后气管内肉芽组织增生治疗体会

目的:寻求气管切开术后气管内肉芽组织增生最佳治疗方法.方法:应用气管内滴药、Nd:YAG激光烧灼及自制气管套管等方法治疗气管内肉芽组织增生14例.结果:4例气管内滴药、7例经气管内滴药联合Nd:YAG激光烧灼、3例通过更换自制气管套管均取得较好的疗效.结论:应用气管内滴药、Nd:YAG激光烧灼及自制气管套管等方法可有效治疗气管内肉芽组织增生.     

气管导管引导下安置胃管在手术中的应用

目的 探讨消化道手术中胃管安置失败的补救措施.方法 选择术中发现胃管安置不到位的在全麻下行手术的患者48例,随机均分为2组,观察组在气管导管(ID=7.0)引导下安置胃管,对照组按常规方法放置胃管,3次不成功者改用在气管导管引导下安置胃管.结果 与对照组比较,观察组一次插管成功率高,咽部疼痛和水肿发生率低,差异有统计学意义(P＜0.05或0.01).结论 气管导管引导下安置胃管是解决在手术中重置胃管较好的方法.     

改良气管切开径路气道异物取出术

对２７例气道异物，采用气管切开途径取出异物后不插气管导管即缝合气管的气道异物取出术，与采用常规经气管切开径路取气道异物手术方法对照比较，该术式具有①减轻术后繁多护理；②减少并发症发生率；③缩短住院时间；④减少医疗费用。     

Modified submental orotracheal intubation using the blue cap on the end of the thoracic catheter

The technique of submental intubation in patients with multiple facial fractures and skull base fracture was originally described by Altemir. This technique provides a secure airway and allows intermaxillary fixation while avoiding the complications of nasotracheal intubation or tracheostomy. However, when the endotracheal pilot balloon and endotracheal tube are pulled through the submental incision site using this technique, soft tissues or blood may enter the endotracheal tube and trauma may result in the surrounding tissues. To overcome these problems, we carried out a modification of submental orotracheal intubation using the blue cap on the end of the thoracic catheter in a patient with mandibular fractures and injury to the skull base and found that this modification resulted in a safer and less traumatic intubation.     

Management of esophageal stenting-associated esophagotracheal fistula,tracheal stenosis and tracheal rupture: a case report and review of the literature

Objective: Although the placement of esophageal self-expandable stents (SES) can effectively relieve dysphagia after radiotherapy in patients with esophageal cancer (EC), it may induce severe esophageal complications. This article reports a case of emergency endotracheal intubation in an EC patient who suddenly developed severe dyspnea two months after SES placement. Methods: Electronic bronchoscopy of the patient’s airway confirmed the diagnosis of esophagotracheal fistula, tracheal stenosis and tracheal rupture. Endotracheal intubation was successfully performed under the guidance of electronic bronchoscopy. Results: Dyspnea due to tracheal stenosis was relieved effectively by inserting the tracheal catheter to a proper place under the guidance of electronic bronchoscopy. Conclusion: Bronchoscopic examination is strongly recommended in EC patients who are highly suspected as having airway stenosis associated with esophageal stenting, for which endotracheal intubation under the guidance of bronchoscopy is suggested.     

Management of detachment of pilot balloon during intraoral repositioning of the submental endotracheal tube

Submental endotracheal intubation for surgery was used as an alternative to nasotracheal intubation in patients with craniomaxillofacial injury. Generally extubation was performed in the operation room by pulling the tube through the submental incision site. When extubation is not indicated, intraoral indwelling is preferred to submental intubation. We report a case of a 35-year-old male patient with multiple facial bone fractures. At the end of the surgery, we noticed the oropharyngeal edema, and so the submental intubation was converted into a standard orotracheal intubation. During that procedure, the pilot balloon was accidentally detached from the endotracheal tube. The situation was managed by cutting a pilot tube from a new, unused endotracheal tube and connecting it to the intubated tube using a needle connector.     

Obstructive Fibrinous Tracheal Pseudomembrane After Tracheal Intubation: A Case Report

Obstructive fibrinous tracheal pseudomembrane is a rare, but potentially fatal complication associated with endotracheal intubation. It has been known that the formation of tracheal pseudomembrane is related with intracuff pressure during endotracheal intubation or infectious cause. But in the patient described in this case, pseudomembrane formation in the trachea was associated with subglottic epithelial trauma or caustic injuries to the trachea caused by aspirated gastric contents during intubation rather than tracheal ischemia due to high cuff pressure. We report a patient with obstructive fibrinous tracheal pseudomembrane after endotracheal intubation who presented with dyspnea and stridor and was treated successfully with mechanical removal using rigid bronchoscopy.     

Post intubation tracheal stenosis

Tracheal stenosis following prolonged intubation is a relatively rare but a serious problem. However, some degree of airway injury is common following intubation, no matter whether it is prolonged or of short duration. Here, we are reporting a fifty six year old male patient who developed multiple web like tracheal stenosis following intubation with high volume low pressure cuff endotracheal tube. Subsequently, the stenosis was successfully dilated by balloon bronchoplasty.     

内置式光纤引导的大鼠经口气管插管方法

目的 利用气管导管内置入直径0.9 mm的光纤作为光源,建立一种新的大鼠经口气管插管方法 .方法 SD大鼠40只分2组:(1)气管导管内置入光纤引导下的经口气管插管组(光纤组,n=20),(2)传统光源直视下的经口气管插管组(传统组,n=20).比较2组经口气管插管时间、插管次数、一次插管成功率、拔除气管插管后l周的存活率.结果 光纤组的插管时间(36.00±16.43)s、插管次数(1.05±0.22)次、一次插管成功率95%均优于传统组[(86.20±56.48)s,(1.75±1.02)次,60%,P<0.05],但2组大鼠拔管1周后的存活率差异无统计学意义.结论 气管导管内置光纤引导下的经口气管插管法是一种创新的大鼠气管插管方法 ,能实现快速、有效、准确的气管插管.     

Diagnosis and management of laryngotracheal trauma

Laryngotracheal trauma is life-threatening. We identified 23 patients between 1992 and 1998 with laryngeal (12), tracheal (8), and combined injuries (3). Nineteen patients had penetrating trauma (gunshot wound, 12; stab wound, 7), and four patients had blunt injury. Flexible laryngoscopy identified the injury in 8 of 12 patients (75%), and computer tomography scan was positive in 9 of 9 patients (100%). Twelve of the 19 patients with penetrating wounds were managed by primary repair, 4 had endotracheal intubation without surgical repair, and 3 were observed. No patient with a blunt tracheal injury required repair. Two had endotracheal intubation, and two were observed. A high index of suspicion is essential to identifying laryngotracheal injury. Computer tomography scan is a sensitive diagnostic test for laryngotracheal injury, and may be indicated despite normal flexible laryngoscopy. The decision to repair injuries or observe injuries is primarily based on respiratory distress and associated injuries.     

逆行牵拉技术在大鼠气管插管中的应用

目的探讨逆行牵拉技术在大鼠气管插管中的应用价值。方法80只SD大鼠，24号留置针穿刺气管环状软骨缝隙，金属丝通过留置针经气管逆行至口腔，引导气管插管进入气管。结果一次性穿刺气管成功75只大鼠，3只大鼠导丝逆行时有阻力，后证实进入鼻腔或上颚孔，退出一段后调整导丝角度后成功进入口腔后插管成功。2只大鼠插管时有阻力，牵拉鼠舌及左颊部暴露口腔后插管成功；该操作只需时间（1±0．5）min，一人操作即可完成。无1例失败，成功率为100％。结论此种大鼠气管插管术无需特殊辅助设备，是一简单、快速、安全、可靠、值得推广的大鼠气管插管方法。     

Submental intubation with reinforced tube for intubating laryngeal mask airway

Submental endotracheal intubation is a simple and secure alternative to either nasoendotracheal intubation or a tracheostomy in the airway management of maxillofacial trauma. However, a submental endotracheal intubation is quite difficult to manage if adverse events such as a tube obstruction, accidental extubation, or a leaking cuff with the endotracheal tube in the submental route occur, which could endanger the patient. This paper describes the use of a LMA-FastrachTMETT in the submental endotracheal intubation of patients suffering from maxillofacial trauma. One of the patients was a 16-year-old male, and the other was a 19-year-old male. They were scheduled for an open reduction and internal fixation of the maxillofacial fracture including naso-orbital-ethmoidal (NOE) complex, and a zygomaticomaxillary complex fracture. A submental intubation with a LMA-FastrachTMETT was performed in both cases, and the operation proceeded without any difficulties. These cases show that the use of the LMA- FastrachTMETT can improve the safety and efficacy of submental endotracheal intubation. This is because the LMA- FastrachTMETT has a freely detachable connector, and is flexible enough to keep the patency despite the acute angle of airway.     

Expression of vascular endothelial growth factor in exuberant tracheal granulation tissue in children

Prolonged tracheotomy and endotracheal intubation often induce symptoms of airway obstruction and delay decannulation and extubation. Bronchoscopic examination of patients undergoing these treatments usually shows the presence of exuberant (pseudopapillary or nodular) granulation tissue occupying the airway lumen. An immunohistochemical analysis was undertaken of vascular endothelial growth factor (VEGF) expression in exuberant tracheal granulation tissue (n=17) obtained from children treated with prolonged tracheotomy or endotracheal intubation. Increased levels of VEGF protein and mRNA were expressed mainly by tracheal epithelial cells that migrated to cover the granulation tissue and partly by pericapillary macrophages in this tissue, whereas normal tracheal epithelium did not express VEGF. The VEGF expression level correlated significantly with the severity of the exuberant granulation tissue response (p=0·0018). As VEGF induces angiogenesis and vascular permeability, characteristics of granulation tissue, and plays a pivotal role in granulation tissue development, enhanced VEGF expression may be involved in the development of exuberant tracheal granulation tissue. Copyright © 1999 John Wiley & Sons, Ltd