颈椎手术患者喉罩辅助纤维支气管镜引导气管插管的效果

目的 评价颈椎手术患者喉罩辅助纤维支气管镜引导气管插管的效果.方法 择期行前路颈椎手术患者40例,性别不限,年龄18～55岁,体重50～75 kg,ASA分级Ⅰ或Ⅱ级,Mallampatis分级Ⅰ或Ⅱ级.采用随机数字表法,将患者随机分为2组(n=20):纤维支气管镜引导气管插管组(FOB组)和喉罩辅助纤维支气管镜引导气管插管组(LMA组).麻醉诱导后,进行气管插管.记录气管插管时间和气管导管置入情况;记录气管插管期间高血压、心动过速和低氧血症的发生情况;记录LMA组喉罩置入情况、置入时间和拔除气管导管时喉罩移位情况.记录拔除喉罩带血和术后咽喉部不良反应的发生情况.结果 喉罩1次置入成功率为90％,置入时间为(13±3)s.两组气管插管成功率均为100％.与FOB组比较,LMA组气管插管时间缩短,1次气管插管成功率升高(P＜0.05).两组气管插管期间血液动力学稳定,均未发生高血压、心动过速和低氧血症.LMA组气管导管拔除时有8例(40％)发生喉罩移位;拔除喉罩时1例发生喉罩带血;术后1例发生咽部轻微疼痛;两组均未见其它不良反应的发生.结论 颈椎手术患者喉罩辅助纤维支气管镜引导气管插管不仅可确保有效通气,还可提高引导气管插管成功率,明显缩短气管插管时间.     

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.     

Supreme喉罩用于高血压病老年患者气道管理的效果

目的 评价Supreme喉罩用于高血压病老年患者气道管理的效果.方法 选择高血压病老年患者40例,年龄65～ 75岁,体重45 ～ 70 kg,BMI＜ 35 kg/m2,ASA分级Ⅱ或Ⅲ级,高血压病程＞1年,采用随机数字表法,将患者随机分为2组(n=20):气管插管组(T组)与Supreme喉罩组(S组).静脉注射芬太尼、丙泊酚、维库溴铵行麻醉诱导,下颌松弛后,S组置入Supreme喉罩,T组置入气管导管,行机械通气.七氟醚,丙泊酚和维库溴铵维持麻醉.于入手术室、置入喉罩/气管导管即刻、1、2、5min、切皮、拔除喉罩/气管导管即刻(T0-6)时记录SP、DP、HR、SpO2;于T0-4,6时采集右颈内静脉血样4ml,测定血浆肾上腺素(AE)、去甲肾上腺素(NE)和多巴胺(DA)浓度;记录插管反应和拔管反应的发生情况、置入时间、置入次数;置入喉罩/气管导管后测定肺顺应性、气道峰压、气道密封压、平台压;记录拔除后咽部不良反应的发生情况.结果 与T组比较,S组SP、HR、插管反应、拔管反应和咽部不良反应的发生率、血浆NE、AE和DA的浓度降低,置入时间缩短(P＜0.05).与T0时比较,S组T2时血浆NE浓度升高,T组T1～46时血浆NE浓度升高,T1～3时血浆AE和DA浓度升高(P＜0.05).结论 Supreme喉罩用于高血压病老年患者气道管理的效果优于气管插管,Supreme喉罩置入和拔除反应小,咽部不良反应少.     

颈椎手术患者i-gel喉罩辅助纤维支气管镜引导气管插管的效果

目的 评价颈椎手术患者i-gel喉罩辅助纤维支气管镜引导气管插管的效果.方法 择期全麻气管插管的颈椎手术患者40例,ASA分级Ⅰ或Ⅱ级,性别不限,年龄36～62岁,体重57～78 kg,身高165～177 cm,Mallampati分级Ⅰ～Ⅲ级,随机分为2组(n=20):口咽通气道辅助FOB引导气管插管组(O组)和i-gel喉罩辅助FOB引导气管插管组(I组).麻醉诱导后,进行气管插管.记录气管插管时间、纤维支气管镜咽部解剖结构显露分级、气管插管置人情况;记录气管插管期间高血压、心动过速和低氧血症的发生情况;记录拔除喉罩带血和术后咽喉部不良反应的发生情况.结果 i-gel喉罩均1次置入成功,置入时间为(10±3)s,两组气管插管成功率均为100%;与O组比较,I组气管插管时间缩短,1次气管插管成功率升高,纤维支气管镜咽部解剖结构显露分级升高(P＜0.05).两组气管插管期间血液动力学稳定,均未发生高血压和心动过速和低氧血症,I组仅1例喉罩粘血,两组均未见其他不良反应发生.结论 颈椎手术患者i-gel喉罩辅助纤维支气管镜引导气管插管不仅可确保有效的通气,而且可提高引导气管插管成功机率,缩短操作时间.     

喉罩置入与气管插管全麻在结肠根治术中的效果观察

目的观察喉罩置入和气管插管全身麻醉在结肠癌根治手术中效果。方法将60例行结肠癌根治手术的患者随机分为喉罩置入(LMA)组和气管插管(TT)组,观察并比较2组麻醉期间的血流动力学变化及麻醉效果。结果麻醉期间2组通气、气体交换良好;TT组在T2和T5时间点HR明显快于T0及LMA组(P<0.05),SBP、DBP明显高于T0及LMA组(P<0.05);TT组麻醉并发症高于LMA组。结论在大肠癌根治手术中,喉罩置全身麻醉的效果于术明显优于气管插管全身麻醉。     

Supreme喉罩用于腹腔镜手术患者气道管理的效果

目的 评价Supreme喉罩用于腹腔镜手术患者气道管理的效果.方法 择期全麻下行腹腔镜手术的患者120例,性别不限,年龄35～60岁,体重48～85 kg,ASA Ⅰ或Ⅱ级,Mallampatis Ⅰ～Ⅲ级,随机分为2组(n=60):Supreme喉罩组(S组)和气管插管组(T组).S组根据患者体重选择喉罩型号,麻醉诱导后置入喉罩,并经引流管放置胃管,T组在直接喉镜下行气管插管.记录气管插管或喉罩置入时间及置人情况;记录S组胃管置入状况和喉罩气道密封压,并行纤维支气管镜检查评分,以评价喉罩对位情况;记录术中SpO2、PrrCO2和气道峰压(Ppeak),记录拔除气管导管或喉罩后不良反应的发生情况;记录手术时间、麻醉时间、拔管时间和苏醒时间.结果 与T组比较,S组喉罩置入时间、拔管时间和苏醒时间缩短,拔除喉罩后低氧血症、呛咳、咽喉痛的发生率降低(P<0.05);两组均无返流误吸发生.各时点spO2、PETCO2、Ppeak均在正常范围内,组间比较差异无统计学意义(P>0.05).S组喉罩置入成功率和T组气管插管成功率比较差异无统计学意义(P>0.05),S组喉罩气道密封压为(25±4)cm H2O,喉罩对位准确率95%,胃管放置成功率100%.结论 Supreme喉罩通气效果好,气道密封性可靠,拔除后不良反应少,可安全有效地用于腹腔镜手术患者的全麻气道管理.     

Supreme喉罩用于妇科腹腔镜手术患者气道管理的效果

目的 评价Supreme喉罩用于妇科腹腔镜手术患者气道管理的效果.方法 择期行妇科腹腔镜手术的患者80例,ASA分级Ⅰ或Ⅱ级,年龄40～64岁,体重50～70 kg,身高158～170 cm,Mallampatis分级Ⅰ或Ⅱ级,随机分为2组(n=40):Supreme喉罩组(S组)和ProSeal喉罩组(P组).麻醉诱导后置入喉罩,行机械通气,并经引流管置入胃管.记录手术时间、气腹时间、清醒时间、喉罩置入时间、喉罩及胃管置入情况;记录喉罩囊内压为60 cm H2O时的充气量和气道密封压,并采用纤维支气管镜进行通气罩咽部解剖结构显露分级;术中监测BP、HR、ECG、SpO2、PETCO2,记录术后咽喉部不良反应的发生情况.结果 两组手术时间、气腹时间、清醒时间比较差异无统计意义(P＞0.05).两组术中BP、HR、SpO2、PETCO2、气道峰压均在正常范围,组间比较差异无统计学意义(P＞0.05).与P组比较,S组喉罩一次置入成功率、胃管一次置入成功率升高,喉罩置入时间缩短,通气罩咽部解剖结构显露分级升高,术后喉罩带血的发生率降低(P＜0.05);两组喉罩置入成功率均为100%,喉罩置入成功率、气道密封压、喉罩充气量比较差异均无统计学意义(P＞0.05).结论 Supreme喉罩通气效果好,气道密封性可靠,易于置入,可安全有效地用于妇科腹腔镜手术患者的气道管理.     

不充气喉罩及气管插管对子宫切除全麻患者应激反应的影响

目的 观察子宫切除全麻患者应用不充气喉罩或气管插管对血浆肾上腺素(E)、去甲肾上腺素(NE)的影响.方法 选择40例经腹子宫切除患者,全麻诱导后随机均分成应用一次性不充气欧普乐喉罩(LMA)组和气管插管(TT)组.监测HR、BP、SpO2、PETCO2和ECG等,并分别于麻醉诱导前(T0)、置入喉罩或气管插管后1 min(T1)、3 min(T2)、5 min(T3)各时点的血浆E、NE浓度.结果 TT组T1、T2时HR明显快于T0时及LMA组(P<0.05),SBP、DBP明显高于T0时及LMA组(P<0.05),两组T0～T3时E水平无明显变化,TT组NE在T1、T2时明显高于T0时及LMA组(P<0.05).结论 子宫切除全麻患者应用不充气喉罩比气管插管明显减少应激反应发生、并能有效通气,可安全应用.     

i-gel喉罩用于术前置入鼻胃管的腹腔镜手术患者气道管理的效果

目的 评价i-gel喉罩用于术前置入鼻胃管的腹腔镜手术患者气道管理的效果.方法 择期全麻下拟行腹腔镜手术患者55例,性别不限,ASA分级Ⅰ～Ⅲ级,年龄26～64,体重54～73 kg,Mallampati分级Ⅰ～Ⅲ级,采用随机数字表法,将患者随机分为2组:经i-gel喉罩放置胃管组(Ⅰ组,n=28)和术前经鼻放置胃管组(Ⅱ组,n=27).Ⅰ组经i-gel喉罩的引流管放置胃管,并经胃管引流胃液及气体,Ⅱ组术前经鼻放置并术中保留胃管,麻醉诱导前充分吸引后,再置入喉罩.术中监测血液动力学指标、SpO2、PETCO2和气道峰压.置入成功后行纤维支气管镜检查评分,并观察胃管位移的发生情况;记录喉罩置入时间、首次置入成功情况、气道密封压、罩体周围漏气和胃管引流情况.拔除喉罩后观察罩体内是否有血液或返流物,记录术后24 h内咽部不良反应的发生情况.结果 两组术中血液动力学平稳,SpO2、气道峰压均在正常范围,气道峰压低于喉罩密封压,组间比较差异无统计学意义(P＞0.05);两组喉罩置入时间、首次置入成功率、胃管引流率、气道密封压、罩体漏气发生率、口咽部解剖结构显露评分、咽部不良反应发生率、罩体内带血和有返流物的发生率比较差异均无统计学意义(P＞0.05),Ⅱ组胃管均未发生位移.结论 对于术前置入鼻胃管的腹腔镜手术患者,i-gel喉罩易于置入,气道密封性可靠,通气效果好,不影响胃管引流,可安全有效地用于该类患者的气道管理.

Abstract：

Objective To assess the efficacy of laryngeal mask airway (LMA) i-gel in patients required insertion of nasogastric tube before laparoscopic surgery. Methods Fifty-five ASA Ⅰ - Ⅲ patients ( Mallampati Ⅰ -Ⅲ ), aged 26-64 yr, weighing 54-73 kg, scheduled for elective laparoscopic surgery were randomly divided into 2 groups: group Ⅰ ( n= 28) and group Ⅱ ( n = 27). The size of i-gel LMA was chosen based on the patient' s weight, and i-gel LMA was inserted after induction of anesthesia with TCI of propofol and remifentanil, and iv injection of rocuronium. In group Ⅰ , the nasogastric tube was inserted through the drain tube of i-gel LMA. In group Ⅱ , the nasogastric tube was inserted through the nostril before operation. The hemodynamic parameters, SpO2 ,PETCO2 and peak airway pressure were monitored during operation. The fiberoptic laryngoscopy scores were assessed and nasogastrice tube displacement was recorled after successful LMA placement. The LMA placement time, success rate of LMA placement at the first attempt, airway sealing pressure, the occurrence of air leakage of LMA, and nasogastric tube drainage were recorded. The problems after removal of the LMA were observed and the adverse reactions within 24 h after operation were recorded. Results The hemodynamics was stable and the SpO2,peak airway pressure were within the normal range during operation in both groups. There was no significant difference in the LMA placement time, success rate of LMA placement at the first attempt, nasogastric tube drainage rate, airway sealing pressure, incidence of air leakage, fiberoptic laryngoscopy scores, problems after removal of the LMA and adverse reactions between the two groups ( P ＞ 0. 05). Conclusion i-gel LMA can provide adequate ventilation and does not interfere with the nasogastric tube drainage during laparoscopic surgery and can be used effectively for the patients required insertion of nasogastric tube before operation.     

妇科手术患者Guardian喉罩与Supreme喉罩气道管理效果的比较

目的 比较Guardian喉罩与Supreme喉罩用于妇科手术患者气道管理的效果.方法 择期全麻下行妇科手术患者120例,年龄19～80岁,体重50～70kg,ASA分级Ⅰ或Ⅱ级,随机分为2组:Supreme喉罩组(S组,n=59)和Guardian喉罩组(G组,n=61).麻醉诱导后置入4号喉罩,行机械通气.术中监测BP、HR、SpO2、PETCO2和Ppeak.记录喉罩置人情况、置入时间、纤维支气管镜检查分级、气道密封压、正常通气时(VT 8 ml/kg)的气道压、大潮气量(VT20 ml/kg)通气试验时的气道压和漏气的发生情况、术中口咽部漏气的发生情况、拔除喉罩时不良反应和术后咽喉部不良反应的发生情况、麻醉时间、手术时间、喉罩拔除时间和苏醒时间.结果 两组喉罩置入成功率、置入时间、正常通气时的气道压、大潮气量通气试验时的气道压、拔除喉罩时罩体带血和术后咽喉疼痛、声音嘶哑和吞咽困难的发生率、麻醉时间、手术时间、喉罩拔除时间和苏醒时间差异无统计学意义(P＜0.05).两组患者BP、HR、SpO2、Ppeak和PETCO2均在正常范围内.与S组比较,G组纤维支气管镜检查分级和气道密封压升高,大潮气量通气试验时漏气和术中口咽部漏气的发生率降低(P＜0.01).结论 Guardian喉罩和Supreme喉罩置入简单易行,气道密封效果好,可有效保证通气,对咽喉部的刺激小.Guardian喉罩用于妇科手术患者气道管理的效果更好.     

Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation

Background: Out-of-hospital airway management is a critical skill, demandingexpert knowledge and experience. The intubating laryngeal maskairway (ILMA) is a ventilatory and intubating device which maybe of value in this arena. We evaluated the ILMA for out-of-hospitalmanagement of the difficult airway. Methods: Twenty-one anaesthesia-trained emergency physicians (EPs) completeda training programme and used the ILMA in patients with difficult-to-manageairways. Indications for use of the ILMA included patients withdifficult laryngoscopy, multiple intubation attempts, limitedaccess to the patient’s head, presence of pharyngo-laryngealtrauma, and gastric fluids or bleeding obscuring the view ofthe vocal cords. Results: During the study period, 146 of 2513 patients underwent trachealintubation or alternate rescue airway insertion. In 135 patients,laryngoscopy was performed and Cormack–Lehane view wasrecorded as grade I in 72 (53.3%), II in 45 (33.3%), III in10 (7.4%), and IV in 8 (5.9%). EPs encountered 11 patients (7.5%)with difficult-to-manage airways. ILMA insertion and ventilationwas possible in 10 patients in the first and one patient inthe second attempt. ILMA-guided tracheal intubation was successfulin all patients, in 10 after the first and in 1 after two attempts. Conclusions: In this study, ventilation and intubation with ILMA was successfulin all patients with difficult-to-manage airways. Our data supportthe use of the ILMA as rescue device for out-of-hospital airwaymanagement by staff who have appropriate airway skills and havereceived appropriate training.     

Comparison of the standard laryngeal mask airway and the ProSeal laryngeal mask airway in obese patients

Background. The ProSeal^TM laryngeal mask airway (PLMA) may haveadvantages over the laryngeal mask airway (LMA     

Training in airway management

Management of the airway is central to the practice of anaesthesia, yet trainees frequently feel poorly trained in this area. A large range of skills needs to be acquired, but there are often problems providing training on live patients. We review the different modalities available for training and assessment in airway management.     

Use of a ProSeal laryngeal mask airway for airway maintenance during emergency Caesarean section after failed tracheal intubation

We report the use of the ProSeal^TM laryngeal mask airway toestablish and maintain the airway during emergency Caesareansection when tracheal intubation had failed with conventionallaryngoscopy and mask ventilation was difficult. The ProSeal^TMlaryngeal mask allowed controlled ventilation without gas leakand facilitated drainage of the stomach. Br J Anaesth 2004; 92: 144–6     

Infraglottic airway devices and techniques

Infraglottic airway management techniques, such as intubation of the trachea with a cuff-sealed endotracheal tube, offer significant advantages for the anaesthetized patient, especially for patients in critical condition.There are numerous ways of intubation of the trachea; the most common and popular is direct laryngoscopy. The variety of laryngoscope blades offers choices to solve difficult intubations, but all different techniques and devices need experience in routine clinical use.In case of failure, unsuccessful attempts to intubate the trachea should be limited to three, in order to use different—e.g. supraglottic or fibreoptic—techniques.Nasotracheal intubation causes an inherent risk of severe epistaxis, which may severely compromise airway management options and endangers the patient's life. Prior to passing the tube through the nose, direct laryngoscopy should be performed to estimate the Cormack–Lehane score.Rigid intubation fibrescopes—as flexible ones—do improve the view of the larynx and permit tracheal intubation with less head and cervical spine movement than direct laryngoscopy. Success with these devices requires considerable experience and clinical practice.The use of retrograde intubation has reduced during recent years, mainly due to the availability of flexible and rigid intubation fibrescopes.The EasyTube—a relatively new device—combines the advantages of both an endotracheal tube with a supraglottic airway device.The Combitube is a well-established emergency airway used widely for solving unanticipated and anticipated difficult airways. International guidelines recommend the use of Combitube following the number of studies and reports associated with its use.     

The laryngeal mask airway

A new form of airway has recently been described, which is introduced blindly into the hypopharynx to form a seal around the larynx, so permitting spontaneous or positive pressure ventilation without penetration of the larynx or oesophagus. The further development of this new airway is described and the results of 18 months' clinical experience are presented. The airway was used successfully in 118 patients, 17 of whom received controlled ventilation of their lungs. It was used in place of the facemask in routine anaesthesia, and was of particular value in ophthalmic, dental and ear, nose and throat procedures and where difficulties with the airway were expected. The incidence of sore throat and other problems was low. Experience of more than 500 cases suggests that the laryngeal mask airway may have a valuable r?le to play in all types of inhalational anaesthesia, while its proven value in some cases of difficult intubation indicates that it may contribute significantly to the safety of general anaesthesia.     

The normal and the challenging pediatric airway

Management of a child’s airway is one of the main sources of stress for anesthetists who do not routinely anesthetize children. Unfortunately, trainees are gaining less experience in pediatric airway management than in the past, which is particularly difficult at a time when some beliefs about airway management are being challenged and airway management is less standardized. Fortunately, most children have an easily managed, normal airway. Nevertheless, it is of vital importance to teach our trainees the basic airway skills that are probably the most important skill in an anesthetists’ repertoire when it comes to a difficult airway situation. This review focuses on the airway management in children with a normal and a challenging airway. Different choices of airway management in children, and their advantages and disadvantages are discussed. Furthermore, the three broad causes of a challenging airway in children and infants are highlighted – the difficulty obtaining a mask seal, difficulty visualizing the vocal cords, and the third cause in which the larynx can be visualized but the difficulty lies at or beyond that level. Guidelines are given how to deal with these patients as well as with the feared but rare scenario of ‘cannot ventilate, cannot intubate’ in children.     

The upper airway during anaesthesia

Upper airway obstruction is common during both anaesthesia andsleep. Obstruction is caused by loss of muscle tone presentin the awake state. The velopharynx, a particularly narrow segment,is especially predisposed to obstruction in both states. Patientswith a tendency to upper airway obstruction during sleep arevulnerable during anaesthesia and sedation. Loss of wakefulnessis compounded by depression of airway muscle activity by theagents, and depression of the ability to arouse, so they cannotrespond adequately to asphyxia. Identifying the patient at riskis vital. Previous anaesthetic history and investigations ofthe upper airway are helpful, and a history of upper airwaycompromise during sleep (snoring, obstructive apnoeas) shouldbe sought. Beyond these, risk identification is essentiallya search for factors that narrow the airway. These include obesity,maxillary hypoplasia, mandibular retrusion, bulbar muscle weaknessand specific obstructive lesions such as nasal obstruction oradenotonsillar hypertrophy. Such abnormalities not only increasevulnerability to upper airway obstruction during sleep or anaesthesia,but also make intubation difficult. While problems with airwaymaintenance may be obviated during anaesthesia by the use ofaids such as the laryngeal mask airway (LMA), identificationof risk and caution are keys to management, and the airway shouldbe secured before anaesthesia where doubt exists. If trachealintubation is needed, spontaneous breathing until intubationis an important principle. Every anaesthetist should have inmind a plan for failed intubation or, worse, failed ventilation. Br J Anaesth 2003; 91: 31–9     

Effect of common airway manoeuvres on upper airway dimensions and clinical signs in anaesthetized, spontaneously breathing children

Chin lift, jaw thrust and these manoeuvres combined with continuouspositive airway pressure (CPAP) can be used to improve the patencyof the upper airway during general anaesthesia. We used videoendoscopy and measurement of stridor to compare the efficacyof these manoeuvres in 24 children (3–10 yr) with adenotonsillarhyperplasia. A bronchofibrescope was passed via the nose whilethe children were breathing spontaneously, to identify (i) theshortest transverse distance between the tonsils during inspirationand during expiration and (ii) the distance from the tip ofthe epiglottis to the posterior pharyngeal wall. Chin lift orjaw thrust lifted the epiglottis and, when combined with CPAP(10 cm H₂O), there was a significant lateral displacement ofthe tonsils. Both chin lift plus CPAP and jaw thrust plus CPAPreduced stridor significantly compared with the unsupportedcondition. In conclusion, in spontaneously breathing childrenwith large tonsils, chin lift plus CPAP is recommended, whereasjaw thrust plus CPAP is no better and may cause post-operativediscomfort. Br J Anaesth 2001; 86: 217–22