可弯曲喉罩的临床应用进展

背景 可弯曲喉罩(flexible laryngeal mask airway,FLMA)是专为头颈、上躯干手术设计的一种声门上人工气道装置,由与经典喉罩(classic laryngeal mask airway,CLMA)相同的通气罩及充气阀和带螺旋形钢丝的通气管组成,兼具普通喉罩操作简便、呼吸道刺激小、血流动力学稳定、术后并发症少等优点,及加强型气管导管的可弯曲性、抗折抗扭曲性、不干扰术野等优点,在临床中被逐渐推广. 目的 了解FLMA的分类,掌握FLMA使用方法及适用范围. 内容 对FLMA的发展历史及特点、应用前选择及检查、置入及拔除操作、术中管理及应用现状进行总结. 趋向 对FLMA目前存在的问题及改良方向进行探讨.     

鼻内窥镜手术患者可弯曲喉罩与一次性双管喉罩气道管理效果比较

目的 观察可弯曲喉罩(flexible laryngeal mask airway,FLMA)与一次性双管喉罩(supreme laryngeal mask airway,SLMA)在鼻内窥镜手术中的气道管理效果,并对二者进行比较. 方法 选取择期行鼻内窥镜手术患者40例.美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级、年龄20岁～70岁、体重指数＜30 kg/m2.按随机数字表法随机分成两组,分别为FLMA组(F组)及SLMA组(S组),每组各20例.记录麻醉时间、手术时间、喉罩拔除时间(术毕至呼吸恢复正常可以拔除喉罩的时间)和苏醒时间(术毕至呼之睁眼的时间);术毕即刻、术后6、24、36 h咽喉疼痛发生情况;术者满意程度.统计学分析处理采用SPSS 19.0软件完成. 结果 ①两组喉罩首次成功率分别为95％、90％,差异无统计学意义(P＞0.05).②F组置入时间(10.2±1.8)s,S组置入时间(6.3±1.3)s,差异有统计学意义(P＜0.05).③气道压、气道密封压、纤维支气管镜(branchofiberoscope,FOB)检查分级、两组术后拔出喉罩即刻咽喉疼痛发生例数、术后6h咽喉疼痛发生例数差异无统计学意义(P＞0.05).④两组之间手术医生的满意度差异无统计学意义(P＞0.05),但是F组有一个上升的趋势. 结论 ①FLMA与SLMA均可应用于全身麻醉下鼻内窥镜手术的气道管理,安全可靠.SLMA比FLMA更易置入.②FLMA可适用于各类鼻内镜手术,SLMA在涉及到额窦的手术时应用受到一定限制.     

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。     

The laryngeal mask airway

A prototype size 3 laryngeal mask was used in 100 patients by 18 anaesthetists with no previous experience of its use. A clear and unobstructed airway was obtained in 98% of patients, without requiring support of the jaw, thus leaving the anaesthetists' hands entirely free. The patency of the airway did not deteriorate during the course of the anaesthetic. In 10 patients there was obstruction of the airway at the first attempt to place it without the introducer and this obstruction appeared to be as a result of downfolding of the epiglottis. Subsequent attempts at passage were successful in all 10 patients. The seal between the mask and the larynx was adequate for artificial ventilation of the patients, but the mean leak pressure was 1.7 kPa.     

Intubating laryngeal mask airway

The Intubating Laryngeal Mask Airway (ILMA) was introduced into clinical practice in 1997 following numerous clinical trials involving 1110 patients. The success rate of blind intubation via the device after two attempts is 88% in "routine" cases. Successful intubation in a variety of difficult airway scenarios, including awake intubation, has been described, with the overall success rate in the 377 patients reported being approximately 98%. The use of the ILMA by the novice operator has also been investigated with conflicting reports as to its suitability for emergency intubation in this setting. Blind versus visualized intubation techniques have also been investigated. These techniques may provide some benefits in improved safety and success rates, although the evidence is not definitive. The use of a visualizing technique is recommended, especially whilst experience with intubation via the ILMA is being gained. The risk of oesophageal intubation is reported as 5% and one death has been described secondary to the complications of oesophageal perforation during blind intubation. Morbidity described with the use of the ILMA includes sore throat, hoarse voice and epiglottic oedema. Haemodynamic changes associated with intubation via the ILMA are of minimal clinical consequence. The ILMA is a valuable adjunct to the airway management armamentarium, especially in cases of difficult airway management. Success with the device is more likely if the head of the patient is maintained in the neutral position, when the operator has practised at least 20 previous insertions and when the accompanying lubricated armoured tube is used.     

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 laryngeal mask airway

The laryngeal mask airway is an important addition to the anaesthetist's armamentarium, but its use is not without the possibility for misfortune. We encountered an unusual and potentially serious complication. A patient's epiglottis became trapped between the pliable grates in the mask portion of the laryngeal mask and partially obstructed his airway. Should this problem occur and remain unnoticed, in addition to the problem of airway obstruction during the anaesthetic, the oedematous epiglottis could be severely injured upon removal of the laryngeal mask. This, in turn, could result in airway obstruction requiring emergency treatment.     

The laryngeal mask airway

Two cases of emergency prehospital airway control using the laryngeal mask are described. The patients were trapped following road traffic accidents and limited access prevented tracheal intubation. The laryngeal mask airway may be a useful alternative to tracheal intubation in some cases of prehospital trauma care.     

Application of nasal flexible laryngeal mask airway in anesthesia for oral surgery

The laryngeal mask airway has been used increasingly in clinics but is seldom applied in anesthesia for oral surgery, as the mask occupies the middle of the mouth and tends to obstruct the surgical field. Here, we report the successful placement and usage of a nasal flexible laryngeal mask airway (FLMA) in an oral surgical procedure. Fifteen patients undergoing dental procedures under general anesthesia were studied. We clinically applied a previously reported method for inserting an FLMA with some modifications. There was no significant bleeding from the intubated nostril in any of the patients. None of the patients complained of sore throat, coughing, hoarseness, or any discomfort in the nose. Although we anticipate that further refinements of the technique may be possible and that the safety of this method using a nasal FLMA needs to be assessed in a greater number of patients, in this preliminary study we provide a proof-of-principle demonstration of the efficacy of nasal LMA ventilation as a method of airway management for oral surgery.     

可弯曲喉罩用于鼻内镜手术患者气道管理的效果

目的 评价可弯曲喉罩用于鼻内镜手术患者气道管理的效果.方法 择期拟行鼻内镜手术患者60例,ASA Ⅰ或Ⅱ级,年龄18～60岁,体重51～83 kg,性别不限,随机分为2组(n=30):气管导管组(T组)和可弯曲喉罩组(F组).静脉注射咪达唑仑、维库溴铵、异丙酚和瑞芬太尼麻醉诱导.T组置入气管导管;F组置入可弯曲喉罩,然后行机械通气.静脉输注异丙酚和瑞芬太尼,吸入七氟烷维持麻醉.术中维持BIS 40～55,维持MAP基础值60%～70%,必要时静脉输注硝酸甘油1～3μg·kg~(-1)·min~(-1)和艾司洛尔20～30μg·kg~(-1)·min~(-1)行控制性降压.术毕待患者清醒后拔出气管导管或可弯曲喉罩.于麻醉诱导前、麻醉诱导后即刻、置人气管导管或喉罩后1、3、5 min和拔出气管导管或喉罩即刻记录SP、DP和HR;于置入气管导管或喉罩后5、30 min和拔出气管导管或喉罩前即刻记录P_(ET)CO_2、气道峰压、平均气道压和SpO_2;记录术中需要控制性降压情况、苏醒时间、患者清醒到拔出气管导管或喉罩前呛咳的发生情况和术后24 h内咽痛的发生情况.结果 与T组比较,F组置人喉罩后各时点和拔出喉罩即刻SP、DP和HR降低,置人喉罩后各时点和拔出喉罩前即刻气道峰压降低(P＜0.05),平均气道压、P_(ET)CO_2和SpO_2差异无统计学意义(P＞0.05),术中需控制性降压率降低,苏醒时间缩短,呛咳和咽痛发生率降低(P＜0.05).结论 可弯曲喉罩用于鼻内镜手术时,可降低对患者血液动力学的干扰,有助于麻醉恢复,且不良反应较少,其效果优于气管导管.     

Resistive load of laryngeal mask airway and ProSeal laryngeal mask airway in mechanically ventilated patients

BACKGROUND: The ProSeal Laryngeal Mask Airway (PLMA) ventilation tube is narrower and shorter than the standard Laryngeal Mask Airway (LMA) and is without the vertical bars at the end of the tube. In this randomized, crossover study, PLMA and LMA resistances were compared. METHODS: Respiratory mechanics was calculated in 26 anesthetized, mechanically ventilated patients with both LMA and PLMA. The laryngeal mask positioning was fiberoptically evaluated. Differences in the respiratory mechanics of the LMA and the PLMA were attributed to the differences between the laryngeal masks. RESULTS: In the total study population the airway resistance was 1.5 +/- 2.6 hPa.l-1.s-1 (P = 0.005) higher with the PLMA than with the LMA. During the PLMA use, the peak expiratory flow reduced by 0.02 +/- 0.05 l min-1 (P = 0.046), the expiratory resistance increased by 0.6 +/- 1.3 hPa.l-1.s-1 (P = 0.022), and the time constant of respiratory system lengthened by 0.09 +/- 0.18 s (P = 0.023). These differences doubled when the LMA was better positioned than the PLMA, whereas they disappeared when the PLMA was positioned better than the LMA. CONCLUSIONS: The standard LMA offers a lower resistive load than the PLMA. Moreover, the fitting between the laryngeal masks and the larynx, as fiberoptically evaluated, plays a major role in determining the resistive properties of these devices.     

An evaluation of the flexiguide introducer with the flexible laryngeal mask airway

Insertion of the flexible Laryngeal Mask Airway has been achieved by a variety of techniques. We have evaluated the Flexiguide for aiding introduction of a flexible Laryngeal Mask Airway in 100 anaesthetised patients. We were successful in establishing a clear airway on the first attempt on 84 (84%) occasions and within two attempts in 97 (97%). The positioning of the laryngeal mask airway was assessed by five measures and was optimally placed in 85% of cases and good in 96%. A clear airway was achieved in 92% of cases. Insertion of the flexible Laryngeal Mask Airway with the Flexiguide was easy in 82 (82%) and slightly difficult in 15 (15%) of cases. Removal of the Flexiguide from the device was easy in 95 (95%) of cases. Airway manoeuvres were used to assist airway placement in 55% of cases with jaw thrust being most common. Minor complications occurred in three (3%) patients: two coughed and one experienced minor tissue trauma during mask insertion. There were no complications associated with use of the Flexiguide during the procedure or after anaesthesia. The Flexiguide is a useful tool to assist insertion of the flexible Laryngeal Mask Airway and is associated with few complications.