气管导管套囊压力研究进展

<正>气管导管套囊在全麻手术中,可以起到封闭气道、固定导管,预防口腔分泌物和胃内容物反流误吸,从而达到提高通气质量和减少肺部并发症的作用。研究表明,接受全麻手术插管的患者套囊压力维持在15~25 mm Hg可以减少术后插管相关性并发症。然而,在实际手术插管操作中患者套囊的充气压力未得到麻醉医师的充分重视。随着对气管导管套囊相关并发症认识的深入,如何减少术后因套囊压力所致气管损伤成为研究的新热点。     

魏氏喷射气管导管用于患者气管插管术的效果

目的 评价魏氏喷射气管导管用于患者气管插管术的效果.方法 择期全麻气管插管术患者102例,性别不限,年龄15～50岁,体重40～99 kg,ASA分级Ⅰ～Ⅲ级,Cormack&Lehane分级Ⅰ～Ⅳ级(Ⅰ或Ⅱ级为非困难气道,Ⅲ或Ⅳ级为困难气道).采用随机数字表法,将患者随机分为2组(n=51):常规导管组(C组)和魏氏喷射气管导管组(WJ组).2组根据Cormack&Lehane分级分为2个亚组:困难气道组(n=16)和非困难气道亚组(n=35).C组使用普通Kendall气管导管进行插管;WJ组使用相同内径的魏氏喷射气管导管,在喷射通气同时行气管插管.记录机械通气即刻PETCO2;记录首次气管插管成功情况及气管插管时间;记录气管导管拔除后24h内的并发症发生情况.结果 与C组比较,WJ组气管插管时间延长,困难气道患者气管插管首次成功率升高(P＜0.01).与非困难气道患者比较,WJ组困难气道患者机械通气即刻PETCO2、气管插管时间和首次成功率比较差异无统计学意义(P＞0.05),C组困难气道患者机械通气即刻PETCO2升高,气管插管首次成功率降低(P＜0.01).WJ组未出现气胸、纵隔气肿及皮下气肿等严重气压伤;2组喉痉挛、咽喉痛和胃胀气发生率比较差异无统计学意义(P＞0.05).结论 魏氏喷射气管导管不仅能安全有效地为气管插管全麻患者提供通气,还可提高困难气道气管插管成功几率.     

气管插管通气导管套囊放气方法改良

气管插管全麻技术在麻醉科广泛使用,患者在麻醉恢复室内拔除气管导管前需常规充分吸引气管内、口腔、咽腔内分泌物,预防术后误吸的发生;但积聚在气管导管套囊上端与声门口之间的分泌物常不易完全吸引干净,气管导管拔除后残留在此腔隙内分泌物可能流入气管内诱发呛咳、误吸.传统的方法是将吸痰管插入气管导管内边吸引边拔管,但此方法会诱发术后低氧血症及肺不张可能.有专家建议将气管导管外气囊压力指示囊剪去,保留气管导管套囊内残留的一些气体,在拔除气管导管时通过气管导管套囊将导管套囊上端可能残留的分泌物带出气管.此方法可能出现套囊内残气无法排出或排出不畅,未完全放气的套囊卡于声门口引起拔管困难.     

气管插管导管套囊压力和持续时间对家兔气管黏膜的影响

气管黏膜对机械刺激敏感。气管插管全麻术后声嘶、咽喉痛甚至气管狭窄造成呼吸窘迫等时有发生。有研究证明以上情况的发生与插管后套囊内压不当有关。本研究拟探讨气管插管导管套囊压力和持续时间对家兔气管黏膜的影响,为临床提供实验依据。     

全麻患者气管插管套囊压力和术后气道并发症的现况调查及影响因素分析

目的调查新疆地区全麻患者气管插管套囊压力及术后插管相关并发症的现状,并分析引起不适套囊压力的影响因素。方法采用整群抽样及单纯随机抽样方法,抽取2017年2—5月新疆地区3家三级甲等医院拟行全身麻醉气管插管并符合纳入标准的患者作为研究对象。登记相关信息,于气管插管后采用一次性压力换能器测量套囊压力,拔管后24h内随访患者,记录术后气管插管相关并发症的发生情况。根据测压结果将患者分为套囊压力正常组(20~30cmH_2O)与套囊压力异常组(20cmH_2O或30cmH_2O),通过Logistic回归分析引起套囊压力过高或过低的危险因素。结果共纳入研究对象430例,气管导管套囊压力为(53.3±20.5)cmH_2O,仅有82例(19.1%)患者套囊压力在推荐范围。术后气道并发症主要有:咽喉痛305例(70.9%),声音嘶哑159例(37.0%),咳嗽147例(34.2%),血丝痰145例(33.7%)。Logistic回归分析显示,BMI≥27kg/m~2(OR=11.000,95%CI 1.064~113.731)、术前气道特殊情况(吸烟、哮喘等,OR=2.809,95%CI1.300~6.070)、麻醉科医师职称(住院医师,OR=60.224,95%CI 18.853~192.380;主治医师,OR=7.364,95%CI 3.112~17.426)和工龄(≤5年,OR=68.500,95%CI 15.253~307.619;6~10年,OR=10.400,95%CI 4.430~24.417)是导致患者出现不适套囊压力升高的危险因素。结论临床工作中套囊压力远高于推荐值,插管相关并发症发生率高,而术前患者肥胖、有吸烟史或合并哮喘、气管炎,麻醉科医师职称较低、工作时间较短是导致气管导管套囊压力异常的危险因素。     

全麻气管插管患者术后咽喉痛分层预防管理方案的构建及应用

目的 构建全麻气管插管患者术后咽喉痛预防管理方案,评价应用效果。方法 将266例全麻气管插管手术患者按时间段分为对照组142例、干预组126例。对照组行常规护理,干预组采用基于循证方法构建的术后咽喉痛分层预防管理方案。结果 干预组术后咽喉痛发生率及咽喉痛程度显著低于对照组,舒适度评分显著优于对照组,相关不良事件发生率显著低于对照组,脊柱科、妇科、泌尿外科、胸外科手术患者进食时间显著早于对照组（均P＜0.05）。结论 基于循证方法构建的术后咽喉痛分层预防管理方案用于全麻气管插管患者,可降低术后咽喉痛发生率和减轻疼痛程度,提高患者舒适度,降低相关不良事件发生率。     

复方利多卡因乳膏在气管插管全麻中的应用

目的:观察复方利多卡因乳膏应用于气管插管全麻,对抑制插管应激反应和术后咽喉痛的效果.方法:60例ASAI～II级拟施气管插管全麻择期手术患者随机均分为两组.对照组(I组)和实验组(II组)分别将石蜡油和复方利多卡因乳膏均匀涂于气管插管的套囊及前端,麻醉诱导后行气管内插管.分别记录诱导前、插管前、插管即刻及插管后3min时患者的收缩压(SBP)、舒张压(DBP)、心率(HR).并记录是否有术后咽喉痛及性质.结果:I组在插管即刻和插管后3min较插管前SBP、DBP、HR明显增加,差异有统计学意义(P<0.05);而II组病人插管即刻和插管后3min上述指标较插管前无显著差异(P>0.05).组间比较,I组插管后SBP、DBP、HR均较II组明显增加,差异有统计学意义(P<0.05).I组患者术后咽喉痛、喉部异物感的发生率显著高于II组 (P<0.01).结论:复方利多卡因乳膏可以有效抑制气管插管全麻所引起的插管应激反应和术后咽喉痛.     

气管导管拔除时适度气囊压力同步口咽部吸引对气道的保护作用

目的减少气管导管拔除时引起的应激反应及囊上滞留物的回落,预防拔管带来的并发症。方法将120例全麻气管插管患者按手术日期单双日分为常规组(60例)和改良组(60例)。常规组采用常规的拔管方法,先吸净口咽及气道内分泌物后抽出气管导管气囊里的气体,吸痰管置于气管导管内持续负压吸引拔管;改良组采取保留适度气囊压力,将气囊上方分泌物随拔管提到口咽部持续吸引清除,拔管中保持气管内压力。比较两组拔管时清除的分泌物量、拔管前后呼吸循环指标的变化和呼吸道不良反应的发生率。结果常规组气囊上方痰液清除量为(1.73±0.79)mL,改良组为(10.09±1.81)mL;常规组拔管前后R、HR、SBP和SaO2数值变化显著;患者窒息感的发生率显著高于改良组(P<0.05)。结论保留适度气囊及气管内压的气管导管拔除方法能有效地清除气囊上方的分泌物,减少拔管时不良反应,预防呼吸循环系统并发症发生。     

全身麻醉体外循环下气管导管套囊压力与体温的关系及其临床意义

目的 研究全身麻醉CPB下心内直视手术患者气管导管套囊压力的变化与体温的关系,探讨其临床意义.方法 本研究为前瞻性、随机的临床研究.择期行全身麻醉CPB下心内直视手术的患者40例,按随机数字表法分为2组(每组20例):初始气管导管套囊压力25 cmH2O(1 cmH20=0.098 kPa)组(A组)及初始气管导管套囊压力30 cmH2O组(B组),记录降温和复温过程中两组患者在不同温度点的套囊压力以及术中CPB时间、心脏停搏时间、术后机械通气时间、术后住院天数和呼吸系统并发症情况. 结果 两组患者年龄、性别、BMI、术中CPB时间、心脏停搏时间、术后机械通气时间、术后住院天数和呼吸系统并发症发生率的差异均无统计学意义(P＞0.05).与36℃时的套囊压力比较,各温度点套囊压力的变化差异均有统计学意义(P＜0.05).当降至最低温度28 ℃时,A组套囊压力降低(17.8±9.9)％,B组套囊压力降低(24.2±7.2)％,差异有统计学意义(P＜0.05).与A组比较,B组各温度点的套囊压力均显著高于A组,差异有统计学意义(P＜0.05). 结论 对于行全身麻醉CPB下心内直视手术的患者,CPB低温会造成套囊压力的明显降低.在临床应用中,25 cmH2O及30 cmH2O的套囊压力均较安全.     

经Airtraq喉镜使用钢丝加强型导管和普通气管导管的比较

目的 观察Airtraq喉镜使用钢丝加强型导管和普通气管导管进行气管插管的临床效果.方法 90例行择期整形外科手术的需气管插管的全麻患者,随机分为钢丝加强型导管组(A组)和普通导管组(B组),每组45例.常规静脉快速诱导后,用Airtraq喉镜分别携带钢丝加强型导管或普通气管导管行气管插管.观察两组患者的插管时间、插管成功率、插管期间的血流动力学变化以及术后并发症的发生情况.结果 所有患者全部用Airtraq喉镜完成气管插管,B组一次插管成功率(91.1%)低于A组(95.6%)(P＜0.05);B组插管时间[(35.4±16.6)s]显著长于A组[(26.8士9.0)s](P＜0.05),两组血流动力学变化及术后并发症的发生情况差异无统计学意义.结论 Airtraq喉镜能够安全有效地应用于全麻患者的气管插管,使用钢丝加强型导管可以进一步提高插管成功率,缩短插管时间.     

Intracuff pressure and tracheal morbidity: influence of filling with saline during nitrous oxide anesthesia.

BACKGROUND: Diffusion of nitrous oxide into the cuff of the endotracheal tube results in an increase in cuff pressure. Excessive endotracheal tube cuff pressure may impair tracheal mucosal perfusion and cause tracheal damage and sore throat. Filling the cuff of the endotracheal tube with saline instead of air prevents the increase in cuff pressure due to nitrous oxide diffusion. This method was used to test whether tracheal morbidity is related to excess in tracheal cuff pressure during balanced anesthesia. METHODS: Fifty patients with American Society of Anesthesiologists physical status I or II were randomly allocated to two groups with endotracheal tube cuffs initially inflated to 20-30 cm H(2)O with either air (group A) or saline (group S). Anesthesia was maintained with isoflurane and nitrous oxide. At the time of extubation, a fiberoptic examination of the trachea was performed by an independent observer, and abnormalities of tracheal mucosa at the level of the cuff contact area were scored. Patients assessed their symptoms (sore throat, dysphagia, and hoarseness) at the time of discharge from the postanesthesia care unit and 24 h after extubation on a 101-point numerical rating scale. RESULTS: Cuff pressure increased gradually during anesthesia in group A but remained stable in group S. The incidence of sore throat was greater in group A than in group S in the postanesthesia care unit (76 vs. 20%) and 24 h after extubation (42 vs. 12%; P < 0.05). Tracheal lesions at time of extubation were seen in all patients of group A and in eight patients (32%) of group S (P < 0.05). CONCLUSION: Excess in endotracheal tube cuff pressure during balanced anesthesia due to nitrous oxide diffusion into this closed gas space causes sore throat that is related to tracheal mucosal erosion.     

Intracuff Pressure and Tracheal Morbidity: Influence of Filling Cuff with Saline during Nitrous Oxide Anesthesia

Background : Diffusion of nitrous oxide into the cuff of the endotracheal tube results in an increase in cuff pressure. Excessive endotracheal tube cuff pressure may impair tracheal mucosal perfusion and cause tracheal damage and sore throat. Filling the cuff of the endotracheal tube with saline instead of air prevents the increase in cuff pressure due to nitrous oxide diffusion. This method was used to test whether tracheal morbidity is related to excess in tracheal cuff pressure during balanced anesthesia.

Methods : Fifty patients with American Society of Anesthesiologists physical status I or II were randomly allocated to two groups with endotracheal tube cuffs initially inflated to 20-30 cm H2O with either air (group A) or saline (group S). Anesthesia was maintained with isoflurane and nitrous oxide. At the time of extubation, a fiberoptic examination of the trachea was performed by an independent observer, and abnormalities of tracheal mucosa at the level of the cuff contact area were scored. Patients assessed their symptoms (sore throat, dysphagia, and hoarseness) at the time of discharge from the postanesthesia care unit and 24 h after extubation on a 101-point numerical rating scale.

Results : Cuff pressure increased gradually during anesthesia in group A but remained stable in group S. The incidence of sore throat was greater in group A than in group S in the postanesthesia care unit (76 vs. 20%) and 24 h after extubation (42 vs. 12%;P < 0.05). Tracheal lesions at time of extubation were seen in all patients of group A and in eight patients (32%) of group S (P < 0.05).     

Flexible, tapered-tip tube facilitates conventional orotracheal intubation by novice intubators

Orotracheal intubation is the standard technique for airway management, but several untoward airway complications are possible with this method. To avoid airway trauma caused by the tube tip during intubation, the Parker Flex-Tip tube (PFT), which has a flexible, tapered tip, was developed. It has been reported that the PFT facilitates fiberoptic orotracheal intubation and introducer-guided tracheal intubation. In this study, we compared the PFT to a standard endotracheal tube (SET), regarding the time of intubation during conventional orotracheal intubation and the incidence of postoperative sore throat and hoarseness. One hundred and thirty-four patients scheduled for elective anesthesia using orotracheal intubation were randomized to either the PFT or SET and 132 completed the study. The intubators were classified into three groups: staff anesthesiologists, inexperienced anesthesiologists, and anesthesia trainees. The tube was selected by another anesthesiologist and the time required for intubation was measured. PFT did not shorten the time required for intubation and did not reduce the incidence of sore throat and hoarseness. However, a detailed analysis revealed that the PFT decreased the time required for intubation in the anesthesia trainee group. The PFT may help novice intubators to conduct a smooth intubation.     

Sore throat after endotracheal intubation.

Nitrous oxide can diffuse into the cuff of an endotracheal tube during tracheal intubation, and the cuff pressure against the tracheal wall may cause mucosal damage. An endotracheal tube has been developed (Brandt Anesthesia Tube) that effectively limits nitrous oxide-related intracuff pressure increases. We determined whether the incidence of postoperative sore throat could be reduced by using this tube. Forty-eight female patients, 18-50 yr of age, were included in the study. Endotracheal intubation was performed with either a Brandt Anesthesia Tube or a Mallinckrodt endotracheal tube. All patients were interviewed postoperatively after 20-30 h by individuals who did not know which tube was used. In the Mallinckrodt group, 12 of 20 patients had a sore throat and 10 patients had intracuff pressures greater than 25 mm Hg. Only 3 of 20 patients in the Brandt group had a sore throat. We found that the incidence of sore throats after intubation could be significantly reduced by using the Brandt Anesthesia Tube (P less than 0.005).     

Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial

BACKGROUND: Vocal cord injuries, postoperative hoarseness, and sore throat are common complications after general anesthesia. One-lung ventilation can be achieved via two techniques: double-lumen endotracheal tube or endobronchial blocker such as the Arndt blocker. The current study was designed to assess the impact of these techniques for one-lung ventilation on the incidence and severity of postoperative hoarseness, vocal cord lesions, and sore throat. METHODS: In this prospective trial, 60 patients were randomly assigned to two groups. One-lung ventilation was achieved with either an endobronchial blocker (blocker group) or a double-lumen-tube (double-lumen group). Postoperative hoarseness and sore throat were assessed at 24, 48, and 72 h after surgery. Bronchial injuries and vocal cord lesions were examined by bronchoscopy immediately after surgery. RESULTS: In 56 included patients, postoperative hoarseness occurred significantly more frequently in the double-lumen group compared with the blocker group: 44% versus 17%, respectively (P = 0.046). Similar findings were observed for vocal cord lesions: 44% versus 17%, respectively (P = 0.046). The incidence of bronchial injuries was comparable between groups (P = 0.540). Cumulative number of days with hoarseness and sore throat were significantly increased in the double-lumen group compared with the blocker group (P < 0.01). No major complications such as bronchial ruptures were observed. CONCLUSIONS: Clinicians should be aware of an increased incidence of minor airway injuries that may impair patient satisfaction when using a double-lumen tube instead of an endobronchial blocker for one-lung ventilation.     

Lidocaine 10% in the endotracheal tube cuff: blood concentrations, haemodynamic and clinical effects

The purpose of this study was to evaluate the effects (common haemodynamic variables, peak cuff pressures, the incidence of reaction ('bucking') during extubation and the incidence of sore throat after operation) of lidocaine 10% instilled into the endotracheal tube cuff in intubated patients. Plasma concentrations of lidocaine were assayed. Seventy ASA class I-II patients scheduled for plastic surgery were studied. Patients were randomly divided in two groups: the cuff of the endotracheal tube was inflated with either lidocaine 10% (group L) or with saline (group S) immediately after endotracheal intubation. In group L patients, the haemodynamic changes were less (P < 0.05), and the peak cuff pressure was lower (P < 0.01) than for group S. At extubation, more patients reacted ('bucked') in group S (70.5% vs. 19.4%, P < 0.01). The incidence and severity of sore throat were significantly lower in group L 1 and 24-h after extubation. Plasma lidocaine concentrations did not reach toxic values. Lidocaine 10%, compared with saline, in the endotracheal tube cuff was associated with less disturbance of haemodynamic responses and less incidence of bucking during tracheal extubation. Lidocaine was also effective in reducing of incidence and severity of sore throat after operation.     

Airway Injuries after One-lung Ventilation: A Comparison between Double-lumen Tube and Endobronchial Blocker: A Randomized, Prospective, Controlled Trial

Background: Vocal cord injuries, postoperative hoarseness, and sore throat are common complications after general anesthesia. One-lung ventilation can be achieved via two techniques: double-lumen endotracheal tube or endobronchial blocker such as the Arndt blocker. The current study was designed to assess the impact of these techniques for one-lung ventilation on the incidence and severity of postoperative hoarseness, vocal cord lesions, and sore throat.

Methods: In this prospective trial, 60 patients were randomly assigned to two groups. One-lung ventilation was achieved with either an endobronchial blocker (blocker group) or a double-lumen-tube (double-lumen group). Postoperative hoarseness and sore throat were assessed at 24, 48, and 72 h after surgery. Bronchial injuries and vocal cord lesions were examined by bronchoscopy immediately after surgery.

Results: In 56 included patients, postoperative hoarseness occurred significantly more frequently in the double-lumen group compared with the blocker group: 44% versus 17%, respectively (P = 0.046). Similar findings were observed for vocal cord lesions: 44% versus 17%, respectively (P = 0.046). The incidence of bronchial injuries was comparable between groups (P = 0.540). Cumulative number of days with hoarseness and sore throat were significantly increased in the double-lumen group compared with the blocker group (P < 0.01). No major complications such as bronchial ruptures were observed.     

Sore throat and hoarseness after fiberoptic nasotracheal intubation

Fiberoptic nasotracheal intubation is frequently chosen for surgery involving the oral cavity. In such cases, the endotracheal tube passes through the vocal cords into the trachea blindly, which may cause laryngeal trauma. We, therefore, studied the incidence of sore throat and hoarseness after fiberoptic nasotracheal intubation (n=44) and compared the results with those after conventional oral intubation (n=35). The incidence of sore throat was lower in the fiberoptic nasotracheal intubation group than in the conventional oral intubation group but the difference was not statistically significant (25.0%s 42.8%). The incidence of hoarseness after fiberoptic nasotracheal intubation was significantly lower than that after conventional oral intubation (4.5%s 34.3%,P<0.05). This study confirms a low incidence of laryngeal trauma in fiberoptic nasotracheal intubation.     

快通道胃肠手术后咽部并发症处理方法的比较

目的探讨一种有效防治快通道胃肠道手术后咽部并发症的处理方法,以更好满足临床和患者的要求。 方法采用前瞻性、随机、双盲的研究方法,选择本院拟在全麻下行开腹胃肠道手术者280例,随机分为4组,各70例,A组（对照组）,气管导管用医用石蜡油润滑;B组,气管导管用丁卡因胶浆润滑;C组,气管导管用丁卡因胶浆润滑+插管后静注地塞米松10 mg;D组,C组基础上加静注帕瑞昔布钠40 mg。记录并比较各组麻醉拔管后10 min、30 min、1 h、6 h、12 h、24 h时的术后咽喉痛（POST）发生率及严重程度,观察在PACU期间1 h内的吸痰例数。 结果拔管后10 min观察点同期比较,B、C、D组POST发生率低于A组（P<0.05）;30 min观察点同期比较,B、C、D组POST发生率低于A组（P<0.05）,D组分别低于B、C组（P<0.05）;1 h观察点同期比较,B、C、D组POST发生率低于A组（P<0.05）,D组分别低于B、C组（P<0.05）;6 h观察点同期比较,D组POST发生率低于A组（P<0.05）;12 h、24 h观察点组间POST发生率差异无统计学意义。在PACU观察期间的吸痰人数,C、D组发生率低于A、B组（P<0.05）;A、B组之间,C、D组间发生率差异无统计学意义。 结论气管导管润滑复合静脉用药的多模式处理可有效防止POST,复合静注激素可有效减少拔管后气道分泌物。