不同方法预测困难气道喉镜插管有效性的比较

目的比较不同方法预测困难气道喉镜插管的有效性,并分析其最佳临界点。方法选择行全麻气管插管择期手术患者300例,年龄18~65岁,体重42~88kg,ASAⅠ或Ⅱ级,麻醉诱导前评估甲颏高度(TMH)、甲颏距离(TMD)、胸颏间距(SMD)、改良Mallampti分级(MMT)和身高甲颏距离比(RHTMD)。在全麻诱导下直接喉镜暴露声门评估Cormack-Lehane(C-L)分级,Ⅲ级和Ⅳ级视为喉镜插管困难。计算上述几种方法的受试者工作特征(ROC)曲线下面积(AUC),预测困难喉镜插管的敏感性、特异性、阳性预测值(PPV)、阴性预测值(NPV)和精确度。绘制TMH的受试者工作特征曲线(ROC曲线)并确定其最佳临界点。结果 300例患者中喉镜插管困难的患者有22例(7.3%)。TMH法的敏感性、特异性、PPV、NPV、精确度明显高于TMD、SMD、MMT法;RHTMD法的敏感性低于TMH法,特异性、PPV、NPV、精确度与TMH法相似。根据ROC曲线TMH法的最佳临界点为4.9cm。结论 TMH预测国人困难喉镜插管的最佳临界点为4.9cm。其评估困难气道效能与RHTMD相似,高于TMD、SMD和MMT。     

LEMON 法预测困难气道的有效性

正困难气道是麻醉中常遇到的紧迫而危险的境况,许多严重麻醉并发症和死亡的发生由困难气道管理失当引起~([1-3])。对未预料的困难气道,后果更为严重。虽然可视喉镜的应用使气管插管变得容易,插管困难的发生率也明显降低~([1~4]),但对全麻患者气道评估和对困难气道的处理是麻醉医师的临床基本技能,需要熟练掌握和应用,况且传统喉镜仍为目前的主要工具。临床麻醉有多种方法用来评估困难气道风险,其中LEMON法是一种相对简便的综合性气道风险评     

超声测量舌体积和舌纵截面积预测困难气道的有效性

目的研究超声测量舌体积和舌纵截面积对喉镜暴露困难,以及气管插管困难的预测作用。方法选取需行气管插管全身麻醉的患者120例,男68例,女52例,年龄18~90岁,BMI 16~39 kg/m^2,ASAⅠ-Ⅲ级。麻醉前进行临床气道评估,并超声测量患者的舌纵截面积和舌横径,两者的乘积为超声舌体积。患者麻醉后进行喉镜暴露和气管插管,分析患者的超声舌体积、舌纵截面积和舌横径与喉镜暴露困难以及气管插管困难的关系,采用受试者工作特征(ROC)曲线结合约登指数得到各指标预测喉镜暴露困难和气管插管困难的临界值,根据临界值计算出各指标预测困难气道的准确率、灵敏性、特异性,阳性预测值和阴性预测值。结果本研究共纳入117例患者,喉镜暴露困难31例(26.5%),气管插管困难13例(11.1%)。患者的超声舌体积、舌纵截面积和舌横径均与喉镜暴露困难、气管插管困难相关(P<0.05)。舌纵截面积>18.7 cm^2和舌体积>82.1 cm^3在预测喉镜暴露困难的准确率、灵敏性、特异性、阳性预测值和阴性预测值方面差异均无统计学意义;超声舌纵截面积>19.2 cm^2在预测气管插管困难的准确率和特异性明显低于舌体积>97.4 cm^3(P<0.05),但两指标在灵敏性、阳性预测值和阴性预测值方面差异均无统计学意义。结论超声舌纵截面积和舌体积都能较好地预测喉镜暴露困难和气管插管困难,超声舌纵截面积有望替代舌体积用于预测喉镜暴露困难。     

超声测量评估阻塞性睡眠呼吸暂停低通气综合征患者困难气道的价值

目的探究超声测量正中位舌骨到皮肤距离、声带水平前联合到皮肤的距离以及颏舌骨肌长度对于阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者困难气道预测的可行性。方法择期行全麻气管插管改良腭咽成形术的OSAHS患者37例,男32例,女5例,年龄20~69岁,ASAⅠ-Ⅲ级。术前评估改良Mallampati气道分级,超声测量正中位舌骨到皮肤距离、声带水平前联合到皮肤距离以及颏舌骨肌长度。根据Cormack-Lehane分级法评定普通喉镜暴露程度(Ⅲ、Ⅳ级为困难气道),采用ROC曲线分析各指标预测困难气道的效能。结果 37例患者中11例纳入困难气道组,26例纳入非困难气道组。困难气道组声带水平前联合到皮肤距离明显长于非困难气道组(P<0.05),而颏舌骨肌长度明显短于非困难气道组(P<0.05)。两组正中位舌骨刮皮肤距离差异无统计学意义。改良Mallampati气道分级、声带水平前联合到皮肤距离及颏舌骨肌长度预测困难气道的AUC及其95%CI分别为0.788(0.640~0.937)、0.804(0.643~0.966)和0.788(0.642~0.935),三者联合的AUC及其95%CI为0.955(0.895~1.000),敏感性100%,特异性84.6%。结论超声测量声带水平前联合到皮肤距离及颏舌骨肌长度对于OSAHS患者困难插管有一定的预测价值,且综合三种预测方法,可提高预测的准确性。     

超声测量气道参数预测困难喉镜暴露的准确性

目的评价超声测量气道参数预测困难喉镜暴露的准确性。方法择期全麻手术患者104例,年龄18～70岁,ASA分级Ⅰ或Ⅱ级。麻醉诱导前行气道评估,记录患者BMI、颈围、张口度、甲颏间距及改良Mallampti分级,并采用超声测量颞下颌移动度、舌下表面深度、舌颏间距和会厌深度。测量结束后,行麻醉诱导,面罩加压通气后使用直接喉镜暴露声门,记录患者CL分级,以CL分级≥2b级作为困难喉镜暴露的标准。根据患者喉镜暴露的困难程度将其分为非困难喉镜暴露组(NDL)和困难喉镜暴露组(DL组)。将组间差异有统计学意义的因素,采用ROC曲线下面积(AUC)及其95%置信区间(95%CI)评价各指标预测困难喉镜暴露的准确性,结合约登指数确定预测喉镜暴露困难临界值,计算灵敏度和特异度。结果与NDL组比较,DL组BMI、会厌深度和改良Mallampti≥Ⅲ级比例升高,张口度和甲颏间距降低(P<0.05)。改良Mallampti分级和会厌深度预测困难喉镜暴露的AUC(95%CI)分别为0.728(0.619～0.836)和0.833(0.743～0.924)。会厌深度临界值为2.125 cm时,其预测困难喉镜暴...     

超声测量颈前软组织厚度预测喉镜暴露困难的价值

目的 应用超声测量不同水平的颈前软组织厚度，评价超声技术预测喉镜暴露困难的价值。

方法 选择行择期全身麻醉气管插管患者86例，男48例，女38例，年龄18～80岁，BMI 18～35 kg/m²，ASA Ⅰ—Ⅲ级。麻醉诱导后记录相应的Cormack-Lehane（C-L）分级， Ⅲ—Ⅳ级为喉镜暴露困难。术后进行传统和超声气道检查，测量改良马氏分级（MMT）、张口度（MO）、颈围（NC）、甲颏距离（TMD）、胸颏距离（SMD）、舌骨至皮肤的距离（DSH）、会厌至皮肤距离（DSE）、声带前联合至皮肤距离（DSV）、甲状腺峡部气管环至皮肤距离（DST）等，绘制受试者工作特征（ROC）曲线，计算曲线下面积（AUC）和95%可信区间（CI），筛选相关变量纳入综合模型，评估喉镜暴露困难的预测价值。

结果 通过ROC曲线评价各项指标预测喉镜暴露困难的诊断价值，DSE的AUC为0.889（95%CI 0.803～0.947）、DST的AUC为0.718（95%CI 0.610～0.810）、SMD的AUC为0.700（95%CI 0.591～0.736），其中DSE的预测效能最佳，截断值为2.10 cm，其余指标BMI、MMT、MO、NC、TMD、DSH、DSV的AUC小于0.7。纳入MO、SMD、DSE、DST四个指标的综合模型， AUC为0.92（95%CI 0.866～0.975）。

结论 超声测量DSE可用于预测喉镜暴露困难，截断值为2.10 cm，比其他指标具有更好的预测能力，纳入MO、SMD、DSE、DST的综合预测模型可以进一步提高预测能力。     

Bonfils纤维喉镜用于困难气管插管的效果

气管插管失败及过长时间尝试气管插管是导致麻醉相关病死率的主要原因之一~([1]).为了能够快速有效地控制气道.特别是对于那些利用常规方法存在困难的患者,各种各样的辅助器械不断被发明,为麻醉医师处理困难插管提供了多种手段.B0nfils纤维喉镜自1983年首次报道应用于临床困难气道处理以来,已成为解决困难插管有效手段之一.现就我科应用Bonfils纤维喉镜完成的19例困难插管报道如下.     

超声测量舌骨-会厌距离对喉镜显露困难的预测价值

目的评估超声测量舌骨-会厌距离预测喉镜显露困难的有效性。方法选择择期行气管插管全身麻醉患者72例,男40例,女32例,年龄18～90岁,ASAⅠ—Ⅲ级。麻醉前测量张口度、甲颏距离,评估改良Mallampati分级,并在"嗅花位"下超声测量患者舌骨-会厌距离。患者麻醉后在相同体位下行气管插管,根据Cormack-Lehane分级分为两组:Ⅰ和Ⅱ级为喉镜显露容易组(n=53),Ⅲ和Ⅳ级为喉镜显露困难组(n=19)。比较常规评估气道方法和舌骨-会厌距离与喉镜显露困难的关系,采用受试者工作特征(ROC)曲线评估各项指标预测喉镜显露困难的效能。结果与喉镜显露容易组比较,喉镜显露困难组中男性比例、BMI值和改良Mallampati分级明显升高(P0.05),甲颏距离和舌骨-会厌距离明显缩短(P0.05)。BMI值、甲颏距离、张口度、Mallampati分极和舌骨-会厌距离曲线下面积(AUC)分别为0.74、0.63、0.71、0.67和0.84,舌骨-会厌距离临界值为1.4 cm其敏感性为79.0%,特异性为83.0%。结论超声测量舌骨-会厌距离可较好预测喉镜显露困难。     

不同气道评估指标预测小耳畸形患儿喉镜显露困难的有效性

目的比较不同气道评估指标预测小耳畸形患儿喉镜显露困难(DLV)的有效性。方法择期全麻下行自体肋软骨耳廓重建术小耳畸形患儿200例,男159例,女41例,年龄6~14岁,ASAⅠ或Ⅱ级,麻醉诱导前评估改良Mallampati分级(MMT)、张口度(IIG)、甲颏间距(TMD)、下颌前伸能力(FPM)和身高/甲颏间距比值(RHTMD)。全麻吸入诱导下置入直接喉镜显露声门,评估Cormack-Lehane(C-L)分级,Ⅲ级和IV级视为DLV。采用受试者工作特征(ROC)曲线评估各项指标预测喉镜显露困难的效能。结果 200例患儿中存在DLV有46例(23%)。MMT、IIG、TMD、FPM、RHTMD预测DLV的AUC(95%CI)分别为0.71(0.64~0.77)、0.74(0.67~0.80)、0.87(0.81~0.91)、0.61(0.54~0.68)和0.85(0.79~0.89),TMD和RHTMD预测效能优于MMT、IIG和FPM。结论 TMD是小耳畸形患儿最佳气道评估指标。     

超声测量不同气道指标预测患儿喉镜暴露困难的价值

目的 评价超声进行气道评估对患儿喉镜暴露困难的预测价值.方法 选择需行气管插管全身麻醉的择期手术患儿287例,男194例,女93例,年龄5～12岁,BMI 10～29 kg/m2.根据年龄和喉镜暴露情况分为四组:5～8岁喉镜暴露困难组(DL5组)和9～12岁喉镜暴露困难组(DL9组)、5～8岁喉镜暴露容易组(EL5组)...     

Survey of patients whose lungs could not be ventilated and whose trachea could not be intubated in university hospitals in Japan

Purpose.We conducted a survey to clarify the actual circumstances in which the lungs could not be ventilated and the trachea could not be intubated (CVCI). Methods.A questionnaire was mailed to all the university hospitals in Japan, asking about CVCI they had experienced during induction of anesthesia in 1998, and before 1997. Results.Answers were obtained from 60 of 83 institutes. CVCI occurred in 26 of 151900 cases of general anesthesia (0.017%) in 1998. Eighteen cases occurred after induction of anesthesia by several induction methods. Five cases occurred after repeated attempts at tracheal intubation by laryngoscopy and fiberscopy in patients under awake or anesthetized conditions. In the remaining 3 cases, the situation of occurrence was not documented. Patients with CVCI had anatomical abnormalities around the upper airways, mostly from acquired diseases. CVCIs after induction of anesthesia were successfully treated by restoration of spontaneous respiration, blind intubation, laryngeal mask airway, and transtracheal approaches, and CVCIs after repeated attempts at intubation were treated mostly by transtracheal approaches. No serious consequences occurred in any patients in 1998. Twenty cases were reported before 1997, and 2 were specific, in which CVCI followed malplacement of a tracheal tube, and serious consequences, death and brain damage, respectively, followed. In other patients, no serious consequences occurred, although cardiac arrest occurred in 1 patient. Conclusion.This survey demonstrates that CVCI can occur in any situation in which the airway is not established. Furthermore, effective treatments may be different depending on the situation, and delayed recognition of tracheal tube misplacement may lead to a serious outcome.     

Eficácia do escore simplificado preditivo de dificuldade de intubação e da altura tiromentoniana em cirurgias de cabeça e pescoço: estudo observacional

Background and objectivesIn this study, we aimed to investigate the predictive value of different airway assessment tools, including parts of the Simplified Predictive Intubation Difficulty Score (SPIDS), the SPIDS itself and the Thyromental Height Test (TMHT), in intubations defined as difficult by the Intubation Difficulty Score (IDS) in a group of patients who have head and neck pathologies.MethodsOne hundred fifty‐three patients who underwent head and neck surgeries were included in the study. The Modified Mallampati Test (MMT) result, Thyromental Distance (TMD), Ratio of the Height/Thyromental Distance (RHTMD), TMHT, maximum range of head and neck motion, and mouth opening were measured. The SPIDSs were calculated, and the IDSs were determined.ResultsA total of 25.4% of the patients had difficult intubations. SPIDS scores > 10 had 86.27% sensitivity, 71.57% specificity and 91.2% Negative Predictive Value (NPV). The results of the Receiver Operating Curve (ROC) analysis for the airway screening tests and SPIDS revealed that the SPIDS had the highest area under the curve; however, it was statistically similar to other tests, except for the MMT.ConclusionsThe current study demonstrates the practical use of the SPIDS in predicting intubation difficulty in patients with head and neck pathologies. The performance of the SPIDS in predicting airway difficulty was found to be as efficient as those of the other tests evaluated in this study. The SPIDS may be considered a comprehensive, detailed tool for predicting airway difficulty.     

病态肥胖患者困难气道预测方式的研究进展

在肥胖人群中,病态肥胖（BMI≥35 kg/m²）是数量增长最快的一类。病态肥胖会使脂肪在颈部和腹部异常积聚,会导致上呼吸道狭窄、舌体肥大、膈肌上抬等解剖及呼吸生理的改变,使得病态肥胖患者成为困难气道的高发人群。要保证此类患者手术时通气的顺利和稳定,麻醉科医师在术前对病态肥胖患者进行针对困难气道有效的预测是至关重要的。本文旨在通过分析病态肥胖的不利影响和总结病态肥胖患者困难气道预测的新趋势,指导麻醉科医师对困难气道做出准确的术前预测。     

Evaluation of super-obesity and super-super-obesity as risk factors for difficult intubation in patients undergoing bariatric surgery

BackgroundSuper-obesity is a serious disorder which requires bariatric surgery. The association of super-obesity and difficult intubation was not adequately established.ObjectivesTo determine if super-obesity and super-super-obesity are associated with difficult intubation or not.SettingUniversity Hospital.MethodsA cohort of obese patients scheduled for bariatric surgery was prospectively recruited. Super-obesity and super-super-obesity were defined as body mass index ≥50 kg/m² and 60 kg/m², respectively. Intubation difficulty was assessed by 2 methods: (1) intubation difficulty scale; (2) number of intubation attempts. Risk factors for difficult intubation were recorded. Univariate and multivariate analysis for risk factors for difficult intubation and difficult mask ventilation were performed.ResultsA total of 658 patients were enrolled in the study including 205 (31%) super-obese and 52 (8%) super-super-obese patients. Ninety-nine (15%) patients required more than 1 intubation attempt, while 215 (33%) patients had intubation difficulty scale ≥5. Ninety-four (14.4%) patients had mask ventilation of moderate difficulty, while only 2 (.3%) patients needed 2-person ventilation. The independent risk factors for difficult intubation using the two stated definitions were STOP-Bang and Mallampati score values. The independent risk factors for mask ventilation of moderate difficulty were STOP-Bang score, Mallampati score, and limited neck extension.ConclusionWithin obese patients, neither super-obesity nor super-super-obesity was associated with difficult intubation or difficult mask ventilation. High STOP-Bang and Mallampati score are the independent factors for difficult intubation.     

困难腹腔镜胆囊切除术100例分析

目的探讨腹腔镜下完成困难胆囊切除术的可行性。方法腹腔镜下进行困难胆囊切除术100例（男53例,女47例）。其中急性化脓性胆囊炎52例（52％）,上腹部手术史导致胆囊三角区严重粘连者18例（18％）,萎缩性胆囊炎合并充满型胆囊结石17例（17％）,胆囊结石合并门脉高压症7例（7％）,Mirizzi综合征6例（6％）。结果95例在腹腔镜下成功完成胆囊切除术,另外5例中转开腹手术,中转率为5％。中转原因包括：腹腔镜下无法控制的出血2例,难以辨认肝外胆管的位置3例。平均手术时间（82．1±18．5）min。所有患者均痊愈出院,平均住院时间（7．2±2．3）d。手术后并发症有：胆瘘2例,切口感染2例,肺部感染1例。结论在技术成熟的前提下,腹腔镜下完成困难的胆囊切除术是可行和相对安全的。     

Successful difficult intubation Tracheal tube placement over a gum-elastic bougie

A randomised study was carried out to assess the effect of tracheal tube rotation on the passage of a tube over a gum-elastic bougie into the trachea in 100 patients. The effect of the presence or absence of a laryngoscope on successful tube placement was also assessed. A grade 3 difficult intubation was simulated in patients with a laryngoscope. There was a significant difference in the rates for successful first-time intubation in those patients with tube orientation of -90 degrees (with the bevel facing posteriorly) as compared with a tube orientation of 0 degrees (the normal orientation with the bevel facing left). The unsuccessful first-time intubations with a 0 degree orientation were frequently converted to successful intubations with the -90 degrees position at a second attempt. The presence of a laryngoscope in the mouth while rail-roading a tube over the bougie also made a significant difference to the rate of successful first-time intubations. The most successful method was to leave the laryngoscope in the mouth and rotate the tube to -90 degrees.     

麻醉诱导期双腔支气管导管插管困难及处理策略:11017例胸科手术患者的回顾性研究

目的分析麻醉诱导期双腔支气管导管(double lumen endobronchial tube,DLT)插管困难的发生率,并探讨解决DLT插管困难及实现术中肺隔离的策略。方法回顾性分析上海市胸科医院麻醉信息系统2009年5月至2012年5月拟行DLT插管的患者,检索同时满足“困难插管”“DLT插管”“单肺通气(one lung ventilation,OLV)”3个关键词的病例,主要研究终点为DLT插管困难的发生率,次要研究终点为困难插管患者术前气道的评估情况、插管困难时的解决策略、实现术中肺萎陷的方式及围麻醉期与插管相关并发症。结果共有11017例患者纳入了此研究。112例患者发生了插管困难,发生率为1.0%。112例患者中22例(19.6%)患者为可预期或可疑的困难气道,其余90例(80.4%)患者诱导前无明显困难气道表现。90例(80.4%)使用了2种或2种以上的插管器械。22例在诱导后插入单腔气管导管的患者中,2例经交换导管引导成功置入DLT进行肺隔离,13例患者经纤维支气管镜(纤支镜)引导放置支气管阻塞器,7例实施了低潮气量的策略。无一例发生严重心血管并发症。结论DLT对声门暴露的条件要求更高,麻醉前气道评估更应谨慎。可视化工具的使用提高了DLT插管的安全性及有效性,支气管阻塞器为DLT困难插管提供了更多选择。