特殊病人慢诱导盲探经鼻气管插管的麻醉

目的 探讨明视经口气管内插管困难的病人采用慢诱导盲探经鼻插管的可行性。方法 4例病人插管前均给予充分的镇痛镇静，进行完善的黏膜表面麻醉，住保留病人自主呼吸的情况下将气管导管通过鼻腔插入气管。结果 4例病人盲探经鼻插管均获得成功，术后随访病人无任何痛占。结论 明视经口插管困难的病人采用慢诱导盲探经鼻插管是较好的选择。     

橡胶导尿管引导经鼻气管内插管的可行性

目的 探讨橡胶导尿管引导经鼻气管内插管的可行性与实用性。方法 临床各科呼吸功能衰竭经鼻气管内插管呼吸支持治疗患者28例。充气套囊气管插管导管ID：6．0、6．5、7．0mm和橡胶导尿管14、16号各一根备用，根据病人鼻孔大小各选一根，将导尿管插入气管导管内使其超出导管尖端5～7cm。经左(或右)侧鼻孔徐徐插入(导管弧型方向与下鼻道、咽腔转折方向～致)，导管过鼻后孔有落空感；过鼻咽腔有抵抗消失感，提示引导导管成功，拔除导尿管。再行盲探或咽喉镜明视气管内插管。结果 导尿管引导经鼻盲探气管内插管17例，成功17例(100％)。经鼻导尿管引导咽喉镜明视气管内插管11例，成功11例(100％)，无1例发生粘膜损伤出血并发症。结论 橡胶导尿管引导经鼻气管内插管可行性强，有推广实用价值。     

健忘镇痛慢诱导用于经鼻盲探气管插管的临床观察

目的探讨健忘镇痛慢诱导经鼻盲探气管插管的临床应用效果及不良反应。方法选择ASAⅠ或Ⅱ级择期手术患者30例,年龄20～66岁,采用健忘镇痛慢诱导方法经鼻盲探气管插管。观察记录插管次数、血流动力学变化、健忘作用及不良反应。结果30例患者中有25例一次性顺利插管到位（83．33％）,4例经变换头部体位和旋转导管方向试插2～3次进入气管内（13．33％）,1例经多次试插未能成功改用经口明视下将导管插入气管（3．33％）。插管过程中血流动力学稳定。术后患者对插管过程健忘（无记忆）。反复插管患者有3例术后诉咽喉部疼痛,于1周内恢复,未见其他与插管有关的并发症。结论健忘镇痛慢诱导经鼻盲探气管插管,在插管期间保留自主呼吸,患者能主动配合,对心血管不良反应小,术后无记忆,取得了安全、有效、并发症少的满意效果。     

经鼻清醒盲探插管技术在临床麻醉15例分析

目的：解决一些特殊患者,经口不能插入气管导管,而无法建立呼吸通道实际问题。方法：15例患者经充分表麻后,在清醒状态下,由鼻腔插入相宜导管,当导管到达声门附近时,据导管内呼吸声流,调整位置,插入气管内,快速推注静脉麻醉剂及肌松剂,即达到麻醉状态。结果：全组15例,均经鼻清醒盲探插管获得成功。结论：经鼻清醒盲探插管,解决了经口无法建立通气道的临床实际问题,整个过程在清醒状态下完成,只要操作熟练,正确,几无特异并发症,是一项实用价值很高的技术。     

可视喉镜结合卵圆钳在气管插管后鼻空肠管置管中的应用

总结2例气管插管后盲插鼻空肠管管端经食管入口处困难的困难置管病例。对于带有气管插管合并吞咽功能障碍,置入鼻空肠管通过食管口困难的患者,给予适当的镇静,必要时给予肌松剂,保证气管插管不发生移位及非计划性拔管。从一侧口角轻柔置入可视喉镜,充分暴露咽喉部,持卵圆钳将鼻空肠管送入食管开口后将管道送至胃部,撤除可视喉镜及卵圆钳,再按盲插法将管道送至空肠。采用可视喉镜结合卵圆钳置管,鼻空肠管管端可快速经过食管口,避免反复多次置管,提高置管成功率。     

吸痰管诱导经鼻气管插管治疗呼吸衰竭的配合及护理26例

经鼻气管插管可作为择期气管插管的首选途径，但盲探经鼻气管插管操作困难，成功率不高。我科2000年1月-2004年12月采用以吸痰管经鼻插入气管成功后再诱导气管插管导人的方法，快速、准确、安全地建立人工气道，成功救治了26例慢性阻塞性肺疾病（COPD）伴呼吸衰竭的患者，现报道如下。     

呼气末二氧化碳分压在困难气道插管中的应用

目的探讨对困难气道应用呼气末二氧化碳分压(PetCO2)监测探头行清醒或半清醒经鼻盲探插管的方法和效果。方法将98例困难气道手术患者在气管导管接PetCO2监测探头行清醒或半清醒经鼻盲探插管。结果手术顺利,插管成功,无插管并发症发生。结论 PetCO2监测应用于困难插管的方法操作方便,安全可靠,在基层医院值得推广。     

经鼻气管插管应用中导管内痰痂形成的原因分析及预防

经鼻气管插管操作方法分为经鼻明视插管术,经鼻盲探气管插管术,纤维支气管引导插管,主要应用于脸部整形、口腔科、耳鼻喉科的手术,使术中术野扩大,便于手术。大部分病人术后需要带管回病房,其护理也是非常重要的,如果护理不当则会在导管内形成痰痂,从而危及病人的生命。我科2007年4月—2010年4月64例病人中,部分或全部堵管4例,由于及时发现,及时抢救均获成功,现就经鼻气管插管应用中导管内痰痂形成的原因分析及预防报告如下。     

困难气道麻醉中经鼻盲探气管插管的临床应用探析

选取我院2011年5月²013年4月收治的12例困难气道麻醉患者的临床资料进行研究分析,分析困难气道麻醉中经鼻盲探气管插管的临床应用效果。结果本次研究中选取的12例困难气道麻醉患者中,8例在清醒、镇痛、经鼻盲探及健忘条件下一次性气管插管成功,4例在经调整头颈和气管导管位置后三次气管插管成功。插管中患者均没有出现显著不适感,且术后其对插管过程没有记忆。经鼻盲探气管插管在困难气道麻醉中具有显著效果,可有效提高患者临床麻醉效果,促使患者早日康复。     

悬雍垂腭咽成形术围术期的麻醉处理

[目的]探讨悬雍垂腭咽成形术(UPPP)围术期适宜的插管和麻醉方法。[方法]对40例行UPPP病人围术期采用不同的插管方法,其中16例采用静脉快诱导经鼻明视气管内插管,12例术前行预防性气管切开,12例采用清醒镇静表麻下经鼻盲探气管内插管．比较插管时情况。其中非静脉诱导插管24例病人根据插管前是否泵入异舒吉分为异舒吉组和对照组,观察插管前后血压变化。[结果]经鼻明视气管内插管4例插管不顺利,2例插管期间SPO2下降明显;清醒镇静表麻下经鼻盲探气管内插管成功率100％,插管期间SPO2无明显变化,4例插管后无呛咳反应。插管前后异舒吉组血压无明显变化,对照组插管后血压明显升高。[结论]清醒镇静表麻下经鼻盲探气管内插管为UPPP首选;合适的麻醉深度加血管活性药物可维持稳定的血流动力学状态。     

Prehospital emergency endotracheal intubation using the Bonfils intubation fiberscope.

Among all prehospital emergency intubations, difficulties occur in 7-10%. Furthermore, intubation conditions often worsen when the cervical spine is immobilized in trauma patients. We report on six patients in whom the Bonfils intubation fiberscope, a reusable, rigid fiberoptic device, was used for emergency endotracheal intubation in the field. Three of these patients had an anticipated or unanticipated difficult airway: two trauma patients with immobilized cervical spine and one patient in cardiac arrest in whom direct laryngoscopy failed twice. Endotracheal intubation with the Bonfils intubation fiberscope was successful in all cases in the first attempt. The Bonfils intubation fiberscope therefore demonstrated its value as an additional airway management device in both emergency and prehospital settings.     

Management of tracheal intubation in the respiratory intensive care unit by pulmonary physicians

BACKGROUND: Expert management of tracheal intubation has become fundamental to the routine practice of pulmonary physicians who work in respiratory intensive care units (ICUs). In Italy, tracheal intubation is not included as part of the training in respiratory medicine, and pulmonary physicians are usually dissuaded from managing intubations. METHODS: We prospectively studied the intubation success rate in 46 consecutive respiratory ICU patients who required either emergency or urgent intubation, conducted by 3 intubation-trained pulmonary physicians in our respiratory ICU. Intubation success was defined as successful tracheal intubation without any of 7 pre-defined complications. RESULTS: There were 17 emergency intubations and 29 urgent intubations. Intubation was successful in 43 of the 46 intubation attempts. Complications occurred in 3 cases: 2 patients needed to be intubated by an anesthesiologist, and 1 patient received fiberoptic intubation. CONCLUSIONS: Pulmonary physicians trained in tracheal intubation can have a high success rate in performing intubation in the respiratory ICU. Collaborative efforts between anesthesiologists and pulmonary physicians are necessary to optimize the training, skill-retention, and back-up for advanced airway management in the respiratory ICU.     

HC 可视喉镜在急诊低年资住院医师紧急气管插管操作中的应用

目的：研究采用 HC 可视喉镜是否可以提高急诊低年资住院医师紧急气管插管的效率及成功率。方法选取急诊科需要进行紧急气管插管的患者共计80例,首先随机（随机数字法）分为低年资住院医师组（A 组）及高年资主治医师组（B 组）,然后每组再随机分为 HC 可视喉镜插管组（HC 组）及传统光学喉镜插管组（N 组）,比较每组的声门暴露成功率、一次插管成功率、插管总成功率、并发症情况以及成功插管病例的平均尝试次数和平均插管时间。结果（1）A-HC组的声门暴露成功率、一次插管成功率、插管总成功率依次为90％、70％、90％,均高于 A-N 组,依次为50％、20％、45％,P ＜0.05;并发症总发生率、成功插管病例的平均尝试次数、平均插管时间依次为15％、（1.28±0.43）次、（31.44±5.06）s,均低于 A-N 组,依次为45％、（1.89±0.79）次、（45.89±4.99）s,P ＜0.05;（2）B-N 组的声门暴露成功率、一次插管成功率、插管总成功率依次为80％、65％、80％,均高于 A-N 组,依次为50％、20％、45％,P ＜0.05;并发症总发生率、成功插管病例的平均尝试次数、平均插管时间依次为15％、（1.25±0.41）次、（39.31±4.23）s,均低于 A-N 组,依次为45％、（1.89±0.79）次、（45.89±4.99）s,P ＜0.05;（3）A-HC 组与 B-HC 组的上述各项指标比较,差异无统计学意义（P ＞0.05）。结论 HC 可视喉镜用于急诊低年资住院医师的紧急气管插管操作时,可提高声门暴露成功率、减少尝试次数、降低并发症发生率、缩短插管时间,可以提高紧急气管插管的效率及成功率,并且可能缩小其与高年资主治医师紧急气管插管操作的差距。     

Use of an emergency sedation protocol to assist intubation in helicopter patient retrieval in Victoria

Abstract Objectives: To review emergency sedation intubation as practised in the Melbourne-based ambulance helicopter. Specifically, to describe patient profiles, drug dosage, difficulties encountered, success rate and patient outcomes. Methods: Retrospective review of all helicopter primary and secondary retrieval patients, who received application of the emergency sedation intubation protocol using morphine and diazepam during a 3 year period (January 1995 to December 1997). Data were collected from an audit of patient care records completed by flight paramedics and from hospital records. Results: Emergency sedation intubation was performed on 128 patients: 103 adults and 25 children. The median dose of drugs required for emergency sedation intubation by adult patients was 20 mg morphine and 20 mg diazepam. The overall success rate for emergency sedation intubation was 94.5%, with 73.6% of these being successful intubations at the first attempt. On intubation, 54.1% of patients were fully relaxed, while a gag reflex was still present in 45.9% of patients during or just after emergency sedation intubation. Twenty-two per cent of patients had a change in blood pressure of more than 20 mmHg. The maximum rise in blood pressure was 60 mmHg and the maximum fall was 80 mmHg. Conclusions: Flight paramedics achieved a high success rate for intubation with the morphine/ diazepam emergency sedation intubation protocol. However, there was still a significant percentage of patients for whom more than one attempt was required to achieve emergency sedation intubation and, in almost half the patients, gag reflexes remained present either during or immediately after intubation. Additionally, some patients experienced blood pressure changes following intubation that may have potential adverse consequences in terms of compromised cerebral perfusion or rises in intracranial pressure. Consideration should be given to revision of the protocol to allow the use of neuromuscular blocking agents and alternative airway management techniques, such as cricothyroidotomy, for specified circumstances in the aeromedical environment.     

Complications of emergency intubation with and without paralysis

Expert and definitive airway management is fundamental to the practice of emergency medicine. In critically ill patients, rapid sedation and paralysis, also known as rapid-sequence intubation, is used to facilitate endotracheal intubation in order to minimize aspiration, airway trauma, and other complications of airway management. An alternative method of emergent endotracheal intubation, intubation minus paralysis, is performed without the use of neuromuscular blocking agents. The present study compared complications of these two techniques in the emergency setting. Sixty-seven intubations minus paralysis were prospectively compared with 166 rapid-sequence intubations. Complications were greater in number and severity in the nonparalyzed group and included aspiration (15%), airway trauma (28%), and death (3%). None of these difficulties were observed in the rapid-sequence group (P < .0001). These results show that rapid-sequence intubation when compared with intubation minus paralysis significantly reduces complications of emergency airway management and should be made available to emergency physicians trained in its use.     

轮转护士急诊气管插管配合培训的效果评价

目的探讨轮转护士急诊气管插管配合培训的方法及效果。方法便利抽样法选择2010年5月至2012年5月在第二军医大学长海医院急诊科培训的106名护士为研究对象。将气管插管操作分解为7个标准化操作流程,采用人科评估、模拟教学以及临床带教等方式实施培训,比较培训前后轮转护士在应急能力、插管前准备、插管时配合、操作熟练度方面的满意率情况。结果相对于培训前,培训后106名轮转护士在应急能力、插管前准备、插管时配合、操作熟练程度等方面的满意率均有提高,差异均有统计学意义（均P〈O．01）。结论气管插管配合培训提高了轮转护士的实际操作能力和综合应急能力,值得推广。     

急诊气管插管患者院内转运的危险因素及护理对策

目的:分析急诊气管插管患者院内转运的危险因素,探讨相应的护理对策。方法:回顾性分析132例急诊气管插管行院内转运患者的临床资料,分析转运过程中出现的危险因素,对采取的护理措施予以总结。结果:气管插管患者院内转运的危险因素有气道阻塞、人工气道移位、供氧不足、转运人员缺乏经验和流程不畅、原发疾病影响等。患者均成功院内转运,未出现相关的并发症。结论:急诊气管插管患者院内转运前应充分做好各项准备工作,加强转运途中的护理,完善转运后的交接,是保证院内安全转运的重要措施。     

持续质量改进对提高紧急气管插管一次成功率的效果观察

目的 观察持续质量改进(continuous quality improvement,CQI)对提高紧急气管插管一次成功率的效果.方法 选择2007年1月～2008年12月本院ICU收治的50例患者为对照组,选择2009年1月～2010年12月收治的52例患者为实验组.对照组采用传统紧急气管插管方法为患者实施插管,实验组采用CQI的方法,分析紧急气管插管失败的原因,通过采用改善医护配合流程后对患者实施气管插管,比较两组患者紧急气管插管一次成功率的差异.结果 两组患者紧急气管插管一次成功率比较,x2=4.258,P＜0.05,差异具有统计学意义,实验组紧急气管插管一次成功率高于对照组.结论 实施CQI可提高紧急气管插管一次成功率,促进医护合作,优化插管流程,为患者的进一步抢救争取时间.     

急诊内科危重病人气管插管时机与方法的探讨

目的:总结急诊内科病人气管插管的特点,分析其治疗效果,并探讨其插管时机、方法与转归。方法:根据病人在急诊科治疗情况,将病人分成三组。第Ⅰ组23例,系到医院前已临床死亡;第Ⅱ组30例,经抢救无效在急诊科死亡;第Ⅲ组30例,经抢救病人在急诊科存活,后转入病房或急诊留观。结果:第Ⅰ组病人经口气管插管,抢救平均30分钟,无一例心跳呼吸恢复;第Ⅱ组虽经急诊CPR,但呼吸功能不能恢复正常,或因其原发病未能控制,最终在急诊科死亡;第Ⅲ组病人经口插管13例,经鼻插管17例,6例病人在急诊留观治疗后出院,12例病人经ICU或病房住院治疗后基本痊愈出院,另12例最终死亡。结论:急诊科所遇垂危病人,多数需气管插管者是由内科医师首诊实施。正确的插管方法和较高的成功率是直接影响病人转归的重要因素。