科学实施麻醉诱导气管插管

气管插管是全麻诱导期的首要关键环节,为了确保这个过程的平稳及患者的安全与舒适,麻醉科医师常个体化选择不同插管途径、插管工具及插管时的麻醉诱导方式,而麻醉诱导方式的合理选择,对某些特殊患者,特别是(潜在)困难气道患者安全顺利建立人工气道尤为重要. 目前各类麻醉书籍及文献对麻醉诱导方式的分类,存在分类不统一、名称不准确及标...     

患儿共享气道类手术气道管理研究进展

共享气道类手术需要外科医师与麻醉科医师在同一气道解剖空间内实施操作及气道管理,围术期需要麻醉、外科和护理团队间保持密切沟通与合作。患儿上气道尤其狭窄,因病变种类多、对正常通气换气功能影响大,其共享气道手术的麻醉管理实施难度更大、风险更高,是临床麻醉的难点问题。在保障氧合与通气安全的基础上,尽可能为外科提供更好的视野暴露是共享气道工具开发及通气策略优化的目标。本文归纳总结了儿科共享气道类手术的种类与特点,重点分析非插管气道管理技术的应用范围和优缺点,以期为安全个性化地实施患儿共享气道的麻醉管理提供参考。     

颈椎手术患者困难气道的评估处理

颈椎手术患者一般伴有脊髓压迫、颈椎活动受限。实施全身麻醉时给气管内插管带来困难．同时经喉镜直视下行气管插管也可能加重颈段脊髓的再次损伤。在全麻诱导前麻醉医师必须对患者的气道进行评什并根据患者的气道评估情况采取适当的麻醉诱导和插管方法。有流行病学资料显示，普通患者面罩通气困难的患者比例为1：10000，使用喉镜困难插管的患者比例为1：100。     

非清醒困难气管插管

1990年,美国协议赔偿案件的资料分析表明,麻醉死亡的30％是由于困难呼吸道管理不当,为此组成的专门工作组于1991年发表权威文章“困难呼吸道管理”,并专门加了副标题“特别强调清醒气管内插管”,在此基础上形成的“困难气道管理规程”于1993年作为美国麻醉医师协会的一项正式操作准则公布。由于专科特点,我院每年有近百例困难气管插管病例,十几年来,所用困难插管技术经历了清醒插管,清醒亚肌松插管,及现在采用的非清醒插管技术的变化。我们现在采用的非清醒插管技术与美国目前提倡的方式不一样,特介绍如下。     

广东省困难气道管理现状调查及分析

目的对广东省部分二级以上医疗机构气道管理的现状进行调查,为广东省气道管理提供参考。方法采用邮寄调查问卷的方法,对66家医院进行调查。问卷内容包括:麻醉科基本情况,业务开展情况,困难气道相关器械配置情况,常碰到的困难气道情况,常用预测方法,困难气道麻醉,困难气道处理方法等。以三甲、二甲医院为分组变量,采用校正χ2对调查结果进行分析比较。结果手术间与麻醉医师之比为1∶0.99。各医院Macintosh喉镜、口咽通气道、鼻咽通气道和喉罩的配置率为100.0%;纤维支气管镜(纤支镜)12.0%,视频喉镜18.0%,急救环甲膜穿刺套件18.2%。困难气道以肥胖多见(三甲57.5%,二甲53.0%),其次是张口困难(三甲48.1%,二甲44.0%)。困难气道中以喉头暴露困难为多见(三甲47.2%,二甲49.5%)。预测困难气道的主要方法是张口度(三甲53.6%,二甲50.0%)。困难气道时选择清醒气管插管的比例为30.0%(三甲)和17.5%(二甲)。对于环甲膜穿刺或气管切开50.0%(三甲)、30.0%(二甲)的麻醉医师从未做过。结论麻醉科室人力资源依然缺乏,困难气道处理工具配备严重不足,在困难气道处理方面仍需不断改善。     

右美托咪啶用于全麻患者清醒气管插管的效果

困难气道患者,表面麻醉联合小剂量麻醉药物行清醒气管插管是预防气道相关并发症的有效方法.但传统的镇静药,如苯二氮革类、阿片类药物和异丙酚,常出现镇静不足,大剂量应用时又易引起呼吸抑制.右美托咪啶是一种α2肾上腺素能受体激动剂,不仅具有良好的镇静作用,而且无明显呼吸抑制作用.本研究拟评价右美托咪啶用于全麻患者清醒气管插管的效果,为困难气道患者清醒气管插管用药提供参考.     

成人纤维支气管镜辅助三维电解剖标测系统Carto导管气管插管在九例瘢痕患儿整形术中的应用

头颈部烧伤患儿因瘢痕挛缩致张口困难或头颈部活动受限,给全身麻醉气管插管造成极大的困难.小儿困难气管插管一直是临床麻醉医师面临的挑战.在纤维支气管镜(fiberbronchoscope,FBS)引导下行气管插管,是解决困难气管的有效方法之一[1-2].然而许多医院麻醉科通常只配备成人FBS,其外径较粗,运用传统的"railroading"技术操作时该FBS不适用于小儿气管插管.近年来,郑州大学第一附属医院麻醉科以三维电解剖标测系统Carto导管联合成人FBS对瘢痕患儿行气管插管,达到预期效果,现报告如下.     

创伤患者急诊气管插管的成功分析：一个大型成年创伤转诊中心的10年经验

背景对于多数麻醉医师来讲急诊气道管理是必须掌握的一项重要技术,我们总结了一个一级创伤中心10年来的经验,评估创伤患者入院后24小时内气管插管的结果。方法通过该中心1996年7月至2006年6月的创伤登记、质量管理记录、收费系统记录,得出入院后1小时内、24小时内需要插管的患者人数,并且回顾每个气管切开患者的医疗记录,了解其特征和无法进行经口或经鼻插管的原因。结果所有插管都在一名处理创伤经验丰富的麻醉医师的指导下进行。研究期间,标准插管法为直接喉镜下快速诱导插管。入院后1小时内,6088名患者进行插管,其中21名患者（0．3％）最终行气管切开。入院后24小时内,累计32000名患者进行插管,共31名行气管切开。意外的困难气道是气管切开的主要因素。31名患者中有4名死于外伤,无人死于插管失败。结论由经验丰富的麻醉医师指导,直接喉镜下快速诱导气管插管是有效的急诊气道管理方法,以其为核心的急诊气道管理规则使得气道管理成功率很高。     

颈前透光法用于Bonfils纤维光导硬镜引导全麻患者气管插管的可行性

Bonfils纤维光导硬镜是一种视觉效果好、操作简单、携带方便的新型气管插管工具，可用于正常气道和不同原因引起的困难气管插管。颈前透光法是一种通过颈前光点来判断气管导管位置的光棒盲探气管插管技术，具有容易掌握、方便快捷、气管插管成功率高等优点，已作为麻醉科医师处理困难气道的首选方法。Bonfils纤维光导硬镜既有光棒盲探引导的特点，又有光导纤维直视观察的优点，颈前透光法是否可用于Bonfils纤维光导硬镜引导气管插管有待进一步探讨。     

麻醉中困难气道的管理

麻醉医师在他们的日常临床实践中面对各种各样影响气道的复杂问题。因此,困难气道的管理是麻醉学的重要课题。本文着重讨论困难气道的定义和分类,建立气道的专用技术,常用的术前估计方法以及处理困难气道的规则。 1 困难气道的定义和分类 1.1 困难气道的定义 1993年ASA从临床应用的角度创造了困难气道的定义如下:①困难气道:是这样一种临床情形,即经过正规训练的麻醉医师在行面罩通气和(或)气道插管时遇到了困难。②困难气管内插管:即一个经过正规训练的麻醉医师使用常规喉镜正确地进行气管插管时,经3次尝试仍不能完成。③面罩通气困难:即一个麻醉医师在无他人帮助的情况下不能维持正常的氧合     

Use of the intubating laryngeal mask airway to facilitate awake orotracheal intubation in patients with cervical spine disorders.

Airway management in patients with unstable cervical spines remains a challenge for anesthesia providers. Because neurologic evaluations may be required following tracheal intubation and positioning for the surgical procedure, an awake intubation technique is desirable in this patient population. In this report, we describe the use of an intubating laryngeal mask airway (ILMA) to facilitate awake tracheal intubation in two patients with cervical spine disorders. After topical local analgesia, the ILMA was inserted easily, and a tracheal tube was passed through the glottic opening without complications. Thus, the ILMA may be an acceptable alternative to the fiberoptic bronchoscope for awake tracheal intubation.     

Awake tracheal intubation through the intubating laryngeal mask airway in a patient with halo traction

PURPOSE: To report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction. Clinical features: A 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo device in situ has seldom been reported in the medical literature. CONCLUSION: Airway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.     

不同的氧气流量对雾化吸入利多卡因进行表面麻醉效果的影响

目的探讨不同的氧气流量对雾化吸入2%利多卡因进行气道表面麻醉效果的影响。方法选择需行清醒气管插管的困难气道患者75例,按随机数字表法分为A、B、C三组(n=25),所有患者都通过氧气驱动雾化吸入2%利多卡因10 m L的方法进行气道黏膜表面麻醉,但A、B、C三组患者所用的氧气流量分别为3 L/min、6 L/min、9 L/min,雾化吸入结束后使用纤支镜引导进行气管插管。评估记录插管条件和导管耐受性;记录气管插管首次成功率、总成功率、插管时间;记录不良心血管反应和并发症发生情况。结果与A组和C组比较,B组的插管条件、导管耐受性更好,气管插管首次成功率更高,插管时间更短(Ρ0.05);A、C两组间比较,无明显差异。结论在清醒气管插管过程中定量雾化吸入2%利多卡因进行气道粘膜表面麻醉时,氧气流量为6 L/min的效果更好。     

Monitoring during difficult airway management

Monitoring is crucial to assure safety during difficult airway management. Several reports have indicated that the most of the adverse outcomes associated with difficult airway management could have been avoided with the use of necessary monitors, such as a pulse oximeter and a capnometer. Nevertheless, airway complications continue to be major problems during anesthesia, in particular, in patients with difficult airways. In this brief review, I stress the role of monitoring in detecting inadvertent esophageal intubation, during sedation for awake tracheal intubation, during general anesthesia, and during emergence from anesthesia, in patients with difficult airways.     

Usability of AirWay Scope for awake tracheal intubation in a burn patient with difficult airway

The AirWay Scope (AWS; PENTAX Corporation, Tokyo, Japan) is a newly developed rigid video laryngoscope with a built-in LCD monitor that provides accurate verification of tube passage through the vocal cords during tracheal intubation procedures. The blade is shaped to fit the oropharyngeal anatomy, which enables operators to achieve an optimal view for tracheal intubation without requiring alignment of the oral, pharyngeal, and laryngeal axes. We used an AWS for awake intubation in a 34-year-old male burn patient with a difficult airway under conscious sedation obtained with infusion of dexmedetomidine (DEX). Following topical anesthesia of the upper airway and preoxygenation, sedation was induced with 6 microg kg(-1) hr(-1) of DEX for 13 minutes and maintained at 0.5 microg kg(-1) hr(-1). Thereafter, insertion of the AWS gave a Cormack grade 1 glottic view, and endotracheal anesthesia was provided by use of a modified spray tube through the AWS blade without patient anxiety or discomfort. The trachea was intubated using the AWS without respiratory depression or other complications while the patient was sedated (Ramsay sedation scale class 4). We consider the AWS to be useful for awake tracheal intubation in patients with a difficult airway.     

Subcutaneous emphysema and pneumomediastinum after translaryngeal intubation: tracheal perforation due to unsuccessful fiberoptic tracheal intubation

A 77-year-old man was scheduled to undergo a cervical lymph node biopsy under general anesthesia. Although awake, nasotracheal fiberoptic intubation was initially planned because of an anticipated difficult airway, the attempt was unsuccessful. Orotracheal intubation was subsequently performed under direct laryngoscopy without difficulty. After initiating positive pressure mechanical ventilation, subcutaneous and mediastinal emphysema developed. The cause of this emphysema was considered to be tracheal perforation after an unsuccessful attempt at fiberoptic tracheal intubation.     

Cardiovascular responses and lidocaine absorption in fiberoptic-assisted awake intubation

Local anesthetic toxicity and cardiovascular stress during fiberoptic-assisted awake tracheal intubation were assessed prospectively in 20 patients with airway management problems. Cardiovascular responses, dose of lidocaine, its systemic absorption, and patient comfort were measured. A standardized topical anesthesia protocol of 4% lidocaine aerosol, topical 2% lidocaine viscous gel, and direct perbronchoscopic laryngeal application was used. Awake intubation produced no significant elevation of blood pressure or pulse rate either during the topical application or after the intubation. Despite a large total dose of topical lidocaine (5.3 +/- 2.1 mg/kg), the mean peak arterial plasma lidocaine concentration was low (0.6 +/- 2.1 micrograms/ml). Patient comfort assessment showed that nine patients had no discomfort, whereas 11 had minimal discomfort. Supplementary sedation used was minimal (fentanyl, 1.4 +/- 0.6 micrograms/kg, and diazepam, 1.9 +/- 1.8 mg). This method of producing topical anesthesia for awake tracheal intubation is recommended as a safe, easy, and comfortable method of managing patients with airway difficulties.     

Management of airway in patients with laryngeal tumors

STUDY OBJECTIVE: To describe our systematic approach to securing the airway in patients with laryngeal tumors, developed over a 10-year period. DESIGN: Retrospective analysis. SETTING: University-affiliated veterans administration medical center. PATIENTS: Eight hundred one patients presenting for laryngeal tumor surgery in a 10-year period, 285 of whom underwent tracheostomy (25 with local anesthesia and 260 with general anesthesia). INTERVENTIONS: Preoperative examination, including history, physical examination, computed axial tomography and/or magnetic resonance imaging, and ear, nose, and throat surgeons' evaluation via indirect laryngoscopy or fiberoptic bronchoscopy were performed before the anesthesiologist's interventions. Local (topical) anesthesia and mild sedation were used for laryngeal evaluation with fiberoptic bronchoscopy. Tumor grade was then established, which determined how the airway would be secured: general anesthesia induction, receive topical anesthesia for awake, direct laryngoscopy, and tracheal intubation, or undergo tracheostomy with local anesthesia. MEASUREMENTS AND MAIN RESULTS: When the airway was secured, surgeons performed the biopsy, (any) tumor debulking, laser excision, or tracheostomy to establish both the airway and the diagnosis. Pulmonary function, including flow-volume loops and blood gas analysis were also useful in evaluating the degree of obstruction and gas exchange. In the event of respiratory distress, tracheostomy was performed after tracheal intubation or with local anesthesia, followed by direct laryngoscopy and biopsy. Depending on the diagnosis, further surgery and radiation treatment were planned next. CONCLUSIONS: With these guidelines, we have reduced the frequency of emergencies because of a lost airway, bleeding, or dislodging of tumor.     

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high-quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post-tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.     

Awake tracheal intubation using the Airtraq® laryngoscope: a case series

The Airtraq^® laryngoscope (AL) is a new single use indirect laryngoscope designed to facilitate tracheal intubation in anaesthetised patients either with normal or difficult airway anatomy. It is designed to provide a view of the glottis without alignment of the oral, pharyngeal and tracheal axes. We report four cases of successful awake tracheal intubation using the AL. The first case is a patient with severe ankylosing spondylitis and the other three cases with anticipated difficult airway. An awake intubation under sedation and topical airway anaesthesia was chosen. We consider that the AL can be used effectively to accomplish an awake intubation in patients with a suspected or known difficult airway and may be a useful alternative where other methods for awake intubation have failed or are not available.