P ARAMEDIC U SE OF E NDOTRACHEAL T UBE I NTRODUCERS FOR THE D IFFICULT A IRWAY

Objective. To evaluate the ability of paramedics to learn and apply the skill of introducer-aided oral intubation in the setting of the simulated “difficult airway.” The authors hypothesized that, following a brief introduction to the device, intubation success rates would not differ for traditional and introducer-aided intubations of an immobilized airway mannequin. Methods. During a paramedic recertification class, experienced paramedics were given a brief didactic introduction to the “bougie-like” Flex Guide endotracheal tube introducer (ETTI). The participants were then asked to intubate adult mannequins immobilized in the head-neutral position, with and without the ETTI. “Successful placement” was defined as completion of the procedure within 30 seconds and endotracheal tube position confirmed by the investigator with direct visualization. Results. For both traditional and ETTI intubations, 34 (97%) of the 35 paramedics successfully intubated within 30 seconds. The two unsuccessful intubation attempts were recognized by the paramedic as esophageal intubations, and correct tube placement was obtained within an additional 30 seconds. Conclusion. In this study, use of the ETTI was mastered by the participants after only a brief didactic introduction to the device, with their ability to intubate an immobilized mannequin using the ETTI being equal to their ability to perform traditional intubation. These results suggest that use of the ETTI is easily learned, and may support the device's role in the prehospital management of the difficult airway.     

一例曾两次拔管后喉痉挛患者成功拔管的体会

喉痉挛（laryngospasm）指喉部肌肉反射性痉挛收缩,使声带内收,声门部分或完全关闭而导致病人出现不同程度的呼吸困难甚至完全性的呼吸道梗阻,本文遇到一例曾两次拔管后出现严重喉痉挛、声门闭合、接近心跳骤停意外,第三次成功拔管患者,现将救治经过与体会介绍如下。1病例介绍患者,刘XX,男,60岁,汉族,以＂咳嗽,咳痰三年伴呼吸困难一年,加重三天＂为主诉于2014年4月9日入ICU,诊断为慢性阻塞性肺疾病,呼吸衰竭,酸碱平衡紊乱，入院时血气分析PH7．31PC0275 mmHg PO245 mmHg HC03-37．8mmol／L，给予抗炎、平喘、呼吸兴奋剂治疗，于4月14日患者呼吸困难加重给予评吸兴奋剂治疗效果不佳，行呼吸机辅助呼吸，曾两次拔出气管插管后出现严重喉痉挛，复插管。于4月24日第三次拔出气管插管，25日转至呼吸内科病房。     

术前不同CT测量方式对指导双腔支气管插管效果的影响

目的探讨CT平扫及重建分别应用于指导患者双腔支气管插管的效果,并分析气管内径与患者一般资料的相关性。方法选择2015年6月至2018年6月于我院行择期肺叶切除的患者53例,按照随机数字表法分为平扫组(n=27)和重建组(n=26),两组患者均于麻醉前行CT检查支气管情况,平扫组采用CT平扫法进行测量,而重建组则采用CT重建法进行测量,而后根据测量结果行双腔支气管插管。比较两组患者导管合适程度评价指标情况,插管并发症之间的差异。对患者通过重建测量出的气管内径与其身高、体重、年龄和BMI等一般资料进行相关性分析。结果重建组LT1、PT1及APP显著低于平扫组,插管1次成功率显著高于平扫组(P<0.05),重建组患者插管并发症总发生率显著低于平扫组(P<0.05);重建组胸廓入口处、主动脉弓处以及气管最狭窄处气管内径值显著高于平扫组(P<0.05);Pearson相关分析显示,身高与气管四个位置的内径呈正相关(P<0.05)。结论CT重建应用于指导双腔支气管导管型号的选择,能有效提升术前气管导管选择型号合适程度,并有效减少插管并发症;患者身高与气管内径呈显著正相关。     

芬太尼复合不同浓度七氟醚吸入诱导对气管插管反应的影响

目的:比较肺活量吸入诱导法中不同七氟醚维持诱导浓度对气管插管反应的影响.方法:选择ASAⅠ~Ⅱ级,年龄20~50岁,将择期行腹腔镜手术的女性患者60例随机分为A、B、C三组各20例.各组诱导前静脉注射2μg·kg-1芬太尼,2 min后使用肺活量法吸入8%七氟醚,意识消后失立即静脉注射0.2 mg·kg-1顺式阿曲库铵,同时三组分别换用3%,5%和8%七氟醚维持诱导,面罩机械通气3 min后气管插管,使用Narcotrend监测诱导期的麻醉深度,记录诱导过程中和气管插管后意识消失的时间,气道反应及血流动力学变化.结果:(1)插管前C组MBP下降最明显,达基础值(MBPbase)的33.6%(P <0.001);(2)插管后1min,三组MBP上升至最大值,与MBPbase相比无统计学差异(P >0.05);与插管前相比,三组上升幅度为A组34.9%(P <0.01)、B组27.7%(P <0.001)和C组32.9%(P <0.01).插管后2 min三组HR上升到最大值,与插管前比较,三组上升幅度分别为A组20.0%(P <0.01)、B组15.2%(P <0.001)和C组20.6%(P <0.01).(3)诱导插管过程中,C组MBPmin较MBPbase下降42.2%(P <0.001),C组HRmax较HRbase升高22.3%(P <0.01).(4)C组MBP降低<30% MBPbase和HR升高>100次/分的发生率均高于A、B组(P <0.001).结论:芬太尼2μg·kg-1复合3%、5%、8%七氟醚吸入诱导均可减轻气管插管反应,芬太尼与5%七氟醚复合诱导血流动力学最稳定.     

Developmental anatomy of the airway

The airway develops from the primitive foregut at 4 weeks’ gestation. Congenital anomalies may result when this process is abnormal. The anatomy of the airway at birth is uniquely different from older children and adults, with a large tongue, long floppy epiglottis, large occiput and cephalad larynx. These features affect the technique required for facemask ventilation, supraglottic airway use and endotracheal intubation. A neutral head position and straight-bladed laryngoscope are usually used for intubation. Neonates are also obligate nasal breathers and simultaneously suckle and breath. Minute volume is rate dependent and the highly compliant chest easily displays sternal and intercostal recession during respiratory distress, and early onset of fatigue. From the neonatal period onwards the anatomy gradually begins to resemble that of adults. The cricoid descends caudally, the epiglottis becomes firmer and shorter, and the relatively large occiput recedes. The conventional wisdom of the cricoid ring being the narrowest part of the paediatric airway is not supported by contemporary investigation. The consequence of these findings on endotracheal tube selection and the rationale for increasing use of cuffed endotracheal tubes in children is discussed.     

机械通气患者气管内吸痰的研究进展

随着医学技术的发展,应用呼吸机机械通气进行生命支持、治疗呼吸衰竭已成为一种常规手段。人工气道的建立使下呼吸道直接与外界相通,咳嗽反射受抑制,咳痰能力丧失,因此气管内吸痰成为清除气道内分泌物的重要方法。但呼吸机相关并发症逐渐引起医护人员的重视,其中最常见的是呼     

镀银气管导管对呼吸机相关性肺炎影响的荟萃分析

目的 评价镀银气管导管,对预防机械通气患者呼吸机相关性肺炎(VAP)的效果.方法 电子检索Cochrane图书馆、PubMed、EMbase、ScienceDirect、中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI)、万方数据库等,各数据库检索时间均从创建到2011年8月；纳入镀银气管导管对预防机械通气患者VAP效果的随机对照试验(RCT);采用RevMan5软件进行荟萃分析,对于无法转换合并的数据,采用描述性分析.结果 共纳入3个RCT、2127例患者,文献异质性较小；荟萃分析结果表明,镀银气管导管可显著降低VAP的发生率[固定效应模型,OR=0.59,95 ％CI(0.41,0.84),P=0.005]、死亡率和负面事件等方面两组差异无统计学意义;住院时间、住ICU时间、气管插管时间、临床肺感染指数及呼吸道细菌浓度等指标,由于数据难以转换及难以获取完整数据等原因未能做荟萃分析,只进行描述性分析,显示两组在上述指标方面差异无统计学意义.结论 与标准非镀银气管导管相比,镀银气管导管能显著降低机械通气患者VAP的发生率,而对患者死亡率及负面事件发生率等指标无明显改善；需要进行更多设计严格的、多中心、大样本随机对照试验,对镀银气管导管的综合效果进行验证.