依据儿科高级生命支持指南行气管插管的错位发生率及对插管深度公式的探讨

目的　探讨多种儿童经口气管插管深度标准技术的准确性,包括儿科高级生命支持（PALS）指南公式预测法以及听诊双肺呼吸音、观察胸廓起伏的临床评估法,并设计更准确的预测公式指导临床。方法　回顾性分析2018年1月至2019年7月中国医科大学附属盛京医院小儿重症监护病房收治的经口气管插管的177例患儿。记录入院后初次插管时患儿的年龄、性别、体重、依据PALS指南公式计算的插管深度、临床评估后的实际插入深度以及胸片显示气管导管（endotracheal tube,ETT）尖端距离第二胸椎下缘和隆突的距离,并对上述数据进行统计分析。结果　依据PALS指南计算所得气管插管深度的错位率（过深或过浅）为74.01%,结合临床评估后,ETT错位率由74.0%下降至55.9%,临床评估对ETT的调整有实际意义。推测新公式：＜2岁患儿,采用1～5月龄：11 cm,6～11月龄：12 cm,12～23月龄：13 cm作为参考插管深度。 ≥2岁患儿：插管深度（cm）＝年龄（岁）×0.7+12。结论　依据PALS指南计算的气管插管深度错位率较高,通过听诊双肺呼吸音、观察胸廓起伏等临床评估后可提高ETT位置的合适率。PALS指南低估了2岁以上儿童ETT的最佳插入深度。新的公式有待验证。     

床边便携式纤维支气管镜引导下经鼻气管插管抢救呼吸衰竭

目的 探讨便携式纤维动气管镜(纤支镜)引导下经鼻气管插管在抢救呼吸衰竭中的应用及意义。方法对58例急慢性呼吸衰竭患者或其他疾病重症患者采用床边便携式纤支镜引导经鼻气管插管并进行机械通气,总结分析其临床资料。结果插管均一次成功,插管过程一般为 30s~5 min,无1例阻断自主呼吸,大喉痉挛、心跳骤停等发生。机械通气30 min后,呼吸衰竭均有明显改善。结论便携式纤支镜具有携带方便、操作简单,引导经鼻气管插管迅速准确、并发症少等优点,值得推广应用。     

持续气道正压通气模式治疗低氧血症78例临床观察

目的 :观察用面罩持续气道正压通气 (mCPAP)的方法能否改善Ⅰ型呼吸衰竭患者的氧合及避免实施气道内气管插管。方法 :急性Ⅰ型呼吸衰竭的患者 ,在普通面罩吸入氧流量 >5L情况下 ,动脉血氧饱和度 (SaO2 )<90 % ,动脉血氧分压 (PaO2 )与吸入氧浓度 (FiO2 )之比 <2 0 0时予面罩持续气道正压通气 ,同时予SaO2 持续及PaO2 间断监测血氧状况。结果 :接受CPAP呼吸器治疗的呼吸衰竭患者 78例 ,其中 73例接受治疗后 1h血氧改善明显 ,有效率为 93% ;4例因全身状况恶化行气管插管 ,插管率为 5 % ;1例患者因出现并发症而停止该方法治疗。结论 :mCPAP是一种简易、安全的改善动脉血氧含量的方法 ,使用该方法可避免对一些急性呼吸衰竭的患者行气管插管术。     

维库溴铵预给法在全身麻醉下气管内插管术中的应用

[目的 ]观察维库溴铵预给法在全身麻醉诱导时的气管内插管时间 .[方法 ]给予静脉麻醉药使病人安静入睡之前 ,先静脉注射 0 0 3mg/kg维库溴铵 ,然后给予静脉麻醉药 ,病人入睡后再静脉注射0 1mg/kg维库溴铵 .[结果 ]预给法可缩短肌肉松弛药的起效时间 ,使全身麻醉诱导插管时间提前 6 0～ 80s.[结论 ]维库溴铵的预给法不仅可缩短肌肉松弛药的起效时间 ,而且可缩短气管内插管时间 ,接近于琥珀胆碱快速诱导气管内插管的起效时间 ,因而在麻醉诱导插管时可替代琥珀胆碱使用 .     

记忆-遗忘规律应用于护士手估气囊测压训练的效果

目的应用艾宾浩斯记忆-遗忘规律对老年病房护士进行气管导管气囊手估测压培训，提高估测法测压的准确率，摸索一种科学的估测法测压培训方法。方法90名各级职称护士手估测压训练，用气囊测压仪进行结果比对，随机测量各压力水平，对培训前后做统计学分析。结果各级职称护士培训后测压准确率提高显著，其中高压水平手估准确率明显高于常压和低压水平，各级职称护士间无显著差异。结论护士经培训后手估气囊测压的准确率较高，此培训方法可靠，值得在临床推广应用。     

经蝶入路垂体腺瘤切除手术的麻醉

我院1990年3月至2002年12月经蝶路治疗垂体腺瘤患者493例,术前应用地塞米松10～20 mg,以咪达唑仑0.1 mg/kg、芬太尼2μg/kg、丙泊酚2 mg/kg、琥珀胆碱2 mg/kg或罗库溴铵0.6 mg/kg快速诱导全麻,术中以异氟烷、丙泊酚静吸复合麻醉维持,术后在丙泊酚镇静下拔管.术中2例出现困难气管插管,4例发生严重高血压,均成功处理,其余麻醉顺利.这提示,因垂体腺瘤患者常并发各种内分泌异常,其麻醉处理有一定特殊性,困难气管插管、术中高血压等处理是关键.     

Human Patient Simulation Is Effective for Teaching Paramedic Students Endotracheal Intubation

Objectives: The primary purpose of this study was to determine whether the endotracheal intubation (ETI) success rate is different among paramedic students trained on a human patient simulator versus on human subjects in the operating room (OR). Methods: Paramedic students (n= 36) with no prior ETI training received identical didactic and mannequin teaching. After randomization, students were trained for ten hours on a patient simulator (SIM) or with 15 intubations on human subjects in the OR. All students then underwent a formalized test of 15 intubations in the OR. The primary outcome was the rate of successful intubation. Secondary outcomes were the success rate at first attempt and the complication rate. The study was powered to detect a 10% difference for the overall success rate (α= 0.05, β= 0.20). Results: The overall intubation success rate was 87.8% in the SIM group and 84.8% in the OR group (difference of 3.0% [95% confidence interval {CI} =?4.2% to 10.1%; p = 0.42]). The success rate on the first attempt was 84.4% in the SIM group and 80.0% in the OR group (difference of 4.4% [95% CI =?3.4% to 12.3%; p = 0.27]). The complication rate was 6.3% in the SIM group and 4.4% in the OR group (difference of 1.9% [95% CI =?2.9% to 6.6%; p = 0.44]). Conclusions: When tested in the OR, paramedic students who were trained in ETI on a simulator are as effective as students who trained on human subjects. The results support using simulators to teach ETI.     

Assessment of a New Method to Distinguish Esophageal from Tracheal Intubation by Measuring the Endotracheal Cuff Pressure in a Porcine Model

Objectives: With the knowledge of differences in anatomic structures between the trachea and the esophagus, the authors conducted an animal study to evaluate the usefulness of endotracheal cuff pressure in distinguishing endotracheal and esophageal intubations. Methods: Six swine were anesthetized and endotracheally intubated with 7.5-mm cuffed endotracheal tubes. The intubations were confirmed by fiber-optic bronchoscopy. Each pilot balloon was connected to a 10-mL syringe and a manometer via a three-way stopcock. The cuff pressures were measured for each 1-mL incremental filling of air (1–10 mL). After removal of the endotracheal tubes, each swine was then intubated with the same endotracheal tubes into its esophagus. The cuff pressures of the esophageal intubation were measured with the same procedure. The cuff pressures and the pressure–volume relationships in both intubations were compared. Results: The cuff pressure increased significantly in the esophageal intubation in comparison with the endotracheal intubation in all the comparisons from 1 mL to 10 mL (p = 0.028 for all Wilcoxon signed-rank tests). The slope of the pressure–volume curve of the cuff pressure was also significantly higher in the esophageal intubation during the inflation of the cuff on average (0.047 vs. 0.032 cm H₂O/mL; p = 0.001), particularly in the first 5 mL of air inflation. Conclusions: The cuff pressure in the esophageal intubation was significantly higher than that in the endotracheal intubation under the same inflated volume from 1 to 10 mL. This may provide the basis for an adjunctive, simple, rapid, and reliable method to verify endotracheal intubation.     

Intrinsic Laryngeal Muscle Regeneration Following Endotracheal Intubation

The larynges of 33 premature and term neonates who were intubated for the management of respiratory difficulties were studied. In addition to the changes commonly associated with endotracheal intubation (epithelial erosion, ulceration, squamous metaplasia, edema, inflammation, and perichondritis), the intrinsic laryngeal muscles were damaged in 26 of the 33 cases and, in 4 cases, oriented striated skeletal muscle regeneration was found. The active synthetic nature of the myotube formations in the latter cases was confirmed by the demonstration of concentrated vimentin intermediate-filament immunoreactivity. In view of the frequency of neonatal intubation, the probability of muscle damage, and the generally infrequent critical sequelae of this procedure, regeneration of the intrinsic muscles may help to explain the excellent functional recovery of the neonatal larynx. This phenomenon also occurs in the postintubated adult larynx and is therefore not limited to the neonatal period. In addition, these findings support the fact that skeletal muscle regeneration occurs in nonmyopathic human skeletal muscles following injury, as has been shown in experimental animal models.     

气管导管误插入食管的判断（附14例病例分析）

目的：找出能快速确诊气管导管误插入食管的客观指标。方法：选择１４例行气管插管全身麻醉的患者，在常规气管插管后，于食管内加插一根同型号气管导管，依次连接呼吸机，观察呼气终末ＣＯ２分压（ＰＥＴＣＯ２）及波形、气道压力及曲线、双侧呼吸音、脉搏、血氧饱和度（ＳｐＯ２）等指标的改变。结果：上胸部听诊是判断导管是否在气管内的简便实用的方法，但有其局限性。导管位于食管内时，ＰＥＴＣＯ２为０ｋＰａ～０１３３ｋＰａ，波形消失成直线；而ＳｐＯ２将于１５６±５ｓ后快速下降。结论：ＰＥＴＣＯ２及波形是最为迅速直观、准确可靠地判断气管导管是否误插的指标；ＳｐＯ２改变虽能提示气管导管误插，但其变化出现较迟