喉罩全麻胸腔镜下纵隔肿瘤切除的临床应用

目的探讨喉罩全麻胸腔镜下纵隔肿瘤切除的临床应用价值。方法将2012年-2015年该科收治的纵隔肿瘤患者40例,随机分为两组,每组20例,喉罩组行喉罩通气静脉麻醉下胸腔镜纵隔肿瘤切除术,插管组行双腔插管麻醉胸腔镜下纵隔肿瘤切除术,对比两者整体效果。结果两组患者均顺利完成胸腔镜下手术,无中转开胸病例,喉罩组术前麻醉时间短,麻醉及手术过程中血压及脉搏波动小,术后复苏躁动少、时间短,术后咽部不适及咽痛发生率低,较插管组差异有统计学意义(P0.05);手术时间,术野暴露满意度,术中出血量,术后拔管时间及住院天数等指标差异无统计学意义(P0.05)。结论喉罩通气静脉麻醉在胸腔镜纵隔肿瘤切除术中实用性好,在术前麻醉时间、对心血管系统影响、术后复苏及术后咽痛等方面优于插管组,可在临床加以推广应用。     

An Evaluation of a Blind Rotational Technique for Selective Mainstem Intubation

OBJECTIVES: Although rare, massive hemoptysis and major bronchial disruptions are associated with high mortality. Selective ventilation of the uninvolved lung can increase the likelihood of survival. Specialized devices used for single lung ventilation are often not readily available and can be difficult to place in the emergency department. The authors evaluated a blind rotational technique for selective mainstem intubation using either a standard endotracheal tube (ET) or a directional-tip endotracheal tube (DTET). METHODS: This was a prospective, randomized trial on 25 human cadavers. The desired side of mainstem intubation was determined by randomization. Each cadaver was used for four ET, four DTET, and four control intubations. In the ET group, the trachea was intubated. The tube was then rotated 90 degrees in the direction of the desired placement and advanced until resistance was met. In the DTET group, the technique was identical, except the trigger was activated to flex the tip during advancement. In the control group, an ET was advanced in neutral alignment until resistance was met. A bronchoscopist blinded to the desired placement determined tube position. Comparison testing was performed using Pearson's chi-square test. RESULTS: When attempting to intubate the left mainstem, use of the ET with the rotational technique was successful 72.3% of the time (95% confidence interval [95% CI] = 57% to 84%). Intubation of the left mainstem using the DTET was successful 68.5% of the time (95% CI = 54% to 81%; p = 0.67). Attempts to selectively intubate the right mainstem using the rotational technique were highly successful in both groups: 94% for the ET (95% CI = 84% to 99%) versus 97.8% for the DTET (95% CI = 89% to 100%). Among controls, the right mainstem was intubated 93% of the time (95% CI = 86% to 97%). CONCLUSIONS: In a cadaveric model, the left mainstem bronchus can be selectively intubated with moderate reliability using this rotational technique. Use of a DTET confers no significant advantage. The ability to generalize these findings to living subjects is unknown.     

密闭式吸痰对急性呼吸窘迫综合征小猪呼吸及循环系统的影响

[目的]探讨密闭式吸痰对急性呼吸窘迫综合征（ARDS）小猪动脉血气、呼吸力学和心率（HR）、血压的影响。[方法]先制作小猪ARDS模型，模型成功后将其随机分为呼气未正压（PEEP）5cmH2O组和10cmH2O组，予机械通气30min后进行密闭式吸痰。监测吸痰前1min及吸痰后1min、3min，5min、10min动脉血专、呼吸力学及HR、血压的变化。[结果]两组在密闭式吸痰后动脉血氧分压（PaO2）和动脉血氧饱和度（SaO2）均下降，直到吸痰后10min仍低于吸痰前基线水平（P〈0．05），而吸痰后舒张压（DBP）与吸痰前比较均无差异（P〉0．05）；在PEEP 5cm H2O组，吸痰后气道峰压（Ppeak）、平台压（Pplat）、平均气道压（Pmean）均升高，持续到吸痰后10min仍显著高于吸痰前基线水平（P〈0．05）；肺静态顺应性（Cs）、平均动脉压（MAP）、收缩压（SBP）均降低，持续到吸痰后10min仍低于吸痰前基线水平（P〈0.05）；在PEEP 10cm H2O组，吸痰后1min及3min Ppeak显著升高（P〈0．05），持续到吸痰后10min仍高于吸痰前基线水平但差异无统计学意义（P〉0．05）；Pplat、Pmean在吸痰后1min显著增高，在吸痰后3min、5min、10min仍高于吸痰前基线水平但无统计学差异（P〉0．05），同时在吸痰后1min及3min Cs显著下降（P〈0．05），持续到吸痰后10min仍低于吸痰前基线水平但差异无统计学意义（P〉0．05）。[结论]不论在PEEP 5cm H2O还是10cm H2O水平，密闭式吸痰可引起脑小猪较严重的低氧血症，使气道压力增高、肺顺应性降低、血压下降。但在PEEP 5cm H2O组，吸痰所引起的缺氧、气道高压及低血压持续时间较长。     

两种气管内滴药湿化气道的效果观察及分析

目的了解应用两种不同的气管内滴药法的气道湿化效果和所需护理人力的情况。方法将62例颌面部复合性外伤行气管切开手术的患者分为试验组（34例）和对照组（28例），试验组采用持续性气管内滴药法，对照组采用间断性气管内滴药法，对比观察两组气道湿化的效果并统计其护理操作消耗的时间。结果试验组患者痰液黏稠的发生率及需要雾化吸入的比例明显低于对照组，P〈0．01；肺部感染的发生率低于对照组，P〈0．05；气管内套管痰痂发生率无差异，P〉0．05。为患者气管内滴药护理操作人平均每天所需的时间，试验组为10min，对照组为144min。结论持续性气管内滴药法的效果优于传统的间断气管内滴药法，且可明显节省气道湿化的护理工作量。     

Evaluation in animals of a system to estimate tracheal pressure from the endotracheal tube cuff

Objective. Flow through an endotracheal tube (ETT) causes a pressure loss across the tube. This loss results in a difference between pressure measured at the airway and pressure measured in the trachea. This difference can lead to errors when calculating pulmonary mechanics and when setting ventilators. We have tested a method of estimating tracheal pressure from the pressure in the ETT cuff.Methods. Pressure transducers were placed in the proximal ETT connector, in the trachea, and in the ETT cuff (through the inflation port). Instantaneous periods of zero flow, detected with a flow meter, were used to calculate the slope and offset of the line relating cuff pressure to tracheal pressure. The system was tested on the bench using a ventilator and lung simulator and in 2 dogs and 5 pigs. Tests were performed at various cuff pressures, trachea diameters, ETT sizes, respiratory rates, tidal volumes, and airway obstructions. Results. In bench tests, our estimate of tracheal pressure was within –4.0±2.6% of the actual tracheal pressure (mean = standard deviation [SD]). In animal tests, our estimation of tracheal pressure was within –0.6±5%. In all bench test measurements and in 40 of 42 animal measurements, the error was less than 1 cm H₂O.Conclusions. The cuff estimation technique gives real-time, continuous, noninvasive tracheal pressure measurements in intubated animals with cuffed ETTs.     

Supraglottic jet ventilation in difficult airway management

Background

Supraglottic jet ventilation (SJV) via the “jet endotracheal tube” (JET) designed by Wei (WEI JET; Wei Medical LLC, Cherry Hill, NJ) provides adequate oxygenation and ventilation during direct laryngoscopy and tracheal intubation in animals. It has facilitated intubation in apneic pigs with a simulated difficult airway.

Objective

To report on the first clinical study to examine the efficacy of using SJV via the WEI JET, in combination with end-tidal CO₂ pressure (PetCO₂) monitoring during SJV, in maintaining oxygenation during direct laryngoscopy, and in facilitating placement of the WEI JET, and comparing it to the standard intubation technique using a conventional endotracheal tube. The relative safety of using SJV via the WEI JET in airway management was also addressed to provide the foundation for a larger-scale clinical study using the WEI JET, to be carried out in the future.

Methods

Patients in the control group were intubated with a conventional endotracheal tube, and patients in the experimental group were intubated with a WEI JET. The effectiveness of SJV through a WEI JET in maintaining proper oxygenation, and the use of PetCO₂ monitoring to facilitate intubation, were studied and compared to the control group. Complications such as sore throat, laryngospasm, and barotrauma were recorded during the study and 24 h after extubation.

Results

In the WEI JET group, pulse oxygen saturation (SpO₂) was 100% in all patients during intubation. No serious complications were detected, and the incidence of minor complications was comparable to the control group. Under PetCO₂ guidance, 100% of patients in the WEI JET group were intubated on the first attempt, compared to 30% of Grade III view patients in the control group, who required two attempts.

Conclusion

Using the WEI JET with SJV provides adequate oxygenation during tracheal intubation in apneic patients for a prolonged period of time, with no difference in complications compared to the standard intubation technique. PetCO₂ monitoring facilitated intubation in patients with a Grade III glottis view.     

早期气管插管在严重胸外伤患者中的应用

目的探讨早期气管插管对严重胸外伤患者的意义。方法58例严重胸外伤患者随机分成两组,其中30例早期气管插管,28例按常规行气管插管作为对照组,比较两组患者气管插管前、后氧分压、二氧化碳分压、氧饱和度和心率的变化,机械通气时间,平均ICU住院时间,肺部感染发生率,多器官功能衰竭发生率及其预后。结果两组患者气管插管后各项指标均明显改善,与对照组比较,早期气管插管患者机械通气和平均ICU住院时间缩短(P<0.01),肺部感染和多器官功能衰竭发生率降低(P<0.05),但预后无显著差异(P>0.05)。结论机械通气是严重胸外伤合并呼吸衰竭的有效治疗,早期气管插管在严重胸外伤的治疗中起着有益的作用。     

The bougie: an inexpensive lifesaving airway device

Background

“Bougies,” otherwise known as endotracheal tube introducers, remain preferred devices for the emergency physician when faced with a difficult airway. Bougies have high success rates for the prehospital provider and the first-time emergency department (ED) user, with few reported complications. Inexpensive, disposable models provide simple yet valuable tools in the challenging patient with an anterior airway or limited neck mobility.

Objectives

Use of the bougie is similar to standard endotracheal intubation. Correct placement is determined by feeling “clicks” as the device passes over the tracheal rings and a “hold up” when entering the distal airways.

Case Reports

Three recent cases from our ED are briefly reported, in which the bougie was invaluable in the management of the difficult airway. All patients had limited visualization of the glottis but were intubated successfully.

Conclusion

This article discusses three example cases, and then reviews the history of the bougie, placement technique, and current evidence for use.     

Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy

Background

Videolaryngoscopy has become a popular method of intubation in the Emergency Department (ED), however, little research has compared this technique with direct laryngoscopy (DL).

Objective

To compare the success rates of GlideScope (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) and DL in emergent airways with known difficult airway predictors (DAPs).

Methods

We evaluated 772 consecutive ED intubations over a 23-month period. After each intubation, the physician completed a data collection form that included: demographics, DAPs, Cormack-Lehane view, optical clarity, lens contamination, and complications. DAPs included: cervical immobility, obesity, small mandible, large tongue, short neck, blood or vomit in the airway, tracheal edema, secretions, and facial or neck trauma. Primary outcome was first-attempt success rates. Multivariate logistic regression was performed to evaluate the odds of failure for DL compared to GVL.

Results

First-attempt success rate with DL was 68%, GVL 78% (Fisher’s exact test, p = 0.001). Adjusted odds of success of GVL compared to DL on first attempt equals 2.20 (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.51–3.19). After statistically controlling for DAPs, GVL was more likely to succeed on first attempt than DL (OR 3.07, 95% CI 2.19–4.30). Logistic regression of DAPs showed that the presence of blood, small mandible, obesity, and a large tongue were statistically significant risk factors for decreasing the odds of success with DL and increasing the odds of success of GVL.

Conclusion

For difficult airways with the presence of blood or small mandible, or a large tongue or obesity, GVL had a higher success rate at first attempt than DL.     

小剂量氨茶碱静脉滴注治疗气管插管下哮喘急性发作可行性分析

目的探讨小剂量氨茶碱静脉滴注治疗气管插管下哮喘急性发作的有效性。方法选择31例气管插管状态下哮喘急性发作患者使用0.25 mg氨茶碱加入0.9%氯化钠注射液250 ml缓慢静脉滴注。分析本方法治疗的有效性和安全性。结果治疗后PaO2高于治疗前(P<0.05),PaCO2低于治疗前(P<0.05),PH和BE值均高于治疗前(P<0.05),血氧饱和度高于治疗前(P<0.05),呼吸频率和心率慢于治疗前(P<0.05),平均动脉压低于治疗前(P<0.05),共出现恶心呕吐者3例,心率增快者2例,躁动1例。结论小剂量氨茶碱治疗气管插管状态下哮喘急性发作患者,其临床效果可靠,且极少发生严重不良反应,值得临床推广。