利多卡因雾化吸入用于纤维支气镜引导清醒气管插管患者的效果观察

目的 观察超声雾化吸入2%利多卡因气道表面麻醉用于经鼻纤维支气管镜(FOB)辅助清醒气管插管的临床效果.方法 择期颈椎手术患者42例,随机均分为两组,分别采用超声雾化吸人2%利多卡因行呼吸道表面麻醉(Ⅰ组)和1%丁卡因鼻拭子鼻腔表面麻醉,环甲膜穿刺及喉上神经阻滞的联合局部麻醉(Ⅱ组).记录插管的时间(FNIT),入室后5 min(基础值,T1)、气管导管过鼻腔(T2)、FOB过咽喉(T3)、FOB过声门进气管确认气管隆突位置(T4)、气管导管进入气管(T5)时患者的反应及血流动力学的变化;记录Ⅰ组患者局部麻醉药物的用量及两组患者局部麻醉药的不良反应;术后第1天随访患者对两种方法的评价.结果 与T1时比较,T2～T5时两组患者HR增快;T2～T5时Ⅰ组及T2、T3时Ⅱ组患者MAP均增高;T2～T4时Ⅱ组SPO2明显降低(P<0.05).Ⅰ组患者利多卡因的平均用量为4.86 mg/kg,最大用量为7.64 mg/kg.Ⅰ组患者对所接受的局部麻醉方法评价为((6.71±1.23)分,明显高于Ⅱ组(4.90±1.41)分(P<0.05).结论 超声雾化吸入2%利多卡因可为经鼻FOB清醒插管提供充分的表面麻醉,易于被患者所接受,值得在临床工作中推广.     

Post-intubation laryngeal injury after COVID-19 treatment causing dyspnea: A report of six cases

Severe cases of COVID-19 often require orotracheal intubation (OTI) and mechanical ventilation, and post-intubation laryngeal injury (PI-LI) is one of the important complications of OTI. Some studies have claimed that the frequency of PI-LI may be higher in COVID-19 patients as compared with that in non-COVID-19 patients, because of the larger size of endotracheal tube used, the longer OTI time, use of prone positioning of the patients, etc. Herein, we describe six cases of PI-LI who presented with dyspnea after recovering from COVID-19. Five of the patients were male and the median OTI period was 9 days. All the patients showed abnormal endoscopic findings, including posterior glottic synechiae/stenosis or subglottic/posterior glottic granulomas. Four patients required surgical intervention, including tracheostomy, laryngomicrosurgery, or laterofixation of the vocal cord. Many post-COVID-19 patients experience persistent symptoms (post-COVID-19 syndrome), including dyspnea. Two of our patients with dyspnea had been treated by internists as cases of post-COVID-19 syndrome. Therefore, we wish to underscore the need for every healthcare professional to be aware of the possibility of PI-LI after OTI, especially during the ongoing COVID-19 pandemic. Otolaryngologists should undertake endoscopic assessment of the larynx in patients presenting with dyspnea after recovering from COVID-19.     

经鼻湿化快速充气通气交换技术在住院医师规范化培训纤维支气管镜引导气管插管中的应用

目的 评价经鼻湿化快速充气通气交换技术（THRIVE）在住院医师规范化培训纤维支气管镜（纤支镜）引导气管插管中的应用效果。

方法 选择非麻醉专业学员10名，依据插管期间供氧方式的不同随机分为两组：THRIVE 组（T组）和对照组（C组），每组5名。每名学员需完成经纤支镜引导气管插管随机病例20例，共200例患者，男108例，女92例，年龄18～64岁，BMI 18～24 kg/m²，ASA Ⅰ或Ⅱ级。两组学员独立完成经纤支镜气管插管操作，插管期间T组使用 THRIVE 装置以FiO₂ 100%给氧，70 L/min，C组移开面罩进行插管。记录每例患者插管成功与否。绘制两组学员学习曲线，用累积和（CUSUM）方法建立学习曲线，运用累积和分析法算出掌握相应插管技术所需要的最小例数。记录学习曲线平台期前SpO₂<90%的例数，气道建立过程中是否有鼻出血、口咽腔处损伤、牙齿损伤、心律失常、喉痉挛等明显通气及插管相关不良反应。

结果 与C组比较，T组学员掌握纤支镜引导气管插管操作所需的最少插管例数明显减少（P<0.05），学习曲线平台期前SpO₂<90% 发生例数明显减少（P＜0.05）。两组在围插管期均未观察到明显通气及插管并发症。

结论 住院医师规范化培训行纤支镜引导气管插管的无呼吸氧合期应用THRIVE通气可明显改善学习曲线，降低围插管期患者低氧血症的发生率，且不增加通气相关并发症，适合临床推广应用。