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困难气道的管理
Management of the Difficult Airway


Thomas Heidegger ... 呼吸系统疾病 • 2021.05.13
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• ICU插管期间使用球囊面罩通气可能有益 • 危重成人患者气管插管期间的球囊面罩通气

困难气道的管理是急诊医师、重症监护医师和麻醉师最关切的问题,因为无意识患者的气道丧失可能导致脑损伤甚至死亡。虽然我们已在气道管理方面取得革新(如喉罩通气道和视频喉镜),并在监测、教育和培训方面做出巨大努力,但我们仍不明确在过去十年间,气道管理的安全性是否有所改善。

英国皇家麻醉师学会(Royal College of Anaesthetists)和英国困难气道学会(Difficult Airway Society in the United Kingdom)的第四个国家审计项目(Fourth National Audit Project,NAP4)指出,在手术室内,每22,000例气管插管中就有1例伴发气道管理重度不良事件(如死亡、脑损伤、需要紧急建立外科气道或非计划入住重症监护病房[ICU])1。而病例数可能还有少报,重度事件的真实发生率可能达到这一数字的4倍(每5,500例中有1例)1,2。因此,在气道管理中保持警惕仍有必要。

之后有一项分析估算出,急诊科的气道管理相关不良事件发生率达到麻醉患者气道管理相关不良事件发生率的35倍,而ICU的不良事件发生率达到55倍3,4。最近,美国涉及困难气管插管的最新已结案理赔分析结果也得出了令人担忧的数字5。在1993—1999年和2000—2012年两个时期,虽然围手术期地点(手术室或恢复室)的困难气管插管相关理赔的分布情况相似,但在后一时期,诱导麻醉时的脑损伤或死亡发生率达到前一时期的5.5倍。在因择期手术而接受麻醉的健康患者中,与气道管理相关的并发症仍然是死亡或永久性脑损伤的主要原因6

为了解决约70亿人口(2010年数据)的疾病负担,每年需实施超过3.2亿台手术7,而美国每年入住ICU的超过500万患者中,20%~40%需要机械通气,考虑到以上两点,很明显即使是气道管理方式的微小变化也与结局高度相关(https://www.sccm.org/Communications/Critical-Care-Statistics)8

本综述给出了困难气道的定义、发生率和预测;非预知性和预知性困难气道的管理;手术室、ICU和急诊科困难气道拔管的处理;以及气道管理中的人员因素。





作者信息

Thomas Heidegger, M.D.
From the Department of Anesthesia, Spital Grabs, Grabs, and the Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern — both in Switzerland; and the Private University of the Principality of Liechtenstein, Triesen, Liechtenstein. Address reprint requests to Dr. Heidegger at the Department of Anesthesia, Spital Grabs, Spitalstrasse 44, 9472 Grabs, Switzerland, or at thomas.heidegger@srrws.ch.

 

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