困难气道的识别和处理刘洋

,困难气道的识别和处理Recognition and Management of Difficult Airway,川北医学院麻醉系教研室,刘 洋,临床麻醉是一门美学,Let the anesthesiologists be beautiful like the summer flowers and the patients like autumn leaves. Derived from Rabindranath Tagore,从容之美,安静之美,困难气道 Versus 从容安静之美,麻醉医师：对困难气道的认识不足，处理方法错误，就会陷入困窘，承担巨大的风险患者：气道损伤，心肌损伤，脑损伤以致死亡,困难气道的危害性,Okazaki 报道：在6742个普外科患者中，有4.9 %发生了意外的困难气管插管；Langeron的研究发现：在1500名手术患者中，5%出现中到重度的面罩通气困难；麻醉相关死亡病例的研究显示：70%的麻醉死亡病例是呼吸道问题所致，主要原因是呼吸道梗阻、困难插管和插管误入食管。,什么是困难气道Definition of the Difficult Airway,困难气道： 通常是指这样一种临床情况，即经过正规训练的麻醉医师在气管插管 (Difficult Endotracheal Intubation ) 和 (或) 面罩通气的时候遇到困难 (Difficult Mask Ventilation)。,困难气道的三种临床情形,喉镜暴露困难 (Difficult Laryngoscopy) ：在常规喉镜暴露 下无法看到声门的任何一部分；气管插管困难 (Difficult Endotracheal Intubation ) ：一个经过正规训练的麻醉医师使用常规喉镜正确地进行气管插管时，插管时间超过10分钟，或三次尝试不能成功。面罩通气困难 (Difficult Mask Ventilation)：患者吸入 100% O2时，其Spo2 1亿。,各种型号镜片和镜柄,Fiberoptic Intubation Equipment,Techniques for Difficult Airway Management,1.Techniques for difficult intubationalternative laryngoscope bladesawake intubation blind intubation (oral or nasal)fiberoptic intubationintubating stylet / tube changerlight wandretrograde intubationsurgical airway access2.Techniques for difficult ventilationesophageal-tracheal combitubeintratracheal jet styletlarygeal maskoral and nasopharnygeal airwaysrigid ventilating bronchoscopesurgical airway accesstranstracheal jet ventilationtwo person mask ventilation,Oral Pharyngeal Airways,不同颜色代表不同型号,Cuffed Types,Conventional Types,Blind Intubation through ILMA,插管喉罩,经ILMA进行气管导管盲插,LMA Airways,From Lopez-gil M et al BJA 1999; 82:132-4,Gastric LMA,Conventional LMA,Light Wand,灯杖用于双腔气管插管,灯杖用于单腔气管插管,Fiberoptic Tracheal Intubation,A from Uezono S et al; Anesthesiology 1998; 88:1677B from Greenberg BJA 82:395,Develop primary and alternative strategies,Awake Intubation,Airway Approached by Non-Surgical Intubation,Airway Secured by Surgical Access,Succeed,Fail,Cancel Case,Consider Feasibility of Other Options,Surgical Airway,Surgery under mask anesthesia, surgery under local anesthesia infiltration or regional nerve blockade, or intubation attempts after induction of general anesthesia,Develop primary and alternative strategies,Intubation Attempts After Induction of General Anesthesia,Initial Intubation attempts Successful,Initial Intubation Attempts Unsuccessful,1.Returning to spontaneous ventilation. 2.Awakening the patient. 3.Calling for help.,Non-Emergency Pathway i.e., Mask Ventilation Adequate,Emergency Pathway i.e., Mask Ventilation inadequate,Alternative Approaches to Intubation,Call for Help,Succeed,Fail After multiple Attempts,Surgical Airway,Awaken Patients,Surgery Under Mask Anesthesia,One More Intubation Attempt,Emergency Non-Surgical Airway Ventilation,Succeed,Fail,Emergency Surgical Airway,Fail,Succeed,Definitive Airway,Strategy for Extubation of the Difficult Airway,Awake extubation versus extubation before the return of consciousness.The depressant effect of general clinical factors on ventilation after extubation.The formulation of an airway management plan that can be implemented if the patient is not able to maintain adequate ventilation after extubation. A consideration of the short-term use of a device that can serve as a guide for expedited reintubation.,Follow-Up Care,A description of the airway difficulties that were encountered.A description of the various airway management techniques that were employed.Information the patient of the airway difficulty.The anesthesiologist should evaluate and follow the patient for potential co