困难气道的识别和处理刘洋

困难气道的识别和处理刘洋临床麻醉是一门美学Lettheanesthesiologistsbebeautifullikethesummerflowersandthepatientslikeautumnleaves.——DerivedfromRabindranathTagore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DefinitionoftheDifficultAirway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(DifficultEndotrachealIntubation)和(或)面罩通气的时候遇到困难(DifficultMaskVentilation)。困难气道的三种临床情形喉镜暴露困难

(DifficultLaryngoscopy)：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

(DifficultEndotrachealIntubation)：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

(DifficultMaskVentilation)：患者吸入100%O2时，其Spo2<90%;困难气道的分类困难气道发生类型插管困难：仍然可控通气困难：缺氧窒息通气情况急症气道：通气、插管均困难(dilemma)非急症气道：仍然可控术前估计确定的困难气道：充分准备，多属非急症气道未能预料的困难气道：没准备，患多属急症气道困难气道分类的意义困难气道处理指南建立的基础；决定了困难气道的风险和预后；术前认真探视和充分的准备对于气道控制具有重要意义。产生困难气道的主要原因气道生理解剖变异：短颈、下颌退缩、错位咬合等；局部或全身疾患：肌肉骨骼病，如：颈椎强直，颞下颌关节强直；内分泌疾病：肢端肥大症、甲状腺肿大等；肿瘤等；颌面部创伤：瘢痕粘连，颌骨骨折等；*了解困难气道原因的意义：如何识别困难气道ASA

困难气道处理规则DifficultAirwayAlgorithmfromASA困难气道一般可在清醒保留自主呼吸的状态下尝试各种插管技术；已全麻、无自主呼吸的病人，应在保证适当通气的情况下选用各种插管技术；极端困难的病人应采用应急措施：经气管喷射通气、喉罩通气等；ContentsofthePortableStorageUnitforDifficultAirwayManagement1Rigidlaryngoscopebladesofalternatedesignandsizefromthoseroutinelyused.2Endotrachealtubesofassortedsize.3Endotrachealtubeguides:semirigidstylets,lightwand,andforceps.4Fiberopticintubationequipment.5Retrogradeintubationequipment.6Atleastonedevicesuitableforemergencynonsurgicalairwayventilation:atranstrachealjetventilator,ahollowjetventilationstylet,thelaryngealmask,andtheesophageal-trachealcombitube.7Equipmentsuitableforemergencysurgicalairwayaccess:circothyrotomy.8AnexhaledCO2detector.各型喉罩(LMA)第一代第二代第三代喉罩(LaryngealMaskAirway)是由英国医生Brain于1981年根据解剖成人咽喉结构所研制的一种人工气道。1988年正式投入生产，并应用于临床。1991年获FDA批准用于临床，2003年使用患者数>1亿。各种型号镜片和镜柄FiberopticIntubationEquipmentTechniquesforDifficultAirwayManagement1.Techniquesfordifficultintubationalternativelaryngoscopebladesawakeintubationblindintubation(oralornasal)fiberopticintubationintubatingstylet/tubechangerlightwandretrogradeintubationsurgicalairwayaccess2.Techniquesfordifficultventilationesophageal-trachealcombitubeintratrachealjetstyletlarygealmaskoralandnasopharnygealairwaysrigidventilatingbronchoscopesurgicalairwayaccesstranstrachealjetventilationtwopersonmaskventilationOralPharyngealAirways不同颜色代表不同型号CuffedTypesConventional

TypesBlindIntubationthroughILMA插管喉罩经ILMA进行气管导管盲插LMAAirwaysFromLopez-gilMetalBJA1999;82:132-4GastricLMAConventionalLMALightWand灯杖用于双腔气管插管灯杖用于单腔气管插管FiberopticTrachealIntubationAfromUezonoSetal;Anesthesiology1998;88:1677BfromGreenberg&Kay;BJA82:395DevelopprimaryandalternativestrategiesAwakeIntubationAirwayApproachedbyNon-SurgicalIntubationAirwaySecuredbySurgicalAccessSucceedFailCancelCaseConsiderFeasibilityofOtherOptionsSurgicalAirwaySurgeryundermaskanesthesia,surgeryunderlocalanesthesiainfiltrationorregionalnerveblockade,orintubationattemptsafterinductionofgeneralanesthesiaDevelopprimaryandalternativestrategiesIntubationAttemptsAfterInductionofGeneralAnesthesiaInitialIntubationattemptsSuccessfulInitialIntubationAttemptsUnsuccessful1.Returningtospontaneousventilation.2.Awakeningthepatient.3.Callingforhelp.Non-EmergencyPathwayi.e.,MaskVentilationAdequateEmergencyPathwayi.e.,MaskVentilationinadequateAlternativeApproachestoIntubationCallforHelpSucceedFailAftermultipleAttemptsSurgicalAirwayAwakenPatientsSurgeryUnderMaskAnesthesiaOneMoreIntubationAttemptEmergencyNon-SurgicalAirwayVentilationSucceedFailEmergencySurgicalAirwayFailSucceedDefinitiveAirwayStrategyforExtubationoftheDifficultAirwayAwakeextubationversusextubationbeforethereturnofconsciousness.Thedepressanteffectofgeneralclinicalfactorsonventilationafterextubation.Theformulationofanairwaymanagementplanthatcanbeimplementedifthepatientisnotabletomaintainadequateventilationafterextubation.Aconsiderationoftheshort-termuseofadevicethatcanserveasaguideforexpeditedreintubation.Follow-UpCareAdescriptionoftheairwaydifficultiesthatwereencountered.Adescriptionofthevariousairwaymanagementtechniquesthatwereemployed.Informationthepatientoftheairwaydifficulty.Theanesthesiologist