A Comparative Study of Hemodynamic Responses to Orotracheal Intubation with Fiberbronchoscope and Laryngoscope<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

孙海燕
薛富善 
李  平  
杨  冬 
李成文   
中国医学科学院中国协和医科大学整形外科医院麻醉科，北京100041

Haiyan Sun, Fushan Xue, Ping Li, Dong Yang and Chengwen Li
Department of Anesthesiology，Plastic Surgery Hospital，Chinese Academy of Medical Sciences and Peking Union Medical college，Beijing 100041

                                                             ABSTRACT

　Objective: This study was to observe and evaluate the hemodynamic responses to orotracheal intubation with fiberbronchoscope (FOB)or laryngoscope (LS) under general anesthesia. 
　Methods:  52 ASA gradⅠ～Ⅱ adult patients undergoing elective plastic surgery and requiring orotracheal intubation were randomly allocated to either LS group or FOB group. After standard intravenous anesthetic induction, intubation through LS or FOB was performed respectively. Noninvasive SBP、DBP、HR and SpO₂ were recorded before and after anesthetic induction, at intubation and 5 minutes after intubation at 1minute interval.
　Results:  SBP、DBP and HR increased from the post-induction values after intubation in both groups, but the maximums of SBP and DBP didn't exceed the pre-induction values while the maximum of HR was higher than the pre-induction value. No significant differences in SBP and DBP at each time point between the two groups were observed. The maximums and the maximal change rates of SBP and DBP didn't differ between the two groups either. The HR values obtained at intubation and 1min after intubation in FOB group were significantly larger than those in the LS group, but their maximums and the maximal change rates didn't differ between the two groups. There were no significant differences in time obtained maximaum values between the two groups.
　Conclusion:  General anesthesia of clinic standard depth can inhibit completely the increase of blood pressure but cannot inhibit the increase of heart rate caused by orotracheal intubation through FOB. Compared with LS, FOB has no special advantages in preventing the hemodynamic responses to intubation.
　Key words:  Fiberbronchoscope; General anesthesia; Intubation; Hemodynamic responses
　Corresponding author: Fushan Xue: Xuebai@fescomail.net

　　光导纤维支气管镜(fiberbronchoscope，FOB)于1967年始应用于临床，到目前为止已发展成为检查呼吸道病变、处理困难气道和救治危重症患者的重要工具^[1]。采用FOB引导气管插管可避免直接喉镜对咽喉部的机械刺激，从而有可能减轻气管插管对心血管的不良刺激。但是，关于FOB引导气管插管心血管应激反应的研究结果目前却存在有相当大的争议^[2-6]。本研究对在临床常用的麻醉深度下应用FOB引导气管插管和直接喉镜气管插管的血流动力学变化进行了观察和比较，现将研究结果报道如下。

                      资料和方法
　　本研究包括52例ASAⅠ～Ⅱ级拟在经口气管插管全身麻醉下实施择期整形外科手术的患者，其中男17例和女35例，患者的年龄为(18～59)岁，体重为(45～90)kg，身高为(145～180)cm。患有严重心血管疾病、长期服用影响血压和心率的药物、重要脏器功能不全、预测为困难气管插管、年龄小于18岁或大于70岁的患者被排除在外。

　　手术前30min肌内注射东莨菪碱0.01mg•kg^-1 (最大用量0.3mg)和咪达唑仑0.1mg•kg^-1(最大用量5mg)。患者进入手术室后，建立静脉输液通道。应用多功能惠普监护仪连续监测SBP、DBP、HR、SpO₂和ECG，取稳定5min后的数值作为麻醉诱导前的基础值。

　　气管插管操作前5min静脉滴注芬太尼2μg•kg^-1; 操作前2min静脉注射维库溴铵0.1mg•kg^-1和丙泊酚2mg•kg^-1。患者自主呼吸消失后，用面罩进行纯氧通气。静脉注射维库溴铵2min后开始采用LS气管插管或FOB引导气管插管操作。所有的气管插管操作均由具有丰富LS或FOB使用经验的麻醉医师来实施。
　　在LS组，采用直接喉镜按照常规方法进行经口气管插管操作。在FOB组，操作者站在患者的左侧，助手站在患者头部，由助手协助开口和托下颌。将FOB镜干表面充分涂抹润滑剂，并预先套上内径为7.5mm的气管导管。操作者在直视下将FOB插入口咽部后，调整镜干前端的角度寻找到会厌和声门。声门显露后，将镜干轻轻地插入声门，持续推进至气管中1/3，可见到气管环和隆突。然后，将气管导管轻柔地送入气管内并缓慢拔出镜干。
　　气管插管成功后，接麻醉呼吸机进行间歇正压通气。潮气量10ml•kg^-1，呼吸频率12次/min，新鲜气流量2.5L/min。安氟烷吸入浓度1%，O₂/NO₂为2/3。乳酸钠林格液的输注速率为15ml.kg^-1•h^-1。

　　记录麻醉诱导前，麻醉诱导后，插入气管导管时，气管插管后1 min、2 min、3 min、4 min和5 min内的SBP、DBP、HR和SpO₂。记录气管插管(面罩通气结束至气管插管成功后进行间歇正压通气)的时间，分析血流动力学变化时将气管插管操作时间超过60s的患者排除。

    所有数据采用均数值±标准差表示，组内采用配对t检验，组间采用单因素方差分析，组间SBP、DBP和HR最大变化率[(最大值-基础值)/基础值]的比较采用Kruskal-Wallis单因素方差分析，以P＜0.05为有显著性差异。

                
                        结　果
　　FOB组的27例患者第1次气管插管操作均获得成功，插入气管导管的平均时间为(39.07±15.16)s。2例因在寻找声门或推送气管导管时遇到困难而使操作时间超过60s。LS组的25例患者第1次气管插管操作均获得成功，插入气管导管的平均时间为(27.84±10.66)s。
　　排除不符合要求的病例后，本研究共对两组50例患者的一般情况和血流动力学数据进行了分析(表1-3和图1-3)。两组患者的一般情况无明显差异。麻醉诱导后，两组的SBP和DBP均明显下降而HR无明显改变。SBP和DBP在插入气管导管时和气管插管后1min均较麻醉诱导后明显升高，但是未超过麻醉诱导前数值，随后均逐渐降低至麻醉诱导后水平。SBP和DBP的最大值与麻醉诱导前相比较无明显差异。HR在插入气管导管时和气管插管后1min较麻醉诱导后明显升高，并超过麻醉诱导前的数值，随后逐渐降低至麻醉诱导前水平。HR的最大值亦明显高于麻醉诱导前水平。
　　两组在各对应时间点的SBP和DBP无明显差异，最大值和最大升高率亦无明显差异。FOB组在插入气管导管时和气管插管后1min的HR明显高于LS组，但是两组的HR最大值和最大升高率无明显差异。两组出现SBP、DBP和HR最大值的时间无明显差异。在操作过程中，无1例患者出现严重心动过缓(HR≤45bpm)或严重低血压(SBP≤60mmHg)。整个3操作过程中各时间点的SpO2均保持在100%。

    总之，本研究的结果显示，在全身麻醉下采用FOB引导气管插管可产生与直接喉镜气管插管相类似的心血管反应。在临床麻醉中，采用FOB来预防气管插管的心血管不良反应并无明显优越性。对高血压、心肌缺血或脑血管病等高危患者采用FOB引导气管插管时，应注意采取适当的措施来控制这种心血管不良反应，尤其是心率增快反应。
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