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唇腭裂小儿困难喉镜显露和困难气管插管的临床观察

时间:2010-08-24 11:29:22  来源:  作者:

The Clinical Observation of Difficult Laryngoscopy and Intubation in Children with Cleft Lip and Palate<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

佟世义    薛富善
邓晓明    张雁鸣
廖 旭    刘建华
唐耿志
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
Shiyi Tong,  Fushan Xue, Xiaoming Deng, Yanming Zhang , Xu Liao, Jianhua Liu, Gengzhi Tang
Department of Anesthesiology
Plastic Surgery HospitalChinese Academy of Medical Sciences and Peking Union Medical collegeBeijing 100041.

ABSTRACT

Objective: To evaluate the incidence of difficult laryngoscopy in children with cleft lip and palate and to explore the relationships of it with children's age and difficult intubation.
Methods: 985 paediatric patients, aged 0
3years, undergoing repair of cleft lip and palate were divided into three groups according to the age: 06m, 612m and 13y. Laryngoscopic views were estimated by classification of Cormack and Lehane, GradeⅠ~Ⅱ as easy laryngoscopy and grade Ⅲ~Ⅳ as difficult laryngoscopy. The easy, uneasy, or difficult intubation manipulations were evaluated by the number of attempt.
Results: The total incidence of difficult laryngoscopy was 4.776% in children with cleft lip and palate. There was a significant association between age and the incidence of difficult laryngoscopy
P<0.05. The incidence of difficult laryngoscopy was 7.06%, 2.99% and 3.13% in the children of 06m, 612m and 13y, respectively. The incidence of uneasy and difficult intubation were 1.02% and 0.91%, respectively. The total incidence of intubation failure was 0.102%. Children with the difficult laryngoscopy had higher possibility of difficult intubation.  The incidence of intubation failure was 2.13% in children with the difficult laryngoscopy. 
Conclusions: Children with cleft lip and palate have a hight incident of difficult laryngoscopy. There was a significant association between children's age and the incidence of difficult laryngoscopy.  The difficult intubation occurred mainly in the children with laryngoscopic views of grade
Ⅲ~Ⅳ
Key words: Laryngoscopy; Cleft Lip and Palate; Children; Difficult Intubation 
Corresonding author: Fushan Xue, MD; E-mail address:
Xuebai@fescomail.net
  *本研究为中国医学科学院整形外科医院基金资助项目,编号:200307
  本临床研究的目的是观察唇腭裂小儿喉镜显露困难的发生率,并探讨其与小儿年龄和气管插管操作难易度的关系。

资料与方法

一般资料
  选择中国医学科学院整形外科医院1998年~2002年间985ASA Ⅰ~Ⅱ级拟在全身麻醉下施唇腭裂修复术的婴幼儿,年龄在22天~3岁,体重3.518kg,男678例,女307例。其中唇裂531例;腭裂426例;唇裂继发畸形15例。根据年龄将小儿分为06m612m13y三个年龄组
麻醉方法  
  手术前0.5h肌内注射阿托品0.010.01mg•kg-1或东莨菪碱0.01mg•kg-1。患儿进入手术室后以2.5%氟烷(或3%安氟烷或2.5%异氟烷)和60%氧化亚氮进行吸入麻醉诱导,患儿意识消失后建立静脉通路,静脉注射丙泊酚1.5~2mgkg-1和琥珀胆碱1~1.5mgkg-1或维库溴铵0.1~0.12mgkg-1进行麻醉诱导,待肌肉松弛满意后进行直接喉镜显露和气管插管操作。

观察项目和气管插管方法  
  由麻醉科主治医师以上的操作者按常规方法进行直接喉镜显露和气管插管操作,选用小号Macintosh喉镜片,将喉镜片的前端置于会厌谷向上提起,以显露喉部,采用Cormack和Lehane提出的分类法[1]进行喉部结构显露的分级。如果声门显露不佳,操作者在用左手进行直接喉镜操作的同时,用右手在颈前部环状软骨至舌骨的区域,向后和向头侧方向推压喉部,以改善喉部结构的显露情况,然后试插入特制的Ring-Adair-Elwyn(RAE)气管导管,根据插入气管导管操作的次数和是否成功对气管插管操作的难易度进行分级。

Cormack和Lehane喉部结构显露的分级标准
   Ⅰ级:声门完全显露,可见前后联合;Ⅱ级:声门部分显露,仅见声门后联合;Ⅲ级: 仅见会厌尖端或会厌,但不能显露声门;Ⅳ级:声门及会厌均不能显露。喉镜显露困难是指在正确直接喉镜操作下不可能看见声带的任何部分,即Ⅲ级和Ⅳ级喉镜显露视野。
气管插管操作难易度的分级  
  气管插管操作容易--1次试操作成功;气管插管操作较困难--2次试操作成功; 气管插管操作困难--3~4次试操作成功; 气管插管操作失败--试操作4次以上不成功。
  数据资料以X2检验进行分析,P<0.05为有显著性意义。
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                                    结 果
  在本组小儿中,喉镜显露容易(Ⅰ~Ⅱ级)的发生率为95.23%(938); 喉镜显露困难(Ⅲ~Ⅳ级)的发生率为
4.77%(47例)(图1)。喉镜显露困难有30例(63.83%)是发生在0~6m组; 7例(14.89%)是发生在6~12m组; 10例(21.28%)是发生在1~3y组(表1)。小儿年龄和喉镜显露困难之间具有明显的关系(P<0.05),在0~6m组、6~12m组和1~3y组,喉镜显露困难的发生率分别为7.06%、2.99%和3.13%(图2)。

  表2为气管插管操作难易度与喉镜显露视野之间的关系。气管插管操作容易者有965例(97.97%),其中935例为Ⅰ~Ⅱ级喉镜显露视野(96.89%),30例为Ⅲ级喉镜显露视野(3.11%)。气管插管较困难者有10例(1.02%),其中3例为Ⅰ~Ⅱ级喉镜显露视野(30%),7例为Ⅲ级喉镜显露视野(70%)。气管插管操作困难者有9例(0.91%),其中7例为Ⅲ级喉镜显露视野(77.78%),2例为Ⅳ级喉镜显露视野(22.22%)。气管插管失败者有1例(0.102%),为 Ⅳ级喉镜显露视野。
  在气管插管操作过程中,全部小儿未发生气管导管误入食管的现象,仅有1例发生血氧饱和度降至90%以下,最低达85%,经人工给氧后回升。所有小儿均未出现呼吸道管理问题及手术后上呼吸道梗阻。

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参 考 文 献
1. Cormack RSand Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984 39: 1105-1111.
2. Gunawardana RH. Difficult laryngoscopy in cleft lip and palate surgery. Br. J. Anaesth. 1996
76: 757-759.
3. Westhorpe RN. The position of the larynx in children and its relationship to the ease of intubation. Anaesthesia and Intensive Care 1987
15:384-388.
4.  Garcia-Guiral M
Garcia-Amigueti FOrtells-Polo MAetal. Relationship between laryngoscopy degree and intubation difficulty. Rev Esp Anestesiol Reanim 199744: 93-97
5. 
薛富善. 困难气管插管技术,科学技术文献出版社,2002年,355-398.
6.  Benumof JL. The ASA difficult airway algorithm
New Thoughts/consideration. IARS 1997 Review Course LectureSupplement to Anesthesia and Analgesia. Present at the International Anesthesia Research SocietySan DiegoCaliforniaMarch 9-1219971-8.

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