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 Hospital，Chinese Academy of Medical Sciences and Peking Union Medical college，Beijing 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: 0～6m, 6～12m and 1～3y. 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 0～6m, 6～12m and 1～3y, 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985例ASA 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3.5～18kg，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0～6m、6～12m和1～3y三个年龄组。
麻醉方法  
　　手术前0.5h肌内注射阿托品0.01～0.01mg•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1.5～2mg•kg^-1和琥珀胆碱1～1.5mg•kg^-1或维库溴铵0.1～0.12mg•kg^-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。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

参 考 文 献
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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 F，Ortells-Polo MA，etal. Relationship between laryngoscopy degree and intubation difficulty. Rev Esp Anestesiol Reanim 1997；44: 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 Lecture，Supplement to Anesthesia and Analgesia. Present at the International Anesthesia Research Society，San Diego，California，March 9-12，1997，1-8.