困難氣道的識別和處理劉洋臨床麻醉是一門美學Lettheanesthesiologistsbebeautifullikethesummerflowersandthepatientslikeautumnleaves.——DerivedfromRabindranathTagore從容之美安靜之美困難氣道

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從容安靜之美麻醉醫(yī)師：對困難氣道的認識不足，處理方法錯誤，就會陷入困窘，承擔巨大的風險……患者：氣道損傷，心肌損傷，腦損傷以致死亡……困難氣道的危害性O(shè)kazaki

報道：在6742個普外科患者中，有4.9%發(fā)生了意外的困難氣管插管；Langeron的研究發(fā)現(xiàn)：在1500名手術(shù)患者中，5%出現(xiàn)中到重度的面罩通氣困難；麻醉相關(guān)死亡病例的研究顯示：70%的麻醉死亡病例是呼吸道問題所致，主要原因是呼吸道梗阻、困難插管和插管誤入食管。什么是困難氣道DefinitionoftheDifficultAirway困難氣道：

通常是指這樣一種臨床情況，即經(jīng)過正規(guī)訓練的麻醉醫(yī)師在氣管插管(DifficultEndotrachealIntubation)和(或)面罩通氣的時候遇到困難(DifficultMaskVentilation)。困難氣道的三種臨床情形喉鏡暴露困難

(DifficultLaryngoscopy)：在常規(guī)喉鏡暴露下無法看到聲門的任何一部分；氣管插管困難

(DifficultEndotrachealIntubation)：一個經(jīng)過正規(guī)訓練的麻醉醫(yī)師使用常規(guī)喉鏡正確地進行氣管插管時，插管時間超過10分鐘，或三次嘗試不能成功。面罩通氣困難

(DifficultMaskVentilation)：患者吸入100%O2時，其Spo2<90%;困難氣道的分類困難氣道發(fā)生類型插管困難：仍然可控通氣困難：缺氧窒息通氣情況急癥氣道：通氣、插管均困難(dilemma)非急癥氣道：仍然可控術(shù)前估計確定的困難氣道：充分準備，多屬非急癥氣道未能預(yù)料的困難氣道：沒準備，患多屬急癥氣道困難氣道分類的意義困難氣道處理指南建立的基礎(chǔ)；決定了困難氣道的風險和預(yù)后；術(shù)前認真探視和充分的準備對于氣道控制具有重要意義。產(chǎn)生困難氣道的主要原因氣道生理解剖變異：短頸、下頜退縮、錯位咬合等；局部或全身疾患：肌肉骨骼病，如：頸椎強直，顳下頜關(guān)節(jié)強直；內(nèi)分泌疾病：肢端肥大癥、甲狀腺腫大等；腫瘤等；頜面部創(chuàng)傷：瘢痕粘連，頜骨骨折等；*了解困難氣道原因的意義：如何識別困難氣道ASA

困難氣道處理規(guī)則DifficultAirwayAlgorithmfromASA困難氣道一般可在清醒保留自主呼吸的狀態(tài)下嘗試各種插管技術(shù)；已全麻、無自主呼吸的病人，應(yīng)在保證適當通氣的情況下選用各種插管技術(shù)；極端困難的病人應(yīng)采用應(yīng)急措施：經(jīng)氣管噴射通氣、喉罩通氣等；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)是由英國醫(yī)生Brain于1981年根據(jù)解剖成人咽喉結(jié)構(gòu)所研制的一種人工氣道。1988年正式投入生產(chǎn)，并應(yīng)用于臨床。1991年獲FDA批準用于臨床，2003年使用患者數(shù)>1億。各種型號鏡片和鏡柄FiberopticIntubationEquipmentTechniquesforDifficultAirwayManagement1.Techniquesfordifficultintubationalternativelaryngoscopebladesawakeintubationblindintubation(oralornasal)fiberopticintubationintubatingstylet/tubechangerlightwandretrogradeintubationsurgicalairwayaccess2.Techniquesfordifficultventilationesophageal-trachealcombitubeintratrachealjetstyletlarygealmaskoralandnasopharnygealairwaysrigidventilatingbronchoscopesurgicalairwayaccesstranstrachealjetventilationtwopersonmaskventilationOralPharyngealAirways不同顏色代表不同型號CuffedTypesConventional

TypesBlindIntubationthroughILMA插管喉罩經(jīng)ILMA進行氣管導管盲插LMAAirwaysFromLopez-gilMetalBJA1999;82:132-4GastricLMAConventionalLMALightWand燈杖用于雙腔氣管插管燈杖用于單腔氣管插管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