處置只能看到會厭時困難氣管插管之較佳策略：假人隨機交叉試驗之研究

Difficult Airway Management – Focus on a Randomized Cross-over Mannequin Study to Improve Difficult Intubation Strategy

洪子堯(Tzu-Yao Hung)

指導教授 ： 楊騰芳

國立交通大學/生物科技學院/生物科技學系暨研究所/博士(2020年)

摘要

背景：在1984年由Cormack-Lehane (簡稱C-L)兩位麻醉科醫師定義之插管難度等級III(只能看見會厭)被認為是極具挑戰的困難插管，插管的成功率明顯的相較等級I或等級II來得低。本研究以C-L III困難插管為對象進行研究，分為兩個階段：
第一階段研究目的為確認最佳之插管策略，研究範圍涵蓋插管者握氣管內管管身的位置(握在頂端或是握在中段)、氣管內管彎折的形狀(香蕉形狀arcuate或是曲棍球桿形狀straight-to-cuff)、彎折角度(大彎折角度50度或是小彎折角度35度)以及氣管內管使用插管通條挑起會厭是否可以增加插管成功率進行一整體之探討。第二階段的研究目的與現行插管策略的主流比較，即比較會厭挑起術與使用氣管內管導引條(bougie)兩種插管方式之優劣，從而找到處理C-L等級III之最佳插管策略。
研究方法：
第一階段蒐集32位受試者，透過隨機交叉的假人試驗，以氣管內管彎折形狀(曲棍球桿形狀和香蕉形狀)、握氣管內管的部位(握頂端或握中段)、使用插管通條挑起會厭，研究插管耗費時間、成功率、受試者的難易度。第二階段以20位受試者 (15位急診主治醫師、2位急診住院醫師、2位專科護理師)，研究使用氣管內管合併氣管內管導引條(pre-loaded bougie)以及使用氣管通條(stylet)會厭挑起術(epiglottic-lift)，以三種張口及喉頭開口大小不同的假人為對象，進行插管試驗 (3種假人x2種插管方式，共六種情境)。
結果：
第一階段，在十組不同的插管設定下，使用插管通條對會厭進行挑起是唯一具有統計學意義的因子(p <0.0001, 95% 信賴區間為 1.34-2.11)。第二階段，會厭挑起術相較於使用氣管內管導引條有更佳的插管成功率及減少插管時間之優勢(p<0.0001, hazard ratio為3.10，95%的信賴區間為1.89-5.08)
結論：
當處置C-L等級III只能看到會厭時的困難插管，使用插管通條作為插管輔助技巧可以加快插管速率並且增加插管成功率，且此一技巧不會增加插管者插管的困難度。會厭挑起術較使用氣管內管導引條可以加快插管成功率。

關鍵字

困難插管 ； 插管技巧 ； 插管通條形狀 ； 會厭挑起 ； 氣管內管導引條 ； 彎折角度 ； Cormack-Lehane插管分級

並列摘要

Background: The Cormack-Lehane grade III airway is a clinical challenging airway intubation situation due to limited anatomic landmarks and associated with poor success rate. Previous studies suggest that both bougie-assisted intubation and epiglottis lifting with a stylet-equipped endotracheal tube (ET) may facilitate and improve intubation success rate. To find out better strategy to manage such difficult airway, we conduct the investigation whether the holding positions, shapes, bend angles of the ET and stylet-assisted lifting of the epiglottis could improve the success rate of intubation. To compare the epiglottic-lift technique with the current recommendations of using bougie-assisted intubation, we investigate these two techniques on three different mannequins with different level of difficulties of intubation.
Methods:
Thirty-two participants were enrolled in a randomized, cross-over mannequin study. We investigated the effects of straight-to-cuff ET shapes with 35° and 50° bend angles, banana-shaped ET with longitudinal distances of 28 cm and 26 cm, two methods of holding the ET (either on the top or in the middle), and lifting or not the epiglottis, on the intubation duration and its success rate, and its subjective difficulty. Twenty participants were enrolled to investigate pre-loaded bougie technique and epiglottic lift technique on three different manikins from largest to smallest mouth and glottis inlets in a randomized order (3x2 possibilities).
Results:
Under ten different subgroup settings, lifting of the epiglottis was the only significant factor (p<0.0001, 95% CI 1.34-2.11). When comparing to pre-loaded bougie technique, epiglottic lift technique had a better success rate and shorter duration of intubation regardless of mouth and glottis inlet diameters. (p<0.0001, hazard ratio=3.10 with 95% confidence interval 1.89-5.08).
Conclusions:
The use of the epiglottic lift as an adjunctive technique can facilitate the intubation and improve its success rate without increasing procedure difficulty, in C-L III airway, when only the epiglottis is seen. The use of epiglottic lift with stylet-equipped ET tube can facilitate the intubation in C-L grade III difficult airway comparing to the pre-loaded bougie technique.
Key words: difficult airway, intubation technique, stylet shapes, lifting of epiglottis, endotracheal tube introducer or bougie, bend angles, Cormack-Lehane grade

並列關鍵字

difficult airway ； intubation technique ； stylet shapes ； lifting of epiglottis ； endotracheal tube introducer or bougie ； bend angles ； Cormack-Lehane grade

參考文獻

1. Adamus, M., Fritscherova, S., Hrabalek, L., Gabrhelik, T., Zapletalova, J., & Janout, V. (2010). Mallampati test as a predictor of laryngoscopic view. Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia, 154(4), 339-343. doi:10.5507/bp.2010.051

2. Adnet, F., Racine, S. X., Borron, S. W., Clemessy, J. L., Fournier, J. L., Lapostolle, F., & Cupa, M. (2001). A survey of tracheal intubation difficulty in the operating room: a prospective observational study. Acta anaesthesiologica Scandinavica, 45(3), 327-332. doi:10.1034/j.1399-6576.2001.045003327.x

3. Aktas, S., Atalay, Y. O., & Tugrul, M. (2015). Predictive value of bedside tests for difficult intubations. European review for medical and pharmacological sciences, 19(9), 1595-1599. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26004598

4. Al Ramadhani, S., Mohamed, L. A., Rocke, D. A., & Gouws, E. (1996). Sternomental distance as the sole predictor of difficult laryngoscopy in obstetric anaesthesia. British journal of anaesthesia, 77(3), 312-316. doi:10.1093/bja/77.3.312

5. Alahyari, E., Ghaemi, S. R., & Azemati, S. (2008). COMPARISON OF SIX METHODS FOR PREDICTING DIFFICULT INTUBATION IN OBSTETRIC PATIENTS. IRANIAN RED CRESCENT MEDICAL JOURNAL (IRCMJ), 10(3), 194-201. Retrieved from https://www.sid.ir/en/journal/ViewPaper.aspx?id=110179