Normal and difficult airways in children: "What's New"-Current evidence.
Normal and difficult airways in children: "What's New"-Current evidence.
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DOI：
10.1111/pan.13798
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发表时间：
2020-03
期刊：
影响因子：
--
通讯作者：
Nishisaki A
中科院分区：
文献类型：
--
作者：
Fiadjoe J;Nishisaki A
小儿气道困难是临床上最具挑战性的情况之一。我们将回顾在手术室（OR）、重症监护病房、急诊科和新生儿重症监护病房中儿科正常和困难气道管理的新概念和新证据。认知因素、团队合作和沟通在处理儿童气道困难中起主要作用。早期的研究以单一的方式评估视频喉镜，对其有效性产生不确定的结果。然而，视频喉镜之间存在着实质性的差异，特别是成角与非成角的叶片，它们具有不同的学习和使用特性。每种气道设备都有优点和缺点，将这些设备结合起来利用两种优点可能会取得成功。在儿科ICU、急诊科和新生儿ICU中，不良气管插管相关事件和低氧血症经常被报道。具体的患者、临床医生和实践因素与这些事件有关。在手术室和其他临床领域，使用被动氧合将提供额外的喉镜检查时间。使用神经肌肉阻滞被认为是禁忌的困难气道患者。来自观察性研究的最新证据表明，有或没有神经肌肉阻断的控制通气与手术室中较少的不良事件相关。同样，一项多中心新生儿ICU研究显示，接受神经肌肉阻断治疗的婴儿不良事件较少。对于有粘多糖病、头颈部放疗、气道肿块和气道外压迫的患者，应避免使用神经肌肉阻滞剂，以免加重气道塌陷。照顾气道困难儿童的临床医生应该考虑新的认知范式和概念，利用多种设备的优势，并考虑替代麻醉入路的作用，如控制通气和在特定情况下使用神经肌肉阻断药物。麻醉师可以与ICU、ED和新生儿临床医生合作，在所有临床环境中提高气道管理的安全性。
Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the Operating Room (OR), intensive care unit, Emergency Department, and neonatal intensive care unit. Expert review of the recent literature Cognitive factors, teamwork and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated video laryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are however, substantial differences among video laryngoscopes particularly angulated vs. non-angulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the Pediatric ICU, ED, and neonatal ICUs, adverse tracheal intubation associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the OR and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the OR. Similarly, a multicenter Neonatal ICU study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration. Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with ICU, ED, and Neonatology clinicians to improve the safety of airway management in all clinical settings.
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