Tracheal intubation in neonates, infants, and children: is there a right way?
Tracheal intubation in neonates, infants, and children: is there a right way?
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新生儿、婴儿和儿童气管插管：有正确的方法吗？
DOI：
10.1097/01.ccm.0000110728.64468.c3
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发表时间：
2004
影响因子：
8.8
通讯作者：
Suresh,Santhanam
中科院分区：
文献类型：
--
作者：
Anand,KJS;Suresh,Santhanam
对于某些新生儿、婴儿或儿童，通常需要进行机械通气或气道保护的气管插管术可能会或可能不会先进行镇痛/镇静。无镇痛或镇静的气管插管在新生儿中比在年龄较大的儿童中更常见（1-3），尽管最近基于证据的共识声明建议仅在产房复苏或其他危及生命的情况下才应考虑清醒插管（4）。在任何年龄组中，清醒插管都与严重的不适和痛苦，生命体征的急性变化（心动过速或心动过缓，高血压，氧饱和度下降和颅内压升高），即使第一次尝试也会延长手术时间，需要多次尝试，以及随之而来的声门上或气管损伤的可能性有关[5]。然而，在某些临床情况下，临床医生可能需要避免延迟获得静脉通路和准备药物，或镇痛/镇静的血流动力学和呼吸效应，或在进行紧急插管前丧失气道保护反射。正如美国麻醉医师协会（6）的实践指南所公布的那样，安全性仍然是正常或困难气道管理的首要问题。由于缺乏广泛接受的标准方法，Simon及其同事（7）着手定义法国大多数新生儿和儿科重症监护病房的现行做法。他们收集了> 90%的气管插管发生在10天内的临床数据，发现37.1%的新生儿、67.3%的婴儿和91.7%的儿童在插管前使用了镇痛和/或镇静，早产儿中使用最少。插管尝试失败和不良反应（低氧血症和心动过缓）与出生体重较低、年龄较小和操作人员经验不足有关，但使用术前用药并没有改变这些事件的成功率或发生率（7）。美国和其他发达国家很可能也采取了类似的做法，尽管这些国家缺乏类似的流行病学数据。
Tracheal intubation, often required for mechanical ventilation or airway protection, may or may not be preceded by analgesia/sedation for some neonates, infants, or children. Tracheal intubation without analgesia or sedation occurs more frequently in neonates than in older children (1–3), although an evidence-based consensus statement has recently recommended that awake intubation should only be considered for delivery room resuscitation or other life-threatening situations (4). In any age group, awake intubation is associated with severe discomfort and distress, acute changes in vital signs (tachycardia or bradycardia, hypertension, oxygen desaturation, and increased intracranial pressure), prolongation of the procedure even with the first attempt, the requirement for multiple attempts, and consequent potential for supraglottic or tracheal damage (5). In some clinical situations, however, clinicians may need to avoid the delay in obtaining intravenous access and preparing drugs, or the hemodynamic and respiratory effects of analgesia/sedation, or the loss of airway protective reflexes before performing emergency intubations. As promulgated in the practice guidelines from the American Society of Anesthesiologists (6), safety remains a primary concern in the management of a normal or difficult airway.Given the lack of a widely accepted standard approach, Simon and colleagues (7) set out to define the current practices in the majority of neonatal and pediatric intensive care units located in France. They collected clinical data on> 90% of tracheal intubations occurring within a 10-day period and found that analgesia and/or sedation was used before intubation in 37.1% of neonates, 67.3% of infants, and 91.7% of children, with minimal use among preterm neonates. Failed intubation attempts and undesirable effects (hypoxemia and bradycardia) were associated with lower birth weights, younger ages, and inexperienced operators, but the use of premedication did not alter the success rate or the incidence of these events (7). It is likely that similar practices are followed in the United States and other developed countries, despite the lack of similar epidemiologic data from these countries.