Management of the Difficult Adult Airway With Special Emphasis on Awake Tracheal Intubation
Management of the Difficult Adult Airway With Special Emphasis on Awake Tracheal Intubation
复制标题
成人困难气道的处理，特别强调清醒气管插管
作者：
J. F. Biebuyck;J. Benumof
呼吸道管理困难是主要麻醉相关发病率和死亡率的最重要原因。困难气道的成功管理始于认识到潜在的问题。所有患者都应检查其张大嘴的能力，以及张口时可见的结构，下颌间隙的大小，以及采取吸气姿势的能力。如果插管和/或面罩通气很有可能困难，则应在患者清醒时保护气道。为了使清醒插管成功，患者做好充分的准备是绝对必要的;否则，麻醉师只会实现一个弄巧成拙的预言。一旦病人做好了适当的准备，许多插管技术中的任何一种都可能成功。如果患者已经麻醉和/或瘫痪，插管困难，应避免多次重复插管尝试，因为喉部水肿和出血将逐渐发展，因此可能失去通过面罩覆盖肺部的能力。在几次插管尝试后，最好唤醒患者，做半选择性气管切开术，或使用面罩通气进行手术。如果失去了通过面罩呼吸的能力，患者的肺部仍然无法通气，应立即开始TTJV。通过喷射式管心针对困难气道患者进行气管拔管，可实现可控、渐进和可逆的气道拔管（因为通气和重新插管可随时进行）。近年来，困难气道的管理取得了重大进展。在这篇文章中的127篇参考文献中，有80%是在1985年之后发表的。然而，在困难气道的识别、患者清醒插管的准备、气管插管的新技术以及无法通过面罩插管或通气的患者的气体交换的建立方面，还有更多的东西需要学习。随着麻醉师处理困难气道的能力显著提高，麻醉相关的发病率和死亡率将降低。
Difficulty in managing the airway is the single most important cause of major anesthesia-related morbidity and mortality. Successful management of a difficult airway begins with recognizing the potential problem. All patients should be examined for their ability to open their mouth widely and for the structures visible upon mouth opening, the size of the mandibular space, and ability to assume the sniff position. If there is a good possibility that intubation and/or ventilation by mask will be difficult, then the airway should be secured while the patient is still awake. In order for an awake intubation to be successful, it is absolutely essential that the patient be properly prepared; otherwise, the anesthesiologist will simply fulfill a self-defeating prophecy. Once the patient is properly prepared, it is likely that any one of a number of intubation techniques will be successful. If the patient is already anesthetized and/or paralyzed and intubation is found to be difficult, many repeated attempts at intubation should be avoided because progressive development of laryngeal edema and hemorrhage will develop and the ability to ventilate the lungs via mask consequently may be lost. After several attempts at intubation, it may be best to awaken the patient, do a semielective tracheostomy, or proceed with the case using mask ventilation. In the event that the ability to ventilate via mask is lost and the patient's lungs still cannot be ventilated, TTJV should be instituted immediately. Tracheal extubation of a patient with a difficult airway over a jet stylet permits a controlled, gradual, and reversible (in that ventilation and reintubation is possible at any time) withdrawal from the airway. Significant advances in the management of the difficult airway have occurred in recent years. Eighty percent of the 127 references in this article were published after 1985. However, there is much more to learn with regard to recognition of the difficult airway, preparation of the patient for an awake intubation, new techniques of endotracheal intubation, and establishment of gas exchange in patients who cannot be intubated or ventilated by mask. As the anesthesiologist's ability to manage the difficult airway significantly improves, respiratory-related morbidity and mortality will decrease.