右旋美托咪定联合纤维支气管镜在巨大甲状腺肿所致困难气道气管插管中的应用

Application of dexmedetomidine combined with fibreoptic bronchoscope for tracheal intubation in difficult airways caused by huge goiter

目的：探讨在巨大甲状腺肿所致的困难气道中应用右旋美托咪定联合纤维支气管镜进行气管插管的有效性。方法：选择巨大甲状腺肿致气管受压移位或变形患者30例,采用计算机随机分为右旋美托咪定组（n=15）和丙泊酚组（n=15）。右旋美托咪定组先给予负荷剂量右旋美托咪定1.0μg·kg^-1,输注超过10 min后以0.4μg·kg^-1·h^-1持续泵人。丙泊酚组先缓慢给予丙泊酚2.0 mg·kg^-1,后以5-8 mg·kg^-1·h^-1持续泵人。对插管条件进行评估分级;观察患者在插管过程中的反应,如咳嗽分级和患者插管时的舒适度;记录麻醉前（T0）、Rassay评分为4时（T1）、气管插管时（T2）、插管后1 min（T3）及插管后3 min（T4）5个时间点的心率和血压的变化;记录阿托品和多巴胺的用量以及低氧血症和呼吸抑制等。结果：2组均成功完成纤维支气管镜下气管插管。右旋美托咪定组患者在插管过程中保持良好的自主呼吸,无气道梗阻发生,均能按照指令配合气管插管。丙泊酚组有6例（40.0%）患者出现呼吸道梗阻,11例（73.3%）不能按指令配合气管插管,2组比较差异有统计学意义（P〈0.05）。右旋美托咪定组有12例声门开放,3例声门活动;丙泊酚组有7例声门开放,6例声门活动;右旋美托咪定组较丙泊酚组提供较好的插管条件（P〈0.05）。在整个插管过程中没有反应或只是轻微的面部表情者,右旋美托咪定组有12例,丙泊酚组有8例,2组比较差异有统计学意义（P〈0.05）。右旋美托咪定组患者在T1和T2时刻心率下降更为明显。插管后T3、T4时刻2组患者心率均加快,但右旋美托咪定组患者心率加快不显著,与丙泊酚组比较差异有统计学意义（P〈0.05）。在插管过程中右旋美托咪定组未出现低氧血症和气道梗阻,而丙泊酚组3例出现低氧血症,6例出现气道梗阻。结论：在处理巨大甲状腺肿所致的困难气道时,与丙泊酚比较,右旋美托咪定耐受性好,患者呼吸通畅,插管时血流动力学稳定。

Objective To study the effectiveness of dexmedetomidine combined with fibreoptic bronchoscope for tracheal intubation in difficult airways caused by huge goiter.Methods Thirty patients with anticipated difficult airways caused by huge goiter were enrolled and randomly divided into dexmedetomidine group（n=15） and propofol group（n=15）.The patients in dexmedetomidine group received a loading dose of dexmedetomidine（1.0 μg·kg^-1,infused over 10 min,then pumped at continuous rate of 0.4 μg·kg^-1·h^- 1.The patients in propofol group received a loading dose of 2.0 mg·kg^-1and pumped at continuous rate of 5-8 mg·kg^-1·h^- 1.The intubating conditions were graded by a scoring system;the reactions to intubation such as coughing and patient tolerance were observed;the heart rates and mean arterial blood pressures（MABP） at different time points of baseline（T0）,Rassay score 4（T1）,intubating（T2）,1 min after intubation（T3） and 3 min after intubation（T4） were recorded;adverse events and haemodynamic support were observed.Results All the patients in two groups were performed successfully with fibreoptic intubation.The patients in dexmedetomidine group could keep better spontaneous breathing without respiratory depression,and were able to command and cooperate tracheal intubation,while in propofol group 11 patients（73.3%） could not cooperate tracheal intubation（P〈0.05）.With respect to intubation scores in propofol group,there were 7 cases of vocal cord opening and 3 cases of vocal cord movement;while in dexmedetomidine group,there were 12 cases in vocal cord opening and 3 cases in vocal cord moving.Compared with propofol group,the patients in dexmedetomidine group had more favorable intubation scores of vocal cord movement（P〈0.05）.With respect to no reaction or slight grimacing of reaction to intubation comfort score,there were 8 cases in propofol group and 12 cases in dexmedetomidine group,and there was significant difference（P〈0.05）.The patients in dexmedetomidine group experienced fewer airway events and less heart rate response to intubation than those in propofol group（P〈0.05）.Conclusion Compared with propofol in management of difficult airways caused by huge goiter,dexmedetomidine has better tolerance,and preserves a patient airway,and has more stable haemodynamic response to intubation.