阻塞性睡眠呼吸暂停低通气综合征患者行悬雍垂颚咽成形术的经鼻气管插管方式

Effects of different nasotracheal intubations in obstructive sleep apnea hypopnea syndrome patients with uvulopalatopharyngoplasty

目的探讨阻塞性睡眠呼吸暂停低通气综合征患者行悬雍垂颚咽成形手术快诱导安全、有效的经鼻气管插管方式。方法经福建医科大学附属第二医院伦理委员会审核通过，将我院2008年8月至2011年11月择期行悬雍垂颚咽成形手术90例，随机数表法随机分为GlideScope视频喉镜（G）组、光导纤维支气管镜（F）组、GlideScope视频喉镜辅助光导纤维支气管镜（G4-F）组，每组30例。记录气管插管时间，气管插管置人情况，气管插管径路损伤情况及并发症。记录麻醉诱导后、气管插管时以及气管插管后1、3、5min时的收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）和心率，计算所有观察时间点的心率收缩压乘积（RPP）。结果3组患者年龄、性别、体质量、MMlampati分级、体质量指数（BMI）、呼吸暂停低通气指数（AHI）、最低血氧饱和度（LSaO2）等差异均无统计学意义（均P〉0．05），90例患者均获得气管插管成功。G组、F组及G＋F组1次插管成功率分别为80％、90％及100％（P〈0．05）。G组和F组一次未成功者均为MallampatiⅢ、Ⅳ级患者，在加深麻醉后改用G＋F组方法均取得成功。麻醉诱导后3组的SBP、DBP、MAP和RPP均降低（P〈0．05），HR改变不明显。与麻醉诱导后相比，气管插管时和插管后1min3组患者的SBP、DBP、MAP、心率和RPP升高（P〈0．05）。F组、G＋F组患者插管时和插管后1min的SBP、DBP、MAP、心率、RPP高于G组（P〈0．05）；F组、G＋F组两组间差异无统计学意义。3组均未见严重插管径路损伤、喉头水肿、声嘶等并发症。结论MallampatisⅠ、Ⅱ级的OSAHS患者行uPPP术经鼻气管插管，采用GlideScope视频喉镜暴露简单易行；Mallampati Ⅲ、Ⅳ级患者采用GlideScope视频喉镜辅助光导纤维支气管镜引导较单独应用FOB插管成功率更高、插管时间更短。

Objective To explore the safe and effective way of nasotracheal intubations in obstructive sleep apnea hypopnea syndrome patients with uvulopalatopharyngoplasty. Methods Upon the approval of the Ethics Committee at Second Affiliated Hospital of Fujian Medical University, from August 2008 to November 2011, 90 sleep apnea hypopnea syndrome patients were randomly divided into 3 groups （ n = 30 each） ： GlideScope （ G）, fiberoptic bronchoscope （F） and combination of Glidescope with fiberoptic bronchoscope （ G ＋ F）. The parameters of tracheal intubation time, placement of endotracheal intubation, tracheal injury and complications were recorded. Also systolic blood pressure （ SBP）, diastolic blood pressure （DBP）, mean arterial pressure （MAP） and heart rate （HR） were recorded at post-induction, the moment of tracheal intubation and post-intubation 1,3,5 rain. Rate pressure product （RPP） was calculated at all timepoints as the product of heart rate and SBP during observation. Results All of them underwent successful endotracheal intubation. There were 24 successful cases of intubation during the first attempt in Group G with a success rate of 80% ; 27 patients successful during the first attempt in group F with a success rate of 90% ; all in group G ＋ F successful during the first attempt with a success rate of 100%. The rates were significantly different in 3 groups （ P 〈 0. 05 ）. Groups G and F patients with failed intubation during the first attempt were of Mallampati III/IV. After induction, SBP, DBP, MAP and RPP were lower in 3 groups （P 〈 O. 05） while HR change was not obvious. Compared with the after induction, the moment of tracheal intubation and after intubation 1 min, 3 groups of patients with SBP, DBP, MAP, HR and RPP increased （p 〈 0. 05）. Groups F and G ＋ F after intubation in intubated patients and 1 rain of SBP, DBP, MAP, HR, RPP were higher than G group （P 〈 0. 05 ）. No difference existed between groups F and G ＋ F. Three groups showed no serious tracheal injury, laryngeal edema, hoarseness or other complications. Conclusion During nasotracheal intubation for Mallampati I / II patients, GlideScope offers better overall glottic views. For those of Mallampati m and IV, the combination of Glidescope with fiberoptic bronchoscope may achieve a higher success rate and shorter intubation time than the latter alone.