喉上神经阻滞联合环甲膜穿刺技术在困难气道中的应用

Combined use of superior laryngeal nerve block with cricothyroid membrane puncture to management of difficult airway

目的:探讨喉上神经阻滞(superior laryngeal nerve block,SLNB)联合环甲膜穿刺技术用于纤维支气管镜(fiberoptic bronchoscopy,FOB)引导下经鼻清醒气管插管。方法:20例困难气道患者,颈椎骨折11例,下颌骨骨折(张口度<3 cm)9例,采用双侧SLNB联合环甲膜穿刺气管内表面麻醉,保留自主呼吸,FOB引导下经鼻腔清醒插管。观察指标:患者入室时(T1)、插管前(T2,导管通过鼻腔后)、插管后即刻(T3)、插管后2 min(T4,麻醉诱导前)及插管后5 min(T5,麻醉诱导后即刻)各时点心率、血压、Sp O2变化;记录气管插管所用时间、SLNB成功率、一次性插管成功率、呛咳程度、患者插管时耐受程度、插管分级、有无相关并发症等。结果:患者心率在T2、T3升高,与T1比较统计学有显著差异(P<0.05),气管插管完成后心率下降,T4心率恢复至T1水平(P>0.05),麻醉诱导后(T5)心率显著下降(P<0.05);血压在导管通过鼻腔及咽喉壁时(T2)明显升高,与T1比较有显著性统计学差异(P<0.05);气管插管后即刻(T3)血压较T2下降(P<0.05),但仍较T1高(P<0.05),气管插管后2 min血压恢复到术前水平,与T1比较无显著统计学差异(P>0.05),诱导完毕后(T5)血压显著下降(P<0.05)。SpO2变化无临床意义。插管时间为(35.9±13.12)s,SLNB成功率为95%,一次性气管插管成功率95%。患者气管插管耐受程度及呛咳程度较理想。结论:SLNB联合环甲膜穿刺麻醉运用于FOB引导下,经鼻腔清醒插管具有方法简单,气管插管一次性成功率高,咽喉部损伤小,效果可靠,安全性高等优点,是一种较为理想的困难气道处理方法。

Objective： To investigate the application of superior laryngeal nerve block（ SLNB） technique combined with cricothyroid membrane puncture to conscious nasotracheal intubation guided by fiber bronchoscope（ FOB）. Methods： Twenty patients with difficult airway（ 11 were cervical spine fracture and9,mandibular fractures with open mouth 3 cm） underwent conscious nasotracheal intubation guided by FOB after bilateral laryngeal nerve block and topical cricothyroid membrane puncture anesthesia while spontaneous breath was maintained. The total patients were observed regarding the heat rate（ HR）,mean arterial pressure（ MAP） and changes of pulse oxygen saturation（ SpO2） at the time of tracheal intubation（ T1）,before intubation（ T2）,the moment of intubation（ T3）,2 min after extubation（ T4） and 5 min after extubation（ T5）,as well as time consumption in intubation,successful SLNB,success rate at one placement,incidence and degree of bucking,tolerance to tracheal intubation,grading of intubation and presence or absence of complication. Results：HR was significantly elevated at T2 and T3 to T1（ P〈0. 05）,yet recovered after tracheal intubation and to normal level from T4 to T1（ P〉0. 05）,and slower HR was observed at T5（ P〉0. 05）. Significantly elevated MAP was seen at T2 compared to T1（ P〈0. 05）. Although MAP was lower at T3 than T2,yet higher at T1（ P〈0. 05）,and recovered to normal level 2 min after intubation,which showed no statistical difference compared with T1（ P〈0. 05）. Significantly decreased MAP was found at T5（ P〈0. 05）,and Sp O2 showed no clinical significance. The time for tracheal intubation was（ 35. 9 ±13. 12） seconds. Successful SLNB and success rate at one placement was 95%. The patients in general had better tolerance to tracheal intubation and moderate incidence of bucking except for the different tolerance at T4 and T5（ P〈0. 05）. Conclusion： Combined SLNB with cricothyroid membrane puncture anesthesia for conscious nasotracheal intubation guided by FOB appears to be better technique to management of patients with difficult airway,for it leads to higher success rate at one placement of the tube and less damage to laryngea pharyngis,yet safe and reliable performance.