两种方法置入ProSeal喉罩和Supreme喉罩用于全身麻醉患者气道管理的对比研究

Comparison of laryngeal mask airway ProSeal with laryngeal mask airway Supreme for the airway management in patients with general anesthesia

目的评估导芯塑形置入法用于全身麻醉患者ProSeal喉罩（LMAP）置入的有效性和安全性，并与传统徒手法置入和Supreme喉罩（LMAS）相比较。方法选择2013年12月--2014年3月在宁波市第一医院择期行腹腔镜胆囊切除术的患者180例，年龄20～78岁，体重42～86kg，美国麻醉医师协会（ASA）分级Ⅰ至Ⅲ级。采用随机数字表法将患者分人LMAP组、LMAP新方法组和LMAS组，每组60例。行麻醉诱导后，LMAP组和LMAP新方法组使用LMAP，其中LMAP组采用传统的徒手置入法，LMAP新方法组采用导芯塑形置入法；LMAS组使用LMAS。记录3组患者尝试置入喉罩次数、置入时间、置入前1rain和置入成功后1min的心率和平均动脉压（MAP）。待喉罩成功置入后，记录胃管从喉罩引流管放置情况，监测口咽漏气压（OLP），应用纤维支气管镜（FOB）对声门和会厌的暴露程度进行评分，记录气腹前和气腹后的气道峰压（PIP）、术中喉罩漏气情况和反流误吸例数，术后观察患者有无喉罩沾血、咽喉疼痛、声音嘶哑等并发症。结果LMAP组喉罩首次置入成功45例（75．0％），LMAP新方法组56例（93．3％），LMAS组57例（95．0％），LMAP新方法组和LMAS组的喉罩首次置入成功率均显著高于LMAP组（P值均〈0．01）。LMAP组有3例患者最终喉罩置入失败改气管插管，喉罩置入总成功率为95．0％，LMAP新方法组和LMAS组的喉罩置入总成功率均为100．0％，3组间差异无统计学意义（P值均〉o．05）。LMAP新方法组和LMAS组的喉罩置入时间均显著短于LMAP组（P值均〈O．01），喉罩置入后1min的MAP均显著低于LMAP组（P值分别〈0．05、0．01）。3组间喉罩置入前、后1min的心率和喉罩置入前1min的MAP的差异均无统计学意义（P值均〉0．05）。3组间胃管顺利插入率、喉罩位置理想（FOB评分≥3分）率的差异均无统计学意义（P值均〉O．05）。LMAP组和LMAP新方法组的OLP均显著高于LMAS组（P值均〈o．01），3组间气腹前、后PIP的差异均无统计学意义（P值均〉0．05）。3组间术中气腹后喉罩漏气率的差异无统计学意义（P值均〉0．05），其中LMAP组和LMAP新方法组经调整喉罩位置后漏气改善，LMAS组有3例（5．0％）调整无效后改行气管插管，3组间差异无统计学意义（P值均〉0．05）。3组术中均未发生反流误吸。LMAP新方法组和LMAS组的喉罩沾血和术后咽痛发生率均显著低于LMAP组（P值均〈0．05）。结论LMAP和LMAS均能安全、有效地用于腹腔镜胆囊切除术患者全身麻醉气道管理。使用导芯塑形法置入LMAP比徒手置入法更加快速、有效，术后并发症少，在操作的简便性上与LMAS相当，且LMAP具有更高的气道密封性，术中气道管理更为安全。

Objective To evaluate the efficacy and safety of a new technique of inserting the laryngeal mask airway ProSeal （LMAP） in patients with general anesthesia, and compare it with the traditional method and laryngeal mask airway Supreme （LMAS）. Methods A total of 180 patients （American Society of Anesthesiologists EASA-I grade Ⅰ - Ⅲ, aged 20 - 78 years, weighing 42 - 86 kg） undergoing elective laparoscopic cholecystectomy in the First Hospital of Ningbo City from December 2013 to March 2014 were randomly divided into three groups： LMAP group, improved LMAP group and LMAS group （n = 60 in each group）. After anesthesia induction, LMAP was inserted with traditional manipulation in the LMAP group, and with a new tube core shaping technique in the improved LMAP group. LMAS was inserted in LMAS group. The success rate and time of LMA insertion were recorded. Heart rate and mean arterial pressure （MAP） were recorded 1 min before and after LMA insertion. The success rate of gastric tube insertion, oropharyngeal leak pressure （OLP）, score of fiberoptic bronchoscope （FOB） location, and peak airway pressure （PIP） before and after pneumoperitoneum were also recorded when the LMA was successfully inserted. Intraoperative complications such as air leakage, gastroesophageal regurgitation and pulmonary micro-aspiration and postoperative complications such as blood stains on the device, sore throat and hoarseness were also recorded. Results There were 45 （75.0%） successful insertion at the first attempt in the LMAP group, 56 （93.3%） in the improved LMAP group and 57 （95.0%） in the LMAS group. The success rates of insertion at the first attempt in the improved LMAP group and LMAS group were significantly higher than that in the LMAP group （both P〈0.01）. There were 3 failed insertion in the LMAP group and then endotracheal intubation was performed. The total success rate of insertion was 95.0% in the LMAP group and 100.0% in the improved LMAP group and LMAS group. There was no significant difference in the total success rate of insertion between groups （all P〈0.05）. It took shorter time in LMA insertion in the improved LMAP group and LMAS group than the LMAP group （both P〈0.01）. MAP at 1 min after insertion in the improved LMAP group and LMAS group was significantly lower than that in the LMAP group （P〈0.05 or 0.01）. There were no significant differences in the heart rate at 1 min before and after insertion or the MAP at 1 min before insertion between groups （all P〉0.05）. Neither were the success rate of insertion of gastric tube or number of patients of FOB score〉3 between groups （all P〉0.05）. OLP in the LMAP group and improved LMAP group was significantly higher than that in the LMAS group （both P〈0.01）. There was no significant difference in the PIP before and after pneumoperitoneum between these groups （all P〉0.05）. Neither was the incidence of air leakage after pneumoperitoneum （all P〉0.05）. In the LMAP group and improved LMAP group, air leakage of LMAP was improved after adjusting the LMA location, but in the LMAS group, endotracheal intubation was used in three patients who failed in LMA adjustment. No gastroesophageal regurgitation or pulmonary micro-aspiration occurred in any patients. The incidence rates of blood stains and sore throat after the operation in the improved LMAP group and LMAS group were significantly lower than those in the LMAP group （both P〈0.05）. Conclusion Both LMAP and LMAS can be safely and effectively used in general anesthesia in patients with laparoscopic cholecystectomy. Compared with traditional LMAP, LMAP insertion by tube core shaping technique is quicker and more efficient and has less postoperative complications. The LMAP insertion is as simple as LMAS. Furthermore, LMAP provides a better leak tightness and higher security in airway management than LMAS.