听诊法、呼气末二氧化碳分压法和颈部透光法判断气管内导管位置准确性的比较

A comparison of degree of precision of auscultation, partial pressure of carbon dioxide in end-expiration, and transillumination technique in verifying accurate position of endotracheal tube

目的：评价听诊法、呼气末二氧化碳分压（PETCO2）法和颈部透光法判断气管内导管是否误入食道的效果。方法采用随机对照双盲试验设计，选择2014年9月至2015年2月上海市奉贤区中心医院收治的符合美国麻醉医师协会（ASA）Ⅰ～Ⅱ级的60例经口气管插管全麻患者。常规麻醉诱导后，由同一位插管者将两根相同型号的气管导管分别插入患者的气管和食道，插入深度相同。由2名不同年资的麻醉医师分别使用听诊法、PETCO2法、颈部透光法对导管的位置进行判断，每次测试的导管（气管内或者食道内）和方法均按照随机数字表选择。高年资医师测试后再由低年资医师按照同样方法测试相同的导管。记录2名医师用不同方法判断气管导管位置的正确和错误例数。结果高年资和低年资两组医师对60例患者共实施180次判断，气管内90次，食道内90次；整体上高、低年资医师用3种方法判断导管位置的正确率无差异〔96.7%（174/180）比92.2%（166/180），χ2＝3.500，P＝0.057〕。使用听诊法判断气管导管位置时，高年资医师正确率高于低年资医师（95.0%比78.3%，χ2＝5.786，P＝0.013）；运用PETCO2法判断时，不同年资医师均能准确判断气管导管位置，准确率均为100%；使用颈部透光法判断时，高年资医师误判3例（正确率为95.0%），低年资医师误判1例（正确率为98.3%），但两者比较差异无统计学意义（χ2＝0.500，P＝0.250）。颈部透光法判断导管位置的正确率明显高于听诊法（χ2＝7.563，P＝0.004）。听诊法判断气管导管位置的敏感度和特异度分别为70.0%、80.0%，颈部透光法分别为96.7%、93.3%，PETCO2法均为100%。结论 PETCO2法能准确判断麻醉后气管导管是否误入食道，优于听诊法和颈部透光法；颈部透光法判断导管是否误入食道的效果优于听诊法，且不受临床经验的影响；听诊法的准确性受临床经验影响最大。

ObjectiveTo evaluate the effect of auscultation, partial pressure of carbon dioxide in end-expiration （PETCO2）, transillumination technique to judge whether the endotracheal tube is misplaced into the esophagus. Methods A blinded randomized controlled trial was conducted. Sixty patients with American Society of Anesthesiology （ASA） gradeⅠ-Ⅱundergoing endotracheal intubation in Fengxian Central Hospital admitted from September 2014 to February 2015 were enrolled. Two endotracheal tubes with the same size were respectively inserted into the trachea and esophagus for the same depth after general anesthesia by the same person. Two blinded anesthetists with different experience checked the tube position using three methods including auscultation, PETCO2, and transillumination technique, respectively. The order of the tubes tested （trachea or esophagus） and the method used were randomized according to randomise numbers table. The experienced anesthetists conducted the test first, followed by an inexperienced anesthetist conducting the same methods. The numbers of right and wrong determinations with different methods by different anesthetists were recorded.Results Sixty patients underwent the procedures for 180 times, with intratracheal intubation for 90 times, and esophageal intubation for 90 times. It was shown that the results were not different in two groups [96.7% （174/180） vs. 92.2% （166/180）,χ2 = 3.500,P = 0.057]. By using auscultation, the correct rate of experienced＆amp;nbsp;anesthetist was higher than that of inexperienced （95.0% vs. 78.3%,χ2 = 5.786,P = 0.013）. Using PETCO2, both anesthetists were correct in all cases, and the accuracy was 100%. Using transillumination, the experienced anesthetist was mistaken in 3 cases （accuracy was 95.0%）, while the inexperienced mistook in 1 case （accuracy was 98.3%）, and no significant difference was found between two groups （χ2 = 0.500,P = 0.250）. The correct rate of using transilluminaion was significantly higher than that of using auscultation （χ2 = 7.563,P = 0.004）. The sensitivity and specificity of the auscultation was 70.0% and 80.0%, that of transillumination technique was 96.7% and 93.3%,and PETCO2 was 100%, respectively, for two groups.ConclusionsPETCO2 is the most reliable method for determining tube position, and it is superior to auscultation and transilluminaion. Transillumintaion technique is superior to auscultation, irrespective of anesthetists＇ experience, while the accuracy of auscultation showed an obvious relationship with the anesthetists＇ experience.