气管导管拔除评分法的对照临床研究

A controlled clinical study of tracheal extubation scoring method

目的建立并验证气管导管拔除评分法(tracheal extubation score,TES),探讨更合适、更精准的拔管时机。方法根据气管拔管的相关指南和专家共识,提取气管拔管中3个关键因素(意识、肌力、呼吸),请麻醉科专家分别就这3个因素的重要性进行评分赋分,建立TES。纳入2020年1月—2020年5月行气管插管的患者183例。患者TES评分≥2分时可拔除气管导管,并按拔管时患者的情况将183例患者分为深麻醉拔管组(A组,潮气量≥6 ml/kg、呼吸频率≥10次/min、呼之不应)、清醒拔管组(B组,潮气量≥6 ml/kg、呼吸频率≥10次/min、肌力≥3级、完全清醒并能遵指令)和实验组(C组,TES评分≥2分的其余患者),每组61例。比较3组患者一般情况、拔管后呼吸不良事件(①SpO_(2)<90%;②拔除气管导管时咬住导管或牙垫;③需抬下颌或插入口咽通气道处理的部分上气道阻塞;④完全性喉痉挛;⑤支气管痉挛;⑥持续10 s以上的严重咳嗽)发生情况、拔管时患者舒适度及躁动发生率(Riker镇静躁动评分≥5分)。对患者入组情况与患者性别、年龄、麻醉时间、术中舒芬太尼用量进行相关性分析。结果3组患者ASA分级、BMI差异无统计学意义(P>0.05)。与A组比较,B组、C组患者术中舒芬太尼用量少(P<0.05)、麻醉时间短(P<0.05)、女性占比高(P<0.05),C组患者年龄大(P<0.05)。与B组比较,C组患者年龄大(P<0.05)、麻醉时间长(P<0.05)。C组患者拔管后呼吸不良事件总发生率低于A组(P<0.05),3组患者拔管时舒适度和躁动发生率差异无统计学意义(P>0.05)。A组患者不良事件③的发生率高于B组和C组(P<0.05),3组患者不良事件①、②、④、⑤、⑥的发生率差异无统计学意义(P>0.05)。患者入组情况与患者性别、年龄呈正相关,与麻醉时间、术中舒芬太尼用量呈负相关。结论TES可以安全应用于临床,并将气管导管拔除时机进行了细化、分值化,可为气管导管拔除时机提供参考。

Objective To establish and validate a tracheal extubation score(TES),so as to determine a more appropriate and accurate extubation time.Methods According to the relevant guidelines and expert consensus on tracheal extubation,three key factors in tracheal extubation were selected:consciousness,muscle strength and respiration.Then,anesthesiology experts were required to evaluate the importance of these factors for establishing the TES method.In the current study,183 patients who underwent endotracheal intubation from January 2020 to May 2020 were enrolled.The endotracheal tube was removed when the patient's TES was≥2.According to the patient's condition at the time of extubation,the patients were divided into three groups(n=61):a deep anesthesia extubation group(group A,tidal volume≥6 ml/kg,and respiratory rate≥10 times/min,with no response to calling),an awake extubation group(group B,tidal volume≥6 ml/kg,respiratory rate≥10 times/min,muscle strength≥grade 3,being fully awaking and able to follow instructions),and an experimental group(group C,other patients with TES≥2).The three groups were compared for their general conditions and respiratory adverse events after extubation[①pulse oxygen saturation(SpO_(2))<90%;②biting the catheter or dental pad when the endotracheal tube was removed;③partial upper airway obstruction requiring mandibular lift or oropharyngeal airway insertion;④complete laryngeal spasm;⑤bronchospasm;⑥severe cough lasting more than 10 s],patients'comfort during extubation and the incidence of agitation(Riker sedation agitation score≥5).The correlation analysis was conducted between patient grouping and gender,age,anesthesia time and intraoperative sufentanil dosage.Results There was no significant difference in American Society of Anesthesiologists(ASA)classification and body mass index(BMI)among the three groups(P>0.05).Compared with group A,group B and group C had reduced intraoperative sufentanil consumption,shortened anesthesia time,and an increased proportion of female patients(P<0.05),and patients in group C were older(P<0.05).Compared with group B,group C presented longer anesthesia time and were older(P<0.05).The total incidence of respiratory adverse events after extubation in group C was lower than that in group A(P<0.05).There was no statistical difference in patient's comfort and the incidence of agitation among the three groups(P>0.05).The incidence of adverse events③in group A was higher than that in groups B and C(P<0.05).There was no significant difference in the incidence of adverse events(①,②,④,⑤,and⑥)among the three groups(P>0.05).Patient grouping was positively correlated with gender and age,and negatively correlated with anesthesia time and intraoperative sufentanil dosage.Conclusions TES can be safely applied in clinical practice,and refine the timing of tracheal extubation,which provide reference for proper determination of the timing of tracheal extubation.