困难气道的识别和处理Recognition and Management of Difficult Airway 川北医学院麻醉系教研室刘 洋临床麻醉是一门美学Let the anesthesiologists be beautiful like the summer flowers and the patients like autumn leaves.Derived from Rabindranath Tagore从容之美安静之美困难气道 Versus 从容安静之美 麻醉医师：对困难气道的认识不足，处理方法错误，就会陷入困窘，承担巨大的风险 患者：气道损伤，心肌损伤，脑损伤以致死亡困难气道的危害性 Okazaki 报道：在6742个普外科患者中，有4.9 %发生了意外的困难气管插管； Langeron的研究发现：在1500名手术患者中，5%出现中到重度的面罩通气困难； 麻醉相关死亡病例的研究显示：70%的麻醉死亡病例是呼吸道问题所致，主要原因是呼吸道梗阻、困难插管和插管误入食管。什么是困难气道Definition of the Difficult Airway困难气道：通常是指这样一种临床情况，即经过正规训练的麻醉医师在气管插管 (Difficult Endotracheal Intubation ) 和 (或) 面罩通气的时候遇到困难 (Difficult Mask Ventilation)。困难气道的三种临床情形 喉镜暴露困难 (Difficult Laryngoscopy) ：在常规喉镜暴露 下无法看到声门的任何一部分； 气管插管困难 (Difficult Endotracheal Intubation ) ：一个经过正规训练的麻醉医师使用常规喉镜正确地进行气管插管时，插管时间超过10分钟，或三次尝试不能成功。 面罩通气困难 (Difficult Mask Ventilation)：患者吸入 100% O2时，其Spo2 1亿。各种型号镜片和镜柄Fiberoptic Intubation EquipmentTechniques for Difficult Airway Management1.Techniques for difficult intubation alternative laryngoscope blades awake intubation blind intubation (oral or nasal) fiberoptic intubation intubating stylet / tube changer light wand retrograde intubation surgical airway access 2.Techniques for difficult ventilation esophageal-tracheal combitube intratracheal jet stylet larygeal mask oral and nasopharnygeal airways rigid ventilating bronchoscope surgical airway access transtracheal jet ventilation two person mask ventilationOral Pharyngeal Airways不同颜色代表不同型号Cuffed TypesConventional TypesBlind Intubation through ILMA插管喉罩经ILMA进行气管导管盲插LMA AirwaysFrom Lopez-gil M et al BJA 1999; 82:132-4Gastric LMAConventional LMALight Wand灯杖用于双腔气管插管灯杖用于单腔气管插管Fiberoptic Tracheal IntubationA from Uezono S et al; Anesthesiology 1998; 88:1677B from Greenberg BJA 82:395Develop primary and alternative strategiesAwake IntubationAirway Approached by Non-Surgical IntubationAirway Secured by Surgical AccessSucceedFailCancel CaseConsider Feasibility of Other OptionsSurgical AirwaySurgery under mask anesthesia, surgery under local anesthesia infiltration or regional nerve blockade, or intubation attempts after induction of general anesthesiaDevelop primary and alternative strategiesIntubation Attempts After Induction of General AnesthesiaInitial Intubation attempts SuccessfulInitial Intubation Attempts Unsuccessful1.Returning to spontaneous ventilation.2.Awakening the patient.3.Calling for help.Non-Emergency Pathway i.e., Mask Ventilation AdequateEmergency Pathway i.e., Mask Ventilation inadequateAlternative Approaches to IntubationCall for HelpSucceedFail After multiple AttemptsSurgical AirwayAwaken PatientsSurgery Under Mask AnesthesiaOne More Intubation AttemptEmergency Non-Surgical Airway VentilationSucceedFailEmergency Surgical AirwayFailSucceedDefinitive AirwayStrategy for Extubation of the Difficult Airway Awake extubation versus extubation before the return of consciousness. The depressant effect of general clinical factors on ventilation after extubation. The formulation of an airway management plan that can be implemented if the patient is not able to maintain adequate ventilation after extubation. A consideration of the short-term use of a device that can serve as a guide for expedited reintubation.Follow-Up Care A description of the airway difficulties that were encountered. A description of the various airway management techniques that were employed. Information the patient of the airway difficulty. The anesthesiologist should evaluate and follow the patient for potential complications of difficult airway management: edema, bleeding, tracheal and esophageal perforation, pneumothorax and aspiration.Versus技巧娴熟、配备先进、 从容自如的麻醉医师轻轻的我来了， 正如我轻轻的走； 悄悄的我来了， 正如我悄悄的走