使用Bonfils硬质纤维光导镜困难插管的预测因素
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Predictors of Difficult Intubation with the Bonfils Rigid Fiberscope
背景与目的
气管内插管通常通过直接喉镜（DL）进行。 然而，在某些患者中，直接喉镜插管可能是困难的或不可行的。Bonfils RigidFiberscope®（BRF）是另一种气管插管设备，它的设计也提出了预测困难DL的因素是否也能预测困难BRF的问题。 我们进行了这项研究，以确定哪些人口统计学和形态学因素能预测使用BRF的困难插管。
方 法
招募了四百名准备择期手术的成年患者。清醒插管、快速诱导或没有计划使用肌松剂的患者被排除在外。记录数据包括年龄，性别，体重，身高，ASA分级，打鼾史和睡眠呼吸暂停史，Mallampati分级，上唇咬合测试评分，甲颏距离，颈屈伸距离，颈围，最大颈部屈曲和伸展度，环状软骨的颈部皮褶厚度以及通过DL困难插管的Cormack和Lehane评分，声门显示质量（好或差）以及插管次数和插管成功的时间。进行单因素分析以评估患者特征与插管需要时间的关系。显示出显着相关性的变量使用标准平方模型进行变量分析。 P <0.05被认为是显着的。
结 果
400例（99％）中396例患者使用了BRF进行声门显像。 在首次尝试中，390例患者成功使用BRF插管; 6名患者需要> 1的尝试; 4名患者不能单独使用BRF进行插管。 这4名患者中有2名患者联合使用DL和BRF，1名患者联合使用DL和Frova探条，1名患者使用DL和具有半刚性管形状气管内插管的组合进行插管。 平均插管时间为26±13秒。分析显示，开放时间缩短（P = 0.008），体重指数升高（P = 0.011），Cormack和Lehanegrade指数升高（P = 0.038）预测了较长的插管时间，而缩短的甲颏距离预示插管时间略短（P <0.0001）。
结 论
与DL相比，口腔开放困难，高BMI和高Cormack和Lehane评分预示更长的插管时间。 甲颏距离的缩短预示着BRF的插管时间略短，这可能是因为最初为是为了针对下颌退缩的儿童而设计的。 这些发现以及BRF在研究中的高成功率以及联合BRF与DL进一步提高成功率的情况有助于确定BRF插管在当代气道管理中的作用
原始文献摘要
Nowakowski M, Williams S, Gallant J, et al. Predictors of Difficult Intubation with the Bonfils Rigid Fiberscope[J]. Anesthesia & Analgesia, 2016, 122(6):1901-1906.
BACKGROUND: Endotracheal intubation is commonly performed via direct laryngoscopy (DL). However, in certain patients, DL may be difficult or
impossible. The Bonfils Rigid Fiberscope®(BRF) is an alternative intubation device, the design of which raises the question of whether factors that predict difficult DL also predict difficult BRF. We undertook this study to determine which demographic, morphologic, and morphometric factors predict difficult intubation with the BRF.
METHODS: Four hundred adult patients scheduled for elective surgery were recruited. Patients were excluded if awake intubation, rapid sequence induction, or induction without neuromuscular blocking agents was planned. Data were recorded, including age, sex, weight, height, American Society of Anesthesiologist classification, history of snoring and sleep apnea, Mallampati class, upper lip bite test score, interincisor, thyromental and sternothyroid distances, manubriomental distances in flexion and extension, neck circumference, maximal neck flexion and extension,neck skinfold thickness at the cricoid cartilage, and Cormack and Lehane grade obtained via DL paralysis was confirmed. Quality of glottic visualization (good or poor), as well as the number of intubation attempts and time to successful intubation with the BRF, was noted. Univariate analyses were performed to evaluate the association between patient characteristics and time required for intubation. Variables that exhibited a significant correlation were included in a multivariate analysis using a standard least squares model. A P < 0.05 was considered significant.
RESULTS: Glottic visualization with the BRF was good in 396 of 400 (99%) cases. On the first attempt, 390 patients were successfully intubated with the BRF; 6 patients required >1 attempt; 4 patients could not be intubated by using the BRF alone. These 4 patients were intubated by using a combination of DL and BRF (2 patients), DL and a Frova bougie (1 patient), and DL and an endotracheal tube shaped with a semirigid stylet (1 patient). Mean time for successful intubation was 26 ± 13 seconds. Multivariate analysis showed that decreased mouth opening (P = 0.008), increased body mass index (P = 0.011), and higher Cormack and Lehanegrade (P = 0.038) predicted longer intubation times, whereas shorter thyromental distance predicted slightly shorter intubation times (P < 0.0001).
CONCLUSIONS: Mouth opening, body mass index, and high Cormack and Lehane grade predict longer intubation times, as with DL. Decreasing thyromental distance predicts slightly shorter intubation times with the BRF, possibly because of a design initially optimized for a pediatric population with receding chins. These findings, along with the high success rate of BRF in
study, and the possibility of further increasing success rates by combining BRF with DL,help define the role of BRF intubation in contemporary airway management. (Anesth Analg 2016;122:1901–6)
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