摘要目的 比较改良颈部透光法与导管厘米刻度法、气囊后标记线法、纤维支气管镜(纤支镜)法确定气管导管插入位置的效果.方法 采用前瞻性随机对照研究方法,选择2015年1月至3月上海市奉贤区中心医院收治的120例符合美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级进行全麻经口插管的成人患者,麻醉诱导后直接用喉镜插入导管.按随机数字表法将患者分为4组(n=30),分别采用导管厘米刻度法、气囊后标记线法、纤支镜法和改良颈部透光法(将自制光纤引导红色激光导管定位器用于导管定位)确定导管位置.插管时各组患者依次采用屈曲位、中立位、后仰位,测量3种头颈位时导管顶端至隆突和气囊后缘至声门的距离;记录各组导管位置不良的发生情况.结果 4组患者性别、年龄、体质指数差异均无统计学意义.采用气囊后标记线法确定导管位置的30例患者中有6例在直接喉镜下未见到声门,未能完成定位;其他3种方法均按照要求完成定位.①患者由屈曲位变为后仰位时,隆突—管尖距离逐渐延长,而气囊—声门距离逐渐缩短;当患者处于屈曲位和后仰位时,导管厘米刻度法测量隆突—管尖距离较纤支镜法明显缩短(cm:1.44±1.14比2.11 ±0.54,3.01±1.18比3.80±0.71,均P＜0.05),也较改良颈部透光法略有缩短(cm:1.44±1.14比1.93±0.81,3.01±1.18比3.45±0.91,均P＞0.05);当患者处于中立位、后仰位时,导管厘米刻度法测量气囊—声门距离较改良颈部透光法、气囊后标记线法、纤支镜法明显延长(cm:3.07±1.08比2.28±0.76、2.29±0.90、2.49±0.86,2.64±0.94比1.82±0.72、1.81±0.94、2.02±0.91,均P＜ 0.05).与纤支镜法比较,改良颈部透光法在3种体位下测量的隆突—管尖和气囊—声门的距离均较短,但差异无统计学意义.②隆突—管尖距离过短可导致导管插入支气管,气囊—声门距离过短可引起气囊压迫声门.采用导管厘米刻度法确定导管位置时,屈曲位有7例,中立位、后仰位各有1例发生导管插入支气管;采用气囊后标记线法时,屈曲位有4例、中立位有1例发生导管插入支气管,后仰位有4例发生气囊压迫声门;改良颈部透光法和纤支镜法仅屈曲位时各有1例发生导管插入支气管.结论 在进行气管插管时,如头颈位置变动,采用导管厘米刻度法更易插入支气管;采用气囊后标记线法既可能插入支气管也可能造成气囊压迫声门;而采用改良颈部透光法和纤支镜法较少发生插入支气管和气囊压迫声门.改良后的气管导管定位器以颈部透光法为原理,可以用于气管导管定位且效果较为满意.

abstractsObjective To compare the efficacy of four different methods to locate tracheal tube in the tracheal:modified transillumination method,21/23 cm rule,marked the intubation at a distance,and fiberoptic bronchoscope.Methods A prospective randomized controlled trial was conducted.120 endotracheally intubated adult patients with American Society of Anesthesiologists (ASA) classification Ⅰ-Ⅱ and admitted to Central Hospital of Fengxian in Shanghai from January to March 2015 were enrolled.The patients were randomly divided into four groups (n =30) and located by 21/23 cm rule,marked the intubation at a distance,fiberoptic bronchoscope and modified transillumination method (using homemade locator guided by a red laser fiber to position the depth of tube) respectively.An endotracheal tube was inserted and measured the distance of the tube tip to the carina (TTC),vocal cords to tracheal tube cuff (VC-TC) in three different neck positions,i.e.neck in flexion,neutral,and extension position.The number of improper position in four groups was recorded.Results There were no significant differences in gender,age,and body mass index among the four groups.Six of the 30 patients using marked tracheal tuba method failed to find vocal cords with laryngoscope,while the other three methods all completed successfully.① From neck flexion to extension,TTC was gradually increased,while VC-TC was gradually decreased.In neck flexion and extension positions,TTC distance in the 21/23 cm rule group was significantly shorter than that in the fiberoptic bronchoscope group (cm:1.44 ± 1.14 vs.2.11 ±0.54,3.01 ±1.18 vs.3.80±0.71,both P ＜ 0.05),and the distance was also shorter than that in modified transillumination method group (cm:1.44 ± 1.14 vs.1.93 ± 0.81,3.01--1.18 vs.3.45 ± 0.91,both P ＞ 0.05).VC-TC distance in the 21/23 cm rule group was significantly longer than that in the modified transillumination,the marked intubation,and the fiberoptic bronchoscope groups in neck neutral and extension positions,respectively (cm:3.07 ± 1.08 vs.2.28±0.76,2.29±0.90,2.49±0.86;2.64±0.94 vs.1.82±0.72,1.81-0.94,2.02±0.91,all P ＜ 0.05).TTC and VC-TC distances in three neck positions in the modified transiflumination group were shorter than those in the fiberoptic bronchoscope group without statistical significance.② If TTC was too short,an accidental bronchus intubation could happen,while if VC-TC was too short,an accidental damage of the vocal cord inducing by the cuff press could happen.In the 21/23 cm rule group,there were 7 cases that the tube wrongly inserted to bronchus in neck flexion,and 1 case in neutral and extension positions respectively.In the marked intubation group,there were 4 cases that the tube wrongly inserted into bronchus in neck flexion,and 1 case in neck neutral position,and there were 4 cases that the vocal cords were pressed by the cuffs in extension position.In the modified transillumintion and the fiberoptic bronchoscope groups,there was only 1 case that the tube wrongly inserted to bronchus in neck flexion respectively.Conclusions When neck position changed during trachea intubation,it was easier that the tube wrongly inserted to bronchus for 21/23 cm rule method to locate the position.Bronchus intubations and cuff press vocal cords could happen using the marked tube method,which was less be found using modified transillumination or fiberoptic bronchoscope methods.Finally,the modified transillumination methods can be used to locate with satisfactory effect.