Strengthen the Management of Difficult Airway and Improve the Treatment of Clinical Practice: Interpretation on 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway
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摘要: 气道管理是急诊医师必须掌握的基本技能, 困难气道管理是急诊工作面临的重要挑战之一。2022年, 美国麻醉医师协会发布了第四版困难气道管理指南, 从困难气道的定义、评估、准备工作、管理流程、拔管过程等方面均给出了最新循证医学证据支持, 为临床医师提供了权威的困难气道管理规范。本文将从急诊医学角度对指南相关内容进行解读, 以帮助临床医师提高认识, 进一步提高我国困难气道管理水平。Abstract: Airway management is a basic skill for emergency doctors. Difficult airways are one of the most important challenges. In 2022, the American Association of anesthesiologists published the fourth edition of guideline on the management of difficult airways, which provided us with the latest evidence-based medicine about the definition, evaluation, preparation, management and extubation of difficult airways. To improve the status of airway management of emergency doctors in China, this paper interprets the key points and updates the contents of the guidelines from the perspective of emergency medicine.
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Key words:
- difficult airway /
- management /
- emergency /
- clinical practice guideline /
- interpretation
作者贡献:徐胜勇负责文献查阅和论文撰写;徐军、朱华栋负责论文选题、解读和审校;于学忠负责论文审校。利益冲突:所有作者均声明不存在利益冲突 -
表 1 2022版和2013版指南推荐的便携式困难气道管理工具箱物品清单
物品分类 2022版指南[4] 2013版指南[3] 可选的紧急通气设备 各种型号的口咽和鼻咽通气道 各种型号带咽部密封套囊的声门上气道 各种型号的喉罩 鼻导管 可选的插管设备 各种型号的气管导管(包括微型喉管) 各种型号的气管导管 插管用各种设计和型号的硬质喉镜片 各种设计和型号的硬质喉镜片,包括硬质纤维喉镜 气管导管导芯,如半硬质管芯、发光管芯和插管钳以便调整导管远端方向 气管导管导芯,如半硬质管芯、通气导管交换芯、光棒和插管钳以调节气管导管远端方向 气管插管型声门上气道 声门上气道(如用于无创通气/气管插管的各种型号的喉罩) 带有配套导芯的视频喉镜 视频喉镜 光学喉镜 插管用可视管芯 可屈曲式插管支气管镜、局麻药品和设备、牙垫 可屈曲式光纤气管插管工具 安特里(Aintree)气管插管引导导管 紧急气道设备 紧急有创气道设备 紧急有创气道设备 喷射通气设备 其他 各种型号的气道交换导管 多种呼气末CO2监测仪 呼气末CO2监测仪 当地可接受的困难气道管理流程图/辅助资料/清单(塑封版) 除雾器 表 2 与困难气道管理相关的人为因素[4]
类别 内容 医师因素 气道管理之前 从业者的知识和培训 可能的候选方案 术前评估 过于自信 气道管理期间 内部和外部压力(疲劳、疾病、工作压力) 决策制订(保持不变、识别判断、态势感知、数据解读) 团队建设(领导力、角色分工、权限范围、无菌原则) 寻求帮助 气道管理之后 总结汇报 外在因素 患者因素 解剖/生理性困难气道风险、误吸风险、感染风险、暴露风险、紧迫性、合并症 环境因素 气道设备 监控设备 个人防护设备 制度因素 机构文化、人力配备、轮岗计划 方案和报告制度 督导/支持、培训 -
[1] American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway[J]. Anesthesiology, 1993, 78: 597-602. doi: 10.1097/00000542-199303000-00028 [2] American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway[J]. Anesthesiology, 2003, 98: 1269-1277. doi: 10.1097/00000542-200305000-00032 [3] Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway[J]. Anesthesiology, 2013, 118: 251-270. doi: 10.1097/ALN.0b013e31827773b2 [4] Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 Ameri- can Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway[J]. Anesthesiology, 2022, 136: 31-81. doi: 10.1097/ALN.0000000000004002 [5] 中国急诊气道管理协作组. 急诊气道管理共识[J]. 中华急诊医学杂志, 2016, 25: 705-708. doi: 10.3760/cma.j.issn.1671-0282.2016.06.003 China Emergency Airway Management Cooperation Group. Emergency airway management consensus[J]. Zhonghua Jizhen Yixue Zazhi, 2016, 25: 705-708. doi: 10.3760/cma.j.issn.1671-0282.2016.06.003 [6] 吴觉伦, 申乐. 全面评估、充分准备、合理决策、重视氧合: 《2022年美国麻醉医师协会困难气道管理实践指南》解读[J]. 协和医学杂志, 2022, 13: 421-426. doi: 10.12290/xhyxzz.2022-0075 Wu JL, Shen L. Evaluation, Preparation, Decision, and Oxygeration: Interpretation on 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway[J]. Xiehe Yixue ZaZhi, 2022, 13: 421-426. doi: 10.12290/xhyxzz.2022-0075
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