阻塞性睡眠呼吸暂停综合征患者围术期气道管理的研究进展

阻塞性睡眠呼吸暂停综合征是一种常见的睡眠呼吸障碍疾病,其发生发展与多种因素有关。此类患者由于大多具有颈短粗、舌体肥大及口咽腔空间狭窄等异常解剖结构,会导致面罩通气以及插管困难,困难气道的发生率高。为降低此类患者围术期气道相关并发症的发生,本文就阻塞性睡眠呼吸暂停综合征患者围术期气道管理的研究进展进行综述,以期为临床提供参考。     

口腔颅颌面部常见综合征手术的麻醉处理

临床上一些口腔颅颌面综合征患者具有严重的解剖畸形和功能异常、影响正常发育或生活质量需要进行整形和功能重建手术治疗.这些手术包括先天性唇腭裂畸形、小颌畸形、尖头畸形、眶距增宽畸形、小耳畸形、半面萎缩畸形和睡眠呼吸暂停综合征等疾病和畸形.本研究总结了我院2000年至2008年间相关口腔颅颌颌面部常见综合征手术麻醉处理504例,现报道如下.     

阻塞性睡眠呼吸暂停患者围术期麻醉管理专家共识（2020修订版）快捷版

阻塞性睡眠呼吸暂停(obstructive sleep apnea,OSA)指患者睡眠时周期性地出现部分或完全的上呼吸道梗阻,以呼吸暂停和低通气为特征的疾病。我国成人OSA总患病率为3.93%,男性为女性的2.62倍[1],但临床诊断率较低。合并OSA的患者围术期并发症显著增多,死亡率显著增高,该类患者均应被列为麻醉的高危患者[2-3]。为此,在2014年ASA阻塞性睡眠呼吸暂停患者的围术期管理指南的基础上,参考国内外最新指南及文献,重点对OSA患者的术前筛查与诊断、危险因素、气道管理、麻醉用药等予以修订,以提高对OSA患者围术期麻醉安全管理。     

口腔正颌手术的麻醉进展

口腔正颌外科是颌面外科中的一个新兴的、前沿的分支学科，它的对象多为牙颌面畸形患者，这些患者的颌骨往往过短或过长，过宽或过窄，不仅影响到患者的面部外形，严重的还会导致咀嚼或吞咽困难，发音障碍，颞颌关节疾病以及心理问题。正颌手术就是根据牙颌面的畸形情况和治疗要求，切开并移动牙一骨复合体，重建牙颌面结构的三维空间关系和功能，从而获得较满意的面部美容效果。通常正颌手术均采用气管内插管全身麻醉，由于手术操作多涉及到上下颌骨的切开、复位和固定，而患者也往往伴有较严重的颅面畸形，因此手术前气道困难的预估、围术期的呼吸、循环管理等都与其他手术的全麻有所不同，风险也相对较大。     

牵张成骨联合正颌外科治疗成人严重小下颌畸形伴重度阻塞性睡眠呼吸暂停低通气综合征

目的:探讨牵张成骨术联合正颌外科的方法治疗小下颌畸形患者下颌骨严重发育不足伴重度睡眠呼吸暂停综合征(OSAHS)的效果。方法:对2例继发于颞下颌关节强直的小颌畸形患者首先采用牵张成骨技术进行治疗。手术在全麻下行双侧下颌角处截骨,安置牵引器,延长下颌升支及下颌体矫正小颌畸形及OSAHS。第二期在拆除牵引器的后行正畸治疗,继而采用正颌外科方法矫正颌面畸形及咬合关系,术后进一步正畸治疗矫正咬合关系排齐牙列。结果:2例患者均顺利完成治疗。下颌骨最小牵引距离25mm,最大牵引距离30mm,牵引区成骨良好。后气道间隙由治疗前的平均3.25mm增加到11.5mm;SNB角由术前平均67°增加到术后80°,OSAHS得以治愈。联合正颌外科及正畸治疗后小颌畸形得以矫治,面型及咬合功能均获得满意的效果。术后经过2年随访,未见复发。结论:牵张成骨技术联合正颌外科治疗成人严重小颌畸形伴重度OSAHS可以获得满意的效果。不仅可有效治疗伴发的OSAHS,而且能很好地矫治小下颌畸形引起的牙颌面畸形。     

超声技术应用于气道管理的研究进展

背景 目前气道评估及管理仍然是一门不断更新的临床科学.近些年超声可视化技术的应用为围手术期、急诊及重症医学科患者的气道管理提供了一个动态的监测工具. 目的 针对超声技术在气道管理中的应用情况进行综述. 内容 描述呼吸道超声解剖结构,并概括超声在围手术期气道管理中的应用. 趋向 超声的应用使围手术期气道管理发生里程碑式的发展,未来将有更广阔的应用前景.     

牵引成骨技术在严重小颌畸形伴中重度阻塞性睡眠呼吸暂停低通气综合征治疗中的应用

目的 探讨应用牵引成骨技术治疗严重小颌畸形伴中、重度阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea and hypopnea syndrome,OSAHS)的疗效。方法 采用下颌骨牵引成骨技术治疗严重小颌畸形伴中、重度OSAHS患者19例,分别于术前、后行多导睡眠监测仪监测及螺旋CT扫描,评价疗效并比较患者上气道三维结构的改变。结果 根据OSAHS疗效判定标准,19例中17例治愈,2例显效;手术后上气道各段的矢状径、矢状面积、横径和横截面积均较术前明显增加,气道容积从治疗前的(15 572.03±3 370.11) mm3变为治疗后的(21 182.69±4 533.15) mm3,变化主要发生在腭咽及舌咽,喉咽变化不明显。腭咽及舌咽区段气道各项检测指标与术前相比,差异均有统计学意义（P＜0.01或P＜0.05））。结论 下颌骨牵引成骨技术可明显扩张上气道腭咽段和舌咽段气道容积,从而有效治疗严重小颌畸形伴中、重度OSAHS。CT作为一种影像学手段,在该研究中有独到和重要的作用。     

人工智能在气道管理中的应用

人工智能技术的发展促进了气道管理方法和设备的更新,具有优化、解决气道管理中延迟插管、气道困难和气管导管位置的评估等问题的潜力。本文总结了气道管理领域常用的人工智能模型,从患者气管插管需求的预测、困难气道患者的识别、气管导管定位、气管插管设备的自动化和智能化进行总结阐述,为围术期气道管理工作提供参考。     

双水平气道正压通气（BiPAP）用于高位硬膜外腔阻滞时的呼吸抑制

双水平气道正压通气（ＢｉＰＡＰ）用于高位硬膜外腔阻滞时的呼吸抑制于布为，徐美英双水平气道正压通气（ＢｉＰＡＰ）是一种新的通气方式，其设计思想是对自主呼吸减弱或暂停患者增强其自发呼吸或促使其自发呼吸恢复。临床主要用于睡眠呼吸暂停和慢阻肺患者的呼吸支持，...     

巨大甲状腺肿物患者围手术期气道管理1例

巨大甲状腺肿物患者具有病程长、气管移位、麻醉手术风险大等特点。对于已知的困难气道, 围手术期全面评估和气道管理至关重要。文章报道1例巨大甲状腺肿物患者施行清醒气管插管麻醉[备体外膜肺氧合(ECMO)]的成功案例, 并结合相关文献总结经验, 为此类手术患者的围手术期气道管理提供参考。     

Anesthetic management for patients with arthrogryposis multiplex congenita and severe micrognathia: case reports

Arthrogryposis multiplex congenita (AMC) is a spectrum syndrome of multiple persistent limb contractures often accompanied by associated anomalies, including cleft palate, genitourinary defects, gastroschisis, and cardiac defects. Pediatric patients with AMC frequently present for multiple surgeries requiring general endotracheal anesthesia. We describe our anesthetic experience with the laryngeal mask airway and endotracheal tube in two neonates with AMC and severe micrognathia. We discuss AMC and outline the problems encountered in difficult airway management.     

Obstructive sleep apnoea and anaesthesia

Obstructive sleep apnoea (OSA) is the most prevalent sleep disorder, affecting up to 5% of the population. It can have a considerable impact upon perioperative morbidity and mortality. Patients require thorough preoperative assessment including a detailed history, the use of scoring systems to assess severity (such as the STOP-Bang questionnaire and the B-APNEIC score) and physical examination, with particular attention to airway assessment. Elective surgical patients who are deemed to be of high risk for OSA should be referred for polysomnography and implementation of continuous positive airway pressure therapy prior to surgery if indicated. Those patients deemed to be of low risk may be suitable for day surgery. Intraoperative anaesthesia management may include regional anaesthesia, local anaesthetic infiltration, or general anaesthesia depending on both patient and surgical factors. Particular attention should be paid to the potential for difficult airway management and avoidance of sedative agents and opioids where possible. Patients with OSA have an increased risk of cardiovascular and respiratory postoperative complications. Postoperative management should be guided by the severity of OSA, the occurrence of adverse respiratory events in the post anaesthesia care unit and the requirement for opioid analgesia.     

小下颌畸形梗阻性睡眠呼吸暂停综合征的整复治疗

我们采用下颌骨颏部截骨前移加植骨术治疗15例小下颌畸形所致的梗阻性睡眠呼吸暂停综合征(Obstructive sleep apnea syndrome 下简称 OSAS)。通过前移下颌骨颏部及附着于截骨块上的颏舌肌,以扩大口腔容积和舌根部的呼吸道,消除了上呼吸道阻塞,治愈了 OSAS 并改善了患者的容貌。     

Correlação entre síndrome da apneia obstrutiva e via aérea difícil na cirurgia otorrinolaringológica

Introduction

ENT patients with obstructive sleep apnea syndrome have a tendency of collapsing the upper airways in addition to anatomical obstacles. Obstructive sleep apnea syndrome is related to the increased risk of difficult airway and also increased perioperative complications. In order to identify these patients in the preoperative period, the STOP Bang questionnaire has been highlighted because it is summarized and easy to apply.

Obstructive sleep apnoea and anaesthesia

Obstructive sleep apnoea (OSA) is a common condition affecting approximately 4% of middle-aged individuals. The condition is more common in men with a history of snoring. Patients experience fragmented sleep caused by repetitive obstruction of the upper airway during sleep. There is mounting evidence that OSA is associated with metabolic syndrome. Metabolic syndrome comprises hypertension and type 2 diabetes, with associated disturbances of lipid metabolism and central obesity that predisposes to cardiovascular disease. Sleep disruption causes excessive daytime sleepiness and patients may be a danger to themselves or others, especially when driving. Anaesthetists meet the condition frequently, and should have a high index of suspicion when assessing overweight middle-aged patients for surgery. Patients may present for ENT or maxillofacial surgery as part of the management of the condition, but the group at greatest risk comprises those who are unrecognized and therefore untreated, who present for surgery for an unrelated condition. Recent screening questionnaires have been developed to aid the anaesthetist in spotting at risk patients, and in predicting the likelihood of postoperative complications.Difficulty with intubation is common, and airway obstruction may occur under anaesthesia if opioid and sedative drugs are used without caution. Many patients also suffer from acid reflux, which may complicate induction of anaesthesia. A plan for difficult airway management is essential, and consideration should be given to carrying out an awake intubation under topical anaesthesia of the upper airway. Knowledge of treatment with nasal continuous positive airway pressure is necessary, and all staff involved should be experienced in the management of such patients during the perioperative period.     

小下颌畸形梗阻性睡眠呼吸暂停综合征的整复治疗

我们采用下颌骨颏部截骨前移加植骨术治疗１５例小下颌畸形所致的梗阻性睡眠呼吸暂停综合征（Ｏｂｓｔｒｕｃｔｉｖｅｓｌｅｅｐａｐｎｅａｓｙｎｄｒｏｍｅ下简称ＯＳＡＳ）。通过前移下颌骨颏部及附着于截骨块上的颏舌肌，以扩大口腔容积和舌根部的呼吸道，消除了上呼吸道阻塞，治愈了ＯＳＡＳ并改善了患者的容貌。     

Obstructive sleep apnoea and anaesthesia

Obstructive sleep apnoea (OSA) is a common condition affecting approximately 4% of middle-aged individuals. The condition is more common in men with a history of snoring. Patients experience fragmented sleep caused by repetitive obstruction of the upper airway during sleep. There is mounting evidence that OSA is associated with metabolic syndrome. This syndrome comprises hypertension and type 2 diabetes, with associated disturbances of lipid metabolism and central obesity that predisposes to cardiovascular disease. Sleep disruption causes excessive daytime sleepiness and patients may be a danger to themselves or others, especially when driving. Anaesthetists meet the condition frequently, and should have a high index of suspicion when assessing overweight middle-aged patients for surgery. Patients may present for ENT or maxillofacial surgery as part of the management of the condition, but the group at greatest risk are those who are unrecognized and therefore untreated who present for surgery for an unrelated condition. Difficulty with intubation is common, and airway obstruction may occur under anaesthesia if opioid and sedative drugs are used without caution. Many patients also suffer from acid reflux, which may complicate induction of anaesthesia. A plan for difficult airway management is essential, and consideration should be given to carrying out an awake intubation under topical anaesthesia of the upper airway. Knowledge of treatment with nasal continuous positive airway pressure is necessary, and all staff involved should be experienced in the management of such patients during the perioperative period.     

Obstructive sleep apnoea and anaesthesia

Obstructive sleep apnoea is the most prevalent sleep disorder, affecting up to 5% of the population. It can have profound effects on patients perioperatively and can have a considerable impact on morbidity and mortality. Patients require thorough preoperative assessment including the taking of a detailed history, the use of scoring systems to assess severity (such as the STOP-Bang questionnaire) and physical examination with particular attention to the airway. Elective surgery patients who are deemed to be high risk for OSA should be referred for polysomnography with implementation of CPAP prior to surgery if indicated. Those deemed low risk may be suitable for day surgery. Intraoperative anaesthesia management may include regional anaesthesia, local anaesthetic infiltration or general anaesthesia, depending on the symptoms and the nature of surgery. Particular attention should be paid to a potential difficult airway, the use of short acting agents with a rapid wake up and avoidance of sedatives and opioids. OSA patients have an increased risk of cardiovascular and respiratory postoperative complications. Postoperative management should be based on the severity of OSA, the occurrence of adverse respiratory events in the recovery unit and the need for opioid analgesia.     

Obstructive sleep apnoea and anaesthesia

Obstructive sleep apnoea is the most prevalent sleep disorder, affecting up to 5% of the population. It can have profound effects on patients perioperatively and can have a considerable impact on morbidity and mortality. Patients require thorough preoperative assessment including the taking of a detailed history, the use of scoring systems to assess severity (such as the STOP-Bang questionnaire) and physical examination with particular attention to the airway. Elective surgery patients who are deemed to be high risk for OSA should be referred for polysomnography with implementation of CPAP prior to surgery if indicated. Those deemed low risk may be suitable for day surgery. Intraoperative anaesthesia management may include regional anaesthesia, local anaesthetic infiltration or general anaesthesia, depending on the symptoms and the nature of surgery. Particular attention should be paid to a potential difficult airway, the use of short-acting agents with a rapid wake up and avoidance of sedatives and opioids. OSA patients have an increased risk of cardiovascular and respiratory postoperative complications. Postoperative management should be based on the severity of OSA, the occurrence of adverse respiratory events in the recovery unit and the need for opioid analgesia.