[Crisis event] Causes and coping strategies of unexpectedly difficult airway during perianaesthesia

Accidentally difficult airway during peri-anesthesia 1 Occurrence and harm of unexpectedly difficult airway during peri-anesthesia One of the basic clinical skills mastered
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Since McEven's first successful tracheal intubation in humans in 1880, difficult airways have plagued medical workers from time to time
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The ASA has recommended the development of a definition of difficult airway: Difficulty in mask ventilation and/or tracheal intubation in patients under the management of routinely trained anesthesiologists.
Difficult airway is classified as emergency air according to the presence or absence of mask difficulty and non-emergency airways
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Difficulty in mask ventilation refers to insufficient ventilation during the process of giving pure oxygen and positive pressure ventilation to the mask, so that patients with SpO2>90% before anesthesia cannot maintain SpO2>90%: Difficulty in laryngoscopy No part of the glottis could be seen; difficult tracheal intubation was defined as routine laryngoscopy for >10 minutes or more than 3 failed intubation attempts
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In the peri-anesthesia period, the most common is the occurrence of difficulty in ventilation after induction of anesthesia or difficult intubation under laryngoscope exposure
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When a difficult airway occurs, effective artificial ventilation cannot be implemented, and the patient can suffer from cardiac arrest, brain damage and even death due to hypoxia in a short period of time
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In critically ill patients, the hazard of difficult airways cannot be ignored, and one or more of the following problems often occur: poor mask sealing, excessive air leakage, and increased resistance to inhalation or outflow
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Mask hypoventilation often occurs with: absent or diminished thoracic respiratory motion, cyanosis, gastric inflow or expansion, decreased oxygen saturation, absent or decreased end-tidal carbon dioxide waveform, and hypoxemia or hypercapnia-related symptoms.
Changes in hemodynamic parameters (eg: hypertension, tachycardia, arrhythmia, etc.
)
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According to statistics, the incidence of difficult airway in China is 1% to 5%, and the incidence is as high as 15% in some special populations such as oral and maxillofacial and plastic surgery patients
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So far, the recognition and management of difficult airway is still a concern of anesthesiologists and an important research content of clinical anesthesiology
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Since 1993, the United States, Canada, France, and Italy have developed practice guidelines for airway management to reduce airway-related complications
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In light of China's national conditions, an expert group organized by the Anesthesiology Branch of the Chinese Medical Association drafted and formulated the "Expert Opinions on Management of Difficult Airways" in 2007, with a view to providing guidance for the management of difficult airways in clinical anesthesia, so as to facilitate the management of difficult airways.
It is more standardized, convenient and accurate, and minimizes the risk of airway-related complications
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For all surgical patients, airway assessment must be performed prior to anesthesia, which aids in the selection of appropriate anesthesia induction methods and endotracheal intubation techniques
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Pre-anesthesia evaluation can detect more than 90% of endotracheal intubation difficulties, known as cognitively difficult airways, which prompts the anesthesiologist to make all necessary preparations before the patient becomes unconscious and apnea
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However, according to the existing methods of predicting airway difficulty, even the most rigorous and careful prediction cannot completely detect every case of difficult airway, which is called non-cognitively difficult airway, or accidental difficult airway
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How to deal with an unexpectedly difficult airway is related to the safety of the patient's life.
We must keep in mind the principle of "ventilation first" at any time of clinical treatment
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Although endotracheal intubation has been practiced for over 200 years and various endotracheal intubation devices have been devised, difficult airways remain a challenge for the anesthesiologist and can even lead to catastrophic events
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Unexpectedly difficult airway can increase the incidence of complications of endotracheal intubation
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The risk of aspiration is increased when the patient is full and with a difficult airway, but aspiration can also occur in patients with a difficult airway who are routinely fasting: with a difficult airway, cardiovascular responses during laryngoscopy exposure include hypertension, Tachycardia and arrhythmias also increase; the incidence and severity of laryngospasm, bronchospasm, and increased intracranial pressure during tracheal intubation also increase in difficult airways
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Especially when effective mask artificial ventilation cannot be implemented, the patient can suffer from cardiac arrest due to hypoxia in a short period of time, or even die, with irreversible consequences for the patient
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According to reports, 70% of anesthesia-related deaths are due to airway problems, mainly airway obstruction, difficult intubation, and intubation into the esophagus
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For the unrecognized difficult airway, its occurrence will cause great mental stimulation and stress to the anesthesiologist in charge of the case, and the probability of serious consequences will be greatly increased due to the lack of necessary preparation
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Finally, the occurrence of potential complications of a difficult airway can also cause great distress to the patient
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These complications often include: throat edema, bleeding, perforation of the trachea and esophagus, pneumothorax, and aspiration
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Clinical signs and symptoms of complications associated with difficult airways often include: sore throat, pain and edema of the face and neck, chest pain, subcutaneous emphysema, dysphagia, hoarseness,
etc.

Due to the failure to predict in advance and the lack of necessary communication with patients and their families, once serious consequences occur, it will cause medical disputes, expand social conflicts, and increase unnecessary medical expenses
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2.
Analysis of the causes of unexpectedly difficult airway during peri-anesthesia period THE MEANING OF LIFE The difficult airway is composed of two types: difficulty in mask ventilation and difficulty in endotracheal intubation.
In clinical work, it is necessary to have a clear understanding of the high-risk factors of difficult airway, so as to effectively guard against
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1.
Difficulty mask ventilation Difficulty mask ventilation is more common in patients with obesity, tumors, infection and inflammation
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Pediatrics show fewer problems than adults, and it is more difficult to keep the mask closed in toothless elderly patients
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Its occurrence is also related to the mastery of the correct mask buckle technique by the anesthesiologist
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2.
Difficulty in endotracheal intubation.
From the oral cavity (or nasal cavity) to the trachea, three anatomical axes can be divided into three anatomical axes, which intersect each other and form an angle: the oral axis is the line from the oral cavity (or nasal cavity) to the posterior pharyngeal wall; the pharyngeal axis is the line from the The line from the posterior pharyngeal wall to the larynx: The laryngeal axis is the line from the larynx to the upper part of the trachea
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During tracheal intubation, these three axes need to overlap for the purpose of exposing the glottis
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Anything that affects the alignment of these three axes and the maneuvering space can be a factor for a difficult airway
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It is generally divided into two aspects: the patient's own aspect and the iatrogenic aspect
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(1) Patient factor: it is dominant in the process of clinical practice
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①Anatomical factors: Whether it is congenital or acquired, if the three axes of the mouth, pharynx, and larynx are in a straight line, factors such as maxillary protrusion, small mouth, macroglossia, deviated nasal septum, and misaligned trachea may become difficult.
Airway causes
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② systemic or local factors: such as obesity, diabetes, goiter, oropharyngeal tumors, musculoskeletal diseases, such as acromegaly, temporomandibular joint stiffness and so on
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③Trauma and inflammatory factors: Intraoral hematoma and intraoral inflammation caused by head and face trauma may reduce the operating space or laryngeal edema.
Cervical spine injury will reduce the range of motion of the neck, and scar contracture formed after extensive facial burns.
restricted mouth opening
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④Other factors: Pregnant women and hungry patients may experience nausea and vomiting during intubation, and some patients with hemodynamic instability and respiratory decompensation cannot lie supine
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(2) Iatrogenic factors: mainly include the clinical operation skills and psychological quality of the doctors who perform anesthesia, and whether the medical institution has advanced intubation equipment and other factors
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3 Coping Strategies for Accidentally Difficult Airway During
Peri-anesthesia Early identification before induction of anesthesia is an important means to prevent the occurrence of unexpectedly difficult airways, make all necessary preparations, and avoid serious consequences .
At the same time, in the event of an accidental difficult airway, certain treatment principles should be followed, and skilled airway management skills should be used to make the patient turn the corner .
1.
Airway assessment before anesthesia can be divided into assessment of difficulty in mask ventilation and assessment of difficulty in tracheal intubation (1) Assessment of difficulty in mask ventilation: factors related to difficulty in mask ventilation include age > 55 years, body mass index (BMI) > 26, snoring History, bearded, missing teeth .
If the above two items are satisfied at the same time, the sensitivity and specificity will be more than 70% .
In addition, there are maxillofacial abnormalities, mandibular retraction or protrusion, obstructive sleep apnea and so on .
(2) Evaluation of difficulty in endotracheal intubation ① Medical history: ask the patient's medical history in detail, most patients can provide valuable information such as whether there is a history of general anesthesia before, whether there is a history of difficult airway, etc.
Certain diseases, surgery, radiation therapy may suggest the occurrence of difficult airways, such as rheumatoid arthritis, ankylosing spondylitis, snoring, pregnancy, acromegaly, diabetes, Down syndrome, temporomandibular joint surgery, neck Fusion, tracheal surgery, oropharyngeal radiotherapy and surgery .
②General physical examination: check for oral, maxillofacial, and neck lesions; check for prominence or loosening of incisors, and patency of the nasal cavity; check the condition of the temporomandibular joints on both sides; certain features may lead to difficulty in tracheal intubation, such as morbid obesity , Small mouth, jaw retraction, tongue hypertrophy, head and neck stiffness .
③ Mallampati grading: The patient sits in front of the anesthesiologist, opens his mouth and stretches his tongue to the maximum (no pronunciation), and the doctor grades the patient according to the pharyngeal structure that can be seen
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Grade I: the soft palate, pharyngeal and palatine arches, and palatine arches are visible; grade II: the soft palate, pharyngeal and palatine arches are visible, and the palatine arch is covered by the base of the tongue; grade III: only the soft palate is seen; grade IV: no soft palate is seen
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The higher the grade, the more difficult the intubation
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Grades III to IV are difficult intubation
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④Incisor spacing: The incisor spacing refers to the distance between the upper and lower anterior teeth at the maximum mouth opening
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The normal value is ≥3cm (2 horizontal fingers), and if it is less than 3cm, intubation may be difficult
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⑤ Nail-buccal spacing: Nail-buccal spacing refers to the distance from the thyroid cartilage notch to the buccal process of the mandible when the patient's head is tilted back to the maximum
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When the distance between nails and whiskers is ≥6.
5cm, there is no difficulty in intubation; in 6-6.
5cm, intubation is difficult, but intubation can be done under the exposure of the laryngoscope; if it is less than 6cm (for adults with 3 fingers), the intubation cannot be performed with a laryngoscope.
tube
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⑥ Neck flexion and extension: Neck flexion and extension refers to the range of motion that the patient can flex the neck to the maximum extent and extend the neck
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The normal value is greater than 90°, and it can reach 35° to 80° from the neutral position to the maximum backward position, and intubation is difficult
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⑦ Mandibular extension: The mandibular extension is an index of mandibular mobility and can be evaluated by the upper lip bite test
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The patient bites the upper lip with the lower incisors, which is grade 1; the lower incisors are lower than the upper lip line, which is grade 2; and the inability to bite the upper lip is grade 3
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Grade 3 may have difficulty intubation
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⑧Cormack-Lehane laryngoscope exposure classification: classification according to the visibility of laryngeal structures under direct laryngoscope exposure
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Grade I, the glottis is completely exposed; Grade II, only the posterior half of the glottis is seen; Grade III, only the epiglottis is seen; Grade IV, no epiglottis is seen
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Among them, grades III to IV often have difficulty in tracheal intubation
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⑨Wilson risk score: Wilson et al used weight, neck mobility, mandibular mobility, mandibular retraction and maxillary protrusion as 5 risk factors to evaluate the airway, each factor has three scores of 0, 1, and 2, and the total score 0 to 10 points
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Difficult airway is present in ≥2 points
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To sum up, the single application of any one of the assessment methods cannot accurately assess the difficult airway because other factors that cause the difficult airway are not considered.
Improve sensitivity and accuracy in identifying difficult airways
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In addition, the presence of difficulties in laryngeal mask placement, cricothyroidotomy, and tracheotomy should also be assessed
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2.
Treatment principles for difficult airways (1) For patients with difficult airways after pre-anesthesia evaluation, the treatment principles are divided into the following three situations
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① If direct laryngoscope exposure is difficult, but mask ventilation can be performed and the patient has a certain tolerance to hypoxia, intubation after induction of general anesthesia can be carefully selected
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② If direct laryngoscope exposure is difficult, and mask ventilation may still be difficult or the patient has poor tolerance to hypoxia, awake intubation is required
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③ If the patient has a full stomach, there is a risk of reflux and aspiration, and awake intubation is still required
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(2) For patients who are not found to have a difficult airway after pre-anesthesia evaluation, the management of unexpectedly difficult airway after induction of anesthesia can be divided into two situations
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①If it is difficult to ventilate without a mask, the patient can maintain satisfactory ventilation and oxygenation, and can have sufficient time to consider other methods of establishing an airway
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For example, use various video laryngoscopes, >
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Awake intubation can also be used after the patient is awake and muscle relaxation recovers
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② When the mask ventilation is difficult at the same time, the patient is in an emergency hypoxia state, and should seek help immediately.
Use the oropharyngeal or nasopharyngeal airway to keep the tongue away from the posterior pharyngeal wall to facilitate positive pressure ventilation, or use the esophagotracheal combination.
Catheter, laryngeal mask ventilation to establish artificial ventilation
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Surgical methods such as cricothyroidotomy (jet tracheal ventilation) or tracheotomy can be performed in emergencies to save life if the patient is at serious risk of aspiration
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3.
Establishment of artificial airway in difficult airway (1) Non-tracheal intubation artificial ventilation ①Mask ventilation: No matter what the airway conditions are, 100% pure oxygen mask ventilation should be used.
If there is difficulty, immediately seek help from a superior doctor
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When ventilating the mask, the fingers should be placed on the bone instead of the soft tissue, relying on the thumb and the index finger to press down and the other 3 fingers to lift the mandible to complete the mask ventilation, by advancing the mandible, extending the upper neck, and raising The lower whiskers allow the tongue and soft tissues to leave the posterior pharyngeal wall, open the upper airway, and provide positive pressure ventilation by an assistant or an anesthesia machine
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When a satisfactory airway cannot be obtained after adjusting the mask, neck, and jaw, an oropharyngeal airway can be used to move the tongue away from the posterior pharyngeal wall
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The oropharyngeal airway should be placed in reverse from the right side of the mouth, with the curved surface facing the palate, and then rotated 180° to the functional position near the posterior pharyngeal wall
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②Esophagotracheal combined catheter ventilation: The combined esophagotracheal catheter is a ventilation tool used in emergency situations
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The surgeon opens the patient's mouth with one hand and holds the catheter with the other, and the curvature is consistent with the natural curve of the pharynx
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Push forward gently until the marker line on the catheter is flush with the teeth
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The large and distal small balloons are inflated separately
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If the combined catheter is located in the esophagus, it is connected to the lumen of the esophageal catheter for ventilation; if the combined catheter is located in the trachea, it is connected to the lumen of the tracheal catheter for ventilation
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③ Laryngeal mask ventilation: The laryngeal mask, as a kind of airway between the mask and the tracheal intubation, is considered to be the most important development in the ventilation device in the past 20 years
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Spontaneous breathing can be preserved, positive pressure ventilation can also be used, and it can also be used to manage difficult airways
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Can be used in routine or emergency situations
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Compared with the endotracheal tube, the insertion of the laryngeal mask has relatively low requirements on the depth of anesthesia and the patient's position, and the laryngeal mask can be placed even in the prone position
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The difficulty of inserting the laryngeal mask was not related to the Mallampati classification and Cormack-Lehane score, and the location of the larynx was its influencing factor
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An anterior larynx may facilitate laryngeal mask intubation
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Choose a suitable laryngeal mask, the patient is in a backward head position, the left hand controls the patient's head, and the right hand inserts the laryngeal mask along the middle of the upper palate to the throat, and stops when there is a great resistance, inflate the air bag, and breathe on both sides of the chest auscultation.
The sound is clear, indicating that the laryngeal mask ventilation function is good
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If an intubated laryngeal mask is used, the tracheal tube can be inserted into the ventilation tube at this time
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(2) Manual ventilation with endotracheal intubation ①Awake endotracheal intubation: At this stage, awake endotracheal intubation is still the most effective means to deal with difficult airways.
The key to its success lies in perfect topical anesthesia, appropriate sedation level and skilled operation
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The main contents include: a.
Explain the necessity of intubation and the whole process patiently and meticulously to the patient; b.
The airway is sufficiently dry (such as intravenous injection of glycopyrronium bromide 0.
2-0.
4 mg); c.
The expansion of the nasal cavity (reasonable use of mucosa Vasoconstrictor such as phenylephrine 0.
25%~1% intranasal); d.
Topical anesthesia of the nasopharynx, oropharynx and hypopharynx [such as using 1% tetracaine to press the mouth (nose) pharyngeal cavity, tongue base, epiglottis , pyriform fossa, glottis, larynx and trachea in order to perform complete topical anesthesia]; e.
sedative drugs (such as fentanyl 25 ~ 500ug starting with a small dose, midavalan starting with a small dose); f.
skilled Master the intubation technique, and the movements are proficient and gentle (for example, during blind probing through the nose, the head should be leaned back and the shoulders should be raised, and the head position should be adjusted appropriately according to the intensity of the breath sounds outside the mouth of the tube (backward to supine).
A forward flexion), external palpation of the neck is helpful to determine the position of the catheter]
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② Fiberoptic bronchoscope guides intubation: In the current technology to solve the difficulty of intubation, fiberoptic bronchoscope is considered to be the most useful auxiliary device
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Successful placement of the fiberoptic bronchoscope takes several minutes, so other methods should be used to quickly establish the airway when the patient is facing severe hypoxia, and if a fiberoptic bronchoscope is used, it must be selected at the beginning because bleeding, secretions, and edema can cause severe hypoxia.
making it difficult to place
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③Light rod: The light rod is a flexible tube with a light bulb at the front
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When using the light rod intubation, the bright light spot can be seen moving down on the front of the patient's neck, which provides a visual indicator for blind intubation, thus effectively improving the success rate of difficult intubation
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④ Retrograde guided intubation: This method is useful for those with severe maxillofacial trauma, temporomandibular joint stiffness, and upper airway masses
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Under topical anesthesia, the cricothyroid membrane was punctured, a guide wire was inserted, and the tracheal tube was inserted through the glottis and into the trachea along the guide wire
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(3) Surgical establishment of artificial airway ①Cricothyroidotomy: In the case of intubation and inability to ventilate, it will lead to a progressive decrease in oxygen saturation, and the classical tracheotomy is too late to perform.
The membrane is cut and a smaller tracheal tube or tracheal cannula is inserted
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The incidence of postoperative subglottic stenosis is significantly higher in children under 12 years of age, so cricothyroidotomy is contraindicated
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② Tracheotomy: In an emergency, when other methods cannot solve the ventilation problem, in order to save the patient's life, a tracheotomy can be performed.
Only do lateral expansion between the upper and lower cartilage rings to insert the tracheal tube.
This method is less traumatic and can avoid postoperative tracheal stenosis
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Summary of the ASA Difficult Airway Clinical Guidelines: Difficult airways remain one of the most important contributors to anesthesia-related complications and deaths
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A careful airway examination should be performed before each intubation
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If the patient is likely to experience difficulty with intubation and/or mask ventilation, ensure that the patient's airway is open when awake
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If the patient is already anesthetized and/or paralyzed before intubation is found to be difficult, multiple attempts at forced intubation should be avoided, as laryngeal edema and hemorrhage will progress and make mask ventilation impossible
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After several attempts at intubation, it is best to awake the patient and perform semi-selective endotracheal intubation, or ventilate with a mask
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If the patient cannot be ventilated with a mask, a laryngeal mask should be used
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If still unsuccessful, a combined tube, rigid bronchoscope, or transtracheal jet ventilation should be used immediately
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If adequate gas exchange cannot be achieved, surgery should be performed immediately to open the airway
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4.
Thoughts on Accidental Difficult Airway During Perianaesthesia THE MEANING OF LIFE The incidence of difficult airway is 1% to 5%
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Among the death cases related to anesthesia, 70% of the deaths are caused by respiratory problems.
Based on the idea of ​​"anesthesia principle - safety first", leaders and anesthesiologists should pay attention to the occurrence of unexpectedly difficult airways
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First, prevention is the most important, the anesthesiologist should carefully ask the airway-related medical history, and recommend removing correctable risk factors for mask ventilation, such as shaving beards, removing dentures, etc.
Imaging, laryngoscopy and fiberoptic bronchoscopy
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Second, under the attention of leaders, departments should be equipped with emergency vehicles for difficult airways, and there should be airway equipment involved in the accidental difficult airway procedures, such as laryngoscopes, tracheal tubes, oropharyngeal airways, laryngeal masks, Anterior cricothyroidotomy tools, etc.
, the anesthesiologist should be proficient in the use of these devices
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Third, anesthesiologists should be familiar with the treatment strategies and procedures in the 2015 Guidelines for the Management of Unexpected Airway Intubation in Adults, so as to prepare for the occurrence of unexpectedly difficult airway, according to the specific conditions of the patient's airway, according to the procedure, the maximum To ensure the safety of patients' lives
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Fourth, anesthesiologists should actively carry out standardized training, strengthen airway management simulation operation training, use familiar equipment to handle the airway and skilled techniques, strengthen consolidation skills, increase the crisis management awareness of unexpectedly difficult airways, and do whatever it takes.
A backup plan for unanticipated difficult airways should be made prior to anesthesia
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Fifth, the routine of induction of anesthesia should be followed.
Before induction of anesthesia, sufficient "pre-oxygenation" should be carried out to ensure the patient's oxygen reserve and maintain the patient's oxygenation
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During the induction process, before the administration of muscle relaxants, ventilation experiments should be performed routinely to avoid the occurrence of emergency difficult airways
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Airway manipulation should be done gently to minimize damage
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Although there are many airway examinations to guide patients for the existence of difficult airways, it is still impossible to completely check the difficult airway.
If the patient unfortunately develops an unexpected difficult airway, the anesthesiologist should resolve the crisis as soon as possible to avoid emergency difficulties.
airway to ensure the safety of the patient's life
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First, the anesthesiologist should be calm, quickly determine the type of difficult airway, and make correct decisions; second, according to the process of the "Guidelines for the Treatment of Unexpected Airway Intubation in Adults" and the patient's condition, immediately formulate rescue.
Plan and prepare countermeasures, and strive to solve ventilation problems in the shortest possible time, ensure oxygenation, and prevent hypoxia
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Third, pay attention to the strength of the team, call for help in time when problems are found, and change ideas and methods or replace personnel and methods after intubation fails; when repeated three or more times and fail to intubate successfully, learn to give up and turn to airway management.
Senior anesthesiologist asking for help
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The incidence of difficult airways remains high in clinical practice, and an ASA analysis of final claims shows a 14% rate of nonspecific respiratory adverse events in medical disputes in the 1990s
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How to avoid such high medical disputes? In addition to anesthesiologists doing their jobs and rescuing in strict accordance with medical procedures and guidelines, anesthesiologists should fully communicate with patients and their families during pre-anesthesia follow-up, and explain the obligations of related risks: According to the current medical level, No matter what prediction and evaluation methods are used, it cannot ensure that difficult airway will not occur after induction.
Once such a situation occurs, under the full rescue of the doctor, the patient may still suffer from hypoxemia, respiratory failure, and finally cardiopulmonary disease.
Brain accident, even life-threatening, obtain the understanding and trust of the patient's family, sign the informed consent, and indicate on the tripartite check that unexpected difficult airway may occur
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At the same time, when the incident occurs, timely explain the illness to the family members and the manpower, advanced equipment, and standardized treatment plan to obtain the understanding of the patients and their families, avoid medical disputes, and protect their legal rights
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5 Typical case sharing of unexpectedly difficult airway during perianesthesia period THE MEANING OF LIFE Case 1, a middle-aged woman, 47 years old, 158cm, 80kg, underwent radical mastectomy for breast cancer
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Preoperative visit: no other diseases, all examinations were basically normal, and there were no signs of difficulty in airway assessment
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General vital signs were stable, anesthesia induction: sufentanil 35ug, atropine 0.
5mg, lidocaine 80mg, propofol 120mg, rocuronium 50mg, no difficulty in mask ventilation
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Mak's laryngoscope looked into the throat, couldn't find the epiglottis for 20 seconds, and was ventilated with a mask
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Changed the McGoy laryngoscope, and can see a little of the top of the epiglottis, close to the back wall of the pharynx
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Blind intubation with fishhook tracheal tube, esophageal intubation was judged after ventilation, the tube was removed, mask ventilation continued, blood oxygen saturation maintained above 90%, sevoflurane inhalation, call for help, difficulty in switching to video laryngoscope Intubation, visual laryngoscope to observe the larynx, can see the epiglottis, close to the posterior wall of the pharynx, unable to provoke the exposure of the glottis, and the cricoid cartilage cannot be exposed, the catheter is tried to be inserted down the epiglottis, and it is still judged as esophageal intubation after ventilation , Pull it out again, and ventilate the mask.
At this time, the blood oxygen saturation is acceptable and maintained above 90%
.

Inhalation of sevoflurane again, intravenous injection of propofol 50mg, re-insertion under video laryngoscope, unable to expose the glottis, damage to tonsillar recess during catheter placement, bleeding, suction, intubation mistakenly inserted into the esophagus, pulled out Immediately thereafter, continue mask ventilation to maintain oxygenation
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Then, under the fiberoptic bronchoscope, the vision into the throat was blurred due to bloody secretions, and it was not clear after suction
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After exiting the mask ventilation, the ventilation pressure was higher than before, but there was no difficulty
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Considering that multiple intubation may lead to laryngeal edema, reintubation was stopped and the patient was awake
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The patient was fully awake 1 hour after induction and had no difficulty breathing spontaneously
.

Explain the situation to the patients and their families that they need to stay awake and keep spontaneous breathing with fiberoptic bronchoscopy for intubation.
The patients expressed their willingness to cooperate and signed the informed consent
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Administer atropine 0.
5mg intravenously and sufentanil 10ug intravenously
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Oropharyngeal injection of 2% lidocaine, and instruct the patient to cough and spit out throat secretions as much as possible
.

The cricothyroid membrane was punctured and injected with 2% lidocaine 20 mg, and the patient coughed
.

The fiberoptic bronchoscope is placed in the oropharyngeal cavity for peeping, the visual field is clear, the patient is instructed to pronounce, the glottis is clearly displayed, there is no edema, the fiberoptic bronchoscope enters the glottis smoothly, and the tracheal ring and carina are clearly visible, and the 7.
0-gauge wire-reinforced catheter along the fiberoptic bronchoscope After implantation, the catheter could not be entered into the airway due to resistance, and the catheter could not be entered and exited by rotating the catheter left and right.
The patient tolerated it well, there was no obvious choking, and there was no difficulty in breathing
.

The tracheal tube was wiped with lubricating oil again, the assistant held up the lower jaw, instructed the patient to inhale, and the tracheal tube was placed homeopathically, which was successfully inserted, and was checked by fiberoptic bronchoscopy
.

The patient's respiratory airflow was obvious, and the anesthesia machine was connected, and the continuous normal waveform of CO2 at the end of breathing appeared
.

Immediately give induction drugs
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Intraoperative vital signs were stable, and the patient was safely returned to the ward after extubation
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Case 2, the patient, female, 45 years old, 57kg, was admitted to the hospital due to "repeated active shortness of breath for 19 years, aggravation for 8 years" and diagnosed as "nasopharyngeal atresia"
.

There was a history of gastric lavage after oral administration of pesticides
.

Physical examination was unremarkable, and preoperative airway assessment was acceptable
.

"Nasopharyngoplasty" is planned to be performed under general anesthesia
.

After the patient entered the operating room, the blood pressure was 128/92mmHg (1mmHg=0.
133kPa), the heart rate was 90 beats/min, the respiratory rate was 18 beats/min, and the pulse oxygen saturation (SpO2) was 95%.
To penehyclidine hydrochloride injection (trade name Changtuoning) 0.
6mg, midazolam 2mg, sufentanil 10ug, propofol 100mg, succinylcholine chloride injection (trade name sucralin) ) 100mg, anesthesia induction, after induction, I feel that the mask ventilation resistance is large, and the thoracic rise and fall is not ideal
.

Immediately, an oropharyngeal airway was placed through the mouth, and the ventilation resistance was still relatively large.
A 6.
5-gauge reinforced tracheal tube was immediately inserted.
After the resident physician failed to intubate, the attending physician was replaced, but the intubation failed because only the epiglottis could be exposed
.

Immediately replace the video laryngoscope (2 minutes after induction), the epiglottis can be exposed, but the glottis is not well exposed.
It is difficult to insert the 6.
0-gauge tube into the glottis, and the replacement of the small tube still cannot pass the glottis smoothly.
At this time, the patient's complexion Cyanosis, SpO2 rapidly dropped from 100% to 19%, the anesthesiologist immediately called for help, quickly performed cricothyroid membrane puncture, connected to the ventilator, SpO2 gradually recovered to 95% within 1 minute, and the skin of the lips returned to rosy
.

2 minutes later, the surgeon expanded the tracheotomy along the cricothyroid membrane puncture site, inserted a special-shaped tracheal tube, stopped bleeding, and performed nasopharyngoplasty
.

During the operation, nasopharyngeal atresia was seen, a small hole with a diameter of about 0.
5 cm, and scar-like stenosis of the pharynx and larynx
.

The vital signs during the operation were stable, the patient woke up 20 minutes after the operation, and was sent to the post-anesthesia recovery room for observation for 1 hour before returning to the ward
.

Postoperative fiberoptic laryngoscopy: the laryngeal vestibule was narrow, and a small hole with a diameter of about 5 mm was visible
.

The patient's vital signs were stable after the operation.
The tracheal tube was successfully blocked 8 days later, the tracheal tube was successfully removed 10 days later, and the patient was discharged from the hospital 14 days later
.

Notes/Hangbo Typography/Meat