耳鼻咽喉科手术中非通道视频喉镜气管插管困难的性质及术前预测：一项1932名成人的回顾性队列研究

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中文摘要

背景/目的： 视频喉镜可改善声门视野，但插管困难仍会发生。在耳鼻咽喉科手术中，困难插管究竟反映视野不佳，还是在视野充分的情况下仍出现，鲜有量化研究。我们描述了这一模式及其术前预测因素。方法：在一项单中心回顾性队列中，纳入1932名接受耳鼻咽喉科手术并使用非通道视频喉镜的成人（2018-2021年），困难插管预先定义为两次或以上喉镜尝试（置入镜片），这是困难的下限。声门视野（Cormack-Lehane分级）和插管时间用于描述困难程度，并通过逻辑回归识别预测因素。主要风险评分为四个解剖学床旁因素的非加权计数，这些因素基于合理性（而非数据驱动的显著性）在预先存在的临床阈值下选择；五因素版本增加了住院医师操作者。结果：120名患者发生困难插管（6.2%；95% CI 5.2-7.4）。大多数发生在视野充分的情况下（64%为Cormack-Lehane I-II级；45%仅为I级）；良好视野与不良视野的困难插管率分别为4.3%（95% CI 3.5-5.4）与29.3%（95% CI 22.5-37.1）（比值比9.2，95% CI 6.0-14.0），困难插管耗时约两倍（中位数90秒 vs 40秒）。独立预测因素为较短的切牙间距离和颏甲距离以及住院医师操作者。四因素计数将风险从4.6%分级至12.9%（每因素比值比1.63；表观曲线下面积0.596，95% CI 0.546-0.645，未校正乐观偏倚；一个或以上因素的阳性预测值为8.8%），五因素计数表现相似（0.631）。在良好视野亚组中，困难似乎更多与操作者经验不足相关，而非解剖因素（校正比值比2.48 vs 1.13）。结论：视野不佳时困难插管可能性大得多，但由于92.4%的患者视野良好，大多数困难插管发生在视野充分的情况下。我们假设此时困难在于导管输送而非可视化；由于分析以视野为条件，这需要前瞻性验证。区分度中等，计数为探索性；这些单中心发现需要外部验证。

英文摘要

Background/Objectives: Video laryngoscopy improves the glottic view, yet difficult intubation still occurs. Whether it reflects a poor view or arises despite an adequate one is rarely quantified in otorhinolaryngological surgery. We described this pattern and its preoperative predictors. Methods: In a single-center retrospective cohort of 1932 adults undergoing otorhinolaryngological surgery with non-channeled video laryngoscopy (2018-2021), difficult intubation was defined a priori as two or more laryngoscopic attempts (blade insertions), a lower bound on difficulty. The glottic view (Cormack-Lehane grade) and intubation time described the difficulty, and predictors were identified by logistic regression. An unweighted count of four anatomical bedside factors, selected on rationale (not data-driven significance) at pre-existing clinical thresholds, was the primary risk score; a five-factor version added a resident operator. Results: Difficult intubation occurred in 120 patients (6.2%; 95% CI 5.2-7.4). Most occurred despite an adequate view (64% at Cormack-Lehane grade I-II; 45% at grade I alone); the rate was 4.3% (95% CI 3.5-5.4) versus 29.3% (95% CI 22.5-37.1) for good versus poor views (odds ratio 9.2, 95% CI 6.0-14.0), and difficult intubations took about twice as long (median 90 versus 40 s). Independent predictors were shorter inter-incisor and thyromental distances and a resident operator. The four-factor count graded risk from 4.6% to 12.9% (odds ratio 1.63 per factor; apparent area under the curve 0.596, 95% CI 0.546-0.645, not corrected for optimism; positive predictive value 8.8% at one or more factors), and a five-factor count performed similarly (0.631). Within the good-view subgroup, difficulty appeared to relate more to operator inexperience than to anatomy (adjusted odds ratio 2.48 versus 1.13). Conclusions: Difficulty was far more likely with a poor view, but because a good view occurred in 92.4% of patients, most difficult intubations arose despite an adequate one. We hypothesize that difficulty then lies in tube delivery rather than visualization; because the analysis conditions on the view, this needs prospective testing. Discrimination was modest and the count exploratory; these single-center findings require external validation.