视频喉镜与直接喉镜用于肥胖患者气管插管的前瞻性随机试验。

文献信息

中文摘要

背景： 肥胖患者存在困难气道情况，包括功能残气量降低和呼吸暂停期间快速去饱和。视频喉镜可改善声门可视化，但在由经验丰富的麻醉医师管理的减重患者中，将其与直接喉镜进行比较的证据仍然有限。我们进行了一项前瞻性随机试验来比较这些技术。
方法： 256例成年患者（BMI > 35 kg/m²）被随机分配至使用标准Macintosh喉镜或高角度视频喉镜（INSIGHT iS3-L）进行插管，视频喉镜组常规使用管芯。所有患者均接受标准化的无阿片类药物麻醉方案。主要结局为插管时间（TOF = 0至呼气末二氧化碳确认）。次要结局包括首次尝试成功率、插管尝试次数和探条使用。
结果： 所有256例患者均实现总体插管成功；然而，Macintosh组有4例患者（3.1%）需要转换为视频喉镜作为补救。Macintosh组的中位插管时间显著更短（35 [IQR 30-47.5]秒 vs 46 [IQR 35-62]秒；p < 0.001），这一差异部分归因于操作者熟悉度，鉴于安全性结局相当，不太可能具有临床相关性。在首次尝试成功率、插管尝试次数或探条使用方面未观察到显著差异。未发生气道损伤或血氧饱和度低于90%；一例Macintosh组插管时间延长与插管期间心动过缓和低血压相关。Mallampati分级和颈围 > 43-44 cm均不能可靠预测插管困难。
结论： 在这项由经验丰富的麻醉医师管理的选定肥胖患者的单中心研究中，直接喉镜比高角度视频喉镜实现了更短的插管时间，且安全性结局相当；然而，中位时间11秒的差异不太可能具有临床相关性。3.1%的转换率强调视频喉镜必须始终立即可用。视频喉镜在预期困难气道管理中仍然至关重要。

英文摘要

BACKGROUND: Obese patients present challenging airway conditions, including reduced functional residual capacity and rapid desaturation during apnoea. Videolaryngoscopy improves glottic visualisation, but evidence comparing it with direct laryngoscopy in bariatric patients managed by experienced anaesthesiologists remains limited. We conducted a prospective randomised trial comparing these techniques.
METHODS: 256 adult patients (BMI > 35 kg/m²) were randomised to intubation with a standard Macintosh laryngoscope or a hyperangulated videolaryngoscope (INSIGHT iS3-L), with a stylet routinely used in the videolaryngoscopy group. All received a standardised opioid-free anaesthesia protocol. The primary outcome was time to intubation (TOF = 0 to capnographic confirmation). Secondary outcomes included first-attempt success rate, number of intubation attempts, and bougie use.
RESULTS: Overall intubation success was achieved in all 256 patients; however, 4 patients (3.1%) in the Macintosh group required conversion to videolaryngoscopy as rescue. Median time to intubation was significantly shorter in the Macintosh group (35 [IQR 30-47.5] s vs 46 [IQR 35-62] s; p < 0.001), a difference partly attributable to operator familiarity and unlikely to be clinically relevant given comparable safety outcomes. No significant differences were observed in first-attempt success, intubation attempts, or bougie use. No airway injury or oxygen desaturation below 90% occurred; one prolonged Macintosh-group intubation was associated with peri-intubation bradycardia and hypotension. Neither Mallampati classification nor neck circumference > 43-44 cm reliably predicted intubation difficulty.
CONCLUSIONS: In this single-centre study of selected obese patients managed by experienced anaesthesiologists, direct laryngoscopy achieved shorter intubation times than a hyperangulated videolaryngoscope with comparable safety outcomes; however, the 11-second difference in median times is unlikely to be clinically relevant. The 3.1% conversion rate underscores that videolaryngoscopy must always be immediately available. Videolaryngoscopy remains essential in anticipated difficult airway management.