• 中国科技论文统计源期刊
  • 中国科技核心期刊
  • 中国高校优秀期刊
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Volume 44 Issue 4
Apr.  2019
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Clinical value of MTDSA measured by ultrasound in selecting the cuffed endotracheal tube size in children

  • Corresponding author: LIU Zhao-fang, liuzhaofan@163.com
  • Received Date: 2018-04-16
    Accepted Date: 2018-07-13
  • ObjectiveTo evaluate the clinical effects of the MTDSA measured by ultrasound in selecting the cuffed pediatric endotracheal tube size.MethodsThe tracheal tube sizes in 180 pediatric patients, aged 4 to 12 years, scheduled by general anesthesia operation were empirically selected according to the age based formula.The appropriate tracheal catheter type was determined according to the leakage gas test after intubation, and MTDSA was measured using ultrasound before anesthesia induction endotracheal intubation.The correlation of MTDSA, age, height and body mass with clinical optimal catheter inner diameter(ID) in cases with suitable catheter was analyzed, and the linear regression equation of which was established.The accuracy of catheter selected by ultrasound and age based formula was validated and analyzed in clinic.ResultsCompared with other factors, MTDSA was well correlated with catheter ID.The linear regression equation determined by ultrasound was established for ID=0.601xMTDSA+0.015(r=0.954).The accuracy rates of ultrasound and age based formula were 80% and 60%, respectively, and the difference of which was statistically significant(χ2=12.40, P < 0.05).ConclusionsMTDSA measured by ultrasound is an accurate and simple method in guiding the selection of cuffed tracheal tube size in children.ObjectiveTo evaluate the clinical effects of the MTDSA measured by ultrasound in selecting the cuffed pediatric endotracheal tube size.MethodsThe tracheal tube sizes in 180 pediatric patients, aged 4 to 12 years, scheduled by general anesthesia operation were empirically selected according to the age based formula.The appropriate tracheal catheter type was determined according to the leakage gas test after intubation, and MTDSA was measured using ultrasound before anesthesia induction endotracheal intubation.The correlation of MTDSA, age, height and body mass with clinical optimal catheter inner diameter(ID) in cases with suitable catheter was analyzed, and the linear regression equation of which was established.The accuracy of catheter selected by ultrasound and age based formula was validated and analyzed in clinic.ResultsCompared with other factors, MTDSA was well correlated with catheter ID.The linear regression equation determined by ultrasound was established for ID=0.601xMTDSA+0.015(r=0.954).The accuracy rates of ultrasound and age based formula were 80% and 60%, respectively, and the difference of which was statistically significant(χ2=12.40, P < 0.05).ConclusionsMTDSA measured by ultrasound is an accurate and simple method in guiding the selection of cuffed tracheal tube size in children.
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  • [1] SHIBASAKI M, NAKAJIMA Y, ISHⅡ S, et al.Prediction of pediatric endotracheal tube size by ultrasonography[J].Anesthesiology, 2010, 113(4):819.
    [2] SHIH MH, CHUNG CY, SU BC, et al.Accuracy of a new body length based formula for predicting tracheal tube size in Chinese children[J].Chang Gung Med Journal, 2008, 31(3):276.
    [3] NEWTH CJ, RACHMAN B, PATEL N, et al.The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care[J].J Pediatr, 2004, 144(3):333. doi: 10.1016/j.jpeds.2003.12.018
    [4] HUSEIN M, MANOUKIAN JJ, PLATT R, et al.Ultrasonography and videobronchoscopy to assess the subglottic diameter in the paediatric population:a first look[J].J Otolaryngol, 2002, 31(4):220.
    [5] LITMAN RS, WEISSEND EE, SHIBATA D, et al.Developmental changes of laryngeal dimensions in unparalyzed, sedated children[J].Anesthesiology, 2003, 98(1):41.
    [6] FAYOUR P, DEVISME L, MERROT O, et al.Determination of endo-tracheal tube size in a perinatal population:an anatomical and experimental study[J].J Anesthesiology, 2006, 104(5):954. doi: 10.1097/00000542-200605000-00011
    [7] TOBIAS JD.Pediatric airway anatomy may not be what thought:implications for clinical practice and the use of cuffed endotracheal tubes[J].Paediatr Anaesth, 2015, 25(1):9.
    [8] GNANAPRAKASAM PV, V SELVARA J.Ultrasound assessment of subglottic region for estimation of appropriate endotracheal tube size in pediatric anesthesia[J].J Anaesthesiol Clin Pharmacol, 2017, 33(2):231.
    [9] SUTAGATTI JG, RAJA R, KURDI MS.Ultrasonographic estimation of endotracheal tube size in paediatric patients and its comparison with physical indices based formulae:A prospective study[J].J Clin Diagn Res, 2017, 11(5):C5.
    [10] ALTUN D, ORHAN-SUNGUR M, ALI A, et al.The role of ultrasound in appropriate endotracheal tube size selection in pediatric patients[J].Paediatr Anaesth, 2017, 27(10):1015.
    [11] KRISHNA SG, HAKIM M, SEBASTIAN R, et al.Cuffed endotracheal tubes in children:the effect of the size of the cuffed endotracheal tube on intracuff pressure[J].Paediatr Anaesth, 2017, 27(5):494. doi: 10.1111/pan.13099
    [12] CHO AR, KIM ES, LEE DW, et al.Comparisons of recursive partitioning analysis and conventional methods for selection of uncuffed endotracheal tubes for pediatric patients[J].Paediatr Anaesth, 2015, 25(7):698.
    [13] 苏相飞, 彭书崚, 杜素娟, 等.超声测定小儿环状软骨横径用于带套囊气管导管型号选择的准确性[J].中华麻醉学杂志, 2017, 37(7):784. doi: 10.3760/cma.j.issn.0254-1416.2017.07.005
    [14] 李倩, 张正迪, 蔡铁良.超声测量声门下气道横径用于小儿无囊气管导管的选择[J].国际麻醉学与复苏杂志, 2017, 38(8):714. doi: 10.3760/cma.j.issn.1673-4378.2017.08.010
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Clinical value of MTDSA measured by ultrasound in selecting the cuffed endotracheal tube size in children

    Corresponding author: LIU Zhao-fang, liuzhaofan@163.com
  • Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu Anhui 241000, China

Abstract: ObjectiveTo evaluate the clinical effects of the MTDSA measured by ultrasound in selecting the cuffed pediatric endotracheal tube size.MethodsThe tracheal tube sizes in 180 pediatric patients, aged 4 to 12 years, scheduled by general anesthesia operation were empirically selected according to the age based formula.The appropriate tracheal catheter type was determined according to the leakage gas test after intubation, and MTDSA was measured using ultrasound before anesthesia induction endotracheal intubation.The correlation of MTDSA, age, height and body mass with clinical optimal catheter inner diameter(ID) in cases with suitable catheter was analyzed, and the linear regression equation of which was established.The accuracy of catheter selected by ultrasound and age based formula was validated and analyzed in clinic.ResultsCompared with other factors, MTDSA was well correlated with catheter ID.The linear regression equation determined by ultrasound was established for ID=0.601xMTDSA+0.015(r=0.954).The accuracy rates of ultrasound and age based formula were 80% and 60%, respectively, and the difference of which was statistically significant(χ2=12.40, P < 0.05).ConclusionsMTDSA measured by ultrasound is an accurate and simple method in guiding the selection of cuffed tracheal tube size in children.ObjectiveTo evaluate the clinical effects of the MTDSA measured by ultrasound in selecting the cuffed pediatric endotracheal tube size.MethodsThe tracheal tube sizes in 180 pediatric patients, aged 4 to 12 years, scheduled by general anesthesia operation were empirically selected according to the age based formula.The appropriate tracheal catheter type was determined according to the leakage gas test after intubation, and MTDSA was measured using ultrasound before anesthesia induction endotracheal intubation.The correlation of MTDSA, age, height and body mass with clinical optimal catheter inner diameter(ID) in cases with suitable catheter was analyzed, and the linear regression equation of which was established.The accuracy of catheter selected by ultrasound and age based formula was validated and analyzed in clinic.ResultsCompared with other factors, MTDSA was well correlated with catheter ID.The linear regression equation determined by ultrasound was established for ID=0.601xMTDSA+0.015(r=0.954).The accuracy rates of ultrasound and age based formula were 80% and 60%, respectively, and the difference of which was statistically significant(χ2=12.40, P < 0.05).ConclusionsMTDSA measured by ultrasound is an accurate and simple method in guiding the selection of cuffed tracheal tube size in children.

  • 目前小儿气管导管型号的选择仍然是根据年龄公式选择为主,儿童由于个体差异较大,此方法常常因导管型号不合适而需更换导管,从而导致插管并发症增加和医疗耗材的浪费,此现象对于4~12岁的小儿更为常见。近年来,可视化超声技术广泛应用于临床麻醉,SHIBASAKI等[1]报道可通过超声测量环状软骨水平气道横径(MTDSA)个体化预测小儿气管导管的最佳型号。本研究针对超声测量MTDSA用于小儿带套囊气管导管的选择的可行性进行临床观察,以期为小儿最佳气管导管的选择提供参考。

1.   资料与方法
  • 所有入组患儿均由其成年监护人签署知情同意书。纳入2017年1月至2018年1月本院收治的行择期手术需全麻气管插管的患儿共180例,年龄4~12岁,性别不限,ASA分级Ⅰ~Ⅱ级、排除有口咽气道疾病或畸形者。采用sonoscape便携式超声仪(高频线阵式,频率5~12 MHz);所用气管导管为标准加强型带囊气管导管(河南驼人医疗器械股份有限公司),导管型号:ID4.0/OD6.1、ID 4.5/OD6.7、ID5.0/OD7.4、ID5.5/OD7.9、ID6.0/OD8.5及ID6.5/OD9.1(ID:气管导管内径;OD:气管导管外径;单位:mm)。

  • 患儿通常入室前开放外周静脉,入室后常规监测血压、心电图、脉搏氧饱和度,插管后行呼气末二氧化碳分压(PETCO2)监测。麻醉诱导:依次给予咪达唑仑0.05~0.10 mg/kg、芬太尼1 μg/kg、丙泊酚2.5 mg/kg、顺式阿曲库铵0.15 mg/kg,不配合者给予七氟烷吸入。诱导后面罩通气,患儿取仰卧位,头轻度后仰,将超声探头短轴垂直于颈正中线,由声门处缓慢向下平扫,直到看到环状软骨弓(内外软骨膜形成的两条高回声弧形边夹着软骨内髓形成的低回声带),测量MTDSA。每次由同一位有丰富超声经验的医师测量,测量3次取平均值。气管导管型号由经验丰富的麻醉医师根据年龄公式:ID=年龄/4+4, 经验性选择(通常减0.5到1号),若插管失败,需更换与之临近小0.5 mm ID导管直至插管成功,插管后根据漏气试验及临床实际情况确定是否至临床插管成功(临床最适),漏气试验是指气管插管后套囊不充气,调整麻醉机氧流量3.0 L/min,调整麻醉机APL阀的压力预设值,如APL阀的压力设定为10 cmH2O时出现漏气,则说明管径过小;如APL阀的压力设定为20 cmH2O时未出现漏气,则说明管径过大,介于两者之间者可认定为临床最适插管。插管深度根据公式(年龄/2+12)计算或临床听诊而定,潮气量预设为10 mL/kg,呼吸频率设为15~20次/分,后依据PETCO2水平进行调整,使之维持于35~45 mmHg。前期纳入80例患儿,其中37例符合临床最适插管,以此37例患儿的导管型号为标准,分别对MTDSA、年龄、身高、体质量与临床最适导管ID之间进行统计学分析并建立MTDSA与ID之间的线性回归方程。然后再选择行择期手术需全身麻醉气管插管的患儿100例,随机分为超声测量法组与年龄公式法组,超声测量法组根据测得的MTDSA代入线性回归方程选择导管型号,而年龄公式法组根据年龄公式(ID=年龄/4+4)经验性选择导管型号(通常根据患儿发育情况减0.5到1号),插管后根据漏气试验分别验证2组选择导管的准确率,并进行比较。

  • 采用t检验、χ2检验、Spearman秩相关性分析和简单线性回归分析。

2.   结果
  • 超声测量法组和年龄公式法组患儿年龄、身高、体质量、性别等一般情况差异均无统计学意义(P>0.05)(见表 1)。年龄、身高、体质量、声门下气(MTDSA)道横径与临床最适导管ID的Spearman秩相关系数(r′s)分别为0.921、0.852、0.879、0.966(P<0.05),说明年龄、身高、体质量、MTDSA与临床最适导管ID之间均存在相关性。其中,MTDSA与临床最适导管ID之间的关联性最强,线性方程为:ID=0.601×MTDSA+0.015(r=0.954)(见图 1)。

    分组 n 年龄/岁 体质量/kg 身高/cm
    超声测量法组 50 8.27±2.82 30.8±13.0 131.5±16.1 26 24
    年龄公式法组 50 8.33±2.83 30.9±13.1 131.9±16.2 27 23
    t 0.10 0.04 0.12 0.04*
    P >0.05 >0.05 >0.05 >0.05
    *示χ2
  • 超声测量法组中50例患儿符合最适插管者40例,不符者10例,最适插管准确率为80%;年龄公式法组中50例患儿符合最适插管者23例,不符者27例,最适插管准确率为46 %,超声测量法的准确率高于公式法(χ2=12.40,P<0.05)。另外,超声测量法组与年龄公式法组中分别有5例与13例病人术后出现相关并发症(声音嘶哑、咽喉肿痛、喉痉挛等),超声测量法的术后相关并发症的发生率10%,低于公式法的26%(χ2=4.34,P<0.05)。

3.   讨论
  • 在临床麻醉中,小儿气管导管型号常常根据经典的年龄预测公式选择,然而由于小儿个体间生长发育情况差异较大,仅根据上述方法预测的结果与实际所需存在较大的差异。此外,SHIH等[2]早期曾提出可根据患儿身高公式选择导管型号,其比年龄公式准确性高。但也有相关研究[1]认为身高公式不适用于小儿,因为身高公式不能反映小儿内在器官包括呼吸道的个体差异。国内外相关研究[3-4]表明根据年龄预测的导管型号的相符率仅为47%(有套囊气管导管)与70%(无套囊气管导管),多数较实际所需的导管型号大1号,甚至偏大2~ 3号,这是因为在胎儿,甚至婴儿出生后的一段时间内,气道的生长发育呈现非线性[5-6]。随着小儿的生长发育,个体间的差异也随之增大。过去儿童的各种生长指标制定的公式是否仍能准确应用于当下,值得重新探讨。

    上世纪80年代,TOBIAS等[7]基于石膏铸模技术的尸体研究发现6岁以内的儿童气道最狭窄的部位位于环状软骨,且气道解剖发现小儿环状软骨的前后径比横径大。故MTDSA被认为是小儿气道最狭窄的部位,国内外多项研究报道可通过超声测量MTDSA个体化预测小儿气管导管的最佳型号,通过线性回归方程选择气管导管的型号较年龄公式更为精准,研究病例多为6岁以下的患儿[1-2, 8]。然而对于6岁以上的患儿,因其气管最狭窄处处于环状软骨过渡至声门水平阶段,此方法在这一人群是否仍具有较高的准确率尚不清楚。因为套囊的存在使气管导管的OD比同型号无囊导管的OD大,导管型号不合适的情况更为多见[3]。所以,对于这一年龄人群就要求我们探讨出临床上更加合适的预测导管型号的方法。本研究将超声测量MTDSA的方法用于4~12岁全身麻醉气管插管(有套囊导管)的小儿,观察超声测量MTDSA与传统的公式法进行比较,探讨更合适的预测导管型号的方法。

    本研究发现,超声测量MTDSA的方法与年龄公式法进行比较,超声测量法预测导管型号的方法准确性更高,这与国内外的一些相关文献[9-14]报道相符, 应用本方法选择有囊气管导管,在一定程度上降低了重复插管的发生率及相关并发症,临床应用安全性更高。而且与其他方法相比,该方法也更符合个体化医疗的理念。

    本研究存在一些不足之处,由于本研究纳入的患儿多为口腔科、耳鼻喉科手术患儿,2组其术后咽喉肿痛、声音嘶哑等插管相关并发症发生率有统计学差异,但不能排除外科手术操作的影响,因此还需纳入更多患儿人群进一步研究。另外,由于病人诊治条件的影响,并未纳入新生儿、生长发育异常及存在困难气道的患儿,对于该方法在这部分患儿中应用还有待进一步研究。

    综上所述,超声测量MTDSA可以作为临床上指导4~12岁小儿全身麻醉有囊气管导管选择的方法,与传统的公式法比较具有更高的准确性。

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