颈部位置与气管插管的深度关系 .doc
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颈部位置与气管插管的深度关系
根据在成人的放射学研究，患者头部的伸展和屈曲可造成气管导管在气管内的移动。当头部从过度伸展位转变成过度屈曲位时，气管导管向隆突方向平均移动3.8cm(左图)；而有一些患者，此种移动可多达6.4cm。
头部向一侧旋转，气管导管平均可移离隆突0.7cm。当头部从正中位转换成完全伸展位时，气管导管平均移离隆突1.9cm(右图)。如果气管导管的远端确切位于成年人的气管中段，此种移动不会造成意外性气管导管脱出。
在患者体位改变、膈肌移动和气管或食管手术操作中，可发生气管导管的移位，在将患者置放成300的Trendelenburg体位后，具有相当高的主支气管插管发生率，此是由于气管隆突向头侧移位使已固定的气管导管进入主支气管的结果。当采用反向Trendelenburg体位时，可出现相反的结果。因为气管和食管均被同样的颈部筋膜所包绕，所以牵拉气管或食管均可使已正确固定的气管导管出现移位，如在实施食管闭锁修复的婴儿或实施食管镜检查的患者。
在小儿头部的伸展和屈曲造成的气管导管移动不同于成年人(可参考以下文献)，在施行气管插管的婴幼儿应特别注意，头部呈屈曲位时易发生支气管内插管，而头部呈伸展位时又易发生意外性气管导管的脱出，尤其是在气管长度仅为4.7~5.7cm长的新生儿。故在婴幼儿实施气管插管时，应采取相应措施来保证气管导管尽可能插至气管远端但又未进入主支气管内。①采用距远端2.2cm处有环状标志的气管导管，在足月婴幼儿，可将此标志插至声带部位；在早产婴幼儿，此标志应稍高于声带部位；在体型稍大的婴幼儿，应将此标志插至声带以下部位。②采用分别在距远端2.2、2.4和2.6cm处有环形标志且直径为2.5mm、3.0mm和3.5mm的气管导管。
1: AJR Am J Roentgenol. 1976 Sep;127(3):433-4.
Radiographic evaluation of endotracheal tube position.
* Goodman LR, Conrardy PA, Laing F, Singer MM.
A malpositioned endotracheal tube is a potential hazard to the intubated patient. Ideally, the tube tip should be 5+/-2 cm from the carina when the head and neck are in neutral position. In 92 of 100 patients studied, the carina overlay T5, T6, or T7 on portable radiographs. Therefore, even when the carina is not visible, it can be assumed that a tube tip positioned at the level of T3 or T4 is safe. The degree of neck flexion or extension at the time of radiography may be determined by evaluating the position of the mandible relative to the vertebral bodies.
PMID: 183529 [PubMed - indexed for MEDLINE]
1: Br J Anaesth. 2006 Apr;96(4):486-91. Epub 2006 Feb 7.
Tracheal tube-tip displacement in children during head-neck movement--a radiological assessment.
* Weiss M, Knirsch W, Kretschmar O, Dullenkopf A, Tomaske M, Balmer C, Stutz K, Gerber AC, Berger F.
Department of Anaesthesia, University Children's Hospital Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland. markus.weiss@kispi.unizh.ch
BACKGROUND: Aims of this study were to assess the maximum displacement of tracheal tube tip during head-neck movement in children, and to evaluate the appropriateness of the intubation depth marks on the Microcuff Paediatric Endotracheal Tube regarding the risk of inadvertent extubation and endobronchial intubation. METHODS: We studied children, aged from birth to adolescence, undergoing cardiac catheterization. The patients' tracheas were orally intubated and the tracheal tubes positioned with the intubation depth mark at the level of the vocal cords. The tracheal tube tip-to-carina distances were fluoroscopically assessed with the patient supine and the head-neck in 30 degrees flexion, 0 degrees neutral position and 30 degrees extension. RESULTS: One hundred children aged between 0.02 and 16.4 yr (median 5.1 yr) were studied. Maximum tracheal tube-tip displacement after head-neck 30 degrees extension and 30 degrees flexion demonstrated a linear relationship to age [maximal upward tube movement (mm)=0 0.71 x age (yr)+9.9 (R(2)=0.893); maximal downward tube movement (mm)=0.83 x age (yr)+9.3 (R(2)=0.949)]. Maximal tracheal tube-tip downward displacement because of head-neck flexion was more pronounced than upward displacement because of head-neck extension. CONCLUSIONS: The intubation depth marks were appropriate to avoid inadvertent tracheal extubation and endobronchial intubation during head-neck movement in all patients. However, during head-neck extension the tracheal tube cuff may become positioned in the subglottic region and should be re-adjusted when the patient remains in this position for a longer time.
PMID: 16464981 [PubMed - indexed for MEDLINE]
1: Pediatr Pulmonol. 1999 Mar;27(3):199-202.
Comment in:
Pediatr Pulmonol. 2000 Mar;29(3):242-4.
Effect of neck position on endotracheal tube location in low birth weight infants.
* Rost JR,Frush DP, Auten RL.
Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA.
Neck position can affect the position of the tip of the endotracheal tube (ETT) in normal neonates; this has not been systematically investigated in low birth weight (LBW) neonates. It was our intention to determine the effect of neck flexion and extension on ETT position in LBW infants. Eight LBW orotracheally-intubated infants underwent postmortem anteroposterior chest radiographs with the neck in a neutral position, in 55 degrees flexion, and in 55 degrees extension. Measurements from the thoracic inlet to the ETT were obtained in each position. The ETT always moved caudad with neck flexion (P = 0.001) and cephalad with neck extension (P = 0.001). The mean extent of ETT displacement was 3.1 mm (SD, 1.7 mm) with neck flexion, and 7.4 mm (SD, 5.2 mm) with extension (P < 0.05). We conclude that in LBW infants: 1) the direction of ETT movement with neck flexion and extension is predictable and identical to that seen in term infants and children, and 2) neck flexion should not be a principal consideration in management of ETT location.
PMID: 10213259 [PubMed - indexed for MEDLINE]
1: Anesth Analg. 1996 Feb;82(2):251-3.
Displacement of the endotracheal tube caused by change of head position in pediatric anesthesia: evaluation by fiberoptic bronchoscopy.
* Sugiyama K, Yokoyama K. Department of Anesthesia, Kagoshima University Dental Hospital, Japan.
Displacement of the endotracheal tube (ETT) caused by flexion and extension of the neck and the placement of a tongue depressor was investigated in 10 small children between the ages of 16 and 19 mo by means of a fiberoptic bronchoscope. The ETT tip moved a mean distance of 0.9 cm toward the carina with flexion and 1.7 cm toward the vocal cords with extension of the neck. After the placement of a tongue depressor, the ETT tip, which had once moved toward the vocal cords with neck extension, was displaced a mean distance of 1.2 cm toward the carina. Our results demonstrate that endobronchial intubation and accidental extubation could occur after significant changes of the head position and careless placement of a tongue depressor in small children.......（后略) ......
颈部位置与气管插管的深度关系
根据在成人的放射学研究，患者头部的伸展和屈曲可造成气管导管在气管内的移动。当头部从过度伸展位转变成过度屈曲位时，气管导管向隆突方向平均移动3.8cm(左图)；而有一些患者，此种移动可多达6.4cm。
头部向一侧旋转，气管导管平均可移离隆突0.7cm。当头部从正中位转换成完全伸展位时，气管导管平均移离隆突1.9cm(右图)。如果气管导管的远端确切位于成年人的气管中段，此种移动不会造成意外性气管导管脱出。
在患者体位改变、膈肌移动和气管或食管手术操作中，可发生气管导管的移位，在将患者置放成300的Trendelenburg体位后，具有相当高的主支气管插管发生率，此是由于气管隆突向头侧移位使已固定的气管导管进入主支气管的结果。当采用反向Trendelenburg体位时，可出现相反的结果。因为气管和食管均被同样的颈部筋膜所包绕，所以牵拉气管或食管均可使已正确固定的气管导管出现移位，如在实施食管闭锁修复的婴儿或实施食管镜检查的患者。
在小儿头部的伸展和屈曲造成的气管导管移动不同于成年人(可参考以下文献)，在施行气管插管的婴幼儿应特别注意，头部呈屈曲位时易发生支气管内插管，而头部呈伸展位时又易发生意外性气管导管的脱出，尤其是在气管长度仅为4.7~5.7cm长的新生儿。故在婴幼儿实施气管插管时，应采取相应措施来保证气管导管尽可能插至气管远端但又未进入主支气管内。①采用距远端2.2cm处有环状标志的气管导管，在足月婴幼儿，可将此标志插至声带部位；在早产婴幼儿，此标志应稍高于声带部位；在体型稍大的婴幼儿，应将此标志插至声带以下部位。②采用分别在距远端2.2、2.4和2.6cm处有环形标志且直径为2.5mm、3.0mm和3.5mm的气管导管。
1: AJR Am J Roentgenol. 1976 Sep;127(3):433-4.
Radiographic evaluation of endotracheal tube position.
* Goodman LR, Conrardy PA, Laing F, Singer MM.
A malpositioned endotracheal tube is a potential hazard to the intubated patient. Ideally, the tube tip should be 5+/-2 cm from the carina when the head and neck are in neutral position. In 92 of 100 patients studied, the carina overlay T5, T6, or T7 on portable radiographs. Therefore, even when the carina is not visible, it can be assumed that a tube tip positioned at the level of T3 or T4 is safe. The degree of neck flexion or extension at the time of radiography may be determined by evaluating the position of the mandible relative to the vertebral bodies.
PMID: 183529 [PubMed - indexed for MEDLINE]
1: Br J Anaesth. 2006 Apr;96(4):486-91. Epub 2006 Feb 7.
Tracheal tube-tip displacement in children during head-neck movement--a radiological assessment.
* Weiss M, Knirsch W, Kretschmar O, Dullenkopf A, Tomaske M, Balmer C, Stutz K, Gerber AC, Berger F.
Department of Anaesthesia, University Children's Hospital Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland. markus.weiss@kispi.unizh.ch
BACKGROUND: Aims of this study were to assess the maximum displacement of tracheal tube tip during head-neck movement in children, and to evaluate the appropriateness of the intubation depth marks on the Microcuff Paediatric Endotracheal Tube regarding the risk of inadvertent extubation and endobronchial intubation. METHODS: We studied children, aged from birth to adolescence, undergoing cardiac catheterization. The patients' tracheas were orally intubated and the tracheal tubes positioned with the intubation depth mark at the level of the vocal cords. The tracheal tube tip-to-carina distances were fluoroscopically assessed with the patient supine and the head-neck in 30 degrees flexion, 0 degrees neutral position and 30 degrees extension. RESULTS: One hundred children aged between 0.02 and 16.4 yr (median 5.1 yr) were studied. Maximum tracheal tube-tip displacement after head-neck 30 degrees extension and 30 degrees flexion demonstrated a linear relationship to age [maximal upward tube movement (mm)=0 0.71 x age (yr)+9.9 (R(2)=0.893); maximal downward tube movement (mm)=0.83 x age (yr)+9.3 (R(2)=0.949)]. Maximal tracheal tube-tip downward displacement because of head-neck flexion was more pronounced than upward displacement because of head-neck extension. CONCLUSIONS: The intubation depth marks were appropriate to avoid inadvertent tracheal extubation and endobronchial intubation during head-neck movement in all patients. However, during head-neck extension the tracheal tube cuff may become positioned in the subglottic region and should be re-adjusted when the patient remains in this position for a longer time.
PMID: 16464981 [PubMed - indexed for MEDLINE]
1: Pediatr Pulmonol. 1999 Mar;27(3):199-202.
Comment in:
Pediatr Pulmonol. 2000 Mar;29(3):242-4.
Effect of neck position on endotracheal tube location in low birth weight infants.
* Rost JR,Frush DP, Auten RL.
Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA.
Neck position can affect the position of the tip of the endotracheal tube (ETT) in normal neonates; this has not been systematically investigated in low birth weight (LBW) neonates. It was our intention to determine the effect of neck flexion and extension on ETT position in LBW infants. Eight LBW orotracheally-intubated infants underwent postmortem anteroposterior chest radiographs with the neck in a neutral position, in 55 degrees flexion, and in 55 degrees extension. Measurements from the thoracic inlet to the ETT were obtained in each position. The ETT always moved caudad with neck flexion (P = 0.001) and cephalad with neck extension (P = 0.001). The mean extent of ETT displacement was 3.1 mm (SD, 1.7 mm) with neck flexion, and 7.4 mm (SD, 5.2 mm) with extension (P < 0.05). We conclude that in LBW infants: 1) the direction of ETT movement with neck flexion and extension is predictable and identical to that seen in term infants and children, and 2) neck flexion should not be a principal consideration in management of ETT location.
PMID: 10213259 [PubMed - indexed for MEDLINE]
1: Anesth Analg. 1996 Feb;82(2):251-3.
Displacement of the endotracheal tube caused by change of head position in pediatric anesthesia: evaluation by fiberoptic bronchoscopy.
* Sugiyama K, Yokoyama K. Department of Anesthesia, Kagoshima University Dental Hospital, Japan.
Displacement of the endotracheal tube (ETT) caused by flexion and extension of the neck and the placement of a tongue depressor was investigated in 10 small children between the ages of 16 and 19 mo by means of a fiberoptic bronchoscope. The ETT tip moved a mean distance of 0.9 cm toward the carina with flexion and 1.7 cm toward the vocal cords with extension of the neck. After the placement of a tongue depressor, the ETT tip, which had once moved toward the vocal cords with neck extension, was displaced a mean distance of 1.2 cm toward the carina. Our results demonstrate that endobronchial intubation and accidental extubation could occur after significant changes of the head position and careless placement of a tongue depressor in small children.......（后略) ......
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