A Comparative Study of Hemodynamic Responses to Orotracheal Intubation with GlideScope Videolaryngoscope and Macintosh Direct Laryngoscope<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

薛富善　李玄英　张国华　
孙海涛　李成文　刘鲲鹏　毛鹏
中国医学科学院中国协和医科大学整形外科医院麻醉科，北京 100041
Fu-shan Xue, Xuan-ying Li, Guo-hua Zhang, Hai-tao Sun, Cheng-wen Li, Kun-peng Liu, Peng Mao
Department of Anesthesiology，Plastic Surgery Hospital，Chinese Academy of Medical Sciences and Peking Union Medical college，Beijing 100041.

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ABSTRACT

Objective：To compare the hemodynamic responses to orotracheal intubation using GlideScope videolaryngoscope（GSVL）and Macintosh direct laryngoscope（MDLS）.
　Method：57 patients ASA physical status Ⅰ～Ⅱ，aged 18～60 years，undergoing elective plastic surgery and requiring orotracheal intubation were randomly allocated to either the GSVL group or the MDLS group. After standard intravenous anesthetic induction，orotracheal intubation was performed with GSVL or MDLS，respectively. Noninvasive SBP，DBP，MAP，HR and SpO₂ were recorded before and after anesthetic induction，at intubation and 5 minutes after intubation at 1 minute interval and was also noted the intubation time. Rate-pressure product（RPP）were calculated.
　Results：The intubation time in GSVL group was significantly longer than in MDLS group. After anesthetic induction，SBP，DBP，MAP and RPP in the two groups decreased significantly as compared with preinduction values. The orotracheal intubation caused significant increases in SBP，DBP，MAP and RPP in the two groups in comparison with postinduction values，but these hemodynamic changes lasted only 1 to 2 min and then decreased gradually. Except for maximal value of DBP，the blood pressure changes caused by orotracheal intubation did not significantly exceed the preinduction values. As compared to preinduction values，HR and RPP at intubation in GSVL group were significantly increased and increase in HR lasted for 4 min. HR at intubation in MDLS group were also significantly increased，but lasted only for 1 min. There was no significant difference in the hemodynamic data at any time point of the observation between the two groups.
　Conclusion：The hemodynamic responses to orotracheal intubation using GSVL and MDLS were similar. As compared with MDLS，GSVL has no special advantages in  palliation of the adverse cardiovascular stress responses to orotracheal intu-bation.
　Key words：GlideScope videolaryngoscope；Macintosh direct laryngoscope；  Orotracheal intubation；Hemodynamic responses
　Corresponding author: Fushan Xue；E-mail: Xuebai@fescomail.net

GlideScope视频喉镜（GlideScope videolaryngoscope，GSVL）是加拿大Saturn生物医疗技术有限公司于2001年研制生产的1种新型视频气管插管系统（video intubation system），具有喉部显露清晰、操作简单、损伤小和可降低气管插管操作难度等优点^[1-5]。虽然GlideScope视频喉镜的操作技术基本同Macintosh型直接喉镜，但是由于其镜片独特的60°弯曲角度设计，所以可明显降低显露声门所需的上提用力。据测量，采用常规直接喉镜显露声门时上提喉镜所需的力量大约为5.4kg，而采用GlideScope视频喉镜满意显露声门时所需的上提力量仅为0.5～1.4kg^[6]。由于上提喉镜用力降低可减小对舌根部和咽喉组织的刺激，所以采用GlideScope视频喉镜实施气管插管有可能减轻相关的心血管系统不良应激反应。但是，目前国内外尚无有关GlideScope视频喉镜经口气管插管对血流动力学影响的研究报道。本研究是从血流动力学角度来考察GlideScope视频喉镜在经口气管插管中是否优于常用的Macintosh直接喉镜，旨在为临床安全应用这一新型气管插管系统提供资料。

资　料　和　方　法<?;xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

本研究包括57例ASAⅠ～Ⅱ级、拟在经口气管插管全身麻醉下实施择期整形外科手术的患者。其中男20例和女37例，患者的年龄为18～60岁、体重为45～90kg、身高为150～180cm。患有严重心血管系统疾病、长期服用影响血压和心率的药物、重要脏器功能不全以及预测为困难气道的患者被排除在外。将入选患者随机分为GlideScope视频喉镜组（GSVL组，n=30）和Macintosh直接喉镜组（MDLS组，n=27）。
　　1、麻醉处理 
　　所有患者手术前30 min肌内注射东莨菪碱0.3mg。患者进入手术室后建立静脉输液通道，并连接惠普多功能监护仪连续监测SBP、DBP、MAP、HR、SpO₂和ECG，取稳定5min后的数值作为麻醉诱导前的基础值。静脉注射咪达唑仑0.05mg•kg^-1，芬太尼2μg•kg^-1，丙泊酚2mg•kg^-1和维库溴铵0.1mg•kg^-1进行麻醉诱导，同时应用面罩进行纯氧通气。静脉注射维库溴铵2min后开始气管插管操作。患者取仰卧位，麻醉诱导后使患者的头部处于“嗅物位”，所有的气管插管操作均是由熟练掌握这两种气管插管技术的同一位麻醉科医师实施。
　　2、气管插管操作 
　　GSVL组患者采用GlideScope视频喉镜实施气管插管操作，其操作方法基本上同Macintosh直接喉镜。按要求连接各部件后，接通电源并打开显示器。将GlideScope视频喉镜的镜片取舌正中位插入患者的口腔内，使镜片沿正常的口腔和咽部弯曲在舌体表面缓慢向下滑动进入咽部，此时在显示器上依次可见舌根、腭垂、会厌，将镜片前端置于会厌谷并轻轻上提显露声门，必要时联合应用喉外部压迫操作，显露声门后在显示器直视下将带有插管芯、前端塑形成60°的气管导管前端对准声门并稍进入声门下区，在由助手拔除插管芯的同时，操作者在显示器的监视下继续向下推送气管导管，直至其套囊完全进入声门下大约2cm。然后退出镜镜片，并固定气管导管于合适位置。MDLS组采用3号Macintosh喉镜片进行常规气管插管操作，必要时联合应用喉外部压迫操作，显露声门后在明视下插入不带插管芯的气管导管。
　　在气管插管成功后，将气管导管套囊适度充气，将气管导管与麻醉呼吸机相连接进行间歇正压通气，潮气量10ml•kg^-1，呼吸频率10次•min^-1。采用1%安氟烷-60% NO₂-氧维持麻醉，新鲜气流量为2.5L•min^-1。观察期以5ml•kg^-1•h^-1的速度静脉输注乳酸钠林格液。
　　3、观察项目  
　　记录麻醉诱导前，麻醉诱导后，气管导管时以及气管插管后1 min、2 min、3 min、4 min和5 min时的SBP、DBP、MAP、HR和SpO₂。记录气管插管时间（从面罩通气结束至气管插管成功后进行间歇正压通气的时间）。在进行资料分析时将一次试操作未获得气管插管成功的患者排除。
　　4、资料统计  
　　采用微软公司Office XP版本中的Excel统计学工具对数据进行统计学处理，全部计量数据是以均数±标准差（±s）表示。两组之间患者性别分布资料的比较采用卡方分析；患者基本情况和血流动力学资料的组间比较采用非配对t检验；血流动力学资料的组内比较采用单因素方差分析和t检验，以P＜0.05为有显著性差异。

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