喉痉挛医学课件.pptx

1、1TreatmentPreventionKey words:2 Introduction:Laryngospasm is mainly seen in children.It is a reflex closure of the upper airway as a result of the glottic musculature spasm.It is essentially a protective reflex that acts to prevent foreign material entering the tracheobronchial tree.The exaggeration

2、 of this reflex may result in complete glottic closure and consequently impeding respira tion.This leads to hypoxia and hypercapnea.In the majority of patients,the prolonged hypoxia and hypercapnea abolishes the spastic reflex and the problem is self-limited.However,in certain cases,the spasm is sus

3、tained as long as the stimulus continues and morbidity such as cardiac arrest,arrhythmia,pulmonary edema,bronchospasm or gastric aspiration may occur.3Risk factors:Anesthesia-related factors:Insufficient depth of anesthesia during both induction and emergence predisposes to laryngospasm.During anest

4、hesia including tracheal intubation,laryngospasm tends to occur after extubation,while anesthesia by spontaneous breathing using a face orlaryngeal mask may result in laryngospasm duringinduction or maintenance.Ketamine may cause hypersalivation which can precipitate laryngospasm byirritating the vo

5、cal cords(23).Also,anesthesia induction with propofol is less associated with laryngospasm than sevoflurane induction.Volatile anesthetics have been associated with laryngospasm in pediatric anesthesia(2.3%).Anesthesia-related factorsPatient-related factorsSurgery-related factors1234Patient-related

6、factors:The incidence of laryngospasm following generalanesthesia is inversely correlated with age.Children with upper respiratory tract infection oractive asthma have irritable airway and are approximately 10-fold more prone to develop laryngospasm.Airway hyperactivity lasts for up to 6 weeks after

7、 respiratory infection,thus elective surgery can be delayed for 6 weeks(4,5,18,3032).Chronic smokers have increased airway reflex sensitivity and are more prone to develop laryn_x0002_gospasm.A period of abstinence from smoking of at least 48 h and possibly up to 10 days may be required to reduce th

8、e risk of airway problems.There is a 10-fold increase in the incidence oflaryngospasm in children who are exposed to tobacco smoke.Therefore,preoperative visit should include questioning about passive smoking History of gastroesophageal reflux is also a risk factor for developing laryngospasm.(34,35

9、).Finally,patients with elongated uvula and those with history of choking during sleep may also develop laryngospasm under general anesthesia 5Surgery-related factors:There is a close association between laryngospasm and the type of surgery(4,8).Tonsillectomy and adenoidectomy have the highest incid

10、ence of laryngospasm(2126%)(1,19,3843).Other types of surgery such as appendicectomy,cervical dilation,hypospadias surgery and skin transplant in children are highly associated with laryngospasm(4).Thyroid surgery has been associated with laryngospasm secondary to superior laryngeal nerve injury or

11、to(44)iatrogenic removal of parathyroid glands causing hypocalcemia that predisposes to laryngospasm(45).Esophageal procedures may cause laryngospasm secondary to stimulation of distal afferent esophageal nerves(4,46).6PreventionThe tracheal tube be removed while the lungs are inflated by positive p

12、ressure;this technique decreases the adductor response of the laryngeal muscles and reduces the incidence of layngospasm Also,positive pressure inflation of the lungs before tracheal extubation is followed by forced exhalation artificial cough after extubation which expels any secretions or blood an

13、d this in turn decreases vocal cord irritation and laryngospasm.Spraying the glottis with 2%lidocaine at 4 mgkg)1 has an important clinical application in decreasing the incidence of larygospasm during awake intubation in neonates.The use of magnesium to prevent laryngospasm after tonsillectomy and

14、adenoidectomy in children,that magnesium acts by both increasing anesthesia depth and providing muscle relaxation in preventing laryngospasm.7Treatment8It involves placing the middle finger of each hand in what they term the laryngospasm notch(Figure 1).This technique consists of firmly pressing inw

15、ard toward the base of the skull withboth fingers,while at the same time applying jaw thrust maneuver(27).This opens the airway and induces periosteal pain by pressing on the styloid process which helps relaxing the vocal cords by the autonomic nervous system.Laryngospasm notch(located behind the lo

16、bule of the pinna of theear,bounded anteriorly by the ascending ramus of the mandibleadjacent to the condyle,posteriorly by the mastoid process of thetemporal bone and cephalad by the base of the skull)9苏醒期谵妄1PACU谵妄2术后谵妄3POD通常发生在术后24-72h内，手术患者术后谵妄发生率可高达50%。POCD按时间分类：10谵妄的危害延长患者的住院时间APOCDC增加住院费用B增加死亡

17、率D 有针对性的早起执行干预措施，可以有效预防或显著降低谵妄的发生。正确认识疾病发生发展的过程及其危险因素，完善良好的术中管理对麻醉医生来说至关重要。11诊断标准主要参考DSM-5躁动-镇静量表RASS/SAS意识紊乱评估法CAMICU意识紊乱评估法CAM-ICU护理谵妄症状量表NuDESC重症监护谵妄筛查表ICDSC12RASS13（1）急性起病：（判断从前驱期到疾病发展期的时间）病人的精神状况有急性变化的证据吗？（2）注意障碍：（请患者按顺序说出21到1之间的所有单数）患者的注意力难以集中吗?例如，容易注意涣散或难以交流吗？（3）思维混乱：患者的思维是凌乱或不连贯的吗？例如，谈话主题散漫或

18、不中肯，思维不清晰或不合逻辑，或从一个话题突然转到另一话题(4)意识水平的改变：总体上看，您是如何评估该患者的意识水平？(5)定向障碍：在会面的任何时间患者存在定向障碍吗？例如，他认为自己是在其它地方而不是在医院，使用错的床位，或错误地判断一天的时间或错误地判断以MMSE为基础的有关时间或空间定向(6)记忆力减退（以回忆MMSE中的三个词的为主）在面谈时患者表现出记忆方面的问题吗？例如，不能回忆医院里发生的事情，或难以回忆指令（包括回忆MMSE中的三个词）？CAM14(7)知觉障碍 患者有知觉障碍的证据吗？例如，幻觉、错觉或对事物的曲解（如，当某一东西未移动，而患者认为它在移动）？(8)精神运

19、动性兴奋 面谈时，患者有行为活动不正常的增加吗？例如坐立不安，轻敲手指或突然变换位置（9）精神运动性迟缓 面谈时，患者有运动行为水平的异常减少吗？例如，常懒散，缓慢进入某一空间、停留某一位置时间过长或移动很慢（10）波动性 患者的精神状况（注意力、思维、定向、记忆力）在面谈前或面谈中有波动吗？（11）睡眠觉醒周期的改变：（患者日间过度睡眠而夜间失眠）患者有睡眠觉醒周期紊乱的证据吗？例如日间过度睡眠而夜间失眠？注：19分以下提示该患者没有谵妄 2022分提示该患者可疑有谵妄 22分以上提示该患者有谵妄 15CAM-ICU16RASS-3-4/-5CAMNuDESCCAM-ICUICDSCCAM:

20、the Confusion Assessment Method CAM-ICU:the Confusion Assessment Method for Intensive Care UnitNuDESC:the Nursing Delirium Symptom Checklist ICDSC:the Intensive Care Delirium Screening Checklist评估流程：172017年4月份欧洲麻醉学杂志（Eur J Anaesthesiol）内容内容推荐等级推荐等级高龄B合并疾病（脑血管疾病包括脑卒中,心血管疾病，外周血管疾病，糖尿病，贫血，帕金森，抑郁，焦虑及慢性疼

21、痛）B术前伴随疾病评分高，如ASA-PS分级，CCI分级，CIAS分级B围术期禁食饮及脱水B低钠血症或高钠血症B抗胆碱药物应用B酒精导致的相关认知减退也应作为围术期危险因素A手术部位（腹部或胸心外科手术）B术中出血情况B手术时间长短A术后疼痛A18老年患者发生谵妄的围术期危险因素老年患者发生谵妄的围术期危险因素内容内容推荐等级推荐等级认知损害认知损害A系统功能减退和系统功能减退和/或虚弱或虚弱A营养不良（低蛋白综合症）营养不良（低蛋白综合症）A感觉障碍感觉障碍A19Etiology andRisk FactorsDelirium PreventionDelirium Treatment20Fa

22、st-track Surgery Model可减少谵妄发生率，并减少术后阿片药的使用Kurbegovic S,Andersen J,Krenk L,Kehlet H:Delirium in fast-track colonic surgery.Langenbecks Arch Surg 2015;400:513-621Kurbegovic S,Andersen J,Krenk L,Kehlet H:Delirium in fast-track colonic surgery.Langenbecks Arch Surg 2015;400:513-622Kinjo S,Lim E,Sands LP

23、,Bozic KJ,Leung JM:Does using a femoral nerve block for total knee replacement decrease postoperative delirium?BMC Anesthesiol 2012;12:423GA VS RAMason SE,Noel-Storr A,Ritchie CW:The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative

24、 delirium:a systematic review with meta-analysis.J Alzheimers Dis 2010;22 Suppl 3:67-7924药物预防药物预防 haloperidol氟哌啶醇，降低谵妄严重性，持续时间，未降低发生率Adexamethasone麻醉诱导后给予地塞米松并不能降低心脏手术后谵妄的发生率或持续时间Cstatin慢性他汀类药物使用者停用他汀类药物的持续时间增加，谵妄的可能性增加Esublingualrisperidone单剂量舌下含服利培酮可以加快患者意识恢复，减少谵妄的发生率Brivastigmine胆碱能神经激动剂，卡巴拉汀与安慰剂

25、进行随机对照试验却发现在术后谵妄的发生率无明显差异Dmelatonin 褪黑素在睡眠觉醒节律中发挥着重要的作用，术前使用褪黑素预防谵妄尚无定论F 25集束化措施（ABCDE bundles）ABCDE唤醒（Awakening trials）呼吸机辅助通气患者的唤醒试验呼吸（breathing trials）自主呼吸试验协作（Coordinated effort）在减少或停止镇静剂、患者恢复自主意识后，注册护士和呼吸治疗师，共同进行自主呼吸实验，重新评估是否减少或改换镇静镇痛剂 谵妄评估(delirium assessment)包括治疗及预防措施重症患者早期活动及步行（Early mobiliz

26、ation and ambulation）26手术方式手术方式Fast-Track Surgery Model镇痛模式镇痛模式多模式镇痛麻醉方式麻醉方式高危患者局麻优先 药物预防药物预防不推荐预防性使用抗精神类药物，术前使用褪黑素预防谵妄尚无定论ABCDE集束化措施集束化措施术后早期执行27Etiology andRisk FactorsDelirium PreventionDelirium Treatment2829应详细了解患者的现病史、并存疾病、药物和手术治疗情况，识别危险因素。筛选药物筛选药物音乐治疗、按摩音乐治疗、按摩对症处理对症处理环境支持环境支持早期活动早期活动3031安慰剂组与

27、氟哌啶醇组与安慰剂组与氟哌啶醇组与齐拉西酮组在所有三组无齐拉西酮组在所有三组无谵妄天差异无统计学意义谵妄天差异无统计学意义氟哌啶醇与奥氮平在氟哌啶醇与奥氮平在ICU患患者谵妄的长度无显着差异，者谵妄的长度无显着差异，喹硫平联用氟哌啶醇可促进喹硫平联用氟哌啶醇可促进早期谵妄的恢复早期谵妄的恢复卡巴拉汀用作氟哌啶卡巴拉汀用作氟哌啶醇的辅助用药醇的辅助用药药物治疗药物治疗32 Djaiani G,Silverton N,Fedorko L,Carroll J,Styra R,Rao V,Katznelson R:Dexmedetomidine versus Propofol Sedation Red

28、uces Delirium after Cardiac Surgery:A Randomized Controlled Trial.Anesthesiology 2016;124:362-8 右美：331.右美托咪定镇静异丙酚相比，降低发病右美托咪定镇静异丙酚相比，降低发病率，延缓和缩短率，延缓和缩短POD在老年患者心脏手术在老年患者心脏手术后持续时间。后持续时间。2.POD的绝对风险降低的绝对风险降低14%。3.然而，右美托咪定有一定的心脏抑制作然而，右美托咪定有一定的心脏抑制作用，有些患者使用过程中会出现血压或心用，有些患者使用过程中会出现血压或心率的显著下降，此时可考虑使用丙泊酚镇率的显著下降，此时可考虑使用丙泊酚镇静。静。34尽快脱机ICU抢救治疗减少血流动力学并发症补救措施避免过度镇静降低谵妄发生率降低谵妄发生率右旋美托咪定右旋美托咪定右美托咪定作为治疗谵妄的一线疗法右美托咪定作为治疗谵妄的一线疗法还还需要更多的研究需要更多的研究3536 谵妄直接关系这患者的预后了解谵妄的危险因素、诱发因素、完善术中管理对麻醉师来说必不可少。现在以证据为基础的用来治疗谵妄的药理选择比较少，并且存在一定的局限性，所以前期非药物预防很重要。1明确诊断明确诊断2正确评估正确评估3前期预防前期预防4多模式镇痛多模式镇痛5药物治疗药物治疗谵妄谵妄37THANKS38