使用便携式超声采集图像进行紧急气道管理
Summary
即时超声（POCUS）越来越多地用于气道管理。本文介绍POCUS的一些临床应用，包括区分气管内插管和食管插管，在需要手术气道时识别环甲膜，以及测量颈部前软组织以预测困难的气道管理。
Abstract
随着便携式超声检查的日益普及和可及性，便携式超声检查已被迅速调整，不仅用于改善患者的围手术期护理，而且还用于解决在气道管理中使用超声的潜在益处。床旁超声（POCUS）的好处包括其便携性，使用速度快，以及患者没有侵入性或暴露于其他成像方式的辐射。
气道 POCUS 的两个主要适应证包括确认气管插管和在需要手术气道时识别环甲膜。在本文中，描述了使用超声确认气管插管和相关解剖结构的技术，以及相关的超声图像。此外，还回顾了环甲膜解剖结构的识别以及超声采集适当的图像以执行此过程。
未来的进展包括利用气道POCUS来识别可能表明气道管理困难的患者特征。传统的床旁临床检查充其量只有公平的预测值。增加超声气道评估有可能提高这种预测准确性。本文介绍了使用POCUS进行气道管理，初步证据表明，这提高了预测困难气道的诊断准确性。鉴于气道POCUS的局限性之一是它需要熟练的超声医师，并且图像分析可能取决于操作人员，本文将为标准化气道超声检查的技术方面提供建议，并促进利用超声检查进行气道管理的进一步研究。该协议的目标是教育研究人员和医疗卫生专业人员，并推进气道POCUS领域的研究。
Introduction
便携式超声检查在患者的围手术期护理中具有明显的实用性。它的可及性和缺乏侵入性是导致即时超声（POCUS）迅速纳入手术患者临床护理的好处1，2。随着POCUS在围手术期领域不断寻找新的适应症，有几个既定的适应症与传统的临床检查相比具有明显的益处。在这种方法论文中，我们回顾了最近的发现，并展示了如何将POCUS整合到临床实践或气道管理中。
未检测到的食管插管可导致显著的并发症发生率和死亡率;因此，立即识别食管插管并将插管置于气管内位置以避免灾难性的呼吸损伤至关重要。气管插管的传统确认依赖于临床检查，例如听诊双侧呼吸音和胸位上升3，4。即使在美国麻醉医师协会 （ASA） 将潮气末 CO2 作为识别气管插管的必要监测器之后，仍然存在未检测到食管插管的病例，导致显着的发病率和死亡率5。将气管超声检查纳入插管程序的一个主要好处是可以立即识别食管插管，并且可以在气管中确认管子的实时、直接可视化。在最近的一项荟萃分析中，气管内确认的汇总敏感性和特异性分别为 98% 和 94%，说明该技术具有卓越的诊断准确性6。在该方法论文中，将展示一个视频示例，说明管子被错误地放置在食道中，立即识别出这种并发症，并将管子正确放置在气管中。这突出了POCUS在插管过程中允许的实时视觉优势。
尽管声门上气道和视频喉镜检查取得了进展，但在“不能插管，不能充氧”的情况下，手术气道可能仍然是挽救生命的必需品。更新后的ASA困难气道指南强调，如果需要挽救生命的侵入性气道，则必须由训练有素的专家尽快执行该程序7。如果需要进行环甲膜切开术，则需要确定正确的解剖结构以防止进一步的并发症。利用超声检查来可视化环甲膜（CTM）的解剖结构是一种快速有效的技术，如果担心气道困难，现在建议在术前使用8。这种技术可以以相对快速的方式教授，学习者在简短的 2 小时教程和 20 次专家指导扫描9 后几乎获得了完全的能力。在这种方法论文中，将展示两种使用POCUS识别CTM的技术，以期进一步教育任何常规进行气道管理的医疗保健提供者。
患者气道的术前评估包括传统的床旁临床检查（例如Mallampati评分、张口、宫颈活动度等）。这些评估存在几个问题。第一个可能也是最突出的是，它们在预测困难的气道情况方面不是很准确10。此外，这些测试需要患者参与，这在所有临床情况下（例如在创伤或精神状态改变的情况下）都是不可能的。
术前气道超声测量显示，预测气管插管放置困难的准确性有所提高11，12。已经测量和分析了不同水平的颈部前软组织厚度，作为插管困难的预测。皮肤到会厌之间距离的超声测量似乎具有迄今为止确定的最佳诊断准确性13。当添加到传统的床边检查中时，这种测量也被证明可以大大提高预测能力14。本文解释了如何使用POCUS测量皮肤到会厌的距离并将其纳入术前气道检查，以帮助医疗保健提供者更好地预测困难的气道情况。
此外，研究人员已开始确定表明面罩通气困难的解剖结构。一种这样的解剖结构是咽侧壁，其厚度（LPWT）已被证明对应于阻塞性睡眠呼吸暂停（OSA）的严重程度和呼吸暂停-低通气指数15。初步数据还表明，术前对LPWT的测量为面罩通气的困难提供了证据16。本文和相关视频将演示如何通过便携式超声检查获取LPWT，以评估患者OSA的严重程度以及面罩通气困难的可能性。
Protocol
Representative Results
Discussion
2018年，心血管麻醉师协会的领导层呼吁采取行动，进行“麻醉学围手术期超声培训”23。值得注意的是，这些领导人强调，POCUS教育应成为麻醉学培训计划的重要组成部分。最近，麻醉学专家进一步解释了POCUS在围手术期患者护理的各个方面（包括气道管理）中的效用和必要性24。专家强调，麻醉学界的领导者必须倡导POCUS的教育，并通过指南和特定的认证流程?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
没有。该项目没有收到任何资金。
Materials
| High Frequency Ultrasound Probe (HFL38xp) | SonoSite (FujiFilm) | P16038 | |
| Low Frequency Ultrasound Probe (C35xp) | SonoSite (FujiFilm) | P19617 | |
| SonoSite X-porte Ultrasound | SonoSite (FujiFilm) | P19220 | |
| Ultrasound Gel | AquaSonic | PLI 01-08 |
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