喉痙攣醫(yī)學(xué)課件

laryngospasm:

preventionandtreatment1laryngospasm:

preventionandLaryngospasmRiskfactorsTreatmentPreventionKeywords:2LaryngospasmRiskfactorsTreatm

Introduction:Laryngospasmismainlyseeninchildren.Itisareflexclosureoftheupperairwayasaresultoftheglotticmusculaturespasm.Itisessentiallyaprotectivereflexthatactstopreventforeignmaterialenteringthetracheobronchialtree.Theexaggerationofthisreflexmayresultincompleteglotticclosureandconsequentlyimpedingrespiration.Thisleadstohypoxiaandhypercapnea.Inthemajorityofpatients,theprolongedhypoxiaandhypercapneaabolishesthespasticreflexandtheproblemisself-limited.However,incertaincases,thespasmissustainedaslongasthestimuluscontinuesandmorbiditysuchascardiacarrest,arrhythmia,pulmonaryedema,bronchospasmorgastricaspirationmayoccur.3Introduction:LaryngospasmisRiskfactors:Anesthesia-relatedfactors:Insufficientdepthofanesthesiaduringbothinductionandemergencepredisposestolaryngospasm.Duringanesthesiaincludingtrachealintubation,laryngospasmtendstooccurafterextubation,whileanesthesiabyspontaneousbreathingusingafaceorlaryngealmaskmayresultinlaryngospasmduringinductionormaintenance.Ketaminemaycausehypersalivationwhichcanprecipitatelaryngospasmbyirritatingthevocalcords(23).Also,anesthesiainductionwithpropofolislessassociatedwithlaryngospasmthansevofluraneinduction.Volatileanestheticshavebeenassociatedwithlaryngospasminpediatricanesthesia(2.3%).Anesthesia-relatedfactorsPatient-relatedfactorsSurgery-relatedfactors1234Riskfactors:Anesthesia-relatePatient-relatedfactors:Theincidenceoflaryngospasmfollowinggeneralanesthesiaisinverselycorrelatedwithage.Childrenwithupperrespiratorytractinfectionoractiveasthmahaveirritableairwayandareapproximately10-foldmorepronetodeveloplaryngospasm.Airwayhyperactivitylastsforupto6weeksafterrespiratoryinfection,thuselectivesurgerycanbedelayedfor6weeks(4,5,18,30–32).Chronicsmokershaveincreasedairwayreflexsensitivityandaremorepronetodeveloplaryn_x0002_gospasm.Aperiodofabstinencefromsmokingofatleast48handpossiblyupto10daysmayberequiredtoreducetheriskofairwayproblems.Thereisa10-foldincreaseintheincidenceoflaryngospasminchildrenwhoareexposedtotobaccosmoke.Therefore,preoperativevisitshouldincludequestioningabout‘passivesmokingHistoryofgastroesophagealrefluxisalsoariskfactorfordevelopinglaryngospasm.(34,35).Finally,patientswithelongateduvulaandthosewithhistoryofchokingduringsleepmayalsodeveloplaryngospasmundergeneralanesthesia5Patient-relatedfactors:TheinSurgery-relatedfactors:Thereisacloseassociationbetweenlaryngospasmandthetypeofsurgery(4,8).Tonsillectomyandadenoidectomyhavethehighestincidenceoflaryngospasm(21–26%)(1,19,38–43).Othertypesofsurgerysuchasappendicectomy,cervicaldilation,hypospadiassurgeryandskintransplantinchildrenarehighlyassociatedwithlaryngospasm(4).Thyroidsurgeryhasbeenassociatedwithlaryngospasmsecondarytosuperiorlaryngealnerveinjuryorto(44)iatrogenicremovalofparathyroidglandscausinghypocalcemiathatpredisposestolaryngospasm(45).Esophagealproceduresmaycauselaryngospasmsecondarytostimulationofdistalafferentesophagealnerves(4,46).6Surgery-relatedfactors:TherePreventionThetrachealtubeberemovedwhilethelungsareinflatedbypositivepressure;thistechniquedecreasestheadductorresponseofthelaryngealmusclesandreducestheincidenceoflayngospasmAlso,positivepressureinflationofthelungsbeforetrachealextubationisfollowedbyforcedexhalation‘a(chǎn)rtificialcough’afterextubationwhichexpelsanysecretionsorbloodandthisinturndecreasesvocalcordirritationandlaryngospasm.Sprayingtheglottiswith2%lidocaineat4mg?kg)1hasanimportantclinicalapplicationindecreasingtheincidenceoflarygospasmduringawakeintubationinneonates.Theuseofmagnesiumtopreventlaryngospasmaftertonsillectomyandadenoidectomyinchildren,thatmagnesiumactsbybothincreasinganesthesiadepthandprovidingmusclerelaxationinpreventinglaryngospasm.7PreventionThetrachealtubebeTreatment8Treatment8Itinvolvesplacingthemiddlefingerofeachhandinwhattheytermthe‘laryngospasmnotch’(Figure1).Thistechniqueconsistsoffirmlypressinginwardtowardthebaseoftheskullwithbothfingers,whileatthesametimeapplyingjawthrustmaneuver(27).Thisopenstheairwayandinducesperiostealpainbypressingonthestyloidprocesswhichhelpsrelaxingthevocalcordsbytheautonomicnervoussystem.Laryngospasmnotch(locatedbehindthelobuleofthepinnaoftheear,boundedanteriorlybytheascendingramusofthemandibleadjacenttothecondyle,posteriorlybythemastoidprocessofthetemporalboneandcephaladbythebaseoftheskull)9Itinvolvesplacingthemiddle蘇醒期譫妄1PACU譫妄2術(shù)后譫妄3POD通常發(fā)生在術(shù)后24-72h內(nèi)，手術(shù)患者術(shù)后譫妄發(fā)生率可高達50%。

POCD按時間分類：10蘇醒期譫妄1PACU譫妄2術(shù)后譫妄3POD通常發(fā)生在術(shù)后24譫妄的危害延長患者的住院時間APOCDC增加住院費用B增加死亡率D

有針對性的早起執(zhí)行干預(yù)措施，可以有效預(yù)防或顯著降低譫妄的發(fā)生。正確認識疾病發(fā)生發(fā)展的過程及其危險因素，完善良好的術(shù)中管理對麻醉醫(yī)生來說至關(guān)重要。11譫妄的危害延長患者的住院時間APOCDC增加住院費用B增加死診斷標(biāo)準主要參考DSM-5躁動-鎮(zhèn)靜量表RASS/SAS意識紊亂評估法CAMICU意識紊亂評估法CAM-ICU護理譫妄癥狀量表NuDESC重癥監(jiān)護譫妄篩查表ICDSC12診斷標(biāo)準主要參考DSM-5躁動-鎮(zhèn)靜量表RASS/SAS意識RASS13RASS13（1）急性起?。海ㄅ袛鄰那膀?qū)期到疾病發(fā)展期的時間）病人的精神狀況有急性變化的證據(jù)嗎？（2）注意障礙：（請患者按順序說出21到1之間的所有單數(shù)）患者的注意力難以集中嗎?例如，容易注意渙散或難以交流嗎？（3）思維混亂：患者的思維是凌亂或不連貫的嗎？例如，談話主題散漫或不中肯，思維不清晰或不合邏輯，或從一個話題突然轉(zhuǎn)到另一話題(4)意識水平的改變：總體上看，您是如何評估該患者的意識水平？(5)定向障礙：在會面的任何時間患者存在定向障礙嗎？例如，他認為自己是在其它地方而不是在醫(yī)院，使用錯的床位，或錯誤地判斷一天的時間或錯誤地判斷以MMSE為基礎(chǔ)的有關(guān)時間或空間定向(6)記憶力減退（以回憶MMSE中的三個詞的為主）在面談時患者表現(xiàn)出記憶方面的問題嗎？例如，不能回憶醫(yī)院里發(fā)生的事情，或難以回憶指令（包括回憶MMSE中的三個詞）？CAM14（1）急性起?。海ㄅ袛鄰那膀?qū)期到疾病發(fā)展期的時間）病人的(7)知覺障礙患者有知覺障礙的證據(jù)嗎？例如，幻覺、錯覺或?qū)κ挛锏那猓ㄈ?，?dāng)某一東西未移動，而患者認為它在移動）？(8)精神運動性興奮面談時，患者有行為活動不正常的增加嗎？例如坐立不安，輕敲手指或突然變換位置（9）精神運動性遲緩面談時，患者有運動行為水平的異常減少嗎？例如，常懶散，緩慢進入某一空間、停留某一位置時間過長或移動很慢（10）波動性患者的精神狀況（注意力、思維、定向、記憶力）在面談前或面談中有波動嗎？（11）睡眠—覺醒周期的改變：（患者日間過度睡眠而夜間失眠）患者有睡眠—覺醒周期紊亂的證據(jù)嗎？例如日間過度睡眠而夜間失眠？注：19分以下提示該患者沒有譫妄20—22分提示該患者可疑有譫妄22分以上提示該患者有譫妄15(7)知覺障礙患者有知覺障礙的證據(jù)嗎？例如，幻覺、錯覺或CAM-ICU16CAM-ICU16RASS>-3-4/-5CAMNuDESCCAM-ICUICDSCCAM:theConfusionAssessmentMethodCAM-ICU:theConfusionAssessmentMethodforIntensiveCareUnitNuDESC:theNursingDeliriumSymptomChecklistICDSC:theIntensiveCareDeliriumScreeningChecklist評估流程：17RASS>-3-4/-5CAMCAM-ICUCAM:the2017年4月份《歐洲麻醉學(xué)雜志》（EurJAnaesthesiol）

內(nèi)容推薦等級高齡B合并疾?。X血管疾病包括腦卒中,心血管疾病，外周血管疾病，糖尿病，貧血，帕金森，抑郁，焦慮及慢性疼痛）B術(shù)前伴隨疾病評分高，如ASA-PS分級，CCI分級，CIAS分級B圍術(shù)期禁食飲及脫水B低鈉血癥或高鈉血癥B抗膽堿藥物應(yīng)用B酒精導(dǎo)致的相關(guān)認知減退也應(yīng)作為圍術(shù)期危險因素A手術(shù)部位（腹部或胸心外科手術(shù)）B術(shù)中出血情況B手術(shù)時間長短A術(shù)后疼痛A182017年4月份《歐洲麻醉學(xué)雜志》（EurJAnaest老年患者發(fā)生譫妄的圍術(shù)期危險因素內(nèi)容推薦等級認知損害A系統(tǒng)功能減退和/或虛弱A營養(yǎng)不良（低蛋白綜合癥）A感覺障礙A19老年患者發(fā)生譫妄的圍術(shù)期危險因素內(nèi)容推薦等級認知損害A系統(tǒng)功ⅠⅡⅢⅣDefinitionandDiagnosisEtiologyandRiskFactorsDeliriumPreventionDeliriumTreatment20ⅠⅡⅢⅣDefinitionandDiagnosisEt

Fast-trackSurgeryModel

可減少譫妄發(fā)生率，并減少術(shù)后阿片藥的使用KurbegovicS,AndersenJ,KrenkL,KehletH:Deliriuminfast-trackcolonicsurgery.LangenbecksArchSurg2015;400:513-621

Fast-trackSurgeryModel

可減KurbegovicS,AndersenJ,KrenkL,KehletH:Deliriuminfast-trackcolonicsurgery.LangenbecksArchSurg2015;400:513-622KurbegovicS,AndersenJ,KrenKinjoS,LimE,SandsLP,BozicKJ,LeungJM:Doesusingafemoralnerveblockfortotalkneereplacementdecreasepostoperativedelirium?BMCAnesthesiol2012;12:423KinjoS,LimE,SandsLP,BoziGAVSRAMasonSE,Noel-StorrA,RitchieCW:Theimpactofgeneralandregionalanesthesiaontheincidenceofpost-operativecognitivedysfunctionandpost-operativedelirium:asystematicreviewwithmeta-analysis.JAlzheimersDis2010;22Suppl3:67-7924GAVSRAMasonSE,Noel-StorrA藥物預(yù)防haloperidol氟哌啶醇，降低譫妄嚴重性，持續(xù)時間，未降低發(fā)生率Adexamethasone麻醉誘導(dǎo)后給予地塞米松并不能降低心臟手術(shù)后譫妄的發(fā)生率或持續(xù)時間Cstatin慢性他汀類藥物使用者停用他汀類藥物的持續(xù)時間增加，譫妄的可能性增加Esublingualrisperidone單劑量舌下含服利培酮可以加快患者意識恢復(fù)，減少譫妄的發(fā)生率Brivastigmine膽堿能神經(jīng)激動劑，卡巴拉汀與安慰劑進行隨機對照試驗卻發(fā)現(xiàn)在術(shù)后譫妄的發(fā)生率無明顯差異Dmelatonin褪黑素在睡眠覺醒節(jié)律中發(fā)揮著重要的作用，術(shù)前使用褪黑素預(yù)防譫妄尚無定論F由于無可靠證據(jù)表明抗精神藥物或聯(lián)合非藥物的預(yù)防策略可以減少成年患者譫妄的發(fā)生率和持續(xù)時間，因此不做推薦常規(guī)用抗精神病藥預(yù)防術(shù)后譫妄。

25藥物預(yù)防haloperidol氟哌啶醇，降低譫妄嚴重性，持集束化措施（ABCDEbundles）ABCDE喚醒（Awakeningtrials）呼吸機輔助通氣患者的喚醒試驗呼吸（breathingtrials）自主呼吸試驗協(xié)作（Coordinatedeffort）在減少或停止鎮(zhèn)靜劑、患者恢復(fù)自主意識后，注冊護士和呼吸治療師，共同進行自主呼吸實驗，重新評估是否減少或改換鎮(zhèn)靜鎮(zhèn)痛劑

譫妄評估(deliriumassessment)包括治療及預(yù)防措施重癥患者早期活動及步行（Earlymobilizationandambulation）26集束化措施（ABCDEbundles）ABCDE喚醒（Aw手術(shù)方式Fast-TrackSurgeryModel鎮(zhèn)痛模式多模式鎮(zhèn)痛麻醉方式高?；颊呔致閮?yōu)先

藥物預(yù)防不推薦預(yù)防性使用抗精神類藥物，術(shù)前使用褪黑素預(yù)防譫妄尚無定論ABCDE集束化措施術(shù)后早期執(zhí)行27手術(shù)方式Fast-TrackSurgeryModel鎮(zhèn)痛ⅠⅡⅢⅣDefinitionandDiagnosisEtiologyandRiskFactorsDeliriumPreventionDeliriumTreatment28ⅠⅡⅢⅣDefinitionandDiagnosisEt非藥物治療29非