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

李玄英　薛富善　张国华　孙海涛　李成文　刘鲲鹏　许亚超　刘毅

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

Xuan-ying Li， Fus-han Xue， Guo-hua Zhang， Hai-tao Sun， Cheng-wen Li， Kun-peng Liu 

Ya-chao Xu， Yi Liu

Department of Anesthesiology，Plastic Surgery Hospital，Chinese Academy of Medical Sciences and Peking Union Medical College，Beijing 100041.

ABSTRACT

Objective：To compare the hemodynamic responses to orotracheal intubation using a GlideScope videolaryngoscope(GSVL)and a Macintosh direct laryngoscope(MDLS).

Method：57 patients ASA physical status aged 18-60 years, scheduled for elective plastic surgery under general anesthesia requiring orotracheal intubation were randomly allocated to either the GSVL group or the MDLS group. After an intravenous anesthetic induction, the orotracheal intubation was performed using a GSVL or a MDLSrespectively. Noninvasive blood pressure and HR were recorded before and after anesthetic induction,at intubation and 5 minutes after intubation with 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, blood pressures and RPP in the two groups decreased significantly compared to their preinduction values. As comparison with their postinduction values, the orotracheal intubation in the two groups caused significant increases in blood pressures, HR and RPP. Except for maximal value of DBP in GSVL group, the rise of blood pressures caused by orotracheal intubation in both groups did not exceed their baseline values. In GSVL group, HR and RPP at intubation were significantly higher than their baseline values, and increase in HR lasted for 4 min. In MDLS group, HR at intubation were also significantly higher than its baseline value, but increase in HR lasted only for 1 min. There was no significant difference in the hemodynamic data at any time point during the observation between the two groups.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

Conclusions：The hemodynamic responses to orotracheal intubation using a GSVL and a MDLS were similar. As compared with MDLS, GSVL does not provide any special advantages in prevention of the adverse hemodynamic responses to orotracheal intubation.

Key words：GlideScope videolaryngoscope; Macintosh direct laryngoscope; Orotracheal intubation; Hemodynamic responses

Corresponding author：Fu-shan Xue; E-mail：Fruitxue@yahoo.com.cn

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血流动力学反应。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。

一、资料和方法<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

1. 研究对象

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。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）。

2. 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血压、HR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，芬太尼2μg/kg，丙泊酚2mg/kg和维库溴铵0.1mg/kg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。

3. 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，将气管导管与麻醉呼吸机相连接进行间歇正压通气，潮气量10ml/kg，呼吸频率10次/min。采用1%安氟烷60% NO2氧维持麻醉，新鲜气流量为2.5L/min。观察期以5ml/kg/h的速度静脉输注乳酸钠林格液。

4. 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时的血压和HR，并计算二重指数（RPP）。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。

5. 统计学分析

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（Ｘ±s）表示。两组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。

参考文献<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

1. Cooper RM. Use of a new videolaryngoscope （GlideScope） in the manage ment of a difficult airway. Can J Anaesth，2003; 50: 611-3.

2. Agro F，Barzoi G，Montecchia F. Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization. Br J Anaesth，2003; 90: 705-6.

3. Doyle DJ. Awake intubation using the GlideScope video laryngoscope: initial experience in four cases. Can J Anaesth，2004; 51: 520-1.

4. Lim Y，Lim TJ，Liu EH. Ease of intubation with the GlideScope or Macintosh laryngoscope by inexperienced operators in simulated difficult airways. Can J Anaesth，2004; 51: 641-2.

5. Doyle DJ. Miniaturizing the GlideScope video laryngoscope system: a new design for enhanced portability. Can J Anaesth，2004; 51: 642-3.

6. GlideScope Operator & Service Manual. Saturn Biomedical Systems Inc.2003.

7. 李平，何农，薛富善. 气管插管的不良生理学影响及其防治. 见: 薛富善主编. 现代呼吸道管理学?麻醉与危重症治疗关键技术. 郑州大学出版社: 郑州， 2002: 1020-30.

8. Shribman AJ，Smith G，Achola KJ. Cardiovascular and catecholamine re sponses to laryngoscopy with and without tracheal intubation. Br J Anaesth， 1987; 59: 295-9.

9. Bichael JB，Bedford RF，Kil HK. Physiologic and pathophysiologic responses to intubation.In: Benumof JL，ed. Airway Management: Principles and Practice， 1st. Boston: Mosby，1996: 102-8.

10. Bucx MJ，van Geel RT，Scheck PA，Stijnen T. Cardiovascular effects of forces applied during laryngoscopy. Anaesthesia，1992; 47: 1029-33.

11. Adachi YU，Takamatsu I，Watanabe K，et al. Evaluation of the cardiovas cular responses to fiberoptic orotracheal intubation with television monitoring: comparison with conventional direct laryngoscopy. J Clin Anesth， 2000; 12: 503-8.

12. Takahashi S，Mizutani T，Miyabe M，Toyooka H. Hemodynamic responses to tracheal intubation with laryngoscope versus lightwand intubating device （Trachlight） in adults with normal airway. Anesth Analg，2002; 95: 480-4.

13. Hirabayashi Y，Hiruta M，Kawakami T，et al. Effects of lightwand   （Trachlight） compared with direct laryngoscopy on circulatory responses to tracheal intubation.Br J Anaesth，1998; 81: 253-5.

14. Adachi YU，Satomoto M，Higuchi H，Watanabe K. Fentanyl attenuates the hemodynamic response to endotracheal intubation more than the response to laryngoscopy. Anesth Analg，2002; 95: 233-7.

15．Benumof JL. Conventional（laryngoscopic） orotracheal and nasotracheal in tubation（single-lumen type）. In: Benumof JL，ed. Clinical Procedures in Anesthesia and Intensive Care. Philadelphia: J.B. Lippincott Company，1992: 131.

16. Gobel FL，Nordstrom LA，Nelson RR，Jorgensen CR，Wang Y. The rate- pressure product as an index of myocardial oxygen consumption during exerc ise in patients with angina pectoris. Circulation 1978; 57: 549-56.

17. Robinson BF. Relation of heart rate and systolic blood pressure to the onset of pain in angina pectoris. Circulation 1967; 35: 1073-83.