Levitan Richard M, Kinkle William C, Levin William J, Everett Worth W
Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
Ann Emerg Med. 2006 Jun;47(6):548-55. doi: 10.1016/j.annemergmed.2006.01.013. Epub 2006 Mar 14.
External cricoid and thyroid cartilage manipulations are commonly taught to facilitate laryngeal view during intubation. We compare the laryngeal views during laryngoscopy with 4 manipulations (no manipulation, cricoid pressure, backward-upward-rightward pressure [BURP], and bimanual laryngoscopy) to determine the method that optimizes laryngeal view.
This was a randomized intervention study involving emergency physicians participating in airway training courses from December 2003 to November 2004. Direct laryngoscopies were performed with curved blades on fresh, non-fixed cadavers by using each of the 4 methods. The percentage of glottic opening (POGO), a validated scoring scale, was recorded for each laryngoscopy. Scores for bimanual laryngoscopy were recorded before the assistant applied external pressure.
A total of 1,530 sets of comparative laryngoscopies were performed by 104 participants. One thousand one hundred eighteen of 1,530 sets (73%) had POGO scores less than 100 with no manipulation. Compared to no manipulation, mean POGO scores with bimanual laryngoscopy improved by 25 (95% confidence interval [CI] 23 to 27); mean POGO score improvement with cricoid pressure and BURP were 5 (95% CI 3 to 8) and 4 (95% CI 1 to 7), respectively. POGO scores with bimanual laryngoscopy were higher compared to cricoid pressure (mean difference 20, 95% CI 17 to 22) and BURP (mean difference 21, 95% CI 19 to 24). Among laryngoscopies with no manipulation in which the POGO score greater than 0 (n=1,434), laryngeal view worsened in 60 cases (4%, 95% CI 3% to 5%) with bimanual laryngoscopy, in 409 cases (29%, 95% CI 26% to 31%) with cricoid pressure, and in 504 cases (35%, 95% CI 33% to 38%) with BURP.
Using a cadaver model, we found pressing on the neck during curved blade laryngoscopy greatly affects laryngeal view. Overall, bimanual laryngoscopy improved the view compared to cricoid pressure, BURP, and no manipulation. Cricoid pressure and BURP frequently worsen laryngoscopy. These data suggest bimanual laryngoscopy should be considered when teaching emergency airway management.
在气管插管过程中，通常会教授外部环状软骨和甲状软骨操作以利于暴露喉部视野。我们比较了喉镜检查时4种操作（不进行操作、环状软骨压迫、向后向上向右压迫[BURP]和双手喉镜检查）下的喉部视野，以确定优化喉部视野的方法。
这是一项随机干预研究，纳入了2003年12月至2004年11月参加气道培训课程的急诊医师。使用每种方法，在新鲜、未固定的尸体上用弯形镜片进行直接喉镜检查。记录每次喉镜检查的声门开口百分比（POGO），这是一种经过验证的评分量表。在助手施加外部压力之前记录双手喉镜检查的评分。
104名参与者共进行了1530组对比喉镜检查。1530组中的1118组（73%）在不进行操作时POGO评分低于100。与不进行操作相比，双手喉镜检查的平均POGO评分提高了25（95%置信区间[CI]23至27）；环状软骨压迫和BURP的平均POGO评分提高分别为5（95%CI 3至8）和4（95%CI 1至7）。双手喉镜检查的POGO评分高于环状软骨压迫（平均差异20，95%CI 17至22）和BURP（平均差异21，95%CI 19至24）。在POGO评分大于0的未进行操作的喉镜检查中（n = 1434），双手喉镜检查有60例（4%，95%CI 3%至5%）喉部视野恶化，环状软骨压迫有409例（29%，95%CI 26%至31%），BURP有504例（35%，95%CI 33%至38%）。
使用尸体模型，我们发现弯形镜片喉镜检查时按压颈部会极大地影响喉部视野。总体而言，与环状软骨压迫、BURP和不进行操作相比，双手喉镜检查改善了视野。环状软骨压迫和BURP经常会使喉镜检查结果恶化。这些数据表明，在教授急诊气道管理时应考虑双手喉镜检查。
