Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.
Can J Anaesth. 2013 Sep;60(9):929-45. doi: 10.1007/s12630-013-9991-x. Epub 2013 Jul 9.
The purpose of this Continuing Professional Development module is to describe anatomic and physiologic challenges in obese patients, review their effects on oxygenation and airway management, and propose strategies for perioperative management.
The combination of excess adipose tissue deposition, increased oxygen consumption, reduced lung volumes, and increased airway resistance in obese patients increases the risk of a difficult airway and rapid oxygen desaturation in the perioperative period. Preoxygenation can be optimized by a head-up or reverse Trendelenburg position, continuous positive airway pressure, and pressure support ventilation. Difficulties in bag and mask ventilation may occur. Laryngeal exposure during direct laryngoscopy is best achieved with the patient in the "ramped" position. Tracheal tube introducers or intubating stylets can assist tracheal intubation when suboptimal laryngeal views are obtained, and video laryngoscopy may help improve the glottic view and success of tracheal intubation. New generation double-lumen supraglottic airway devices provide higher leak pressures and may be safer in obese patients, and they can also provide a conduit for bronchoscopic intubation. In patients with anticipated difficult airways, preparations should be made for awake tracheal intubation. Intraoperatively, ventilatory strategies, such as recruitment maneuvers with positive end-expiratory pressure, may reduce atelectasis and improve oxygenation. Tracheal extubation in the head-up position and continuous positive airway pressure reduce postoperative hypoxemia. Following a difficult tracheal intubation, extubation over an airway exchange catheter should be considered.
Rapid oxygen desaturation may occur in obese patients. Potential difficulties in airway management should be assessed and anticipated, and oxygenation, ventilation, and airway management strategies should be optimized perioperatively.
本继续职业发展模块旨在描述肥胖患者的解剖和生理挑战，回顾它们对氧合和气道管理的影响，并提出围手术期管理策略。
肥胖患者中过多的脂肪组织沉积、增加的氧耗量、减少的肺容量和增加的气道阻力增加了围手术期困难气道和快速氧饱和度下降的风险。通过头高脚低位或反向特伦德伦堡位、持续气道正压通气和压力支持通气可以优化预充氧。可能会出现困难的球囊面罩通气。在直接喉镜检查中，患者处于“斜坡”位置时，可获得最佳的喉暴露。当获得不理想的声带视图时，喉管导入器或插管引导器可协助气管插管，视频喉镜可帮助改善声门视图和气管插管成功率。新一代双腔声门上气道装置可提供更高的泄漏压力，在肥胖患者中可能更安全，还可作为支气管插管的通道。对于预计有困难气道的患者，应做好清醒气管插管的准备。术中，采用呼气末正压的复张手法等通气策略，可能减少肺不张并改善氧合。头高位拔管和持续气道正压通气可减少术后低氧血症。在困难气管插管后，应考虑在气道交换导管上进行拔管。
肥胖患者可能会出现快速的氧饱和度下降。应评估和预测气道管理的潜在困难，并优化围手术期的氧合、通气和气道管理策略。
