De Jong A, Futier E, Millot A, Coisel Y, Jung B, Chanques G, Baillard C, Jaber S
Unité Inserm U1046, Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint-Eloi Teaching Hospital, Université Montpellier 1, Université Montpellier 2, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier, France.
Département d'Anesthésie et Réanimation, Hôpital Estaing, Université de Clermont-Ferrand, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France.
Ann Fr Anesth Reanim. 2014 Jul-Aug;33(7-8):457-61. doi: 10.1016/j.annfar.2014.08.001. Epub 2014 Aug 29.
Intubation is one of the most common procedures performed in operative rooms. It can be associated with life-threatening complications when difficult airway access occurs, in patients who cannot tolerate even a slight hypoxemia or when performed in patients at risk of oxygen desaturation during intubation, as obese, critically-ill and pregnant patients. To improve intubation safety, preoxygenation is a major technique, extending the duration of safe apnoea, defined as the time until a patient reaches an arterial saturation level of 88% to 90%, to allow for placement of a definitive airway. Preoxygenation consists in increasing the lung stores of oxygen, located in the functional residual capacity, and helps preventing hypoxia that may occur during intubation attempts. Obese, critically-ill and pregnant patients are especially at risk of reduced effectiveness of preoxygenation because of pathophysiological modifications (reduced functional residual capacity (FRC), increased risk of atelectasis, shunt). Three minutes tidal volume breathing or 3-8 vital capacities are recommended in general population, mostly allowing achieving a 90% end-tidal oxygen level. Recent studies have indicated that in order to maximize the value of preoxygenation (i.e, oxygenation stores) obese and critically-ill patients can benefit from the combination of breathing 100% oxygen and non-invasive positive pressure ventilation (NIV) with end-expiratory positive pressure (PEEP) in the proclive position (Trendelenburg reverse). Recruitment manoeuvres may be of interest immediately after intubation to limit the risk of lung derecruitment. Further studies are needed in the field of preoxygenation in pregnant women.
气管插管是手术室中最常见的操作之一。当气道难以进入时,在无法耐受哪怕轻微低氧血症的患者中,或者在插管过程中有氧饱和度降低风险的患者(如肥胖、重症和孕妇)中,气管插管可能会伴有危及生命的并发症。为提高气管插管的安全性,预充氧是一项主要技术,它能延长安全无呼吸时间(定义为患者动脉饱和度降至88%至90%之前的时间),以便能够建立确定性气道。预充氧在于增加肺内储氧量(位于功能残气量中),有助于预防插管尝试期间可能发生的缺氧。肥胖、重症和孕妇由于病理生理改变(功能残气量减少、肺不张风险增加、分流),尤其存在预充氧效果降低的风险。一般人群建议进行3分钟的潮气量呼吸或3 - 8次肺活量呼吸,大多能使呼气末氧水平达到90%。最近的研究表明,为了使预充氧(即氧储备)的价值最大化,肥胖和重症患者可受益于在头低脚高位(特伦德伦伯格卧位反向)下吸入100%氧气并结合无创正压通气(NIV)及呼气末正压(PEEP)。插管后立即进行肺复张手法可能有助于降低肺不张的风险。在孕妇预充氧领域还需要进一步研究。