Center for Simulation, Advanced Education and Innovation, Children's Hospital of Philadelphia, Philadelphia, PA.
Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
Pediatr Crit Care Med. 2018 Feb;19(2):106-114. doi: 10.1097/PCC.0000000000001373.
External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs.
A retrospective observational study using a multicenter emergency airway quality improvement registry.
Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand).
Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015.
Propensity score-matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62-0.75; p < 0.001). In propensity score-matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90-0.95; p < 0.001).
External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.
在儿童气管插管过程中，外部喉部操作是一种常用的改善声门可视化的手法。然而，在非麻醉环境下，它对提高气管插管尝试成功率的效果尚不清楚。本研究的目的是评估在儿科重症监护病房（PICU）中，外部喉部操作的使用与初始气管插管尝试成功率之间的关系。
一项使用多中心急诊气道质量改进登记处的回顾性观察研究。
35 个 PICU 分布于综合医院和儿童医院（美国 29 个，加拿大 3 个，日本 1 个，新加坡 1 个，新西兰 1 个）。
2010 年 7 月 1 日至 2015 年 12 月 31 日期间，在 PICU 中接受直接喉镜下初始气管插管的危重症儿童（<18 岁）。
采用倾向评分匹配分析来评估外部喉部操作与初始尝试成功之间的关系，同时调整患者和临床护理因素（年龄、肥胖、气管插管指征、困难气道特征、提供者培训水平和神经肌肉阻滞剂使用）的潜在差异。外部喉部操作被定义为在喉镜检查过程中对颈部的任何外力。在 7825 次气管插管中，有外部喉部操作的 3274 次插管中，初始气管插管尝试成功 1935 次（59%），无外部喉部操作的 4551 次插管中，3086 次插管尝试成功（成功率为 68%）（未调整的优势比，0.69；95%置信区间，0.62-0.75；p <0.001）。在倾向评分匹配分析中，外部喉部操作与较低的初始气管插管尝试成功率相关（调整后的优势比，0.93；95%置信区间，0.90-0.95；p <0.001）。
即使在调整了患者因素和提供者水平的潜在差异后，在直接喉镜检查中使用外部喉部操作与危重症儿童初始气管插管尝试成功率降低相关。不能推荐不分青红皂白地使用外部喉部操作。
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