Nagata Mariko, Shimomura Yasuyo, Hara Yoshitaka, Nakamura Tomoyuki, Hayakawa Seiko, Komura Hidefumi, Shibata Junpei, Yamashita Chizuru, Nishida Osamu
Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan.
JA Clin Rep. 2017;3(1):21. doi: 10.1186/s40981-017-0091-8. Epub 2017 May 3.
Extubation is a more challenging medical practice than intubation, and countermeasures against it are similar to those described in the Difficult Intubation Guidelines, but problems cannot be overcome by completely the same methods. We predicted difficult extubation in a pediatric patient with left recurrent laryngeal nerve paralysis and devised an extubation method.
The patient was a 2-year-and-8-month-old boy scheduled for cleft palate repair. Concomitant cardiac anomaly and first and second branchial arch syndrome-associated facial malformations, such as mandibular micrognathia and auricular malformation, were observed. He had a past medical history of difficult intubation and respiratory arrest on a catheter test under intravenous sedation at 4 months old. Left recurrent laryngeal nerve paralysis was discovered on preoperative examination of the cleft palate, based on which difficulty in postoperative extubation was predicted. A catheter for tracheal tube exchange proposed by the extubation guidelines of the Difficult Airway Society (DAS) was placed, endoscopic examination was performed while inducing spontaneous breathing and swallowing reflex by an otolaryngologist, and the tube was removed while movement of the tissue around the glottis was visually evaluated. The patient was managed in an ICU after extubation, and both the systemic and respiratory conditions were favorable.
Extubation and airway management could be safely performed by devising extubation while conforming to the DAS guidelines.
拔管是一项比插管更具挑战性的医疗操作，针对其的应对措施与《困难插管指南》中描述的类似，但问题无法通过完全相同的方法解决。我们预测了一名左侧喉返神经麻痹的儿科患者拔管困难，并设计了一种拔管方法。
该患者为一名2岁8个月大的男孩，计划进行腭裂修复术。观察到伴有心脏异常以及第一和第二鳃弓综合征相关的面部畸形，如下颌小颌畸形和耳廓畸形。他有4个月大时在静脉镇静下进行导管测试时插管困难和呼吸骤停的既往病史。在腭裂术前检查中发现左侧喉返神经麻痹，据此预测术后拔管困难。放置了困难气道协会（DAS）拔管指南中提出的气管导管更换导管，在耳鼻喉科医生诱导自主呼吸和吞咽反射时进行内镜检查，并在视觉评估声门周围组织的运动时拔除导管。患者拔管后在重症监护病房进行管理，全身和呼吸状况均良好。
通过设计符合DAS指南的拔管方法，可以安全地进行拔管和气道管理。
