成人危重症患者经气管插管时的球囊面罩通气。
Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults.
机构信息
From the Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine-New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) - both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle.
出版信息
N Engl J Med. 2019 Feb 28;380(9):811-821. doi: 10.1056/NEJMoa1812405. Epub 2019 Feb 18.
BACKGROUND
Hypoxemia is the most common complication during tracheal intubation of critically ill adults and may increase the risk of cardiac arrest and death. Whether positive-pressure ventilation with a bag-mask device (bag-mask ventilation) during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration remains controversial.
METHODS
In a multicenter, randomized trial conducted in seven intensive care units in the United States, we randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device or no ventilation between induction and laryngoscopy. The primary outcome was the lowest oxygen saturation observed during the interval between induction and 2 minutes after tracheal intubation. The secondary outcome was the incidence of severe hypoxemia, defined as an oxygen saturation of less than 80%.
RESULTS
Among the 401 patients enrolled, the median lowest oxygen saturation was 96% (interquartile range, 87 to 99) in the bag-mask ventilation group and 93% (interquartile range, 81 to 99) in the no-ventilation group (P = 0.01). A total of 21 patients (10.9%) in the bag-mask ventilation group had severe hypoxemia, as compared with 45 patients (22.8%) in the no-ventilation group (relative risk, 0.48; 95% confidence interval [CI], 0.30 to 0.77). Operator-reported aspiration occurred during 2.5% of intubations in the bag-mask ventilation group and during 4.0% in the no-ventilation group (P = 0.41). The incidence of new opacity on chest radiography in the 48 hours after tracheal intubation was 16.4% and 14.8%, respectively (P = 0.73).
CONCLUSIONS
Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation. (Funded by Vanderbilt Institute for Clinical and Translational Research and others; PreVent ClinicalTrials.gov number, NCT03026322.).
背景
低氧血症是危重症成人气管插管中最常见的并发症，可能增加心脏骤停和死亡的风险。在危重症成人气管插管期间使用球囊面罩装置进行正压通气（球囊面罩通气）是否可以防止低氧血症而不增加误吸的风险仍存在争议。
方法
在一项在美国 7 家重症监护病房进行的多中心、随机试验中，我们将接受气管插管的成人随机分为接受球囊面罩通气或诱导和喉镜检查之间不进行通气的两组。主要结局是诱导和气管插管后 2 分钟之间观察到的最低氧饱和度。次要结局是严重低氧血症（定义为氧饱和度低于 80%）的发生率。
结果
在纳入的 401 名患者中，球囊面罩通气组的最低氧饱和度中位数为 96%（四分位距，87 至 99），无通气组为 93%（四分位距，81 至 99）（P=0.01）。球囊面罩通气组有 21 名（10.9%）患者发生严重低氧血症，无通气组有 45 名（22.8%）患者发生（相对风险，0.48；95%置信区间[CI]，0.30 至 0.77）。球囊面罩通气组有 2.5%的插管操作中报告了操作者感知的误吸，无通气组为 4.0%（P=0.41）。气管插管后 48 小时内胸部 X 线新出现不透光的发生率分别为 16.4%和 14.8%（P=0.73）。
结论
在接受气管插管的危重症成人中，与不接受通气的患者相比，接受球囊面罩通气的患者氧饱和度更高，严重低氧血症的发生率更低。（由范德比尔特临床与转化研究研究所和其他机构资助；PreVent ClinicalTrials.gov 编号，NCT03026322。）
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