From the Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center and.
Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
Anesth Analg. 2021 Aug 1;133(2):491-499. doi: 10.1213/ANE.0000000000005620.
Cricoid pressure has been used as a component of the rapid sequence induction and intubation technique. However, concerns have been raised regarding the effectiveness and safety of cricoid pressure. Paratracheal pressure, a potential alternative to cricoid pressure to prevent regurgitation of gastric contents or aspiration, has been studied to be more effective to cricoid pressure in preventing gastric insufflation during positive pressure ventilation. However, to adopt paratracheal compression into our practice, adverse effects including its effect on the glottic view during direct laryngoscopy should be studied. We conducted a randomized, double-blind, noninferiority trial comparing paratracheal and cricoid pressures for any adverse effects on the view during direct laryngoscopy, together with other secondary outcome measures.
In total, 140 adult patients undergoing general anesthesia randomly received paratracheal pressure (paratracheal group) or cricoid pressure (cricoid group) during anesthesia induction. The primary end point was the incidence of deteriorated laryngoscopic view, evaluated by modified Cormack-Lehane grade with a predefined noninferiority margin of 15%. Secondary end points included percentage of glottic opening score, ease of mask ventilation, change in ventilation volume and peak inspiratory pressure during mechanical mask ventilation, ease of tracheal intubation, and resistance encountered while advancing the tube into the glottis. The position of the esophagus was assessed by ultrasound in both groups to determine whether pressure applied to the respective area would be likely to result in esophageal compression. All secondary outcomes were tested for superiority, except percentage of glottic opening score, which was tested for noninferiority.
Paratracheal pressure was noninferior to cricoid pressure regarding the incidence of deterioration of modified Cormack-Lehane grade (0% vs 2.9%; absolute risk difference, -2.9%; 95% confidence interval, -9.9 to 2.6, P <.0001). Mask ventilation, measured on an ordinal scale, was found to be easier (ie, more likely to have a lower score) with paratracheal pressure than with cricoid pressure (OR, 0.41; 95% confidence interval, 0.21-0.79; P = .008). The increase in peak inspiratory pressure was significantly less in the paratracheal group than in the cricoid group during mechanical mask ventilation (median [min, max], 0 [-1, 1] vs 0 [-1, 23]; P = .001). The differences in other secondary outcomes were nonsignificant between the groups. The anatomical position of the esophagus was more suitable for compression in the paratracheal region, compared to the cricoid cartilage region.
Paratracheal pressure was noninferior to cricoid pressure with respect to the effect on glottic view during direct laryngoscopy.
环甲膜压迫已被用作快速序贯诱导和插管技术的组成部分。然而，人们对环甲膜压迫的有效性和安全性提出了担忧。甲状旁腺压力是一种潜在的替代环甲膜压迫的方法，可以更有效地预防正压通气时胃充气，防止胃内容物反流或误吸。然而，要将甲状旁腺压迫纳入我们的实践，应研究其对直接喉镜检查时声门视图的影响等不良反应。我们进行了一项随机、双盲、非劣效性试验，比较了甲状旁腺压迫和环甲膜压迫对直接喉镜检查时声门视图的任何不良反应，以及其他次要结局。
总共 140 名接受全身麻醉的成年患者在麻醉诱导期间随机接受甲状旁腺压迫（甲状旁腺组）或环甲膜压迫（环甲膜组）。主要终点是改良 Cormack-Lehane 分级评估的喉镜检查视野恶化发生率，预先设定的非劣效性边界为 15%。次要终点包括声门张开评分百分比、面罩通气的难易程度、机械面罩通气期间通气量和吸气峰压的变化、气管插管的难易程度以及将导管推进声门时遇到的阻力。两组均通过超声评估食管位置，以确定在相应区域施加压力是否可能导致食管压迫。所有次要结局均进行了优效性检验，除了声门张开评分百分比进行了非劣效性检验。
甲状旁腺压迫在改良 Cormack-Lehane 分级恶化发生率方面不劣于环甲膜压迫（0%比 2.9%；绝对风险差异，-2.9%；95%置信区间，-9.9 至 2.6，P <.0001）。通过ordinal 量表测量的面罩通气被发现更容易（即更有可能得分更低），甲状旁腺压迫优于环甲膜压迫（比值比，0.41；95%置信区间，0.21-0.79；P =.008）。在机械面罩通气期间，甲状旁腺组的吸气峰压升高明显低于环甲膜组（中位数[最小，最大]，0[-1，1]比 0[-1，23]；P =.001）。两组间其他次要结局的差异无统计学意义。与环甲软骨区相比，食管的解剖位置更适合在甲状旁腺区进行压迫。
甲状旁腺压迫在直接喉镜检查时对声门视图的影响不劣于环甲膜压迫。
