發(fā)布時(shí)間：2018-01-05 08:17

  本文關(guān)鍵詞：超聲檢查的上氣道解剖參數(shù)預(yù)測(cè)困難氣道的臨床研究　出處：《安徽醫(yī)科大學(xué)》2017年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 困難氣道 超聲 舌頦距離 髁狀凸活動(dòng)度

【摘要】：背景:困難氣道是危及圍術(shù)期患者安全的主要因素之一,一旦發(fā)生常危及患者生命。精準(zhǔn)的預(yù)測(cè)出困難氣道患者有助于減少相應(yīng)風(fēng)險(xiǎn)。雖然已有數(shù)種基于體表解剖的困難氣道預(yù)測(cè)方法應(yīng)用臨床,但預(yù)測(cè)準(zhǔn)確性都偏低。準(zhǔn)確預(yù)測(cè)依賴于對(duì)上氣道解剖準(zhǔn)確的探查。超聲成像相比CT或MRI具有方便、無(wú)害、成本低的特點(diǎn)。前期研究證實(shí),超聲成像可應(yīng)用于上氣道解剖探查。但是否可應(yīng)用于困難氣道的預(yù)測(cè)尚不明確。目的:本研究旨在探討以下問(wèn)題:1,精確測(cè)量的上氣道參數(shù)能否提供困難氣道預(yù)測(cè)能力;2,超聲檢查測(cè)量舌頦距離、顳頜關(guān)節(jié)髁狀突活動(dòng)度的可行性、可靠性;3,超聲檢查測(cè)量的舌頦距離、顳頜關(guān)節(jié)髁狀突活動(dòng)度能否預(yù)測(cè)困難氣道;4,基于超聲檢查的精確解剖參數(shù)的綜合預(yù)測(cè)模型的建立及預(yù)測(cè)價(jià)值。方法:第一部分:應(yīng)用前瞻性病例隊(duì)列觀察研究設(shè)計(jì),納入需全麻插管的擇期手術(shù)成人患者。術(shù)前評(píng)估:精確測(cè)量的張口度,指寬估測(cè)的張口度是否小于2指、是否小于3指。全麻誘導(dǎo)氣管插管后由麻醉主治醫(yī)師評(píng)估試驗(yàn)結(jié)果。主要觀察結(jié)果:是否困難喉鏡顯露;次要觀察結(jié)果:是否困難插管。計(jì)算并比較每種方法預(yù)測(cè)困難氣道的ROC曲線下面積。第二部分:招募20名健康成人志愿者。兩名超聲檢查者分別獨(dú)立地對(duì)20名志愿者進(jìn)行超聲測(cè)量舌頦距離、髁狀突活動(dòng)度。一名檢查者分別檢查志愿者兩側(cè)的髁狀突活動(dòng)度。分析兩檢查者測(cè)量結(jié)果之間的相關(guān)性、重復(fù)可靠性、區(qū)別;分析兩側(cè)測(cè)量結(jié)果之間的相關(guān)性、重復(fù)可靠性、區(qū)別。第三部分:應(yīng)用前瞻性病例隊(duì)列觀察研究設(shè)計(jì),納入需全麻插管的擇期手術(shù)成人患者。術(shù)前評(píng)估:甲頦距離,張口度,體重指數(shù),Mallampati分級(jí),超聲測(cè)量的舌頦距離,超聲測(cè)量的髁狀突活動(dòng)度。全麻誘導(dǎo)氣管插管后由麻醉主治醫(yī)師評(píng)估試驗(yàn)結(jié)果。主要觀察結(jié)果:否困難喉鏡顯露;次要觀察結(jié)果:是否困難插管。分析各變量在困難氣道患者和非困難氣道患者中是否有區(qū)別;計(jì)算各變量預(yù)測(cè)困難喉鏡顯露的ROC曲線下面積,以及各變量預(yù)測(cè)困難插管的ROC曲線下面積,并進(jìn)行比較。通過(guò)Youden指數(shù)確定舌頦距離、髁狀突活動(dòng)度預(yù)測(cè)困難喉鏡顯露及困難插管的最佳截點(diǎn)值。第四部分:基于第三部分研究數(shù)據(jù),首先對(duì)各單一變量進(jìn)行預(yù)測(cè)困難喉鏡顯露及困難插管的Logistic回歸分析。在單變量回歸分析中有顯著性統(tǒng)計(jì)學(xué)意義的變量,被納入多元Logistic回歸分析,篩選鑒別獨(dú)立預(yù)測(cè)因子,建立綜合預(yù)測(cè)模型。分析新模型預(yù)測(cè)困難喉鏡顯露及困難插管的能力。結(jié)果:第一部分:共有732例患者,成功納入統(tǒng)計(jì)分析。67例困難喉鏡顯露患者,25例困難插管患者。預(yù)測(cè)困難喉鏡顯露時(shí),精確測(cè)量的張口度ROC曲線下面積為0.72,與指寬估測(cè)的張口度(張口度3指:0.63;張口度2指:0.57)比較差異有統(tǒng)計(jì)學(xué)意義(P0.001)。預(yù)測(cè)困難插管時(shí),精確測(cè)量的張口度ROC曲線下面積為0.82,與指寬估測(cè)的張口度(張口度3指:0.67;張口度2指:0.65)比較差異有統(tǒng)計(jì)學(xué)意義(P0.001)。第二部分:成功招募20位健康志愿者,兩位超聲檢查者測(cè)量的舌頦距離分別為5.2±0.4cm、5.1±0.4cm,相關(guān)性r=0.95(P0.01),Krippendorff's alpha值為0.91,配對(duì)t檢驗(yàn)顯示差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.119)。兩位超聲檢查者測(cè)量的髁狀凸活動(dòng)度分別為1.40±0.29cm、1.38±0.26cm,相關(guān)性r=0.96(P0.01),Krippendorff's alpha值為0.92,配對(duì)t檢驗(yàn)顯示差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.204)。一位超聲檢查者測(cè)量的雙側(cè)髁狀凸活動(dòng)度分別為左側(cè)1.36±0.25cm、右側(cè)1.39±0.26cm,相關(guān)性r=0.97(P0.01),Krippendorff's alpha值為0.95,配對(duì)t檢驗(yàn)顯示差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.665)。第三部分:共有2357例患者,成功納入統(tǒng)計(jì)分析。159例困難喉鏡顯露患者,62例困難插管患者。預(yù)測(cè)困難喉鏡顯露時(shí),舌頦距離ROC曲線下面積為0.81,髁狀凸活動(dòng)度ROC曲線下面積為0.92。與其他參數(shù)的預(yù)測(cè)ROC曲線下面積相比,髁狀凸活動(dòng)度最高,差異有統(tǒng)計(jì)學(xué)意義(P0.001)。預(yù)測(cè)困難插管時(shí),舌頦距離ROC曲線下面積為0.86,髁狀凸活動(dòng)度ROC曲線下面積為0.97,與其他參數(shù)的預(yù)測(cè)ROC曲線下面積相比,髁狀凸活動(dòng)度最高,差異有統(tǒng)計(jì)學(xué)意義(P0.001)。第四部分:關(guān)于困難喉鏡顯露的單變量回歸分析顯示有統(tǒng)計(jì)學(xué)意義的變量納入多元回歸顯示,男性、Mallampati分級(jí)2、舌頦距離5.0cm、髁狀凸活動(dòng)度1.1cm具有獨(dú)立預(yù)測(cè)價(jià)值。回歸模型的ROC曲線下面積為0.96。關(guān)于困難插管的單變量回歸分析顯示有統(tǒng)計(jì)學(xué)意義的變量納入多元回歸顯示,男性、張口度4.0cm、舌頦距離5.0cm、髁狀凸活動(dòng)度1.1cm具有獨(dú)立預(yù)測(cè)價(jià)值�；貧w模型的ROC曲線下面積為0.98。結(jié)論:1,精確測(cè)量上氣道相關(guān)解剖參數(shù)有助于提高困難氣道的預(yù)測(cè)效果;2,基于超聲成像檢查精確測(cè)量舌頦距離、顳下頜關(guān)節(jié)髁狀凸活動(dòng)度的方法方便可行,結(jié)果可靠。3,基于超聲測(cè)量的舌頦距離、髁狀凸活動(dòng)度具有預(yù)測(cè)困難氣道的獨(dú)立預(yù)測(cè)價(jià)值,且優(yōu)于相應(yīng)的甲頦距離、張口度等;4,納入了新型評(píng)估方法的困難氣道綜合預(yù)測(cè)模型進(jìn)一步提高預(yù)測(cè)能力,具有可觀的預(yù)測(cè)效果
[Abstract]:Background: difficult airway is one of the main factors that endanger the safety of patients with peri operation period, the event often endanger the lives of patients. The accurate prediction of the difficult airway, helps to reduce the risk. Although there are a number of difficult airway anatomic prediction method based on clinical application, but the prediction accuracy is low. Accurate prediction depends on the upper airway anatomy and accurate exploration. Ultrasound imaging compared to CT or MRI is convenient, harmless, low cost. Previous studies demonstrated that ultrasound imaging can be applied to the upper airway. But whether it can be applied to the exploration of difficult airway prediction is unclear. Objective: This study aims to explore the following questions: 1, upper airway precise measurement of parameters can provide the difficult airway prediction ability; 2, ultrasound measurement of tongue chin distance, the feasibility of temporomandibular joint condylar mobility reliability; 3, ultrasound measurement of tongue chin temporal distance The temporomandibular joint condylar activity can predict the difficult airway; 4, establish a comprehensive and predictive value of accurate prediction model based on the anatomic parameters of ultrasound. Methods: the first part: a prospective case cohort study design, into the required intubation of general anesthesia for elective surgery patients. A preoperative evaluation: the accurate measurement of the mouth the degree of mouth opening, the finger width estimation is less than 2, if less than 3. Tracheal intubation of general anesthesia after anesthesia by the attending physician assessment test results. The main results: whether difficult laryngoscopy; secondary outcomes: whether difficult intubation were calculated and compared. Each prediction method of ROC curve area of difficult airway. Second part 20: recruitment of healthy adult volunteers. Two sonographers independently of the 20 volunteers were measured by ultrasound tongue chin condylar distance activity. A volunteer examination examination respectively People on both sides of the condyle. The correlation between activity and analysis of two to check the repeatability reliability, correlation analysis, difference between both sides; the repeatability and reliability, difference. The third part: a prospective case cohort study design, in all adult patients undergoing elective surgery anesthesia intubation: preoperative evaluation. The thyromental distance, mouth opening, body mass index, Mallampati grade, ultrasound measurement of tongue chin distance, ultrasonic measurement of condylar activity. Tracheal intubation of general anesthesia after anesthesia by the attending physician assessment test results. The main observation results: not difficult laryngoscopy; secondary outcomes: whether difficult intubation. To analyze whether the variables there are differences in difficult airway patients and non patients with difficult airway; calculation of the forecast variable ROC curve area of difficult laryngoscopy, and the ROC curve of each variable to predict difficult intubation under the area, and Compared. Determine the tongue mental distance through the Youden index, the condyle activity prediction of the optimal cut-off of difficult laryngoscopy and intubation difficulties. The fourth part: the third part of the study based on the data, the first prediction of Logistic difficult laryngoscopy and intubation of the regression analysis on every single variable. There was statistical significance in univariate regression in the analysis of variables were included in the multivariate Logistic regression analysis, screening to identify independent predictors, establish a comprehensive prediction model. A new analytical model for predictive ability of difficult laryngoscopy and difficult intubation. Results: the first part: a total of 732 patients were included in the statistical analysis of.67, the successful cases of difficult laryngoscopy patients, 25 cases of difficult intubation. Prediction of difficult laryngoscopy, mouth opening area under the ROC curve of accurate measurement is 0.72, and the estimated refers to the width of mouth opening (opening 3: 0.63; mouth opening 2 refers to: 0.57) than The difference is statistically significant (P0.001). Prediction of difficult intubation, the mouth opening area under the ROC curve of accurate measurement is 0.82, and the estimated refers to the width of mouth opening (opening 3: 0.67; mouth opening 2 refers to: 0.65) the difference was statistically significant (P0.001). The second part: the successful recruitment of 20 healthy volunteers, two ultrasound measurement of tongue chin distance were 5.2 + 0.4cm, 5.1 + 0.4cm, the correlation between r=0.95 (P0.01), Krippendorff's alpha 0.91, paired t test showed no statistically significant difference (P=0.119). Two ultrasound measurements of condylar convex activities respectively 1.40. 0.29cm, 1.38 + 0.26cm, the correlation between r=0.96 (P0.01), Krippendorff's alpha 0.92, paired t test showed no statistically significant difference (P=0.204). An ultrasound examination of bilateral condylar convex activity measurements were left on the right side of 1.36 + 0.25cm, 1.39 + 0.26cm, the correlation between r=0.97 (P0. 01), Krippendorff's alpha 0.95, paired t test showed no statistically significant difference (P=0.665). The third part: a total of 2357 patients were included in the statistical analysis of.159, the successful cases of difficult laryngoscopy patients, 62 cases of difficult intubation patients. Predicting difficult laryngoscopy, area of tongue chin distance under the ROC curve was 0.81, compared with area forecast ROC curve area of condylar convex activity under the ROC curve for 0.92. and other parameters, condylar convex activity is the highest, the difference was statistically significant (P0.001). Prediction of difficult intubation, tongue chin distance area under the ROC curve was 0.86, the area of condylar convex activity under the ROC curve was 0.97, compared with area ROC prediction curve and other parameters, condylar convex activity is the highest, the difference was statistically significant (P0.001). The fourth part: a single variable of difficult laryngoscopy regression analysis showed statistically significant variables in multivariate regression shows, Male, Mallampati grade 2, tongue chin distance 5.0cm, condylar convex activity 1.1cm has independent predictive value. The area under the ROC curve regression model for 0.96. on difficult intubation univariate regression analysis showed statistically significant variables in multivariate regression showed that male, mouth opening 4.0cm, tongue chin distance 5.0cm, condylar convex activity 1.1cm has independent predictive value. ROC curve regression model for 0.98. conclusions: 1, accurate measurement of the upper airway anatomy parameters is helpful to improve the prediction effect of difficult airway; 2, ultrasound imaging accurate measurement method based on the distance of tongue chin, temporomandibular joint condylar convex activity is convenient and feasible. Reliable.3, ultrasound measurement of the distance based on the tongue chin, condylar convex activity has independent predictive value for predicting difficult airway, and better than the corresponding thyromental distance, mouth opening degree; 4, included in the new assessment method The difficult airway prediction model to further improve the comprehensive prediction ability, prediction effect is considerable

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R614

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5 記者 李艷梅　通訊員 聶一鋼 涂曉晨 張方方;王新房獲“超聲之父”稱號(hào)[N];長(zhǎng)江日?qǐng)?bào);2011年

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8 張艷蓉邋楊亞利;超聲檢查前 準(zhǔn)備早知道[N];家庭醫(yī)生報(bào);2007年

9 翟云云;怎樣做好腹部超聲前檢查準(zhǔn)備[N];農(nóng)村醫(yī)藥報(bào)（漢）;2007年

10 彭光生;為超聲檢查定規(guī)矩[N];健康報(bào);2006年

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8 何愛(ài)軍;超聲心臟圖象的多維多參數(shù)功能重建[D];四川大學(xué);2002年

9 李冬凱;肺部超聲在急性呼吸窘迫綜合征肺復(fù)張過(guò)程中的應(yīng)用[D];北京協(xié)和醫(yī)學(xué)院;2013年

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