1、【文摘发布】新英格兰杂志 4 月 26 日公布的气管插管规范（编译完毕，中文版 PDF）RESOURCE: NEJM，Volume 356:e15 April 26, 2007 Number 17 TITLE: Orotracheal IntubationAUTHOR: Christopher Kabrhel, M.D., Todd W. Thomsen, M.D., Gary S. Setnik, M.D., and Ron M. Walls, M.D.Chapters:1、Indications2、Contraindications3、Equipment4、Preparation5、Sed
2、ation and Paralysis6、The Procedure7、Troubleshooting8、Confirmation9、Securing the Tube10、Complications本文是新英格兰杂志4 月 26 日发表的，气管插管在临床上常用，本文提供了一个指南，请有兴趣的战友翻译，分成 12，3，4，5，6，7，8，9、10 部分，8 人完成 e15.pdf (192.06k) INDICATIONSOrotracheal intubation is indicated in any situation that requires definitive control o
3、f the airway. Orotracheal intubation is commonly performed to facilitate control of the airway in a patient undergoing general anesthesia. It is also performed as part of the care of critically ill patients with multisystem disease or injuries. Emergency indications include cardiac or respiratory ar
4、rest, failure to protect the airway from aspiration, inadequate oxygenation or ventilation, and existing or anticipated airway obstruction.适应症气管插管适用于任何确实需要气道管理的状况。为了便于气道管理，患者全身麻醉时常常需要气管插管;气管插管也是多系统疾病或损害的危重患者监护的一部分。紧急适应症包括心跳或呼吸骤停、气道不能防止误吸、缺氧或通气不足、气道阻塞。CONTRAINDICATIONS禁忌症In urgent situations or emerg
5、encies, such as when a patient is in cardiac arrest,airway management is of paramount importance, and there are very few contraindications to orotracheal intubation. Orotracheal intubation by direct laryngoscopy is somewhat contraindicated in a patient with partial transection of the trachea, becaus
6、e the procedure can cause complete tracheal transection and loss of the airway.在紧急状态下或急症时，如患者心跳骤停，气道管理极为重要，但气管插管仍有极少的禁忌症。直接喉镜下气管插管对已行部分气管切除的患者相对禁忌，因为气管插管步骤导致气管全部横断及气道损伤。In these cases, surgical airway management may be necessary. Unstable cervical spine injury is not a contraindication, but strict,
7、in-line stabilization of the cervical spine must be maintained during intubation. An assistant should stand at the side of the bed and hold the patients head, neck, and shoulders in an anatomically neutral position. The anterior portion of the cervical collar is opened or removed to permit the patie
8、nts mouth to be fully opened.在这些患者中，手术气道管理可能是必需的，不稳定颈椎损伤不是禁忌症，但是插管时颈椎必须保持严格的、呈线性固定。助手应该站在床旁一侧托住患者的头、颈，使患者双肩保持自然体位。敞开或去掉患者颈部衣领口，保持患者口腔全部张开。When immediate intubation is not required, the difficulty of intubation should first be assessed. This assessment is discussed in detail in the Preparation sectio
9、n,under Sedation and Paralysis.当不需要紧急插管，则应该首先评估插管的难点，在下面的术前准备、镇静与麻醉章节中详细讨论评估。编译：适应症气管插管适用于任何确实需要气道管理的状况。为了便于气道管理，患者全身麻醉时常常需要气管插管;气管插管也是多系统疾病或损害的危重患者监护的一部分。紧急适应症包括心跳或呼吸骤停、气道不能防止误吸、缺氧或通气不足、气道阻塞。禁忌症在紧急状态下或急症时，如患者心跳骤停，气道管理极为重要，但气管插管仍有极少的禁忌症。直接喉镜下气管插管对已行部分气管切除的患者相对禁忌，因为气管插管步骤导致气管全部横断及气道损伤。在这些患者中，手术气道管理可能
10、是必需的，不稳定颈椎损伤不是禁忌症，但是插管时颈椎必须保持严格的、呈线性固定。助手应该站在床旁一侧托住患者的头、颈，使患者双肩保持自然体位。敞开或去掉患者颈部衣领口，保持患者口腔全部张开。当不需要紧急插管，则应该首先评估插管的难点，在下面的术前准备、镇静与麻醉章节中详细讨论评估。 本人认领 9、10 部分。如在 48 小时内未能提交译文，其他战友可自由认领。 第一时间权威内容热点内容赞一个 EQUIPMENT（插管所需）器材You will need the following equipment: gloves, a protective face shield, a workingsuct
11、ion system, a bag-valve mask attached to an oxygen source, an endotracheal tubewith stylet, a 10-ml syringe, an endotracheal-tube holder (cloth tape may be used ifa tube holder is not available), an end-tidal carbon dioxide detector, a stethoscope,and laryngoscopes with appropriate blades. 进行插管前你需要准
12、备好以下器材：手套，口罩，吸引器（确保其工作正常），球瓣面罩(连接好氧气源),气管插管及管芯， 10ml 注射器，口咽通气道（或用布带代替）潮气末二氧化碳检测器,喉镜及合适的叶片。The two main types of laryngoscope blades are the Macintosh blade, which is curved, and the Miller blade, which is straight. Each is available in various sizes, and each requires a slightly different technique.
13、 The choice of blade depends on the operators experience and personal preference. 主要使用的喉镜叶片有两种：Macintosh 叶片(弯)和 Miller 叶片(直). 每种叶片都有多种型号可供选择，而且不同叶片的操作技术上略有差异。 使用那种叶片主要取决于术者的经验和个人喜好。A size 3 or 4 Macintosh blade or size 2 or 3 Miller blade can be used in most adult patients.3 号或 4 号 Macintosh 叶片及 2 号
14、或 3 号 Miller 叶片适用于大多数的成年病人。Endotracheal tubes are sized according to the internal diameter of the tube;7.0-, 7.5-, or 8.0-mm tubes are appropriate for most adults.1-3 The appropriate tube size for use in children can be determined by adding 4 to the patients age in years and then dividing by 4 (age
15、in years + 4 4 = tube size), by matching the external diameter of the tube to the width of the patients little fingernail, or by using a system based on the childs height or length (such as the BroslowLuten resuscitation tape).气管内插管的型号取决于气管内径 .7.0-, 7.5-, or 8.0-mm 的气管内插管适用于大多数成年人， 对于小儿可用如下方法推算：1、 年
16、龄 + 4 4 =插管型号, 2、小儿的手指宽度插管的外径 3、根据小儿的身高或身长推算（如使用 BroslowLuten resuscitation tape）Tubes can be cuffed or uncuffed. Cuffed tubes are appropriate for adults andolder children. Uncuffed tubes are used for younger patients (those requiring atube smaller than 5.5 mm).1,2 After inserting a cuffed tube, you
17、 must inflate theballoon on the distal end to create a seal between the tube and the tracheal lumen.This seal will prevent leakage of air and aspiration of gastric contents.可以使用有套囊的插管或无套囊的插管，有套囊的插管适用于成人或年长儿无套囊的插管，无套囊的插管则用于年幼儿（插管直径小于 5.5 mm）插入有套囊的插管后，应注入气体使套囊膨胀，封闭气管和插管之间的腔隙，这可以避免漏气及胃内容物的吸入。编译：（插管所需）器
18、材：进行插管前你需要准备好以下器材：(一) 手套。(二) 口罩。(三) 吸引器（确保其工作正常）。(四) 球瓣面罩( 连接好氧气源)。(五) 10ml 注射器。(六) 口咽通气道（或用布带代替。(七) 潮气末二氧化碳检测器。(八) 气管插管及管芯。1、型号：气管内插管的型号取决于气管内径 .7.0-, 7.5-, or 8.0-mm 的气管内插管适用于大多数成年人， 对于小儿可用如下方法推算：（1）、 年龄 + 4 4 =插管型号。（2）、小儿的手指宽度插管的外径。(3)、根据小儿的身高或身长推算（如使用 BroslowLuten resuscitation tape）2、套囊：插管可以选择有
19、套囊的或无套囊的。有套囊的插管适用于成人或年长儿。无套囊的插管则适用于年幼儿（所需的插管直径小于 5.5mm）。插入有套囊的插管后，应注入气体使套囊膨胀，封闭气管和插管之间的腔隙，这可以避免漏气及胃内容物的吸入。(九) 喉镜及合适的叶片。主要使用的喉镜叶片有两种：Macintosh 叶片( 弯)和 Miller 叶片(直)。每种叶片都有多种型号可供选择，而且不同叶片的操作技术上略有差异。 使用那种叶片主要取决于术者的经验和个人喜好。3 号（或 4 号）Macintosh 叶片及 2 号（或 3 号）Miller 叶片适用于大多数的成年病人。 Securing the Tube导管固定Secur
20、e the endotracheal tube to the patients head once you have confirmed that thetube is in the proper position. 一旦可以证实气管插管在合适位置，随即把导管固定在患者头部。You should use an endotracheal-tube holder to securethe tube, because this device helps prevent accidental displacement.要使用气管内插管固定器来固定导管，因为这个固定器可以帮助防止导管突发的移位。If s
21、uch a device is not available, you may use adhesive tape or cloth endotracheal-tube tape.如果固定器不能完全有效的固定，可以使用一根胶带或布的气管插管固定带。Pharmacologic sedation and hand restraints may be used to prevent the patient from inadvertentlyremoving the tube.镇定药的使用和手的固定也可以用来防止患者不慎拔出插管。COMPLICATIONS并发症The most serious com
22、plication of endotracheal intubation is unrecognized esophagealintubation, which may lead to hypoxemia, hypercapnia, and death. 气管插管最严重的并发症是误插入食管，这会导致胃内容物吸入、高碳酸血症和死亡。Laryngoscopy can provoke vomiting and aspiration of gastric contents, causing pneumonitis orpneumonia. 喉镜检查会刺激呕吐和胃内容物吸入，引起吸入性肺炎。Additi
23、onal complications include bradycardia, laryngospasm, bronchospasm, and apnea owing to pharyngeal stimulation. 其它并发症包括因为咽部刺激导致的心动过缓、喉痉挛、支气管痉挛和呼吸暂停。Trauma to teeth, lips, and vocal cords and exacerbation of cervical spine injuries can also occur.也能发生牙齿、嘴唇、声带的损失和颈椎棘突损伤的加重。编译：导管固定一旦可以证实气管插管在合适位置，随即把导管固
24、定在患者头部。要使用气管内插管固定器来固定导管，因为这个固定器可以帮助防止导管突发的移位。如果固定器不能完全有效的固定，可以使用一根胶带或布的气管插管固定带。镇定药的使用和手的固定也可以用来防止患者不慎拔出插管。并发症气管插管最严重的并发症是误插入食管，这会导致胃内容物吸入、高碳酸血症和死亡。喉镜检查会刺激呕吐和胃内容物吸入，引起吸入性肺炎。其它并发症包括因为咽部刺激导致的心动过缓、喉痉挛、支气管痉挛和呼吸暂停。也能发生牙齿、嘴唇、声带的损失和颈椎棘突损伤的加重。 7Troubleshooting故障排除If you cannot see the vocal cords or epiglott
25、is after positioning the laryngoscope blade, you have probably inserted the blade too far or have not placed the blade precisely in the midline. 如果在调整好喉镜窥视片位置后，不能观察到声带或会厌，可能是由于窥视片插入太深或未能将其精确地放置于正中线所致。Withdrawing the blade gradually in the midline will often allow the epiglottis or larynx to drop int
26、o view. Manipulating the larynx with your right hand or having an assistant apply firm backward, upward, and rightward pressure (the so-called BURP maneuver) to the larynx can also facilitate visualization of the vocal cords.慢慢地在正中线退出窥视片，经常可以使声带或会厌跃然出现于视野中。用你的右手处理好喉头，或者让助手给喉头施加一个稳定的向后、向上、向右的压力（此称之为
27、BURP 动作），这样也可以更方便地观察到声带。An assistant can gently pull the right side of the patients lip and cheek to enhance visibility of the glottis. If you still cannot see the cords clearly, an assistant should gently release the cricoid pressure, since this compression can sometimes compromise the view. You sh
28、ould always achieve the best possible view of the vocal cords before attempting to insert the endotracheal tube.助手可以轻轻地牵拉患者唇及颊的右侧，增加声门的可视度。如果你仍不能清晰地看到声带，助手应轻轻地缓解环状软骨的压力，因为此压迫有时会影响到观察。总之，在尝试气管插管前，你应当总是尽可能使声带调节到最佳的观察视野。编译7 故障排除如果在调整好喉镜窥视片位置后，不能观察到声带或会厌，可能是由于窥视片插入太深或未能将其精确地放置于正中线所致。慢慢地在正中线退出窥视片，经常可以使声带
29、或会厌跃然出现于视野中；用你的右手处理好喉头，或者让助手给喉头施加一个稳定的向后、向上、向右的压力（此称之为 BURP 动作），这样也可以更方便地观察到声带；助手可以轻轻地牵拉患者唇及颊的右侧缘，增加声门的可视度。如果你仍不能清晰地看到声带，助手应轻轻地缓解环状软骨的压力，因为此压迫有时会影响到观察。总之，在尝试气管插管前，你应当总是尽可能使声带调节到最佳的观察视野。 5Sedation and Paralysis镇静与麻醉In many cases, a neuromuscular-blocking agent and a potent sedative are needed to faci
30、litate intubation. These agents will improve your visualization of the vocal cords and prevent the patient from vomiting and aspirating gastric contents.在许多病例中，需要使用神经肌肉阻断剂和有效的镇静剂。这些药物能改善声带的可视度，防止患者呕吐及吸入胃内容物，使插管更加便利。If you plan to use such agents, you must assess the difficulty of intubation before p
31、roceeding. 如果你计划使用此类药物，在操作前必须对插管的难点进行评估。You can generally predict that intubation will be difficult if the patient has a history of difficult intubation, limited neck mobility, a small mandible, pharyngeal structures that are poorly visible through the open mouth with tongue extruded, a limited abil
32、ity to open his or her mouth, or a laryngeal prominence that is close to the mentum. 通常你能够预测到，以下情况插管会比较困难：如患者既往有插管困难的病史、颈部活动度受限、鄂部较小、通过开口牵拉舌而咽部结构可视度差、口腔开口受限、喉结与颏部较近等。Anatomical distortion (such as by tumors, trauma, or infection), edema, or obstruction of the airway may also lead to difficult orotra
33、cheal intubation. 另外，解剖学畸形（如肿瘤、创伤或感染所致）、水肿、气道阻塞也可能增加气管插管的难度。When faced with a potentially difficult intubation, you should make contingency plans, including preparation for an alternative intubation technique, such as using a gumelastic bougie, a laryngeal mask airway, a fiberoptic intubating bronch
34、oscope, or a surgical technique.如果面对的是一个具潜在性困难的插管，你应当制定好应付偶发事故的计划，包括准备插管的替代技术，如使用弹性树胶探条、喉罩通气、纤维支气管镜或者外科方法。编译5 镇静与麻醉在许多病例中，需要使用神经肌肉阻断剂和有效的镇静剂。这些药物能改善声带的可视度，防止患者呕吐及吸入胃内容物，使插管更加便利。如果你计划使用此类药物，在操作前必须对插管的难点进行评估。通常你能够预测到，以下情况插管会比较困难：如患者既往有插管困难的病史、颈部活动度受限、鄂部较小、通过开口牵拉舌而咽部结构可视度差、口腔开口受限、喉结与颏部较近等。另外，解剖学畸形（如肿瘤、
35、创伤或感染所致）、水肿、气道阻塞也可能增加气管插管的难度。因此，如果面对的是一个具潜在性困难的插管，你应当制定好应付偶发事故的计划，包括准备插管的替代技术，如使用弹性树胶探条、喉罩通气、纤维支气管镜或者外科方法。 good translation! thank you! 太好啦，收获颇深。 谢谢楼主了，自己慢慢研究一下 有视频的，可以免费下载的。大家可以去看看 www.nejm.org PREPARATION准备Before proceeding, be sure that all equipment is readily accessible and functioning,that per
36、sonnel are properly prepared, and that written informed consent has beenobtained from the patient or the patients health care proxy if the clinical situationpermits.气管插管前，首先应准备好必需的器材并保证其均可正常使用，人员到位，若情况允许，必须让病人或其家属签好知情同意书。Inflate the cuff of the endotracheal tube to check for leaks.注入气体使套囊膨胀，以此来检查套囊是
37、否漏气。Insert the stylet into the endotracheal tube, maintaining the tubes natural curve.把导管管芯插入气管导管，保持导管正常的曲度。Make sure the tip of the stylet does not extend beyond the end of the tube.切勿使管芯的末端露出导管。If necessary, the stylet can be used to reshape the endotracheal tube, as in the “hockey stick” maneuver
38、, to facilitate intubation of an anterior larynx.必要时，管芯还起类似“曲棍球”的方法来重塑气管导管，使其易于进入上咽喉部。Ensure that the suction catheter is secure and within easy reach. Obtain intravenous access, and place the patient on a monitorif time and conditions permit.还应准备好吸痰管以备用。开放静脉通道，若时间和病情允许时，最好接好监护仪。Assign an assistant
39、to watch the monitor during the procedure and to report any changes.插管时，让助手观察监视仪并及时汇报病情变化。Adjust the height of the bed so that the patients head is level with the lower portion of your sternum.调整病床的高度与操作者的胸骨下缘水平。Unless there are contraindications, move the patient into the “sniffing” position by pla
40、cing a pillow or folded towel under the patients occiput.无禁忌症时，把枕头或折叠的毛巾置于患者枕部使其呈吸气位。This combination of flexion of the neck and extension of the head improves the alignment of the axes of the oral cavity, pharynx, and larynx, facilitating optimal visualization of the vocal cords.颈部屈曲、头部过伸使口腔、咽部、喉部成
41、一直线，使声带充分暴露。When intubating an infant, you typically do not need to provide additional head support, because the infants large occiput naturally causes the head to assume the sniffing position.当患者是婴儿时，通常则不需使用上述方法，因为婴儿的枕部较大，以其枕部为支撑点时即可使其呈吸气位。If the clinical situation allows, preoxygenate the patient
42、with a non-rebreather mask or by having the patient breathe 100% oxygen through a bag-valve mask for at least 3 minutes before intubation.若患者情况允许，可于插管前，用非回吸面罩或球瓣面罩先与患者以至少 3 分钟以上的100纯氧。Preoxygenation replaces the primarily nitrogenous mixture of ambient air, which constitutes the patients functional
43、residual capacity, with oxygen. 这样可以用氧气取代之前被氮气占据的肺泡。This increases the interval before desaturation in a patient who is hypoventilating or apneic. This preliminary step is essential to minimize the need for positive-pressure ventilation during intubation, thus reducing the risk of aspiration of gast
44、ric contents.这一步骤还可大大减少插管时正压通气的时间，从而进一步降低了误吸胃内容物的风险。Remove the patients upper and lower dentures, if present, immediately before laryngoscopy. Re-insert the patients dentures to improve the mask seal if bagvalvemask ventilation is required.插入喉镜前，如佩戴假牙者，应先取下全部假牙。若使用球瓣面罩通气时，则需重新戴上假牙以保持面罩的密封性。If the pa
45、tients mental status is diminished or if the patient is pharmacologically sedated, an assistant should apply firm pressure to the cricoid cartilage. 若患者呈昏迷状或镇静状，助手应用力压迫环状软骨。This maneuver (the Sellick maneuver) compresses the soft-walled esophagus between the cricoid cartilage and the cervical verteb
46、rae, theoretically preventing passiveregurgitation of gastric contents.这种方法（Sellick 方法）可以压迫处于环状软骨和颈椎之间的食道，避免胃内容物的反流。If the airway becomes distorted, releasing cricoid pressure may improve visualization of the glottis.若气道扭曲，则应减少压力以充分暴露声门。 希望能将所有的翻译汇集起来做成 WORD 或是 PDF 以便大家下载学习，谢一个！ 提点不同的意见供译者参考。Orotrac
47、heal intubation by direct laryngoscopy is somewhat contraindicated in a patient with partial transection of the trachea, because the procedure can cause complete tracheal transection and loss of the airway.直接喉镜下气管插管对已行部分气管切除的患者相对禁忌，因为气管插管步骤导致气管全部横断及气道损伤。partial transection of the trachea 气管部分横断An as
48、sistant should stand at the side of the bed and hold the patients head, neck, and shoulders in an anatomically neutral position. The anterior portion of the cervical collar is opened or removed to permit the patients mouth to be fully opened.助手应该站在床旁一侧托住患者的头、颈，使患者双肩保持自然体位。敞开或去掉患者颈部衣领口，保持患者口腔全部张开。hol
49、d the patients head, neck, and shoulders 托住患者的头、颈和双肩the cervical collar 颈套 专业内容，关注 ing 感谢您们的翻译，努力学习 “有视频的，可以免费下载的。大家可以去看看 www.nejm.org “视频非常好！视频可以下载吗？怎么下？谢谢指教！本人 emial: 1.年龄 + 4 4 =插管型号, 应该是 ： 年龄/4 + 4=插管型号 (ID)吧。2、小儿的手指宽度插管的外径 应该是：小儿的小指末节宽度插管的外径 吧 ConfirmationThe end of the endotracheal tube should lie in the mid-trachea, 3 to 7 cm above the carina. A good general rule is to align the 22-cm marking on the tube with the front teeth of an average-sized adult.2 For children, you can use the following formula to estimate the
