支气管封堵器与气管内插管在接受单肺通气的幼儿中的比较：一项多中心回顾性队列研究

贵州医科大学                麻醉与心脏电生理课题组

翻译：柏雪           编辑：田明德   审校：曹莹

背景: 儿童胸外科手术和单肺通气具有很大的风险。幼儿单肺通气的方法包括气管内插管(主气管插管)和支气管封堵器的使用。我们假设气管内插管与支气管封堵器相比，气道并发症的发生率更高。

方法: 查询2004年至2022年多中心围手术期结局组数据库中2个月至3岁(含)儿童单肺通气病例。审查气道记录和自由文本评论（借助Watson捕获和分析关键信息和情感倾向）是否有气道并发症。记录在案的气道并发症被认为是主要结局，分为“中度”和“严重”。中度气道并发症包括支气管封堵器或气管内导管移动导致隔离丧失、需要通气干预的低氧血症、支气管封堵器迁移入气管导管内、通气明显受阻等。严重并发症包括术中再插管或气管导管置换，完全气管内管堵塞，心脏骤停或气道相关性心动过缓，以及因气道问题而中止手术。随后采用调整的倾向评分匹配分析评估支气管封堵器对中度和严重并发症结果的影响。

结果：经过排除后，704例患者被纳入初步分析。在未调整的分析中，气管内插管组与支气管封堵器组在中度气道并发症的发生率没有统计学差异：444例中的37例（8.3%；95%置信区间[CI]，5.9%–11.3%）与260例中的28例（10.8%；95% CI，7.3%–15.2%），P =0.281。在未调整的分析中，气管内插管组的严重气道并发症发生率显著高于支气管封堵器组：444例中的28例（6.3%；95% CI，4.2%–9.0%）与260例中的5例（1.9%；95% CI，0.6%–4.4%），P =0.008。在已调整的倾向评分匹配队列分析中，与使用支气管封堵器组相比，气管内插管组严重并发症的风险略有增加：243例中的14例（5.8%；95% CI，2.8%–8.7%）与243例中的5例（2.1%；95% CI，0.3%–3.8%），P =0.035。

结论: 在接受胸外科手术和单肺通气的幼儿中，与使用支气管封堵器相比，气管内插管可能与严重气道并发症风险的略微增加相关。但在推荐明确改变临床实践之前，仍需进一步的前瞻性研究。

原始文献来源：Christopher S. McLaughlin, Anusha Samant, Amit K. Saha, et al. Bronchial Blocker Versus Endobronchial Intubation in Young Children Undergoing One-Lung Ventilation: A Multicenter Retrospective Cohort Study. Anesthesia & Analgesia, doi: 10.1213/ANE.0000000000006973

Bronchial Blocker Versus Endobronchial Intubation in Young Children Undergoing One-Lung Ventilation: A Multicenter Retrospective Cohort Study

ABSTRACT

BACKGROUND: Thoracic surgery and one-lung ventilation in young children carry significant risks. Approaches to one-lung ventilation in young children include endobronchial intubation (mainstem intubation) and use of a bronchial blocker. We hypothesized that endobronchial intubation is associated with a greater prevalence of airway complications compared to use of a bronchial blocker.

METHODS: The Multicenter Perioperative Outcomes Group database was queried from 2004 to 2022 for one-lung ventilation cases in children, 2 months to 3 years of age, inclusive. Airway notes and free-text comments were manually reviewed for airway complications. Documented airway complications were considered the primary outcome and were divided into “Moderate” and “Critical.” Moderate airway complications were bronchial blocker or endotracheal tube movement leading to loss of isolation, hypoxemia requiring ventilatory intervention, bronchial blocker migration into the trachea, significant impairment of ventilation, and other. Critical complications included reintubation or airway replacement intraoperatively, complete endotracheal tube occlusion, cardiac arrest or airway-related bradycardia, and procedure aborted due to an airway issue. An adjusted propensity scorematched analysis was then used to assess the impact of a bronchial blocker on the outcomes of moderate and critical complications 

RESULTS:After exclusions, 704 patients were included in the primary analysis. In unadjusted analyses, no statistically significant difference was observed in moderate airway complications between endobronchial intubation and bronchial blocker cohorts: 37 of 444 (8.3%; 95% confidence interval [CI], 5.9%–11.3%) vs 28 of 260 (10.8%; 95% CI, 7.3%– 15.2%) with P = .281. In the unadjusted analysis, the prevalence of critical airway complications was significantly higher in the endobronchial intubation cohort compared to the bronchial blocker cohort: 28 of 444 (6.3%; 95% CI, 4.2%–9.0%) vs 5 of 260 (1.9%; 95% CI, 0.6%–4.4%) with P = .008. In the propensity-matched cohort analysis, endobronchial intubation was associated with a slightly increased risk of critical complications compared to use of a bronchial blocker: 14 of 243 (5.8%; 95% CI, 2.8%–8.7%) vs 5 of 243 (2.1%; 95% CI, 0.3%–3.8%) with P = .035.

CONCLUSIONS:Endobronchial intubation might be associated with a slightly increased risk of critical airway complications compared to use of a bronchial blocker in young children undergoing thoracic surgery and one-lung ventilation. Further, prospective studies are needed before a definitive change in practice is recommended.