超声检查的上气道解剖参数预测困难气道的临床研究

发布时间：2018-01-05 08:17

本文关键词：超声检查的上气道解剖参数预测困难气道的临床研究　出处：《安徽医科大学》2017年博士论文　论文类型：学位论文

【摘要】：背景:困难气道是危及围术期患者安全的主要因素之一,一旦发生常危及患者生命。精准的预测出困难气道患者有助于减少相应风险。虽然已有数种基于体表解剖的困难气道预测方法应用临床,但预测准确性都偏低。准确预测依赖于对上气道解剖准确的探查。超声成像相比CT或MRI具有方便、无害、成本低的特点。前期研究证实,超声成像可应用于上气道解剖探查。但是否可应用于困难气道的预测尚不明确。目的:本研究旨在探讨以下问题:1,精确测量的上气道参数能否提供困难气道预测能力;2,超声检查测量舌颏距离、颞颌关节髁状突活动度的可行性、可靠性;3,超声检查测量的舌颏距离、颞颌关节髁状突活动度能否预测困难气道;4,基于超声检查的精确解剖参数的综合预测模型的建立及预测价值。方法:第一部分:应用前瞻性病例队列观察研究设计,纳入需全麻插管的择期手术成人患者。术前评估:精确测量的张口度,指宽估测的张口度是否小于2指、是否小于3指。全麻诱导气管插管后由麻醉主治医师评估试验结果。主要观察结果:是否困难喉镜显露;次要观察结果:是否困难插管。计算并比较每种方法预测困难气道的ROC曲线下面积。第二部分:招募20名健康成人志愿者。两名超声检查者分别独立地对20名志愿者进行超声测量舌颏距离、髁状突活动度。一名检查者分别检查志愿者两侧的髁状突活动度。分析两检查者测量结果之间的相关性、重复可靠性、区别;分析两侧测量结果之间的相关性、重复可靠性、区别。第三部分:应用前瞻性病例队列观察研究设计,纳入需全麻插管的择期手术成人患者。术前评估:甲颏距离,张口度,体重指数,Mallampati分级,超声测量的舌颏距离,超声测量的髁状突活动度。全麻诱导气管插管后由麻醉主治医师评估试验结果。主要观察结果:否困难喉镜显露;次要观察结果:是否困难插管。分析各变量在困难气道患者和非困难气道患者中是否有区别;计算各变量预测困难喉镜显露的ROC曲线下面积,以及各变量预测困难插管的ROC曲线下面积,并进行比较。通过Youden指数确定舌颏距离、髁状突活动度预测困难喉镜显露及困难插管的最佳截点值。第四部分:基于第三部分研究数据,首先对各单一变量进行预测困难喉镜显露及困难插管的Logistic回归分析。在单变量回归分析中有显著性统计学意义的变量,被纳入多元Logistic回归分析,筛选鉴别独立预测因子,建立综合预测模型。分析新模型预测困难喉镜显露及困难插管的能力。结果:第一部分:共有732例患者,成功纳入统计分析。67例困难喉镜显露患者,25例困难插管患者。预测困难喉镜显露时,精确测量的张口度ROC曲线下面积为0.72,与指宽估测的张口度(张口度3指:0.63;张口度2指:0.57)比较差异有统计学意义(P0.001)。预测困难插管时,精确测量的张口度ROC曲线下面积为0.82,与指宽估测的张口度(张口度3指:0.67;张口度2指:0.65)比较差异有统计学意义(P0.001)。第二部分:成功招募20位健康志愿者,两位超声检查者测量的舌颏距离分别为5.2±0.4cm、5.1±0.4cm,相关性r=0.95(P0.01),Krippendorff's alpha值为0.91,配对t检验显示差异无统计学意义(P=0.119)。两位超声检查者测量的髁状凸活动度分别为1.40±0.29cm、1.38±0.26cm,相关性r=0.96(P0.01),Krippendorff's alpha值为0.92,配对t检验显示差异无统计学意义(P=0.204)。一位超声检查者测量的双侧髁状凸活动度分别为左侧1.36±0.25cm、右侧1.39±0.26cm,相关性r=0.97(P0.01),Krippendorff's alpha值为0.95,配对t检验显示差异无统计学意义(P=0.665)。第三部分:共有2357例患者,成功纳入统计分析。159例困难喉镜显露患者,62例困难插管患者。预测困难喉镜显露时,舌颏距离ROC曲线下面积为0.81,髁状凸活动度ROC曲线下面积为0.92。与其他参数的预测ROC曲线下面积相比,髁状凸活动度最高,差异有统计学意义(P0.001)。预测困难插管时,舌颏距离ROC曲线下面积为0.86,髁状凸活动度ROC曲线下面积为0.97,与其他参数的预测ROC曲线下面积相比,髁状凸活动度最高,差异有统计学意义(P0.001)。第四部分:关于困难喉镜显露的单变量回归分析显示有统计学意义的变量纳入多元回归显示,男性、Mallampati分级2、舌颏距离5.0cm、髁状凸活动度1.1cm具有独立预测价值。回归模型的ROC曲线下面积为0.96。关于困难插管的单变量回归分析显示有统计学意义的变量纳入多元回归显示,男性、张口度4.0cm、舌颏距离5.0cm、髁状凸活动度1.1cm具有独立预测价值。回归模型的ROC曲线下面积为0.98。结论:1,精确测量上气道相关解剖参数有助于提高困难气道的预测效果;2,基于超声成像检查精确测量舌颏距离、颞下颌关节髁状凸活动度的方法方便可行,结果可靠。3,基于超声测量的舌颏距离、髁状凸活动度具有预测困难气道的独立预测价值,且优于相应的甲颏距离、张口度等;4,纳入了新型评估方法的困难气道综合预测模型进一步提高预测能力,具有可观的预测效果
[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

【学位授予单位】：安徽医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R614

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