听译：李雪 浙江大学医学院附属第二医院
校对：陈一萌 首都医科大学附属北京同仁医院
2022 年更新版困难气道管理指南在《Anesthesiology》杂志上发表。这个新的指南全面提高了8年前旧的指南。新的指南更符合临床实践的实际情况，需要尽快推广和合理使用。耶鲁大学麻醉系William Rosenblatt教授是指南的撰写人之一，公认的气道管理专家。本文将带来William Rosenblatt教授对该指南的解读。
【视频主讲人介绍】
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该工作组致力于设定某种使用顺畅、且同时兼具决策准确、运行有序的气道管理流程。
该流程图首先评估病例的气道情况及管理策略，相当于对患者进行操作前的核查核对。评估方面包括对解剖风险、生理风险、设备和监测以及气道管理计划的讨论。
评估完成后，进行预充氧和麻醉诱导，实施气道管理。如果气道管理计划成功，则进行后续手术及治疗。如果气道管理方案失败，医生应该明确通气是否足够？无论使用何种设备或技术，应始终通过监测呼气末二氧化碳浓度确认通气情况。
若确认通气情况良好，进入到非紧急流程，应考虑寻求帮助并认识到该流程的目标是建立安全的气道。通过监测呼气末二氧化碳浓度判断通气不足，则进入紧急流程，立刻寻求帮助，认识到当前的目标是建立有效通气。
在非紧急流程中，应考虑使用替代设备。例如：直接喉镜、可视喉镜、使用纤维支气管镜、组合技术、声门上气道通气设备、及其他辅助设备（如面罩通气情况下使用口咽/鼻咽通气道或气管插管情况下使用管芯）。重点是限制尝试通气操作次数，限制在3次以内更为合理，再由操作更熟练的医生额外进行1次尝试。
或者，在通气充足但未实现气道管理计划的情况下，团队可以考虑建立有创气道。有创气道的建立可在睡着的患者身上进行，也可唤醒患者后再进行。在建立有创气道时应持续性上气道通气以保证情况可控，并且尽可能经由有经验丰富的医生行有创气道操作。
例如，医生可能认为改用某种气管插管技术合适，或改用声门上气道通气装置，或尝试不同类型气管插管技术，或操作时使用某些辅助装置。
医生可能会再次采用面罩通气，若既往已发现面罩通气时出现通气不足，应添加辅助装置（如口咽/鼻咽通气道）。又或者换用不同类型、不同尺寸的声门上气道通气装置。
Importantly, clinician should limit their attempts to three，plus an additional attempt if a clinician of higher skill is available. Limit attempts to three or less plus one for a clinician with higher skill. Optimize every attempt. With intubation, this might mean a change in device or angulation of the video laryngoscopy blade, change in size of a blade, use of a rigid stylet, use an external laryngeal manipulation, combining techniques, employing a flexible intubation scope.
将尝试的次数限制在3次以内非常重要，如果能找到技术更熟练的医生可额外进行1次尝试，也就是最多进行3+1次尝试。应当优化每一次尝试，就插管而言，可改换可视喉镜、改变镜片角度、更换不同尺寸镜片、使用硬质管芯、采用喉外按压手法、多种技术联合应用、使用插管软镜等。
医生必须避免钻牛角尖，对氧饱和度、尝试时间、尝试次数保持高度警惕。
每次尝试都应关注通气量，确定通气是否充足，如果通气不足，在3+1次尝试后，或者氧饱和度开始下降时，应考虑建立紧急有创气道。如果通气充足，可考虑非紧急流程，但应该时刻评估通气情况，出现通气不足，及时返回紧急流程，考虑紧急有创气道或其他选择。（幻灯中出现的其他选择包括：硬质支气管镜及体外循环）
总之，此专家推荐处置流程图强调灵活性。首先，进入流程图的气道管理计划的灵活性与医生是否打算使用何种气道管理技术，无论是气管插管，面罩通气、声门上气道，还是其他气道管理技术，均无关。而是由通气是否充分决定。如果通气充分，可以改选更换设备、唤醒患者行清醒插管或建立有创气道。此过程中始终关注通气情况，如果通气不足，紧急流程图鼓励医生根据自身经验、资源、患者气道状态以及在该气道上操作所得的经验来选择合适的下一步处置。必须时刻注意氧饱和度、通气情况、以及尝试次数。
威廉·罗森布拉特，医学博士
麻醉学教授； ASA 标准和实践参数委员会困难气道管理实践指南工作组委员；通用气道管理项目工作组成员（Project for Universal Airway Management,PUMA）;麻醉科耳鼻喉科麻醉主任；REMEDY总裁兼创始人；麻醉学气道管理学会名誉主席。
题目：2022年美国麻醉医师协会困难气道管理实践指南
Title: 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway
出处：围术期医学院 孜孜网上教
In January 2021, the American Society of Anesthesiologist, Task Force on Management of the Difficulty Airway proposed a new series of infographics to be included in the management of the difficult airway guidelines. In this video. I would like to discuss the adult infographic and specifically part three, airway management with the induction of anesthesia.
This infographic was developed with the input of the 12 clinical members of the ASA task force on management of the difficult airway.
该流程图凝结了ASA困难气道管理工作组12名医生的努力。
The mission of this group in developing infographic was to have a tool that reflects the fluid nature of airway resuscitation，while maintaining sequential and clear decision points.
该工作组致力于设定某种使用顺畅、且同时兼具决策准确、运行有序的气道管理流程。
The infographic starts with a review of airway management and strategy similar to a check out or sign in that is done with any procedure on a patient. The review includes discussion of the anatomical risk, the physiological risk, equipment and monitoring, and the airway management plan.
After the review is completed, preoxygenation and induction of anesthesia takes place. The airway plan is implemented. If the airway plan is successful, then the case continues. If the airway plan is not successful, the clinician asks, is ventilation adequate? Ventilation is always confirmed by capnography and is regardless of the device or technique that is used.
If ventilation is adequate, the clinician has entered the non-emergency pathway, should consider calling for help and recognize that the goal of this pathway is to establish a secure airway. If the clinician judges by capnography that ventilation is not adequate, they have now entered the emergency pathway, should call for help, recognizing that the goal is to establish ventilation.
In the non-emergency pathway，the clinician should consider the use of alternative devices that is alternative to the original plan. For example, direct laryngoscopy, video laryngoscopy, use of flexible bronchoscope, combined techniques, supraglottic airways, adjuncts to other devices, for example, oral or nasal airways in the case of mask validation or introducers in the case of tracheal intubation. Importantly, attempts should be limited, and a reasonable approach is to limit attempts to three with one additional attempt by clinician with higher skill.
Why limit attempts？With each attempt, there’s trauma to the airway that may degrade your ability to achieve ventilation. And additionally, with each plateaued attempt, safe apneic time is being expanded as oxygen is being consumed at the alveolar level
为什么要限制尝试次数？因为每次尝试都会对气道造成损伤，可能会增加通气难度。此外，随着尝试失败，肺泡水平正在消耗氧气，安全无呼吸时间都在缩短。The clinician should always assess ventilation between attempts, asking is ventilation adequate by capnography? If the answer is no, then the clinician is now reverting to the emergency pathway.
每次尝试操作之前都应监测呼气末二氧化碳浓度以评估是否充分通气。若出现通气不足情况，立即切换至紧急流程处理途径。Another option in the non-emergency pathway is to awaken the patient. At this time, the clinician can elect to proceed with an awake intubation or postpone and return with appropriate resources, consider regional or infiltrated anesthesia for the procedure, consider an elective invasive airway.
非紧急流程中的另一个选择是唤醒患者。此时，医生可以选择进行清醒插管或推迟手术、待准备好各类必备物品再进行，也可考虑选择区域神经阻滞或局部浸润麻醉，或考虑建立有创气道。Alternatively, in a situation where ventilation is adequate, but the airway plan is not achieved. The team can consider an invasive airway. The invasive airway can be performed asleep, or after the patient is emerged. Upper airway ventilation should be continued during the invasive airway, controlled conditions should be maintained, and whenever possible, the invasive airways should be performed by an experienced clinician.
If after failure of the initial airway plan, the clinician determines that ventilation by any device and as measured by capnography is inadequate, they have now entered the emergency pathway. The first manoeuvre is to call for help, and then proceed with the goal of establishing ventilation. The next manoeuvre to be undertaken are variable and going to differ with every clinical situation. The state of the airway and the patient, the preferences and experience of the clinician, the availability of equipment, and capable help will all influence the decision as to how to proceed.
如果最初的气道管理计划失败，监测呼气末二氧化碳浓度发现使用任何设备都无法保证通气，即刻进入紧急流程。第一步：呼救，以建立通气为首要目标。随后的处理灵活性较高，根据临床情况选择相应处理方案。气道情况、患者状态、医生操作习惯和经验、可寻求到的设备及有效帮助等，都将影响后续处理决定。
For example, the clinician may decide an alternative technique of tracheal intubation is appropriate, or maybe they turn to a supraglottic airway. Maybe at this time, they try a different type of tracheal intubation, and or add an adjunct to that attempt.
They may go back to mask ventilation. And if mask ventilation has proven to be non-adequate, before they might add an adjunct, such as oral or nasal airway. They might decide to change the type of the supraglottic airway they try next，or maybe the size of the supraglottic airway.
Importantly, clinician should limit their attempts to three，plus an additional attempt if a clinician of higher skill is available. Limit attempts to three or less plus one for a clinician with higher skill. Optimize every attempt. With intubation, this might mean a change in device or angulation of the video laryngoscopy blade, change in size of a blade, use of a rigid stylet, use an external laryngeal manipulation, combining techniques, employing a flexible intubation scope.
With the face mask，the clinician might decide to use an oral airway, a nasal airway, try a different hand grip, change the mask size or the mask type.
面罩通气时，医生可以决定使用口咽通气道、鼻咽通气道、尝试不同的手柄、改变面罩尺寸或类型。 For supraglottic ventilation，it may include changing size, changing design, or deciding between first or second generation device.
对于声门上通气，可作出调整如：改变其尺寸、改变设计或决定使用一代或二代设备。The clinician must avoid task fixation, stay oxygen saturation aware, stay time, and attempt aware.
Assess ventilation with each attempt, determining if ventilation is adequate, if ventilation is not adequate, after three plus possibly one more attempt or oxygen saturation starts to fall, the clinician moves towards the emergency invasive airways. If ventilation becomes adequate, the clinician can move to the non-emergency pathway, but always assessing ventilation and ventilation becomes inadequate, returning to the emergency pathway and the possibility of an emergency invasive airway or other option.
In summary, the expert opinion guided infographic emphasizes flexibility. First, flexibility in the airway plan that is entry into the infographic is independent of whether or not the clinician intends to use tracheal intubation, face mask ventilation, supraglottic airway or other technique to manage the airway. Decisions are made based upon whether or not ventilation is adequate. If ventilation is adequate, the clinician has the ability to choose between alternative devices, waking the patient, performing invasive airway. Always assessing for ventilation. If ventilation is inadequate, the emergency pathway encourages the clinician to choose the appropriate next manoeuvre based upon their experiences, their resources, the state of the airway, and the knowledge has been gained with each procedure performed on the airway. The clinician must always stay aware of the oxygen saturation, the ability to ventilate the patient, and the number of attempts that have been employed.
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