應用改良後之Fastmch插管式喉頭罩於僵直性脊椎炎病患之氣管內管插管之病例報告

A Modified Method for Intubation of a Patient with Ankylosing Spondylitis Using Intubating Laryngeal Mask Airway (LMA-Fastrach™)-- A Case Report

困難插管一直是所有的麻醉醫師最為恐懼的惡夢。而呼吸道的維持以及暢通更是執行全身麻醉時的必要條件。針對於僵直性脊椎炎病患的麻醉，第一個所要克服的問題就是此類病患的頸椎通常很僵硬，甚至於無法活動，在執行插管動作時可能有很大的困難。因此，這類病患在施行全身麻醉時，通常會採清醒狀態，直接以喉頭鏡挑起插管，不然就是以纖維氣管鏡來輔助插管，不但病人痛苦，同時由於刺激太強烈，甚至有引發心臟病、腦出血之風險。我們將傳統的Fastrach插管式喉頭罩插管方式予以改良，在喉頭罩正對著聲門，且通氣良好時，置放一條90公分長度的氣管內管換管通條，當作是通條，此時將潮氣末端二氧化碳監視器之管線接到換管通條末端，確定換管通條在氣管內，再把Fastrach插管式喉頭罩拔出，僅存換管通條留置於氣管內，然後把氣管內管順著換管通條插入氣道，之後再移出換管通條，在確認過兩側肺葉之呼吸聲及潮氣末端二氧化碳後，固定氣管內管，完成平順且安全的插管動作。經由臨床使用的經驗，此種方式不但可以針對困難插管的病患，提昇第一次的插管成功率，同時可以減少使用纖維氣管鏡及減少感染風險，並且可以降低單位操作成本。此外，對於一些併發有多重器官功能障礙，或是心血管疾病的重症病患，亦可藉由此方式減少氣管內管插管時所引發的併發症。

We present an instance of successful use of an intubating laryngeal mask airway (LMA-Fastrach™) and a Cook airway exchanger (CAE) for ventilation and intubation in a patient with severe ankylosing spondilitis (AS) receiving total hip arthroplasty. This measure may serve as an effective alternative for airway management in patients with difficult airway. A 61-year-old male was scheduled for right total hip arthroplasty because of degenerative osteoarthritis. He had been suffering from extensive ankylosing spondylitis, with the cervical spine markedly fixed in anterior flexion. Besides he could not open his mouth widely (35 mm when fully open) also because of ankylosis of jaw. Although we advised an awake fiberoptic tracheal intubation for anesthesia but he refused owing to a previous painful experience. After induction of anesthesia with glycopyrrolate, fentanyl, thiamylal sodium and succinylcholine, we inserted a # 5 Fastrach™ ILMA for primary airway maintenance. Then through the lumen of the ILMA we introduced the CAE as a guide for endotracheal tube (ETT) intubation. After applying the RAPI-FIT™ adapter to the CAE, we connected it to the capnography monitor for the confirmation of airway. We finally inserted an endotracheal tube into the trachea using the CAE as a guide. The whole procedure was uneventful and smooth. In sum, the modified Fastrach™ intubation method may facilitate tracheal intubation in patients with severe ankylosing spondilitis. It may be an alternative way for successful airway management in patients with difficult airway.