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1 대한응급의학회지제 21 권제 5 호 Volume 21, Number 5, October 2010 원 저 외상환자에서 Glidescope 비디오후두경을이용한응급기도관리 연세대학교의과대학응급의학교실 김정언 김민정 정성필 박인철 김승호 이한식 Emergency Airway Management Using a Glidescope Video Laryngoscope in Trauma Patients Jung Eon Kim, M.D., Min Joung Kim, M.D., Sung Phil Chung, M.D., In Cheol Park, M.D., Seung Ho Kim, M.D., Hahn Shick Lee, M.D. Purpose: To describe the current status of airway management for trauma patients in the emergency department (ED) and to evaluate the success rate and associated factors for selecting the Glidescope video laryngoscope. Methods: This was a retrospective observational study of prospectively collected data from the Koran Emergency Airway Management Registry in two university hospitals between April 2006 and March The study population included all trauma patients presenting at the ED who required emergency airway management. Demographic and airway related parameters were collected. The success rate was compared between the Glidescope and the direct laryngoscope. Factors associated with selecting the Glidescope were analyzed using multiple logistic regression. Results: Among the 1,974 patients who received airway management in the ED during the study period, 341 were identified as trauma patients. The Glidescope was used in 130 (38%) of the patients. Difficult airway was identified in 46.9% of the Glidescope group compared with 22.6% in the direct laryngoscope group (p<0.001). Success rate on the first attempt was not different between the direct laryngoscope and the Glidescope. The Glidescope was selected in favor of cervical immobilization, difficult airway, and senior 책임저자 : 김민정서울특별시강남구언주로 712 연세대학교의과대학응급의학교실 Tel: 02) , Fax: 02) boringzzz@yuhs.ac 접수일 : 2010년 8월 11일, 1차교정일 : 2010년 8월 26일게재승인일 : 2010년 9월 25일 grade resident. Conclusion: Among intubated patients in the ED, trauma patients accounted for 17.6%. The Glidescope video laryngoscope was selected in 38% of cases. It was usually used in cases of difficult airway such as cervical immobilization by senior grade residents. Key Words: Intratracheal intubation, Emergencies, Wounds and injuries Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea 서 외상환자들은의식변화또는기도의손상이나폐쇄의가능성이있는경우응급실에서기관내삽관을하게된다. 외상환자에서는안면부골절이나출혈로인한불안정한기도상태, 경부혈종으로인한직접적인기도의압박, 잠재적인경추손상이있을수있고, 또한금식상태가아닌환자에서구토와흡인의위험성까지함께있어기관내삽관을더어렵게만들수있다 1). 특히경추손상이배제되지않은환자에서입기관내삽관을하는경우에는도수경추고정을시행한상태에서해야하기때문에일반적인기관내삽관에비해시야가확보되지않아어려움을만들수있다 2). 최근에는광학기술의발전으로 Glidescope 이나 Pentax-AWS 등어려운기도에서시야를개선하기위한다양한비디오후두경들이개발되었고, 이를통해경추고정술을시행함에도불구하고기관내삽관을용이하게할수있다는연구들이많이진행되었다 3-5). 국내의한연구에서는 67개의수련병원응급실을조사한결과, 16.4% 에서비디오후두경을보유하고있다고보고하였다 6). 하지만실제응급실에서외상환자의기관내삽관시에비디오후두경의사용현황과그효과에대한연구는아직보고된바가없다. 이에본저자는응급실에서외상환자들에게시행된기도관리의현황을알아보고, 기관내삽관시 Glidescope 비디 론 575

2 576 / 대한응급의학회지 : 제 21 권제 5 호 2010 오후두경의사용현황과도구선택에영향을주는요인, 그리고도구에따른시야개선과삽관결과의차이에대해알아보고자하였다. 대상과방법이연구는후향적관찰연구로 2006년 4월부터 2010년 3월까지 48개월동안 2군데의 3차수련병원의응급의료센터에서외상으로인해시행한기관내삽관환자를대상으로하였다. 두응급의료센터의연간진료환자수는 40,000~60,000명이고연간기관내삽관은 200~300건이다. 타병원에서기관내삽관을하고내원한환자는연구에포함되지않았다. 목맴과익수로인한기관내삽관은포함하였고, 약물중독으로인한삽관은포함시키지않았다. 두응급의료센터에서이루어지는모든기관내삽관을 Korean Emergency Airway Management Registry (KEAMR) 에등록하였다. KEAMR은국내응급실에서의기도관리현황을파악하기위하여 2006년에시작한데이터베이스로현재수도권의대학병원 13곳이참여하고있다. 이는삽관을시행한의료진이정해진기록지를작성한후웹사이트에등록을하는형식으로되어있다. 기록지에는환자의나이, 성별, 추정되는체중, 내원당시의활력징후, 질병기전 ( 외상과약물중독또는내과적문제 ), 기관내삽관을하는이유, 어려운기도여부, 삽관방법, 삽관도구, 삽관시시야확보정도, 시야확보를위한조작, 사용한약물, 삽관의성공여부, 삽관자의정보등이포함되어있다. 또한외상의경우는외상의기전과, 얼굴손상여부, 경추고정술여부등의항목이추가로포함되어있다. 삽관시시야확보정도는시야를확보하기위한조작을하지않은상태에서평가하였고, Modified Cormack & Lehane 분류법 (Glottic exposure grade, GEG grade) 및 POGO (percentage of glottic opening) 척도를사용하였다 7). GEG grade는성문이모두보이면등급 Ⅰ, 성문의후면만보이면등급 Ⅱ, 후두개만보이면등급 Ⅲ, 후두개나성문이보이지않으면등급 Ⅳ로분류한다. POGO 척도는육안적으로보이는성대의노출정도를 0~100% 로수치화하였다 8). 시야확보를위해외부조작을하는경우는후두경을잡은손에힘을가하여들어올리는견인력증가, 외부후두조작, 머리위치변경등세가지로구분하여기록하였다. 삽관의성공여부는첫번째시도에서의성공여부로판단하였다. 만약첫번째삽관을실패하여두번째시도를하게되는경우, 두번째삽관은연구에포함시키지않았다. 통계학적분석은 SPSS for Windows 12.0 K를통하여 Mann-Whitney검정과카이제곱검정, 경향분석을위해로지스틱회귀분석을이용하였고 p값은 0.05 미만을유의 하다고판단하였다. Mann-Whitney 검정결과는중앙값과사분위값으로표현하였다. 결 2006년 4월부터 2010년 3월까지 48개월동안등록된기관내삽관환자는 1,974명이었으며, 이중자료입력이불충분한 31명을제외하였다. 1,943명의환자가운데내과적인문제로인해기관내삽관을시행한환자가 1,541명 (79.3%) 이었다. 나머지 402명중약물중독환자를제외한 341명 (17.6%) 의환자가외상으로인해기관내삽관을하게된환자들이었다. 341명환자의기관내삽관에서사용한도구는 Table 1 과같다. 이중입기관내삽관을시행한 338명을분석대상으로하였고, Macintosh 후두경및 Miller 후두경을사용한직접후두경군과 Glidescope 비디오후두경을사용한 Glidescope군으로구분하였다. 직접후두경군과 Glidescope군의특성을비교하였다. 내원당시의활력징후나의식상태, 외상의중증도는양군간에차이가없었다. 외상의기전에서는목맴의환자군에서 Glidescope의선택비율이 48%(22:20) 로가장높았다. 어려운기도 (difficult airway) 로판단된경우는직접후두경군에서 22.6%, Glidescope군에서 46.9% 로유의한차이를보였다 (p<0.001). Glidescope군의 86.9% 와직접후두경군의 61.5% 에서경추고정을시행하였다. 삽관시도자는 Glidescope군에서 3,4년차전공의비율이높았다. 기관내삽관시 POGO 척도는 Glidescope군에서 90% 로직접후두경군의 80% 에비해유의하게높았다. GEG에서는등급 III~IV에해당하는환자가 Glidescope군에서 16.9% 로직접후두경군의 23.1% 에비해적었지만통계적으로유의하지는않았다. 삽관성공률및치료결과 ( 사망률 ) 는유의한차이를보이지않았다 (Table 2). Glidescope과직접후두경의선택에영향을주는요인들을살펴보았다. 경추고정술을시행할수록, 어려운기도일수록, 전공의연차가높을수록 Glidescope을선호하였다 과 Table 1. First attempted airway management techniques Airway management maneuver N (%) Orotracheal intubation Macintosh laryngoscope 199 (58.4)0 Glidescope video laryngoscope 130 (38.1)0 Miller laryngoscope 009 (02.6)0 Cricothyroidotomy 002 (00.6)0 Nasotracheal intubation 001 (00.3)0 Total 341 (100.0)

3 김정언외 : 외상환자에서 Glidescope 비디오후두경을이용한응급기도관리 / 577 Table 2. Comparison of variables related to airway management between direct laryngoscope group and Glidescope video laryngoscope group Variables DL (n=208) N of patient (%) GVL (n=130) Male, sex 147 (70.7) 91 (70.0) <0.895* Age 420 (26,58)00 43 (28,58)0 <0.409* SBP 122 (100,151) 125 (89,143)0 <0.525* DBP 75 (60,87)0 75 (53,85)0 <0.678* PR 90 (76,111) 90 (79,107) <0.695* Sat 95 (88,99)0 95 (82,99)0 <0.846* GCS 05 (03,11)0 06 (04,10)0 <0.551* RTS 13 (11,19)0 14 (11,17)0 <0.895* Vector <0.032* Traffic accident 085 (40.9) 059 (45.4) Fall down 042 (20.2) 031 (23.8) Blunt injury 028 (13.5) 014 (10.8) Hanging 022 (10.6) 020 (15.4) Etc. 031 (14.9) 006 (04.6) Crash airway 069 (33.2) 048 (36.9) <0.481* Difficult airway 047 (22.6) 061 (46.9) <0.001* Facial trauma 064 (30.8) 050 (38.5) <0.146* C-spine immobilization 128 (61.5) 113 (86.9) <0.001* Level of training <0.001* PGY1 130 (62.5) 054 (41.5) PGY2 053 (25.5) 038 (29.2) PGY3 012 (05.8) 022 (16.9) PGY4 013 (06.3) 016 (12.3) RSI <0.989* No med 065 (31.3) 040 (30.8) Sedation only 009 (04.3) 006 (04.6) RSI 134 (64.4) 084 (64.6) GEG <0.124* Grade I 098 (47.1) 78 (60.0) Grade II 062 (29.8) 30 (23.1) Grade III 022 (10.6) 12 (09.2) Grade IV 026 (12.5) 10 (07.7) POGO 80 (30,90)0 90 (70,100) <0.001* Manipulation for visual improvement Selick maneuver 090 (43.3) 33 (25.4) <0.001* Increasing lifting force 050 (24.0) 35 (26.9) <0.552* Head movement 003 (01.4) 01 (00.8) <0.578* 1st attempt success 158 (76.0) 98 (75.4) <0.904* Esophageal intubation 013 (06.3) 03 (02.3) <0.097* ED mortality 066 (31.7) 45 (34.6) <0.583* Hospital mortality 089 (42.8) 52 (40.0) <0.613* SBP: systolic blood pressure, DBP: diastolic blood pressure, PR: pulse rate Sat: O 2 saturation, GCS: Glasgow coma scale, RTS: revised trauma score PGY: post-graduate year, RSI: rapid sequence intubation, GEG: glottic exposure grade POGO: percentage of glottic opening, ED: emergency department DL: direct laryngoscope, GVL: Glidescope video laryngoscope * p values were significant p

4 578 / 대한응급의학회지 : 제 21 권제 5 호 2010 (Table 3). 어려운기도에서의삽관성공률은 Glidescope군에서 77.0%, 직접후두경군에서 55.3% 로 Glidescope을사용하였을때더높은성공률을보였다. 경추고정여부와전공의수련정도에따라나누어분석하였을때에는성공률에유의한차이를보이지않았다 (Table 4). 고찰 KEAMR을이용한국내다기관연구를보면 Glidescope 도입후첫 2년간조사하였을때전체환자의약 10.7% 에서 Glidescope이사용되었다고한다 9). 외상환자에초점을맞추어조사한본연구에서는기관내삽관시첫번째삽관시도에서 37.9% 가 Glidescope을선택하였다. 상급전공의들의 Glidescope 선택률이더높았으나 1, 2년차전공의들도 30~40% 의높은비율로선택하였다. 두응급의료센터의모든전공의들은 1년차수련이시작되는시기에응급기도관리에관한워크샵을통해직접후두경과 Glidescope을포함한비디오후두경의사용방법을익히게 되고어려운기도에서의비디오후두경의장점과특징에대해교육을받는다. 이러한교육과정을통해서새로운장비선택에대한부담감을덜어주어비디오후두경을실제응급환자의진료에적용하도록유도할수있었다. 전체환자를비교하였을때기관내삽관도구에따른 1 차시도성공률의차이는없었지만, 어려운기도가예상되는환자에서는 Glidescope을선택한경우직접후두경보다성공률이높았다. 이전에마취과의사들을대상으로한마네킹연구에서도쉬운기도에서는여러도구에서성공률의차이를보이지않았지만어려운기도를연출하였을때에는 Glidescope이 Machintosh laryngoscope 보다높은성공률을보여준바가있다 10). 또한수술전환자를대상으로한무작위대조군연구에서도어려운기도에서 Glidescope 을사용할경우시야가개선됨을확인하였다 11,12). 상급연차일수록 Glidscope을선호하는것이성공률에영향을미칠수있겠지만, 본연구결과는이전의많은연구결과들과상충되지않는다. 또한 Cooper 등 13) 은 Glidescope에숙련된사람이아니더라도직접후두경과비슷하거나우월한시야확보가가능하다하였고, Powell 등 14) 의연구에서도 Glidescope에서과거경험과상관없이높은성공률을보 Table 3. The result of logistic regression analysis associated with selecting direct laryngoscope vs Glidescope video laryngoscope Variable B Odd ratio p Lower 95% CI Upper C-spine immobilization < Difficult airway < Facial trauma < Level of training < Table 4. Comparison of success rate between two types of laryngoscope Variables N of patient Success rate (%) DL GVL DL GVL Difficult airway Y * N C-spine immobilization Y N Level of training PGY PGY PGY PGY Total DL: direct laryngoscope, GVL: Glidescope video laryngoscope PGY: post-graduate year * p values were significant p

5 김정언외 : 외상환자에서 Glidescope 비디오후두경을이용한응급기도관리 / 579 여주었고 Bonfils fiberscope 등의다른삽관장비에비해사용하기가쉽다고제시하였다. 본연구에서삽관도구와상관없이경추고정여부가성공률에변화를주지않았다. Thiboutot 등 15) 이 Machintosh laryngoscope을이용하여도수고정이기관내삽관의성공률에영향을주는지연구하였는데, 시간을 30초로제한하였을때의성공률이 50% 로저하된다는결과를보여주었다. 본연구에서는기관내삽관에소요되는시간을측정하지않았고, 경추고정을얼마나확실하게하였는지와기관내삽관으로인해경추손상이가중되지는않았는지에대한정보는얻을수없었다. 따라서경추고정시에삽관도구가삽관의성공에얼마나영향을주는지는해석하기어렵다. 하지만, 시야확보면에서는 Glidescope의 POGO 척도가높았고시야개선을위해조작을가한비율이적었다. Malik 등 5) 도수술전환자를대상으로도수고정상태에서기관내삽관을시도하였을때삽관도구에따른성공률의차이는없었지만, Glidescope이 Machintosh laryngoscope 보다시야확보에우월하다는결과를제시하였다. 기관내삽관시에시야확보가되지않을때삽관자는시야확보를위해기도에힘을가하게되고이는경추의움직임을유발하게된다 2). 이때도수고정을하더라도경추의움직임을예방할수없다는연구결과들은이미제시된바있다 16). 하지만, Turkstra 등 17) 은도수고정상태에서기관내삽관시경추의움직임을측정하였을때, Glidescope을사용한경우 Machintosh laryngoscope 보다 2번부터 5번경추의움직임을 50% 감소시켰다고하였다. 따라서경추를고정하는측면에서생각해볼때시야확보에우월한Glidescope을선택하는것이유리할것이라는결론에도달할수있다. 본연구는다음의몇가지한계점을가지고있다. 첫째, 삽관을시행한후에삽관자가직접서식지에기록을하였기때문에회상바이어스 (recall bias) 가작용할수있다. 둘째, 어려운기도로예측되는환자의선정에있어서객관화된지표를사용하지못하였고, 삽관자가응급삽관시에판단한것을토대로어려운기도 / 어렵지않은기도가예측되었다. 셋째, 안면부외상이삽관도구의선택에유의한영향을주지않는결과를보였는데, 안면부외상가운데하악골골절이나출혈등의기도와관련된경우를파악하지못하였기때문에좀더기록의항목을세분화하였다면결과가달라졌을수있다. 넷째, 후향적관찰연구이기때문에경추고정방법을일관되게적용하지못하였고, 경추고정이얼마나확실하게이루어졌는지확인할수없었다. 결론 2개응급의료센터에서시행된기도관리의 17.6% 가외상환자들에게시행되었다. 외상환자의기관내삽관시에 어려운기도나경추고정을해야하는경우직접후두경에비해 Glidescope이선호되고있으며, Glidescope이시야확보면에서우월하고어려운기도에서더높은성공률을보였다. 참고문헌 01. Langeron O, Birenbaum A, Amour J. Airway management in trauma. Minerva Anestesiol 2009;75: Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, et al. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscope and orotracheal Intubation. Anesthesiology 2009;110: Sun DA, Warriner CB, Parsons DG, Klein R, Umedaly HS, Moult M. The GlideScope Video Laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005; 94: Enomoto Y, Asai T, Arai T, Kamishima K, Okuda Y. Pentax-AWS, a new videolaryngoscope, is more effective than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: a randomized comparative study. Br J Anaesth 2008;100: Malik MA, Maharaj CH, Harte BH, Laffey JG. Comparison of Macintosh, Truview EVO2, Glidescope, and Airwayscope laryngoscope use in patients with cervical spine immobilization. Br J Anaesth 2008;101: Kim MS, Choi HJ, Im TH, Chung HS, Cho JH, Kang KH, et al. Equipment for difficult airways in 67 Korean academic emergency departments. J Korean Soc Emerg Med 2009;20: Krobbuaban B, Diregpoke S, Kumkeaw S. An assessment of the ratio of height to thyromental distance compared to thyromental distance as a predictive test for prediction of difficult tracheal intubation in Thai patients. J Med Assoc Thai 2006;89: Levitan RM, Hollander JE, Ochroch EA. A grading system for direct laryngoscope. Anaesthesia 1999;54: Choi HJ, Kang HG, Lim TH, Chung HS, Cho J, Oh YM, et al. Endotracheal intubation using a GlideScope video laryngoscope by emergency physicians: a multicentre analysis of 345 attempts in adult patients. Emerg Med J 2010;27: Malik MA, O Donoghue C, Carney J, Maharaj CH, Harte BH, Laffey JG. Comparison of the Glidescope, the Pentax AWS, and the Truview EVO2 with the Macintosh laryngoscope in experienced anaesthetists: a manikin study. Br J Anaesth 2009;102:

6 580 / 대한응급의학회지 : 제 21 권제 5 호 Serocki G, Bein B, Scholz J, Dörges V. Management of the predicted difficult airway: a comparison of conventional blade laryngoscope with video-assisted blade laryngoscopy and the GlideScope. Eur J Anaesthesiol 2010; 27: Malik MA, Subramaniam R, Maharaj CH, Harte BH, Laffey JG. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation. Br J Anaesth 2009;103: Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anaesth 2005;52: Powell L, Andrzejowski J, Taylor R, Turnbull D. Comparison of the performance of four laryngoscopes in a high-fidelity simulator using normal and difficult airway. Br J Anaesth 2009;103: Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth 2009;56: Lennarson PJ, Smith D, Todd MM, Carras D, Sawin PD, Brayton J, et al. Segmental cervical spine motion during orotracheal intubation of the intact and injured spine with and without external stabilization. J Neurosurg 2000;92(2 Suppl): Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg 2005;101:910-5.

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untitled Anesth Pain Med 2012; 7: 91~96 임상연구 Mallampati 분류 1 또는 2의 환자에서 Pentax AWS, Glidescope, Macintosh laryngoscope를 이용한 기관삽관의 비교연구 한양대학교병원 마취통증의학과 정지선ㆍ정미애ㆍ조주원ㆍ조재현ㆍ심재항ㆍ서정국 Comparison of the Pentax AWS and the