대한응급의학회지제 21 권제 6 호 Volume 21, Number 6, December, 2010 원 저 개인보호장비 C 단계착용이전문기도관리장비를사용한기도관리에미치는영향 : 마네킹연구 한양대학교의과대학응급의학교실 이용화 강형구 최혁중 강보승 임태호 The Effect of Personal Protection Equipment Level C on Airway Management with Advanced Airway Devices: A Manikin Study Yong Hwa Lee, M.D., Hyung Goo Kang, M.D., Hyuk Joong Choi, M.D., Bo Seung Kang, M.D., Tae Ho Lim, M.D. 책임저자 : 임태호서울특별시성동구행당동 17 한양대학교의과대학응급의학교실 Tel: 02) 2290-8999, Fax: 02) 2290-9280 E-mail: erthim@hanyang.ac.kr 접수일 : 2010년 9월 4일, 1차교정일 : 2010년 10월 4일게재승인일 : 2010년 11월 3일 801 Purpose: Personal protection equipment (PPE) is compulsory for the safety of physicians and patients in the presence of biological hazards. In particular, such equipment is required for airway management of patients with highly contagious respiratory diseases. However, there are only a few studies about the effect of PPE on airway management with various advanced airway devices including the newly developed video-laryngoscope. We conducted a study on the effect of PPE level C on airway management with five different types of advanced airway devices including the laryngeal mask airway (LMA), direct laryngoscope (DL), airwayscope (AWS), video-laryngoscope made by Stortz (DCI), and the Levitanscope (LE). Methods: Twenty-two emergency physician and residents in two emergency centers were trained to do trials with PPE and without PPE while performing airway management with five different airway devices. The procedures were done on two types of manikins. We compared the time from the start of the procedure to the first successful ventilation for each device and for each type of manikin. A short questionnaire was used to examine participants subjective experiences. Results: For both types of manikin, there were no significant differences in performance time between the group not wearing PPE and the PPE wearing group for any device. However, when compared with the other devices, the performance time for the LMA was faster than the other devices, and the Levitanscope took a significantly longer time in both groups. According to the questionnaires, the most comfortable & uncomfortable airway devices were the LMA and the Levitanscope. Conclusion: When PPE level C was compared with the no protection state, there were no significant statistical time differences for performing advanced airway management with any particular airway device. Key Words: Protective Clothing, Airway management, Biohazard Release Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea 서 운송수단의발달로인해전세계는거미줄처럼얽혀있어세계의어느지역도감염성질환으로부터안전할수없게되었다. 또한최근세계곳곳에서벌어지는테러의방식도이제는생화학무기를사용한생물테러까지도고려해야하는시대가되었다. 테러뿐만아니라감염성질환만하더라도최근수년사이에조류독감과중증급성호흡기증후군을비롯하여, 2009년멕시코와미국에서시작되어전세계적으로유행한돼지독감으로어느지역도안전한곳은없다는사실이입증되었다 1). 이와같은생화학적인재해상황에서의료진이착용해야하는개인보호장비 (personal protection equipment, PPE) 는의료진및환자의안전을위해반드시필요한장비이다. 하지만방독면이나장갑등의개인보호장구착용이의료진의활동과의료행위에제약을발생시켜환자의처치가힘들어질가능성이있다. 특히조류독감, 중증급성호흡기증후군이나돼지독감등과같은급성호흡기증상을유발하는감염성질환에이환된 론
802 / 대한응급의학회지 : 제 21 권제 6 호 2010 환자의기도관리는그환자의생명과밀접한관련이있을수있다. 2009년 2월중순에멕시코의작은마을에서시작되어 3개월만인 5월 21일까지 41개국가에서 11,034건의돼지독감감염이발생하였으며이중 85명이사망하였다는보고를고려하면이와같은상황에서의응급기도관리방안에대한연구가필요하다 2). 최근이와같이감염될가능성이높은호흡기질환을가진환자및생화학적재해상황에서의기도관리를위해개인보호장비를착용한상태에서의기도관리에대한연구결과가많이보고되고있으나, 직접후두경과후두마스크기도기를이용해진행된연구들이많고그이외의기도관리장비를대상으로한연구는드물며, 국내의료진을대상으로한연구는없다 8-17). 이연구는미국산업안전보건청 (The Occupational Safety and Health Administration, OSHA) 에서권장하고있는개인보호장비의 4가지단계중양압공기공급장치가필요할정도의위험한상황에서사용을권장하고있는개인보호장비 A와 B단계를제외하고공기를통해전염되는호흡기질환의전파를차단하고오염된공기를정화시켜주는장치로구성된 개인보호장비 C단계 를착용하는것이동일한기도관리장비를사용하여기도관리를시행하는데개인보호장비미착용시에비해술기종료시간에유의한차이를보이는지조사하고자했다 18). 연구에사용된기도관리장비로는이에대한연구보고가많은직접후두경과후두마스크기도기를포함하고, 최근개발되어나오는다양한종류의광학기관삽관장비들을연구에포함하여개인보호장비착용에따른수행시간의차이뿐아니라, 연구참여자들이가장편안해하는기도관리장비가무엇인지도알아보고자했다. 대상과방법이연구는 500 병상이상의대학부속응급의료센터 2 곳에근무하는 22명의의사 ( 응급의학과전문의 4명, 응급의학과전공의 18명 ) 를대상으로했다. 이연구에사용된두개의마네킹은기도관리관련교육에있어서신선동결카데바를대신하여사용할수있다고보고된에어심마네킹 (AirSim, Trucorp, Belfast, Northern Ireland) 과레어달사의기도관리훈련마네킹 (Laerdal Airway Management Trainer ) 을사용했다 19). 에어심 (AirSim ) 마네킹은구강내구조물이상대적으로부드럽고입이잘벌어지는특성을지니고있으며, 레어달사의기도관리훈련 (Laerdal Airway Management Trainer ) 마네킹은내부구조물이딱딱하고입이상대적으로잘벌어지지않으나치아손상, 식도삽관등의합병증을보다잘알수있는특성을지니고있다 (Fig. 1). 연구에사용한 5가지의전문기도관리장비는직접후두경, 후두마스크기도기, 펜탁스 (Pentax, Pentax, Japan) 사의에어웨이스코프 (AirwayScope, AWS), 스톨즈 (Storz) 사의디씨아이비디오후두경 (DCI -video-laryngoscope, Storz, German), 그리고반경직광학속심의일종인레비탄스코프 (Levitanscope, Levitan, USA) 를사용하였다 (Fig. 2). 직접후두경은전통적으로가장많이사용되는맥킨토시 3번후두경날을부착한후두경을사용했다 20). 대표적인성문위기구인후두마스크기도기는 4번을사용했다 21). 최근가장많은제품의발전을이루고있는광학기관삽관도구중에서는적은경추움직임하에서도삽관이가능한광학속심기구중레비탄스코프를, 비디오후두경중에는모니터와연결선이없어휴대가가능하며신체생리변화를적게유발한다고보고된펜탁스사의에어웨이스코프와모 A B Fig. 1. Two types of manikin. (A) Laerdal Airway Management Trainer : mouth opening is smaller than AirSim, (B) Airsim
이용화외 : 개인보호장비 C 단계착용이전문기도관리장비를사용한기도관리에미치는영향 : 마네킹연구 / 803 니터와연결선이있으면서모양이전통적인직접후두경과가장유사한비디오후두경인스톨즈사의디씨아이비디오후두경을사용했다 22-24). 개인보호장비는 C단계에해당하는보호복과방독면, 그리고장갑의특성이약간씩다른두종류의 C단계개인보호장비를사용했다. 이두종류의개인보호장비는 C1과 C2로구분하여연구를진행했다. C1 개인보호장비는보호복 3M microguard microchem 3000 과방독면 3M 6800 respirator, 그리고장갑 Nitri-Solve 760-09 로구성했다. 그리고 C2 개인보호장비는보호복 Dupont Tychem CPF 1S414와방독면防毒 1721HG (Japan), 그리고장갑 North Butyl B324/9(Japan) 으로구성하였다 (Fig. 3). 연구대상자는개인보호장비를착용하지않은상태, 개인보호장비-C1단계 와 개인보호장비-C2단계 를착용한상태에서위에기술한다섯가지기도장비를무작위순서로이용하여에어심마네킹에술기를시행하고, 충분한휴식후앞서선택한기도관리장비순서대로레어달사의기도관리훈련마네킹에술기를시행했다. 시행시작에서성공적인술 A B C D E Fig. 2. Five different types of airway equipment. (A) Direct laryngoscope (MAC #3), (B) Laryngeal mask airway (LMA #4), (C) Airway Scope, (D) DCI videolaryngoscope, (E) Levitanscope A-1 B-1 A A-2 Fig. 3. Comparison of personal protection equipment (PPE). (A) PPE-C1: 3M microguard microchem 3000, 3M 6800 respirator, Nitri-Solve 760-09, (A-1) Glove in PPE-C1 level: Nitri-Solve 760-09, (A-2) Gas Mask in PPE-C1: 3M 6800 respirator, (B) PPE-C2: Dupont Tychem CPF 1S414, 防毒 1721HG, North Butyl B324/9, (B-1) Glove in PPE-C2 level: North Butyl B324/9, (B-2) Gas Mask in PPE-C2: 防毒 1721HG B B-2
804 / 대한응급의학회지 : 제 21 권제 6 호 2010 기종료까지의시간을연구자 1인이스톱워치를사용하여초단위로측정했다. 성공적인술기종료의기준은후두마스크기도기를사용한경우삽입후튜브커프에공기를넣은후백마스크를연결해성공적인첫환기가이루어지는때까지를기준으로하였고, 그외기구는직경 7.0 mm의기관내관을사용하여삽관을시행하고튜브커프에공기를넣은후백마스크를연결하고성공적인첫환기가이루어진때까지를기준으로했다. 각연구대상자의측정값을모아사용한기도장비별로평균값을구하고반복시행다변량분산분석 (repeated multivariate analysis of variance, rmanova) 과동질성검정 (Scheffe method) 을사용하여유의성검정을시행했다. 그리고응급의학과수련기간이연구결과에미치는영향을분석하기위해 1~2년차전공의와 3~4년차및전문의, 두군으로나누어각기도관리장비별로두군간의술기종료까지의시간차이를비모수검정으로확인했다. 실험후연구대상자를상대로한설문을통해 C단계의개인보호장비착용상태에서어떤기도관리장비가기도관리수행에있어서가장편리하였는지를알아보았다. 본연구의통계프로그램으로는 SPSS 12.0 K를이용했다. 결과후두마스크기도기를사용한경우에어심마네킹에서개인보호장비착용하지않았을때 11.4±3.8초, C1과 C2 개인보호장비착용시 10.4±3.9초와 11.0±3.9초로유의한차이가없었으며, 레어달사의기도관리훈련마네킹에서도개인보호장비착용하지않았을때 9.5±2.6 초, C1 과 C2 개인보호장비착용시 12.4±16.0초와 9.3±2.8초로유의한차이가없었다. 직접후두경을사용한경우에어심마네킹에서개인보호장비착용하지않았을때 16.7±4.5초, C1과 C2 개인보호장비착용시 16.3±3.9초와 17.4±3.8초로유의한차이가없었으며, 레어달사의기도관리훈련마네킹에서는미착용, C1과 C2 착용시 16.7±4.3초, 15.9±3.2초와 18.2± 5.9 초로유의한차이가없었다. 펜탁스사의에어웨이스코프는에어심마네킹에서개인보호장비미착용, C1과 C2 착용시 17.1±8.3초, 16.0±4.3초, 17.7±10.2초로유의한차이가없었고, 레어달사의기도관리훈련마네킹에서는미착용, C1과 C2 착용시 16.9±9.6초, 14.8±2.8초와 19.3±17.7초로유의한차이가없었다. 스톨즈사의디씨아이비디오후두경은에어심마네킹에서개인보호장비미착용, C1과 C2 착용시 17.6±4.9초, 17.2±3.5초, 20.4± 8.2초로유의한차이가없었고, 레어달사의기도관리훈련마네킹에서는미착용, C1과 C2 착용시 18.3±5.3초, 22.1 ±13.4초와 22.2±11.5초로유의한차이가없었다. 광학속심형태의레비탄스코프는에어심마네킹에서개인보호 장비미착용, C1과 C2 착용시 23.7±10.7초, 29.3±16.4 초, 32.4±22.1초로유의한차이가없었고, 레어달사의기도관리훈련마네킹에서는미착용, C1과 C2 착용시 39.6± 42.3초, 80.7±144.3초와 54.9±78.8초로유의한차이가없었으나다른기구들에비해개인보호장비를입기전과후모두에서가장많은시간이소요되었다 (Table 1). 비교적수련기간이적은응급의학과전공의 1~2년차와그이상으로대상자를나누어각기도관리장비별로술기종료까지의시간을비교하였으나모든장비에서수련기간에따른통계적유의한차이는보이지않았다 (Table 2). 설문조사결과, 개인보호장비에대한질문에대해서는전체연구대상자 22명중 21명 (95.5%) 이상대적으로얇은장갑으로구성된개인보호장비 C1단계를착용하였을때가더편했다고응답했다. 개인보호장비를착용한상태에서가장편하게수행할수있었던기도장비로는연구대상자 22 명중 17명 (77.4%) 이후두마스크기도기를골랐고, 가장사용하기어려웠던기도장비로는모든연구대상자가연구결과에서가장오랜시간을필요로했던레비탄스코프를선택했다. 구조장비로사용되는후두마스크기도기를제외한나머지 4가지장비중에서가장시술이편했던장비에대한질문에는연구대상자 22명중 12명 (54.6%) 이에어웨이스코프를, 9명 (40.9%) 이직접후두경을선택했으며, 1명 (4.5%) 은디씨아이비디오후두경을선택하였다 (Table 3). 고찰 Zimmerman 등 3) 은방독면, 장갑, 가운, 보호복등의개인보호장비가질병의전파를줄이고의료진을전염성질환이나유해환경으로부터보호하기위해반드시필요하다고주장하였으며, 미국응급의학회 (The American College of Emergency Physicians, ACEP) 에서는의료진을위한개인보호장비지침을작성하여공표한바있다 4). 그럼에도 Visentin 등 5) 에의하면캐나다토론토의응급구조사 463명을대상으로한설문조사에서설문에응답한 230명중 168 명 (72.9%) 이이용할개인보호장비가없어서, 필요성을판단하지못해서, 시야가나빠져서등의이유로개인보호장비를사용하지않고있는것을보고했다. 그러나여전히 Tan 과 Fitzgerald 6) 그리고 Sansom 7) 은화학적-생물학적-방사선학적사건발생시의료진을효과적으로보호하기위해 개인보호장비 를반드시착용해야한다고주장하고있다. 이연구에서이용한개인보호장비는미국의산업안전보건청 (The Occupational Safety and Health Administration, OSHA) 에서권장하고있는방독면과보호복그리고장갑으로구성했다. 개인보호장비-C1 단계 는쓰리엠 (3M) 사에서제작한보호복 3M microguard microchem 3000 과방독면 3M 6800 respirator, 그
이용화외 : 개인보호장비 C 단계착용이전문기도관리장비를사용한기도관리에미치는영향 : 마네킹연구 / 805 Table 1. Comparison of successful skill completion times*(seconds) by airway equipments and manikins for three personal protection level group Using AirSim manikin Using Laerdal Airway management trainer manikin Airway equipments Personal protection level p-value Personal protection level p-value No protection C1 C2 No protection PPE-C1 PPE-C2 LMA 11.4±3.8 10.4±3.9 11.0±3.9 0.242 9.5±2.6 012.4±16.0 9.3±2.8 0.599 Direct laryngoscope 16.7±4.5 16.3±3.9 17.4±3.8 0.596 16.7±4.30 15.9±3.2 18.2±5.90 0.150 AWS 17.1±8.3 16.0±4.3 017.7±10.2 0.781 16.9±9.60 14.8±2.8 19.3±17.7 0.372 Video laryngoscope DCI 17.6±4.9 17.2±3.5 20.4±8.2 0.073 18.3±5.30 022.1±13.4 22.2±11.5 0.251 Video laryngoscope Levitan ** 023.7±10.7 029.3±16.4 032.4±22.1 0.149 39.6±42.3 0080.7±144.3 54.9±78.8 0.361 Fiberoptic stylet Values in mean±sd, p-value was calculated by repeated MANOVA (multivariate analysis of variance) test, * successful skill completion times: measured the time from intubation to first successful bag mask ventilation, C1: personal protection equipment-c1 composed with protective clothing, gas mask and gloves as 3M microguard microchem 3000, 3M 6800 respirator, Nitri-Solve 760-09, C2: personal protection equipment-c2composed with protective clothing, gas mask and gloves as Dupont Tychem CPF 1S414, 防毒 1721HG, North Butyl B324/9, LMA: laryngeal mask airway, AWS : Airway Scope as portable video laryngoscope made by Pentax, DCI : as video laryngoscope made by Stroz, ** Levitan scope : as semi-rigid fiberscope made by Levitan Table 2. Comparison of successful skill completion times*(seconds) by the years in practice (YIP ) of emergency medicine, airway equipment & manikins for three personal protection level group Using AirSim manikin Using Laerdal Airway management trainer manikin YIP 2 (n=10) YIP 3 (n=12) YIP 2 (n=10) YIP 3 (n=12) Protection equipment Protection equipment p-value Protection equipment Protection equipment p-value No C1 C2 No C1 C2 No C1 C2 No C1 C2 LMA 12.9±3.5 10.1±4.3 10.8±3.5 10.2±3.7 10.6±3.7 11.1±4.3 0.624 9.3±2.5 09.5±2.0 09.7±3.4 09.7±2.8 014.9±21.7 09.0±2.3 0.691 DL** 17.5±5.5 15.8±4.9 17.7±3.3 16.0+3.5 16.8±2.9 17.1±4.3 0.868 18.5±4.90 16.2±2.9 20.8±7.5 15.1±3.6 15.7±3.6 16.1±3.2 0.110 AWS 019.2±11.5 15.5±4.9 020.8±14.0 15.4±4.2 16.5±4.0 15.2±4.5 0.707 18.4±13.7 14.1±2.7 018.1±10.3 15.5±4.2 15.4±2.9 020.2±22.6 0.897 DCI 17.6±4.4 17.9±4.2 023.7±10.4 17.6±5.5 16.6±2.9 17.7±4.5 0.316 19.9±6.20024.7±16.2 020.8±10.1 16.9±4.0 020.0±10.8 023.4±12.8 0.653 LE 027.8±12.3 028.3±12.8036.1±20.3 20.2±8.0 030.1±19.5 029.4±23.8 0.198 51.6±58.70.84.1±129.0.82.2±109 029.6±19.0077.9±161.7032.0±28.1 0.154 Values in mean±sd, p-value was calculated by nonparametric test, * successful skill completion times : measured the time from intubation to first successful bag mask ventilation, YIP: the years in practice, No: no protection, C1: personal protection equipment-c1 composed with protective clothing, gas mask and gloves as 3M microguard microchem 3000, 3M 6800 respirator, Nitri-Solve 760-09 C2: personal protection equipment-c2 composed with protective clothing, gas mask and gloves as Dupont Tychem CPF 1S414, 防毒 1721HG, North Butyl B324/9, LMA: laryngeal mask as rescue device, ** DL: direct laryngoscope as conventional airway management device, AWS: Airway Scope as portable video laryngoscope made by Pentax, DCI: as video laryngoscope made by Stroz, LE: Levitan scope as Semi-rigid fiberscope made by Levitan
806 / 대한응급의학회지 : 제 21 권제 6 호 2010 Butyl B324/9, LMA: laryngeal mask airway 760-09, PPE-C2: personal protection equipment-c2 composed with protective clothing, gas mask and gloves as Dupont Tychem CPF 1S414, 防毒 1721HG, North * PPE-C1: personal protection equipment-c1 composed with protective clothing, gas mask and gloves as 3M microguard microchem 3000, 3M 6800 respirator, Nitri-Solve without LMA in wearing PPE? Q4. Which airway management device is the most comfortable 40.9% (n=9) 54.6% (n=12) 4.5% (n=1) 000% (n=0)0 in wearing PPE? Q3. Which airway management device is the most uncomfortable 00.0% (n=0) 00.0% (n=0)0 0.0% (n=0) 100% (n=22) 0.0% (n=0) in wearing PPE? Q2. Which airway management device is the most comfortable 13.6% (n=3) 00.9% (n=2)0 0.0% (n=0) 000% (n=0)0 77.4% (n=17) of airway management? Q1. Which PPE provided better conditions for all methods 95.5% (n=21) 4.5% (n=1) Direct Airway Levitan PPE-C1* PPE-C2 DCI-Storz LMA laryngoscope Scope scope Table 3. Results for questionnaire 리고장갑은 Nitri-Solve 760-09 로구성되었고, 개인보호장비-C2단계 는듀퐁 (Dupont ) 사에서제작한보호복 Dupont Tychem CPF 1S414 와방독면 防毒 1721HG, 그리고장갑은 개인보호장비-C1단계 에서사용한것보다더두꺼운재질로만들어진 North Butyl B324/9 로구성했다. 이연구에서는이렇게동일한단계의개인보호장비이나서로특성이조금씩다른방독면과보호복그리고장갑을사용하는경우기도관리술기에영향이있는지도확인해보고자했다. 그러나연구결과, 동일한기도관리장비를사용하는경우개인보호장비미착용시나 C1단계와 C2단계의착용시사이에술기시행시간에서통계적으로유의한차이를보이지는않았다. 본연구결과와비슷하게개인보호장비를착용하는것이기도관리술기에영향을주지않는다는기존의보고들이있었다. Greenland 등 8) 은직접후두경, 삽관용후두마스크기도기, 굴곡내시경삽관을비교연구한결과, 세종류의다른개인보호장비착용시, 각각을비교하였을때개인보호장비착용에따른유의한차이가없다는결과를보고했다. Greenland 등 8) 의연구에서도후두마스크기도기를이용한환기까지의시간이빠르게측정되었고, 굴곡내시경을이용한삽관이오래걸린것으로나타났다. 본연구에서는레비탄스코프를사용한경우다른장비를사용할때보다시간이오래걸렸는데평상시흔히사용하여익숙해있는도구가아니라는점이영향을미쳤을수있으나, 기구가가늘어장갑을낀상태에서조작이두께가넓고크기가큰다른도구들에비해어려웠을수있다고생각된다. 또한기구의아이피스 (eye-piece) 자체가상당히작고, 마스크를쓰고있어기구까지의거리가이미존재하고있는불편한상태에서, 작은아이피스를통해또다시삽관시야를확보해야하는이중적어려움이이러한수행시간지연을초래한다고생각해볼수있다. Udayasiri 등 9) 은개인보호장비의착용이외상환자의소생을위한처치나기도관리, 중심정맥관삽입등의응급실내에서의임상술기시행에있어서통계적으로유의하게술기시간을연장시키지않음을보고했다. Garner 등 10) 은A 단계에서 D 단계에이르는 4 종류의개인보호장비를이용하여각개인보호장비사이에기도관리에영향을미치는정도를비교하여개인보호장비 A단계에서만통계적으로유의하게술기시행시간이연장되었음을보고했다. 본연구에서는각장비들간의차이를비교하는조사는하지않았으나, 연구참여자들에게설문조사를시행하여사용편의도를조사했다. 가장사용하기편한장비로후두마스크기도기가선택되었고, 다음으로에어웨이스코프, 직접후두경, 디씨아이비디오후두경순이었다. Ben- Abraham과 Weinbroum 11) 은한가지의개인보호장비를착용한상태에서기도관리장비간의차이를비교하여직접후두경을이용한경우가후두마스크기도기를이용할때환기까지걸린시간보다통계적으로유의하게오래걸리는
이용화외 : 개인보호장비 C 단계착용이전문기도관리장비를사용한기도관리에미치는영향 : 마네킹연구 / 807 것을보고했다. Flaishon 등 12) 은개인보호장비착용후유용한기도관리장비에대해연구한결과에서후두마스크기도기를이용한경우가환기까지걸린시간이통계적으로유의하게빠른것을보고했다. 이들은개인보호장비를착용하고도기관내삽관이충분히가능하지만, 대량재해상황에서는더빠르고성공적으로기도관리를할수있는방법을선택해야하며그방법으로적절한것은후두마스크기도기를이용하는것이라고주장했다. 또한 Flaishon 등 13) 은또다른연구에서마취과의사 20명과외과의사 22명, 그리고 6명의경험이없는사람들을대상으로개인보호장비를착용한상태에서직접후두경으로기관삽관을시행하고, 후두마스크기도기로기도관리시행을하고첫환기까지걸리는시간을측정하고, 외과의사와경험이없는사람들의직접후두경과후두마스크기도기의학습커브 (learning curve) 를조사했다. 이연구에서는마취과의사들이외과의사와비교하였을때직접후두경과후두마스크기도기를이용한첫환기까지걸리는시간이통계적으로유의하게빨랐지만, 외과의사와경험이없는사람들은통계적으로유의한차이를보이지않았고외과의사와경험이없는사람들의후두마스크기도기의학습커브는직접후두경의학습커브와비교하여통계적으로유의하게빠른것을보고했다. 그리고이런결과로부터이들은후두마스크기도기를배우기도쉽고제약이심한상황 ( 대량재해, 생물학적재해상황등 ) 에서어떤사람이든쉽고빠르게사용할수있는유용한장비로소개했다. Talmor 14) 도대량재해상황의기도관리에대한소개에서전통적인직접후두경을통한기관삽관이이용될수있으나, 최근에는대체장비로소개되고있는후두마스크기도기가개인보호장비를착용한상태에서도빠르고쉽게환자의기도관리를할수있는장비라고보고했다. Wedmore 등 15) 과 Castle 등 16) 도역시개인보호장비를착용한상태에서전통적인직접후두경을이용한기관삽관보다는후두마스크기도기를사용하는것이통계적으로유의하게신속한기도관리를할수있다고보고했다. 본연구에서는앞서살펴본논문들과같이개인보호장비착용시에각기도관리장비사이의차이를비교하지는않았으므로어떤기도관리장비가더좋은지에대해서는평가할수는없다는제한점이있다. 그러나후두마스크기도기의경우다른기도관리장비와비교하였을때술기종료까지시간이연구전부분에서짧았으며, 실험후시행한설문조사결과에서도연구대상자들에의해후두마스크기도기를가장편하고쉽게시행할수있는장비로선택하였다는점에서후두마스크기도기가개인보호장비를입고있는상태에서추천할수있는전문기도관리방법으로생각된다. 이러한결과는후두마스크기도기의사용법이경구개에밀착시켜서구강내로밀어넣기만하면되는간편한특징때문인것으로생각된다. 이전연구들에서는조사되지않았던비디오후두경들인에어웨이스코프 나디씨아이비디오후두경은직접후두경의삽관시행시간과유사한범주에서삽관이가능했으며, 연구대상자의사용편의성에서도호응도가높아개인보호장비착용하에서직접후두경을통한삽관의대안으로고려해볼수있을것으로생각된다. 하지만앞서기술한데로이연구에서는이러한장비들을비교한연구가아니므로추후이러한비디오후두경및광학기관삽관장비들을대상으로비교하는추가적인연구가좀더필요할것으로생각된다. 본연구와상반되는결과를보고한연구들도있다. Hendler 등 17) 에의하면개인보호장비착용시에도기관삽관은효과적으로할수있지만, 삽관의시간이통계적으로유의하게연장되는것을보고하였고자신들의연구가전통적인직접후두경만을이용한연구결과이며, 삽관완료의기준을튜브의고정까지로정하고있어, 개인보호장비의착용으로인한튜브고정의어려움으로그결과가더나쁘게나왔을가능성이있다는점을제한점으로지적했다. 본연구에서동일한단일기도관리장비를사용할경우개인보호장비 C단계의착용이미착용상태와비교하여기도관리수행에드는시간에미치는유의한영향은통계적으로없었다. 하지만실험에참가한대상자수가상대적으로적고, 실험중이전의술기시행에의한학습효과가다음삽관수행에영향을미쳤을가능성이있고, 개인보호장비를착용후일정시간이지나면급격히증가하는피로도가기관삽관에영향을미쳤을수있으나본연구에서는이러한피로도에대한영향과반복시행으로인한학습효과로인한오류를정밀히교정하지못한점을평가에포함시키지못했다는점등이이연구의제한점이라할수있다. 또한두종류의개인보호장비 C단계착용과미착용상태만을비교하였기때문에다른단계의개인보호장비착용시에대한영향에대해서는논할수없으며, 마네킹을통한제한된연구였기때문에어려운기도등의여러실제임상상황에대한결과도알수없다는것이이연구의또다른제한점이며향후추가적연구가필요한부분이라하겠다. 결론후두마스크기도기, 직접후두경, 에어웨이스코프, 디씨아이비디오후두경, 레비탄스코프를사용한기도관리에서 C 단계의개인보호장비착용후각각의기구를사용한기도관리에서술기수행시간은개인보호장비미착용시의각각의기구들의술기수행시간과유의한차이가없다. 이기도관리장비중개인보호장비를착용한상태에서가장선호하는기도관리장비는후두마스크기도기이며, 가장불편한장비는레비탄스코프였다. 개인보호장비착용상태에서의여러기도관리장비간의실제적비교와어려운기도등의다양한상황에서의개인보호장비착용이미치는영향
808 / 대한응급의학회지 : 제 21 권제 6 호 2010 을알아보기위해서는더욱많은연구자를대상으로추가적인연구가필요할것으로생각된다. 이해관계명시 (Statement on Conflict of Interest) 본연구와관련된모든상업적제품및기구등과관련하 여모든저자들은일체의이해관계가없음을밝힙니다. 참고문헌 01. Schnitzler SU, Schnitzler P. An update on swine-origin influenza virus A/H1N1: a review. Virus Genes 2009;39: 279-92. 02. Neumann G, Noda T, Kawaoka Y. Emergence and pandemic potential of swine-origin H1N1 influenza virus. Nature 2009;459:931-9. 03. Zimmerman JL, Sprung CL; European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Chapter 8. Medical procedures. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med 2010;36 Suppl 1:S65-9. 04. American College of Emergency Physicians (ACEP). Personal protective equipment guidelines for health care facility staff. Ann Emerg Med 2010; 55:398-9. 05. Visentin LM, Bondy SJ, Schwartz B, Morrison LJ. Use of personal protective equipment during infectious disease outbreak and non-outbreak conditions: a survey of emergency medical technicians. CJEM 2009;11:44-56. 06. Tan GA, Fitzgerald MC. Chemical-biological-radiological (CBR) response: a template for hospital emergency departments. Med J Aust 2002 ;177:196-9. 07. Sansom GW. Emergency department personal protective equipment requirements following out-of-hospital chemical biological or radiological events in Australasia. Emerg Med Australas 2007;19:86-95. 08. Greenland KB, Tsui D, Goodyear P, Irwin MG. Personal protection equipment for biological hazards: does it affect tracheal intubation performance? Resuscitation 2007;74: 119-26. 09. Udayasiri R, Knott J, McD Taylor D, Papson J, Leow F, Hassan FA. Emergency department staff can effectively resuscitate in level C personal protective equipment. Emerg Med Australas 2007;19:113-21. 10. Garner A, Laurence H, Lee A. Practicality of performing medical procedures in chemical protective ensembles. Emerg Med Australas 2004;16:108-13. 11. Ben-Abraham R, Weinbroum AA. Laryngeal mask airway control versus endotracheal intubation by medical personnel wearing protective gear. Am J Emerg Med 2004;22: 24-6. 12. Flaishon R, Sotman A, Ben-Abraham R, Rudick V, Varssano D, Weinbroum AA. Antichemical protective gear prolongs time to successful airway management: a randomized, crossover study in humans Anesthesiology 2004;100:260-6. 13. Flaishon R, Sotman A, Friedman A, Ben-Abraham R, Rudick V, Weinbroum AA. Laryngeal mask airway insertion by anesthetists and nonanesthetists wearing unconventional protective gear: a prospective, randomized, crossover study in humans. Anesthesiology 2004; 100:267-73. 14. Talmor D. Airway management during a mass casualty event. Respir Care 2008;53:226-31. 15. Wedmore IS, Talbo TS, Cuenca PJ. Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear, biological, and chemical environment. Mil Med 2003;168:876-9. 16. Castle N, Owen R, Hann M, Clark S, Reeves D, Gurney I. Impact of chemical, biological, radiation, and nuclear personal protective equipment on the performance of lowand high-dexterity airway and vascular access skills. Resuscitation 2009;80:1290-5. 17. Hendler I, Nahtomi O, Segal E, Perel A, Wiener M, Meyerovitch J. The effect of full protective gear on intubation performance by hospital medical personnel. Mil Med 2000;165:272-4. 18. Available at: http://www.va.gov/. Accessed June 6, 2010. 19. Yang JH, Kim YM, Chung HS, Cho J, Lee HM, Kang GH, et al. Comparison of four manikins and fresh frozen cadaver models for direct laryngoscopic orotracheal intubation training. Emerg Med J 2010;27:13-6. 20. Scott J, Baker PA. How did the Macintosh laryngoscope become so popular? Paediatr Anaesth 2009;19 Suppl 1:24-9. 21. Grier G, Bredmose P, Davies G, Lockey D. Introduction and use of the ProSealTM laryngeal mask airway as a rescue device in a pre-hospital trauma anaesthesia algorithm. Resuscitation 2009;80:138-41. 22. Kihara S, Yaguchi Y, Taguchi N, Brimacombe JR, Watanabe S. The StyletScopeTM is a better intubation tool than a conventional stylet during simulated cervical spine immobilization. Can J Anaesth 2005;52:105-10. 23. Asai T. Tracheal intubation with restricted access: a randomized comparison of the Pentax-Airway Scope and Macintosh laryngoscope in a manikin. Anaesthesia 2009;64:1114-7. 24. Vlatten A, Aucoin S, Litz S, Macmanus B, Soder C. A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway-a randomized clinical trial. Paediatr Anaesth 2009;19: 1102-7.