임상연구 Anesth Pain Med 2010; 5: 125 129 Levitan FPS scope와 Macintosh 후두경 하 기관내 삽관이 혈압 및 심박수에 미치는 영향 충북대학교 의과대학 마취통증의학교실 박상용ㆍ김상태ㆍ신영덕 Key Words: Endotracheal intubation, Hemodynamic changes, The effect of tracheal intubation with the Levitan FPS scope or Macintosh larynogoscope on the arterial pressure and heart rate Laryngoscopy, Levitan FPS scope. 서 론 Sang Yong Park, Sang Tae Kim, and Young Duck Shin 후두경을 사용한 기관내 삽관은 혈압상승과 빈맥을 초래 Department of Anesthesiology and Pain Medicine, School of Medicine, Chungbuk National University, Cheongju, Korea 한다[1,2]. 이러한 반응의 주요원인은 기관내 튜브의 커프 Background: The hemodynamic changes associated with orotracheal intubation may result from direct laryngoscopy and the endotracheal intubation. This study was designed to compare the hemodynamic changes after the endotracheal intubation with either the Levitan FPS scope or Macintosh laryngoscope. Methods: Sixty patients, aged 20 to 60 years, were randomly allocated into two groups, the Levitan FPS scope group (LF group, n = 30) and the Macintosh group (M group, n = 30). The endotracheal intubation with the Levitan FPS scope or Macintosh blade was performed after inducing anesthesia. The heart rate and arterial pressure were measured before induction, just before intubation and at 1, 3 and 5 min after intubation. Results: There were no significant differences in the arterial pressure and heart rate responses to tracheal intubation with the Levitan FPS scope and the Macintosh laryngoscope. In both groups, the arterial pressures at 1 and 3 and 5 min after intubation were increased significantly compared with the preintubation values, and the heart rates at 1 and 3 min after intubation were increased significantly compared with the preintubation values. Conclusions: The Levitan FPS scopic intubation does not attenuate the hemodynamic responses associated with endotracheal intubation compared with the Macintosh laryngoscopy. (Anesth Pain Med 2010; 5: 125 129) region)의 자극에 의한 교감신경계 흥분에 의해 발생된다고 (cuff) 팽창과 더불어 후두경 날에 의해 성문상부(supraglottic 알려져 있다[3]. 따라서 이러한 자극을 최소화하는 것이 혈 역학적 변화를 둔화시키는데 도움이 될 수 있기 때문에 후 두경을 사용하지 않고 기관내 삽관을 시행하여 혈역학적 변화를 비교한 연구들이 있다[4-7]. 국내에 소개된 Levitan FPS (First Pass Success) scope (Clarus Medical, USA)는 경직성 기관지경으로(Fig. 1) 후두경을 사 용하지 않고 기관내 삽관이 가능하여 후두경에 의한 후두 상부 연부 조직에 가해지는 자극은 피할 수 있으나 이로 인한 혈역학적 변화에 대한 연구는 드물다. 그래서 저자들 은 Levitan FPS scope와 전통적인 후두경 날을 비교한 문헌 Received: January 13, 2010. Revised: 1st, January 26, 2010; 2nd, March 1, 2010 Accepted: March 22, 2010. Corresponding author: Sang Tae Kim, M.D., Department of Anesthesiology and Pain Medicine, School of Medicine, Chungbuk National University, 410, Seongbang-ro, Heungduk-gu, Cheongju 361-711, Korea. Tel: 82-43-269-6237, Fax: 82-43-272-0264, E-mail: kimst@chungbuk.ac.kr *This article is a Master's Thesis by Sang Yong Park. Fig. 1. The Levitan FPS scope. 125
126 Anesth Pain Med Vol. 5, No. 2, 2010 은아직없기때문에실험을계획하여 Levitan FPS scope와전통적인후두경을사용한기관내삽관시혈압과심박수변화를비교하여알아보고자하였다. 대상및방법정규수술이예정된미국마취과학회신체등급분류 1 또는 2에해당하는 20세이상부터 60세이하성인환자 60명을남녀구분없이무작위로선택하였다. 목, 인두부, 후두부및구강내해부학적이상이나기형, 구강내선천적혹은종물등후천적질환, 이전에두경부수술을시행받은경우, 처음시도시기관내삽관에실패한경우, 폐질환또는고혈압이있는환자는연구대상에서제외하였다. 이연구는임상윤리위원회의허가와환자들에게동의를얻은후에시행하였다. 각각 30명의대상자를무작위로선택하여한군은 Levitan FPS scope을사용하였고 (LF군, n = 30) 다른군은 Macintosh 3번후두경을사용하여 (M군, n = 30) 기관내삽관을하였다. 마취유도 10분전에미리 glycopyrrolate 0.2 mg을정주하였다. 수술방에도착후심전도, 동맥압, 심박수, 맥박산소포화도측정에필요한장치 (Multi Channel Anesthesia Monitor S/5, Datex-ohmeda, USA) 를부착하였다. 마취유도는 fentanyl 1μg/kg, thiopental sodium 5 mg/kg를정주하였고, 약 30초후에의식이소실되면 vecuronium 0.15 mg/kg을정주하였다. 안면마스크를통해서 enflurane 3 vol%, O 2 4 L/min로조절호흡을시행한후 Levitan FPS scope혹은 Macintosh 3번을이용하여기관내삽관을시행하였다. 기관내삽관은남성의경우에는내경 7.5 mm, 여성의경우에는내경 7.0 mm 크기의 polyvinyl chloride 튜브를사용하였다. 삽관은 Levitan FPS scope와 Macintosh 후두경에숙련된 1명의마취과의사에의해시행되었으며, Levitan FPS scope을이용하는경우에는정중접근법으로인후두부위를보면서삽관하였고, Macintosh 후두경은설후두개와 (glosso-epiglottic fossa) 에후두경날을거치시킨후전상방으로힘을가하는방법으로 성대 (vocal cord) 를최대한노출시킨후삽관하였다. 기관내삽관후실험을계획한삽관후 5분까지는마취유도할때와동일한 enflurane 3 vol%, O 2 4 L/min로기계호흡을하여마취를유지하였다. 기관내삽관시기도평가를위해 POGO (percentage of glottic opening) 점수를기록하였고, 기관내삽관에소요된시간을기록하였다. 기관내삽관에소요된시간은 M군의경우에는시술자가후두경의핸들을왼손으로잡을때부터기관내튜브가성대를통과하는시점까지소요된시간으로표시하였고, LF군의경우에는보조자가삼중기도를확보하는때부터기관내튜브가성대를통과하는시점까지소요된시간을표시하였다. 환자가수술실도착후마취유도전안정된상태에서혈압과심박수를측정하여연구를위한기본혈역학적지표로정하였으며, 기관내삽관직전, 그리고삽관후 1, 3, 5분에혈압과심박수를측정하였고, 시간에따른두군간의차이를비교하였다. 그리고동일군내에서기관내삽관직전과비교하여삽관후 1, 3, 5분에혈압과심박수의변화정도를비교하였다. 동일군내에서시간에따른측정치의변화는반복분산분석을이용하였고, 두군간의비교는 unpaired t-test를사용하여분석하였다. P값이 0.05 미만인경우를통계적으로유의한차이가있다고판정하였다. 결과 LF군과 M군간의나이, 키, 몸무게, POGO score는유의한차이가없었고, 기관삽관의시도횟수는 LF군과 M군모두에서한번으로동일하였으나, 기관삽관시간에는두 Table 1. Patients' Characteristics Group LF Group M (n = 30) (n = 30) Age (yr) 37.0 ± 8.5 37.7 ± 9.9 Sex (M/F) 11/19 14/16 Height (cm) 162.5 ± 8.7 164.4 ± 8.0 Weight (kg) 60.3 ± 12.3 61.6 ± 10.3 Intubation time (s) 16.8 ± 1.8 12.0 ± 1.5* POGO score (%) 100.0 ± 0.0 95.6 ± 11.9 All values are Mean ± SD. Group LF: Levitan FPS scope, Group M: Macintosh laryngoscope. *: P < 0.05 compared with group LF. Fig. 2. Changes of systolic arterial pressure before and after intubation. Baseline: before induction, BI: just before intubation, T1, 3 and 5: 1, 3, and 5 min after intubation, LF: Levitan FPS scope, M: Macintosh laryngoscope. *: P < 0.05 compared with BI values. No significant differences were found between the two groups in the changes in systolic arterial pressure.
박상용외 2 인 :Levitan FPS scope 와 Macintosh 후두경하기관내삽관이혈압및심박수에미치는영향 127 Fig. 3. Changes of diastolic arterial pressure before and after intubation. Baseline: before induction, BI: just before intubation, T1, 3 and 5: 1, 3, and 5 min after intubation, LF: Levitan FPS scope, M: Macintosh laryngoscope. *: P < 0.05 compared with BI values. No significant differences were found between the two groups in the changes in diastolic arterial pressure. Fig. 4. Changes of heart rate before and after intubation. Baseline: before induction, BI: just before intubation, T1, 3 and 5: 1, 3, and 5 min after intubation, LF: Levitan FPS scope, M: Macintosh laryngoscope. *: P < 0.05 compared with BI values. : P < 0.05 compared with group M. No significant differences were found between the two groups in the changes in heart rate, T1, 3. 군간유의한차이가있었다 (Table 1). LF군과 M군간의수축기및이완기혈압, 심박수를시간대별로비교분석한결과마취유도전심박수 (baseline HR) 에서만두군간유의한차이가있었을뿐나머지에있어서는유의한차이를관찰할수없었다 (Fig. 2 4). 동일군내혈압변화를비교하였을때, 기관삽관직전에비하여수축기혈압과이완기혈압이 1분, 3분, 5분후에유의하게상승하였다 (Fig. 2, 3). 심박수는기관삽관직전에비하여 LF군에서는 1분, 3분후에유의하게상승하였으나 5분후에는유의한차이를보이지않은반면 M군에서는 1분, 3분후에유의하게상승하였으나 5분후에는유의하게하락하였다 (Fig. 4). 고찰후두경검사및기관내삽관은동맥압과심박수의급격한변화를초래하는데, 입인후두부위의후두경조작이기관삽관과연관된혈역학적스트레스반응에있어중요한인자라는보고가있다 [3]. 그러나, Montes 등은 [8] 후두경에의한자극보다는기관내튜브의삽입자체로인한자극이혈역학적변화를야기시킨다고하였다. 기관내삽관에의한혈압의상승은위험하며폐부종, 심부전, 뇌출혈을포함한합병증을초래할수있다 [9]. 혈역학적인변화는건강한환자에서는일시적이고큰문제가되지않으나특히고혈압이있는노인환자에서는심근경색이나뇌경색의위험도를크게증가시킨다 [10-12]. 기관내삽관에의한빈맥은심근산소요구량을증가시키며, 허혈성심장질환이있는환자에서는이러한혈역학적인변화가수술중심근경색을유 발시킬수있다 [13]. 이와같이기관내삽관에의해발생되는고혈압과빈맥은여러합병증을발생시킬수있기때문에, 고혈압과빈맥의발생을예방하기위한여러가지방법들이연구되었다. Mostafa 등은 [14] 기관내삽관전에국소마취제의전처치를통하여혈역학적인변화를효과적으로감소시킬수있었다고보고하였으며, Martin 등은 [1] fentanyl의사용이기관내삽관과관계된스트레스로부터심혈관계질환이있는환자를보호하는효과적인방법이라고보고하였다. Fujii 등은 [11] nicardipine과 diltiazem을사용하여기관내삽관에따른혈역학적인변화를줄여줄수있음을보고하였다. 기관내삽관방법을바꿈으로써혈압변동을감소시키려는시도가있으며그러한경우로는광봉 (lightwand), Bonfils Scope, StyletScope을이용하여후두경을사용하지않고기관내삽관을시도할수있는방법등이있다. 이러한후두경에의한자극을피할수있는방법을이용하여기관내삽관시혈역학적인변화를알아보고자한여러연구가있었다. Hirabayashi 등 [4], Takahashi 등 [15], 및 Oh 등은 [16] 광봉을이용한기관내삽관이후두경을이용한기관내삽관시와비교하여혈역학적인변화를줄여주지않았다고보고하였다. 그리고 Yoon 등은 [17] 뇌동맥류환자에서기관내삽관시광봉을이용한방법이후두경을이용하는방법에비하여혈역학적인변화를줄여주는데차이가없다고보고하였다. 그러나 Nishikawa 등은 [18] 광봉을이용한기관내삽관이고혈압환자에서는차이가없으나정상혈압환자에서는혈역학적인변화를줄여주었다고보고하였다. Yun과 Lee의 [7] 보고에의하면, Bonfils Scope을이용한기관내삽관시정상혈압환자에서후두경을사용한경우와비교하
128 Anesth Pain Med Vol. 5, No. 2, 2010 여혈압과심박수가유의하게완화되지않음을보고하였다. Kitamura 등은 [19] StyletScope을사용한기관내삽관이삽관하는동안심박수의상승을감소시킨다고보고하였다. 그리고 Kimura 등은 [20] 정상혈압환자와고혈압환자모두에서 StyletScope을사용한기관내삽관이혈역학적인변화를줄여주며인후통의발생빈도를감소시킨다고보고하였다. 이와같이직접적으로후두개에자극을주지않고기관내삽관을실시하는경우에기관내삽관후혈압과심박수에미치는영향에대한연구는다양한결과를보여주고있으며, 후두개자극이빈맥과고혈압을일으키는주된요인인가에대해서는더많은후속연구가필요하리라생각된다. Levitan에의해소개된 Levitan FPS scope는후두경없이기관내삽관을시도할수있는기구로철탐침내부에는빛을투과할수있는렌즈가있다. Levitan FPS scope는굴곡성후두경에비하여소독이용이하며기구를준비하는시간이짧으므로응급상황에좀더적합하며광섬유를통하여성대를보면서튜브를삽입하기때문에삽관과정에서일어날수있는손상을최소화할수있는장점이있으나경비기관삽관을할수없다는단점이있다. 또한, 길이가 30 cm로써 Bonfils Scope나 Shikani Stylet에비하여 30 cm의길이로더짧아서기구를다루기가더용이하며 60 cm의굴곡성기관지경에비하여가격이 1/5로저렴하다 [21]. Levitan FPS scope에의한기관내삽관방법은후두경으로후두개를들어올린뒤기구를통해성대를보면서시행하는방법과후두경을이용하지않고성문상부의기도를통하여천천히안으로접근하여기관삽관을시도하는방법이있다. 이연구에서는후두경에의한성문상부조직에가해지는자극이혈역학적변화를크게한다고생각하였기때문에후자의방법을사용하였다. 정중접근법을사용하였고성문이잘노출되도록하기위하여보조자의도움하에삼중기도확보를시행한상태에서 Levitan FPS scope을진입하였다. 이러한삼중기도를확보하는과정이 LF군의기관삽관시간에포함되어기관삽관시간에두군간유의한차이를주었다고생각된다. 기관내삽관시에후두개를전상방으로들어올리는 Macintosh군에비해 Levitan FPS scope 군에서는보조자의엄지와검지손가락을이용하여환자의턱을전상방으로들어올리는동작을할뿐, 후두개에가해지는조작이없기때문에환자의혈압과심박수를상승시키는유해한자극이적을것으로생각하였다. 그러나본연구의결과에서볼수있듯이 Levitan FPS scope가 Macintosh 사용군에비해기관내삽관에의한혈역학적변화를둔화시키는데있어서특별한장점이없는것으로보인다. Macintosh와 Levitan FPS scope의두군모두에서기관내삽관후혈압및심박수증가가유의하게있었으며, 각각기관내삽관 1, 3 및 5분후에두군간에유의한차이가없는것으로보아, Levitan FPS scope의사용이 Macintosh에비해 유의하게혈역학적상승을억제하는것으로볼수없으며, 그효과는비슷한것으로생각된다. 본연구에서후두경에의한자극을피하여혈역학적인변화를줄여줄것이라는예상과는달리 Levitan FPS scope 을사용한기관내삽관은후두경을이용한기관내삽관과비교하여혈압과심박수의변화를줄여주지못하였음을알수있었다. 아마도기관내삽관시삼중기도확보과정에서하악거상으로인한자극이혈역학적인변화를초래할수있었을것이다 [4]. 또한 Montes 등의 [8] 주장처럼후두경에의한자극보다는기관내튜브의삽입자체로인한자극이혈역학적변화를가져왔다고생각된다. 결론적으로 Levitan FPS scope을사용한기관내삽관방법이 Macintosh 후두경을사용한고전적인방법과비교하여기관내삽관후에혈압및심박수상승의유의한차이가없었으며, 혈역학적변화가비슷하였다. 참고문헌 1. Martin DE, Rosenberg H, Aukburg SJ, Bartkowski RR, Edwards MW Jr, Greenhow DE, et al. Low-dose fentanyl blunts circulatory responses to tracheal intubation. Anesth Analg 1982; 61: 680-4. 2. Nishikawa T, Namiki A. Attenuation of the pressor response to laryngoscopy and tracheal intubation with intravenous verapamil. Acta Anaesthesiol Scand 1989; 33: 232-5. 3. Shribman AJ, Smith G, Achola KJ. Cardiovascular and catecholamine response to laryngoscopy with and without tracheal intubation. Br J Anaesth 1987; 59: 295-9. 4. Hirabayashi Y, Hiruta M, Kawakami T, Inoue S, Fukuda H, Saitoh K, et al. Effects of lightwand (Trachlight) compared with direct laryngoscopy on circulatory responses to tracheal intubation. Br J Anaesth 1998; 81: 253-5. 5. Kihara S, Watanabe S, Taguchi N, Suga A, Brimacombe JR. Tracheal intubation with the Macintosh laryngoscope versus intubating laryngeal mask airway in adults with normal airways. Anaesth Intensive Care 2000; 28: 281-6. 6. Kihara S, Brimacombe J, Yaguchi Y, Watanabe S, Taguchi N, Komatsuzaki T. Hemodynamic responses among three tracheal intubation devices in normotensive and hypertensive patients. Anesth Analg 2003; 96: 890-5. 7. Yun JH, Lee DH. A comparison of hemodynamic changes after endotracheal intubation by using the Bonfils intubation fibrescope and the laryngoscope. Korean J Anesthesiol 2006; 51: 547-51. 8. Montes FR, Giraldo JC, Betancur LA, Rincon JD, Rincon IE, Vanegas MV, et al. Endotracheal intubation with a lightwand or a laryngoscope results in similar hemodynamic variations in patients with coronary artery disease. Can J Anaesth 2003; 50: 824-8. 9. Fox EJ, Sklar GS, Hill CH, Villanueva R, King BD. Complications related to the pressor response to endotracheal intubation. Anesthesiology 1977; 47: 524-5. 10. Omote K, Kirita A, Namiki A, Iwasaki H. Effects of nicardipine
박상용외 2 인 :Levitan FPS scope 와 Macintosh 후두경하기관내삽관이혈압및심박수에미치는영향 129 on the circulatory responses to tracheal intubation in normotensive and hypertensive patients. Anaesthesia 1992; 47: 24-7. 11. Fujii Y, Tanaka H, Saitoh Y, Toyooka H. Effects of calcium channel blockers on circulatory response to tracheal intubation in hypertensive patients: nicardipine versus diltiazem. Can J Anaesth 1995; 42: 785-8. 12. Goldman L, Caldera DL. Risks of general anesthesia and elective operation in the hypertensive patients. Anesthesiology 1979; 50: 285-92. 13. Estafanous FG, Tarazi RC. Systemic arterial hypertension associated with cardiac surgery. Am J Cardiol 1980; 46: 685-94. 14. Mostafa SM, Murthy BV, Barrett PJ, McHugh P. Comparison of the effects of topical lignocaine spray applied before or after induction of anaesthesia on the pressor response to direct laryngoscopy and intubation. Eur J Anaesthesiol 1999; 16: 7-10. 15. Takahashi S, Mizutani T, Miyabe M, Toyooka H. Hemodynamic responses to tracheal intubation with laryngoscope versus lightwand intubating device (Trachlight) in adults with normal airway. Anesth Analg 2002; 95: 480-4. 16. Oh YS, Yum KW, Oh SE.. Comparative study of hemodynamic changes and complications following lightwand of laryngoscopic intubation. Korean J Anesthesiol 1995; 28: 203-9. 17. Yoon C, Park KS, Park SY, Chae YJ, Min SK, Lee SY, et al. Hemodynamic changes after endotracheal intubation in patients with cerebral aneurysm. Anesth Pain Med 2008; 3: 49-54. 18. Nishikawa K, Omote K, Kawana S, Namiki A. A comparison of hemodynamic changes after endotracheal intubation by using the lightwand device and the laryngoscope in normotensive and hypertensive patients. Anesth Analg 2000; 90: 1203-7. 19. Kitamura T, Yamada Y, Chinzei M, Du HL, Hanaoka K. Attenuation of haemodynamic responses to tracheal intubation by the styletscope. Br J Anaesth 2001; 86: 275-7. 20. Kimura A, Yamakage M, Chen X, Kamada Y, Namiki A. Use of the fiberoptic stylet scope (StyletscopeTM) reduces the hemodynamic response to intubation in normotensive and hypertensive patients. Can J Anaesth 2001; 48: 919-23. 21. Levitan RM. Design rationale and intended use of a short optical stylet for routine fiberoptic augmentation of emergency laryngoscopy. Am J Emerg Med 2006; 24: 490-5.