대한마취과학회지 2006; 51: 547~51 Korean J Anesthesiol Vol. 51, No. 5, November, 2006 임상연구 Bonfils Intubation Fibrescope 과후두경을이용한기관내삽관시혈압과심박수변화의비교 영남대학교의과대학마취통증의학교실 윤지환 이덕희 A Comparison of Hemodynamic Changes after Endotracheal Intubation by using the Bonfils Intubation Fibrescope and the Laryngoscope Ji Hwan Yun, M.D., and Deok Hee Lee, M.D. Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea Background: The hemodynamic changes associated with orotracheal intubation may result from direct laryngoscopy and the endotracheal intubation. This study evaluated and compared the cardiovascular changes after either Bonfils intubation fibrescope or conventional laryngoscopic endotracheal intubation. Methods: Sixty patients, aged 20 to 30 years, were randomly allocated into two groups, the Bonfils intubation fibrescope group ( group, n = 30) and conventional intubation using a rigid laryngoscope ( group, n = 30). Bonfils intubation fibrescope or laryngoscopic oral endotracheal intubation was performed after inducing anesthesia. The systolic and diastolic arterial pressures, heart rate, peripheral oxygen saturation and intubation time were recorded before and after orotracheal intubation. Results: In both groups, the systolic and diastolic arterial pressures increased significantly after endotracheal intubation. The heart rate increased significantly after the induction of anesthesia in both groups. However, the arterial blood pressure, heart rate and intubation time were similar in both groups. Conclusions: The use of a Bonfils intubation fibrescope does not modify the hemodynamic response associated with endotracheal intubation compared with conventional laryngoscopy. (Korean J Anesthesiol 2006; 51: 547~51) Key Words: bonfils intubation fibrescope, cardiovascular responses, endotracheal intubation, laryngoscopy. 서 후두경을사용한기관내삽관은마취유도동안가장강력한심혈관계자극요소라할수있다. 기관내삽관에따른급격한동맥압과심박수의상승은심혈관계질환이있는경우종종심각한합병증을초래한다. 1) 기관내삽관에의한혈역학적변화의발생기전에는후두경에의한입인후두 (oropharyngolarynx) 를직접압박하는자극이하나의인자가되며따라서이러한자극을최소화하는것이혈역학적변화를둔화시키는데도움이될수도있다는배경하에후두경을사용하지않고기관내삽관을시행하여혈역학적 논문접수일 :2006 년 5 월 25 일책임저자 : 이덕희, 대구광역시남구대명동 317-1 번지영남대학교의과대학마취통증의학교실, 우편번호 : 705-717 Tel: 053-620-3368, Fax: 053-626-5275 E-mail: dhlee415@ynu.ac.kr 론 변화를비교하고자한연구들이있다. 2-4) 최근국내에소개된 Bonfils intubation fibrescope (Karl Storz GmbH, Tuttlingen, Germany) 은경직성기관지경으로 (Fig. 1) 후두경을사용하지않고기관내삽관이가능하므로후두경에의한후두상부연부조직에가해지는자극은피할수있으나이로인한혈역학적변화에대한연구는드물다. 이연구에서는 Bonfils intubation fibrescope과후두경을사용하여기관내삽관을시행할때발생하는혈압과심박수변화를비교하여알아보고자하였다. 대상및방법전신마취가예정된환자중미국마취과학회신체등급분류 1 또는 2에해당하는 20세이상부터 30세이하의남녀환자 60명을대상으로하였다. 이연구는병원윤리위원회의허가를받은후모든환자들에게이연구의목적에대하여충분히설명하여동의를얻은후에시행하였다. 대상환자 547
대한마취과학회지 : 제 51 권제 5 호 2006 Fig. 1. Bonfils intubation fibrescope. 들을무작위로두군으로나누어한군은 Bonfils intubation fibrescope을사용하였고 (군, n = 30) 다른군은 Macintosh 3번후두경을사용하여 (군, n = 30) 기관내삽관을하였으며, 기관내삽관이어려울것으로예측되는환자, 처음시도시기관내삽관에실패한경우, 심각한심혈관질환, 폐질환또는고혈압이있는환자는연구대상에서제외하였다. 두군간대상환자의인구학적자료, 삽관까지소요되는시간그리고마취유도전혈압과심박수의차이는통계적으로유의한차이가없었다 (Table 1). 전투약으로마취유도약 1시간전에 glycopyrrolate 0.2 mg과 fentanyl 1μg/kg을근주하였다. 안면마스크를통해서 sevoflurane 2.5 vol.%, O 2/N 2O 4/4 L/min를흡입시키면서 pentothal sodium 4 mg/kg와 rocuronium bromide 0.8 mg/kg를정주하였으며, 삽관 60초전에 esmolol 0.5 mg/kg를정주하였다. 환자감시장치 (Multi Channel Anesthesia Monitor S/5, Datexohmeda, USA) 를이용하여심전도표준유도 II, 동맥압, 심박수, 맥박산소포화도, 호기말이산화탄소분압그리고호기말 sevoflurane 농도를측정하였다. 남성의경우에는 8.0 mm, 여성의경우에는 7.5 mm 튜브를사용하여경구기관내삽관을시행하였다. 삽관은 Bonfils intubation fibrescope과 Macintosh 후두경에 30회이상의경험을가진 1명의마취과의사에의해시행되었으며, Bonfils intubation fibrescope을이용하는경우에는보조마취과의사가삼중기도확보를시행한상태에서정중접근법으로 Bonfils intubation fibrescope을삽입하여기관내삽관을하였다. 환자가수술실도착후마취유도전안정된상태에서혈압과심박수를측정하여연구를위한기본혈역학적지표로정하였다. 삽관직전, 삽관직후, 삽관후 1, 3, 5분에혈압과심박수를각각기록하였다. 삽관까지소요되는시간은삽관을시행하기위하여안면마스크를이탈한시점부터 Table 1. Characteristics of the Patients group group Number (n) 30 30 Age (yr) 25.2 ± 3.2 26.7 ± 2.7 Sex (M/F) 15/15 12/18 Height (cm) 168.5 ± 7.6 165.5 ± 7.6 Weight (kg) 62.7 ± 10.9 58.3 ± 9.8 Intubation time (sec) 14.1 ± 8.5 10.7 ± 6.4 Baseline hemodynamics SBP (mmhg) 123.6 ± 10.6 126.2 ± 10.5 DBP (mmhg) 73.8 ± 10.3 73.9 ± 9.3 HR (bpm) 74.1 ± 10.8 75.4 ± 14.3 Value are express as mean ± SD. group: intubation with Bonfils intubation fibrescope, group: intubation with laryngoscope, SBP: systolic blood pressure, DBP: diastolic blood pressure, HR: heart rate, bpm: beats per minute. 삽관후기관내튜브와마취회로가연결되는순간까지로정하여기록하였다. 맥박산소포화도는 pentothal sodium 정주후부터삽관후 5분까지의시간중가장낮은수치를기록하였다. 통계처리는 SPSS 12.0.7 프로그램을이용하였으며모든측정치는평균 ± 표준편차로표시하였다. 두군간의인구학적자료 (demographic data) 와혈압및심박수는 t-test를사 용하여분석하고, 각군의군내혈압과심박수는 repeated measures of ANOVA를이용하여분석하였다. P값이 0.05 미만인경우를통계적으로유의한차이가있다고판정하였다. 결 군과 군간의수축기및이완기혈압을시간대별로비교분석한결과유의한차이를관찰할수없었다 (Fig. 2, 3). 심박수의변화역시두군간유의한차이를보이지않았다 (Fig. 4). 군내혈압변화를비교하였을때, 마취유도전에비하여수축기혈압이 군에서는기관내삽관직후에만유의하게상승하였으며 (P < 0.01) 군에서는기관내삽관직후와 (P < 0.01) 삽관후 1분까지 (P < 0.05) 유의하게상승하였다 (Fig. 2). 이완기혈압은마취유도전에비하여양군모두에서기관내삽관직후와삽관후 1분까지유의하게상승하였다 (P < 0.05, Fig. 3). 심박수는양군에서마취유도전에비하여모든시간대에서유의하게상승하였다 (P < 0.01, Fig. 4). 맥박산소포화도는두군모두에서 97% 이하로떨어진경우를볼수없었다. 과 548
윤지환 이덕희 :Bonfils Intubation Fibrescope 과후두경 Systolic arterial pressure (mmhg) 170 150 130 110 90 Heart rate (bpm) 140 120 100 80 60 70 40 Fig. 2. Changes of systolic blood pressure before and after intubation. BI: immediately before intubation, AI: immediately after intubation, 1, 3, 5 min AI: 1, 3, 5 min after intubation, : intubation with Bonfils intubation fibrescope, : intubation with laryngoscope. : P < 0.01 compared with baseline values. : P < 0.05 compared with baseline values. Fig. 4. Changes of heart rate before and after intubation. BI: immediately before intubation, AI: immediately after intubation, 1, 3, 5 min AI: 1, 3, 5 min after intubation, : intubation with Bonfils intubation fibrescope, : intubation with laryngoscope. : P < 0.01 compared with baseline values. Diastolic arterial pressure (mmhg) 130 110 90 70 50 30 Fig. 3. Changes of diastolic blood pressure before and after intubation. BI: immediately before intubation, AI: immediately after intubation, 1, 3, 5 min AI: 1, 3, 5 min after intubation, : intubation with Bonfils intubation fibrescope, : intubation with laryngoscope. : P < 0.05 compared with baseline values. 고 기관내삽관은전신마취에서안전하게기도를확보할수있는가장확실한방법으로서조절환기를가능하게하고, 이물질의기관내흡인으로인한기도폐쇄를예방할수있으며응급상황에서정맥로가확보되기전약물의투여경로가될수있다. 그러나기관내삽관시행해지는후두경조작에의해동맥압과심박수가급격히상승할수있는 찰 데, 후두경에의해혀의기저부에가해지는최대힘은 40 newtons 정도로이는심혈관계에영향을미칠만큼매우유해한자극으로간주되며 5) Shribman 등은 6) 기관내삽관과는관계없이후두경조작만으로도현저한동맥압상승과혈중카테콜라민농도가증가됨을보고하였다. 이와같이기관내삽관시발생하는혈역학적변화는건강한환자에서는큰문제가되지않으나관상혈관질환, 심근경색, 고혈압또는뇌혈관질환등을가지고있는환자에서는사망률과이환율을증가시킨다. 7,8) 이연구에서사용된 Bonfils intubation fibrescope은 1983년 P. Bonfils에의해처음소개되었다. 이는 5 mm 외경에 40 cm의길이를가진경직성기관지경으로재생하여사용이가능하며, 한쪽기관지경끝은 40 o 로굽어져있고그반대쪽기관지경말단에위치한렌즈를통해입인후두를직접관찰하면서기관내삽관을시도하는기구이다. 기도를유지하는데필요한다른장비들과비교하였을때 Bonfils intubation fibrescope은여러가지장점과단점들이있다. 굴곡성후두경에비해소독이용이하며가격이저렴하고기구를준비하는시간이짧으므로응급상황에좀더적합하다. 또한, 내시경을통해직접성대를확인하면서튜브를삽입하기때문에삽관과정에서일어날수있는손상을최소화할수있고, 경추의움직임을최소화하면서도기관내삽관이가능하므로사고로인한경추손상환자에게도움이될수있다. 9) 그러나, 흡인통로가없으므로기도내분비물이나혈액을제거하기가힘들고경비기관삽관을할수없으며, 기구를사용하는데있어숙련되지않은경우에는후두경을이용한기관내삽관이나후두마스크에비해응급상 549
대한마취과학회지 : 제 51 권제 5 호 2006 황에서즉각적인기도유지를수행하기에는부적합하다. 한편, 이연구의결과에서나타나듯이기관내삽관에의한혈역학적변화를완화시키는데있어서는특별한장점이없는것으로보인다. 군과비교하였을때수축기및이완기혈압과심박수는기관내삽관후두군간차이가없이기관내삽관전에비해유의하게상승하였다. 또한 군에서는수축기혈압이삽관전에비해삽관직후에만유의하게상승한반면, 군에서는삽관직후와삽관후 1분까지상승함을볼때기관내삽관에따른혈역학적변화가 군에서오래지속됨을알수있었다. 후두경을사용하지않고기관내삽관을하는경우혈역학적인변화에대해서는다소논란의여지가있다. 광봉 (lightwand) 이나굴곡성후두경을이용한기관내삽관은후두경을사용하지않고기관내삽관을시도하여후두경으로인해조직에가해지는직접적인자극을피할수는있으나, 혈역학적인반응에대한연구결과는일치하지않는다. Nishikawa 등은 10) 40명의정상혈압환자와 40명의고혈압환자에서광봉을이용하여기관내삽관을시행한결과, 고혈압환자에서는차이가없으나정상혈압환자에서는광봉을이용한군에서후두경을사용한군에비해혈역학적변화가유의하게완화되었다고하였다. 그러나, Casati 등 11), Hirabayashi 등 2), Friedman 등 12) 그리고 Takahashi 등은 13) 성인환자에서광봉을이용한기관내삽관시동맥압이나심박수는후두경사용과비교하였을때기관내삽관동안이나삽관후에유의한차이를보이지않았다고보고하였다. 그원인으로서 Hirabayashi 등은 2) 광봉을이용한기관내삽관시기관내튜브의원활한통과를위해하악을잡아상방으로당기는힘자체가혈역학적변화를일으키기에충분하다고하였으며, Montes 등은 14) 기관내삽관시후두경에의한연부조직의자극보다기관내튜브의삽입자체로인한기관지자극이주된혈역학적변화를야기시킨다고하였다. 한편, 굴곡성후두경을사용하는경우기관내삽관시후두경으로인해후두조직에가해지는강력한자극을피할수가있으므로심혈관계반응을둔화시킬것으로예측할수있다. 그러나, 실제로 Adachi 등은 15) 기관내삽관시심혈관계반응을둔화시키는데있어서굴곡성후두경의유용성이없다고하였으며, 그주된이유는기관내로삽입되는튜브로인한기관지자극자체가혈역학적변화를야기시키는가장강력한자극이기때문이라하였다. 많은보고들에서기관지에대한이러한자극은국소마취제로기관지를전처치하거나 16-18) fentanyl, alfentanil과같은마약성진통제나 lidocaine을전신적으로투여하여야심혈관계반응을둔화시킨다고한다. 19-21) Bonfils intubation fibrescope을사용하는경우구강내로진입시목젖을기준으로한정중접근법과인두측벽을따 라기관지경을진입하는측부접근법이있으며, 단독으로기관지경을사용시후두개와성문의노출을용이하게하기위해서는일반적으로하악거상법을사용하거나하악과혀를동시에거상하기도한다. 22) 이연구에서는정중접근법을사용하였으며성문이잘노출되도록하기위하여보조자의도움하에삼중기도확보를시행한상태에서기관지경을진입하였는데, 이과정에서 Hirabayashi 등이 2) 제시한것처럼하악거상으로인한자극이매개체가되어혈역학적인변화를초래할수있었을것이다. 그러나, 혈역학적인변화를야기시키는주된자극은 Montes 등과 14) Adachi 등의 15) 주장처럼기관내삽관시후두경에의한연부조직의자극보다기관내튜브의삽입자체로인한기관지자극일것으로생각된다. 결론적으로 Bonfils intubation fibrescope 사용하에기관내삽관을시도하여혈압과심박수변화를관찰한결과후두경을사용한경우와비교하여혈압과심박수가유의하게완화되지않음을알수있었다. 참고문헌 1. Fox EJ, Sklar GS, Hill CH, Villanueva R, King BD: Complications related to the pressor response to endotracheal intubation. Anesthesiology 1977; 47: 524-5. 2. 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. 3. 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. 4. 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. 5.Hastings RH, Hon ED, Nghiem C, Wahrenbrock EA: Force, torque, and stress relaxation with direct laryngoscopy. Anesth Analg 1996; 82: 456-61. 6. Shribman AJ, Smith G, Achola KJ: Cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation. Br J Anaesth 1987; 59: 295-9. 7. Omote K, Kirita A, Namiki A, Iwasaki H: Effects of nicardipine on the circulatory responses to tracheal intubation in normotensive and hypertensive patients. Anaesthesia 1992; 47: 24-7. 8. 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. 9. Rudolph C, Schneider JP, Wallenborn J, Schaffranietz L: Move- 550
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