支氣管鏡的基本操作

.,1,支氣管鏡的基本操作,方蘇榕,.,2,支氣管鏡的適應(yīng)癥，禁忌癥支氣管鏡術(shù)前的準(zhǔn)備工作氣管-支氣管的解剖結(jié)構(gòu)支氣管鏡的基本操作方法,.,3,支氣管鏡的適應(yīng)癥,.,4,診斷方面,不明原因的咯血，慢性咳嗽，聲音嘶啞，局限性哮鳴音支氣管感染性疾病的病因?qū)W診斷肺炎胸片或CT檢查異常已診斷肺癌術(shù)前檢查，指導(dǎo)手術(shù)范圍及估計(jì)預(yù)后食管-支氣管瘺的確診胸部外傷，懷疑有支氣管裂傷和斷裂,.,5,治療方面,取出支氣管異物某些肺不張，肺膿瘍等咯血治療引導(dǎo)氣管插管支氣管鏡下治療,.,6,支氣管鏡的禁忌癥,.,7,活動(dòng)性大出血不能糾正的出血傾向尿毒癥，活檢易出血者嚴(yán)重肺動(dòng)脈高壓，活檢易出血者嚴(yán)重心、肺功能障礙嚴(yán)重心律失常新近發(fā)生心肌梗死或心絞痛疑有主動(dòng)脈瘤全身情況極度衰竭嚴(yán)重的上腔靜脈阻塞綜合征,.,8,支氣管鏡術(shù)前準(zhǔn)備,.,9,術(shù)前檢查,了解病史、測(cè)量血壓及心肺體檢胸片或胸部CT檢查出、凝血時(shí)間、血小板記數(shù)乙肝兩對(duì)半ECG檢查血?dú)夥治?.,10,患者準(zhǔn)備,向患者講明檢查目的、意義、配合方法術(shù)前簽字術(shù)前禁食6小時(shí)術(shù)前30分鐘肌注安定和阿托品有異齒術(shù)前摘下,.,11,氣管支氣管的解剖結(jié)構(gòu),.,12,.,13,氣管,上段固定于喉部，下段與主支氣管相連接。氣管由1520個(gè)軟骨環(huán)構(gòu)成，成人氣管橫徑1820mm，長(zhǎng)度1013cm，氣管分叉角度5565。氣管前有甲狀腺，后與食道相鄰。,.,14,主支氣管,右主支氣管短而粗，平均長(zhǎng)度25mm，直徑1115mm。左主支氣管細(xì)而長(zhǎng),平均長(zhǎng)度50mm,直徑911mm。,.,15,右側(cè)葉支氣管,右上葉支氣管長(zhǎng)度9mm，直徑8mm右中間段支氣管長(zhǎng)度820mm，直徑8mm右中葉支氣管長(zhǎng)度1020mm,直徑7mm右下葉支氣管長(zhǎng)度9mm,直徑7mm,.,16,左側(cè)葉支氣管,左上葉支氣管距左上葉支氣管開(kāi)口約5mm處，向前下處方發(fā)出舌段。左下葉支氣管距左下葉支氣管開(kāi)口約5mm處，向后發(fā)出背段。,.,17,支氣管鏡操作方法,.,18,.,19,.,20,.,21,.,22,支氣管分支命名,.,23,Group1Exercises,.,24,Step1:nosetolarynx,Thescopeisadvancedfromthenosetothelarynx.Thisstepincludeslocalanesthesia,.,25,Step2:larynxtosubglottis,Fromthelarynxthetracheaisenteredtothesubglotticarea.Iffromthehead:oncethevocalcordsarepassedthescopeisslightlyflexeddownwards.Iffromthefront:oncethevocalcordsarepassedthescopeisslightlyflexedupwards.,.,26,Step3:Followthecurvetothecarina,TheTracheaisnota“straightpipe”;Itdeviatesposteriorlyandslightlytotherightwhenapproachingthemaincarina.,.,27,Step4a:Carinatoleftmainbronchus,FromtheneutralpositiontheLMBisenteredjustbytwistingthewristtotheleftandadvancingfor1-2cm.,.,28,Step4b:Carinatorightmainbronchus,FromtheneutralpositiontheRMBisenteredjustbytwistingthewristtotherightandadvancingthescopefor1-2cm,.,29,Fromtheneutralpositiontheleftandrightmainbronchiareenteredalternativelyjustbytwistingthewristandadvancingthescopeforfewcm.,Step4c:Left-right-neutral,.,30,Step5a:Down-up-leftmainbronchus,ThescopeisslowlyadvancedthepulledbackuptheLMBwhilealwayskeepingitinthemiddleoftheairwaylumen.,.,31,Step5b:Down-uprightmainbronchus,ThescopeisslowlyadvanceddowntheRMBtoRLLandpulledbackupwardswhilealwayskeepingitinthemiddleoftheairwaylumen.,.,32,Group2Exercises,.,33,Step6a:Leftmaintoleftupperlobebronchus,FromtheLMBthescopeisadvancedtotheentranceoftheLULbronchus.,.,34,Step6b:Leftmaintoleftlowerlobebronchus,ThescopeisadvanceddowntheLMBtotheentranceoftheLLLbronchus.,.,35,Step6c:Rightmaintorightupperlobebronchus,ThescopeisadvanceddowntheRMBthenwiththewristtwisted60degreesfrommidlinethescopeisflexeduptotheentranceofRUL.,.,36,Step6d:Rightmaintobronchusintermedius,FromthecarinaadvancethescopedowntheRMBtothedistalbronchusintermediusandvisualizetheentrancetoRB456andthebasalpyramid.,.,37,Step6e:Rightmaintorightlowerlobebronchus,AdvancethescopefromthecarinatotheentranceoftheRLLwhilealwayskeepingitinthemidline.,.,38,Group3Exercises,.,39,Step7a:Leftupperlobeunodos,Fromthecarina,thescopeisadvancedtoLULentrance;there,justbythumbmovement,thelingulaandupperdivisionbronchusarevisualized.,.,40,Step7b:Leftbeforefivesix(LB456),FromtheLMB,thelingulaisentered,thenthescopeispulledbackintothedistalLMBandthescopeisadvancedintothesuperiorsegmentoftheLLL.!Wristmovementsare“inthemirror”,.,41,Step7c:LeftB6-8,9,10,WiththescopeattheLLLbronchusentrance,thesuperiorsegmentisentered,thenalternately,theantero,lateralandpostero-basalsegmentsoftheLLLareentered.,.,42,Step7d:Rightupperlobeuno-dos-tres,FromtheRMBthescopeisadvancedandflexedupintotheRULbronchuswherejustbywristandthumbmovementsthethreesegmentsarevisualized;thenthescopeiswithdrawntothemaincarina.,.,43,Step7e:Rightbeforefivesix(RB4,5,6),Fromthedistalbronchusintermedius,theRMLandsuperiorsegmentareenteredalternatively;!Wristmovementsare“inthemirror”.,.,44,Step7f:Rightmedialbasal(RB7)(d”Artagnan),Fromthedistalbronchusintermediusthescopeisadvancedandthemedio-basalsegmentisentered.,.,45,Step8a:Leftlowerlobebasalpyramid,FromtheentranceoftheLLLbronchusgoinandoutofthe3basalsegments,thenwithdrawthescopetothecarina.,.,46,Step8b:Right