呼吸系統(tǒng)模組氣道維護及氣管內(nèi)管置放(四),(四),(四)

1、呼吸系統(tǒng)模組氣道維護及氣管內(nèi)管置放5/11(四), 5/18(四), 5/25(四)13:0017:00立夫教學大樓10樓示範病房教學內(nèi)容1.Airway 及周邊構(gòu)造。2.呼吸狀況的評估。3.Airway obstruction的表徵。4.氣道維持及相關(guān)工具介紹使用。5.助手角色。6.插管注意事項及可能引起的傷害。7.實作及評分。模組準備用物CPR face shield CPR面膜Pocket size mask 口袋型急救面罩盒Resuscitator 復(fù)甦球Nasal airwayOral airwayGuedel Airway 中導型口腔氣道Mouth opener 張口器Bite b

2、lock 防咬器Suction tubeETT固定膠布Stylet手套、空針、壓舌板自備：自備：LMAAnatomyNosePharynxLarynxTracheaNoseWarming and humidification.The resistance of airflow through nasal passages = 2/3 total airway resistance.The resistance with mouth opening = 1/2 the resistance through nose. Exercise mouth breathing.PharynxNasopha

3、rynx: tonsilOropharynx: tongue (tone of genioglossus muscle)HypopharynxLarynxLie at the level of C3C5,6Phonation and glottic closure reflexCartilage, muscle, ligamentTracheaLie at the level of C6 (thyroid cartilage)T5 (carina)1015 cm in length; 1620 horseshoe-shaped cartilaginous rings.Stretch recep

4、tor and irritant (cough) receptor.Evaluation of the AirwayHistoryPEFurther evaluation: CXR, C-spine film, CT, MRI.Conditions that predispose to a difficult airway include:Infections : epiglottitis, abscesses, croup, bronchitis, pneumonia.Trauma maxillofacial trauma, cervical spine injury, laryngeal

5、injury.Endocrine : morbid obesity, diabetes mellitus, acromegaly.Foreign BodyInflammatory Conditions ankylosing spondylitis, rheumatoid arthritis.Tumors : upper and lower airway tumors.Congenital Problems choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome

6、, Hallermann-Streiff syndrome.Physiologic Conditions : pregnancy.PENostril size and patency.Beard, teeth.Mouth opening (Temporo-mandibular joint).Tongue, incisors.Mallampati classification.Thyromental distance.Neck mobility-lower C-spine flexion, higher C-spine extension (atlanto-occipital joint).Ma

7、llampati classificationUpper Airway ObstructionComplete UAO: rapidly progressing series of events patient is unable to breathe, speak, or cough and may hold the throat between the thumb and index finger (the universal choking sign) anxious and agitated. Vigorous attempts at respiration with intercos

8、tal and supraclavicular retraction. Heart rate and blood pressure raised Patient becomes rapidly cyanosed respiratory efforts diminish, loss of consciousness, bradycardia and hypotension cardiac arrest death is inevitable if the obstruction is not relieved within 2-5 minutes of the onset Partial UAO

9、: stable, or progressive deterioration signs and symptoms may be mild but as they worsen include coughing, inspiratory stridor, crowing or noisy respiration, dysphonia, aphonia, choking, drooling and gagging dyspnoea, feeble cough, respiratory distress and signs of hypoxaemia and hypercarbia such as

10、 anxiety, confusion, lethargy and cyanosis may be present as the obstruction worsens powerful inspiratory efforts against an obstruction may produce dermal ecchymoses and subcutaneous emphysema. Partial airway obstruction that is worsening should be aggressively managed and if rapidly progressing im

11、mediate preparation for treatment as complete obstruction should be made (see Figures 1 and 2) Aetiology Functional causes CNS depression Peripheral nervous system and neuromuscular abnormalities - Recurrent laryngeal nerve interruption (postoperative, inflammatory, tumour infiltration), - obstructi

12、ve sleep apnoea - laryngospasm - myasthenia gravis - Guillain-Barre polyneuritis - hypocalcaemia (causing vocal cord spasm). - tetanus Mechanical causesForeign body aspiration Infections epiglottitis; supraglottitis; retropharyngeal cellulitis or abscess; parapharyngeal abscess; Ludwigs angina; diph

13、theria; bacterial tracheitis laryngotracheobronchitis Laryngeal oedema: allergic; hereditary angioedema Haemorrhage and haematoma : post operative anticoagulation therapy coagulopathy Trauma, Burns, NeoplasmCongenital: vascular rings; laryngeal webs, laryngocoele Miscellaneous: crico-arytenoid arthr

14、itis achalasia of the oesophagus hysterical stridor, myxoedema Maintain AirwayOpen the airway: head tilt, chin lift, jaw thrust.Suction: 100% O2 supplement; less than 15 seconds.Adjuvant airway: oropharyngeal airway nasopharyngeal airwayBag-valve-maskIntubationSurgical airwayGuedel AirwayOropharynge

15、al airwayfor use in unconscious (unresponsive) patients with no cough or gag reflex.Nasopharyngeal airwayfor condition such as clenched jaw; better tolerated than oral airways in pts who are not deeply unconscious; 30% bleeding; craniofascial injuryResuscitatorCombi tubesize 1 up to 5 kg (4 ml); siz

16、e 1.5, 5 10 kg (7 ml) size 2, 10 to 20 kg (10 ml)size 2.5, 20 30 kg (14 mL)size 3, children or small adults weighing more than 30 kg (20 mL); size 4, normal and large adults (30 mL); size 5, large adults (40 mL). Indications for tracheal intubation -Airway protection. -Maintenance of patent airway.

17、-Pulmonary toilet. -Application of positive-pressure ventilation. -Maintenance of adequate oxygenation. -Predictable FIO2. -Positive end-expiratory pressure. Straight: provide excellent exposure of the glottic openingCurved: good view of oropharynx and hypopharynx, thus allow more room for ETT passa

18、ge with decreased epiglottis traumaCuff pressures that afford good (but not perfect) protection (20 to 25 mm Hg) are just below the perfusion pressure of the tracheal mucosa (25 to 35 mm Hg).Endotracheal tube leak pressure is a clinically useful way to fit or confirm proper selection of uncuffed tube size in children. Leak should occur at 15 to 20 cm H2 O pressure. Sellick maneuver: BURP (backward; upward; rightward; pressure)30 secDifficult tracheal intubation accounts for 17% of the respiratory-related injury and results in significant cost morbidity an