纖維支氣管鏡的臨床應(yīng)用d課件

1、纖維支氣管鏡的臨床應(yīng)用Review on Clinical Flexible Bronchoscopy 內(nèi)容綱要 FB簡介 FB診斷應(yīng)用 FB治療應(yīng)用 FB新進(jìn)展FB簡介Brief Introduction of Flexible Bronchoscopy 1897年德國醫(yī)師Killian 用硬質(zhì)窺鏡 (Rigid Endoscope) 取出骨性異物;1964年 日本Olympus公司 Ikeda 制成 標(biāo)準(zhǔn)的光導(dǎo)纖維支氣管鏡，命名為可曲式光導(dǎo)纖維支氣管鏡( Flexible Fiberoptic Bronchoscope )；發(fā)展史：3. 硬質(zhì)氣官鏡 (Rigid Bronchoscope)

2、 介入氣管學(xué)(Interventional Bronchology)常規(guī)FB探察氣管范圍（27級分支）：氣管 0主支氣管葉支氣管段支氣管 100%亞段支氣管 74% 摘要幻燈片RB1: 右上葉尖段RB1a : 右上葉尖段尖分支RB1b : 右上葉尖段前分支禁忌證 ( Contraindications to Bronchoscopy) 絕對禁忌證 / 相對禁忌證1 活動性大咯血；2 嚴(yán)重的上腔靜脈阻塞綜合征；3 嚴(yán)重的肺動脈高壓；4 氣管部分狹窄/（患側(cè)支氣管）；5 支氣管哮喘；禁忌證 (Contraindications to Bronchoscopy)6 全身情況極度衰竭；嚴(yán)重心、肺功能障

3、礙；7 不能糾正的出血傾向；尿毒癥；8 嚴(yán)重心律失常；新近發(fā)生的心肌梗死/不穩(wěn)定心絞痛；9 疑有主動脈瘤；禁忌證 ( Contraindications to Bronchoscopy)絕對禁忌證 / 相對禁忌證1 咯血宜在緩解后兩周再進(jìn)行；2 新近有較重的支氣管和肺部感染伴發(fā)熱，待炎癥控制后再做檢查；3 有肺大皰的病人，應(yīng)慎重檢查，避免發(fā)生氣胸；4 較大的氣管內(nèi)異物，一般活檢鉗難以經(jīng)FB取出；FB輔助設(shè)備 (Accessories for FB)氧氣監(jiān)護(hù)FB輔助設(shè)備 (Accessories for FB)氣管內(nèi)套管(endotrcheal tube)支氣管病變的纖維支氣管鏡鏡下分類( JR

4、S分類 )支氣管管壁的異常改變支氣管腔內(nèi)異常支氣管腔內(nèi)異常物質(zhì)呼吸動力學(xué)改變 1. 支氣管管壁的異常改變支氣管黏膜腫脹（水腫）1. 支氣管管壁的異常改變 支氣管黏膜 充血1. 支氣管管壁的異常改變支氣管黏膜 萎縮，綜行皺襞1. 支氣管管壁的異常改變 潰瘍2. 支氣管管腔的異常改變氣管狹窄2. 支氣管管腔的異常改變 支氣管狹窄（外壓性）2.支氣管管壁的異常改變氣管食道瘺3. 支氣管管腔的異物肉芽腫FB診斷應(yīng)用Diagnostic Procedures of Flexible Bronchoscopy 適應(yīng)證 (Indications for Diagnostic Bronchoscopy)不明原

5、因的咯血;不明原因的的慢性咳嗽；不明原因的局限性哮鳴音(Unexplained localized wheezing)； 不明原因的聲音嘶??；5. 痰中發(fā)現(xiàn)癌細(xì)胞或可疑癌細(xì)胞(Roentgenographically occult lung cancer) Tx；6. CXR、CT提示：肺不張、肺部腫快、阻塞性肺炎、 肺炎不吸收、肺部彌漫性病變、肺門/縱隔淋巴結(jié)腫大、氣管支氣管狹窄、原因不明的胸腔積液等；適應(yīng)證 (Indications for Diagnostic Bronchoscopy) 臨床已診斷肺癌的術(shù)前檢查;胸部外傷、懷疑氣管支氣管挫裂/斷裂、肺移植后氣管支氣管吻合面觀察等；食道-

6、氣管瘺的確診；10. 肺/支氣管感染性疾病的病因?qū)W診斷（BAL、PBL）;11. 引導(dǎo)下的選擇性支氣管造影；支氣管灌洗（Bronchial Lavage，BL)支氣管肺泡灌洗（Bronchoalveolar Lavage，BAL)保護(hù)套管刷（Protected catheter brush）細(xì)胞刷檢 （Cytology brushing）氣管內(nèi)鉗取活檢（Endobronchial forceps biopsy）經(jīng)支氣管肺活檢(Transbronchial Lung Biopsy,TBLB)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)診斷應(yīng)用的基本

7、技術(shù) (Basic Techniques in Diagnostic Procedures) 并發(fā)癥 (Complications of Bronchoscopy)麻醉藥物過敏：丁卡因麻醉藥物過量：利多卡因300mg/次低氧: PaO2 1020mmHg出血并發(fā)癥 (Complications of Bronchoscopy)損傷胸膜損傷氣管心血管異常感染喉頭水腫、支氣管痙攣：麻醉不充分并發(fā)癥 (Complications of Bronchoscopy) 輕度并發(fā)癥發(fā)生率 0.01% 0.04% 死亡率 0.01% 經(jīng)支氣管肺活檢(Transbronchial Lung Biopsy,TBL

8、B)適應(yīng)證普通FB可見范圍以外的肺組織內(nèi)的孤立性結(jié)節(jié) (solitary pulmonary nodule, SPN); 肺彌漫性病變(interstitial lung disease, ILD)性質(zhì)不明;經(jīng)支氣管肺活檢(Transbronchial Lung Biopsy,TBLB)禁忌證病變不能除外血管畸形所致；懷疑病變?yōu)榉伟x囊腫者；心肺功能差，預(yù)計無法耐受可能發(fā)生的氣胸者；進(jìn)行機械通氣者；有出血傾向者；經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)Dr. Wang KP 1978年首次開展經(jīng)支氣管針吸術(shù)(Transbronchial Ne

9、edle Aspiration,TBNA)針吸細(xì)胞標(biāo)本經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)適應(yīng)證 (Indications for Diagnostic Bronchoscopy)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBN

10、A)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)臨床評價氣胸縱隔積血菌血癥、細(xì)菌性心包炎TBNA 是比TBLB更安全的診斷技術(shù)經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA)FB治療應(yīng)用Therapeutic Procedures

11、of Flexible Bronchoscopy取出支氣管異物 (Removal of foreign bodies)；清除氣道內(nèi)異常分泌物(肺不張、肺膿腫)(Bronchial toilet)；鏡檢中對咯血的出血部位試行局部止血(冰鹽水、 麻黃素）；纖支鏡引導(dǎo)下氣管插管(Intubation)；經(jīng)纖支鏡局部放療 (Brachytherapy) 或 局部注射化療藥物(Intralesional Injection）；FB治療應(yīng)用6.纖支鏡對氣道內(nèi)腫瘤進(jìn)行激光、 微波、 冷凍(Cryotherapy)、 高頻電刀治療(Electrocautery) ；7. 支氣管肺泡灌洗 (BAL)治療嚴(yán)重哮喘

12、 祛除黏液栓治療肺泡蛋白沉 著癥 (PAP)治療感染性疾病對氣道狹窄的治療：支氣管鏡氣囊擴張術(shù) (Balloon Bronchoplasty)放置氣管內(nèi)支架 (Tracheobronchial stenting) FB治療應(yīng)用支架種類 ： 2種人造金屬內(nèi)支架(Endoprosthetic metal stent) 適應(yīng)證: 各種腫瘤或良性病變引起的氣管支氣管狹窄 姑息治療禁忌證 ： 有氣管支氣管瘺者禁用無膜支架 氣管支氣管狹窄無法擴張或狹窄口直徑過小( 4mm),FB或硬質(zhì)內(nèi)鏡無法通過 存在氣管鏡檢禁忌證放置支架(Tracheobronchial stenting)1. 人造金屬內(nèi)支架 (En

13、doprosthetic metal stent)2 . 硅膠內(nèi)支架 (silicone stent) 適應(yīng)證:禁忌證 ：存在咽喉狹窄或其他硬質(zhì)內(nèi)鏡禁忌證 FB新進(jìn)展 自發(fā)性熒光纖支鏡(Autofluorescence Bronchoscopy , AFB）/光動力治療(Photodynamic therapy，PDT) 氣管鏡超聲 (Endobronchial Ultrasonography, EBUS) 介入氣管學(xué) (Interventional Bronchology)Foreign body removal; Nd YAG Laser(摻汝釔鋁石榴石)/ 氬離子 (Ar)激光; Ele

14、ctrosurgery;Argon plasma coagulation; Balloon Bronchoplasty; Tracheobronchial stenting)自發(fā)性熒光纖支鏡(AFB） Stage 0, n=3, 100% Stage l ,n=796, 68.5% Stage ll,n=304,46.9% Total, 39.3% Stage llA, n=719, 26.1% Stage lV,n=327, 11.2% Stage lllB,n=233, 9.0%Survival rates for 2,382 patients after resection of lun

15、g cancer -Chest 2019;112(4):242自發(fā)性熒光纖支鏡(AFB）Although surgery for early stage tumors provides the best prospects of cure, 80% patients already have advanced and inoperable disease when present to their physicians.024682468 5 10 15 20 25 30 35TUMOR SIZE (mm)YEARSVisible GrowthInvisible Growth自發(fā)性熒光纖支鏡(

16、AFB） 檢查原理CANCERNORMALStandard (white light) BronchoscopyAutofluorescence BronchoscopyNORMALCANCER反射光自發(fā)性熒光纖支鏡(AFB）Case Study #168 year old male Ex-smoker Presented with a persistent cough and sputum production Sputum cytology showed cells suggestive of squamous carcinoma 自發(fā)性熒光纖支鏡(AFB）RB8 Image-1(WLB)

17、 RB8 Image-2(LIFE) RB8 Image-3(LIFE) Image-1(WLB): In the right lower lobe it was noted that some thickening had occurred in bronchus Image-2,3(LIFE): There was an area of abnormal brownish red fluorescence in the sub-carina,which measured 2 to 3 millimeters in width and was confirmed by biopsy as c

18、arcinoma-in-situ with small foci of microinvasion. Case Study #2 77 year old male Ex-smoker (118 pack-years) Abnormal sputum cytology Chest x-ray indicated Chronic Obstructive Pulmonary Disease (COPD) CT Scan was negative 自發(fā)性熒光纖支鏡(AFB） LB6 Image-1 (WLB) LB6 Image-2 (LIFE)LB6 Image-1(WLB): no abnormal areas were located.LB6 Image-2(LIFE): There were two areas considered to be suspicious, LB1+2 and LB6, which pathological results indicated carcinoma in-situ for LB1+2 and seve