纤维支气管镜的临床应用d.ppt

纤维支气管镜的临床应用 Review on Clinical Flexible Bronchoscopy,内容纲要, FB简介 FB诊断应用 FB治疗应用 FB新进展,FB简介 Brief Introduction of Flexible Bronchoscopy,1897年德国医师Killian 用硬质窥镜 (Rigid Endoscope) 取出骨性异物; 1964年 日本Olympus公司 Ikeda 制成 标准的光导纤维支气管镜，命名为可曲式光导纤维支气管镜( Flexible Fiberoptic Bronchoscope )；,发展史：,3. 硬质气官镜 (Rigid Bronchoscope) 介入气管学(Interventional Bronchology),常规FB探察气管范围（27级分支）： 气管 0 主支气管 叶支气管 段支气管 100% 亚段支气管 74%,摘要幻灯片,RB1: 右上叶尖段 RB1a : 右上叶尖段尖分支 RB1b : 右上叶尖段前分支,禁忌证 ( Contraindications to Bronchoscopy), 绝对禁忌证 / 相对禁忌证 1 活动性大咯血； 2 严重的上腔静脉阻塞综合征； 3 严重的肺动脉高压； 4 气管部分狭窄/（患侧支气管）； 5 支气管哮喘；,禁忌证 (Contraindications to Bronchoscopy),6 全身情况极度衰竭；严重心、肺功能障碍； 7 不能纠正的出血倾向；尿毒症； 8 严重心律失常；新近发生的心肌梗死/不稳定心绞痛； 9 疑有主动脉瘤；,禁忌证 ( Contraindications to Bronchoscopy),绝对禁忌证 / 相对禁忌证 1 咯血宜在缓解后两周再进行； 2 新近有较重的支气管和肺部感染伴发热，待炎症控制后再做检查； 3 有肺大疱的病人，应慎重检查，避免发生气胸； 4 较大的气管内异物，一般活检钳难以经FB取出；,FB辅助设备 (Accessories for FB),氧气 监护,FB辅助设备 (Accessories for FB),气管内套管(endotrcheal tube),支气管病变的纤维支气管镜镜下分类 ( JRS分类 ),支气管管壁的异常改变 支气管腔内异常 支气管腔内异常物质 呼吸动力学改变,1. 支气管管壁的异常改变 支气管黏膜肿胀（水肿）,1. 支气管管壁的异常改变 支气管黏膜 充血,1. 支气管管壁的异常改变 支气管黏膜 萎缩， 综行皱襞,1. 支气管管壁的异常改变, 溃疡,2. 支气管管腔的异常改变 气管狭窄,2. 支气管管腔的异常改变 支气管狭窄（外压性）,2.支气管管壁的异常改变 气管食道瘘,3. 支气管管腔的异物 肉芽肿,FB诊断应用 Diagnostic Procedures of Flexible Bronchoscopy,适应证 (Indications for Diagnostic Bronchoscopy) 不明原因的咯血; 不明原因的的慢性咳嗽； 不明原因的局限性哮鸣音(Unexplained localized wheezing)； 不明原因的声音嘶哑；,5. 痰中发现癌细胞或可疑癌细胞(Roentgenographically occult lung cancer) Tx； 6. CXR、CT提示：肺不张、肺部肿快、阻塞性肺炎、 肺炎不吸收、肺部弥漫性病变、肺门/纵隔淋巴结 肿大、气管支气管狭窄、原因不明的胸腔积液等；,适应证 (Indications for Diagnostic Bronchoscopy),临床已诊断肺癌的术前检查; 胸部外伤、怀疑气管支气管挫裂/断裂、肺移植后气管支气管吻合面观察等； 食道-气管瘘的确诊；,10. 肺/支气管感染性疾病的病因学诊断（BAL、PBL）; 11. 引导下的选择性支气管造影；,支气管灌洗（Bronchial Lavage，BL) 支气管肺泡灌洗（Bronchoalveolar Lavage，BAL) 保护套管刷（Protected catheter brush） 细胞刷检 （Cytology brushing） 气管内钳取活检（Endobronchial forceps biopsy） 经支气管肺活检(Transbronchial Lung Biopsy,TBLB) 经支气管针吸术(Transbronchial Needle Aspiration,TBNA),诊断应用的基本技术 (Basic Techniques in Diagnostic Procedures),并发症 (Complications of Bronchoscopy), 麻醉药物过敏：丁卡因 麻醉药物过量：利多卡因300mg/次 低氧: PaO2 1020mmHg 出血,并发症 (Complications of Bronchoscopy), 损伤胸膜 损伤气管 心血管异常 感染 喉头水肿、支气管痉挛：麻醉不充分,并发症 (Complications of Bronchoscopy), 轻度并发症发生率 0.01% 0.04% 死亡率 0.01%,经支气管肺活检 (Transbronchial Lung Biopsy,TBLB),适应证 普通FB可见范围以外的肺组织内的孤立性结节 (solitary pulmonary nodule, SPN); 肺弥漫性病变(interstitial lung disease, ILD)性质不明;,经支气管肺活检 (Transbronchial Lung Biopsy,TBLB),禁忌证 病变不能除外血管畸形所致； 怀疑病变为肺包虫囊肿者； 心肺功能差，预计无法耐受可能发生的气胸者； 进行机械通气者； 有出血倾向者；,经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),Dr. Wang KP 1978年首次开展,经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),针吸细胞标本,经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),适应证 (Indications for Diagnostic Bronchoscopy),经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),经支气管针吸术 (Transbronchial Needle Aspiration,TBNA) 临床评价, 气胸 纵隔积血 菌血症、细菌性心包炎 TBNA 是比TBLB更安全的诊断技术,经支气管针吸术 (Transbronchial Needle Aspiration,TBNA),FB治疗应用 Therapeutic Procedures of Flexible Bronchoscopy,取出支气管异物 (Removal of foreign bodies)； 清除气道内异常分泌物(肺不张、肺脓肿)(Bronchial toilet)； 镜检中对咯血的出血部位试行局部止血(冰盐水、 麻黄素）； 纤支镜引导下气管插管(Intubation)； 经纤支镜局部放疗 (Brachytherapy) 或 局部注射化疗药物(Intralesional Injection）；,FB治疗应用,6.纤支镜对气道内肿瘤进行激光、 微波、 冷冻(Cryotherapy)、 高频电刀治疗(Electrocautery) ；,7. 支气管肺泡灌洗 (BAL) 治疗严重哮喘 祛除黏液栓 治疗肺泡蛋白沉 着症 (PAP) 治疗感染性疾病 对气道狭窄的治疗： 支气管镜气囊扩张术 (Balloon Bronchoplasty) 放置气管内支架 (Tracheobronchial stenting),FB治疗应用,支架种类 ： 2种 人造金属内支架(Endoprosthetic metal stent) 适应证: 各种肿瘤或良性病变引起的 气管支气管狭窄 姑息治疗 禁忌证 ： 有气管支气管瘘者禁用无膜支架 气管支气管狭窄无法扩张或狭窄口直径过小( 4mm),FB或硬质内镜无法通过 存在气管镜检禁忌证,放置支架(Tracheobronchial stenting),1. 人造金属内支架 (Endoprosthetic metal stent),2 . 硅胶内支架 (silicone stent),适应证: 禁忌证 ： 存在咽喉狭窄或其他硬质内镜禁忌证,FB新进展, 自发性荧光纤支镜(Autofluorescence Bronchoscopy , AFB）/光动力治疗(Photodynamic therapy，PDT) 气管镜超声 (Endobronchial Ultrasonography, EBUS) 介入气管学 (Interventional Bronchology) Foreign body removal; Nd YAG Laser(掺汝钇铝石榴石)/ 氩离子 (Ar)激光; Electrosurgery; Argon plasma coagulation; Balloon Bronchoplasty; Tracheobronchial stenting),自发性荧光纤支镜(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 lung cancer -Chest 1997;112(4):242,自发性荧光纤支镜(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.,自发性荧光纤支镜(AFB）,Case Study #1 68 year old male Ex-smoker Presented with a persistent cough and sputum production Sputum cytology showed cells suggestive of squamous carcinoma,自发性荧光纤支镜(AFB）,RB8 Image-1(WLB) 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 carcinoma-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,自发性荧光纤支镜(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 severe dysplasia for LB6.,A