支气管镜的基本操作

1、关于支气管镜的基本操作现在学习的是第一页，共46页 w 支气管镜的适应症，禁忌症w 支气管镜术前的准备工作w 气管-支气管的解剖结构w 支气管镜的基本操作方法现在学习的是第二页，共46页支气管镜的适应症 现在学习的是第三页，共46页诊断方面w 不明原因的咯血，慢性咳嗽，声音嘶哑，局限性哮鸣音w 支气管感染性疾病的病因学诊断w 肺炎w 胸片或CT检查异常w 已诊断肺癌术前检查，指导手术范围及估计预后w 食管-支气管瘘的确诊w 胸部外伤，怀疑有支气管裂伤和断裂现在学习的是第四页，共46页治疗方面w 取出支气管异物w 某些肺不张，肺脓疡等w 咯血治疗w 引导气管插管w 支气管镜下治疗现在学习的是第五

2、页，共46页 支气管镜的禁忌症现在学习的是第六页，共46页 w 活动性大出血w 不能纠正的出血倾向w 尿毒症，活检易出血者w 严重肺动脉高压，活检易出血者w 严重心、肺功能障碍w 严重心律失常w 新近发生心肌梗死或心绞痛w 疑有主动脉瘤w 全身情况极度衰竭w 严重的上腔静脉阻塞综合征现在学习的是第七页，共46页 支气管镜术前准备现在学习的是第八页，共46页术前检查术前检查w 了解病史、测量血压及心肺体检w 胸片或胸部CT检查w 出、凝血时间、血小板记数w 乙肝两对半w ECG检查w 血气分析现在学习的是第九页，共46页患者准备患者准备w 向患者讲明检查目的、意义、配合方法w 术前签字w 术前禁

3、食6小时w 术前30分钟肌注安定和阿托品w 有异齿术前摘下 现在学习的是第十页，共46页 气管支气管的 解剖结构现在学习的是第十一页，共46页现在学习的是第十二页，共46页现在学习的是第十三页，共46页 现在学习的是第十四页，共46页 现在学习的是第十五页，共46页现在学习的是第十六页，共46页支气管镜操作方法 现在学习的是第十七页，共46页现在学习的是第十八页，共46页现在学习的是第十九页，共46页现在学习的是第二十页，共46页现在学习的是第二十一页，共46页支气管分支命名右肺右肺左肺左肺上叶B1尖段上叶上叶分支B1+2尖后段B2后段B3前段B3前段中叶B4外段舌叶B4上舌段B5内段B5下舌

4、段下叶B6背段下叶B6背段B7内基底段B8前基底段B8前基底段B9外基底段B9外基底段B10后基底段B10后基底段现在学习的是第二十二页，共46页Group 1 Exercises现在学习的是第二十三页，共46页Step 1: nose to larynxw The scope is advanced from the nose to the larynx .w This step includes local anesthesia现在学习的是第二十四页，共46页Step 2: larynx to subglottisw From the larynx the trachea is enter

5、ed to the subglottic area.wIf from the head:If from the head: once the vocal cords are passed the scope is slightly flexed downwards.wIf from the front:If from the front: once the vocal cords are passed the scope is slightly flexed upwards.现在学习的是第二十五页，共46页Step 3: Follow the curve to the carina w The

6、 Trachea is not a “straight pipe”;w It deviates posteriorly and slightly to the right when approaching the main carina.现在学习的是第二十六页，共46页Step 4a: Carina to left main bronchuswFrom the neutral position the LMB is entered just by twisting the wrist to the left and advancing for 1 -2 cm.现在学习的是第二十七页，共46页S

7、tep 4b: Carina to right main bronchuswFrom the neutral position the RMB is entered just by twisting the wrist to the right and advancing the scope for 1 -2 cm现在学习的是第二十八页，共46页wFrom the neutral position the left and right main bronchi are entered alternatively just by twisting the wrist and advancing

8、the scope for few cm.Step 4c: Left-right-neutral 现在学习的是第二十九页，共46页Step 5a: Down-up-left main bronchusw The scope is slowly advanced the pulled back up the LMB while always keeping it in the middle of the airway lumen.现在学习的是第三十页，共46页Step 5b: Down-up right main bronchusw The scope is slowly advanced do

9、wn the RMB to RLL and pulled back upwards while always keeping it in the middle of the airway lumen.现在学习的是第三十一页，共46页Group 2 Exercises现在学习的是第三十二页，共46页Step 6a: Left main to left upper lobe bronchusw From the LMB the scope is advanced to the entrance of the LUL bronchus.现在学习的是第三十三页，共46页Step 6b: Left ma

10、in to left lower lobe bronchusw The scope is advanced down the LMB to the entrance of the LLL bronchus.现在学习的是第三十四页，共46页Step 6c: Right main to right upper lobe bronchuswThe scope is advanced down the RMB then with the wrist twisted 60 degrees from midline the scope is flexed up to the entrance of RUL

11、.现在学习的是第三十五页，共46页Step 6d: Right main to bronchus intermediusw From the carina advance the scope down the RMB to the distal bronchus intermedius and visualize the entrance to RB456 and the basal pyramid.现在学习的是第三十六页，共46页Step 6e: Right main to right lower lobe bronchuswAdvance the scope from the carina

12、 to the entrance of the RLL while always keeping it in the midline.现在学习的是第三十七页，共46页Group 3 Exercises现在学习的是第三十八页，共46页Step 7a: Left upper lobe uno dosw From the carina, the scope is advanced to LUL entrance; there, just by thumb movement, the lingula and upper division bronchus are visualized.现在学习的是第三

13、十九页，共46页Step 7b: Left before five six (LB 456)w From the LMB, the lingula is entered, then the scope is pulled back into the distal LMB and the scope is advanced into the superior segment of the LLL.w ! Wrist movements are “in the mirror”现在学习的是第四十页，共46页Step 7c: Left B6-8,9,10w With the scope at the

14、LLL bronchus entrance, the superior segment is entered, then alternately, the antero, lateral and postero-basal segments of the LLL are entered.现在学习的是第四十一页，共46页Step 7d: Right upper lobe uno-dos-tresw From the RMB the scope is advanced and flexed up into the RUL bronchus where just by wrist and thumb

15、 movements the three segments are visualized; then the scope is withdrawn to the main carina.现在学习的是第四十二页，共46页Step 7e: Right before five six (RB 4,5,6)w From the distal bronchus intermedius, the RML and superior segment are entered alternatively; w ! Wrist movements are “in the mirror”.现在学习的是第四十三页，共46页Step 7f: Right medial basal (RB7) (d”Artagnan)w From the distal bronchus intermedius the scope is advanced and the med