一种介入工具的历史和未来课件

1、Rigid Bronchoscopy一种介入工具的历史和未来浙江大学附属邵逸夫医院呼吸内科 陈恩国历史回顾1897年，德国ENT医生Gustav Killian第一次应用RB取异物支气管镜技术之父2纤维支气管镜阶段1967年，历史上第一台纤维支气管镜1974年，东京，第一届世界支气管学大会WCB3现代电子支气管镜与RB共用时代FB的缺点：管腔狭小、操作器械单一、吸引管口径小易堵塞RB的优点：操作孔道大、气道控制好、吸引好、可使用各种介入器械两者结合，联合介入治疗方法4Case 18设备 BRONCHOSCOPE EFER-DUMON 9Optics10Video Equipment11A se

2、t of tubes 12The BRONCHOSCOPE EFER-DUMON 侧孔与可移除的帽13激光管与吸引管15辅助设备吸引管钳子16其他设备Endoscopic scalpel Wire cutterEndoscopic scissors The endoscopic resector 17Balloons Mechanical dilator The laser fiber sheath Assessment 病史与体检（是否存在）： 凝血病病 合并存在的心肺疾病 颞下颌关节异常 颈部固定 与麻醉相关的并发症辅助检查： 血常规有凝血功能 血生化 动脉血气 心电图 胸部CT18Cas

3、e 2M,声嘶,有强直性脊炎，颈椎畸形伴活动障碍。202124Case 2302. Endoscopic assessmentThe appearance of any lesions, their intrinsic or extrinsic nature, and their location with respect to the carina, vocal cords, etc. The degree of obstruction and length of involvement The apparent vascularity of a tumor. 胸部CT（2014.7.28）

4、支气管镜（2014.7.30）40AnesthesiaThe majority of endoscopic resections require the use of the rigid bronchoscope under general anesthesia. Suppressing consciousness and vagal reflexes, but allowing spontaneous ventilation：spontaneous manually assisted ventilation 4142Induction : Midazolam = 0,05 mg/kg IV

5、Alfentanyl 40 80 mg gamma/kg IV During spontaneous ventilation, FiO2 = 100% Anesthesia of the glottis is performed under direct visualization with the laryngoscope by spraying 5% Xylocaine. 43IntubationThe patient is supine and the neck hyperextended. The upper teeth are protected by the left thumb.

6、The beveled tip of the bronchoscope should always be anterior. 44Once the epiglottis is lifted gently with the beveled tip of the bronchoscope, 45Arytenoids must be identified. 46The vocal cords are located anteriorly in the medial axis of these landmarks. 47The bronchoscope is then advanced past th

7、e vocal cords and into the trachea while rotating the tip. 4849Location of the tumor & Successful resection 50Mechanical debridementMechanical debridement is often carried out following laser coagulation. 51ResectorThe endoscopic resector acts as a guillotine-like instrument sectioning large tumor f

8、ragments effortlessly under direct visualization. 5253Laser5455DilatationProgressive dilatation of airway stenosis can be achieved with bronchoscopes of growing diameter. Tube orientation is simple in the trachea and slightly harder in the main stem bronchi, particularly the left main stem. 56Case 3

9、60Scissors, scalpel, and forceps61The Montgomery T tubeThis stent is widely used today and can be employed in the treatment of tight stenoses or complete obstruction. 626364Silicone Stents Dumon in Marseille proposed an original tracheobronchial silicone stent in 1987 (the Dumon-stent). 65tubular st

10、ents The tracheal stents are generally 50 to 60 mm long (maximum 110 mm), and 14 to 16 mm in diameter (maximum 18 mm).Bronchial stents are manufactured with diameters ranging from 10 to 12 mm and lengths between 20 to 40 mm.66Y stents Y stents designed to treat tumors extending to the carina.The len

11、gths reaching up to 110 mm for the trachea, and 50 mm for the main stem bronchi.The right main stem limb may be fenestrated. 67Indications The principal indication for airway stenting is extrinsic compression of the airway. other indications : bronchial fistula, tracheobronchomalacia 68Y stent place

12、ment is reserved for tumors extending to the carina. 69Choice of the diameter and the lenght The diameter of the stent will depend on the external diameter of the bronchoscope used (yellow tube 16/15, red tube 14/13/12), while the length is measured by retracting the bronchoscope or telescope along

13、the entire length of the stenosis. 70Placement Placement is performed using a tracheal or bronchial rigid tube.The stent is lubricated with silicone and loaded into a stent applicator.The applicator is the inserted through the bronchoscope and the stent is pushed out into the trachea or the bronchus

14、.71Efer-Dumon applicator Two kind of loaders: tracheal or bronchial stent, Y stent or long and large straight stent.On the right two size of applicators.72Adjusting the stent is made by grasping the upper rim of the prosthesis with forceps.7374Stent related complications Stent obstructionMigrationGranulomatous inflammation 75Silicone coated stents are also available, either reinforced by a me