插管探条临床应用课件

1、插管探条之临床应用 陳昭良主任彰化基督教醫院麻醉科What a bad luck !If this is a Difficult Intubation situation.What are our back-up plans ?What other gadgets do we have ? Non-invasive Glottis InvasiveFrom Below the Glottis (Invasive) Transtracheal Jet Ventilation (TTJV) Retrograde Intubation Percutaneous dilational tracheal

2、 entry Surgical AirwayFrom Above the Glottis Laryngoscope Gum Elastic Bougie Blind Oral/Nasal Intubation Fiberoptic Bronchoscopy Intubating LMA (Fastrach) GlideScope Lighted Stylet (Trachlight) Optical StyletEschmann tracheal tube introducer “Gum Elastic Bougie”History of Gum Elastic BougieThe Eschm

3、ann tracheal tube introducer (gum elastic bougie) was marketed in the United Kingdom (UK) in the early 1970s. It differs from previous introducers in its greater length (60 cm), angled tip, and the combination of flexibility and malleability.Anesthesiology: 100(5) 2019:1146-50 “GEB“ vs Difficult Int

4、ubation2019 巴黎聖心堂Lighted Stylet (Lightwand)光棒History of Lighted StyletThe first reported use of a lighted stylet used to facilitate intubation came in 1957.Macintosh described an 18-inch illuminated tracheal tube introducer, which was designed to stiffen the tube and better illuminate the cords by s

5、upplementing the light of the laryngoscope.Anaesthesia 1957; 12:2235History of Lighted StyletYamamura et al. described a light bulb-tipped wire that was inserted into the tracheal tube before blind nasal intubation in awake patients. The tube position was then determined by the medial transilluminat

6、ion of the external throat and neck.Anesthesiology 1959; 20:221History of Lighted StyletIn 1977, Foster used a transilluminating fiberoptic bundle to facilitate tracheal intubation in a young child with trismus.Anaesthesia 1977; 32:1038Ducrow used a Flexi-lum to achieve the same end by first passing

7、 a guide into the trachea followed by passage of the tracheal tube over the guide.Anaesthesia 1978; 33:8279History of Lighted StyletRayburn commented that the Flexi-lum (flexible surgical light) could be positioned inside the tracheal tube, thereby shortening the intubation sequence and claimed that

8、 the technique, nicknamed “lightwand intubation.”Anaesthesia 1979; 34:6778TrachlightWandETT size Small2.5 # 4.0 #Medium4.5 # 5.5 #Large6.0 # Lightwand Intubation Transillumination of neck tissues Flexible stylet contains a distal light bulbJaw lifted with non-dominant handObserving the glow on the n

9、eckHelpful Maneuvers for Trachlight Jaw lift (Jaw thrust) Hyperextension of the head and neck Use of the thumb to lift the tongue Having an assistant to pull the tongue Anesthesiology 2019;83:509-514Intubation with Trachlight (I)Intubation with Trachlight (II)Advantages of Trachlight Easy to learn a

10、nd use Less traumatic Suitable for pediatric patients May use in nasal tracheal intubation May use in ambient lightComplicationsInstrument disarticulationTrauma to the upper airwaybleedingsore throat hoarsenessdysphagia Arytenoid cartilage dislocationIndications Difficult airway Unintubatable by dir

11、ect or fiberoptic laryngoscopy Neck mobility is limited or contraindicated Prevention of dental injuryContraindicationsAbsolute Upper airway foreign body, tumor, polyp, retropharyngeal abscess.Relativetrauma victim with laryngeal injuryknown difficult airwayEnvironment for Trachlight Ambient light -

12、 78.5% Dimmed - 8.7% Dark - 12.2% Anesthesiology 2019;83:509-514Effect of Cricoid Pressure on Lightwand Intubation Time to successful intubation is significantly prolonged The failure rate for the first attempt is 13%. Anesthesiology. 94(2):259-262, 2019Intubation with Trachlight (I)Intubation with

13、Trachlight (II)Intubation with Trachlight (III)Hybrid Techniques With Direct Laryngoscopy Light-guided Nasal Intubation With Laryngeal Mask Airway With Fiberoptic Scope Airway Introducer Light-guided Retrograde IntubationOptical Stylet可視光棒History of Orotracheal IntubationThe earliest reports of blin

14、d orotracheal intubation (BOI) in anaesthesia date back to 1880.William MacEwen described awake BOI by internal palpation.Br Med J 1880; 2: 122-4 and 163-5.History of Orotracheal IntubationFranz Kuhn (1866-1929)He recommended the use of flexible metal tubes which were generally introduced into the t

15、rachea under digital control. He suggested the advantageous use of Kirsteins autoscope (a forerunner of modern laryngoscopes) Techniques for BOI1. Palpation2. Malleable stylet3. Divided oropharyngeal airway4. Williams airway intubator5. Lightwand6. Laryngeal Mask Airway7. Endotrol tube with capnogra

16、phy8. Augustine Guide9. Combitube10. Retrograde intubation11. FluoroscopyAlternative Intubation Devices Flexible fiberoptic bronchoscope (64%)Retrograde intubation kit (45%)Lighted stylet (35%)Rigid fiberoptic device (6%)BullardWu-scope Annals of Emergency Medicine. 33(6):694-8,2019Flexible Fibreoptic and IntubationIn 1967 Murphy reported successful nasal intubation using a flexible choledochoscope placed through a tracheal tube.A