插管探条之临床应用课件

插管探条之临床应用陳昭良主任彰化基督教醫院麻醉科插管探条之临床应用陳昭良主任Whatabadluck!!!Whatabadluck!!!Ifthisisa

DifficultIntubation

situation.Whatareourback-upplans???Whatothergadgetsdowehave???IfthisisaDifficultIntubatNon-invasive

Glottis

InvasiveNon-invasiveFromBelowtheGlottis(Invasive)TranstrachealJetVentilation(TTJV)RetrogradeIntubationPercutaneousdilationaltrachealentrySurgicalAirwayFromBelowtheGlottis(InvasiFromAbovetheGlottisLaryngoscope±GumElasticBougieBlindOral/NasalIntubationFiberopticBronchoscopy

IntubatingLMA(Fastrach®)GlideScope®LightedStylet(Trachlight®)

OpticalStyletFromAbovetheGlottisLaryngoEschmanntrachealtubeintroducer

“GumElasticBougie”EschmanntrachealtubeintroduHistoryofGumElasticBougieTheEschmanntrachealtubeintroducer("gumelasticbougie")wasmarketedintheUnitedKingdom(UK)intheearly1970s.Itdiffersfrompreviousintroducersinitsgreaterlength(60cm),angledtip,andthecombinationofflexibilityandmalleability.HistoryofGumElasticBougieTAnesthesiology:100(5)2019:1146-50“GEB“vsDifficultIntubationAnesthesiology:100(5)2019:112019巴黎聖心堂2019巴黎聖心堂LightedStylet(Lightwand)

光棒LightedStylet(Lightwand)

光棒HistoryofLightedStyletThefirstreporteduseofalightedstyletusedtofacilitateintubationcamein1957.Macintoshdescribedan18-inchilluminatedtrachealtubeintroducer,whichwasdesignedtostiffenthetubeandbetterilluminatethecordsbysupplementingthelightofthelaryngoscope.Anaesthesia1957;12:223–5HistoryofLightedStyletThefHistoryofLightedStyletYamamuraetal.describedalightbulb-tippedwirethatwasinsertedintothetrachealtubebeforeblindnasalintubationinawakepatients.Thetubepositionwasthendeterminedbythemedialtransilluminationoftheexternalthroatandneck.Anesthesiology1959;20:221HistoryofLightedStyletYamamHistoryofLightedStyletIn1977,Fosterusedatransilluminatingfiberopticbundletofacilitatetrachealintubationinayoungchildwithtrismus.Anaesthesia1977;32:1038DucrowusedaFlexi-lum™toachievethesameendbyfirstpassingaguideintothetracheafollowedbypassageofthetrachealtubeovertheguide.Anaesthesia1978;33:827–9HistoryofLightedStyletIn19HistoryofLightedStyletRayburncommentedthattheFlexi-lum™(flexiblesurgicallight)couldbepositionedinsidethetrachealtube,therebyshorteningtheintubationsequenceandclaimedthatthetechnique,nicknamed“lightwandintubation.”Anaesthesia1979;34:677–8HistoryofLightedStyletRaybuTrachlight®Wand ETTsizeSmall 2.5#~4.0#Medium 4.5#~5.5#Large 6.0#~Trachlight®LightwandIntubationTransilluminationofnecktissuesFlexiblestyletcontainsadistallightbulbLightwandIntubationTransilluJawliftedwithnon-dominanthandJawliftedwithnon-dominanthObservingtheglowontheneckObservingtheglowontheneckHelpfulManeuversforTrachlightJawlift(Jawthrust)HyperextensionoftheheadandneckUseofthethumbtoliftthetongueHavinganassistanttopullthetongue

Anesthesiology2019;83:509-514HelpfulManeuversforTrachligIntubationwithTrachlight(I)IntubationwithTrachlight(I)IntubationwithTrachlight(II)IntubationwithTrachlight(IIAdvantagesofTrachlightEasytolearnanduseLesstraumaticSuitableforpediatricpatientsMayuseinnasaltrachealintubationMayuseinambientlightAdvantagesofTrachlightEasyComplicationsInstrumentdisarticulationTraumatotheupperairwaybleedingsorethroathoarsenessdysphagiaArytenoidcartilagedislocationComplicationsInstrumentdisartIndicationsDifficultairwayUnintubatablebydirectorfiberopticlaryngoscopyNeckmobilityislimitedorcontraindicatedPreventionofdentalinjuryIndicationsDifficultairwayContraindicationsAbsoluteUpperairwayforeignbody,tumor,polyp,retropharyngealabscess.RelativetraumavictimwithlaryngealinjuryknowndifficultairwayContraindicationsAbsoluteEnvironmentforTrachlightAmbientlight--78.5%Dimmed--8.7%Dark--12.2%

Anesthesiology2019;83:509-514EnvironmentforTrachlightAmbEffectofCricoidPressureonLightwandIntubationTimetosuccessfulintubationissignificantlyprolongedThefailurerateforthefirstattemptis13%.

Anesthesiology.94(2):259-262,2019EffectofCricoidPressureonIntubationwithTrachlight(I)IntubationwithTrachlight(I)IntubationwithTrachlight(II)IntubationwithTrachlight(IIIntubationwithTrachlight(III)IntubationwithTrachlight(IIHybridTechniquesWithDirectLaryngoscopyLight-guidedNasalIntubationWithLaryngealMaskAirwayWithFiberopticScopeAirwayIntroducerLight-guidedRetrogradeIntubationHybridTechniquesWithDirectOpticalStylet

可視光棒OpticalStylet

可視光棒HistoryofOrotrachealIntubationTheearliestreportsofblindorotrachealintubation(BOI)inanaesthesiadatebackto1880.WilliamMacEwendescribedawakeBOIbyinternalpalpation.BrMedJ1880;2:122-4and163-5.HistoryofOrotrachealIntubatHistoryofOrotrachealIntubationFranz

Kuhn(1866-1929)Herecommendedtheuseofflexiblemetaltubeswhichweregenerallyintroducedintothetracheaunderdigitalcontrol.HesuggestedtheadvantageoususeofKirstein'sautoscope(aforerunnerofmodernlaryngoscopes)

HistoryofOrotrachealIntubatTechniquesforBOI1.Palpation2.Malleablestylet3.Dividedoropharyngealairway4.Williamsairwayintubator5.Lightwand6.LaryngealMaskAirway7.Endotroltubewithcapnography8.AugustineGuide9.Combitube10.Retrogradeintubation11.FluoroscopyTechniquesforBOI1.PalpationAlternativeIntubationDevicesFlexiblefiberopticbronchoscope(64%)Retrogradeintubationkit(45%)Lightedstylet(35%)Rigid