支气管镜的基本操作课件

支气管镜的基本操作1支气管镜的基本操作1

支气管镜的适应症，禁忌症支气管镜术前的准备工作气管-支气管的解剖结构支气管镜的基本操作方法2支气管镜的适应症，禁忌症2支气管镜的适应症

3支气管镜的适应症3诊断方面

不明原因的咯血，慢性咳嗽，声音嘶哑，局限性哮鸣音支气管感染性疾病的病因学诊断肺炎胸片或CT检查异常已诊断肺癌术前检查，指导手术范围及估计预后食管-支气管瘘的确诊胸部外伤，怀疑有支气管裂伤和断裂4诊断方面不明原因的咯血，慢性咳嗽，声音嘶哑，局限性哮鸣音4治疗方面取出支气管异物某些肺不张，肺脓疡等咯血治疗引导气管插管支气管镜下治疗5治疗方面取出支气管异物5

支气管镜的禁忌症6支气管镜的禁忌症6

活动性大出血不能纠正的出血倾向尿毒症，活检易出血者严重肺动脉高压，活检易出血者严重心、肺功能障碍严重心律失常新近发生心肌梗死或心绞痛疑有主动脉瘤全身情况极度衰竭严重的上腔静脉阻塞综合征7活动性大出血7

支气管镜术前准备8支气管镜术前准备8术前检查

了解病史、测量血压及心肺体检胸片或胸部CT检查出、凝血时间、血小板记数乙肝两对半ECG检查血气分析9术前检查

了解病史、测量血压及心肺体检9患者准备

向患者讲明检查目的、意义、配合方法术前签字术前禁食6小时术前30分钟肌注安定和阿托品有异齿术前摘下

10患者准备

向患者讲明检查目的、意义、配合方法10

气管—支气管的解剖结构11气管—支气管的解剖结构111212气管

上段固定于喉部，下段与主支气管相连接。气管由15－20个软骨环构成，成人气管横径18－20mm，长度10－13cm，气管分叉角度55－65°。

气管前有甲状腺，后与食道相邻。13气管

上段固定于喉部，下段与主支气管相连接。13主支气管

右主支气管

短而粗，平均长度25mm，直径11－15mm。左主支气管

细而长,平均长度50mm,直径9－11mm。14主支气管

右主支气管14右侧叶支气管

右上叶支气管

长度9mm，直径8mm右中间段支气管

长度8－20mm，直径8mm右中叶支气管

长度10－20mm,直径7mm右下叶支气管

长度9mm,直径7mm15右侧叶支气管

右上叶支气管15左侧叶支气管

左上叶支气管

距左上叶支气管开口约5mm处，向前下处方发出舌段。左下叶支气管

距左下叶支气管开口约5mm处，向后发出背段。16左侧叶支气管

左上叶支气管16支气管镜操作方法

17支气管镜操作方法171818191920202121支气管分支命名22支气管分支命名22Group1Exercises23Group1Exercises23Step1:nosetolarynxThescopeisadvancedfromthenosetothelarynx.Thisstepincludeslocalanesthesia24Step1:nosetolarynxThescopStep2:larynxtosubglottisFromthelarynxthetracheaisenteredtothesubglotticarea.Iffromthehead:oncethevocalcordsarepassedthescopeisslightlyflexeddownwards.Iffromthefront:oncethevocalcordsarepassedthescopeisslightlyflexedupwards.25Step2:larynxtosubglottisFrStep3:FollowthecurvetothecarinaTheTracheaisnota“straightpipe”;Itdeviatesposteriorlyandslightlytotherightwhenapproachingthemaincarina.26Step3:FollowthecurvetothStep4a:CarinatoleftmainbronchusFromtheneutralpositiontheLMBisenteredjustbytwistingthewristtotheleftandadvancingfor1-2cm.27Step4a:CarinatoleftmainbStep4b:CarinatorightmainbronchusFromtheneutralpositiontheRMBisenteredjustbytwistingthewristtotherightandadvancingthescopefor1-2cm28Step4b:CarinatorightmainFromtheneutralpositiontheleftandrightmainbronchiareenteredalternativelyjustbytwistingthewristandadvancingthescopeforfewcm.Step4c:Left-right-neutral29FromtheneutralpositiontheStep5a:Down-up-leftmainbronchusThescopeisslowlyadvancedthepulledbackuptheLMBwhilealwayskeepingitinthemiddleoftheairwaylumen.30Step5a:Down-up-leftmainbroStep5b:Down-uprightmainbronchusThescopeisslowlyadvanceddowntheRMBtoRLLandpulledbackupwardswhilealwayskeepingitinthemiddleoftheairwaylumen.31Step5b:Down-uprightmainbrGroup2Exercises32Group2Exercises32Step6a:LeftmaintoleftupperlobebronchusFromtheLMBthescopeisadvancedtotheentranceoftheLULbronchus.33Step6a:LeftmaintoleftuppStep6b:LeftmaintoleftlowerlobebronchusThescopeisadvanceddowntheLMBtotheentranceoftheLLLbronchus.34Step6b:LeftmaintoleftlowStep6c:RightmaintorightupperlobebronchusThescopeisadvanceddowntheRMBthenwiththewristtwisted60degreesfrommidlinethescopeisflexeduptotheentranceofRUL.35Step6c:RightmaintorightuStep6d:RightmaintobronchusintermediusFromthecarinaadvancethescopedowntheRMBtothedistalbronchusintermediusandvisualizetheentrancetoRB456andthebasalpyramid.36Step6d:RightmaintobronchuStep6e:RightmaintorightlowerlobebronchusAdvancethescopefromthecarinatotheentranceoftheRLLwhilealwayskeepingitinthemidline.37Step6e:RightmaintorightlGroup3Exercises38Group3Exercises38Step7a:LeftupperlobeunodosFromthecarina,thescopeisadvancedtoLULentrance;there,justbythumbmovement,thelingulaandupperdivisionbronchusarevisualized.39Step7a:LeftupperlobeunodStep7b:Leftbeforefivesix(LB456)FromtheLMB,thelingulaisentered,thenthescopeispulledbackintothedistalLMBandthescopeisadvancedintothesuperiorsegmentoftheLLL.!Wristmovementsare“inthemirror”40Step7b:LeftbeforefivesixStep7c:LeftB6-8,9,10WiththescopeattheLLLbronchusentrance,thesuperiorsegmentisentered,thenalternately,theantero,lateralandpostero-basalsegmentsoftheLLLareentered.41Step7c:LeftB6-8,9,10WiththStep7d:Rightupperlobeuno-dos-tresFromtheRMBthescopeisadvancedandflexedupintotheRULbronchuswherejustbywristandthumbmovementsthethreesegmentsarevisualized;thenthescopeiswithdrawntothemaincarina.42Step7d:Rightupperlobeuno-Step7e:Rightbeforefivesix(RB4,5,6)Fromthedistalbronchusintermedius,theRMLandsuperiorsegmentareenteredalternatively;!Wristmovementsare“inthemirror”.43Step7e:RightbeforefivesixStep7f:Rightmedialbasal(RB7)(d”Artagnan)Fromthedistalbronchusintermediusthescopeisadvancedandthemedio-basalsegmentisentered.44Step7f:Rightmedialbasal(RStep8a:LeftlowerlobebasalpyramidFromtheentranceoftheLLLbronchusgoinandoutofthe3basalsegments,thenwithdrawthescopetothecarina.45Step8a:LeftlowerlobebasalStep8b:Rightlowerlobebasalpyramid

(D’Artagnanandthethreemusketeers)FromthecarinaadvancethescopetotheRLLbronchusentranceandthenenterthemedial-basalsegment,pullbackandthenexaminetheotherthreesegmentsofthebasalpyramid.46Step8b:Rightlowerlobebasa支气管镜的基本操作47支气管镜的基本操作1

支气管镜的适应症，禁忌症支气管镜术前的准备工作气管-支气管的解剖结构支气管镜的基本操作方法48支气管镜的适应症，禁忌症2支气管镜的适应症

49支气管镜的适应症3诊断方面

不明原因的咯血，慢性咳嗽，声音嘶哑，局限性哮鸣音支气管感染性疾病的病因学诊断肺炎胸片或CT检查异常已诊断肺癌术前检查，指导手术范围及估计预后食管-支气管瘘的确诊胸部外伤，怀疑有支气管裂伤和断裂50诊断方面不明原因的咯血，慢性咳嗽，声音嘶哑，局限性哮鸣音4治疗方面取出支气管异物某些肺不张，肺脓疡等咯血治疗引导气管插管支气管镜下治疗51治疗方面取出支气管异物5

支气管镜的禁忌症52支气管镜的禁忌症6

活动性大出血不能纠正的出血倾向尿毒症，活检易出血者严重肺动脉高压，活检易出血者严重心、肺功能障碍严重心律失常新近发生心肌梗死或心绞痛疑有主动脉瘤全身情况极度衰竭严重的上腔静脉阻塞综合征53活动性大出血7

支气管镜术前准备54支气管镜术前准备8术前检查

了解病史、测量血压及心肺体检胸片或胸部CT检查出、凝血时间、血小板记数乙肝两对半ECG检查血气分析55术前检查

了解病史、测量血压及心肺体检9患者准备

向患者讲明检查目的、意义、配合方法术前签字术前禁食6小时术前30分钟肌注安定和阿托品有异齿术前摘下

56患者准备

向患者讲明检查目的、意义、配合方法10

气管—支气管的解剖结构57气管—支气管的解剖结构115812气管

上段固定于喉部，下段与主支气管相连接。气管由15－20个软骨环构成，成人气管横径18－20mm，长度10－13cm，气管分叉角度55－65°。

气管前有甲状腺，后与食道相邻。59气管

上段固定于喉部，下段与主支气管相连接。13主支气管

右主支气管

短而粗，平均长度25mm，直径11－15mm。左主支气管

细而长,平均长度50mm,直径9－11mm。60主支气管

右主支气管14右侧叶支气管

右上叶支气管

长度9mm，直径8mm右中间段支气管

长度8－20mm，直径8mm右中叶支气管

长度10－20mm,直径7mm右下叶支气管

长度9mm,直径7mm61右侧叶支气管

右上叶支气管15左侧叶支气管

左上叶支气管

距左上叶支气管开口约5mm处，向前下处方发出舌段。左下叶支气管

距左下叶支气管开口约5mm处，向后发出背段。62左侧叶支气管

左上叶支气管16支气管镜操作方法

63支气管镜操作方法176418651966206721支气管分支命名68支气管分支命名22Group1Exercises69Group1Exercises23Step1:nosetolarynxThescopeisadvancedfromthenosetothelarynx.Thisstepincludeslocalanesthesia70Step1:nosetolarynxThescopStep2:larynxtosubglottisFromthelarynxthetracheaisenteredtothesubglotticarea.Iffromthehead:oncethevocalcordsarepassedthescopeisslightlyflexeddownwards.Iffromthefront:oncethevocalcordsarepassedthescopeisslightlyflexedupwards.71Step2:larynxtosubglottisFrStep3:FollowthecurvetothecarinaTheTracheaisnota“straightpipe”;Itdeviatesposteriorlyandslightlytotherightwhenapproachingthemaincarina.72Step3:FollowthecurvetothStep4a:CarinatoleftmainbronchusFromtheneutralpositiontheLMBisenteredjustbytwistingthewristtotheleftandadvancingfor1-2cm.73Step4a:CarinatoleftmainbStep4b:CarinatorightmainbronchusFromtheneutralpositiontheRMBisenteredjustbytwistingthewristtotherightandadvancingthescopefor1-2cm74Step4b:CarinatorightmainFromtheneutralpositiontheleftandrightmainbronchiareenteredalternativelyjustbytwistingthewristandadvancingthescopeforfewcm.Step4c:Left-right-neutral75FromtheneutralpositiontheStep5a:Down-up-leftmainbronchusThescopeisslowlyadvancedthepulledbackuptheLMBwhilealwayskeepingitinthemiddleoftheairwaylumen.76Step5a:Down-up-leftmainbroStep5b:Down-uprightmainbronchusThescopeisslowlyadvanceddowntheRMBtoRLLandpulledbackupwardswhilealwayskeepingitinthemiddleoftheairwaylumen.77Step5b:Down-uprightmainbrGroup2Exercises78Group2Exercises32Step6a:LeftmaintoleftupperlobebronchusFromtheLMBthescopeisadvancedtotheentranceoftheLULbronchus.79Step6a:LeftmaintoleftuppStep6b:LeftmaintoleftlowerlobebronchusThescopeisadvanceddowntheLMBtotheentranceoftheLLLbronchus.80Step6b:LeftmaintoleftlowStep6c:RightmaintorightupperlobebronchusThescopeisadvanceddowntheRMBthenwiththewristtwisted60degreesfrommidlinethescopeisflexeduptotheentranceofRUL.81Step6c:RightmaintorightuStep6d:RightmaintobronchusintermediusFromthecarinaadvancethescopedowntheRMBtothedistalbronchusintermediusandvisualizetheentrancetoRB456andthebasalpyramid.82Step6d:RightmaintobronchuStep6e:RightmaintorightlowerlobebronchusAdvancethescopefromthecarinatotheentranceoftheRLLwhilealwayskeepingitinthemidline.83Step6e:RightmaintorightlGroup3Exercises84Group3Exercises38Step7a:LeftupperlobeunodosFromthecarina,thescopeisadvancedtoLULentrance;there,justbythumbmovement,thelingulaandupperdivisionbronchusarevisualized.85Step7a:LeftupperlobeunodStep7b:Leftbeforefivesix(LB456)FromtheLMB,thelingulaisentered,thenthescopeispulledbackintothedistalLMBandthescopeisadvancedintothesuperiorsegmentoftheLLL.!Wristmovementsare“inthemirror”86Step7b:LeftbeforefivesixStep7c:LeftB6-8,9,10WiththescopeattheLLLbronchusentrance,thesuperiorsegmentisentered,thenalternately,theantero,lateralandpostero-basalsegmentsoftheLLLareentered.87Step