气道异物邹宏运课件

七氟醚在小儿支气管异物取出术中的应用病例12岁3个月男童，诊断气道异物，拟行急诊气道异物取出术。术中住院总医生将异物从右主支气管取出时突然卡在主气道内，患儿随即通气困难，紫绀。氧饱和度，心率下降。麻醉及耳鼻喉科住院总急呼二线，麻醉二线复苏后建议将异物推向远端支气管，但反复操作困难，患儿低氧时间长，反复复苏效果不佳，插管后送ICU后，家属放弃抢救出院病例21岁10月男童，行气管异物取出术，术中操作困难，取出异物后反复检查未发现残留，气管支气管粘膜水肿明显。麻醉复苏后患儿清醒，哭闹。送回病房。4小时后，要求麻醉科紧急气管插管。5分钟内赶到发现患儿双瞳散大，无心跳呼吸。气管插管后复苏效果不佳。送入ICU后2小时后死亡。麻醉手术风险大！流行病学气管（支气管）异物吸入多数发于4岁以下儿童，男童占61%。死亡率3.4%左右，在支气管镜检中死亡率约0.42%。只有11%异物在X线下不透光，17%的患儿胸片正常。诊断金标准：支气管镜检诊断吸入异物的病史急性症状：剧烈咳嗽，呼吸困难，喘鸣，哮鸣，紫绀。慢性症状：持续咳嗽，一侧呼吸音降低，干罗音，反复发作的肺炎，偶见气胸。胸片：患侧肺阻塞性肺气肿

Among94patients70.2%were

within5yearsofageandmostwerewithin2–3yearsof

age.Rigidbronchoscopywasdoneinallthecasesand

foreignbodywassuccessfullyretrievedin78.7%ofcases.The

Mostcommonsiteoflodgmentwastherightbronchus

followedbytheleftbronchus,thetracheaandothersites.

VegetableswerethemostcommonFBsastheywerefound

in26cases.-----IndianJOtolaryngolHeadNeckSurg

(October–December2011)63(4):313–316;DOI10.1007/s12070-011-0227-5急诊支气管镜检指征已存在呼吸衰竭可能成为全部的呼吸道梗阻喉部较大异物银币等尖锐异物气肿致纵隔移位花生（可肿胀含油脂）Someauthors

suggestthatbronchoscopymaybeperformedduringnormal

daytimeoperatinghourstoensureoptimalconditions

withanexperiencedbronchoscopistandanesthesiologist.Theseauthorsfoundnoincreaseinmorbidityinstable

patientsbydelayingbronchoscopyforasuspectedforeign

bodyuntilthenextavailableelectivedaytimeslot.---ManiN,SomaM,MasseyS,AlbertD,BaileyCM.Removalofinhaledforeignbodiesmiddleofthenightorthenextmorning.IntJPediatrOtorhinolaryngol2009;73:1085–9麻醉难点气道管理自主呼吸VS控制通气麻醉深度保留自主呼吸VS抑制呼吸道反射麻醉方法的选择？

麻醉难点Fewanaesthesiologistsagree

onthebestmethodofprovidinggeneralanaesthesia

andthebestmodeofventilation.Thereisgood

reasonforthisaslittleornoevidenceexistswith

whichtoguideanaestheticmanagement。

RonaldS.Litman，Anaesthesiaforbronchialforeignbodyremoval:whatreallymatters?EuropeanJournalofAnaesthesiology2010,Vol27No11Timeforloc(GroupVIMA95.6±15.2secvsGroupTIVA146.2±26.9sec,p<0.05)ThetimeofBISvaluedecreasedto40(GroupVIMA115.3±16.5secvsGroupTIVA160.4±25.8sec,p<0.05).Theemergencetime(GroupVIMA10.5±2.6minvsGroupTIVA16.9±3.1min,p<0.05)inGroupVIMAweresignificantlyshorterthanthoseinGroupTIVA.LiaoR,YiLiJ,YueLiuG.Comparisonofsevofluranevolatileinduction

maintenanceanaesthesiaandpropofol-remifentaniltotalintravenous

anaesthesiaforrigidbronchoscopyunderspontaneousbreathingfor

tracheal/bronchialforeignbodyremovalinchildren.EurJAnaesth2010;27:930–934.ThestudybyLiaoetal.,however,coversonlyone

aspectofanaestheticmanagementfortheseprocedures.Intheirpractice,spontaneousventilationrepresentsthe‘standardofcare’forbronchoscopicretrieval.Advantages

ofspontaneousventilationincludetheabilityto

providecontinuousventilationdespiteinterruptionsin

theanaesthesiabreathingcircuit,andinthecaseof

obstructivelesions.negative-pressurebreathingmay

providebetteroxygenationandventilation.建议隆突近端or主气道内or大异物--保留自主呼吸隆突远端and支气管树内小异物--可正压控制通气麻醉方法术前询问病史：异物种类，大小，病史时间（炎症，肉芽，位置变化）主要症状，有无发热。充分解释麻醉风险。读片（位置，大小），听诊患儿双肺呼吸音。由患儿家长将患儿抱入手术室。麻醉方法术前：禁食8h（stable）,<6h(indanger)6%七氟醚预充回路1.5-2分钟（新鲜气流量5L/分）面罩吸入麻醉镇静后建立静脉通路予阿托品0.01mg/kgiv，地塞米松5-10mgiv麻醉方法继续七氟醚吸入约5分钟，及时听诊小儿双肺呼吸音，调整吸入浓度。耳鼻喉科医生喉镜暴露声门，以2%利多卡因喉麻管声门附近，声门下喷雾局部麻醉。麻醉方法同时静脉予1ug/kg芬太尼。继续吸入七氟醚麻醉5分钟，如果双肺可闻及呼吸音，氧饱和度在90%以上，不需要降低吸入气体浓度。视手术时间长短追加芬太尼和异丙酚。若手术困难，或医生水平一般可打开人工心肺复苏机或其他喷射通气装置连接硬质气管镜侧端。此时可完全打断患儿呼吸（非大异物）。纵膈积气气管，支气管撕伤低氧性脑损伤（0.96%）Individualanaesthesiologistsmayhavetheirownideas

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