纤维支气管镜在ICU中运用

适应症–诊断观察喉、气管、支气管：损伤、咯血定位、肺不张原因、肿瘤、粘膜改变（支气管侵袭性曲霉菌）、分泌物性状、支气管食道瘘。支气管肺泡灌洗（细胞学、革兰氏染色、致病菌培养）：支气管肺感染、肿瘤、结核病、肺泡蛋白沉着症、肺泡出血。经纤支镜肺活检：真菌、结核、肿瘤、血管炎第一页，共21页。适应症–治疗协助气管插管、换管、拔管吸除血块及浓稠分泌物去除支气管异物支气管胸膜瘘封堵气管狭窄扩张局部用药第二页，共21页。相对禁忌症不能纠正的凝血功能异常机械通气需要高PEEP时的TBLB。进食后心肺功能级不稳定第三页，共21页。并发症误吸喉、气管支气管痉挛心律失常低氧血症，继发发热感染加用麻醉镇静剂导致的呼吸抑制及低血压。损伤性操作后的咯血及气胸第四页，共21页。注意事项

BRONCHOSCOPYIN(ICU)术前应充分考虑气管导管内径.ICU病人应充分考虑术后的高并发症，操作的必要性和操作者的熟练程度。充分的生理指标监测恰当设置机械通气参数，操作过程保证充分的氧合操作者应熟悉并充分准备麻醉镇静剂5第五页，共21页。气管导管尺寸在非插管病人仅占全部气管面积的10–15%。5.7mm纤支镜占9mm气管插管面积的40%占7mmtrachealtube的66%。

因此，操作前应充分考虑插管导管内径及纤支镜外径。气管导管会对纤支镜造成损伤，特别是当纤支镜回撤时，边缘锐利的导管前端易损伤纤支镜。应使用润滑剂.6第六页，共21页。机械通气设置术前、术中及术后的短时间内尽量给与100%的氧浓度。一般设置成控制通气模式.PSB模式常不能保持充分的通气。带隔膜孔的延长管可在机械通气的同时进行纤支镜检查。7第七页，共21页。注意安全性?5.7-mm支气管镜通过8-mm内径气管导管截面积减少66%.吸气压升高高PEEP增加气压伤风险感染播散的风险第八页，共21页。↑CO,HR(50%),BP↑myocardialoxygendemandandriskofcardiacischemia2/3of107pts↓PaO2>30%,6%majorarrythmiain120sprocedureTrouilletetal.Chest1990;97:927-93317%ofpts>50yearsoldhadST-segmentchangeMatotetal.Chest1997;112:1454-1458↑ICP(81%),from12to38mmHgKerwinetal.JTrauma2000;48:878-882第九页，共21页。Matsushimaetal.Chest1984;86:184-188第十页，共21页。Lindholmetal.Chest1978;74:362-368第十一页，共21页。与纤支镜相关的ICU绿脓杆菌播散

17pts(riskratio3.8,95%CI2.5-3.9)Bouetal.JHospInfect2006;64:129-13518ptsCDC.MMWRMorbMorralWklyRep1999;48:557-56039ptsSrinivasanetal.NEJM2003;348:221-227第十二页，共21页。13SEDATIONDURINGFLEXIBLEBRONCHOSCOPY(2)Howsedationisgiven?

mostsedationregimensarebaseduponasingledoseorincrementaldosesofanintravenoussedativeagentadministeredatthetimeofbronchoscopy.MIDAZOLAM(Dormicum)Midazolamisawatersolublebenzodiazepinewithaneliminationhalflifeofabout2hoursandisgenerallypreferredtodiazepam.Itsonsetisrapidanddurationofactionbriefinhealthyindividuals.Abetterapproachofgivingisincrementaldosingwhichachievesimprovedtoleranceofbronchoscopy,第十三页，共21页。14SEDATIONDURINGFLEXIBLEBRONCHOSCOPY(3)COMBINATIONSWITHNARCOTICDRUGSAcombinationofabenzodiazepineandnarcotichasbeenwidelyused.Unfortunately,suchacombinationmaybeassociatedwithmorearterialdesaturationandCO2retentionthanwhenusingmidazolamalone.

第十四页，共21页。诊断——感染性疾病Non-invasiveRoutinetrachealaspiratetrappingOftencolonizedandrelativelyinsensitiveInvasiveProtectedBrushspecimenBALTrialin2000suggestedthatpatientsmanagedaccordingtoresultsfromspecimenscollectedbyPBSorBALshowedimprovedsurvival,reducedantibioticuse,earlierresolutionoforgandysfunction(Fagon,ChastrefortheVAPtrialgroup.AnnalsInternMed2000;132:621-30)第十五页，共21页。支气管肺泡灌洗BALObtainedbywedgingthetipofabronchoscopeinthemediumsizedbronchusrelevanttotheareaofpulmonaryinfiltrateonCXRSamplesapprox1millalveoliLavagewith20-30mlsNaClandafter5-10secasampleof5-10mlisobtainedbygentlesuctioningCultureof>104colonyformingunits/mlindicativeofpneumoniaBlindnonbronchoscopiclavagemayalsobecarriedoutbutsubjecttocontaminationComplicationssimilartobronchoscopy第十六页，共21页。BALObtainedbywedgingthetipofabronchoscopeinthemediumsizedbronchusrelevanttotheareaofpulmonaryinfiltrateonCXRSamplesapprox1millalveoliLavagewith20-30mlsNaClandafter5-10secasampleof5-10mlisobtainedbygentlesuctioningCultureof>104colonyformingunits/mlindicativeofpneumoniaBlindnonbronchoscopiclavagemayalsobecarriedoutbutsubjecttocontaminationComplicationssimilartobronchoscopy第十七页，共21页。防污染毛刷

ProtectedbrushspecimenPBSdoublelumenbrushsystemthatavoidsupperairwaycontaminationofthesampleIntroducedblindlyorfibreopticallyintotheareaofinfiltratesonCXRInnercannulaadvancedandspecimencollected>103cfu/mldiagnosticofpneumoniaOnlysmallareasampled,mayleadtofalsenegatives,especiallyifonantibiotics(preventingadminofantibiotics)ContaminationcanstilloccurComplications-arrhythmias,pneumothorax第十八页，共21页。EvidenceMCRCTcomparingBALandETaspirationfordiagnosisofVAPConcludedbothassociatedwithsimilarclinicaloutcomesandsimilaruseofantibioticsHoweveratleast40%patientsexcludedrepresenttheusualthatwouldconcernus(Canadiancriticalcaretrialsgroup,NEJM2006;355:2619-30)第十九页，共21页。PBSvBALComparisonshowsconflictingresultsNorealagreementonwhichhasbettersensitivityorspecificityRecentmeta-analysisconcludedbothequallyaccurateindiagnosingpneumoniabut,inpatientsalready