气道异物邹宏运课件

安徽医科大学第一附属医院麻醉科邹宏运病例1病例2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病症：剧烈咳嗽，呼吸困难，喘鸣，哮鸣，紫绀。慢性病症：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%werewithin5yearsofageandmostwerewithin2–3yearsofage.Rigidbronchoscopywasdoneinallthecasesandforeignbodywassuccessfullyretrievedin78.7%ofcases.TheMostcommonsiteoflodgmentwastherightbronchusfollowedbytheleftbronchus,thetracheaandothersites.VegetableswerethemostcommonFBsastheywerefoundin26cases.-----IndianJOtolaryngolHeadNeckSurg(October–December2021)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锋利异物气肿致纵隔移位花生〔可肿胀含油脂〕Someauthorssuggestthatbronchoscopymaybeperformedduringnormaldaytimeoperatinghourstoensureoptimalconditionswithanexperiencedbronchoscopistandanesthesiologist.Theseauthorsfoundnoincreaseinmorbidityinstablepatientsbydelayingbronchoscopyforasuspectedforeignbodyuntilthenextavailableelectivedaytimeslot.---ManiN,SomaM,MasseyS,AlbertD,BaileyCM.Removalofinhaledforeignbodiesmiddleofthenightorthenextmorning.IntJPediatrOtorhinolaryngol2021;73:1085–9麻醉前考量麻醉难点气道管理自主呼吸VS控制通气麻醉深度保存自主呼吸VS抑制呼吸道反射麻醉方法的选择？

麻醉难点Fewanaesthesiologistsagreeonthebestmethodofprovidinggeneralanaesthesiaandthebestmodeofventilation.Thereisgoodreasonforthisaslittleornoevidenceexistswithwhichtoguideanaestheticmanagement。RonaldS.Litman，Anaesthesiaforbronchialforeignbodyremoval:whatreallymatters?EuropeanJournalofAnaesthesiology2021,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.Comparisonofsevofluranevolatileinductionmaintenanceanaesthesiaandpropofol-remifentaniltotalintravenousanaesthesiaforrigidbronchoscopyunderspontaneousbreathingfortracheal/bronchialforeignbodyremovalinchildren.EurJAnaesth2021;27:930–934.Theincidenceratesofbreathholding(GroupVIMA6.25%vsGroupTIVA31.25%,p<0.05)Thedesaturation(GroupVIMA15.63%vsGroupTIVA37.50%,p<0.05)inGroupVIMAweresignificantlylowerthanthoseinGroupTIVA.Heartrate,meanbloodpressureandrespiratoryrateweresignificantlyhigherinGroupVIMAthaninGroupTIVA.LiaoR,YiLiJ,YueLiuG.Comparisonofsevofluranevolatileinductionmaintenanceanaesthesiaandpropofol-remifentaniltotalintravenousanaesthesiaforrigidbronchoscopyunderspontaneousbreathingfortracheal/bronchialforeignbodyremovalinchildren.EurJAnaesth2021;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--保存自主呼吸隆突远端and支气管树内小异物--可正压控制通气麻醉方法麻醉方法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。麻醉方法常见问题保存自主呼吸，外科操作时患儿屛气，呛咳-常发生于麻醉浅，外科医生进退气管镜时。解决方法：加深麻醉，辅助通气。严重并发症气道完全阻塞喉痉挛-加深麻醉-异物移位〔假设完全梗阻，用硬镜推送入远端支气管，通气后找熟练外科医生继续操作)气胸张力性气胸〔胸腔闭式引流〕气道出血〔肾上腺素棉球压迫〕纵膈积气气管，支气管撕伤低氧性脑损伤〔0.96%〕Individualanaesthesiologistsmayhavetheirownideas

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