支氣管鏡的基本操作.ppt

支氣管鏡的基本操作 方蘇榕 支氣管鏡的適應癥 禁忌癥支氣管鏡術(shù)前的準備工作氣管 支氣管的解剖結(jié)構(gòu)支氣管鏡的基本操作方法 支氣管鏡的適應癥 診斷方面 不明原因的咯血 慢性咳嗽 聲音嘶啞 局限性哮鳴音支氣管感染性疾病的病因?qū)W診斷肺炎胸片或CT檢查異常已診斷肺癌術(shù)前檢查 指導手術(shù)范圍及估計預后食管 支氣管瘺的確診胸部外傷 懷疑有支氣管裂傷和斷裂 治療方面 取出支氣管異物某些肺不張 肺膿瘍等咯血治療引導氣管插管支氣管鏡下治療 支氣管鏡的禁忌癥 活動性大出血不能糾正的出血傾向尿毒癥 活檢易出血者嚴重肺動脈高壓 活檢易出血者嚴重心 肺功能障礙嚴重心律失常新近發(fā)生心肌梗死或心絞痛疑有主動脈瘤全身情況極度衰竭嚴重的上腔靜脈阻塞綜合征 支氣管鏡術(shù)前準備 術(shù)前檢查 了解病史 測量血壓及心肺體檢胸片或胸部CT檢查出 凝血時間 血小板記數(shù)乙肝兩對半ECG檢查血氣分析 患者準備 向患者講明檢查目的 意義 配合方法術(shù)前簽字術(shù)前禁食6小時術(shù)前30分鐘肌注安定和阿托品有異齒術(shù)前摘下 氣管 支氣管的解剖結(jié)構(gòu) 氣管 上段固定于喉部 下段與主支氣管相連接 氣管由15 20個軟骨環(huán)構(gòu)成 成人氣管橫徑18 20mm 長度10 13cm 氣管分叉角度55 65 氣管前有甲狀腺 后與食道相鄰 主支氣管 右主支氣管短而粗 平均長度25mm 直徑11 15mm 左主支氣管細而長 平均長度50mm 直徑9 11mm 右側(cè)葉支氣管 右上葉支氣管長度9mm 直徑8mm右中間段支氣管長度8 20mm 直徑8mm右中葉支氣管長度10 20mm 直徑7mm右下葉支氣管長度9mm 直徑7mm 左側(cè)葉支氣管 左上葉支氣管距左上葉支氣管開口約5mm處 向前下處方發(fā)出舌段 左下葉支氣管距左下葉支氣管開口約5mm處 向后發(fā)出背段 支氣管鏡操作方法 支氣管分支命名 Group1Exercises Step1 nosetolarynx Thescopeisadvancedfromthenosetothelarynx Thisstepincludeslocalanesthesia Step2 larynxtosubglottis Fromthelarynxthetracheaisenteredtothesubglotticarea Iffromthehead oncethevocalcordsarepassedthescopeisslightlyflexeddownwards Iffromthefront oncethevocalcordsarepassedthescopeisslightlyflexedupwards Step3 Followthecurvetothecarina TheTracheaisnota straightpipe Itdeviatesposteriorlyandslightlytotherightwhenapproachingthemaincarina Step4a Carinatoleftmainbronchus FromtheneutralpositiontheLMBisenteredjustbytwistingthewristtotheleftandadvancingfor1 2cm Step4b Carinatorightmainbronchus FromtheneutralpositiontheRMBisenteredjustbytwistingthewristtotherightandadvancingthescopefor1 2cm Fromtheneutralpositiontheleftandrightmainbronchiareenteredalternativelyjustbytwistingthewristandadvancingthescopeforfewcm Step4c Left right neutral Step5a Down up leftmainbronchus ThescopeisslowlyadvancedthepulledbackuptheLMBwhilealwayskeepingitinthemiddleoftheairwaylumen Step5b Down uprightmainbronchus ThescopeisslowlyadvanceddowntheRMBtoRLLandpulledbackupwardswhilealwayskeepingitinthemiddleoftheairwaylumen Group2Exercises Step6a Leftmaintoleftupperlobebronchus FromtheLMBthescopeisadvancedtotheentranceoftheLULbronchus Step6b Leftmaintoleftlowerlobebronchus ThescopeisadvanceddowntheLMBtotheentranceoftheLLLbronchus Step6c Rightmaintorightupperlobebronchus ThescopeisadvanceddowntheRMBthenwiththewristtwisted60degreesfrommidlinethescopeisflexeduptotheentranceofRUL Step6d Rightmaintobronchusintermedius FromthecarinaadvancethescopedowntheRMBtothedistalbronchusintermediusandvisualizetheentrancetoRB456andthebasalpyramid Step6e Rightmaintorightlowerlobebronchus AdvancethescopefromthecarinatotheentranceoftheRLLwhilealwayskeepingitinthemidline Group3Exercises Step7a Leftupperlobeunodos Fromthecarina thescopeisadvancedtoLULentrance there justbythumbmovement thelingulaandupperdivisionbronchusarevisualized Step7b Leftbeforefivesix LB456 FromtheLMB thelingulaisentered thenthescopeispulledbackintothedistalLMBandthescopeisadvancedintothesuperiorsegmentoftheLLL Wristmovementsare inthemirror Step7c LeftB6 8 9 10 WiththescopeattheLLLbronchusentrance thesuperiorsegmentisentered thenalternately theantero lateralandpostero basalsegmentsoftheLLLareentered Step7d Rightupperlobeuno dos tres FromtheRMBthescopeisadvancedandflexedupintotheRULbronchuswherejustbywristandthumbmovementsthethreesegmentsarevisualized thenthescopeiswithdrawntothemaincarina Step7e Rightbeforefivesix RB4 5 6 Fromthedistalbronchusintermedius theRMLandsuperiorsegmentareenteredalternatively Wristmovementsare inthemirror Step7f Rightmedialbasal RB7 d Artagnan Fromthedistalbronchusintermediusthescopeisadvancedandthemedio basalsegmentisentered Step8a Leftlowerlobebasalpyramid FromtheentranceoftheLLLbronchusgoinandoutofthe3basalsegments thenwithdrawthescopetothecarina Step8b Rightlowerlobeb