一種介入工具的歷史和未來課件

1、Rigid Bronchoscopy一種介入工具的歷史和未來浙江大學附屬邵逸夫醫(yī)院呼吸內(nèi)科 陳恩國歷史回顧1897年，德國ENT醫(yī)生Gustav Killian第一次應(yīng)用RB取異物支氣管鏡技術(shù)之父2纖維支氣管鏡階段1967年，歷史上第一臺纖維支氣管鏡1974年，東京，第一屆世界支氣管學大會WCB3現(xiàn)代電子支氣管鏡與RB共用時代FB的缺點：管腔狹小、操作器械單一、吸引管口徑小易堵塞RB的優(yōu)點：操作孔道大、氣道控制好、吸引好、可使用各種介入器械兩者結(jié)合，聯(lián)合介入治療方法4Case 18設(shè)備 BRONCHOSCOPE EFER-DUMON 9Optics10Video Equipment11A se

2、t of tubes 12The BRONCHOSCOPE EFER-DUMON 側(cè)孔與可移除的帽13激光管與吸引管15輔助設(shè)備吸引管鉗子16其他設(shè)備Endoscopic scalpel Wire cutterEndoscopic scissors The endoscopic resector 17Balloons Mechanical dilator The laser fiber sheath Assessment 病史與體檢（是否存在）： 凝血病病 合并存在的心肺疾病 顳下頜關(guān)節(jié)異常 頸部固定 與麻醉相關(guān)的并發(fā)癥輔助檢查： 血常規(guī)有凝血功能 血生化 動脈血氣 心電圖 胸部CT18Cas

3、e 2M,聲嘶,有強直性脊炎，頸椎畸形伴活動障礙。202124Case 2302. Endoscopic assessmentThe appearance of any lesions, their intrinsic or extrinsic nature, and their location with respect to the carina, vocal cords, etc. The degree of obstruction and length of involvement The apparent vascularity of a tumor. 胸部CT（2014.7.28）

4、支氣管鏡（2014.7.30）40AnesthesiaThe majority of endoscopic resections require the use of the rigid bronchoscope under general anesthesia. Suppressing consciousness and vagal reflexes, but allowing spontaneous ventilation：spontaneous manually assisted ventilation 4142Induction : Midazolam = 0,05 mg/kg IV

5、Alfentanyl 40 80 mg gamma/kg IV During spontaneous ventilation, FiO2 = 100% Anesthesia of the glottis is performed under direct visualization with the laryngoscope by spraying 5% Xylocaine. 43IntubationThe patient is supine and the neck hyperextended. The upper teeth are protected by the left thumb.

6、The beveled tip of the bronchoscope should always be anterior. 44Once the epiglottis is lifted gently with the beveled tip of the bronchoscope, 45Arytenoids must be identified. 46The vocal cords are located anteriorly in the medial axis of these landmarks. 47The bronchoscope is then advanced past th

7、e vocal cords and into the trachea while rotating the tip. 4849Location of the tumor & Successful resection 50Mechanical debridementMechanical debridement is often carried out following laser coagulation. 51ResectorThe endoscopic resector acts as a guillotine-like instrument sectioning large tumor f

8、ragments effortlessly under direct visualization. 5253Laser5455DilatationProgressive dilatation of airway stenosis can be achieved with bronchoscopes of growing diameter. Tube orientation is simple in the trachea and slightly harder in the main stem bronchi, particularly the left main stem. 56Case 3

9、60Scissors, scalpel, and forceps61The Montgomery T tubeThis stent is widely used today and can be employed in the treatment of tight stenoses or complete obstruction. 626364Silicone Stents Dumon in Marseille proposed an original tracheobronchial silicone stent in 1987 (the Dumon-stent). 65tubular st

10、ents The tracheal stents are generally 50 to 60 mm long (maximum 110 mm), and 14 to 16 mm in diameter (maximum 18 mm).Bronchial stents are manufactured with diameters ranging from 10 to 12 mm and lengths between 20 to 40 mm.66Y stents Y stents designed to treat tumors extending to the carina.The len

11、gths reaching up to 110 mm for the trachea, and 50 mm for the main stem bronchi.The right main stem limb may be fenestrated. 67Indications The principal indication for airway stenting is extrinsic compression of the airway. other indications : bronchial fistula, tracheobronchomalacia 68Y stent place

12、ment is reserved for tumors extending to the carina. 69Choice of the diameter and the lenght The diameter of the stent will depend on the external diameter of the bronchoscope used (yellow tube 16/15, red tube 14/13/12), while the length is measured by retracting the bronchoscope or telescope along

13、the entire length of the stenosis. 70Placement Placement is performed using a tracheal or bronchial rigid tube.The stent is lubricated with silicone and loaded into a stent applicator.The applicator is the inserted through the bronchoscope and the stent is pushed out into the trachea or the bronchus

14、.71Efer-Dumon applicator Two kind of loaders: tracheal or bronchial stent, Y stent or long and large straight stent.On the right two size of applicators.72Adjusting the stent is made by grasping the upper rim of the prosthesis with forceps.7374Stent related complications Stent obstructionMigrationGranulomatous inflammation 75Silicone coated stents are also available, either reinforced by a me