支氣管鏡的基本操作課件

支氣管鏡的基本操作1支氣管鏡的基本操作1

支氣管鏡的適應(yīng)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2支氣管鏡的適應(yīng)癥，禁忌癥2支氣管鏡的適應(yīng)癥

3支氣管鏡的適應(yīng)癥3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(dǎo)手術(shù)范圍及估計預(yù)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4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4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(dǎo)氣管插管支氣管鏡下治療5治療方面取出支氣管異物5

支氣管鏡的禁忌癥6支氣管鏡的禁忌癥6

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7活動性大出血7

支氣管鏡術(shù)前準備8支氣管鏡術(shù)前準備8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9術(shù)前檢查

了解病史、測量血壓及心肺體檢9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

10患者準備

向患者講明檢查目的、意義、配合方法10

氣管—支氣管的解剖結(jié)構(gòu)11氣管—支氣管的解剖結(jié)構(gòu)111212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。13氣管

上段固定于喉部，下段與主支氣管相連接。13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。14主支氣管

右主支氣管14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7mm15右側(cè)葉支氣管

右上葉支氣管15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。16左側(cè)葉支氣管

左上葉支氣管16支氣管鏡操作方法

17支氣管鏡操作方法171818191920202121支氣管分支命名22支氣管分支命名22Group1Exercises23Group1Exercises23Step1:nosetolarynxThescopeisadvancedfromthenosetothelarynx.Thisstepincludeslocalanesthesia24Step1:nosetolarynxThescopStep2:larynxtosubglottisFromthelarynxthetracheaisenteredtothesubglotticarea.Iffromthehead:oncethevocalcordsarepassedthescopeisslightlyflexeddownwards.Iffromthefront:oncethevocalcordsarepassedthescopeisslightlyflexedupwards.25Step2:larynxtosubglottisFrStep3:FollowthecurvetothecarinaTheTracheaisnota“straightpipe”;Itdeviatesposteriorlyandslightlytotherightwhenapproachingthemaincarina.26Step3:FollowthecurvetothStep4a:CarinatoleftmainbronchusFromtheneutralpositiontheLMBisenteredjustbytwistingthewristtotheleftandadvancingfor1-2cm.27Step4a:CarinatoleftmainbStep4b:CarinatorightmainbronchusFromtheneutralpositiontheRMBisenteredjustbytwistingthewristtotherightandadvancingthescopefor1-2cm28Step4b:CarinatorightmainFromtheneutralpositiontheleftandrightmainbronchiareenteredalternativelyjustbytwistingthewristandadvancingthescopeforfewcm.Step4c:Left-right-neutral29FromtheneutralpositiontheStep5a:Down-up-leftmainbronchusThescopeisslowlyadvancedthepulledbackuptheLMBwhilealwayskeepingitinthemiddleoftheairwaylumen.30Step5a:Down-up-leftmainbroStep5b:Down-uprightmainbronchusThescopeisslowlyadvanceddowntheRMBtoRLLandpulledbackupwardswhilealwayskeepingitinthemiddleoftheairwaylumen.31Step5b:Down-uprightmainbrGroup2Exercises32Group2Exercises32Step6a:LeftmaintoleftupperlobebronchusFromtheLMBthescopeisadvancedtotheentranceoftheLULbronchus.33Step6a:LeftmaintoleftuppStep6b:LeftmaintoleftlowerlobebronchusThescopeisadvanceddowntheLMBtotheentranceoftheLLLbronchus.34Step6b:LeftmaintoleftlowStep6c:RightmaintorightupperlobebronchusThescopeisadvanceddowntheRMBthenwiththewristtwisted60degreesfrommidlinethescopeisflexeduptotheentranceofRUL.35Step6c:RightmaintorightuStep6d:RightmaintobronchusintermediusFromthecarinaadvancethescopedowntheRMBtothedistalbronchusintermediusandvisualizetheentrancetoRB456andthebasalpyramid.36Step6d:RightmaintobronchuStep6e:RightmaintorightlowerlobebronchusAdvancethescopefromthecarinatotheentranceoftheRLLwhilealwayskeepingitinthemidline.37Step6e:RightmaintorightlGroup3Exercises38Group3Exercises38Step7a:LeftupperlobeunodosFromthecarina,thescopeisadvancedtoLULentrance;there,justbythumbmovement,thelingulaandupperdivisionbronchusarevisualized.39Step7a:LeftupperlobeunodStep7b:Leftbeforefivesix(LB456)FromtheLMB,thelingulaisentered,thenthescopeispulledbackintothedistalLMBandthescopeisadvancedintothesuperiorsegmentoftheLLL.!Wristmovementsare“inthemirror”40Step7b:LeftbeforefivesixStep7c:LeftB6-8,9,10WiththescopeattheLLLbronchusentrance,thesuperiorsegmentisentered,thenalternately,theantero,lateralandpostero-basalsegmentsoftheLLLareentered.41Step7c:LeftB6-8,9,10WiththStep7d:Rightupperlobeuno-dos-tresFromtheRMBthescopeisadvancedandflexedupintotheRULbronchuswherejustbywristandthumbmovementsthethreesegmentsarevisualized;thenthescopeiswithdrawntothemaincarina.42Step7d:Rightupperlobeuno-Step7e:Rightbeforefivesix(RB4,5,6)Fromthedistalbronchusintermedius,theRMLandsuperiorsegmentareenteredalternatively;!Wristmovementsare“inthemirror”.43Step7e:RightbeforefivesixStep7f:Rightmedialbasal(RB7)(d”Artagnan)Fromthedistalbronchusintermediusthescopeisadvancedandthemedio-basalsegmentisentered.44Step7f:Rightmedialbasal(RStep8a:LeftlowerlobebasalpyramidFromtheentranceoftheLLLbronchusgoinandoutofthe3basalsegments,thenwithdrawthescopetothecarina.45Step8a:LeftlowerlobebasalStep8b:Rightlowerlobebasalpyramid

(D’Artagnanandthethreemusketeers)FromthecarinaadvancethescopetotheRLLbronchusentranceandthenenterthemedial-basalsegment,pullbackandthenexaminetheotherthreesegmentsofthebasalpyramid.46Step8b:Rightlowerlobebasa支氣管鏡的基本操作47支氣管鏡的基本操作1

支氣管鏡的適應(yīng)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48支氣管鏡的適應(yīng)癥，禁忌癥2支氣管鏡的適應(yīng)癥

49支氣管鏡的適應(yīng)癥3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(dǎo)手術(shù)范圍及估計預(yù)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50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4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(dǎo)氣管插管支氣管鏡下治療51治療方面取出支氣管異物5

支氣管鏡的禁忌癥52支氣管鏡的禁忌癥6

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53活動性大出血7

支氣管鏡術(shù)前準備54支氣管鏡術(shù)前準備8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55術(shù)前檢查

了解病史、測量血壓及心肺體檢9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

56患者準備

向患者講明檢查目的、意義、配合方法10

氣管—支氣管的解剖結(jié)構(gòu)57氣管—支氣管的解剖結(jié)構(gòu)115812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。59氣管

上段固定于喉部，下段與主支氣管相連接。13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。60主支氣管

右主支氣管14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7mm61右側(cè)葉支氣管

右上葉支氣管15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。62左側(cè)葉支氣管

左上葉支氣管16支氣管鏡操作方法

63支氣管鏡操作方法176418651966206721支氣管分支命名68支氣管分支命名22Group1Exercises69Group1Exercises23Step1:nosetolarynxThescopeisadvancedfromthenosetothelarynx.Thisstepincludeslocalanesthesia70Step1:nosetolarynxThescopStep2:larynxtosubglottisFromthelarynxthetracheaisenteredtothesubglotticarea.Iffromthehead:oncethevocalcordsarepassedthescopeisslightlyflexeddownwards.Iffromthefront:oncethevocalcordsarepassedthescopeisslightlyflexedupwards.71Step2:larynxtosubglottisFrStep3:FollowthecurvetothecarinaTheTracheaisnota“straightpipe”;Itdeviatesposteriorlyandslightlytotherightwhenapproachingthemaincarina.72Step3:FollowthecurvetothStep4a:CarinatoleftmainbronchusFromtheneutralpositiontheLMBisenteredjustbytwistingthewristtotheleftandadvancingfor1-2cm.73Step4a:CarinatoleftmainbStep4b:CarinatorightmainbronchusFromtheneutralpositiontheRMBisenteredjustbytwistingthewristtotherightandadvancingthescopefor1-2cm74Step4b:CarinatorightmainFromtheneutralpositiontheleftandrightmainbronchiareenteredalternativelyjustbytwistingthewristandadvancingthescopeforfewcm.Step4c:Left-right-neutral75FromtheneutralpositiontheStep5a:Down-up-leftmainbronchusThescopeisslowlyadvancedthepulledbackuptheLMBwhilealwayskeepingitinthemiddleoftheairwaylumen.76Step5a:Down-up-leftmainbroStep5b:Down-uprightmainbronchusThescopeisslowlyadvanceddowntheRMBtoRLLandpulledbackupwardswhilealwayskeepingitinthemiddleoftheairwaylumen.77Step5b:Down-uprightmainbrGroup2Exercises78Group2Exercises32Step6a:LeftmaintoleftupperlobebronchusFromtheLMBthescopeisadvancedtotheentranceoftheLULbronchus.79Step6a:LeftmaintoleftuppStep6b:LeftmaintoleftlowerlobebronchusThescopeisadvanceddowntheLMBtotheentranceoftheLLLbronchus.80Step6b:LeftmaintoleftlowStep6c:RightmaintorightupperlobebronchusThescopeisadvanceddowntheRMBthenwiththewristtwisted60degreesfrommidlinethescopeisflexeduptotheentranceofRUL.81Step6c:RightmaintorightuStep6d:RightmaintobronchusintermediusFromthecarinaadvancethescopedowntheRMBtothedistalbronchusintermediusandvisualizetheentrancetoRB456andthebasalpyramid.82Step6d:RightmaintobronchuStep6e:RightmaintorightlowerlobebronchusAdvancethescopefromthecarinatotheentranceoftheRLLwhilealwayskeepingitinthemidline.83Step6e:RightmaintorightlGroup3Exercises84Group3Exercises38Step7a:LeftupperlobeunodosFromthecarina,thescopeisadvancedtoLULentrance;there,justbythumbmovement,thelingulaandupperdivisionbronchusarevisualized.85Step7a:LeftupperlobeunodStep7b:Leftbeforefivesix(LB456)FromtheLMB,thelingulaisentered,thenthescopeispulledbackintothedistalLMBandthescopeisadvancedintothesuperiorsegmentoftheLLL.!Wristmovementsare“inthemirror”86Step7b:LeftbeforefivesixStep7c:LeftB6-8,9,10WiththescopeattheLLLbronchusentrance,thesuperiorsegmentisentered,thenalternately,theantero,lateralandpostero-basalsegmentsoftheLLLareentered.87Step