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(zhǔn)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(yán)重肺動脈高壓，活檢易出血者嚴(yán)重心、肺功能障礙嚴(yán)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(yán)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(zhǔn)備8支氣管鏡術(shù)前準(zhǔn)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(zhǔn)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(zhǔn)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(xì)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(zhǔn)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(yán)重肺動脈高壓，活檢易出血者嚴(yán)重心、肺功能障礙嚴(yán)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(yán)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(zhǔn)備54支氣管鏡術(shù)前準(zhǔn)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(zhǔn)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(zhǔn)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(xì)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