气道插管.ppt

一、概述,维持良好的呼吸功能是保证人体成活的关键之一，其中气道管理（或维持气道通畅）是首要的。如果没有完善的气道管理，是极端危险的。气道管理技术很多，本节介绍临床上最常见、最佳的方法：气管插管。,气道管理的基本措施ThePrimarySkillsOfAirwayManagement,面罩通气MasksVentilation口咽通气道Oropharyngeal喉罩LaryngealMaskAirway联合通气道Combitube气管插管EndotrachealIntubation,上呼吸道的结构和功能,鼻Nose咽Pharynx喉Larynx气管Trachea上气道梗阻UpperAirwayObstruction,鼻Nose,主要的呼吸通道theprimarybreathingpathway正常呼吸的起始点startofnormalairway生理功能Physiologicalfunctions嗅觉器官organofolfaction加温warming,加湿humidification,过滤filtration气道阻力theairflowresistance平静呼吸（Quietbreathing）时占气道总阻力的2/3阻力是用嘴呼吸的2倍（twicethanmouthbreathing）,咽Pharynx,喉头位于颈前部、喉咽部的前方，上与喉咽部相通，下与气管相通。Thepharyngealairwayextendsfromtheposterioraspectofthenosedowntothecricoidcartilage喉头是气道梗阻的主要好发部位Theprincipalimpedimentstoairpassagenasopharynx:theprominenttonsillarlymphoidstructures.oropharyngeal:Thetongueistheprincipalsourceofobstruction,咽Pharynx,喉Larynx,喉的位置：C3C6椎体Thelarynxliesatthelevelofthethirdthroughsixthcervicalvertebrae生理功能Physiologicalfunctions发声器官Theorganofphonation会厌分隔气道和消化道Theepiglottisasavalvetoseparatethelowerairwaysandalimentarytract会厌谷是弯喉镜片插管的着力点Theepiglotticvalleculaprovidethesiteforplacementofthecurvedlaryngoscopeblade,喉Larynx,声门GlottisThetruevocalcordsarepale,white,ligamentousstructures成人声门是气道的最狭窄处TheGlottisrepresentsthenarrowestsegmentofthelaryngealopeninginadults小儿气道最狭窄处位于环状软骨Inchildrenyoungerthan10years,thenarrowestsegmentliesjustbelowthecordsatthelevelofthecricoidring,喉Larynx,气管Trachea,气管的上端从环状软骨下缘（相当于第6颈椎水平），下行进入胸腔，抵达第5胸椎下缘（相当于胸骨角）水平时分叉为左右主支气管。成人气管的长度约为1015cm，内腔横径约16mm。,Thetracheaisatubularstructurethatbeginsoppositethesixthcervicalvertebraatthelevelofthethyroidcartilage.Itisflattenedposteriorlyandsupportedalongits10-to15-cmlengthby16to20horseshoe-shapedcartilaginousringsuntilbifurcatingintorightandleftmainbronchiatthelevelofthefifththoracicvertebra.,气道的评估EVALUATIONOFAIRWAY,病史HistoryHistoryofdifficultieswithgeneralanesthesiaor,difficultmaskventilationandintubation.体格检查PhysicalExaminationThepatientmustbeinitiallysubjectedtoasimpleinspectionfromthefrontandsidetoidentifyobviousproblemssuchasmassiveobesity,cervicalcollars,tractiondevices,externaltrauma,oranyindicationsofrespiratorydifficultysuchasstridor.Thepresenceofearandhandanomaliesoftensuggeststhepresenceofadifficultairway.,面罩通气的相关设备及技术MASKS:VENTILATIONEQUIPMENTANDTECHNIQUE,面罩、口咽通气管、麻醉机Anesthesiafacemasksofrubberorplasticareemployedtoadministeroxygenandanestheticgasesandtoventilatethenonintubatedpatient.Maskscomeinalargevarietyofshapes,buttheanatomicmaskismostcommonlyusedinadults.Adultmaskscomeinsmall,medium,andlargesizes(nos.3,4,and5).,单手法Themaskisheldwithonehand,asshowninFigure.Thefingersshouldbekeptontheboneratherthansofttissuesbecausethelatterpositioncancausediscomfortintheawakepatientandcancauseairwayobstructionifsuchpressuresufficientlyraisesthebaseofthetongue.Ventilationwithamaskrequiresatightfitthatinvolvesdownwarddisplacementofthemaskwiththethumbandfirstfingerandupwarddisplacementofthemandiblewiththeotherthreefingers.,面罩通气的相关设备及技术MASKS:VENTILATIONEQUIPMENTANDTECHNIQUE,双手法Mandibulardisplacementalongwithuppercervicalextensionandchinliftalltendtopullthetongueandsofttissuesupofftheposteriorpharyngealwallandrelievetheupperairwayobstructionthatoccursintheanesthetizedorunconsciouspatient.Thismayrequireholdingthemaskwithtwohandsandvigorouslypullingthemandibleupward(jawthrust),面罩通气的相关设备及技术MASKS:VENTILATIONEQUIPMENTANDTECHNIQUE,注意事项对于肥胖、口腔颌面部肿瘤、感染及炎症的病人采用面罩通气可能相当困难；小儿病人若非发生喉痉挛，一般不会出现面罩通气困难。对于老年病人发生全口无牙或缺牙时，采用面罩通气时易漏气，应采用其它防漏装置。此外，进行面罩通气时除出现面罩通气困难外，尚可能出现其它一些严重并发症如胃内容物返流误吸及眼球的损伤，使用时应注意。,面罩通气的相关设备及技术MASKS:VENTILATIONEQUIPMENTANDTECHNIQUE,注意事项Maskventilationmaybeextremelydifficultforpatientswithproblemssuchasobesity,tumors,infections,andinflammatorydisorders.Thepediatricpatientusuallypresentslessofaproblemthantheadultbecausethepediatricairwaycanusuallybemanagedbymaskventilationunlesslaryngospasmensues.Providingaleak-freesealwiththemaskmaybeparticularlydifficultintheolder,edentulouspatient,andthismaybehelpedbyleavingdenturesinplace,usingpacking,oremployingamaskstraporassistanttopullupthesaggingcheeks.Inadditiontotheinabilitytoventilate,otherseriousproblemswithmaskventilationincludepulmonaryaspirationandpressuredamagetotheeyes.,面罩通气的相关设备及技术MASKS:VENTILATIONEQUIPMENTANDTECHNIQUE,气管内插管ENDOTRACHEALINTUBATION,适应症Indications保护气道Airwayprotection；维持气道通畅Maintenanceofpatentairway；肺灌洗Pulmonarytoilet；正压通气的应用Applicationofpositive-pressureventilation；维持适当的氧合Maintenanceofadequateoxygenation,气管导管、喉镜、纤支镜、插管钳、管芯、牙垫及其它Inadditiontoendotrachealtubesandlaryngoscopes,otheressentialitemsincludeanoxygensource,bagandmask,airways,stylet,lubricant,tape,andreliablesuction.Otherdevicesthatmaybeusedinspecialsituationsarealsodiscussed.,器材准备Equipment,Laryngoscopes,气管内插管ENDOTRACHEALINTUBATION,器材准备Equipment气管导管EndotrachealTubesTheendotrachealtubethatismostcommonlyusedincurrentpracticeisapolyvinylchloridetubethathasalow-pressure,high-volumecuff.Clinicaluseofthetubeisgenerallydictatedbytheinternaldiameterthatlimitsairflow.Inadults,externaldiameterislimitedattheleveloftheglotticaperture,whereasinchildrenthesubglottic(cricoidcartilage)areaisthelimitingfactorinexternaldiameter.,气管内插管ENDOTRACHEALINTUBATION,器材准备Equipment气管导管EndotrachealTubes气管导管的型号Tubesaremanufacturedin0.5-mmIDincrementsfrom2.5to9.0mm,气管内插管ENDOTRACHEALINTUBATION,*Approximatesize,whichvariesamongmanufacturers.+Add2to3cmfornasaltubes.,操作技术Techniques麻醉诱导Theusualintubationsequenceincludestheadministrationofarapidlyactinginductionagent(e.g.,thiopental),demonstrationofadequatemaskventilation,andadministrationofarapidlyactingneuromuscularblockingagent(e.g.,succinylcholine).去氮给氧Preoxygenationstronglywasrecommendedbecauseitprovidesanaddedmarginofsafety.Preoxygenationisessentialwhenarapid-sequenceintubationischosenbecauseofafull-stomachsituationorotherpropensitytoaspiration(e.g.,esophagealdisease).,气管内插管ENDOTRACHEALINTUBATION,操作技术Techniques经口气管插管OralEndotrachealIntubation插管时的头位Unlessthereisacontraindication,theheadismaintainedintheclassicsniffingpositiontoaligntheoral,pharyngeal,andlaryngealaxes(seeFig.),气管内插管ENDOTRACHEALINTUBATION,操作技术Techniques经口气管插管OralEndotrachealIntubation手术室中经口气管插管的步骤：静脉快速诱导、面罩通气、肌松药的使用、候镜插管Oralendotrachealintubationistheusualmethodofintubationintheoperatingroom:arapidlyactinganestheticisusuallygivenintravenously,maskventilationisensured,andamusclerelaxantisadministeredtofacilitatelaryngoscopy.,气管内插管ENDOTRACHEALINTUBATION,弯候镜片插管法CurvedBladeTechniques用左手持喉镜沿口角右侧置入口腔，将舌体推向左，使喉镜版移至正中位，见到悬雍垂后慢慢推进使其顶端抵达舌根与会厌交界处，然后上提喉镜，以撬起而显露声门Aftervisualizationoftheepiglottis,thecurvedbladeisinsertedintothevallecula,andthelaryngoscopeispulledforwardandupwardtoexposetheglottis.,气管内插管ENDOTRACHEALINTUBATION,弯候镜片插管法StraightBladeTechniques使用直型喉镜片见到会厌后，应继续稍进喉镜，使其顶端越过会厌侧面，然后上提喉镜，以挑起会厌而显露声门Astraightbladeisusedinsomewhatsimilarfashionexceptthatitisusuallyadvancedbeyondtheepiglottis,ensuringthattheepiglottisisincludedinthestructuresliftedupbytheblade.,气管内插管ENDOTRACHEALINTUBATION,判断导管在气管内的方法直接证据：插管时看到导管进入声门；直接看到导管在气管内：喉镜、纤维支气管镜；影像学导管在气管内：CT等。,气管内插管ENDOTRACHEALINTUBATION,判断导管在气管内的方法-间接证据听诊（Auscultation）双侧肺呼吸音应一致观察呼出气的CO2曲线（Capnographic）：Petco2胸廓呼吸动度双侧应均匀一致,Petco2,气管内插管ENDOTRACHEALINTUBATION,经鼻气管插管NasalEndotrachealIntubation鼻腔准备：表面麻醉、收缩粘膜血管Whennasalintubationischosensolelyforpurposesofsurgicalconvenience,anesthesiamaybeinducedbeforeintubation.Avasoconstrictorshouldbeappliedbeforenasalinstrumentation.Afteranesthesiaisinducedandmaskventilationisestablished,theendotrachealtubeisintroducedintothenoseinaplanethatisroughlyperpendiculartotheface.,气管内插管ENDOTRACHEALINTUBATION,经鼻气管插管NasalEndotrachealIntubation明视法、盲探法、纤维支气管镜引导法Thepatientmaybeallowedtobreathespontaneouslytofacilitateblindintubation.Inthiscase,thetubeisinserteduntilmaximumbreathsoundsareheard,indicatingthatthetubetipisjustabovetheglottis.Thetubeistheninsertedintotheglottisduringinspiration.,气管内插管ENDOTRACHEALINTUBATION,纤维支气管镜引导气管插管法FiberopticBronchoscopy常用于困难气道和支气管插管Fiberopticbronchoscopyisatechniquethatmaybeusedforallofthedifficultairwaysituationspreviouslydescribedinthischapter.,气管内插管ENDOTRACHEALINTUBATION,气管内插管ENDOTRACHEALINTUBATION,支气管插管位置的判断纤维支气管镜检FiberopticBronchoscopy听诊Auscultation,气管内插管ENDOTRACHEALINTUBATION,并发症Complications牙齿、软组织损伤、出血Dental,softtissues(lipsorgums),anyareaofcontactcanbeinjured.呛咳、侯痉挛、支气管痉挛、呕吐误吸Whenlaryngoscopyisperformedunderinadequateanesthesia,coughing,laryngospasm,bronchospasm,andvomiting(withthepossibilityofaspiration)mayoccur,气管内插管ENDOTRACHEALINTUBATION,并发症Complications低氧血症和高碳酸血症Hypoxemiaandhypercarbiaarepotentialcomplicationsoflaryngoscopiesandintubationsthatarenotsuccessfulinareasonableamountoftime.心血管反应和呼吸系统反应Thecardiovascularandrespiratoryresponse其他Others,气管插管拔管法EXTUBATION,拔管的指针ExtubationGuidelinesExtubationofthetracheamaybeperformedwhilethepatientisdeeplyanesthetizedorisnearlyfullyawake.Deepor,moreprecisely,anesthetizedextubationisperformedaftermusclerelaxantshavebeenfullyreversedandthepatientismaintaininganacceptablerespiratoryrateanddepth.Adifficultmaskairway,difficultintubation,riskofaspiration,orsurgerythatmayproduceairwayedemaormaintenanceproblemsarecontraindicationstosuchextubation.,困难气道管理技术新进展,光导芯（opticalstylet）装置的改进盲探光导芯，如Trachlight，,困难气道管理技术新进展,光导芯（opticalstylet）装置的改进可视光导