支气管镜的基本操作

.,1,支气管镜的基本操作,方苏榕,.,2,支气管镜的适应症，禁忌症支气管镜术前的准备工作气管-支气管的解剖结构支气管镜的基本操作方法,.,3,支气管镜的适应症,.,4,诊断方面,不明原因的咯血，慢性咳嗽，声音嘶哑，局限性哮鸣音支气管感染性疾病的病因学诊断肺炎胸片或CT检查异常已诊断肺癌术前检查，指导手术范围及估计预后食管-支气管瘘的确诊胸部外伤，怀疑有支气管裂伤和断裂,.,5,治疗方面,取出支气管异物某些肺不张，肺脓疡等咯血治疗引导气管插管支气管镜下治疗,.,6,支气管镜的禁忌症,.,7,活动性大出血不能纠正的出血倾向尿毒症，活检易出血者严重肺动脉高压，活检易出血者严重心、肺功能障碍严重心律失常新近发生心肌梗死或心绞痛疑有主动脉瘤全身情况极度衰竭严重的上腔静脉阻塞综合征,.,8,支气管镜术前准备,.,9,术前检查,了解病史、测量血压及心肺体检胸片或胸部CT检查出、凝血时间、血小板记数乙肝两对半ECG检查血气分析,.,10,患者准备,向患者讲明检查目的、意义、配合方法术前签字术前禁食6小时术前30分钟肌注安定和阿托品有异齿术前摘下,.,11,气管支气管的解剖结构,.,12,.,13,气管,上段固定于喉部，下段与主支气管相连接。气管由1520个软骨环构成，成人气管横径1820mm，长度1013cm，气管分叉角度5565。气管前有甲状腺，后与食道相邻。,.,14,主支气管,右主支气管短而粗，平均长度25mm，直径1115mm。左主支气管细而长,平均长度50mm,直径911mm。,.,15,右侧叶支气管,右上叶支气管长度9mm，直径8mm右中间段支气管长度820mm，直径8mm右中叶支气管长度1020mm,直径7mm右下叶支气管长度9mm,直径7mm,.,16,左侧叶支气管,左上叶支气管距左上叶支气管开口约5mm处，向前下处方发出舌段。左下叶支气管距左下叶支气管开口约5mm处，向后发出背段。,.,17,支气管镜操作方法,.,18,.,19,.,20,.,21,.,22,支气管分支命名,.,23,Group1Exercises,.,24,Step1:nosetolarynx,Thescopeisadvancedfromthenosetothelarynx.Thisstepincludeslocalanesthesia,.,25,Step2:larynxtosubglottis,Fromthelarynxthetracheaisenteredtothesubglotticarea.Iffromthehead:oncethevocalcordsarepassedthescopeisslightlyflexeddownwards.Iffromthefront:oncethevocalcordsarepassedthescopeisslightlyflexedupwards.,.,26,Step3:Followthecurvetothecarina,TheTracheaisnota“straightpipe”;Itdeviatesposteriorlyandslightlytotherightwhenapproachingthemaincarina.,.,27,Step4a:Carinatoleftmainbronchus,FromtheneutralpositiontheLMBisenteredjustbytwistingthewristtotheleftandadvancingfor1-2cm.,.,28,Step4b:Carinatorightmainbronchus,FromtheneutralpositiontheRMBisenteredjustbytwistingthewristtotherightandadvancingthescopefor1-2cm,.,29,Fromtheneutralpositiontheleftandrightmainbronchiareenteredalternativelyjustbytwistingthewristandadvancingthescopeforfewcm.,Step4c:Left-right-neutral,.,30,Step5a:Down-up-leftmainbronchus,ThescopeisslowlyadvancedthepulledbackuptheLMBwhilealwayskeepingitinthemiddleoftheairwaylumen.,.,31,Step5b:Down-uprightmainbronchus,ThescopeisslowlyadvanceddowntheRMBtoRLLandpulledbackupwardswhilealwayskeepingitinthemiddleoftheairwaylumen.,.,32,Group2Exercises,.,33,Step6a:Leftmaintoleftupperlobebronchus,FromtheLMBthescopeisadvancedtotheentranceoftheLULbronchus.,.,34,Step6b:Leftmaintoleftlowerlobebronchus,ThescopeisadvanceddowntheLMBtotheentranceoftheLLLbronchus.,.,35,Step6c:Rightmaintorightupperlobebronchus,ThescopeisadvanceddowntheRMBthenwiththewristtwisted60degreesfrommidlinethescopeisflexeduptotheentranceofRUL.,.,36,Step6d:Rightmaintobronchusintermedius,FromthecarinaadvancethescopedowntheRMBtothedistalbronchusintermediusandvisualizetheentrancetoRB456andthebasalpyramid.,.,37,Step6e:Rightmaintorightlowerlobebronchus,AdvancethescopefromthecarinatotheentranceoftheRLLwhilealwayskeepingitinthemidline.,.,38,Group3Exercises,.,39,Step7a:Leftupperlobeunodos,Fromthecarina,thescopeisadvancedtoLULentrance;there,justbythumbmovement,thelingulaandupperdivisionbronchusarevisualized.,.,40,Step7b:Leftbeforefivesix(LB456),FromtheLMB,thelingulaisentered,thenthescopeispulledbackintothedistalLMBandthescopeisadvancedintothesuperiorsegmentoftheLLL.!Wristmovementsare“inthemirror”,.,41,Step7c:LeftB6-8,9,10,WiththescopeattheLLLbronchusentrance,thesuperiorsegmentisentered,thenalternately,theantero,lateralandpostero-basalsegmentsoftheLLLareentered.,.,42,Step7d:Rightupperlobeuno-dos-tres,FromtheRMBthescopeisadvancedandflexedupintotheRULbronchuswherejustbywristandthumbmovementsthethreesegmentsarevisualized;thenthescopeiswithdrawntothemaincarina.,.,43,Step7e:Rightbeforefivesix(RB4,5,6),Fromthedistalbronchusintermedius,theRMLandsuperiorsegmentareenteredalternatively;!Wristmovementsare“inthemirror”.,.,44,Step7f:Rightmedialbasal(RB7)(d”Artagnan),Fromthedistalbronchusintermediusthescopeisadvancedandthemedio-basalsegmentisentered.,.,45,Step8a:Leftlowerlobebasalpyramid,FromtheentranceoftheLLLbronchusgoinandoutofthe3basalsegments,thenwithdrawthescopetothecarina.,.,46,Step8b:Right