超声在气道管理中的应用

上海交通大学附属第六人民医院麻醉科赵达强

超声在气道管理中的应用2016-5-27当前第1页\共有34页\编于星期三\15点颈部气道解剖当前第2页\共有34页\编于星期三\15点定位喉上神经Thethyrohyoidmembraneasatargetforultrasonography-guidedblockoftheinternalbranchofthesuperiorlaryngealnerveStopar-PintaricT,VlassakovK,AzmanJ.JClinAnesth.2015Nov;27(7):548-52.Inconclusion,weareproposingananatomicalconceptforanew,simpler,consistentlyreproducible

US-guidediSLNblocktechniqueusingthethyrohyoidmembraneto

definethetargetplaneforlow-volumelocalanestheticinjection.当前第3页\共有34页\编于星期三\15点外侧舌骨外侧舌骨超声影像——舌骨、喉上神经外侧过拱桥，甲舌膜里寻喉上当前第4页\共有34页\编于星期三\15点定位环甲膜Theconventionalmethod,inspectionandpalpation,hasalowsuccessrate,especiallyinwomen(24–35%).ElliottDS,BakerPA,ScottMR,etal.Accuracyofsurfacelandmarkidentificationforcannulacricothyroidotomy.Anaesthesia2010;65:889–94

LambA,ZhangJ,HungO,etal.AccuracyofidentifyingthecricothyroidmembranebyanesthesiatraineesandstaffinaCanadianinstitution.CanJAnaesth2015;62:495–503当前第5页\共有34页\编于星期三\15点BarbeN,MartinP,PascalJ,etal.AnnFrAnesthReanim.2014Mar;33(3):163-6.定位环甲膜Locatingthecricothyroidmembraneinlearningphase:Valueofultrasonography?TheCTMwasaccuratelyidentifiedbypalpationandultrasoundby46%and100%ofresidentsrespectively(P<0.05).当前第6页\共有34页\编于星期三\15点KristensenMS,TeohWH,RudolphSS,etal.BrJAnaesth.2015Jun;114(6):1003-4.

定位环甲膜Structuredapproachtoultrasound-guidedidentificationofthecricothyroidmembrane:arandomizedcomparisonwiththepalpationmethodinthemorbidlyobeseWhenusingtheconventionaldigitalpalpationmethod,13of35anaesthetists(37%)wereabletolocatethecricothyroidmembranesuccessfullywithin2min,whereasthesuccessratewas29of35(83%)whenthestructuredstepwiseultrasonographymethodwasapplied(P=0.0008,McNemar’stest).当前第7页\共有34页\编于星期三\15点SiddiquiN,ArzolaC,FriedmanZ,etal.Anesthesiology.2015Nov;123(5):1033-41.

定位环甲膜UltrasoundImprovesCricothyrotomySuccessinCadaverswithPoorlyDefinedNeckAnatomyUltrasoundguidancesignificantlydecreasedtheincidenceofinjuriestothelarynxandtracheaIncreasedtheprobabilityofcorrectinsertionby5.6times

incadaverswithdifficultandimpossiblelandmarkpalpation.当前第8页\共有34页\编于星期三\15点外侧甲状软骨声带声带环甲膜外侧超声影像——甲状软骨、环甲膜外侧越尖峰，缺口伪影环甲膜甲状软骨声带声带伪影当前第9页\共有34页\编于星期三\15点超声影像环状软骨外侧气管软骨甲状腺峡部外侧气管软骨外侧当前第10页\共有34页\编于星期三\15点Ultrasound-guidedsuperiorlaryngealnerveblockandtranslaryngealblockforawaketrachealintubationinapatientwithlaryngealabscessIidaT,SuzukiA,KunisawaT,etal.JAnesth(2013)27:309–310临床应用1—清醒插管当前第11页\共有34页\编于星期三\15点SonographicallyGuidedSuperiorLaryngealNerveBlockDuringAwakeFiberopticIntubationSawkaA,TangR,VaghadiaH.AACaseRep.2015Apr15;4(8):107-10.Sonographicallyguidedsuperiorlaryngealnerveblockmaybeusefulinpatientswhereidentificationoflandmarksintheneckisdifficult

asaresultofpatientanatomy临床应用1—清醒插管当前第12页\共有34页\编于星期三\15点临床应用1—清醒插管Ultrasound-guided

CannulaCricothyroidotomySuzukiA,IidaT,kunisawaT,etal.Anesthesiology2012Nov;117(5):1128Ultrasound-assistedtranslaryngealblockforawakefibreopticintubationDeOliveiraGSJr,FitzgeraldP,KendallM.CanJAnesth.201158:664–665当前第13页\共有34页\编于星期三\15点临床应用1—清醒插管病态肥胖BMI60当前第14页\共有34页\编于星期三\15点临床应用1—清醒插管当前第15页\共有34页\编于星期三\15点临床应用1—清醒插管当前第16页\共有34页\编于星期三\15点临床应用2—判断喉镜显露困难气管软骨外侧食管甲状腺WuJ,DongJ,

DingY,

etal.MedSciMonit,2014;20:2343-2350RoleofanteriornecksofttissuequantificationsbyultrasoundinpredictingdifficultlaryngoscopyAnteriornecksofttissuethicknessesmeasuredbyUSathyoidbone,thyrohyoidmembrane,andanteriorcommissurelevelsareindependentpredictorsofdifficultlaryngoscopy.CombinationsofthosescreeningtestsorriskfactorswithUSmeasurementsmightincreasetheabilitytopredictdifficultlaryngoscopy.当前第17页\共有34页\编于星期三\15点临床应用2—判断喉镜显露困难气管软骨外侧食管甲状腺当前第18页\共有34页\编于星期三\15点Ultrasonographicmeasurementoftheminimaltransversediameterofthesubglotticairwayinthetransverseplane,typicallyatthecaudaloutletofthecricoidring临床应用3—选择适合气管导管当前第19页\共有34页\编于星期三\15点临床应用4—判断气管导管位置气管软骨外侧食管甲状腺排除食管内插管证实气管导管在气管内当前第20页\共有34页\编于星期三\15点临床应用4—判断气管导管位置THESENSITIVITYANDSPECIFICITYOFTRANSCRICOTHYROIDULTRASONOGRAPHYTOCONFIRMENDOTRACHEALTUBEPLACEMENTINACADAVERMODELDynamicassessmentresultedin97%sensitivityand100%specificityfordetectingesophagealETplacement.Staticassessmentresultedinonly51%sensitivityand91%specificity.MaG,DavisDP,SchmittJ,etal.JEmergMed.2007May;32(4):405-7.

当前第21页\共有34页\编于星期三\15点气管插管过程中环甲膜改变当前第22页\共有34页\编于星期三\15点气管导管气囊充气表现当前第23页\共有34页\编于星期三\15点临床应用5—判断喉罩位置Laryngo-trachealultrasonographytoconfirmcorrectendotrachealtubeand

laryngealmaskairwayplacementSonographicupperairwayassessmentemergesasa

rapidandeasily

availablemethodtopredictdifficultintubation,toassessthelaryngealandhypopharyngealsizeandvisualizethepositionofthelaryngealmaskairwayinsitu.WojtczakJA,CattanoD.JournalofUltrasonography2014;14:362–366当前第24页\共有34页\编于星期三\15点临床应用5—判断喉罩位置蝴蝶征Unique喉罩的位置ESupreme喉罩的位置E当前第25页\共有34页\编于星期三\15点临床应用6—定位气管切开Real-timeultrasound-guidedpercutaneousdilatationaltracheostomy:afeasibilitystudyPercutaneoustracheostomyperformedunderreal-timeultrasoundguidanceisfeasibleandappears

accurateandsafe,includinginpatientswithmorbidobesityandcervicalspineprecautions.VenkatakrishnaRajajee,JeffreyJFletcher,LaurynRRochlen,etal.CriticalCare2011,15:R67当前第26页\共有34页\编于星期三\15点临床应用6—定位气管切开Traditionallandmarkversusultrasoundguidedtrachealpunctureduringpercutaneousdilatationaltracheostomyinadultintensivecarepatients:arandomisedcontrolledtrialUltrasoundguidancesignificantlyimprovedtherateoffirst-passpunctureandpunctureaccuracy.Fewerproceduralcomplicationswereobserved;however,thisdidnotreachstatisticalsignificance.Theseresultssupportwidergeneraluseofreal-timeultrasoundguidanceasanadditionaltooltoimprovePDT.MátéRudas,IanSeppelt,RobertHerkes,etal.CriticalCare2014,18:514当前第27页\共有34页\编于星期三\15点临床应用6—定位气管切开可视化操作才能有意识避开血管当前第28页\共有34页\编于星期三\15点临床应用6—定位气管切开当前第29页\共有34页\编于星期三\15点其他的临床应用1—

迅速准确建立通气MallinM,CurtisK,DawsonM,etal.AmJEmergMed2014Jan;32(1):61-3.Accuracyofultrasound-guidedmarkingofthecricothyroidmembranebeforesimulatedfailedintubationUltrasound

markingoftheCTMofhealthyvolunteersbeforesimulatedintubation