医学支气管镜的基本操作专题.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,支气管镜的基本操作,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,支气管镜的适应症,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,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,支气管镜的禁忌症,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,支气管镜术前准备,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,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,气管,支气管的 解剖结构,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1820,mm，,长度1013,cm，,气管分叉角度5565。,气管前有甲状腺，后与食道相邻。,主支气管,右主支气管,短而粗，平均长度25,mm，,直径1115,mm。,左主支气管,细而长,平均长度50,mm,直径911,mm。,右侧叶支气管,右上叶支气管,长度9,mm，,直径8,mm,右中间,段,支气管,长度820,mm，,直径8,mm,右中叶支气管,长度1020,mm,直径7,mm,右下叶支气管,长度9,mm,直径7,mm,左侧叶支气管,左上叶支气管,距左上叶支气管开口约5,mm,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5,mm,处，向后发出背段。,支气管镜操作方法,支气管分支命名,右肺,左肺,上叶,B1,尖段,上叶,上叶分支,B1+2,尖后段,B2,后段,B3,前段,B3,前段,中叶,B4,外段,舌叶,B4,上舌段,B5,内段,B5,下舌段,下叶,B6,背段,下叶,B6,背段,B7,内基底段,B8,前基底段,B8,前基底段,B9,外基底段,B9,外基底段,B10,后基底段,B10,后基底段,Group 1 Exercises,Step 1:nose to larynx,The scope is advanced from the nose to the larynx.,This step includes local anesthesia,Step 2:larynx to subglottis,From the larynx the trachea is entered to the subglottic area.,If from the head:,once the vocal cords are passed the scope is slightly flexed downwards.,If from the front:,once the vocal cords are passed the scope is slightly flexed upwards.,Step 3:Follow the curve to the carina,The Trachea is not a“straight pipe”;,It deviates posteriorly and slightly to the right when approaching the main carina.,Step 4a:Carina to left main bronchus,From the neutral position the LMB is entered just by twisting the wrist to the left and advancing for 1-2 cm.,Step 4b:Carina to right main bronchus,From the neutral position the RMB is entered just by twisting the wrist to the right and advancing the scope for 1-2 cm,From the neutral position the left and right main bronchi are entered alternatively just by twisting the wrist and advancing the scope for few cm.,Step 4c:Left-right-neutral,Step 5a:Down-up-left main bronchus,The scope is slowly advanced the pulled back up the LMB while always keeping it in the middle of the airway lumen.,Step 5b:Down-up right main bronchus,The scope is slowly advanced down the RMB to RLL and pulled back upwards while always keeping it in the middle of the airway lumen.,Group 2 Exercises,Step 6a:Left main to left upper lobe bronchus,From the LMB the scope is advanced to the entrance of the LUL bronchus.,Step 6b:Left main to left lower lobe bronchus,The scope is advanced down the LMB to the entrance of the LLL bronchus.,Step 6c:Right main to right upper lobe bronchus,The scope is advanced down the RMB then with the wrist twisted 60 degrees from midline the scope is flexed up to the entrance of RUL.,Step 6d:Right main to bronchus intermedius,From the carina advance the scope down the RMB to the distal bronchus intermedius and visualize the entrance to RB456 and the basal pyramid.,Step 6e:Right main to right lower lobe bronchus,Advance the scope from the carina to the entrance of the RLL while always keeping it in the midline.,Group 3 Exercises,Step 7a:Left upper lobe uno dos,From the carina,the scope is advanced to LUL entrance;there,just by thumb movement,the lingula and upper division bronchus are visualized.,Step 7b:Left before five six(LB 456),From the LMB,the lingula is entered,then the scope is pulled back into the distal LMB and the scope is advanced into the superior segment of the LLL.,!Wrist movements are“in the mirror”,Step 7c:Left B6-8,9,10,With the scope at the LLL bronchus entrance,the superior segment is entered,then alternately,the antero,lateral and postero-basal segments of the LLL are entered.,Step 7d:Right upper lobe uno-dos-tres,From the RMB the scope is advanced and flexed up into the RUL bronchus where just by wrist and thumb movements the three segments are visualized;then the scope is withdrawn to the main carina.,Step 7e:Right before five six(RB 4,5,6),From the distal bronchus intermedius,the RML and superior segment are entered alternatively;,!Wrist movements are“in the mirror”.,Step 7f:Right medial basal(RB7)(d”Artagnan),From the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered.,Step 8a:Left lower lobe basal pyramid,From the entrance of the LLL bronchus go in and out of the 3 basal segments,then withdraw the scope to the carina.,Step 8b:Right lower lobe basal pyramid(DArtagnan and the three musketeers),From the carina advance the scope to the RLL bronchus entrance and then enter the medial-basal segment,pull back and then examine the other three segments of the basal pyramid.,