支氣管鏡的基本操作

1、支氣管鏡的基本操作方蘇榕 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支氣管鏡的適應(yīng)癥 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 支氣管鏡的禁忌癥 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

2、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 支氣管鏡術(shù)前準(zhǔn)備術(shù)前檢查術(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?dú)夥治龌颊邷?zhǔn)備患者準(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 氣管支氣管的 解剖結(jié)構(gòu) 支氣管鏡操作方法 支氣管分支命名右肺右肺左肺左肺上葉b1尖段上葉上葉分支b1+2尖后段b2后段b3前段b3前段中葉b4外段舌葉b4上舌段b5內(nèi)段b5下舌段下葉b6背段下葉b6背段b7內(nèi)基底段b8前基底段b8前基底段b9外基底段b9外基底段b10

3、后基底段b10后基底段group 1 exercisesstep 1: nose to larynx the scope is advanced from the nose to the larynx . this step includes local anesthesiastep 2: larynx to subglottisfrom the larynx the trachea is entered to the subglottic area.if from the head:if from the head: once the vocal cords are passed the s

4、cope is slightly flexed downwards.if from the front: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.

5、step 4a: carina to left main bronchusfrom 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 bronchusfrom the neutral position the rmb is entered just by twisting the wrist to the right and advancing the scope for 1

6、-2 cmfrom 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 bronchusthe scope is slowly advanced the pulled back up the lmb while always keeping it in the

7、 middle of the airway lumen.step 5b: down-up right main bronchusthe 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 exercisesstep 6a: left main to left upper lobe bronchus from the lmb the scope is advanced to the

8、 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 bronchusthe scope is advanced down the rmb then with the wrist twisted 60 degrees from midline the scope is flex

9、ed up to the entrance of rul.step 6d: right main to bronchus intermediusfrom 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 bronchusadvance the scope from the carina to the

10、 entrance of the rll while always keeping it in the midline.group 3 exercisesstep 7a: left upper lobe uno dosfrom 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 l

11、mb, 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, t

12、he 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

13、.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 pyra