插管探條之臨床應用課件

插管探條之臨床應用陳昭良主任彰化基督教醫(yī)院麻醉科插管探條之臨床應用陳昭良主任Whatabadluck!!!Whatabadluck!!!Ifthisisa

DifficultIntubation

situation.Whatareourback-upplans???Whatothergadgetsdowehave???IfthisisaDifficultIntubatNon-invasive

Glottis

InvasiveNon-invasiveFromBelowtheGlottis(Invasive)TranstrachealJetVentilation(TTJV)RetrogradeIntubationPercutaneousdilationaltrachealentrySurgicalAirwayFromBelowtheGlottis(InvasiFromAbovetheGlottisLaryngoscope±GumElasticBougieBlindOral/NasalIntubationFiberopticBronchoscopy

IntubatingLMA(Fastrach?)GlideScope?LightedStylet(Trachlight?)

OpticalStyletFromAbovetheGlottisLaryngoEschmanntrachealtubeintroducer

“GumElasticBougie”EschmanntrachealtubeintroduHistoryofGumElasticBougieTheEschmanntrachealtubeintroducer("gumelasticbougie")wasmarketedintheUnitedKingdom(UK)intheearly1970s.Itdiffersfrompreviousintroducersinitsgreaterlength(60cm),angledtip,andthecombinationofflexibilityandmalleability.HistoryofGumElasticBougieTAnesthesiology:100(5)2019:1146-50“GEB“vsDifficultIntubationAnesthesiology:100(5)2019:112019巴黎聖心堂2019巴黎聖心堂LightedStylet(Lightwand)

光棒LightedStylet(Lightwand)

光棒HistoryofLightedStyletThefirstreporteduseofalightedstyletusedtofacilitateintubationcamein1957.Macintoshdescribedan18-inchilluminatedtrachealtubeintroducer,whichwasdesignedtostiffenthetubeandbetterilluminatethecordsbysupplementingthelightofthelaryngoscope.Anaesthesia1957;12:223–5HistoryofLightedStyletThefHistoryofLightedStyletYamamuraetal.describedalightbulb-tippedwirethatwasinsertedintothetrachealtubebeforeblindnasalintubationinawakepatients.Thetubepositionwasthendeterminedbythemedialtransilluminationoftheexternalthroatandneck.Anesthesiology1959;20:221HistoryofLightedStyletYamamHistoryofLightedStyletIn1977,Fosterusedatransilluminatingfiberopticbundletofacilitatetrachealintubationinayoungchildwithtrismus.Anaesthesia1977;32:1038DucrowusedaFlexi-lum?toachievethesameendbyfirstpassingaguideintothetracheafollowedbypassageofthetrachealtubeovertheguide.Anaesthesia1978;33:827–9HistoryofLightedStyletIn19HistoryofLightedStyletRayburncommentedthattheFlexi-lum?(flexiblesurgicallight)couldbepositionedinsidethetrachealtube,therebyshorteningtheintubationsequenceandclaimedthatthetechnique,nicknamed“l(fā)ightwandintubation.”Anaesthesia1979;34:677–8HistoryofLightedStyletRaybuTrachlight?Wand ETTsizeSmall 2.5#~4.0#Medium 4.5#~5.5#Large 6.0#~Trachlight?LightwandIntubationTransilluminationofnecktissuesFlexiblestyletcontainsadistallightbulbLightwandIntubationTransilluJawliftedwithnon-dominanthandJawliftedwithnon-dominanthObservingtheglowontheneckObservingtheglowontheneckHelpfulManeuversforTrachlightJawlift(Jawthrust)HyperextensionoftheheadandneckUseofthethumbtoliftthetongueHavinganassistanttopullthetongue

Anesthesiology2019;83:509-514HelpfulManeuversforTrachligIntubationwithTrachlight(I)IntubationwithTrachlight(I)IntubationwithTrachlight(II)IntubationwithTrachlight(IIAdvantagesofTrachlightEasytolearnanduseLesstraumaticSuitableforpediatricpatientsMayuseinnasaltrachealintubationMayuseinambientlightAdvantagesofTrachlightEasyComplicationsInstrumentdisarticulationTraumatotheupperairwaybleedingsorethroathoarsenessdysphagiaArytenoidcartilagedislocationComplicationsInstrumentdisartIndicationsDifficultairwayUnintubatablebydirectorfiberopticlaryngoscopyNeckmobilityislimitedorcontraindicatedPreventionofdentalinjuryIndicationsDifficultairwayContraindicationsAbsoluteUpperairwayforeignbody,tumor,polyp,retropharyngealabscess.RelativetraumavictimwithlaryngealinjuryknowndifficultairwayContraindicationsAbsoluteEnvironmentforTrachlightAmbientlight--78.5%Dimmed--8.7%Dark--12.2%

Anesthesiology2019;83:509-514EnvironmentforTrachlightAmbEffectofCricoidPressureonLightwandIntubationTimetosuccessfulintubationissignificantlyprolongedThefailurerateforthefirstattemptis13%.

Anesthesiology.94(2):259-262,2019EffectofCricoidPressureonIntubationwithTrachlight(I)IntubationwithTrachlight(I)IntubationwithTrachlight(II)IntubationwithTrachlight(IIIntubationwithTrachlight(III)IntubationwithTrachlight(IIHybridTechniquesWithDirectLaryngoscopyLight-guidedNasalIntubationWithLaryngealMaskAirwayWithFiberopticScopeAirwayIntroducerLight-guidedRetrogradeIntubationHybridTechniquesWithDirectOpticalStylet

可視光棒OpticalStylet

可視光棒HistoryofOrotrachealIntubationTheearliestreportsofblindorotrachealintubation(BOI)inanaesthesiadatebackto1880.WilliamMacEwendescribedawakeBOIbyinternalpalpation.BrMedJ1880;2:122-4and163-5.HistoryofOrotrachealIntubatHistoryofOrotrachealIntubationFranz

Kuhn(1866-1929)Herecommendedtheuseofflexiblemetaltubeswhichweregenerallyintroducedintothetracheaunderdigitalcontrol.HesuggestedtheadvantageoususeofKirstein'sautoscope(aforerunnerofmodernlaryngoscopes)

HistoryofOrotrachealIntubatTechniquesforBOI1.Palpation2.Malleablestylet3.Dividedoropharyngealairway4.Williamsairwayintubator5.Lightwand6.LaryngealMaskAirway7.Endotroltubewithcapnography8.AugustineGuide9.Combitube10.Retrogradeintubation11.FluoroscopyTechniquesforBOI1.PalpationAlternativeIntubationDevicesFlexiblefiberopticbronchoscope(64%)Retrogradeintubationkit(45%)Lightedstylet(35%)Rigid