1、PPT内容可自行编辑内镜与清醒纤支镜插管主讲：XX XX 凡大医治病，必当安神凡大医治病，必当安神定志，无欲无求，先发大慈恻定志，无欲无求，先发大慈恻隐之心，誓愿普救含灵之苦。隐之心，誓愿普救含灵之苦。-孙思邈孙思邈开始上课！PPT内容可自行编辑困难气道管理技术困难通气技术困难插管技术插管策略Strategies for Intubation麻醉医生应事先制定困难气道的插管策略Anesthesiologist should preformulate strategy for intubation of the difficult airway.策略将取决于择期手术类型、患者情况、麻醉医生的技术
2、和喜好Strategy will depend on the anticipated surgery,the condition of the patient,and the skills and preferences of the anesthesiologist.Anesthesiology 2013,ASA Practice Guidelines建议策略Recommended Strategy1.评估气道条件Assess the basic airway problem2.考虑四套基本管理选择方案Consider four basic management choices3.确认首选的
3、插管方案Identify the preferred approach to intubation4.确认一套可供替代的插管方案Identify an alternative approach to intubation5.用呼末CO2 确认气管插管Confirm tracheal intubation with exhaled CO2Anesthesiology 2013,ASA Practice Guidelines气道问题的评估Assessment of Airway Problem评估6项可能单独或合并发生的气道问题其可能性和临床影响Assess the likelihood and
4、clinical impact of 6 basic problems that may occur alone or in combination:1.患者合作或知情同意困难difficulty with patients cooperation or consent2.面罩通气困难difficult mask ventilation3.声门上喉罩放置困难difficult supraglottic airway placement4.困难喉镜difficult laryngoscopy5.困难插管difficult intubation6.困难外科气道通路difficult surgica
5、l airway access管理选择Management Choices考虑四套基本管理选择方案Consider the four basic management choices1.清醒插管v.s 镇静插管 awake intubation versus asleep intubation2.非侵袭性技术v.s 侵袭性技术noninvasive versus invasive techniques3.可视喉镜video-assisted laryngoscopy4.保留自主呼吸v.s无自主呼吸preservation versus ablation of spontaneous venti
6、lation 首选的插管方案Preferred Intubation Approach 确认1套主要或首选的插管方案：Identify a primary or preferred approach to:1.清醒插管awake intubation2.可实施通气但插管困难的患者the patient who can be ventilated but is difficult to intubate3.不能实施通气或插管患者面对的生命威胁状况life threatening situation in which the patient cannot be ventilated or intu
7、bated可选的插管方案Alternative Approach to Intubation如果首选方案失败或不可行，确定可选的插管方案有效Identify alternative approaches that can be used if the primary approach fails or is not feasible1.患者不合作或儿科患者uncooperative or pediatric patient2.局麻手术或区域神经阻滞仍旧需要气道管理计划surgery using local anesthetic or regional nerve blockadestill n
8、eeds plan for airway management通气或气管插管的确认方法Confirm Ventilation or Tracheal Intubation1.CO2 浓度监测仪Capnography2.呼末CO2 监测仪End-tidal carbon dioxide detector困难气道管理的基本准备Basic Preparation for Difficult Airway Management有可用的困难气道设备Have equipment for difficult airway available对伴有明确或可疑困难气道患者的告知Inform the patien
9、t with known or suspected difficult airway有可用的助手Have an assistant available预先面罩供氧Pre-oxygenate by mask整个困难气道管理过程中辅助氧气的供给Administer supplemental oxygen throughout the process of difficult airway management Techniques for Difficult Ventilation气管内喷射探针Intratracheal jet stylet侵入性导气管Invasive airway access
10、声门上喉罩Supraglottic airway口咽和鼻咽通气道Oral and nasopharyngeal airways刚性通气支气管镜Rigid ventilating bronchoscope双人面罩通气Two person mask ventilationAnesthesiology 2013,ASA Practice Guidelines清醒插管Awake intubation盲探插管Blind intubation纤支镜插管Fiberoptic intubation管芯或导管转换装置Intubating stylet or tube-changers声门上喉罩作为插管导引管Su
11、pragottic airway as an intubating conduit不同型号和尺寸的喉镜片Laryngoscope blades of varying design and size光索气管插管Light wand可视喉镜VideolaryngoscopeAnesthesiology 2013,ASA Practice Guidelines困难插管技术Techniques for Difficult Intubation插管所需的内镜及装置Scopes andDevices For IntubationFlexible Fiberoptic Scope纤支镜Flexible Fi
12、beroptic Scope 相比其它插管装置有较多用途Has more universal application than any other device可经口、鼻使用，当进入受限时亦可评估上、下气道问题Can be used orally or nasally,to assess both upper and lower airway problems when access is limited可用于任何年龄患者Can be used in any age patient任何情况下均可使用Can be used in any position管端或导槽-可行分泌物吸引、液体注射或注氧
13、Instrument port or working channelcan be used for aspiration of secretion,injection of fluid,or insufflation with O2有助气管导管形成想要的弧度Help to shape endotracheal tubes to the desired curvature 管芯Intubating Stylets插管探条Bougie Stylet对伴有喉头前突和张口受限的患者有用Useful in patients with anterior larynx and those with limi
14、ted mouth opening探条头端置入声门，然后顺探条滑动气管导管Place bent tip into the glottis then slide endotracheal tube over stylet导管转换装置Tube-Changers促进气管导管的转换Facilitate exchange of tracheal tubes 可行供氧Allows oxygenation Aintree 导管(56cm)-较粗的直径允许纤支镜通过其内腔，亦可作为桥接装置将喉罩转换成气管导管 Aintree Catheter(56cm)-larger diameter allows pass
15、age of fiberoptic scope through its lumen,can be used as a bridging device to exchange LMA for endotracheal tube光索和光导芯Light Wand and Optical StyletShikani 内镜Shikani Scope光索Light Wands光索和光导芯Light Wand and Optical Stylet当声门直视困难时用以环甲膜透照Use transillumination of cricothyroid membrane when direct visualiz
16、ation of glottis is difficult创伤病例时最小的颈部弯曲和过度伸展Minimizes neck flexion and hyperextension in trauma cases光导芯预塑形亦可直视声门Optical Stylet-preshaped,also allows for direct visualization of glottis喉镜Laryngoscopes光导/可视喉镜Optical/VideolaryngoscopeC-MacAirtraqGlideScope可视喉镜Videolaryngoscope较好的气道成像，用图例1喉镜通常可降低气道分级
17、Better view of airway,usually decrease airway grade by 1对清醒插管有用Useful for awake intubation用以教学，观摩者亦可看到Useful for education,others can see also可联合管芯使用May need to use in combination with stylet 某些伴有最小张口度的患者不能使用May not work in someone with minimal mouth openingAirtraq instructional video基本清醒插管技术Basic A
18、wake Intubation Technique告诉患者程序，获得知情同意Talk to the patient about the process,obtain consentGive antisialoguoge,oxygen必要时给予镇静药Give sedation as neededTopicalize airway插管Intubate清醒纤支镜插管是已知困难气道管理的金标准Awake Fiberoptic Intubation is the GOLD STANDARD for known difficult airway management.纤支镜插管经常被认为是一项困难的技术F
19、iberoptic intubation is often thought of as a difficult technique.成功的关键在于系统性培训和经常使用The key to success is a structured training program and regular use.可以考虑首先在容易气道入睡患者身上练习直至熟练内镜操作May consider practice in asleep patients with easy airway until proficient with scope first.上呼吸道神经阻滞技术Techniques for Block
20、ing Nerves of Upper Airway1.应用喷雾剂Topical spray application2.脱脂棉浸泡直接粘膜接触Direct mucosal contact of soaked pledgets3.直接注射浸润Direct infiltration by injection4.以上技术联合使用Combination of above techniques上呼吸道3支神经3 Nerves of Upper Airway1.舌咽神经Glossopharyngeal nerve(CN IX)口咽和舌的后1/3 oropharynx and posterior 1/3 o
21、f tongue2.喉上神经Superior laryngeal nerve(branch of vagus nerve or CN X)-声带以上喉部larynx above the cords3.喉返神经Recurrent laryngeal nerve(branch of CN X)-声带以下喉和气管larynx and trachea below the cords神经阻滞Nerve Blocks舌咽神经阻滞Glossopharyngeal block口咽for oropharynx喉上神经阻滞Superior laryngeal block声带以上喉部larynx above the
22、 cords喉/气管阻滞Translaryngeal/transtracheal block 阻滞喉返神经(blocking recurrent laryngeal nerve)声带以下喉和气管larynx and tracheal below the cords舌咽神经阻滞Glossopharyngeal Block口内入路：口内入路：Intraoral approach:张口后表面麻醉舌，采用22g针，在扁桃体后的咽腭弓注射5ml利多卡因the mouth is opened and after anesthetizing the tongue with topical anesthesi
23、a,5 ml of lidocaine is injected at the caudal aspect of posterior tonsillar pillar(咽腭弓褶皱处palatopharyngeal fold),using 22g needle喉上神经阻滞Superior Laryngeal Block阻滞于舌骨和甲状软骨间也就是穿过甲状舌骨膜Blocked between hyoid bone and thyroid cartilage where it penetrates the thyrohyoid membranePhoto from Peripheral Nerve B
24、locks,2nd Edition(2004)by JE Chelly喉/气管阻滞Translaryngeal/Transtracheal Block在呼气末通过环甲膜回抽到空气，注射2利多卡因2ml和3ml空气。After aspirating air through the cricothyroid membrane on end expiration,inject 2 ml of 2%lidocaine and 3 ml air in 1 syringe咳嗽有助于局麻药在气管内扩散。Cough will help spread local anesthetic.局麻喷雾首选技术 Topi
25、cal SprayPreferred Technique1.通过使用标准雾化器2-10L/min雾化4利多卡因（2-4ml）超过10分钟,在此期间患者应深慢呼吸以使局麻药物向更深气道扩散Deliver nebulized 4%lidocaine(2-4 ml)over 10 minutes using a standard nebulizer/atomizer with O2 10L/minutepatient should take slow deep breaths to facilitate distribution of local anesthetic to the lower ai
26、rway2.若为鼻部使用，可在鼻内置入2利多卡因凝胶（1-2ml）并借助鼻内扩张器使鼻腔不断扩大。For the nose,place 2%lidocaine jelly(1-2 ml)within the nostril and serially dilate with nasal trumpets3.Administer additional 4%lidocaine(2 ml aliquots/each)via the working channel of the bronchoscope 1.right above the vocal cords2.right below the voc
27、al cords清醒纤支镜插管技术Awake Fiberoptic Intubation Technique 向患者解释操作过程以取得患者合作。Explain process to the patient to obtain patients cooperation.术前静注0.1-0.2mg格隆溴铵来帮助减少分泌物。Premedicate with glycopyrrolate 0.1-0.2 mg IVhelps to reduce secretions.用鼻导管给予氧气补充Give supplemental oxygen by nasal cannula.根据需要给予最小剂量镇静（咪达唑
28、仑，右美托咪啶，瑞芬太尼）保持患者清醒并能够配合。Give minimal sedation as needed(Midazolam,Precedex,Remifentanil)Keep patient awake and cooperative.经口、经鼻路径都应进行气道表面麻醉Topicalize airway for both nasal and oral routes.当咽反射消失时评估表麻是否充分Assess topicalizationadequate when gag reflex is absent.充分表麻后再插管Intubate after adequate topical
29、 anesthesia.成功要点Tips for Success经鼻气管插管要比经口插管容易Nasal intubation is easier than oral intubation请助手帮忙挡开舌并托起下颌打开气道，同样可用Ovassapian 通气道帮助经口气管插管。Ask assistant to pull our tongue and give chin liftto open up airway.Can also use Ovassapian Airway to aid in oral intubation.纤支镜更容易通过内径较小的气管导管是因为其直径差异更小Easier to
30、 thread smaller endotracheal tube over fiberscope because of the smaller difference in diameter如果气管内导管不能轻易的通过，旋转180度。同样可以使用末端呈锥形的气管导管。If endotracheal tube(ETT)does not pass easily,turn it 180 degrees.Can also use tapered end ETT.气道阻滞不充分可能会导致喉痉挛Inadequate airway block may cause laryngospasm练习，练习，再练习！练习，练习，再练习！PRACTICE,PRACTICE,PRACTICE!Awake FOI videoAristotle,The Nicomachean Ethics“For the things we have to learn before we can do them,we learn by doing them.”“对于很多事情我们需要先学习，才能去做，我们从实践中学习他们。”亚里士多德,Nicomachean 伦理学谢谢聆听
