1、Rigid Bronchoscopy一种介入工具的历史和未来一种介入工具的历史和未来浙江大学附属邵逸夫医院呼吸内科 陈恩国历史回顾历史回顾 1897年，德国ENT医生Gustav Killian第一次应用RB取异物 支气管镜技术之父2纤维支气管镜阶段纤维支气管镜阶段 1967年，历史上第一台纤维支气管镜 1974年，东京，第一届世界支气管学大会WCB3现代电子支气管镜与现代电子支气管镜与RB共用时代共用时代 FB的缺点：管腔狭小、操作器械单一、吸引管口径小易堵塞 RB的优点：操作孔道大、气道控制好、吸引好、可使用各种介入器械 两者结合，联合介入治疗方法4Case 18设备设备 BRONCHOS
2、COPE EFER-DUMON 9Optics10Video Equipment11A set of tubes 12 The BRONCHOSCOPE EFER-DUMON 侧孔与可移除的帽13 激光管与吸引管15辅助设备辅助设备 吸引管 钳子16其他设备其他设备 Endoscopic scalpel Wire cutter Endoscopic scissors The endoscopic resector 17 Balloons Mechanical dilator The laser fiber sheath Assessment 病史与体检（是否存在）：凝血病病 合并存在的心肺疾病
3、 颞下颌关节异常 颈部固定 与麻醉相关的并发症 辅助检查：血常规有凝血功能 血生化 动脉血气 心电图 胸部CT18Case 2lM,声嘶声嘶,有强直性脊炎，颈椎畸形伴活动障碍有强直性脊炎，颈椎畸形伴活动障碍。202124Case 2302.Endoscopic assessment The appearance of any lesions,their intrinsic or extrinsic nature,and their location with respect to the carina,vocal cords,etc.The degree of obstruction and
4、length of involvement The apparent vascularity of a tumor.胸部胸部CT（2014.7.28）支气管镜（支气管镜（2014.7.30）40Anesthesia The majority of endoscopic resections require the use of the rigid bronchoscope under general anesthesia.Suppressing consciousness and vagal reflexes,but allowing spontaneous ventilation：spont
5、aneous manually assisted ventilation 4142 Induction:Midazolam=0,05 mg/kg IV Alfentanyl 40 80 mg gamma/kg IV During spontaneous ventilation,FiO2=100%Anesthesia of the glottis is performed under direct visualization with the laryngoscope by spraying 5%Xylocaine.43Intubation The patient is supine and t
6、he neck hyperextended.The upper teeth are protected by the left thumb.The beveled tip of the bronchoscope should always be anterior.44 Once the epiglottis is lifted gently with the beveled tip of the bronchoscope,45 Arytenoids must be identified.46 The vocal cords are located anteriorly in the media
7、l axis of these landmarks.47 The bronchoscope is then advanced past the vocal cords and into the trachea while rotating the tip.4849Location of the tumor&Successful resection 50Mechanical debridement Mechanical debridement is often carried out following laser coagulation.51Resector The endoscopic re
8、sector acts as a guillotine-like instrument sectioning large tumor fragments effortlessly under direct visualization.5253Laser5455Dilatation Progressive dilatation of airway stenosis can be achieved with bronchoscopes of growing diameter.Tube orientation is simple in the trachea and slightly harder
9、in the main stem bronchi,particularly the left main stem.56Case 360Scissors,scalpel,and forceps61The Montgomery T tube This stent is widely used today and can be employed in the treatment of tight stenoses or complete obstruction.626364Silicone Stents Dumon in Marseille proposed an original tracheob
10、ronchial silicone stent in 1987(the Dumon-stent).65tubular stents The tracheal stents are generally 50 to 60 mm long(maximum 110 mm),and 14 to 16 mm in diameter(maximum 18 mm).Bronchial stents are manufactured with diameters ranging from 10 to 12 mm and lengths between 20 to 40 mm.66Y stents Y stent
11、s designed to treat tumors extending to the carina.The lengths reaching up to 110 mm for the trachea,and 50 mm for the main stem bronchi.The right main stem limb may be fenestrated.67Indications The principal indication for airway stenting is extrinsic compression of the airway.other indications:bro
12、nchial fistula,tracheobronchomalacia 68 Y stent placement is reserved for tumors extending to the carina.69Choice of the diameter and the lenght The diameter of the stent will depend on the external diameter of the bronchoscope used(yellow tube 16/15,red tube 14/13/12),while the length is measured b
13、y retracting the bronchoscope or telescope along the entire length of the stenosis.70Placement Placement is performed using a tracheal or bronchial rigid tube.The stent is lubricated with silicone and loaded into a stent applicator.The applicator is the inserted through the bronchoscope and the sten
14、t is pushed out into the trachea or the bronchus.71Efer-Dumon applicator Two kind of loaders:tracheal or bronchial stent,Y stent or long and large straight stent.On the right two size of applicators.72 Adjusting the stent is made by grasping the upper rim of the prosthesis with forceps.7374Stent rel
15、ated complications Stent obstruction Migration Granulomatous inflammation 75 Silicone coated stents are also available,either reinforced by a metallic(dynamic stent de Freitag)or synthetic(Polyflex)frame.76气管气管/支气管支架支气管支架Case 480气管插管气管插管 OR 喉罩喉罩?硬质气管镜硬质气管镜8384综合治疗综合治疗8586总总 结结 Interventional PulmonologyNot your grandfathers pulmonary medicine!RB仍是肺脏介入病学专业基础 支气管镜介入治疗大有发展前景：RB与FB结合87Thanks!
