1、插管探条之临床应用插管探条之临床应用 u陳昭良主任u彰化基督教醫院麻醉科What a bad luck!If this is a Difficult Intubation situation.What are our back-up plans?What other gadgets do we have?Non-invasive Glottis InvasiveFrom Below the Glottis(Invasive)u Transtracheal Jet Ventilation(TTJV)u Retrograde Intubationu Percutaneous dilational
2、tracheal entryu Surgical AirwayFrom Above the Glottisu Laryngoscope Gum Elastic Bougieu Blind Oral/Nasal Intubationu Fiberoptic Bronchoscopyu Intubating LMA(Fastrach)u GlideScopeu Lighted Stylet(Trachlight)u Optical StyletEschmann tracheal tube introducer“Gum Elastic Bougie”History of Gum Elastic Bo
3、ugieuThe Eschmann tracheal tube introducer(gum elastic bougie)was marketed in the United Kingdom(UK)in the early 1970s.uIt differs from previous introducers in its greater length(60 cm),angled tip,and the combination of flexibility and malleability.Anesthesiology:100(5)2019:1146-50“GEB“vs Difficult
4、Intubation2019 巴黎聖心堂巴黎聖心堂Lighted Stylet(Lightwand)光棒光棒History of Lighted StyletuThe first reported use of a lighted stylet used to facilitate intubation came in 1957.uMacintosh described an 18-inch illuminated tracheal tube introducer,which was designed to stiffen the tube and better illuminate the
5、cords by supplementing the light of the laryngoscope.Anaesthesia 1957;12:2235History of Lighted StyletuYamamura et al.described a light bulb-tipped wire that was inserted into the tracheal tube before blind nasal intubation in awake patients.The tube position was then determined by the medial transi
6、llumination of the external throat and neck.Anesthesiology 1959;20:221History of Lighted StyletuIn 1977,Foster used a transilluminating fiberoptic bundle to facilitate tracheal intubation in a young child with trismus.Anaesthesia 1977;32:1038uDucrow used a Flexi-lum to achieve the same end by first
7、passing a guide into the trachea followed by passage of the tracheal tube over the guide.Anaesthesia 1978;33:8279History of Lighted StyletuRayburn commented that the Flexi-lum(flexible surgical light)could be positioned inside the tracheal tube,thereby shortening the intubation sequence and claimed
8、that the technique,nicknamed“lightwand intubation.”Anaesthesia 1979;34:6778TrachlightWandETT size Small2.5#4.0#Medium4.5#5.5#Large6.0#Lightwand Intubationu Transillumination of neck tissuesu Flexible stylet contains a distal light bulb1.Jaw lifted with non-dominant hand2.Observing the glow on the ne
9、ckHelpful Maneuvers for Trachlightu Jaw lift(Jaw thrust)u Hyperextension of the head and necku Use of the thumb to lift the tongueu Having an assistant to pull the tongue Anesthesiology 2019;83:509-514Intubation with Trachlight(I)Intubation with Trachlight(II)Advantages of Trachlightu Easy to learn
10、and useu Less traumaticu Suitable for pediatric patientsu May use in nasal tracheal intubation u May use in ambient lightComplicationsuInstrument disarticulationuTrauma to the upper airway bleeding sore throat hoarseness dysphagiau Arytenoid cartilage dislocationIndicationsu Difficult airwayu Unintu
11、batable by direct or fiberoptic laryngoscopyu Neck mobility is limited or contraindicatedu Prevention of dental injuryContraindicationsuAbsolute Upper airway foreign body,tumor,polyp,retropharyngeal abscess.uRelative trauma victim with laryngeal injury known difficult airwayEnvironment for Trachligh
12、tu Ambient light -78.5%u Dimmed -8.7%u Dark -12.2%Anesthesiology 2019;83:509-514Effect of Cricoid Pressure on Lightwand Intubationu Time to successful intubation is significantly prolongedu The failure rate for the first attempt is 13%.Anesthesiology.94(2):259-262,2019Intubation with Trachlight(I)In
13、tubation with Trachlight(II)Intubation with Trachlight(III)Hybrid Techniquesu With Direct Laryngoscopyu Light-guided Nasal Intubationu With Laryngeal Mask Airwayu With Fiberoptic Scopeu Airway Introduceru Light-guided Retrograde IntubationOptical Stylet可視光棒可視光棒History of Orotracheal IntubationuThe e
14、arliest reports of blind orotracheal intubation(BOI)in anaesthesia date back to 1880.uWilliam MacEwen described awake BOI by internal palpation.uBr Med J 1880;2:122-4 and 163-5.History of Orotracheal IntubationuFranz Kuhn(1866-1929)uHe recommended the use of flexible metal tubes which were generally
15、 introduced into the trachea under digital control.uHe suggested the advantageous use of Kirsteins autoscope(a forerunner of modern laryngoscopes)Techniques for BOI1.Palpation2.Malleable stylet3.Divided oropharyngeal airway4.Williams airway intubator5.Lightwand6.Laryngeal Mask Airway7.Endotrol tube
16、with capnography8.Augustine Guide9.Combitube10.Retrograde intubation11.FluoroscopyAlternative Intubation Devices uFlexible fiberoptic bronchoscope(64%)uRetrograde intubation kit(45%)uLighted stylet(35%)uRigid fiberoptic device(6%)Bullard Wu-scope Annals of Emergency Medicine.33(6):694-8,2019Flexible
17、 Fibreoptic and IntubationuIn 1967 Murphy reported successful nasal intubation using a flexible choledochoscope placed through a tracheal tube.Anaesthesia 1967;22:489-91History of“Optical Stylet”Katz and Berci coined the term“Optical Stylet”in 1979 to describe a straight rigid endoscope used as a tracheal tube stylet during intubation.Anesthesiology 1979;51:251-4Shikani Optical Stylet(S.O.S)
