1、支气管镜的基本操作1 w 支气管镜的适应症，禁忌症w 支气管镜术前的准备工作w 气管-支气管的解剖结构w 支气管镜的基本操作方法2支气管镜的适应症 3诊断方面w 不明原因的咯血，慢性咳嗽，声音嘶哑，局限性哮鸣音w 支气管感染性疾病的病因学诊断w 肺炎w 胸片或CT检查异常w 已诊断肺癌术前检查，指导手术范围及估计预后w 食管-支气管瘘的确诊w 胸部外伤，怀疑有支气管裂伤和断裂4治疗方面w 取出支气管异物w 某些肺不张，肺脓疡等w 咯血治疗w 引导气管插管w 支气管镜下治疗5 支气管镜的禁忌症6 w 活动性大出血w 不能纠正的出血倾向w 尿毒症，活检易出血者w 严重肺动脉高压，活检易出血者w 严
2、重心、肺功能障碍w 严重心律失常w 新近发生心肌梗死或心绞痛w 疑有主动脉瘤w 全身情况极度衰竭w 严重的上腔静脉阻塞综合征7 支气管镜术前准备8术前检查术前检查w 了解病史、测量血压及心肺体检w 胸片或胸部CT检查w 出、凝血时间、血小板记数w 乙肝两对半w ECG检查w 血气分析9患者准备患者准备w 向患者讲明检查目的、意义、配合方法w 术前签字w 术前禁食6小时w 术前30分钟肌注安定和阿托品w 有异齿术前摘下 10 气管支气管的 解剖结构111213 14 1516支气管镜操作方法 1718192021支气管分支命名右肺右肺左肺左肺上叶B1尖段上叶上叶分支B1+2尖后段B2后段B3前段
3、B3前段中叶B4外段舌叶B4上舌段B5内段B5下舌段下叶B6背段下叶B6背段B7内基底段B8前基底段B8前基底段B9外基底段B9外基底段B10后基底段B10后基底段22Group 1 Exercises23Step 1:nose to larynxw The scope is advanced from the nose to the larynx.w This step includes local anesthesia24Step 2:larynx to subglottisw From the larynx the trachea is entered to the subglottic
4、 area.w If from the head:If from the head:once the vocal cords are passed the scope is slightly flexed downwards.w If from the front:If from the front:once the vocal cords are passed the scope is slightly flexed upwards.25Step 3:Follow the curve to the carina w The Trachea is not a“straight pipe”;w
5、It deviates posteriorly and slightly to the right when approaching the main carina.26Step 4a:Carina to left main bronchusw From the neutral position the LMB is entered just by twisting the wrist to the left and advancing for 1-2 cm.27Step 4b:Carina to right main bronchusw From the neutral position t
6、he RMB is entered just by twisting the wrist to the right and advancing the scope for 1-2 cm28w From 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 29Step 5a:Down-up-left main bro
7、nchusw The scope is slowly advanced the pulled back up the LMB while always keeping it in the middle of the airway lumen.30Step 5b:Down-up right main bronchusw The scope is slowly advanced down the RMB to RLL and pulled back upwards while always keeping it in the middle of the airway lumen.31Group 2
8、 Exercises32Step 6a:Left main to left upper lobe bronchusw From the LMB the scope is advanced to the entrance of the LUL bronchus.33Step 6b:Left main to left lower lobe bronchusw The scope is advanced down the LMB to the entrance of the LLL bronchus.34Step 6c:Right main to right upper lobe bronchusw
9、 The scope is advanced down the RMB then with the wrist twisted 60 degrees from midline the scope is flexed up to the entrance of RUL.35Step 6d:Right main to bronchus intermediusw From the carina advance the scope down the RMB to the distal bronchus intermedius and visualize the entrance to RB456 an
10、d the basal pyramid.36Step 6e:Right main to right lower lobe bronchusw Advance the scope from the carina to the entrance of the RLL while always keeping it in the midline.37Group 3 Exercises38Step 7a:Left upper lobe uno dosw From the carina,the scope is advanced to LUL entrance;there,just by thumb m
11、ovement,the lingula and upper division bronchus are visualized.39Step 7b:Left before five six(LB 456)w From the LMB,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.w!Wrist movements are“in the mirror”40Step 7c:Le
12、ft B6-8,9,10w With the scope at the LLL bronchus entrance,the superior segment is entered,then alternately,the antero,lateral and postero-basal segments of the LLL are entered.41Step 7d:Right upper lobe uno-dos-tresw From the RMB the scope is advanced and flexed up into the RUL bronchus where just b
13、y wrist and thumb movements the three segments are visualized;then the scope is withdrawn to the main carina.42Step 7e:Right before five six(RB 4,5,6)w From the distal bronchus intermedius,the RML and superior segment are entered alternatively;w!Wrist movements are“in the mirror”.43Step 7f:Right med
14、ial basal(RB7)(d”Artagnan)w From the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered.44Step 8a:Left lower lobe basal pyramidw From the entrance of the LLL bronchus go in and out of the 3 basal segments,then withdraw the scope to the carina.45Step 8b:Right lower lobe basal pyramid(DArtagnan and the three musketeers)w From the carina advance the scope to the RLL bronchus entrance and then enter the medial-basal segment,pull back and then examine the other three segments of the basal pyramid.46
