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1、纤维支气管镜检查在ICU中的应用,翁恒,Bronchoscopy in the ICU,适应症 诊断,观察喉、气管、支气管：损伤、咯血定位、肺不张原因、肿瘤、粘膜改变（支气管侵袭性曲霉菌）、分泌物性状、支气管食道瘘。 支气管肺泡灌洗（细胞学、革兰氏染色、致病菌培养）：支气管肺感染、肿瘤、结核病、肺泡蛋白沉着症、肺泡出血。 经纤支镜肺活检：真菌、结核、肿瘤、血管炎,适应症 治疗,协助气管插管、换管、拔管 吸除血块及浓稠分泌物 去除支气管异物 支气管胸膜瘘封堵 气管狭窄扩张 局部用药,相对禁忌症,不能纠正的凝血功能异常 机械通气需要高PEEP时的TBLB。 进食后 心肺功能级不稳定,并发症,误吸
2、喉、气管支气管痉挛 心律失常 低氧血症，继发发热感染 加用麻醉镇静剂导致的呼吸抑制及低血压。 损伤性操作后的咯血及气胸,注意事项 BRONCHOSCOPY IN (ICU),术前应充分考虑气管导管内径. ICU病人 应充分考虑术后的高并发症，操作的必要性和操作者的熟练程度。 充分的生理指标监测 恰当设置机械通气参数，操作过程保证充分的氧合 操作者应熟悉并充分准备麻醉镇静剂,6,气管导管尺寸,在非插管病人仅占全部气管面积的1015%。 5.7 mm 纤支镜占9 mm气管插管面积的40% 占 7 mm tracheal tube的66% 。 因此，操作前应充分考虑插管导管内径及纤支镜外径。 气管导
3、管会对纤支镜造成损伤，特别是当纤支镜回撤时，边缘锐利的导管前端易损伤纤支镜。 应使用润滑剂.,7,机械通气设置,术前、术中及术后的短时间内尽量给与100%的氧浓度。 一般设置成控制通气模式. PSB模式常不能保持充分的通气。 带隔膜孔的延长管可在机械通气的同时进行纤支镜检查。,8,注意安全性?,5.7-mm 支气管镜通过8-mm内径气管导管截面积减少66%. 吸气压升高 高PEEP 增加气压伤风险 感染播散的风险,CO, HR (50%), BP myocardial oxygen demand and risk of cardiac ischemia 2/3 of 107 ptsPaO2 3
4、0%, 6% major arrythmia in 120s procedureTrouillet et al. Chest 1990;97:927-933 17% of pts 50 years old had ST-segment changeMatot et al. Chest 1997;112:1454-1458 ICP (81%), from 12 to 38 mmHgKerwin et al. J Trauma 2000;48:878-882,Matsushima et al. Chest 1984;86:184-188,Lindholm et al. Chest 1978;74:
5、362-368,与纤支镜相关的ICU绿脓杆菌播散,17 pts (risk ratio 3.8, 95% CI 2.5-3.9)Bou et al. J Hosp Infect 2006;64:129-135 18 pts CDC. MMWR Morb Morral Wkly Rep 1999;48:557-560 39 pts Srinivasan et al. NEJM 2003;348:221-227,14,SEDATION DURING FLEXIBLE BRONCHOSCOPY(2),How sedation is given? most sedation regimens are
6、based upon a single dose or incremental doses of an intravenous sedative agent administered at the time of bronchoscopy. MIDAZOLAM (Dormicum) Midazolam is a water soluble benzodiazepine with an elimination half life of about 2 hours and is generally preferred to diazepam. Its onset is rapid and dura
7、tion of action brief in healthy individuals. A better approach of giving is incremental dosing which achieves improved tolerance of bronchoscopy,15,SEDATION DURING FLEXIBLE BRONCHOSCOPY(3),COMBINATIONS WITH NARCOTIC DRUGSA combination of a benzodiazepine and narcotic has been widely used. Unfortunat
8、ely, such a combination may be associated with more arterial desaturation and CO2 retention than when using midazolam alone.,诊断感染性疾病,Non-invasive Routine tracheal aspirate trapping Often colonized and relatively insensitive Invasive Protected Brush specimen BAL Trial in 2000 suggested that patients
9、managed according to results from specimens collected by PBS or BAL showed improved survival, reduced antibiotic use, earlier resolution of organ dysfunction (Fagon, Chastre for the VAP trial group. Annals Intern Med 2000;132:621-30),支气管肺泡灌洗BAL,Obtained by wedging the tip of a bronchoscope in the me
10、dium sized bronchus relevant to the area of pulmonary infiltrate on CXR Samples approx 1 mill alveoli Lavage with 20-30mls NaCl and after 5-10sec a sample of 5-10ml is obtained by gentle suctioning Culture of 104 colony forming units /ml indicative of pneumonia Blind non bronchoscopic lavage may als
11、o be carried out but subject to contamination Complications similar to bronchoscopy,BAL,Obtained by wedging the tip of a bronchoscope in the medium sized bronchus relevant to the area of pulmonary infiltrate on CXR Samples approx 1 mill alveoli Lavage with 20-30mls NaCl and after 5-10sec a sample of
12、 5-10ml is obtained by gentle suctioning Culture of 104 colony forming units /ml indicative of pneumonia Blind non bronchoscopic lavage may also be carried out but subject to contamination Complications similar to bronchoscopy,防污染毛刷 Protected brush specimen,PBS double lumen brush system that avoids
13、upper airway contamination of the sample Introduced blindly or fibreoptically into the area of infiltrates on CXR Inner cannula advanced and specimen collected 103 cfu/ml diagnostic of pneumonia Only small area sampled, may lead to false negatives, especially if on antibiotics (preventing admin of a
14、ntibiotics) Contamination can still occur Complications -arrhythmias,pneumothorax,Evidence,MCRCT comparing BAL and ET aspiration for diagnosis of VAP Concluded both associated with similar clinical outcomes and similar use of antibiotics However at least 40% patients excluded represent the usual tha
15、t would concern us(Canadian critical care trials group, NEJM 2006;355:2619-30),PBS v BAL,Comparison shows conflicting results No real agreement on which has better sensitivity or specificity Recent meta-analysis concluded both equally accurate in diagnosing pneumonia but, in patients already on antibiotics at the time of sampling BAL is more sensitive (de Jaeger, Litalien, lacroix, Protected brush specimen or BAL to diagnose bacterial pneumonia in ventilated patients. CCM 1999;27:2548-60),临床应用经验,诊断：病例分享 治疗：病例分享,
