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1、RigidBronchoscopy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4Case18设备设备BRONCHOSCOPEEFER-D
2、UMON 9Optics10VideoEquipment11Asetoftubes12The 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Endoscopicscalpel WirecutterEndoscopicscissors Theendoscopicresector 17Balloons Mechanicaldilator The laser fiber sheathAssessment病史与体检（是否存在）： 凝血病病 合并存在的心肺疾病 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
3、常规有凝血功能 血生化 动脉血气 心电图 胸部CT18Case2lM,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。202124Case2302.EndoscopicassessmentThe 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 length of involvement The ap
4、parent vascularity of a tumor. 胸部胸部CT（2014.7.28）支气管镜（支气管镜（2014.7.30）40AnesthesiaThe majority of endoscopic resections require the use of the rigid bronchoscope under general anesthesia. Suppressing consciousness and vagal reflexes, but allowing spontaneous ventilation：spontaneous manually assisted v
5、entilation 4142Induction : 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. 43IntubationThe patient is supine and the neck hyperexten
6、ded. The upper teeth are protected by the left thumb.The beveled tip of the bronchoscope should always be anterior. 44Once the epiglottis is lifted gently with the beveled tip of the bronchoscope, 45Arytenoids must be identified. 46The vocal cords are located anteriorly in the medial axis of these l
7、andmarks. 47The bronchoscope is then advanced past the vocal cords and into the trachea while rotating the tip. 4849Locationofthetumor&Successfulresection50MechanicaldebridementMechanical debridement is often carried out following laser coagulation. 51ResectorThe endoscopic resector acts as a guillo
8、tine-like instrument sectioning large tumor fragments effortlessly under direct visualization. 5253Laser5455DilatationProgressive dilatation of airway stenosis can be achieved with bronchoscopes of growing diameter. Tube orientation is simple in the trachea and slightly harder in the main stem bronc
9、hi, particularly the left main stem. 56Case360Scissors,scalpel,andforceps61TheMontgomeryTtubeThis stent is widely used today and can be employed in the treatment of tight stenoses or complete obstruction. 626364SiliconeStentsDumon in Marseille proposed an original tracheobronchial silicone stent in
10、1987 (the Dumon-stent). 65tubularstentsThe 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.66YstentsYstentsdesigned to treat tumors e
11、xtending 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. 67IndicationsThe principal indication for airway stenting is extrinsic compression of the airway. other indications : bronchial fistula, tracheob
12、ronchomalacia 68Y stent placement is reserved for tumors extending to the carina. 69ChoiceofthediameterandthelenghtThe 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 by retracting the bronchosco
13、pe or telescope along the entire length of the stenosis. 70PlacementPlacement 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 stent is pushed out into the tr
14、achea or the bronchus.71Efer-DumonapplicatorTwo kind of loaders: tracheal or bronchial stent, Y stent or long and large straight stent.On the right two size of applicators.72Adjusting the stent is made by grasping the upper rim of the prosthesis with forceps.7374StentrelatedcomplicationsStent obstru
15、ctionMigrationGranulomatous inflammation 75Silicone 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Case480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!
