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1、上海交通大学附属第六人民医院麻醉科赵达强 超声在气道管理中的应用2016-5-27上海市第六人民医院ShanghaiSixthPeoplesHospital颈部气道解剖上海市第六人民医院ShanghaiSixthPeoplesHospital定位喉上神经Thethyrohyoidmembraneasatargetforultrasonography-guidedultrasonography-guidedblockoftheinternalbranchofthesuperiorlaryngealnerveStopar-PintaricT,VlassakovK,AzmanJ.JClinAnest
2、h.2015Nov;27(7):548-52.Inconclusion,weareproposingananatomicalconceptforanew,new,simpler,consistentlyreproduciblesimpler,consistentlyreproducibleUS-guidediSLNblocktechniqueusingthethyrohyoidmembranetodefinethetargetplaneforlow-volumelocalanestheticinjection.上海市第六人民医院ShanghaiSixthPeoplesHospital外外侧侧舌
3、骨舌骨外外侧侧舌骨舌骨超声影像舌骨、喉上神经外外侧侧过拱桥，甲舌膜里寻喉上上海市第六人民医院ShanghaiSixthPeoplesHospital定位环甲膜Theconventionalmethod,inspectionandpalpation,hasalowsuccessrate,especiallyinwomen(2435%).ElliottDS,BakerPA,ScottMR,etal.AccuracyofsurfacelandmarkidentificationforcannulaElliottDS,BakerPA,ScottMR,etal.Accuracyofsurfaceland
4、markidentificationforcannulacricothyroidotomy.Anaesthesia2010;65:88994cricothyroidotomy.Anaesthesia2010;65:88994 LambA,ZhangJ,HungO,etal.AccuracyofidentifyingthecricothyroidmembranebyanesthesiaLambA,ZhangJ,HungO,etal.AccuracyofidentifyingthecricothyroidmembranebyanesthesiatraineesandstaffinaCanadian
5、institution.CanJAnaesth2015;62:495503traineesandstaffinaCanadianinstitution.CanJAnaesth2015;62:495503上海市第六人民医院ShanghaiSixthPeoplesHospital上海市第六人民医院ShanghaiSixthPeoplesHospital上海市第六人民医院ShanghaiSixthPeoplesHospitalSiddiquiN,ArzolaC,FriedmanZ,etal.Anesthesiology.2015Nov;123(5):1033-41.定位环甲膜Ultrasound U
6、ltrasound ImprovesCricothyrotomySuccessinCadaverswithPoorlyDefinedNeckAnatomyUltrasoundguidancesignificantlydecreasedtheincidenceofinjuriestothelarynxandtracheaIncreasedtheprobabilityofcorrectinsertionby5.6timesincadaverswithdifficultandimpossiblelandmarkpalpation.上海市第六人民医院ShanghaiSixthPeoplesHospit
7、al外外侧侧甲状软骨甲状软骨声声带带声声带带环甲膜环甲膜外外侧侧超声影像甲状软骨、环甲膜外外侧侧越尖峰，缺口越尖峰，缺口伪影伪影环甲膜环甲膜甲状软骨甲状软骨声声带带声声带带伪影伪影上海市第六人民医院ShanghaiSixthPeoplesHospital超声影像环状软骨环状软骨外外侧侧气管软骨气管软骨甲状腺峡部甲状腺峡部外外侧侧气管软骨气管软骨外外侧侧上海市第六人民医院ShanghaiSixthPeoplesHospitalUltrasound-guidedsuperiorlaryngealnerveblockandtranslaryngealblockforawaketrachealintu
8、bationinapatientwithlaryngealabscessIidaT,SuzukiA,KunisawaT,etal.JAnesth(2013)27:309310临床应用1清醒插管上海市第六人民医院ShanghaiSixthPeoplesHospitalSonographically Sonographically GuidedSuperiorLaryngealNerveBlockDuringAwakeFiberopticIntubationSawkaA,TangR,VaghadiaH.AACaseRep.2015Apr15;4(8):107-10.Sonographicallyg
9、uidedsuperiorlaryngealnerveblockmaybeusefulusefulinpatientswhereidentificationoflandmarksintheneckisdifficultdifficultasaresultofpatientanatomy临床应用1清醒插管上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用1清醒插管Ultrasound-guided CannulaCricothyroidotomySuzukiA,IidaT,kunisawaT,etal.Anesthesiology2012Nov;117(5):11
10、28Ultrasound-assistedtranslaryngealblockforawakefibreopticintubationDeOliveiraGSJr,FitzgeraldP,KendallM.CanJAnesth.201158:664665上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用1清醒插管上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用1清醒插管上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用1清醒插管上海市第六人民医院ShanghaiSixthPeoplesHospi
11、tal临床应用2判断喉镜显露困难气管软骨气管软骨外外侧侧食管食管甲状腺甲状腺WuJ,DongJ,DingY,etal.MedSciMonit,2014;20:2343-2350RoleofanteriornecksofttissuequantificationsbyultrasoundinpredictingdifficultlaryngoscopyAnteriornecksofttissuethicknessesmeasuredbyUSathyoidbone,thyrohyoidmembrane,andanteriorcommissurelevelsareindependentpredict
12、orsofdifficultlaryngoscopy.CombinationsofthosescreeningtestsorriskfactorswithUSmeasurementsmightincreasetheabilitytopredictdifficultlaryngoscopy.上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用2判断喉镜显露困难气管软骨气管软骨外外侧侧食管食管甲状腺甲状腺上海市第六人民医院ShanghaiSixthPeoplesHospitalUltrasonographicmeasurementoftheminimaltransve
13、rsediameterofthesubglotticairwayinthetransverseplane,typicallyatthecaudaloutletofthecricoidring临床应用3选择适合气管导管上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用4判断气管导管位置气管软骨气管软骨外外侧侧食管食管甲状腺甲状腺排除食管内插管排除食管内插管证实气管导管在气管内证实气管导管在气管内上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用4判断气管导管位置THESENSITIVITYANDSPECIFICITYOFTRANSC
14、RICOTHYROIDULTRASONOGRAPHYTOCONFIRMENDOTRACHEALTUBEPLACEMENTINACADAVERMODELDynamicassessmentresultedin97%97%sensitivityand100%100%specificityfordetectingesophagealETplacement.Staticassessmentresultedinonly51%51%sensitivityand91%91%specificity.MaG,DavisDP,SchmittJ,etal.JEmergMed.2007May;32(4):405-7.上
15、海市第六人民医院ShanghaiSixthPeoplesHospital气管插管过程中环甲膜改变上海市第六人民医院ShanghaiSixthPeoplesHospital气管导管气囊充气表现上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用5判断喉罩位置Laryngo-trachealultrasonographytoconfirmcorrectendotrachealtubeandlaryngealmaskairwayplacementSonographicupperairwayassessmentemergesasa rapidandrapidandeasi
16、lyeasily availablemethodavailablemethodtopredictdifficultintubation,toassessthelaryngealandhypopharyngealsizeandvisualizethepositionofthelaryngealmaskairwayinsitu.WojtczakJA,CattanoD.JournalofUltrasonography2014;14:362366上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用5判断喉罩位置蝴蝶征蝴蝶征Unique喉罩的位置ESupreme喉罩的位置E
17、上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用6定位气管切开Real-timeultrasound-guidedpercutaneousdilatationaltracheostomy:afeasibilitystudyPercutaneoustracheostomyperformedunderreal-timeultrasoundguidanceisfeasibleandappears accurateandsafeaccurateandsafe,includinginpatientswithmorbidobesityandcervicalspinepre
18、cautionsmorbidobesityandcervicalspineprecautions.VenkatakrishnaRajajee,JeffreyJFletcher,LaurynRRochlen,etal.CriticalCare2011,15:R67上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用6定位气管切开Traditionallandmarkversusultrasoundguidedtrachealpunctureduringpercutaneousdilatationaltracheostomyinadultintensivecarepa
19、tients:arandomisedcontrolledtrialUltrasoundguidancesignificantlyimprovedtherateoffirst-passpunctureandpunctureaccuracy.Fewerproceduralcomplicationswereobserved;however,thisdidnotreachstatisticalsignificance.Theseresultssupportwidergeneraluseofreal-timeultrasoundguidanceasanadditionaltooltoimprovePDT
20、.MtRudas,IanSeppelt,RobertHerkes,etal.CriticalCare2014,18:514上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用6定位气管切开可可视视化化操操作作才才能能有有意意识识避避开开血血管管上海市第六人民医院ShanghaiSixthPeoplesHospital临床应用6定位气管切开上海市第六人民医院ShanghaiSixthPeoplesHospital其他的临床应用1迅速准确建立通气MallinM,CurtisK,DawsonM,etal.AmJEmergMed2014Jan;32(1):61-3.Acc
21、uracyofultrasound-guidedmarkingofthecricothyroidmembranebeforesimulatedfailedintubationfailedintubationUltrasound markingoftheCTMofhealthyvolunteersbeforesimulatedintubationaccuratelyaccuratelyidentifiestheCTMafterneckmanipulationexpectedduringafailedintubationfailedintubation.上海市第六人民医院ShanghaiSixth
22、PeoplesHospital其他的临床应用2改良Sellick法向后方压迫向后方压迫环状软骨环状软骨无效无效向向左后左后方压迫方压迫环状软骨环状软骨有效有效上海市第六人民医院ShanghaiSixthPeoplesHospital其他的临床应用3耐受插管AdvancedDiagnosticBronchoscopyUsingConsciousSedationandtheLaryngealNerveBlock:TolerabilityTolerability,Thoroughness,andDiagnosticYieldGoyalG,PisaniMA,MurphyTE,etal.Lung(201
23、4)192:905913如何更好耐受长期气管插管？或许喉上神经阻滞是一个选择上海市第六人民医院ShanghaiSixthPeoplesHospital1.清醒插管超声引导喉上神经阻滞和环甲膜穿刺过拱桥，甲舌膜里寻过拱桥，甲舌膜里寻喉上喉上越尖峰，缺口越尖峰，缺口伪影伪影环甲膜环甲膜总结4.判断气管导管的位置环甲膜气管插管气管插管进行时更敏感进行时更敏感5.判断喉罩位置蝴蝶征蝴蝶征6.定位气管切开准确定位、避免损伤准确定位、避免损伤7.迅速建立紧急通气超声引导超声引导环甲膜穿刺环甲膜穿刺8.改良Sellick法向向左后方左后方压迫环状软骨压迫环状软骨2.判断喉镜显露困难颈前部软组织厚度颈前部软组织厚度3.选择气管导管型号气管最小内径气管最小内径上海市第六人民医院ShanghaiSixthPeoplesHospital谢谢聆听谢谢聆听
