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1、支气管镜的基本操作方苏榕 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支气管镜的适应症支气管镜的适应症 诊断方面诊断方面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治疗方面治疗方面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 支气管镜的禁忌症 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严重心、肺功能障
2、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 支气管镜术前准备术前检查术前检查术前检查术前检查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wECG检查w血气分析患者准备患者准备患者准备患者准备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 气管支气管的 解剖结构气气气气 管管管管上段固定于喉部，下段与上段固定于喉部，下段与上段固定于喉部，下段与上段固定于喉部，下段与主支气管相连接。主支气管相连接。主支气管相连接。主支气管相连接。 气气
3、 管管 由由气气 管管 由由 1 15 51 15 52 20 02 20 0个个 软软 骨骨个个 软软 骨骨环环构构成成，成成人人气气管管横横径径环环构构成成，成成人人气气管管横横径径 1 18 81 18 82 20 02 20 0m m m m m m m m ，长长 度度长长 度度 1 10 01 10 01 13 31 13 3c c m m c c m m ，气气管管分分叉叉角角度度气气管管分分叉叉角角度度 5 55 55 55 56 65 56 65 5。 气管前有甲状腺，后与气管前有甲状腺，后与气管前有甲状腺，后与气管前有甲状腺，后与食道相邻。食道相邻。食道相邻。食道相邻。主支
4、气管主支气管主支气管主支气管右主支气管右主支气管 短短而而粗粗，平平均均长长 度度 2 25 5m m m m ，直直 径径 1 11 11 15 5m mm m 。左主支气管左主支气管 细细而而长长 , ,平平均均长长度度5 50 0m mm m, , 直直 径径 9 91 11 1m m m m 。右侧叶支气管右侧叶支气管右侧叶支气管右侧叶支气管右上叶支气管右上叶支气管 长度长度长度长度9 9 9 9mmmmmmmm，直径直径直径直径8 8 8 8mmmmmmmm右中间右中间段段支气管支气管 长度长度长度长度8 8 8 820202020mmmmmmmm，直径直径直径直径8 8 8 8mm
5、mmmmmm右中叶支气管右中叶支气管 长度长度长度长度1010101020202020mm,mm,mm,mm,直径直径直径直径7 7 7 7mmmmmmmm右下叶支气管右下叶支气管 长度长度长度长度9 9 9 9mm,mm,mm,mm,直径直径直径直径7 7 7 7mmmmmmmm左侧叶支气管左侧叶支气管左侧叶支气管左侧叶支气管左上叶支气管左上叶支气管 距左上叶支气距左上叶支气管开口约管开口约5 5mmmm处，向前处，向前下处方发出舌段。下处方发出舌段。左下叶支气管左下叶支气管 距左下叶支气距左下叶支气管开口约管开口约5 5mmmm处，向后处，向后发出背段。发出背段。支气管镜操作方法 支气管分
6、支命名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Group 1 ExercisesGroup 1 ExercisesStep 1: nose to larynxStep 1: nose to larynxwThe scope is advanced from the nose to the larynx .wThis step includes local anesthesiaStep 2:
7、 larynx to subglottisStep 2: larynx to subglottiswFrom the larynx the trachea is entered to the subglottic area.wIf from the head: once the vocal cords are passed the scope is slightly flexed downwards.wIf from the front: once the vocal cords are passed the scope is slightly flexed upwards.Step 3: F
8、ollow the curve to the Step 3: Follow the curve to the carina carina wThe Trachea is not a “straight pipe”;wIt deviates posteriorly and slightly to the right when approaching the main carina.Step 4a: Carina to left Step 4a: Carina to left main bronchusmain bronchuswFrom the neutral position the LMB
9、is entered just by twisting the wrist to the left and advancing for 1 -2 cm.Step 4b: Carina to right Step 4b: Carina to right main bronchusmain bronchuswFrom the neutral position the RMB is entered just by twisting the wrist to the right and advancing the scope for 1 -2 cmwFrom the neutral position
10、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 Step 4c: Left-right-neutral Step 5a: Down-up-left Step 5a: Down-up-left main bronchusmain bronchuswThe scope is slowly advanced the pulled back up the L
11、MB while always keeping it in the middle of the airway lumen.Step 5b: Down-up right Step 5b: Down-up right main bronchusmain bronchuswThe scope is slowly advanced down the RMB to RLL and pulled back upwards while always keeping it in the middle of the airway lumen.Group 2 ExercisesGroup 2 ExercisesS
12、tep 6a: Left main to left Step 6a: Left main to left upper lobe bronchusupper lobe bronchuswFrom the LMB the scope is advanced to the entrance of the LUL bronchus.Step 6b: Left main to left Step 6b: Left main to left lower lobe bronchuslower lobe bronchuswThe scope is advanced down the LMB to the en
13、trance of the LLL bronchus.Step 6c: Right main to Step 6c: Right main to right upper lobe bronchusright upper lobe bronchuswThe 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.Step 6d: Right main to Step 6d: Right main
14、to bronchus intermediusbronchus intermediuswFrom the carina advance the scope down the RMB to the distal bronchus intermedius and visualize the entrance to RB456 and the basal pyramid.Step 6e: Right main to Step 6e: Right main to right lower lobe bronchusright lower lobe bronchuswAdvance the scope f
15、rom the carina to the entrance of the RLL while always keeping it in the midline.Group 3 ExercisesGroup 3 ExercisesStep 7a: Left upper lobe Step 7a: Left upper lobe uno dosuno doswFrom the carina, the scope is advanced to LUL entrance; there, just by thumb movement, the lingula and upper division br
16、onchus are visualized.Step 7b: Left before five Step 7b: Left before five six (LB 456)six (LB 456)wFrom 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”Step 7c: Lef
17、t B6-8,9,10Step 7c: Left B6-8,9,10wWith 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.Step 7d: Right upper lobe Step 7d: Right upper lobe uno-dos-tresuno-dos-treswFrom the RMB the scope
18、 is advanced and flexed up into the RUL bronchus where just by wrist and thumb movements the three segments are visualized; then the scope is withdrawn to the main carina.Step 7e: Right before five Step 7e: Right before five six (RB 4,5,6)six (RB 4,5,6)wFrom the distal bronchus intermedius, the RML
19、and superior segment are entered alternatively; w! Wrist movements are “in the mirror”.Step 7f: Right medial basal Step 7f: Right medial basal (RB7) (d”Artagnan)(RB7) (d”Artagnan)wFrom the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered.Step 8a: Left lower lo
20、be Step 8a: Left lower lobe basal pyramidbasal pyramidwFrom the entrance of the LLL bronchus go in and out of the 3 basal segments, then withdraw the scope to the carina.Step 8b: Right lower lobe basal pyramidStep 8b: Right lower lobe basal pyramid(DArtagnan and the three musketeers)(DArtagnan and the three musketeers)wFrom 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.
