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1、What a bad luck!,If this is a Difficult Intubation situation.,What are our back-up plans?What other gadgets do we have?,Non-invasive Glottis Invasive,From Below the Glottis(Invasive),Transtracheal Jet Ventilation(TTJV)Retrograde Intubation Percutaneous dilational tracheal entry Surgical Airway,From
2、Above the Glottis,Laryngoscope Gum Elastic Bougie Blind Oral/Nasal Intubation Fiberoptic Bronchoscopy Intubating LMA(Fastrach)GlideScope Lighted Stylet(Trachlight)Optical Stylet,Eschmann tracheal tube introducer“Gum Elastic Bougie”,History of Gum Elastic Bougie,The Eschmann tracheal tube introducer(
3、gum elastic bougie)was marketed in the United Kingdom(UK)in the early 1970s.It differs from previous introducers in its greater length(60 cm),angled tip,and the combination of flexibility and malleability.,Anesthesiology:100(5)2004:1146-50,“GEB“vs Difficult Intubation,2004 巴黎聖心堂,Lighted Stylet(Light
4、wand)光棒,History of Lighted Stylet,The first reported use of a lighted stylet used to facilitate intubation came in 1957.Macintosh described an 18-inch illuminated tracheal tube introducer,which was designed to stiffen the tube and better illuminate the cords by supplementing the light of the laryngo
5、scope.Anaesthesia 1957;12:2235,History of Lighted Stylet,Yamamura et al.described a light bulb-tipped wire that was inserted into the tracheal tube before blind nasal intubation in awake patients.The tube position was then determined by the medial transillumination of the external throat and neck.An
6、esthesiology 1959;20:221,History of Lighted Stylet,In 1977,Foster used a transilluminating fiberoptic bundle to facilitate tracheal intubation in a young child with trismus.Anaesthesia 1977;32:1038Ducrow used a Flexi-lum to achieve the same end by first passing a guide into the trachea followed by p
7、assage of the tracheal tube over the guide.Anaesthesia 1978;33:8279,History of Lighted Stylet,Rayburn commented that the Flexi-lum(flexible surgical light)could be positioned inside the tracheal tube,thereby shortening the intubation sequence and claimed that the technique,nicknamed“lightwand intuba
8、tion.”Anaesthesia 1979;34:6778,TrachlightWandETT size Small2.5#4.0#Medium4.5#5.5#Large6.0#,Lightwand Intubation,Transillumination of neck tissues Flexible stylet contains a distal light bulb,Jaw lifted with non-dominant hand,Observing the glow on the neck,Helpful Maneuvers for Trachlight,Jaw lift(Ja
9、w thrust)Hyperextension of the head and neck Use of the thumb to lift the tongue Having an assistant to pull the tongue Anesthesiology 1995;83:509-514,Intubation with Trachlight(I),Intubation with Trachlight(II),Advantages of Trachlight,Easy to learn and use Less traumatic Suitable for pediatric pat
10、ients May use in nasal tracheal intubation May use in ambient light,Complications,Instrument disarticulationTrauma to the upper airwaybleedingsore throat hoarsenessdysphagia Arytenoid cartilage dislocation,Indications,Difficult airway Unintubatable by direct or fiberoptic laryngoscopy Neck mobility
11、is limited or contraindicated Prevention of dental injury,Contraindications,Absolute Upper airway foreign body,tumor,polyp,retropharyngeal abscess.Relativetrauma victim with laryngeal injuryknown difficult airway,Environment for Trachlight,Ambient light-78.5%Dimmed-8.7%Dark-12.2%Anesthesiology 1995;
12、83:509-514,Effect of Cricoid Pressure on Lightwand Intubation,Time to successful intubation is significantly prolonged The failure rate for the first attempt is 13%.Anesthesiology.94(2):259-262,2001,Intubation with Trachlight(I),Intubation with Trachlight(II),Intubation with Trachlight(III),Hybrid T
13、echniques,With Direct Laryngoscopy Light-guided Nasal Intubation With Laryngeal Mask Airway With Fiberoptic Scope Airway Introducer Light-guided Retrograde Intubation,Optical Stylet可視光棒,History of Orotracheal Intubation,The earliest reports of blind orotracheal intubation(BOI)in anaesthesia date bac
14、k to 1880.William MacEwen described awake BOI by internal palpation.Br Med J 1880;2:122-4 and 163-5.,History of Orotracheal Intubation,Franz Kuhn(1866-1929)He recommended the use of flexible metal tubes which were generally introduced into the trachea under digital control.He suggested the advantage
15、ous use of Kirsteins autoscope(a forerunner of modern laryngoscopes),Techniques for BOI,1.Palpation2.Malleable stylet3.Divided oropharyngeal airway4.Williams airway intubator5.Lightwand6.Laryngeal Mask Airway7.Endotrol tube with capnography8.Augustine Guide9.Combitube10.Retrograde intubation11.Fluor
16、oscopy,Alternative Intubation Devices,Flexible fiberoptic bronchoscope(64%)Retrograde intubation kit(45%)Lighted stylet(35%)Rigid fiberoptic device(6%)BullardWu-scope Annals of Emergency Medicine.33(6):694-8,1999,Flexible Fibreoptic and Intubation,In 1967 Murphy reported successful nasal intubation
17、using a flexible choledochoscope placed through a tracheal tube.Anaesthesia 1967;22:489-91,History of“Optical Stylet”,Katz and Berci coined the term“Optical Stylet”in 1979 to describe a straight rigid endoscope used as a tracheal tube stylet during intubation.Anesthesiology 1979;51:251-4,Shikani Optical Stylet(S.O.S),
