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1、支气管镜的基本操作,方苏榕,支气管镜的适应症，禁忌症支气管镜术前的准备工作气管-支气管的解剖结构支气管镜的基本操作方法,支气管镜的适应症,诊断方面,不明原因的咯血，慢性咳嗽，声音嘶哑，局限性哮鸣音支气管感染性疾病的病因学诊断肺炎胸片或CT检查异常已诊断肺癌术前检查，指导手术范围及估计预后食管-支气管瘘的确诊胸部外伤，怀疑有支气管裂伤和断裂,治疗方面,取出支气管异物某些肺不张，肺脓疡等咯血治疗引导气管插管支气管镜下治疗,支气管镜的禁忌症,活动性大出血不能纠正的出血倾向尿毒症，活检易出血者严重肺动脉高压，活检易出血者严重心、肺功能障碍严重心律失常新近发生心肌梗死或心绞痛疑有主动脉瘤全身情况极度衰竭
2、严重的上腔静脉阻塞综合征,支气管镜术前准备,术前检查,了解病史、测量血压及心肺体检胸片或胸部CT检查出、凝血时间、血小板记数乙肝两对半ECG检查血气分析,患者准备,向患者讲明检查目的、意义、配合方法术前签字术前禁食6小时术前30分钟肌注安定和阿托品有异齿术前摘下,气管支气管的 解剖结构,气 管,上段固定于喉部，下段与主支气管相连接。气管由1520个软骨环构成，成人气管横径1820mm，长度1013cm，气管分叉角度5565。气管前有甲状腺，后与食道相邻。,主支气管,右主支气管 短而粗，平均长度25mm，直径1115mm。左主支气管 细而长,平均长度50mm,直径911mm。,右侧叶支气管,右上
3、叶支气管 长度9mm，直径8mm右中间段支气管 长度820mm，直径8mm右中叶支气管 长度1020mm,直径7mm右下叶支气管 长度9mm,直径7mm,左侧叶支气管,左上叶支气管 距左上叶支气管开口约5mm处，向前下处方发出舌段。左下叶支气管 距左下叶支气管开口约5mm处，向后发出背段。,支气管镜操作方法,支气管分支命名,Group 1 Exercises,Step 1:nose to larynx,The scope is advanced from the nose to the larynx.This step includes local anesthesia,Step 2:lary
4、nx to subglottis,From the larynx the trachea is entered to the subglottic area.If from the head:once the vocal cords are passed the scope is slightly flexed downwards.If from the front:once the vocal cords are passed the scope is slightly flexed upwards.,Step 3:Follow the curve to the carina,The Tra
5、chea is not a“straight pipe”;It deviates posteriorly and slightly to the right when approaching the main carina.,Step 4a:Carina to left main bronchus,From the neutral position the LMB is entered just by twisting the wrist to the left and advancing for 1-2 cm.,Step 4b:Carina to right main bronchus,Fr
6、om the neutral position the RMB is entered just by twisting the wrist to the right and advancing the scope for 1-2 cm,From the neutral position 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 5a:
7、Down-up-left main bronchus,The scope is slowly advanced the pulled back up the LMB while always keeping it in the middle of the airway lumen.,Step 5b:Down-up right main bronchus,The scope is slowly advanced down the RMB to RLL and pulled back upwards while always keeping it in the middle of the airw
8、ay lumen.,Group 2 Exercises,Step 6a:Left main to left upper lobe bronchus,From the LMB the scope is advanced to the entrance of the LUL bronchus.,Step 6b:Left main to left lower lobe bronchus,The scope is advanced down the LMB to the entrance of the LLL bronchus.,Step 6c:Right main to right upper lo
9、be bronchus,The 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 bronchus intermedius,From the carina advance the scope down the RMB to the distal bronchus intermedius and visualize the entrance to
10、 RB456 and the basal pyramid.,Step 6e:Right main to right lower lobe bronchus,Advance the scope from the carina to the entrance of the RLL while always keeping it in the midline.,Group 3 Exercises,Step 7a:Left upper lobe uno dos,From the carina,the scope is advanced to LUL entrance;there,just by thu
11、mb movement,the lingula and upper division bronchus are visualized.,Step 7b:Left before five six(LB 456),From 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.!Wrist movements are“in the mirror”,Step 7c:Le
12、ft B6-8,9,10,With 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 uno-dos-tres,From the RMB the scope is advanced and flexed up into the RUL bronchus where just by w
13、rist and thumb movements the three segments are visualized;then the scope is withdrawn to the main carina.,Step 7e:Right before five six(RB 4,5,6),From the distal bronchus intermedius,the RML and superior segment are entered alternatively;!Wrist movements are“in the mirror”.,Step 7f:Right medial bas
14、al(RB7)(d”Artagnan),From the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered.,Step 8a:Left lower lobe basal pyramid,From 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 pyramid(DArtagnan and the three musketeers),From 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.,
