氣道異物鄒宏運(yùn)

1、安徽醫(yī)科大學(xué)第一附屬醫(yī)院麻醉科 鄒宏運(yùn),七氟醚在小兒支氣管異物取出術(shù)中的應(yīng)用,病例1,2歲3個(gè)月男童，診斷氣道異物，擬行急診氣道異物取出術(shù)。術(shù)中住院總醫(yī)生將異物從右主支氣管取出時(shí)突然卡在主氣道內(nèi)，患兒隨即通氣困難，紫紺。氧飽和度，心率下降。麻醉及耳鼻喉科住院總急呼二線，麻醉二線復(fù)蘇后建議將異物推向遠(yuǎn)端支氣管，但反復(fù)操作困難，患兒低氧時(shí)間長，反復(fù)復(fù)蘇效果不佳，插管后送ICU后，家屬放棄搶救出院,病例2,1歲10月男童，行氣管異物取

2、出術(shù)，術(shù)中操作困難，取出異物后反復(fù)檢查未發(fā)現(xiàn)殘留，氣管支氣管粘膜水腫明顯。麻醉復(fù)蘇后患兒清醒，哭鬧。送回病房。4小時(shí)后，要求麻醉科緊急氣管插管。5分鐘內(nèi)趕到發(fā)現(xiàn)患兒雙瞳散大，無心跳呼吸。氣管插管后復(fù)蘇效果不佳。送入ICU后2小時(shí)后死亡。麻醉手術(shù)風(fēng)險(xiǎn)大！,早在19世紀(jì)，對(duì)氣道異物的治療有瀉藥、放血、催吐。死亡率在23%。1897年，Gustav Killian成功用硬質(zhì)食管鏡對(duì)一個(gè)農(nóng)民實(shí)施了右主支氣管內(nèi)豬骨取出術(shù)1898年，Al

3、gernon Coolidge在麻省總院成功實(shí)施了一例氣道異物取出術(shù)。此后不久Chevalier Jackson發(fā)明了有光源的支氣管鏡以及取物裝置。麻醉方式----表面麻醉,流行病學(xué),氣管（支氣管）異物吸入多數(shù)發(fā)于4歲以下兒童，男童占61%。死亡率3.4%左右，在支氣管鏡檢中死亡率約0.42%。只有11%異物在X線下不透光， 17%的患兒胸片正常。診斷金標(biāo)準(zhǔn)：支氣管鏡檢,診斷,吸入異物的病史急性癥狀：劇烈咳嗽，呼吸困難，喘鳴

4、，哮鳴，紫紺。慢性癥狀：持續(xù)咳嗽，一側(cè)呼吸音降低，干羅音，反復(fù)發(fā)作的肺炎，偶見氣胸。胸片：患側(cè)肺阻塞性肺氣腫,,Among 94 patients 70.2% were within 5 years of age and most were within 2–3 years of age. Rigid bronchoscopy was done in all the cases and foreign body was succe

5、ssfully retrieved in 78.7% of cases.The Most common site of lodgment was the right bronchus followed by the left bronchus, the trachea and other sites. Vegetables were the most common FBs as they were found in 26 cases.

6、-----Indian J Otolaryngol Head Neck Surg (October–December 2011) 63(4):313–316; DOI 10.1007/s12070-011-0227-5,,,急診支氣管鏡檢指征,已存在呼吸衰竭可能成為全部的呼吸道梗阻喉部較大異物銀幣等尖銳異物氣腫致縱隔移位花生（可腫脹 含油脂）,Some authors suggest that bronchoscopy m

7、ay be performed during normal daytime operating hours to ensure optimal conditions with an experienced bronchoscopist and anesthesiologist.These authors found no increase in morbidity in stable patients by delaying bro

8、nchoscopy for a suspected foreign body until the next available elective daytime slot.---Mani N, Soma M, Massey S, Albert D, Bailey CM. Removal of inhaled foreign bodies middle of the night or the next morning.Int J Pe

9、diatrOtorhinolaryngol 2009;73:1085–9,麻醉前考量,麻醉與外科聯(lián)系緊密。外科醫(yī)生手術(shù)水平直接決定麻醉的順利程度。良好的溝通非常重要。氣道既要進(jìn)行外科操作又要通氣。既要保證通氣又要抑制外科操作對(duì)呼吸道的傷害刺激。,麻醉難點(diǎn),氣道管理自主呼吸 VS 控制通氣麻醉深度保留自主呼吸 VS 抑制呼吸道反射麻醉方法的選擇？,麻醉難點(diǎn),Few anaesthesiologists agree on th

10、e best method of providing general anaesthesia and the best mode of ventilation.There is good reason for this as little or no evidence exists with which to guide anaesthetic management。 Ronald S. Litman，Anaesthesi

11、a for bronchial foreign body removal: what really matters?European Journal of Anaesthesiology 2010, Vol 27 No 11,Time for loc (Group VIMA 95.6±15.2 sec vs Group TIVA 146.2±26.9 sec, p<0.05)The time of BIS v

12、alue decreased to 40 (Group VIMA 115.3±16.5 sec vs Group TIVA 160.4±25.8 sec, p<0.05).The emergence time (Group VIMA 10.5±2.6 min vs Group TIVA 16.9±3.1 min, p<0.05) in Group VIMA were signific

13、antly shorter than those in Group TIVA.,Liao R, Yi Li J, Yue Liu G. Comparison of sevoflurane volatile induction maintenance anaesthesia and propofol-remifentanil total intravenous anaesthesia for rigid bronchoscopy unde

14、r spontaneous breathing for tracheal/bronchial foreign body removal in children. Eur J Anaesth 2010;27:930–934.,The incidence rates of breath holding (Group VIMA 6.25% vs Group TIVA 31.25%, p<0.05) The desaturation (

15、Group VIMA 15.63%vs Group TIVA 37.50%, p<0.05) in Group VIMA were significantly lower than those in Group TIVA.Heart rate, mean blood pressure and respiratory rate were significantly higher in Group VIMA than in Grou

16、p TIVA.,Liao R, Yi Li J, Yue Liu G. Comparison of sevoflurane volatile induction maintenance anaesthesia and propofol-remifentanil total intravenous anaesthesia for rigid bronchoscopy under spontaneous breathing for trac

17、heal/bronchial foreign body removal in children. Eur J Anaesth 2010;27:930–934.,The study by Liao et al., however, covers only one aspect of anaesthetic management for these procedures.In their practice, spontaneous ven

18、tilation represents the‘standard of care’ for bronchoscopic retrieval. Advantages of spontaneous ventilation include the ability to provide continuous ventilation despite interruptions in the anaesthesia breathing circu

19、it, and in the case of obstructive lesions.negative-pressure breathing may provide better oxygenation and ventilation.,建議,隆突近端or主氣道內(nèi)or大異物--保留自主呼吸隆突遠(yuǎn)端and支氣管樹內(nèi)小異物--可正壓控制通氣,麻醉方法,術(shù)前詢問病史：異物種類，大小，病史時(shí)間（炎癥，肉芽，位置變化）主要癥狀，有無發(fā)熱。充

20、分解釋麻醉風(fēng)險(xiǎn)。讀片（位置，大小），聽診患兒雙肺呼吸音。由患兒家長將患兒抱入手術(shù)室。,,麻醉方法,術(shù)前：禁食8h（stable）,<6h(in danger)6%七氟醚預(yù)充回路1.5-2分鐘（新鮮氣流量5L/分）面罩吸入麻醉鎮(zhèn)靜后建立靜脈通路予阿托品0.01mg/kg iv，地塞米松5-10mg iv,麻醉方法,繼續(xù)七氟醚吸入約5分鐘，及時(shí)聽診小兒雙肺呼吸音，調(diào)整吸入濃度。耳鼻喉科醫(yī)生喉鏡暴露聲門，以2%利多卡因喉麻管

21、聲門附近，聲門下噴霧局部麻醉。,麻醉方法,同時(shí)靜脈予1ug/kg芬太尼。繼續(xù)吸入七氟醚麻醉5分鐘，如果雙肺可聞及呼吸音，氧飽和度在90%以上，不需要降低吸入氣體濃度。,麻醉方法,手術(shù)開始前經(jīng)脈予異丙酚1mg/kg，并根據(jù)手術(shù)時(shí)間追加。建議在取異物和移動(dòng)硬質(zhì)支氣管鏡前加深麻醉。,視手術(shù)時(shí)間長短追加芬太尼和異丙酚。若手術(shù)困難，或醫(yī)生水平一般可打開人工心肺復(fù)蘇機(jī)或其他噴射通氣裝置連接硬質(zhì)氣管鏡側(cè)端。此時(shí)可完全打斷患兒呼吸（非大異物）。,,

22、,常見問題,保留自主呼吸，外科操作時(shí)患兒屛氣，嗆咳-常發(fā)生于麻醉淺，外科醫(yī)生進(jìn)退氣管鏡時(shí)。解決方法：加深麻醉，輔助通氣。,嚴(yán)重并發(fā)癥,氣道完全阻塞喉痙攣-加深麻醉 -異物移位（若完全梗阻，用硬鏡推送入遠(yuǎn)端支氣管，通氣后找熟練外科醫(yī)生繼續(xù)操作)氣胸張力性氣胸（胸腔閉式引流）氣道出血（腎上腺素棉球壓迫）,縱膈積氣氣管，支氣管撕傷低氧性腦損傷 （0.96%）,,Individual anaesthesiologist

23、s may have their own ideas as to the best clinical technique for paediatric bronchoscopy, but the fact remains that there is no scientific evidence to indicate that one mode of ventilation is any safer than another.Wha