支气管镜的基本操作支气管镜的基本操作1XIQI 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2XIQI支气管镜的适应症 3XIQI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4XIQI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5XIQI 支气管镜的禁忌症6XIQI 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7XIQI 支气管镜术前准备8XIQI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9XIQI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10XIQI 气管支气管的 解剖结构11XIQI12XIQI气气 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 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 mm mm mm 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。13XIQI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 m m 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 。14XIQI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 8mmmmmmmm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 7mmmmmmmm15XIQI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管开距左上叶支气管开口约口约5 5mmmm处，向前下处，向前下处方发出舌段。处方发出舌段。左下叶支气管左下叶支气管 距左下叶支气管开距左下叶支气管开口约口约5 5mmmm处，向后发处，向后发出背段。出背段。16XIQI支气管镜操作方法支气管镜操作方法 17XIQI18XIQI19XIQI20XIQI21XIQI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22XIQIGroup 1 Exercises23XIQIStep 1: nose to larynxwThescopeisadvancedfromthenosetothelarynx.wThisstepincludeslocalanesthesia24XIQIStep 2: larynx to subglottiswFromthelarynxthetracheaisenteredtothesubglotticarea.wIffromthehead:oncethevocalcordsarepassedthescopeisslightlyflexeddownwards.wIffromthefront:oncethevocalcordsarepassedthescopeisslightlyflexedupwards.25XIQIStep 3: Follow the curve to the carina wTheTracheaisnota“straightpipe”;wItdeviatesposteriorlyandslightlytotherightwhenapproachingthemaincarina.26XIQIStep 4a: Carina to left main bronchuswFromtheneutralpositiontheLMBisenteredjustbytwistingthewristtotheleftandadvancingfor1-2cm.27XIQIStep 4b: Carina to right main bronchuswFromtheneutralpositiontheRMBisenteredjustbytwistingthewristtotherightandadvancingthescopefor1-2cm28XIQIwFromtheneutralpositiontheleftandrightmainbronchiareenteredalternativelyjustbytwistingthewristandadvancingthescopeforfewcm.Step 4c: Left-right-neutral 29XIQIStep 5a: Down-up-left main bronchuswThescopeisslowlyadvancedthepulledbackuptheLMBwhilealwayskeepingitinthemiddleoftheairwaylumen.30XIQIStep 5b: Down-up right main bronchuswThescopeisslowlyadvanceddowntheRMBtoRLLandpulledbackupwardswhilealwayskeepingitinthemiddleoftheairwaylumen.31XIQIGroup 2 Exercises32XIQIStep 6a: Left main to left upper lobe bronchuswFromtheLMBthescopeisadvancedtotheentranceoftheLULbronchus.33XIQIStep 6b: Left main to left lower lobe bronchuswThescopeisadvanceddowntheLMBtotheentranceoftheLLLbronchus.34XIQIStep 6c: Right main to right upper lobe bronchuswThescopeisadvanceddowntheRMBthenwiththewristtwisted60degreesfrommidlinethescopeisflexeduptotheentranceofRUL.35XIQIStep 6d: Right main to bronchus intermediuswFromthecarinaadvancethescopedowntheRMBtothedistalbronchusintermediusandvisualizetheentrancetoRB456andthebasalpyramid.36XIQIStep 6e: Right main to right lower lobe bronchuswAdvancethescopefromthecarinatotheentranceoftheRLLwhilealwayskeepingitinthemidline.37XIQIGroup 3 Exercises38XIQIStep 7a: Left upper lobe uno doswFromthecarina,thescopeisadvancedtoLULentrance;there,justbythumbmovement,thelingulaandupperdivisionbronchusarevisualized.39XIQIStep 7b: Left before five six (LB 456)wFromtheLMB,thelingulaisentered,thenthescopeispulledbackintothedistalLMBandthescopeisadvancedintothesuperiorsegmentoftheLLL.w!Wristmovementsare“inthemirror”40XIQIStep 7c: Left B6-8,9,10wWiththescopeattheLLLbronchusentrance,thesuperiorsegmentisentered,thenalternately,theantero,lateralandpostero-basalsegmentsoftheLLLareentered.41XIQIStep 7d: Right upper lobe uno-dos-treswFromtheRMBthescopeisadvancedandflexedupintotheRULbronchuswherejustbywristandthumbmovementsthethreesegmentsarevisualized;thenthescopeiswithdrawntothemaincarina.42XIQIStep 7e: Right before five six (RB 4,5,6)wFromthedistalbronchusintermedius,theRMLandsuperiorsegmentareenteredalternatively;w!Wristmovementsare“inthemirror”.43XIQIStep 7f: Right medial basal (RB7) (d”Artagnan)wFrom the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered.44XIQIStep 8a: Left lower lobe basal pyramidwFromtheentranceoftheLLLbronchusgoinandoutofthe3basalsegments,thenwithdrawthescopetothecarina.45XIQIStep 8b: Right lower lobe basal pyramid(DArtagnan and the three musketeers)wFromthecarinaadvancethescopetotheRLLbronchusentranceandthenenterthemedial-basalsegment,pullbackandthenexaminetheotherthreesegmentsofthebasalpyramid.46XIQI