上呼吸道管理与气管插管上呼吸道管理与气管插管The Difference Between Life and Death1临床教训与急诊医师责任n教训n气管肿物病人住下观第三天清晨猝然憋死nCOPD急发住下观一周后因痰清晨憋死n颈部淋巴瘤已知主气管受压，在急诊等专科床3周，进血液科第二天憋死n大咯血憋死n经验n支气管肿瘤压迫急作支架成活n会及时上呼吸道控制是急诊医师基本功2讨论内容讨论内容n解剖与生理n气管插管优点n气管插管指征n禁忌症n气管插管并发症n气管插管所需设备n插管技术n气管插管规则n插管管径的选择n吸引技术与原则n其它人工气道装置n结论n困难插管3解剖与生理解剖与生理气道可区分为:上呼吸道：The upper airway下呼吸道：The lower airway分界在会厌4The Upper Airway5The Lower Airway6气管插管的作用气管插管的作用n有气囊的插管防误吸n直接吸引气管分泌物n不造成胃涨，减少胃返流n保持上呼吸道通畅n便于雾化药物的使用7插管指征插管指征 n不能用常规氧疗法纠正的氧合衰竭 (decreased arterial PO2) n肺泡低通气 (increased arterial PCO2).n上呼吸道不通畅 (分泌物、肿物等)n所有心跳停止的病人 (CPR)8Indications for Intubation n深昏迷、不能自主维持呼吸道者(Gag reflex absent)n意识低下病人 GCS 55mmhg 2. Arterial hypoxemia refractory to O2 PaO2 70 on 100% O210气管插管禁忌症气管插管禁忌症n吞咽反射完好n病人可能因气管插管引发喉头或气管痉挛 e.g. Children with epiglottitis. n颅底骨折 避免经鼻气管插管、经鼻胃管11气管插管并发症气管插管并发症n组织损伤，如牙、会厌、声带、梨状窝等n经鼻插管可能损伤鼻甲、咽壁等，甚至可能导致鼻咽部黏膜的穿透伤n强刺激可导致血压升高和心率加快，对一些高危病人如AMI、高血压脑出血等有直接危害n可能因迷走刺激导致一过性心律紊乱12并发症并发症 (Cont.)n气管插管气囊破损，导致气道不严n误插入食道，导致胃胀、返流n插管过程中操作不当，致气道内高压和气压伤n咽部过度刺激，导致喉痉挛和可能完全性呼吸道梗阻n插管过深，导致单侧通气（右侧）n异物、吹干了的分泌物、血液等导致插管堵塞13所需设备所需设备14Equipment ContnLaryngoscope with relevant size blades.nMagill forceps.nFlexible introducer.n10-20 ml syringe.nOropharangeal airways all sizes.nTape or adhesive plaster.nE.T tubes relevant sizes.nBag-valve-mask with oxygen connected. nSuction unit with Yankauer nozzle and endotracheal suction catheter.15Technique Contn平卧位、头后仰、下颌提起、纯氧面罩 (Suspected spinal injury, attempt naso-tracheal intubation, spine in neutral position).n麻醉：Rapid Sequence IntubationnHTN/高ICP/哮喘-Lidocaine 1mg/kg ivpnivp 3后nThiopental 3-5mg/kg + mg/kg ivp 30”后n推开嘴唇，以右手食指拉上颌，从而使张嘴n左手持喉镜，将叶片插入，向右扁桃体方向推进n一旦叶片到达右扁桃体，将叶片横推向中线，从而使舌体被叶片挡在口腔左部16Technique Contn暴露会厌” DO NOT LOOSE SIGHT OF IT!”n将叶片继续往前推进，直到叶片顶端到达舌根与会厌间的结合部( volecular space) n左手握住喉镜把向前上方提起，这样多数情况下已可看到声门。有时可能需有人帮助压一下喉头以更好看清声门和咽部结构n右手持气管插管，先使管子的弯曲弧度向右，插入嘴里n在直视下将管子插入声门n待管子气囊刚好全部进到声门下、并继续插入1-2cm时，即可气囊充气，并固定插管n用听诊器听双肺尖和侧胸部，确认双侧呼吸音以确认气管插管是否成功或位置是否适当 1718气管插管技术气管插管技术1920插管注意事项插管注意事项n必须有良好吸引器必须有良好吸引器n一次插管操作不要超过一次插管操作不要超过 30 秒秒n插管前后都要用纯氧面罩和皮球辅助呼吸插管前后都要用纯氧面罩和皮球辅助呼吸n抽好一支镇静药备用抽好一支镇静药备用 (如如Midazolam 15mg/3ml)n插管中及后持续监测插管中及后持续监测Spo2，以指导操作和插管后以指导操作和插管后辨认插管位置辨认插管位置21正常氧储备吸入 空气ml 纯氧ml肺内FRC 450 3000血红蛋白 850 950组织溶解 50 100肌红蛋白 200 200合计 1550 4250机体氧耗 200-250ml/minn约50%氧储备不能用(肌红蛋白/FRC/血红蛋白)n正常成人氧储备可供停氧3，纯氧过度氧合后8n病人代偿差/储备少/安全系数：40”/122Tube sizesnNewborn to 4 kg - 2.5 mm (uncuffed)n1-6 months 4-6 kg 3.5 mm (uncuffed)n7-12 months 6-9 kg 4.0 mm (uncuffed)n1 year 9 kg 4.5 mm (uncuffed)n2 years 11 kg 5.0 mm (uncuffed)n3-4 years 1416 kg - 5.5 mm (uncuffed)n5-6 years 1821 kg 6.0 mm (uncuffed)n7-8 years 22-27 kg 6.5 mm ( uncuffed)23Tube Sizesn 9-11 years 28-36 kg 7.0 mm(cuffed)n14 to adults 46+ kg 7.0 80 mm (cuffed)nAdult female 7.0 8.0mm (cuffed)nAdult male 7.5 8.5 mm (cuffed)nThe size of the tube may also be determined by the size of the patients little fingerPatients below the age of 8 require uncuffed ETT due to damage caused by the cuff in younger patients. Always monitor the ECG activity during intubation.24吸引注意事项吸引注意事项n看着吸Never suction further than you can seen自己憋口气Never suction for longer than15 secondsn出管时吸Always suction on the way outn吸引前后都先过度氧合Always oxygenate the patient before and after suctioning25其它人工气道用的管子其它人工气道用的管子nKombi-tubenOropharangeal airways/tubesnNasopharyngeal airways/tubesnOro-tracheal tubesnNaso-tracheal tubes 26ConclusionnAlways oxygenate patient before and after intubation.nDo not attempt intubation unless you are totally skilled, rather perform bag-valve-mask ventilation.nAlways reconfirm tube placement from time to time. 27