气道异物-邹宏运.ppt

病例1 2岁3个月男童，诊断气道异物，拟行急诊气道异物取出术。 术中住院总医生将异物从右主支气管取出时突然卡在主气道内，患儿随即通气困难，紫绀。氧饱和度，心率下降。 麻醉及耳鼻喉科住院总急呼二线，麻醉二线复苏后建议将异物推向远端支气管，但反复操作困难，患儿低氧时间长，反复复苏效果不佳，插管后送ICU后，家属放弃抢救出院 病例2 1岁10月男童，行气管异物取出术，术中操作困难，取出异物后反复检查未发现残留，气管支气管粘膜水肿明显。 麻醉复苏后患儿清醒，哭闹。送回病房。4小时后，要求麻醉科紧急气管插管。5分钟内赶到发现患儿双瞳散大，无心跳呼吸。气管插管后复苏效果不佳。送入ICU后2小时后死亡。 麻醉手术风险大！ 早在19世纪，对气道异物的治疗有泻药、放血、催吐。死亡率在23%。 1897年，Gustav Killian成功用硬质食管镜对一个农民实施了右主支气管内猪骨取出术 1898年，Algernon Coolidge在麻省总院成功实施了一例气道异物取出术。 此后不久Chevalier Jackson发明了有光源的支气管镜以及取物装置。 麻醉方式----表面麻醉 诊断 吸入异物的病史 急性症状：剧烈咳嗽，呼吸困难，喘鸣，哮鸣，紫绀。 慢性症状：持续咳嗽，一侧呼吸音降低，干罗音，反复发作的肺炎，偶见气胸。 胸片：患侧肺阻塞性肺气肿 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 successfully 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. -----Indian J Otolaryngol Head Neck Surg (October–December 2011) 63(4):313–316; DOI 10.1007/s12070-011-0227-5 急诊支气管镜检指征 Some authors suggest that bronchoscopy may 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 bronchoscopy 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 PediatrOtorhinolaryngol 2009;73:1085–9 麻醉前考量 麻醉与外科联系紧密。外科医生手术水平直接决定麻醉的顺利程度。良好的沟通非常重要。 气道既要进行外科操作又要通气。 既要保证通气又要抑制外科操作对呼吸道的伤害刺激。 麻醉难点 气道管理 自主呼吸 VS 控制通气 麻醉深度 保留自主呼吸 VS 抑制呼吸道反射 麻醉方法的选择？ 麻醉难点 Few anaesthesiologists agree on the 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，Anaesthe