1、1,气管及支气管内插管,2,气道（airway） ：呼吸道 呼吸管理：保持呼吸道通畅和气体交换良好 呼吸管理是麻醉科最重要的业务工作之一，也是每一个麻醉科医师必须掌握的重点技能 在气道内根据具体情况置入不同类型的通气道（airway），包括口咽通气管、鼻咽通气管、喉罩通气管、气管内导管或支气管内导管等 可以主动掌握气道通畅，施行控制呼吸,3,第一节 插管前准备和麻醉,气道评估 插管器具准备 插管前麻醉,4,EVALUATION OF THE AIRWAY,History Physical Examination Further Evaluation,5,EVALUATION OF THE AI
2、RWAY History,A history of difficult airway management in the past may be the best predictor of a challenging airway Particular importance should also be placed on diseases that may affect the airway.,6,EVALUATION OF THE AIRWAY History,If old medical records are available, prior anesthetic records sh
3、ould be reviewed for the ease of intubation and ventilation number of intubation attempts ability to mask ventilate type of laryngoscope blade used use of stylet any other modifications of intubation technique,7,EVALUATION OF THE AIRWAY History,Arthritis or cervical disk disease decrease neck mobili
4、ty spinal cord injury Infections of the floor of the mouth, salivary glands , tonsils, or pharynx cause pain, edema, and trismus with limited mouth opening Tumors obstruct the airway extrinsic compression ，tracheal deviation Morbidly obese individuals have a history of obstructive sleep apnea from h
5、ypertrophied tonsils and adenoids, as well as a short neck or increased soft tissue at the neck and upper airway.,8,EVALUATION OF THE AIRWAY History,Trauma may be associated with airway injuries, cervical spine injury, basilar skull fracture, or intracranial injury Previous surgery, radiation, or bu
6、rns may produce scarring , contractures, and limited tissue mobility Acromegaly肢端巨大症may cause mandibular hypertrophy and overgrowth and enlargement of the tongue and epiglottis The glottic opening may be narrowed because of enlargement of the vocal cords,9,EVALUATION OF THE AIRWAY,History Physical E
7、xamination Further Evaluation,10,EVALUATION OF THE AIRWAY Physical Examination,1. Specific findings that may indicate a difficult airway: a. Inability to open the mouth b. Poor cervical spine mobility c. Receding chin (micrognathia) d. Large tongue (macroglossia) e. Prominent incisors f. Short muscu
8、lar neck g. Morbid obesity,11,EVALUATION OF THE AIRWAY Physical Examination,2. Head examination Patency of the nares or the presence of a deviated septum- nasotracheal intubation Macroglossia巨舌症, facial scars or contractures, temporomandibular joint disease - mouth opening Poor dentition牙列不良- increa
9、se the risk of tooth injury or loss Loose teeth should be identified preoperatively and protected or removed before initiation of airway management,12,Physical Examination 3 neck examination,a Thyromental distance : the distance from the lower border of the mandible下颌角下缘to the thyroid notch甲状切迹with
10、the neck fully extended 6 cm may be difficulty visualizing the glottis b assesse the mobility of laryngeal structures scars from previous neck surgery enlarged thyroid paratracheal masses,C Look for,13,EVALUATION OF THE AIRWAY Physical Examination,d. Cervical spine mobilityPatients should be able to
11、 touch their chin to their chest, extend their neck posteriorly Lateral rotation should not produce pain or paresthesia. e. Healed or patent tracheostomy stoma a clue to subglottic stenosis orprior complications with airway management Smaller diameter endotracheal tubes (ETTs),14,EVALUATION OF THE A
12、IRWAY Physical Examination,when the base of the tongue is disproportionately large, visualization of the glottis is impaired Assessment is made with the patient sitting upright the head in the neutral position the mouth open as wide as possible the tongue protruded maximally Intubation predicted to
13、be difficult: Only hard palate is visible Soft palate, faucial pillars, and uvula are not visible.,15,Samsoon and Young modification of the Mallampati classification.,Class I: Tonsillar pillars are easily visualized. Class II: The entire uvula is visualized. Class III: Only the base of the uvula is
14、visualized. Class IV: Only the hard palate is seen.,16,faucial pillars, soft palate, and uvula are visible,none of the three pharyngeal structures is visible.,17,EVALUATION OF THE AIRWAY Further Evaluation,Useful adjuncts may include ： 1. Laryngoscopy provide information regarding the hypopharynx, l
15、aryngeal inlet, and vocal cord function. 2. Chest or cervical radiographs reveal tracheal deviation or narrowing and bony deformities in the neck Cervical spine films are particularly important in trauma cases 。Lateral cervical spine films may be useful in the rheumatoid patient to assess for atlant
16、oaxial subluxation寰枢半脱位. 3. Tracheal tomograms or computed tomography Delineate masses obstructing the airway.,18,气管插管用具,基本器械用具： 任何麻醉方法都适用的器械用具麻醉面罩（facemask） 口咽通气管（oral airway） 鼻咽通气管(nasal airway) 喉镜(laryngoscope) 气管内导管(endotracheal tube),特殊器械用具： 根据病人特殊病理解剖特点或手术需要而设计的特殊用途器械用具双腔支气管导管 （dubble lumen br
17、onchial tube） 喉罩通气管（larygeal mask airway） 纤维光束喉镜和支气管镜 （fiberoptic larygoscope and bronchoscope） 发光棒（lightwand） 改良型特殊喉镜 气管导管换置器（tube changer）等,19,气管内导管(endotracheal tube),有经口 或 经鼻 带套囊 或 无套囊 特殊型,20,气管内导管(endotracheal tube),制作材料 以聚氯乙烯最为常用 标号 导管内径(ID)，各号之间相差0.5 mm 法制(F)标号：F导管的外周径，F导管外径(mm)3.14 结构与规格 标准的
18、气管导管： 远端呈斜面开口；袖套状充气套囊；衔接管，直径统一为15 mm；套囊由细导管与测试小气囊连接；Murphy侧孔；小儿气管导管,21,特殊型气管导管,预铸直角弯度型气管导管（preformed tube, molded angle tube，RAE） 经口或经鼻两种，方便应用于颌面外科 螺旋丝增强型气管导管（armored tube）管壁内镶有螺旋形金属圈或尼龙螺旋形丝圈，防止导管折屈或压扁 导引式气管导管（guidable tube，Endotrol）、 激光屏蔽导管(laser-shield tube) 专门为激光手术中保护气管导管和病人避受激光伤害而设计 婴幼儿气管导 婴幼儿气管
19、导管直径 5.0 mm，均为不带充气套囊的平管。 双腔导管(double-lumen tube),22,激光屏蔽导管,(A) Cuffed and uncuffed rubber endotracheal tubes wrapped with reflective metallic tape. (B) Cuffed and uncuffed flexible metal endotracheal tubes for use during laser surgery of the airway.,23,Various types of endotracheal tubes,(A) An armo
20、red or anode tube with a built-in spiral wire to minimize the opportunity of collapse or kinking (BD) Tubes made of smooth plastic and recommended for single use. Tube B is uncuffed and is a size appropriate for a child. Tubes C and D are appropriate for adult patients,24,Preformed RAE endotracheal
21、tubes 预铸直角弯度型气管导管,25,气管导管选择,长度和口径 根据 插管途径、病人的年龄、性别和身材等因素 选择 一般成人导管长度 稍长于唇至环状软骨水平或稍下处 (相当于气管中段)的长度。 选择导管可供参考： 成年男子可较同年龄的女子大2F 发音低沉者可较发音尖细者大2F 经鼻导管口径需比经口导管小24 F 对小儿(1岁以上)可利用公式推算出参考值： Cole公式：导管口径(F)年龄18 ID (年龄4)4（4.5） Levine公式：插管深度(cm) (年龄2)12,26,套囊(cuff),防漏气装置 有带套囊导管（cuff tube）；不带套囊导管（“平管”plane tube）。
22、 设置目的 为施行控制呼吸或扶助呼吸提供气道无漏气的条件 防止呕吐物等流入下呼吸道(误吸) 防止吸入麻醉气体从麻醉通气系统外逸，维持麻醉平稳。 套囊结构 三部分组成：“充气套囊”、 “套囊细导管” “套囊内压测试小囊” 充气技术 合理充气量既能控制囊内压不超过30 mmHg，又能完全防漏和防误吸 缓慢不间断充气，直至挤压麻醉机贮气囊时喉部刚刚听不到漏气声为准,27,套囊种类,根据套囊充气容量大小 高压容量套囊(high-pressure volume cuff) 体积较小，充气容量较少，低顺应性，已基本废弃不用 低压 容量套囊(low-pressure volume cuff) 体积较长大，较
23、大容量，较高顺应性。在正确充气套囊下，套囊与气管原形比较吻合而不致使气管变形，气管壁受压范围较广，囊内压相对较低，气管黏膜毛细血管血流受阻较轻。目前普遍通用,28,辅助器械 喉镜(laryngoscope),气管内插管时显露声门必备器械 由喉镜柄、窥视片和光源三个基本部分组成,29,Laryngoscopes,The Macintosh and Miller blades are most commonly used. can be used interchangeably on the same handle,30,Examples of the most frequently used d
24、etachable laryngoscope blades,The uppermost blade is the straight or Jackson-Wisconsin design The middle blade incorporates a curved distal tip (Miller ) The lowermost blade is the curved or MacIntosh blade All three blades are available in appropriate for neonates and adults,31,纤维光束支气管镜 （flexible f
25、ibroptic bronchscope）,32,Fiberoptic Intubation,具有柔韧可屈、可延展的特性 已逐渐应用 操作相对比较容易，并发症较少，能清楚显露气管支气管系，插入导管期间不需要全身麻醉 操作需要大量实践经验，不熟练者不能单独进行操作,33,Fiberoptic intubation Technique,34,其他用具,衔接管 导管芯，探条(stylet) 前端距导管的前端至少应保持有2 cm的距离，且不能插入 Murphe孔 。可不常规使用探条，但在困难插管或环圈型气管导管时有使用价值 插管钳（intubating forceps） 将气管导管送入声门 牙垫 喷雾
26、器,35,插管前麻醉,全身麻醉 局部麻醉,36,插管前麻醉 全身麻醉,单次静注2.5%硫喷妥钠最常用，也可用羟丁酸钠、异丙酚、咪哒唑仑或安定 病人入睡后静注琥珀胆碱0.81 mg/kg及芬太尼48 g /kg 病人达神志消失、肌肉完全松弛、呼吸停止和镇痛良好状态,37,插管前麻醉 局部麻醉,表面麻醉（topical anesthesia）咽喉黏膜表面麻醉 气管黏膜表面麻醉 神经阻滞,38,插管前麻醉 局部麻醉 表面麻醉,清醒插管前要求对上呼吸道必须有完善的黏膜表面麻醉 方法： 喷雾和棉片贴敷局麻药； 喉镜直视下喷雾咽喉腔黏膜 气管内注入局麻药； 上喉神经阻滞(superior laryngea
27、l nerve block) 经环甲膜（cricothyroid membrane）穿刺 气管注射局麻药 喷雾程序依次是：口咽腔、舌根、会厌、梨状窝、声门、喉及气管内 经鼻清醒插管，要求有良好的全鼻表面麻醉 警惕局麻药中毒反应：尽量控制使用最小有效剂量局麻药，4%利多卡因总量不超过4 ml，1%丁卡因不超过6 ml。,39,插管前麻醉 局部麻醉 表面麻醉,环甲膜穿刺,40,气管内插管,绝对适应证：指病人的生命安危取决于是否采用气管内插管 全麻颅内手术 胸腔和心血管手术 俯卧或坐位等特殊体位的全麻手术 湿肺全麻手术 呼吸道难以保持通畅的病人（如颌面等大手术） 腹内压增高频繁呕吐（如肠梗阻）或饱胃
28、病人 某些特殊麻醉，如降温术、降压术 需并用肌松药的全麻手术,41,气管内插管,相对适应证： 取决于麻醉医师个人技术经验和设备条件，一般均为简化麻醉管理而选用，如时间长于2小时的任何全麻手术；颌面、颈、五官等中、小型全麻手术等,42,气管内插管 禁忌证,绝对禁忌证： 喉水肿、急性喉炎、喉头黏膜下血肿、插管创伤可引起严重出血，除非急救，禁忌。 相对禁忌证： 呼吸道不全梗阻者禁忌快速诱导插管 并存出血性血液病者 主动脉瘤压迫气管者可能导致动脉瘤破裂 鼻道不通畅、鼻咽部纤维血管瘤、鼻息肉或有反复鼻出血史者，禁忌经鼻 麻醉对插管未掌握、技术不熟练或插管设备不完善者,43,气管内插管 方法分类,44,明
29、视经口气管内插管法,为麻醉医师必须熟练掌握的基本技能，为临床最常用的插管方法，要求做到安全、正确、无损伤。 不论在清醒 + 镇静状态或全麻肌松药作用下，都能迅速完成插管。 清醒插管 _在咽喉气管内表面麻醉下，施行气管内插管。缺点：需病人合作，可出现恶心、呕吐优点：保存呼吸道反射，心血管、呼吸和神经系统抑制最轻。 全麻诱导插管 _全麻达到一定深度后，进行插管操作。为显露声门，要求嚼肌完全松弛和咽喉反射消失多用浅全麻 + 肌松药 ， 即快速诱导插管法优点：可提供有利插管条件（肌肉松弛，呼吸道反射消失的）缺点：但可能出现药物副作用，遇到插管困难时麻烦,45,Technique Patient Pos
30、ition,The patient should be positioned in sniffing position, with the occiput elevated by pads or folded blankets and the neck extended,46,Technique Patient Position,(A) With the patient supine and no head support, the oral, pharyngeal, and tracheal axes do not overlap.,(B) The “sniff” position maxi
31、mally overlaps the three axes so that the pathway from the lips to the glottis is nearly in a straight line,47,Technique insertion,The laryngoscope is held in the left hand near the junction between the handle and blade. Prop the mouth open with a scissoring motion of the right thumb and index finge
32、r.,48,Technique insertion,The laryngoscope is inserted into the right side of the patients mouth while sweeping the tongue to the left.,49,Technique insertion,The blade is then advanced toward the midline until the epiglottis comes into view. The tongue and pharyngeal soft tissues are then lifted to expose the glottic opening,
