气道异物邹宏运

安徽医科大学第一附属医院麻醉科 邹宏运七氟醚在小儿支气管异物取出七氟醚在小儿支气管异物取出术中的应用术中的应用病例12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21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！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-表面麻醉流行病学气管（支气管）异物吸入多数发于4岁以下儿童，男童占61%。死亡率3.4%左右，在支气管镜检中死亡率约0.42%。只有11%异物在X线下不透光，17%的患儿胸片正常。诊断金标准：支气管镜检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 23 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(OctoberDecember 2011)63(4):313316;DOI 10.1007/s12070-011-0227-5急诊支气管镜检指征已存在呼吸衰竭可能成为全部的呼吸道梗阻喉部较大异物银币等尖锐异物气肿致纵隔移位花生（可肿胀 含油脂）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;73:10859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，Anaesthesia for bronchial foreign body removal:what really matters?European Journal of Anaesthesiology 2010,Vol 27 No 11Time for loc(Group VIMA 95.615.2 sec vs Group TIVA 146.226.9 sec,p0.05)The time of BIS value decreased to 40(Group VIMA 115.316.5 sec vs Group TIVA 160.425.8 sec,p0.05).The emergence time(Group VIMA 10.52.6 min vs Group TIVA 16.93.1 min,p0.05)in Group VIMA were significantly 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 under spontaneous breathing for tracheal/bronchial foreign body removal in children.Eur J Anaesth 2010;27:930934.The incidence rates of breath holding(Group VIMA 6.25%vs Group TIVA 31.25%,p0.05)The desaturation(Group VIMA 15.63%vs Group TIVA 37.50%,p0.05)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 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 under spontaneous breathing for tracheal/bronchial foreign body removal in children.Eur J Anaesth 2010;27:930934.The study by Liao et al.,however,covers only one aspect of anaesthetic management for these procedures.In their practice,spontaneous ventilation represents thestandard of care for bronchoscopic retrieval.Advantages of spontaneous ventilation include the ability to provide continuous ventilation despite interruptions in the anaesthesia breathing circuit,and in the case of obstructive lesions.negative-pressure breathing may provide better oxygenation and ventilation.建议隆突近端or主气道内or大异物-保留自主呼吸隆突远端and支气管树内小异物-可正压控制通气麻醉方法术前询问病史：异物种类，大小，病史时间（炎症，肉芽，位置变化）主要症状，有无发热。充分解释麻醉风险。读片（位置，大小），听诊患儿双肺呼吸音。由患儿家长将患儿抱入手术室。麻醉方法术前：禁食8h（stable）,6h(in danger)6%七氟醚预充回路1.5-2分钟（新鲜气流量5L/分）面罩吸入麻醉镇静后建立静脉通路予阿托品0.01mg/kg iv，地塞米松5-10mg iv麻醉方法继续七氟醚吸入约5分钟，及时听诊小儿双肺呼吸音，调整吸入浓度。耳鼻喉科医生喉镜暴露声门，以2%利多卡因喉麻管声门附近，声门下喷雾局部麻醉。麻醉方法 同时静脉予1ug/kg芬太尼。继续吸入七氟醚麻醉5分钟，如果双肺可闻及呼吸音，氧饱和度在90%以上，不需要降低吸入气体浓度。麻醉方法 手术开始前经脉予异丙酚1mg/kg，并根据手术时间追加。建议在取异物和移动硬质支气管镜前加深麻醉。视手术时间长短追加芬太尼和异丙酚。若手术困难，或医生水平一般可打开人工心肺复苏机或其他喷射通气装置连接硬质气管镜侧端。此时可完全打断患儿呼吸（非大异物）。常见问题保留自主呼吸，外科操作时患儿屛气，呛咳-常发生于麻醉浅，外科医生进退气管镜时。解决方法：加深麻醉，辅助通气。严重并发症气道完全阻塞 喉痉挛-加深麻醉 -异物移位（若完全梗阻，用硬镜推送入远端支气管，通气后找熟练外科医生继续操作)气胸 张力性气胸（胸腔闭式引流）气道出血（肾上腺素棉球压迫）纵膈积气气管，支气管撕伤低氧性脑损伤（0.96%）Individual anaesthesiologists 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.What about yours?谢谢！