超声在气道管理中的应用培训 医学ppt课件

超声在气道管理中的应用超声在气道管理中的超声在气道管理中的应应用用颈部气道解剖颈颈部气道解剖部气道解剖定位喉上神经Thethyrohyoidmembraneasatargetforultrasonography-guidedultrasonography-guidedblockoftheinternalbranchofthesuperiorlaryngealnerveStopar-PintaricT,VlassakovK,AzmanJ.JClinAnesth.2015Nov;27(7):548-52.Inconclusion,weareproposingananatomicalconceptforanew,new,simpler,consistentlyreproduciblesimpler,consistentlyreproducibleUS-guidediSLNblocktechniqueusingthethyrohyoidmembranetodefinethetargetplaneforlow-volumelocalanestheticinjection.定位喉上神定位喉上神经经The thyrohyoid membrane 外外侧侧舌骨舌骨外外侧侧舌骨舌骨超声影像舌骨、喉上神经外外侧侧过拱桥，甲舌膜里寻过拱桥，甲舌膜里寻喉上喉上外外侧侧舌骨外舌骨外侧侧舌骨超声影像舌骨超声影像舌骨、喉上神舌骨、喉上神经经外外侧过侧过拱拱桥桥，甲舌膜，甲舌膜定位环甲膜Theconventionalmethod,inspectionandpalpation,hasalowsuccessrate,especiallyinwomen(2435%).ElliottDS,BakerPA,ScottMR,etal.Accuracyofsurfacelandmarkidentificationforcannulacricothyroidotomy.Anaesthesia2010;65:88994LambA,ZhangJ,HungO,etal.AccuracyofidentifyingthecricothyroidmembranebyanesthesiatraineesandstaffinaCanadianinstitution.CanJAnaesth2015;62:495503定位定位环环甲膜甲膜The conventional method,BarbeN,MartinP,PascalJ,etal.AnnFrAnesthReanim.2014Mar;33(3):163-6.定位环甲膜定位环甲膜Locatingthecricothyroidmembraneinlearningphase:Valueofultrasonography?TheCTMwasaccuratelyidentifiedbypalpationandultrasoundby46%and100%46%and100%ofresidentsrespectively(P0.05).Barbe N,Martin P,Pascal J,et aKristensenMS,TeohWH,RudolphSS,etal.BrJAnaesth.2015Jun;114(6):1003-4.定位环甲膜定位环甲膜Structuredapproachtoultrasound-guidedultrasound-guidedidentificationofthecricothyroidmembrane:arandomizedcomparisonwiththepalpationmethodinthemorbidlyobesemorbidlyobeseWhenusingtheconventionaldigitalpalpationmethod,13of35anaesthetists(37%)wereabletolocatethecricothyroidmembranesuccessfullywithin 2 min,whereasthesuccessratewas29of35(83%)whenthestructuredstepwiseultrasonographymethodwasapplied(P=0.0008,McNemarstest).Kristensen MS,Teoh WH,RudolpSiddiquiN,ArzolaC,FriedmanZ,etal.Anesthesiology.2015Nov;123(5):1033-41.定位环甲膜定位环甲膜Ultrasound Ultrasound ImprovesCricothyrotomySuccessinCadaverswithPoorlyDefinedNeckAnatomyUltrasoundguidancesignificantlydecreasedtheincidenceofinjuriestothelarynxandtracheaIncreasedtheprobabilityofcorrectinsertionby5.6timesincadaverswithdifficultandimpossiblelandmarkpalpation.Siddiqui N,Arzola C,Friedman外外侧侧甲状软骨甲状软骨声声带带声声带带环甲膜环甲膜外外侧侧超声影像甲状软骨、环甲膜外外侧侧越尖峰，缺口越尖峰，缺口伪影伪影环甲膜环甲膜甲状软骨甲状软骨声声带带声声带带伪影伪影外外侧侧甲状甲状软软骨声骨声带带声声带环带环甲膜外甲膜外侧侧超声影像超声影像甲状甲状软软骨、骨、环环甲膜外甲膜外超声影像环状软骨环状软骨外外侧侧气管软骨气管软骨甲状腺峡部甲状腺峡部外外侧侧气管软骨气管软骨外外侧侧超声影像超声影像环环状状软软骨外骨外侧侧气管气管软软骨甲状腺峡部外骨甲状腺峡部外侧侧气管气管软软骨外骨外侧侧Ultrasound-guidedsuperiorlaryngealnerveblockandtranslaryngealblockforawaketrachealintubationinapatientwithlaryngealabscessIidaT,SuzukiA,KunisawaT,etal.JAnesth(2013)27:309310临床应用1清醒插管Ultrasound-guided superior larSonographically Sonographically GuidedSuperiorLaryngealNerveBlockDuringAwakeFiberopticIntubationSawkaA,TangR,VaghadiaH.AACaseRep.2015Apr15;4(8):107-10.Sonographicallyguidedsuperiorlaryngealnerveblockmaybeusefulusefulinpatientswhereidentificationoflandmarksintheneckisdifficultdifficultasaresultofpatientanatomy临床应用1清醒插管Sonographically Guided Superio临床应用1清醒插管Ultrasound-guided CannulaCricothyroidotomySuzukiA,IidaT,kunisawaT,etal.Anesthesiology2012Nov;117(5):1128Ultrasound-assistedtranslaryngealblockforawakefibreopticintubationDeOliveiraGSJr,FitzgeraldP,KendallM.CanJAnesth.201158:664665临临床床应应用用1清醒插管清醒插管Ultrasound-guided Ca临床应用1清醒插管病态肥胖病态肥胖 BMI BMI 6060临临床床应应用用1清醒插管病清醒插管病态态肥胖肥胖 BMI 60临床应用1清醒插管临临床床应应用用1清醒插管清醒插管临床应用1清醒插管临临床床应应用用1清醒插管清醒插管临床应用2判断喉镜显露困难气管软骨气管软骨外外侧侧食管食管甲状腺甲状腺WuJ,DongJ,DingY,etal.MedSciMonit,2014;20:2343-2350RoleofanteriornecksofttissuequantificationsbyultrasoundinpredictingdifficultlaryngoscopyAnteriornecksofttissuethicknessesmeasuredbyUSathyoidbone,thyrohyoidmembrane,andanteriorcommissurelevelsareindependentpredictorsofdifficultlaryngoscopy.CombinationsofthosescreeningtestsorriskfactorswithUSmeasurementsmightincreasetheabilitytopredictdifficultlaryngoscopy.临临床床应应用用2判断喉判断喉镜显镜显露困露困难难气管气管软软骨外骨外侧侧食管甲状腺食管甲状腺Wu J,临床应用2判断喉镜显露困难气管软骨气管软骨外外侧侧食管食管甲状腺甲状腺临临床床应应用用2判断喉判断喉镜显镜显露困露困难难气管气管软软骨外骨外侧侧食管甲状腺食管甲状腺Ultrasonographicmeasurementoftheminimaltransversediameterofthesubglotticairwayinthetransverseplane,typicallyatthecaudaloutletofthecricoidring临床应用临床应用3选择适合气管导管选择适合气管导管Ultrasonographic measurement o临床应用4判断气管导管位置气管软骨气管软骨外外侧侧食管食管甲状腺甲状腺排除食管内插管排除食管内插管证实气管导管在气管内证实气管导管在气管内临临床床应应用用4判断气管判断气管导导管位置气管管位置气管软软骨外骨外侧侧食管甲状腺排除食管内食管甲状腺排除食管内临床应用4判断气管导管位置THESENSITIVITYANDSPECIFICITYOFTRANSCRICOTHYROIDULTRASONOGRAPHYTOCONFIRMENDOTRACHEALTUBEPLACEMENTINACADAVERMODELDynamicassessmentresultedin97%97%sensitivityand100%100%specificityfordetectingesophagealETplacement.Staticassessmentresultedinonly51%51%sensitivityand91%91%specificity.MaG,DavisDP,SchmittJ,etal.JEmergMed.2007May;32(4):405-7.临临床床应应用用4判断气管判断气管导导管位置管位置THE SENSITIVITY 气管插管过程中环甲膜改变气管插管气管插管过过程中程中环环甲膜改甲膜改变变气管导管气囊充气表现气管气管导导管气囊充气表管气囊充气表现现临床应用5判断喉罩位置Laryngo-trachealultrasonographytoconfirmcorrectendotrachealtubeandlaryngealmaskairwayplacementSonographicupperairwayassessmentemergesasa rapidandrapidandeasilyeasily availablemethodavailablemethodtopredictdifficultintubation,toassessthelaryngealandhypopharyngealsizeandvisualizethepositionofthelaryngealmaskairwayinsitu.WojtczakJA,CattanoD.JournalofUltrasonography2014;14:362366临临床床应应用用5判断喉罩位置判断喉罩位置Laryngo-tracheal u临床应用5判断喉罩位置蝴蝶征蝴蝶征蝴蝶征蝴蝶征Unique喉罩的位置ESupreme喉罩的位置E临临床床应应用用5判断喉罩位置蝴蝶征判断喉罩位置蝴蝶征Unique喉罩的位置喉罩的位置ESup临床应用6定位气管切开Real-timeultrasound-guidedpercutaneousdilatationaltracheostomy:afeasibilitystudyPercutaneoustracheostomyperformedunderreal-timeultrasoundguidanceisfeasibleandappears accurateandsafeaccurateandsafe,includinginpatientswithmorbidobesityandcervicalspineprecautionsmorbidobesityandcervicalspineprecautions.VenkatakrishnaRajajee,JeffreyJFletcher,LaurynRRochlen,etal.CriticalCare2011,15:R67临临床床应应用用6定位气管切开定位气管切开Real-time ultrasou临床应用6定位气管切开Traditionallandmarkversusultrasoundguidedtrachealpunctureduringpercutaneousdilatationaltracheostomyinadultintensivecarepatients:arandomisedcontrolledtrialUltrasoundguidancesignificantlyimprovedtherateoffirst-passpunctureandpunctureaccuracy.Fewerproceduralcomplicationswereobserved;however,thisdidnotreachstatisticalsignificance.Theseresultssupportwidergeneraluseofreal-timeultrasoundguidanceasanadditionaltooltoimprovePDT.MtRudas,IanSeppelt,RobertHerkes,etal.CriticalCare2014,18:514临临床床应应用用6定位气管切开定位气管切开Traditional landma临床应用6定位气管切开可可可可视视视视化化化化操操操操作作作作才才才才能能能能有有有有意意意意识识识识避避避避开开开开血血血血管管管管临临床床应应用用6定位气管切开可定位气管切开可视视化操作才能化操作才能临床应用6定位气管切开临临床床应应用用6定位气管切开定位气管切开其他的临床应用1迅速准确建立通气MallinM,CurtisK,DawsonM,etal.AmJEmergMed2014Jan;32(1):61-3.Accuracyofultrasound-guidedmarkingofthecricothyroidmembranebeforesimulatedfailedintubationfailedintubationUltrasound markingoftheCTMofhealthyvolunteersbeforesimulatedintubationaccuratelyaccuratelyidentifiestheCTMafterneckmanipulationexpectedduringafailedintubationfailedintubation.其他的其他的临临床床应应用用1迅速准确建立通气迅速准确建立通气Mallin M,Cu其他的临床应用2改良Sellick法向后方压迫向后方压迫向后方压迫向后方压迫环状软骨环状软骨环状软骨环状软骨无效无效无效无效向向向向左后左后左后左后方压迫方压迫方压迫方压迫环状软骨环状软骨环状软骨环状软骨有效有效有效有效其他的其他的临临床床应应用用2改良改良Sellick法向后方法向后方压压迫向左后方迫向左后方压压迫迫其他的临床应用3耐受插管AdvancedDiagnosticBronchoscopyUsingConsciousSedationandtheLaryngealNerveBlock:TolerabilityTolerability,Thoroughness,andDiagnosticYieldGoyalG,PisaniMA,MurphyTE,etal.Lung(2014)192:905913如何更好如何更好耐受耐受长期气管插管？长期气管插管？或许或许喉上神经阻滞喉上神经阻滞是一个选择是一个选择其他的其他的临临床床应应用用3耐受插管耐受插管Advanced Diagnost1.清醒插管超声引导喉上神经阻滞和环甲膜穿刺过拱桥，甲舌膜里寻过拱桥，甲舌膜里寻喉上喉上越尖峰，缺口越尖峰，缺口伪影伪影环甲膜环甲膜总 结 4.判断气管导管的位置环甲膜气管插管气管插管进行时更敏感进行时更敏感5.判断喉罩位置蝴蝶征蝴蝶征6.定位气管切开准确定位、避免损伤准确定位、避免损伤7.迅速建立紧急通气超声引导超声引导环甲膜穿刺环甲膜穿刺8.改良Sellick法向向左后方左后方压迫环状软骨压迫环状软骨2.判断喉镜显露困难颈前部软组织厚度颈前部软组织厚度3.选择气管导管型号气管最小内径气管最小内径1.清醒插管清醒插管超声引超声引导导喉上神喉上神经经阻滞和阻滞和环环甲膜穿刺甲膜穿刺总总 结结 4.谢谢谢谢聆听聆听