超声在气道管理中的应用.ppt

上海交通大学附属第六人民医院麻醉科赵达强 超声在气道管理中的应用 2016 5 27 颈部气道解剖 定位喉上神经 Thethyrohyoidmembraneasatargetforultrasonography guidedblockoftheinternalbranchofthesuperiorlaryngealnerve Stopar PintaricT VlassakovK AzmanJ JClinAnesth 2015Nov 27 7 548 52 Inconclusion weareproposingananatomicalconceptforanew simpler consistentlyreproducibleUS guidediSLNblocktechniqueusingthethyrohyoidmembranetodefinethetargetplaneforlow volumelocalanestheticinjection 超声影像 舌骨 喉上神经 外侧 过拱桥 甲舌膜里寻喉上 定位环甲膜 Theconventionalmethod inspectionandpalpation hasalowsuccessrate especiallyinwomen 24 35 ElliottDS BakerPA ScottMR etal Accuracyofsurfacelandmarkidentificationforcannulacricothyroidotomy Anaesthesia2010 65 889 94LambA ZhangJ HungO etal AccuracyofidentifyingthecricothyroidmembranebyanesthesiatraineesandstaffinaCanadianinstitution CanJAnaesth2015 62 495 503 SiddiquiN ArzolaC FriedmanZ etal Anesthesiology 2015Nov 123 5 1033 41 定位环甲膜 UltrasoundImprovesCricothyrotomySuccessinCadaverswithPoorlyDefinedNeckAnatomy UltrasoundguidancesignificantlydecreasedtheincidenceofinjuriestothelarynxandtracheaIncreasedtheprobabilityofcorrectinsertionby5 6timesincadaverswithdifficultandimpossiblelandmarkpalpation 外侧 甲状软骨 声带 声带 超声影像 甲状软骨 环甲膜 外侧 越尖峰 缺口伪影环甲膜 甲状软骨 声带 声带 伪影 超声影像 环状软骨 外侧 气管软骨 甲状腺峡部 外侧 气管软骨 外侧 Ultrasound guidedsuperiorlaryngealnerveblockandtranslaryngealblockforawaketrachealintubationinapatientwithlaryngealabscess IidaT SuzukiA KunisawaT etal JAnesth 2013 27 309 310 临床应用1 清醒插管 SonographicallyGuidedSuperiorLaryngealNerveBlockDuringAwakeFiberopticIntubation SawkaA TangR VaghadiaH AACaseRep 2015Apr15 4 8 107 10 Sonographicallyguidedsuperiorlaryngealnerveblockmaybeusefulinpatientswhereidentificationoflandmarksintheneckisdifficultasaresultofpatientanatomy 临床应用1 清醒插管 临床应用1 清醒插管 Ultrasound guidedCannulaCricothyroidotomy SuzukiA IidaT kunisawaT etal Anesthesiology2012Nov 117 5 1128 Ultrasound assistedtranslaryngealblockforawakefibreopticintubation DeOliveiraGSJr FitzgeraldP KendallM CanJAnesth 201158 664 665 临床应用1 清醒插管 病态肥胖BMI60 临床应用1 清醒插管 临床应用1 清醒插管 临床应用2 判断喉镜显露困难 气管软骨 外侧 食管 甲状腺 WuJ DongJ DingY etal MedSciMonit 2014 20 2343 2350 Roleofanteriornecksofttissuequantificationsbyultrasoundinpredictingdifficultlaryngoscopy AnteriornecksofttissuethicknessesmeasuredbyUSathyoidbone thyrohyoidmembrane andanteriorcommissurelevelsareindependentpredictorsofdifficultlaryngoscopy CombinationsofthosescreeningtestsorriskfactorswithUSmeasurementsmightincreasetheabilitytopredictdifficultlaryngoscopy 临床应用2 判断喉镜显露困难 气管软骨 外侧 食管 甲状腺 Ultrasonographicmeasurementoftheminimaltransversediameterofthesubglotticairwayinthetransverseplane typicallyatthecaudaloutletofthecricoidring 临床应用3 选择适合气管导管 临床应用4 判断气管导管位置 气管软骨 外侧 食管 甲状腺 排除食管内插管证实气管导管在气管内 临床应用4 判断气管导管位置 THESENSITIVITYANDSPECIFICITYOFTRANSCRICOTHYROIDULTRASONOGRAPHYTOCONFIRMENDOTRACHEALTUBEPLACEMENTINACADAVERMODEL Dynamicassessmentresultedin97 sensitivityand100 specificityfordetectingesophagealETplacement Staticassessmentresultedinonly51 sensitivityand91 specificity MaG DavisDP SchmittJ etal JEmergMed 2007May 32 4 405 7 气管插管过程中环甲膜改变 气管导管气囊充气表现 临床应用5 判断喉罩位置 Laryngo trachealultrasonographytoconfirmcorrectendotrachealtubeandlaryngealmaskairwayplacement Sonographicupperairwayassessmentemergesasarapidandeasilyavailablemethodtopredictdifficultintubation toassessthelaryngealandhypopharyngealsizeandvisualizethepositionofthelaryngealmaskairwayinsitu WojtczakJA CattanoD JournalofUltrasonography2014 14 362 366 临床应用5 判断喉罩位置 蝴蝶征 Unique喉罩的位置E Supreme喉罩的位置E 临床应用6 定位气管切开 Real timeultrasound guidedpercutaneousdilatationaltracheostomy afeasibilitystudy Percutaneoustracheostomyperformedunderreal timeultrasoundguidanceisfeasibleandappearsaccurateandsafe includinginpatientswithmorbidobesityandcervicalspineprecautions VenkatakrishnaRajajee JeffreyJFletcher LaurynRRochlen etal CriticalCare2011 15 R67 临床应用6 定位气管切开 Traditionallandmarkversusultrasoundguidedtrachealpunctureduringpercutaneousdilatationaltracheostomyinadultintensivecarepatients arandomisedcontrolledtrial Ultrasoundguidancesignificantlyimprovedtherateoffirst passpunctureandpunctureaccuracy Fewerproceduralcomplicationswereobserved however thisdidnotreachstatisticalsignificance Theseresultssupportwidergeneraluseofreal timeultrasoundguidanceasanadditionaltooltoimprovePDT M t Rudas IanSeppelt RobertHerkes etal CriticalCare2014 18 514 临床应用6 定位气管切开 可视化操作才能有意识避开血管 临床应用6 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 guidedmarkingofthecricothyroidmembranebeforesimulatedfailedintubation UltrasoundmarkingoftheCTMofhealthyvolunteersbeforesimulatedintubationaccuratelyidentifiestheCTMafterneckmanipulationexpectedduringafailedintubation 其他的临床应用2 改良Sellick法 向后方压迫环状软骨无效 向左后方压迫环状软骨有效 其他的临床应用3 耐受插管 AdvancedDiagnosticBronchoscopyUsingConsciousSedationandtheLaryngealNerveBlock Tolerability Thoroughness andDiagnosticYield GoyalG PisaniMA MurphyTE etal Lung 2014 192 905 913 如何更好耐受长期气管插管 或许喉上神经阻滞是一个选择 1 清醒插管 超声引导喉上神经阻滞和环甲膜穿刺过拱桥 甲舌膜里寻喉上越尖峰 缺口伪影环甲膜 总结 4 判断气管导管的位置 环甲膜气管插管进行时更敏感 5 判断喉罩位置 蝴蝶征 6 定位气管切开 准确定位 避免损伤 7 迅速建立紧急通气 超声引导环甲膜穿刺 8 改良Sellick法 向左后方压迫环状软骨 2 判断喉镜显露困难 颈前部软组织厚度 3 选择气管导管型号 气管最小内径 谢谢聆听