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上海市第六人民医院Shanghai Sixth Peoples Hospital颈部气道解剖上海市第六人民医院Shanghai Sixth Peoples Hospital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.上海市第六人民医院Shanghai Sixth Peoples Hospital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，甲舌膜里寻喉上上海市第六人民医院Shanghai Sixth Peoples Hospital定位环甲膜Theconventionalmethod,inspectionandpalpation,hasalowsuccessrate,especiallyinwomen(2435%).Elliott DS,Baker PA,Scott MR,et al.Accuracy of surface landmark identification for cannula Elliott DS,Baker PA,Scott MR,et al.Accuracy of surface landmark identification for cannula cricothyroidotomy.Anaesthesia 2010;65:889cricothyroidotomy.Anaesthesia 2010;65:889 9494 Lamb A,Zhang J,Hung O,et al.Accuracy of identifying the cricothyroid membrane by Lamb A,Zhang J,Hung O,et al.Accuracy of identifying the cricothyroid membrane by anesthesia trainees and staff in a Canadian institution.Can J Anaesth 2015;62:495anesthesia trainees and staff in a Canadian institution.Can J Anaesth 2015;62:495 503503上海市第六人民医院Shanghai Sixth Peoples HospitalBarbeN,MartinP,PascalJ,etal.AnnFrAnesthReanim.2014Mar;33(3):163-6.定位环甲膜Locatingthecricothyroidmembraneinlearningphase:Valueofultrasonography?TheCTMwasaccuratelyidentifiedbypalpationandultrasoundby46%and100%46%and100%ofresidentsrespectively(P0.05).上海市第六人民医院Shanghai Sixth Peoples HospitalKristensenMS,TeohWH,RudolphSS,etal.BrJAnaesth.2015Jun;114(6):1003-4.定位环甲膜Structuredapproachtoultrasound-guidedultrasound-guidedidentificationofthecricothyroidmembrane:arandomizedcomparisonwiththepalpationmethodinthemorbidlyobesemorbidlyobeseWhenusingtheconventionaldigitalpalpationmethod,13of35anaesthetists(37%)wereabletolocatethecricothyroidmembranesuccessfullywithin 2 min,whereasthesuccessratewas29of35(83%)whenthestructuredstepwiseultrasonographymethodwasapplied(P=0.0008,McNemarstest).上海市第六人民医院Shanghai Sixth Peoples HospitalSiddiquiN,ArzolaC,FriedmanZ,etal.Anesthesiology.2015Nov;123(5):1033-41.定位环甲膜Ultrasound Ultrasound ImprovesCricothyrotomySuccessinCadaverswithPoorlyDefinedNeckAnatomyUltrasoundguidancesignificantlydecreasedtheincidenceofinjuriestothelarynxandtracheaIncreasedtheprobabilityofcorrectinsertionby5.6timesincadaverswithdifficultandimpossiblelandmarkpalpation.上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples HospitalUltrasound-guidedsuperiorlaryngealnerveblockandtranslaryngealblockforawaketrachealintubationinapatientwithlaryngealabscessIidaT,SuzukiA,KunisawaT,etal.JAnesth(2013)27:309310临床应用1清醒插管上海市第六人民医院Shanghai Sixth Peoples HospitalSonographically Sonographically GuidedSuperiorLaryngealNerveBlockDuringAwakeFiberopticIntubationSawkaA,TangR,VaghadiaH.AACaseRep.2015Apr15;4(8):107-10.Sonographicallyguidedsuperiorlaryngealnerveblockmaybeusefulusefulinpatientswhereidentificationoflandmarksintheneckisdifficultdifficultasaresultofpatientanatomy临床应用1清醒插管上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples Hospital临床应用1清醒插管病态肥胖病态肥胖 BMI 60BMI 60上海市第六人民医院Shanghai Sixth Peoples Hospital临床应用1清醒插管上海市第六人民医院Shanghai Sixth Peoples Hospital临床应用1清醒插管上海市第六人民医院Shanghai Sixth Peoples Hospital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.上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples HospitalUltrasonographicmeasurementoftheminimaltransversediameterofthesubglotticairwayinthetransverseplane,typicallyatthecaudaloutletofthecricoidring临床应用3选择适合气管导管上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples Hospital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.上海市第六人民医院Shanghai Sixth Peoples Hospital气管插管过程中环甲膜改变上海市第六人民医院Shanghai Sixth Peoples Hospital气管导管气囊充气表现上海市第六人民医院Shanghai Sixth Peoples Hospital临床应用5判断喉罩位置Laryngo-trachealultrasonographytoconfirmcorrectendotrachealtubeandlaryngealmaskairwayplacementSonographicupperairwayassessmentemergesasa rapidandrapidandeasilyeasily availablemethodavailablemethodtopredictdifficultintubation,toassessthelaryngealandhypopharyngealsizeandvisualizethepositionofthelaryngealmaskairwayinsitu.WojtczakJA,CattanoD.JournalofUltrasonography2014;14:362366上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples Hospital临床应用6定位气管切开上海市第六人民医院Shanghai Sixth Peoples Hospital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.上海市第六人民医院Shanghai Sixth Peoples Hospital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上海市第六人民医院Shanghai Sixth Peoples Hospital其他的临床应用3耐受插管AdvancedDiagnosticBronchoscopyUsingConsciousSedationandtheLaryngealNerveBlock:TolerabilityTolerability,Thoroughness,andDiagnosticYieldGoyalG,PisaniMA,MurphyTE,etal.Lung(2014)192:905913如何更好耐受长期气管插管？或许喉上神经阻滞是一个选择上海市第六人民医院Shanghai Sixth Peoples Hospital1.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上海市第六人民医院Shanghai Sixth Peoples Hospital