气管镜下介入诊疗适宜技术.pptx

The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First介入肺脏病学适宜技术的应用介入肺脏病学适宜技术的应用The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First内内 容容概述概述面向基层的适宜技术虚拟导航引导下TBLBTBNA冷冻治疗及活检病例演示小结The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First介入肺脏病学介入肺脏病学是“一门涉及呼吸系统疾病侵入性诊断和治疗操作的医学科学和艺术”。诊治范围 复杂气道病变的处理;良、恶性病变所致的中央气道的阻塞;胸膜疾病和肺血管性病变The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First介入肺脏病学技术介入肺脏病学技术-1硬质支气管镜检查术经支气管针吸活检术(transbronchialneedleaspiration，TBNA)自荧光支气管镜检术支气管腔内超声(endobronchialultrasound，EBUS)经皮针吸肺活检术支气管镜介导下的激光、高频电灼、氩等离子体凝固(argon-plasmacoagulation，APC)The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First介入肺脏病学技术介入肺脏病学技术-2经支气管镜冷冻治疗和活检经支气管镜冷冻治疗和活检经支气管镜冷冻治疗和活检经支气管镜冷冻治疗和活检气道内支架植入支气管内近距离后装放疗、光动力治疗经皮扩张气管造口术(percutaneousdilationaltracheotomy)经气管氧气导管置入术内科胸腔镜影像引导的胸腔介入诊疗The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First硬质支气管镜硬质支气管镜The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstEBUSThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstAPC工作站工作站The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First内内 容容概述面向基层的适宜技术面向基层的适宜技术虚拟导航引导下TBLBTBNA冷冻治疗及活检病例演示小结The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First肺外周病变诊断方法比较肺外周病变诊断方法比较 CT引导下经皮肺穿刺引导下经皮肺穿刺:TTNA常规经支气管镜活检术常规经支气管镜活检术:TBLB 有创性操作有创性操作较高的并发症发生率较高的并发症发生率(气胸气胸15%-38%)射线暴露射线暴露 高诊断率高诊断率 诊断率不高诊断率不高 无法确定是否到达病变部位重复活检时到达同一支气管较困难耗时较长耗时较长支气管壁损伤支气管壁损伤/出血出血射线暴露射线暴露侵袭性小侵袭性小The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First降低定位和活检等的降低定位和活检等的难度难度缩短操作时间缩短操作时间减少辐射暴露的剂量减少辐射暴露的剂量经支气管镜活检所需解决的问题经支气管镜活检所需解决的问题病变病变30mm30mmThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First虚拟支气管软件的技术优势虚拟支气管软件的技术优势引导支气管镜到达所指定的病变部位能把握支气管镜当前位置 减少不必要的透视能确认支气管镜行进方向 顺利通过支气管分叉处缩短支气管镜插入的实施时间 减轻患者的痛苦和减少操作的危险性插入支气管镜引导支气引导支气管镜操作管镜操作(参照参照DirectPathDirectPath虚虚拟支气管镜图像拟支气管镜图像)识别肿瘤位置提取样本The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstDirectPathDirectPath使用流程便捷使用流程便捷使用流程便捷使用流程便捷放射科呼吸科检查室导航虚拟支气管镜图像取得DICOM数据拍摄患者肺部CT以DICOM数据格式提供以DICOM数据生成虚拟支气管镜图像确定病变部位拍摄CT数据在操作支气管镜检查时,可参考虚拟支气管镜图像和路径走向引导医师的支气管镜插入操作The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstDirectPathDirectPathDirectPathDirectPath的操作步骤的操作步骤的操作步骤的操作步骤加载数据DirectPath 可直接加载DICOM数据设定目标和路径设定目标点确认到达目标点的路径导航确认虚拟内镜图像插入支气管镜操作过程中需要参照虚拟支气管镜图像The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First加载DICOM数据设定目标确认路径编辑缩略图播放虚拟支气管镜图像DirectPath按照每个支气管分支部位置自动生成缩略图移动到下一个缩略图位置时，会自动播放虚拟支气管镜图像的行进过程可以增加或减少缩略图的数量、旋转缩略图的方向，符合内镜医生的操作习惯DirectPathDirectPath的操作步骤的操作步骤编辑缩略图编辑缩略图The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First虚拟导航虚拟导航TBLB病例病例患者，男，61岁，因“咳嗽、胸闷1月余”胸部CT：左肺上叶尖后段毛玻璃结节，腺癌可能，建议穿刺活检；左肺下叶团块影，肿瘤可能，建议穿刺活检。纵隔及左肺门肿块，考虑淋巴结转移；左侧胸腔少量积液。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First肺部肺部CTThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First虚拟导航路径虚拟导航路径The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First虚拟导航下支气管镜虚拟导航下支气管镜TBLB及及TBNA隆突隆突前壁隆突前壁右第二隆突左固有上支隆突4L组TBNAThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First病病理理报报告告The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First虚拟导航需要注意的地方虚拟导航需要注意的地方非实时，虚拟环境下人体存在变异，部分引导位置不十分准确；与盲检的TBLB相比，阳性率有大幅度提高，但要进一步提高则需要EBUS或借助于X线透视软件对于CT图像的质量有限制；非常适合气管镜模拟训练The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstTBNA是一项应用于硬质或软质气管镜的一项技术，目前主要应用于软性支气管镜，通过应用一种特制的带有可弯曲导管的穿刺针，通过气管镜的活检通道进入气道内，然后穿透气道壁对气管、支气管腔外病变，如结节、肿块、肿大的淋巴结以及肺部的病灶等进行针刺吸引，获取细胞或组织标本进行病理学、细菌学及其它特殊检查。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First适应证适应证主要 对以下情况建立诊断：纵隔或肺门淋巴结 对已知或怀疑肺癌进行分期 气管外病变对气管的外压病灶 粘膜下病变 肺周围性结节次要 对气道内坏死肿瘤、出血性肿瘤病 变建立诊断 预测外科切除线 追踪小细胞肿瘤 对纵隔囊肿及脓肿进行诊断及引流 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First24TBNA理解容易，操作有技巧，需过几个关口。理解容易，操作有技巧，需过几个关口。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First25第一关：阅读胸部第一关：阅读胸部CT片，明确病灶部位。片，明确病灶部位。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First26第二关：参照第二关：参照CT，进行，进行TBNA穿刺点定位穿刺点定位第一层面：隆突层面第一层面：隆突层面l前隆突淋巴结前隆突淋巴结l后隆突淋巴结后隆突淋巴结l右气管旁淋巴结右气管旁淋巴结l左气管旁淋巴结左气管旁淋巴结l右主支气管淋巴结右主支气管淋巴结l左主支气管淋巴结左主支气管淋巴结第二层面：右主支气管层第二层面：右主支气管层面面l右上肺门淋巴结右上肺门淋巴结l隆突下淋巴结隆突下淋巴结第三层面：中间支气管层第三层面：中间支气管层面面l右下肺门淋巴结右下肺门淋巴结l隆突远端淋巴结隆突远端淋巴结第四层面：左主支气管层第四层面：左主支气管层面面l左肺门淋巴结左肺门淋巴结The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First27Station 1Anterior Carina6514310879112定位定位：左右主支气交汇点的前上方。左右主支气交汇点的前上方。穿刺穿刺：气管下端第气管下端第1-21-2气管环间，气管环间，1212点。点。（气管环从隆突向声门处数）（气管环从隆突向声门处数）The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First286514310879112Station 2Posterior carina定位：左右支气管交汇点的后下方，或直接位于右支气管后方。穿刺：隆突后方，5-6点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First296514310879112Station 3Right paratracheal LN定位：上腔静脉后方、气管下端前侧方近奇静脉弓。穿刺：气管下端第2-4气管环间，1-2点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First306514310879112Station 4A-P window定位：气管左侧壁近气管支气管转角处，主动脉弓下、左肺动脉上。穿刺：气管下端左侧第1-2气管环间，9点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First316514310879112Station 5Right mainstem bronchus LN定位：右主支气管前上方。穿刺：右主支气管第1-2气管环间（从开口 向远端数），12点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First326514310879112Station 6Left main bronchus定位：左主支气管前上方。穿刺：左主支气管第1-2气管环间，12点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First336514310879112Station 7Right hilar LNRUL takeoffRight bronchus intermedius7定位：右上支气管与中间支气管之间。穿刺：右上支气管分嵴前方。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First346514310879112RUL takeoffBronchus IntermediusStation 8Sub carina定位：左右主支气管之间或近右上支气管开口水平。穿刺：右主支气管内侧壁，或近右上支气管开口，9点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First356514310879112Station 9Right lower hilarRMLSuperior segmentRLL9定位：中间支气管的侧方或前方，近右中叶支气管开口水平穿刺：右中间支气管侧壁，3点；或中叶支气管开口水平，12点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First366514310879112Station 10 Sub-sub carina定位：中间支气管和左主支气管之间，近右中叶支气管 开口水平。穿刺：中间支气管内侧壁，近右中叶支气管开口水平，9点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First376514310879112Station 11Left hilar LNLLLLingulaLUL11定位：左上下叶支气管分嵴处。穿刺：左下支气管外侧壁近背段开口，9点。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First38第三关：穿刺针透过定位点管壁第三关：穿刺针透过定位点管壁The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstTBNA病例病例-1患者，男，59岁，因“咳嗽咳痰伴发热半月入院；查体：右下肺呼吸音低，未闻及明显干湿啰音。辅助检查：胸部CT：右肺下叶可疑团块伴炎症，建议增强CT进一步检查；右侧少量胸腔积液；两肺肺气肿伴两肺尖肺大泡、肺气囊形成；右肺中叶局部轻度支扩考虑；两肺散在纤维增殖灶。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First胸部胸部CTThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First支气管镜下支气管镜下TBNA隆突左第二隆突右中间支气管隆突7组淋巴结TBNA突The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First病例病例2女，58岁，退休干部，因干咳一月余入院。既往有乳腺癌病史8年余，曾经行左乳房切除术并行化疗。入院体检：左腋窝可触及一枚轻度肿大淋巴结，小绿豆大小，质硬，无压痛。左下肺呼吸音偏低。外院肺部CT：左侧胸腔积液，纵隔淋巴结肿大The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First诊 治 经 过胸水示渗出液，结核相关检查阴性；常规胸膜活检找到异型细胞，免疫组化后考虑是炎症。外院多次及我院两次胸水找脱落细胞阴性；外科会诊认为腋窝淋巴结位置深，偏小，不宜行淋巴结活检。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First下一步怎么办？The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 右气管旁淋巴结右气管旁淋巴结TBNA气管镜下肉眼所见未见明显异常；右前隆突淋巴结和右气管旁淋巴结活检提示腺癌细胞，符合乳腺癌转移。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First病例分享病例分享-3男年龄：22岁，因“干咳5天，加重伴胸痛、胸闷、气促2天入院患者5天前无明显诱因下出现干咳，无痰。2天前干咳症状加重伴有胸痛、胸闷、气促，无声音嘶哑，无畏寒发热，无心悸，无咯血，无胸痛气急，无午后低热个人史、家族史无殊；The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First体格检查体格检查神清，精神可，皮肤巩膜无黄染，颈部锁骨上腋下等浅表淋巴结未及肿大。气管居中，甲状腺不肿，颈静脉无怒张，胸廓无畸形，呼吸运动对称，叩诊清音。双肺呼吸音清，未及干湿啰音。心音中等，心律齐，各瓣膜听诊区未闻及明显病理性杂音。心脏浊音区正常。腹软，无压痛反跳痛，肝脾肋下未及，双下肢无浮肿。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First纵隔纵隔CTThe Needs of The Patients and The Customers Come FirstThe Needs of The Patient