上呼吸道管理与气管插管.ppt

1,上呼吸道管理与气管插管,The Difference Between Life and Death,2,临床教训与急诊医师责任,教训 气管肿物病人住下观第三天清晨猝然憋死 COPD急发住下观一周后因痰清晨憋死 颈部淋巴瘤已知主气管受压，在急诊等专科床3周，进血液科第二天憋死 大咯血憋死 经验 支气管肿瘤压迫急作支架成活 会及时上呼吸道控制是急诊医师基本功,3,讨论内容,解剖与生理 气管插管优点 气管插管指征 禁忌症 气管插管并发症 气管插管所需设备,插管技术 气管插管规则 插管管径的选择 吸引技术与原则 其它人工气道装置 结论 困难插管,4,解剖与生理,气道可区分为: 上呼吸道：The upper airway 下呼吸道：The lower airway 分界在会厌,5,The Upper Airway,6,The Lower Airway,7,气管插管的作用,有气囊的插管防误吸 直接吸引气管分泌物 不造成胃涨，减少胃返流 保持上呼吸道通畅 便于雾化药物的使用,8,插管指征,不能用常规氧疗法纠正的氧合衰竭 (decreased arterial PO2) 肺泡低通气 (increased arterial PCO2). 上呼吸道不通畅 (分泌物、肿物等) 所有心跳停止的病人 (CPR),9,Indications for Intubation,深昏迷、不能自主维持呼吸道者(Gag reflex absent) 意识低下病人 GCS = 8 所有可能发生上呼吸道梗阻的病人 (如Burns of the upper airways) 严重头面部创伤，呼吸道可能不能自主维持者,10,Indications Cont…,自主呼吸停止者 呼吸衰竭 1. Hypoventilation/Hypercarbia PaCO2 55mmhg 2. Arterial hypoxemia refractory to O2 PaO2 70 on 100% O2,11,气管插管禁忌症,吞咽反射完好 病人可能因气管插管引发喉头或气管痉挛 e.g. Children with epiglottitis. 颅底骨折 – 避免经鼻气管插管、经鼻胃管,12,气管插管并发症,组织损伤，如牙、会厌、声带、梨状窝等 经鼻插管可能损伤鼻甲、咽壁等，甚至可能导致鼻咽部黏膜的穿透伤 强刺激可导致血压升高和心率加快，对一些高危病人如AMI、高血压脑出血等有直接危害 可能因迷走刺激导致一过性心律紊乱,13,并发症 (Cont.),气管插管气囊破损，导致气道不严 误插入食道，导致胃胀、返流 插管过程中操作不当，致气道内高压和气压伤 咽部过度刺激，导致喉痉挛和可能完全性呼吸道梗阻 插管过深，导致单侧通气（右侧） 异物、吹干了的分泌物、血液等导致插管堵塞,14,所需设备,15,Equipment Cont…,Laryngoscope with relevant size blades. Magill forceps. Flexible introducer. 10-20 ml syringe. Oropharangeal airways – all sizes. Tape or adhesive plaster. E.T tubes – relevant sizes. Bag-valve-mask with oxygen connected. Suction unit with Yankauer nozzle and endotracheal suction catheter.,16,Technique Cont…,平卧位、头后仰、下颌提起、纯氧面罩 (Suspected spinal injury, attempt naso-tracheal intubation, spine in neutral position). 麻醉：Rapid Sequence Intubation HTN/高ICP/哮喘--Lidocaine 1mg/kg ivp 5 old -- Atropine 0.02mg/kg ivp 3’后 Thiopental 3-5mg/kg + 司可林1.5mg/kg ivp 30”后 推开嘴唇，以右手食指拉上颌，从而使张嘴 左手持喉镜，将叶片插入，向右扁桃体方向推进 一旦叶片到达右扁桃体，将叶片横推向中线，从而使舌体被叶片挡在口腔左部,17,Technique Cont…,暴露会厌” DO NOT LOOSE SIGHT OF IT!” 将叶片继续往前推进，直到叶片顶端到达舌根与会厌间的结合部( volecular space) 左手握住喉镜把向前上方提起，这样多数情况下已可看到声门。

有时可能需有人帮助压一下喉头以更好看清声门和咽部结构 右手持气管插管，先使管子的弯曲弧度向右，插入嘴里 在直视下将管子插入声门 待管子气囊刚好全部进到声门下、并继续插入1-2cm时，即可气囊充气，并固定插管 用听诊器听双肺尖和侧胸部，确认双侧呼吸音以确认气管插管是否成功或位置是否适当,18,19,气管插管技术,20,21,插管注意事项,必须有良好吸引器 一次插管操作不要超过 30 秒 插管前后都要用纯氧面罩和皮球辅助呼吸 抽好一支镇静药备用 (如Midazolam 15mg/3ml) 插管中及后持续监测Spo2，以指导操作和插管后辨认插管位置,22,正常氧储备,吸入 空气ml 纯氧ml 肺内FRC 450 3000 血红蛋白 850 950 组织溶解 50 100 肌红蛋白 200 200 合计 1550 4250 机体氧耗 200-250ml/min,约50%氧储备不能用(肌红蛋白/FRC/血红蛋白) 正常成人氧储备可供停氧3‘，纯氧过度氧合后8’ 病人代偿差/储备少/安全系数：40”/1’,23,Tube sizes,Newborn – to 4 kg - 2.5 mm (uncuffed) 1-6 months 4-6 kg – 3.5 mm (uncuffed) 7-12 months 6-9 kg – 4.0 mm (uncuffed) 1 year 9 kg – 4.5 mm (uncuffed) 2 years 11 kg – 5.0 mm (uncuffed) 3-4 years 14–16 kg - 5.5 mm (uncuffed) 5-6 years 18–21 kg – 6.0 mm (uncuffed) 7-8 years 22-27 kg – 6.5 mm ( uncuffed),24,Tube Sizes,9-11 years 28-36 kg – 7.0 mm(cuffed) 14 to adults 46+ kg – 7.0 – 80 mm (cuffed) Adult female 7.0 – 8.0mm (cuffed) Adult male 7.5 – 8.5 mm (cuffed) The size of the tube may also be determined by the size of the patients little finger Patients below the age of 8 require uncuffed ETT due to damage caused by the cuff in younger patients. Always monitor the ECG activity during intubation.,25,吸引注意事项,看着吸Never suction further than you can see 自己憋口气Never suction for longer than15 seconds 出管时吸Always suction on the way out 吸引前后都先过度氧合Always oxygenate the patient before and after suctioning,26,其它人工气道用的管子,Kombi-tube Oropharangeal airways/tubes Nasopharyngeal airways/tubes Oro-tracheal tubes Naso-tracheal tubes,27,Conclusion,Always oxygenate patient before and after intubation. Do not attempt intubation unless you are totally skilled, rather perform bag-valve-mask ventilation. Always reconfirm tube placement from time to time.,。