纤维支气管镜检查在ICU中的应用

纤维支气管镜检查在ICU中的应用翁恒BronchoscopyintheICU适应症–诊断观察喉、气管、支气管：损伤、咯血定位、肺不张原因、肿瘤、粘膜改变（支气管侵袭性曲霉菌）、分泌物性状、支气管食道瘘。支气管肺泡灌洗（细胞学、革兰氏染色、致病菌培养）：支气管肺感染、肿瘤、结核病、肺泡蛋白沉着症、肺泡出血。经纤支镜肺活检：真菌、结核、肿瘤、血管炎适应症–治疗协助气管插管、换管、拔管吸除血块及浓稠分泌物去除支气管异物支气管胸膜瘘封堵气管狭窄扩张局部用药相对禁忌症不能纠正的凝血功能异常机械通气需要高PEEP时的TBLB。进食后心肺功能级不稳定并发症误吸喉、气管支气管痉挛心律失常低氧血症，继发发热感染加用麻醉镇静剂导致的呼吸抑制及低血压。损伤性操作后的咯血及气胸注意事项BRONCHOSCOPYIN(ICU)术前应充分考虑气管导管内径.ICU病人应充分考虑术后的高并发症，操作的必要性和操作者的熟练程度。充分的生理指标监测恰当设置机械通气参数，操作过程保证充分的氧合操作者应熟悉并充分准备麻醉镇静剂6气管导管尺寸在非插管病人仅占全部气管面积的10–15%。5.7mm纤支镜占9mm气管插管面积的40%占7mmtrachealtube的66%。因此，操作前应充分考虑插管导管内径及纤支镜外径。气管导管会对纤支镜造成损伤，特别是当纤支镜回撤时，边缘锐利的导管前端易损伤纤支镜。应使用润滑剂.7机械通气设置术前、术中及术后的短时间内尽量给与100%的氧浓度。一般设置成控制通气模式.PSB模式常不能保持充分的通气。带隔膜孔的延长管可在机械通气的同时进行纤支镜检查。8注意安全性?5.7-mm支气管镜通过8-mm内径气管导管截面积减少66%.吸气压升高高PEEP增加气压伤风险感染播散的风险↑CO,HR(50%),BP↑myocardialoxygendemandandriskofcardiacischemia2/3of107pts↓PaO230%,6%majorarrythmiain120sprocedureTrouilletetal.Chest1990;97:927-93317%ofpts50yearsoldhadST-segmentchangeMatotetal.Chest1997;112:1454-1458↑ICP(81%),from12to38mmHgKerwinetal.JTrauma2000;48:878-882Matsushimaetal.Chest1984;86:184-188Lindholmetal.Chest1978;74:362-368与纤支镜相关的ICU绿脓杆菌播散17pts(riskratio3.8,95%CI2.5-3.9)Bouetal.JHospInfect2006;64:129-13518ptsCDC.MMWRMorbMorralWklyRep1999;48:557-56039ptsSrinivasanetal.NEJM2003;348:221-22714SEDATIONDURINGFLEXIBLEBRONCHOSCOPY(2)Howsedationisgiven?mostsedationregimensarebaseduponasingledoseorincrementaldosesofanintravenoussedativeagentadministeredatthetimeofbronchoscopy.MIDAZOLAM(Dormicum)Midazolamisawatersolublebenzodiazepinewithaneliminationhalflifeofabout2hoursandisgenerallypreferredtodiazepam.Itsonsetisrapidanddurationofactionbriefinhealthyindividuals.Abetterapproachofgivingisincrementaldosingwhichachievesimprovedtoleranceofbronchoscopy,15SEDATIONDURINGFLEXIBLEBRONCHOSCOPY(3)COMBINATIONSWITHNARCOTICDRUGSAcombinationofabenzodiazepineandnarcotichasbeenwidelyused.Unfortunately,suchacombinationmaybeassociatedwithmorearterialdesaturationandCO2retentionthanwhenusingmidazolamalone.诊断——感染性疾病Non-invasive–Routinetrachealaspiratetrapping–OftencolonizedandrelativelyinsensitiveInvasive–ProtectedBrushspecimen–BALTrialin2000suggestedthatpatientsmanagedaccordingtoresultsfromspecimenscollectedbyPBSorBALshowedimprovedsurvival,reducedantibioticuse,earlierresolutionoforgandysfunction(Fagon,ChastrefortheVAPtrialgroup.AnnalsInternMed2000;132:621-30)支气管肺泡灌洗BALObtainedbywedgingthetipofabronchoscopeinthemediumsizedbronchusrelevanttotheareaofpulmonaryinfiltrateonCXRSamplesapprox1millalveoliLavagewith20-30mlsNaClandafter5-10secasampleof5-10mlisobtainedbygentlesuctioningCultureof104colonyformingunits/mlindicativeofpneumoniaBlindnonbronchoscopiclavagemayalsobecarriedoutbutsubjecttocontaminationComplicationssimilartobronchoscopyBALObtainedbywedgingthetipofabronchoscopeinthemediumsizedbronchusrelevanttotheareaofpulmonaryinfiltrateonCXRSamplesapprox1millalveoliLavagewith20-30mlsNaClandafter5-10secasampleof5-10mlisobtainedbygentlesuctioningCultureof104colonyformingunits/mlindicativeofpneumoniaBlindnonbronchoscopiclavagemayalsobecarriedoutbutsubjecttocontaminationComplicationssimilartobronchoscopy防污染毛刷ProtectedbrushspecimenPBSdoublelumenbrushsystemthatavoidsupperairwaycontaminationofthesampleIntroducedblindlyorfibreopticallyintotheareaofinfiltratesonCXRInnercannulaadvancedandspecimencollected103cfu/mldiagnosticofpneumoniaOnlysmallareasampled,mayleadtofalsenegatives,especiallyifonantibiotics–(preventingadminofantibiotics)ContaminationcanstilloccurComplications-arrhythmias,pneumothoraxEvidenceMCRCTcomparingBALandETaspirationfordiagnosisofVAPConcludedbothassociatedwithsimilarclinicaloutcomesandsimilaruseofantibioticsHoweveratleast40%patientsexcludedrepresenttheusualthatwouldconcernus(Canadiancriticalcaretrialsgroup,NEJM2006;355:2619-30)PBSvBALComparisonshowsconflictingresultsNorealagreementonwhichhasbettersensitivityorspecificityRecentmeta-analysisconcludedbothequallyaccurateindiagnosingpneumoniabut,inpatientsalreadyonantibioticsatthetimeofsamplingBALismoresensitive(deJaeger,Litalien,lacroix,ProtectedbrushspecimenorBALtodiagnosebacterialpneumoniainventilatedpatients.CCM1999;27:2548-60)临床应用经验诊断：病例分享治疗：病例分享