1、纖維支氣管鏡檢查在ICU中的應(yīng)用,翁恒,Bronchoscopy in the ICU,適應(yīng)癥 診斷,觀察喉、氣管、支氣管：損傷、咯血定位、肺不張原因、腫瘤、粘膜改變（支氣管侵襲性曲霉菌）、分泌物性狀、支氣管食道瘺。 支氣管肺泡灌洗（細胞學(xué)、革蘭氏染色、致病菌培養(yǎng)）：支氣管肺感染、腫瘤、結(jié)核病、肺泡蛋白沉著癥、肺泡出血。 經(jīng)纖支鏡肺活檢：真菌、結(jié)核、腫瘤、血管炎,適應(yīng)癥 治療,協(xié)助氣管插管、換管、拔管 吸除血塊及濃稠分泌物 去除支氣管異物 支氣管胸膜瘺封堵 氣管狹窄擴張 局部用藥,相對禁忌癥,不能糾正的凝血功能異常 機械通氣需要高PEEP時的TBLB。 進食后 心肺功能級不穩(wěn)定,并發(fā)癥,誤吸

2、喉、氣管支氣管痙攣 心律失常 低氧血癥，繼發(fā)發(fā)熱感染 加用麻醉鎮(zhèn)靜劑導(dǎo)致的呼吸抑制及低血壓。 損傷性操作后的咯血及氣胸,注意事項BRONCHOSCOPY IN (ICU),術(shù)前應(yīng)充分考慮氣管導(dǎo)管內(nèi)徑. ICU病人 應(yīng)充分考慮術(shù)后的高并發(fā)癥，操作的必要性和操作者的熟練程度。 充分的生理指標監(jiān)測 恰當設(shè)置機械通氣參數(shù)，操作過程保證充分的氧合 操作者應(yīng)熟悉并充分準備麻醉鎮(zhèn)靜劑,6,氣管導(dǎo)管尺寸,在非插管病人僅占全部氣管面積的1015%。 5.7 mm 纖支鏡占9 mm氣管插管面積的40% 占 7 mm tracheal tube的66% 。 因此，操作前應(yīng)充分考慮插管導(dǎo)管內(nèi)徑及纖支鏡外徑。 氣管導(dǎo)管

3、會對纖支鏡造成損傷，特別是當纖支鏡回撤時，邊緣銳利的導(dǎo)管前端易損傷纖支鏡。 應(yīng)使用潤滑劑.,7,機械通氣設(shè)置,術(shù)前、術(shù)中及術(shù)后的短時間內(nèi)盡量給與100%的氧濃度。 一般設(shè)置成控制通氣模式. PSB模式常不能保持充分的通氣。 帶隔膜孔的延長管可在機械通氣的同時進行纖支鏡檢查。,8,注意安全性?,5.7-mm 支氣管鏡通過8-mm內(nèi)徑氣管導(dǎo)管截面積減少66%. 吸氣壓升高 高PEEP 增加氣壓傷風(fēng)險 感染播散的風(fēng)險,CO, HR (50%), BP myocardial oxygen demand and risk of cardiac ischemia 2/3 of 107 ptsPaO2 30

4、%, 6% major arrythmia in 120s procedure Trouillet et al. Chest 1990;97:927-933 17% of pts 50 years old had ST-segment change Matot et al. Chest 1997;112:1454-1458 ICP (81%), from 12 to 38 mmHg Kerwin et al. J Trauma 2000;48:878-882,Matsushima et al. Chest 1984;86:184-188,Lindholm et al. Chest 1978;7

5、4:362-368,與纖支鏡相關(guān)的ICU綠膿桿菌播散,17 pts (risk ratio 3.8, 95% CI 2.5-3.9) Bou et al. J Hosp Infect 2006;64:129-135 18 pts CDC. MMWR Morb Morral Wkly Rep 1999;48:557-560 39 pts Srinivasan et al. NEJM 2003;348:221-227,14,SEDATION DURING FLEXIBLE BRONCHOSCOPY(2),How sedation is given? most sedation regimens a

6、re based upon a single dose or incremental doses of an intravenous sedative agent administered at the time of bronchoscopy. MIDAZOLAM (Dormicum) Midazolam is a water soluble benzodiazepine with an elimination half life of about 2 hours and is generally preferred to diazepam. Its onset is rapid and d

7、uration of action brief in healthy individuals. A better approach of giving is incremental dosing which achieves improved tolerance of bronchoscopy,15,SEDATION DURING FLEXIBLE BRONCHOSCOPY(3),COMBINATIONS WITH NARCOTIC DRUGS A combination of a benzodiazepine and narcotic has been widely used. Unfort

8、unately, such a combination may be associated with more arterial desaturation and CO2 retention than when using midazolam alone.,診斷感染性疾病,Non-invasive Routine tracheal aspirate trapping Often colonized and relatively insensitive Invasive Protected Brush specimen BAL Trial in 2000 suggested that patie

9、nts managed according to results from specimens collected by PBS or BAL showed improved survival, reduced antibiotic use, earlier resolution of organ dysfunction (Fagon, Chastre for the VAP trial group. Annals Intern Med 2000;132:621-30),支氣管肺泡灌洗BAL,Obtained by wedging the tip of a bronchoscope in th

10、e medium sized bronchus relevant to the area of pulmonary infiltrate on CXR Samples approx 1 mill alveoli Lavage with 20-30mls NaCl and after 5-10sec a sample of 5-10ml is obtained by gentle suctioning Culture of 104 colony forming units /ml indicative of pneumonia Blind non bronchoscopic lavage may

11、 also be carried out but subject to contamination Complications similar to bronchoscopy,BAL,Obtained by wedging the tip of a bronchoscope in the medium sized bronchus relevant to the area of pulmonary infiltrate on CXR Samples approx 1 mill alveoli Lavage with 20-30mls NaCl and after 5-10sec a sampl

12、e of 5-10ml is obtained by gentle suctioning Culture of 104 colony forming units /ml indicative of pneumonia Blind non bronchoscopic lavage may also be carried out but subject to contamination Complications similar to bronchoscopy,防污染毛刷Protected brush specimen,PBS double lumen brush system that avoi

13、ds upper airway contamination of the sample Introduced blindly or fibreoptically into the area of infiltrates on CXR Inner cannula advanced and specimen collected 103 cfu/ml diagnostic of pneumonia Only small area sampled, may lead to false negatives, especially if on antibiotics (preventing admin o

14、f antibiotics) Contamination can still occur Complications -arrhythmias,pneumothorax,Evidence,MCRCT comparing BAL and ET aspiration for diagnosis of VAP Concluded both associated with similar clinical outcomes and similar use of antibiotics However at least 40% patients excluded represent the usual that would concern us (Canadian critical care trials group, NEJM 2006;355:2619-30),PBS v BAL,Comparison shows conflicting results No real agreement on which has better sensitivity or specificity Recent meta-analysis concluded both equally accurate in diagnosing pneumonia but, in patie