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1、纤维支气管镜检查在ICU中的应用翁恒Bronchoscopy in the ICU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
2、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BRONCHOSCOPY IN(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1015%。5.7 mm 纤支镜占9 mm气管插管面积的40%占 7 mm tracheal tube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
3、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 myocardial oxygen demand and risk of cardiac ischemia2/3 of 107 ptsPaO2 30%,6%major arrythmia in 120s procedure Trouillet et al.Chest
4、 1990;97:927-93317%of pts 50 years old had ST-segment change Matot et al.Chest 1997;112:1454-1458ICP(81%),from 12 to 38 mmHg Kerwin et al.J Trauma 2000;48:878-882Matsushima et al.Chest 1984;86:184-188Lindholm et al.Chest 1978;74:362-368与纤支镜相关的ICU绿脓杆菌播散 17 pts(risk ratio 3.8,95%CI 2.5-3.9)Bou et al.J
5、 Hosp Infect 2006;64:129-13518 pts CDC.MMWR Morb Morral Wkly Rep 1999;48:557-56039 pts Srinivasan et al.NEJM 2003;348:221-22714SEDATION DURING FLEXIBLE BRONCHOSCOPY(2)How sedation is given?How sedation is given?most sedation regimens are based upon a single dose or incrementaldoses of an intravenous
6、 sedative agent administered at the time of bronchoscopy.MIDAZOLAM(Dormicum)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 duration of action brief in healthy individuals.A be
7、tter approach of giving is incremental dosing which achieves improved tolerance of bronchoscopy,15SEDATION DURING FLEXIBLE BRONCHOSCOPY(3)COMBINATIONS WITH NARCOTIC DRUGSCOMBINATIONS WITH NARCOTIC DRUGSA combination of a benzodiazepine and narcotic has been widely used.Unfortunately,such a combinati
8、on may be associated with more arterial desaturation and CO2 retention than when using midazolam alone.诊断感染性疾病Non-invasiveRoutine tracheal aspirate trappingOften colonized and relatively insensitiveInvasive Protected Brush specimenBALTrial in 2000 suggested that patients managed according to results
9、 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)支气管肺泡灌洗BALObtained by wedging the tip of a bronchoscope in the medium sized bronchus relevant to the
10、 area of pulmonary infiltrate on CXRSamples approx 1 mill alveoliLavage 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 pneumoniaBlind non bronchoscopic lavage may also be carried out but subject to contami
11、nationComplications similar to bronchoscopyBALObtained by wedging the tip of a bronchoscope in the medium sized bronchus relevant to the area of pulmonary infiltrate on CXRSamples approx 1 mill alveoliLavage with 20-30mls NaCl and after 5-10sec a sample of 5-10ml is obtained by gentle suctioning Cul
12、ture of 104 colony forming units/ml indicative of pneumoniaBlind non bronchoscopic lavage may also be carried out but subject to contaminationComplications similar to bronchoscopy防污染毛刷Protected brush specimenPBS double lumen brush system that avoids upper airway contamination of the sampleIntroduced
13、 blindly or fibreoptically into the area of infiltrates on CXRInner cannula advanced and specimen collected 103 cfu/ml diagnostic of pneumoniaOnly small area sampled,may lead to false negatives,especially if on antibiotics(preventing admin of antibiotics)Contamination can still occurComplications-ar
14、rhythmias,pneumothoraxEvidenceMCRCT comparing BAL and ET aspiration for diagnosis of VAPConcluded both associated with similar clinical outcomes and similar use of antibioticsHowever at least 40%patients excluded represent the usual that would concern us(Canadian critical care trials group,NEJM 2006
15、;355:2619-30)PBS v BALComparison shows conflicting resultsNo real agreement on which has better sensitivity or specificityRecent meta-analysis concluded both equally accurate in diagnosing pneumonia but,in patients already on antibiotics at the time of sampling BAL is more sensitive(de Jaeger,Litalien,lacroix,Protected brush specimen or BAL to diagnose bacterial pneumonia in ventilated patients.CCM 1999;27:2548-60)临床应用经验诊断：病例分享治疗：病例分享