Microsoft PowerPoint - dificult airway-張家昇

Size: px

Start display at page:

Download "Microsoft PowerPoint - dificult airway-張家昇"

其占
7 years ago
Views:

1 張家昇主任 Basic Management Update Adjuncts Application in ICU Main in ICU Universal Emergency Management Crash Difficult Management of Unrecognized Difficult : (1) Flexible Fiberoptic Intubation (2) Retrograde Intubation (3) Cricothyrotomy (4) Open Tracheostomy (5) Percutaneous Dilatation Tracheostomy. Difficult Assessment Characteristics of Patients In ICU Unstable Hemodynamics Poor Hypoxemia Tolerance Poor Oral Hygiene with Tubing Soft Tissue Edematous Change arious Coagulopathy arious Enteric Paralytic illus Electrolytes & Acid-Base Fluctuation N-M dystrophy with arious Organs dysfunction Universal Emergency Management R S I Fail Unconscious, unreactive, near death Difficult? Difficult Fail Failed Failed Crash Fail Failed Walls, RM. The Emergency s, 2004 Difficult The clinic situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both. (ASA Task Force) Difficult Mask entilation It is not possible for the unassisted anesthesiologist to maintain the SPO 2 >90%using 100% oxygen and positive pressure mask ventilation in a patient whose SPO 2 was > 90% before anesthetic intervention; and /or it is not possible for the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation. (ASA Task Force) 1

lidocaine I if head injury suspected sedative: Thiopental (50 mg test dose, then 2-4 mg/kg,onset: 1 min, effect: 10-30 min) ; Propofol Midazolam: 2-10mg I (onset: 1-2 min, effect: 2-4 hr) ketamine

2 Main Management Walls, RM. The Emergency s 2004 From Difficult 預估為困難氣道嗎? R S I Failed 熟手經口插管 3 次 Failed 插管成功嗎? BM?, SPO2>90%? Need Intubation? Unconscious, unreactive, near death Crash Difficult 做插管後的處理 RSI (Medication) atropine blocks vagal response to airway stimulation, may be protective against arrhythmias seen with Succinylcholine lidocaine I if head injury suspected sedative: Thiopental (50 mg test dose, then 2-4 mg/kg,onset: 1 min, effect: min) ; Propofol Midazolam: 2-10mg I (onset: 1-2 min, effect: 2-4 hr) ketamine good choice for patient with status asthmaticus; may raise IICP morphine, fentanyl neuromuscular blocker: Succinylcholine: 1 mg/kg I (onset 1 min, effect: 4-8 min) rocuronium (Esmeron): 0.6 mg/kg 引導意識不清的鎮靜劑 Thiopental Ketamine Diazepam Midazolam Fentanyl 劑量 (I) 3-5 mg/kg 1-2 mg/kg mg/kg 最大 10mg mg/kg 最大 15mg 2-10 μg/kg 作用開始時間秒 1-2 分 2-4 分 1-2 分 1 分藥效期間分分分分分 Ketamine 的作用口內分泌物胃內壓腦內壓血壓心跳心輸出量眼內壓張力過強支氣管擴張緊急反應 (emergency reaction) Succinylcholine Rocuronium (Esmeron) Pancuronium Atracurium 肌肉鬆弛劑 0.6mg/kg 劑量 (I) mg/kg(>10kg) mg/kg(<10kg) 0.6mg/kg( 標準劑量 ) 0.06mg/kg( 去顫抖劑量 ) 0.1 mg/kg 0.01m/kg( 去顫抖劑量 ) 作用開始時間秒秒 2-3 分 2-5 分 2-4 分藥效時間 4-10 分分分分 Succinylcholine 的禁忌使用 SCH 的禁忌症, 它包括眼球穿刺傷青光眼神經肌肉疾病惡性高體溫病史壓性傷害和超過 48 小時以上的創傷或燒傷它的快速作用和短效作用可抵消它的不良影響 2

3 Crash Failed BM 可以嗎? Crash Failed BM 熟手經口插管 3 次嘗試經口插管成功? 再次嘗試經口插管成功? 做插管後的處理 Succinylcholine 2 mg/kg IP 做插管後的處理 Walls, RM. The Emergency s, 2004 BM?, SPO2>90%? 考慮 Fiberoptic method, I- LMA, Lighted stylet, supra-glottic airway Time allows and successful? Cuffed ETT Placed? Failed Criteria 等做氣管造口時可嘗試 LMA, Combitube 做插管後的處理 2007/12/01 安排 Definite 張家昇 Management CMUH Cricothyrotomy Cricothyrotomy 求救 Failed Walls, RM. The Emergency s, 2004 該如何選擇以及放置輔助氣道口咽輔助氣道的放置? 口咽輔助氣道 (Oropharyngeal airway; 如何適當的選擇大小口咽輔助氣道 Oral 可以度量由嘴角至耳垂或下頷骨角之距離 (Oropharyngeal airway) airway; Oral airway) 太短正確位置與長度 Guedel 兩個種類 Bermen 正確口咽輔助氣道的長度為 0-5 號嘴唇至舌根之距離 0:40mm,1:60mm,2:70mm,3:80mm,4 :90mm,5:100mm 0-5 號 40mm-110mm ( 每 10mm 一個 size) 1. 中空式, 方便抽痰 2. 以顏色代表號數, 易區分 1. 管身的中隔間採實心設計, 較為堅固避免病患咬扁 2. 圓弧形管尖出口, 病患不易受傷太長單人操作仍須維持打開呼吸 Mask 道的姿勢操作時仍罩要持續打開壓額抬呼吸道下巴法或下顎上提法雙人操作 PMR II 如何扣緊 BM 如何正確的擠如何正確地操作 (Bag-alve-Mask) BM 的面罩 BM? Bag?? BM 袋 - 瓣 - 罩的結構為何? 稍難 BM 3 C 力道方向 Bag 袋 Bag 袋 alve 瓣稍差 less effective T:700cc 3 C ( 單手擠壓 ) 較簡單較好 more effective T: cc ( 雙手擠壓 ) Open Open ( ( 打開呼吸道 ) ) Jaw thrust: 第一要務為三軸合一壓, 提, 推 Head : tilt chin lift Jaw thrust: Head tilt chin lift Sniffing position ( 下顎上提法口軸 Mouth ) ( 壓額抬下巴法 ) 下顎上提法口軸 ( 壓額抬下巴法咽軸 ) A Pharynx Open ( 打開呼吸道 ) 咽軸 B Trachea Extend-the-head-on-neck ( look up ): aligns axis A relative to B Flex-the-neck-on-shoulders ( look down ): aligns axis B relative to C C 喉軸頸部伸張則可以使 A ( 口軸 ) 靠近 B ( 咽軸 ) 墊枕頭可以使 B ( 咽軸 ) 靠近 C ( 喉軸 ) A B C 喉軸 3

Certain Difficult Problems Limited mouth opening Anterior larynx Sternal space

如何依據各種情境選擇適當的呼吸道 (the airway hierarchy ), 包括下列.

Esophageal-tracheal (Combitube) tube (Class IIa) Tracheal tube (well trained HCP, Class

End-tidal CO 2 detection (Class IIa) (for Combitube, LMA (Class Indeterminate))

entilatory Devices 喉罩與插管喉罩 Laryngeal mask airway (LMA) Intubating LMA (I-LMA) 食道氣管聯合管

4 Certain Difficult Problems Limited mouth opening Anterior larynx Sternal space restriction Small intraoral cavity Immobile or unstable cervical spines 如何依據各種情境選擇適當的呼吸道 (the airway hierarchy ), 包括下列.. 如何選擇適當並正確使用較具侵襲性的呼吸道 : Laryngeal mask airway (LMA) (Class Class IIa) Esophageal-tracheal (Combitube) tube (Class IIa) Tracheal tube (well trained HCP, Class I) (well trained EMS, Class IIa) 如何確定 tracheal tube 放置的位置正確 : Physical exam criteria End-tidal CO 2 detection (Class IIa) (for Combitube, LMA (Class Indeterminate)) Esophageal detector device (EDD) (Class IIa) 如何固定 tracheal tube 以防止其滑脫 Supraglottic entilatory Devices 喉罩與插管喉罩 Laryngeal mask airway (LMA) Intubating LMA (I-LMA) 食道氣管聯合管 Esophageal Tracheal Combitube 氣囊式口咽氣道 Cuffed oropharyngeal airway 喉管 Laryngeal tube Mile End Hospital, /12/01 4

Esophageal Tracheal Combitube (I) Kendall Sheridan A disposible double lumen tube Combine a conventional ET and an esophageal obturator airway

placement Should protect against aspiration Especially useful --- Direct visualization of the vocal cords is not possible 優點適應症禁忌症併發症 1.

無法插管及無法通氣 (cannot intubated cannot ventilated) 時氣管食道聯合管 (Esophageal-Tracheal Combitube) 3. 執行心肺復甦術時 1. 病患仍存在強烈引吐反射 (gag relexes) 2.

撕裂咽壁 (laceration of pharyngeal wall) 3. 咽部血腫 (pharyngeal hematoma) 4. 食道破裂 5. 氣胸氣縱膈 (pneumothorax,pneumomediastinum) 2007/12/01 6.

5 Esophageal Tracheal Combitube (I) Kendall Sheridan A disposible double lumen tube Combine a conventional ET and an esophageal obturator airway entilation is possible with either tracheal or esophageal intubation Esophageal Tracheal Combitube (II) Inserted blindly, or laryngoscopy to enhance placement Should protect against aspiration Especially useful --- Direct visualization of the vocal cords is not possible 優點適應症禁忌症併發症 1. 可作為困難插管或緊急氣道處理 2. 因屬於盲式插管, 不需喉頭鏡幫助 3. 方便快速不需特殊技巧 4. 只需將管子送至建議深度即可, 不論到達氣管或食道, 都可維持肺部通氣 5. 胃部減壓效果好, 減少吸入逆流物的風險 1. 插管失敗 2. 無法插管及無法通氣 (cannot intubated cannot ventilated) 時氣管食道聯合管 (Esophageal-Tracheal Combitube) 3. 執行心肺復甦術時 1. 病患仍存在強烈引吐反射 (gag relexes) 2. 身高矮於 4 呎 (4 feet), 約 112cm 3. 已知有食道方面疾病, 如食道靜脈瘤 (esophageal varies) 4. 食入腐蝕性物體 ; 懷疑食道灼傷的病人 5. 喉部或低於喉部之氣道阻塞 ( 異物腫瘤 ) 1. 吞嚥困難 (dysphagia) 2. 撕裂咽壁 (laceration of pharyngeal wall) 3. 咽部血腫 (pharyngeal hematoma) 4. 食道破裂 5. 氣胸氣縱膈 (pneumothorax,pneumomediastinum) 2007/12/01 6. 皮下氣腫 (subcutaneous emphysema) 7. 可能會造成喉部神經傷害氣管食道聯合管 Where is the hole? allecula AE fold Cuniform Corniculate Arytenoid Three primary laryngoscope blades Jackson laryngoscope blade Miller laryngoscope blade MacIntosh laryngoscope blade 5

6 History First elective oral intubation INTUBATION OF THE LARYN.htm 插管要點 Curved Straight-Blade Laryngoscope Inserted Against Past Epiglottis ( 彎的喉頭鏡前端應放置於會厭軟骨上方即舌谿處 ( 直的喉頭鏡前端應放置於會厭軟骨下方 ) ) 會厭軟骨 2. allecula 舌谿聲帶 6. Arytenoid 聲門杓狀軟骨 7. Piriform sinus 梨狀竇隱窩食道 Modifications of Laryngoscopes Rigid laryngoscopes Flexible tip laryngoscopes McCoy levering laryngoscope Bullard Indirect rigid fiberoptic laryngoscopes Bullard laryngoscope WuScope system UpsherScope WuScope ideo Intubation Laryngoscope Pentax-AWS Glidescope Endotracheal tube guides Eschmann tracheal tube introducer Rüsch Intubation stylet Frova intubation introducer Arndt airway exchange catheter set Aintree airway exchange catheter Lighted Stylets Trachlight Shikani Optical Stylet 6

asleep and awake patients (1,3). This type of intubation technique has a reported success rate as high as 99% in experienced hands (3).

7 Lighted Stylet Intubation A.K.A. : Trachlite (Rusch), Trachlight (Laerdal), Surch-lite (Aaron Medical), "Lightwand" Introduction Lighted stylet guided intubation can be a useful technique for oral and nasal intubations in both asleep and awake patients (1,3). This type of intubation technique has a reported success rate as high as 99% in experienced hands (3). It can be used in anticipated and unexpected difficult airways where conventional direct laryngoscopy has failed (2,7). It can be achieved as fast as conventional direct laryngoscopy by one skilled in its use (3,4,5). Trachlight product description Indications and Contraindications Using the Trachlight isual Demo (in-line JPEG files - ideally your browser should be configured to view tables eg Netscape 1.1) Text Only Warnings and Precautions(text) Cleaning, Battery Check & Installation (text) Battery Installation and Battery Check(in-line JPEG files) Bibliography Cannot entilate, Cannot Intubate Situation Insertion of LMA Insertion of the combitube Insertion of transtracheal jet ventilation Creation of a surgical airway Special Techniques Flexible fiberoptic intubation Retrograde intubation Transtracheal jet ventilation Cricothyrotomy Percutaneous dilatation tracheostomy Fiberoptic Bronchoscope FOB FOB assisted endotracheal intubation 7

8 Fiberoptic Intubation Oral vs nasal approach Under general anesthesia Under rapid sequence Induction & intubation Fiberoptic intubation aided by rigid laryngoscopy Fiberoptic intubation through LMA or combitube Fiberoptic and retrograde intubation Fiberoptic intubation Retrograde Intubation Retrograde Intubation Through cricothyriod membrane A blind technique Useful in patients with cervical injury or airway trauma As a adjunct for fiberoptic intubation Arndt airway exchange catheter 氧氣和通氣的方法環甲狀膜切開術氣管切開術 8

9 Cricothyrotomy Percutaneous tracheostomy PT 2007/12/ /12/01 PT Surgical airway Blue Rhino Dilating forcep 2007/12/ /12/ /12/ /12/01 9

Needle cricothyrotomy Transtracheal Jet entilation (TTJ) Temporizing means of rescue ventilation TTJ Equipment Transtracheal catheter Large-bore I catheter: 14#, 16#, 20# Commercial non-kinking

10 Needle cricothyrotomy Transtracheal Jet entilation (TTJ) Temporizing means of rescue ventilation TTJ Equipment Transtracheal catheter Large-bore I catheter: 14#, 16#, 20# Commercial non-kinking wire-coiled entilation system 1. High pressure oxygen source: adult: 50 psi; 5-12 y/o: psi 2. Jet ventilator: Manujet, ventilator 3. Bag ventilation (for childs < 5 y/o) TTJ vs Cricothyrotomy advantage Speed Simple Less bleeding Age not related (used in child) disadvantage Supraglottic (upper airway) obstruction must be patent (expir( expir.) Not provide airway protection Suction cannot be done Difficult Difficult Predicted SPO2>90%? 求救 Y BM?, SPO2>90%? BM 可成功 Failed Y 插管可能成功 Y RSI Awake technique Go to Main Blind nasaltracheal, cricothyrotomy, fiberoptic, I-LMA,lighted stylet Y 做插管後的處理 Y 預估 SPO2 可 >90%? Failed 10

Difficult Evaluation ( LEMON) Look externally Evaluate 3-3-2- rules Mallampati scoring Obstruction? Neck mobility Difficult 1. Head anomalies 2. Facial anomalies a.

nasal masses c. palatal anomalies d. enlarged adenoids e. tonsillar disease f. pharyngeal diseases g. retropharyngeal and parapharyngeal diseases h. pharyngeal bullae or scarring 5.

11 Difficult Evaluation ( LEMON) Look externally Evaluate rules Mallampati scoring Obstruction? Neck mobility Difficult 1. Head anomalies 2. Facial anomalies a. maxillary and mandibular diseases b. temporomandibular joint disease 3. Mouth and tongue anomalies a. microstomia b. tongue disease 4. Nasal, palatal and pharyngeal anomalies a. choanal atresia b. nasal masses c. palatal anomalies d. enlarged adenoids e. tonsillar disease f. pharyngeal diseases g. retropharyngeal and parapharyngeal diseases h. pharyngeal bullae or scarring 5. Laryngeal anomalies a. laryngomalacia b. epigottitis c. congenital glottic lesions d. laryngeal papillomatosis e. laryngeal granalomas f. congenital and acquired subglottic disease 6. Tracheobronchial tree anomalies a. tracheomalasia b. croup c. bacterial tracheitis d. mediastinal masses e. vascular malformations f. foreign body aspiration 7. Neck and spine anomalies a. neck b. limited cervical spine mobility c. congenital and acquired cervical spine instability Pre-intubation Exam (1) Length of upper Incisors Involuntary: Maxillary Teeth Anterior to Mandibular Teeth oluntary: Protrusion of Mandibular Teeth Anterior to the Maxillary Teeth Inter-cisor Distance Oropharyngeal Class Pre-intubation Exam (2) Narrowness of Palate Mandibular Space Length (thyromental distance) Mandibular Space (MS) Compliance Length of Neck Thickness of Neck Range of Motion of Head and Neck Certain difficult airway problems Limited mouth opening Anterior larynx Sternal space restriction Small intraoral cavity Immobile or unstable cervical spines Rule Predicting difficulty Mallampati Class 1 Class 2 Class 3 Class 4 11

如何確定氣管內管的位置? Primary 2005 年的準則已經取消所謂的次級評估也就是全部都是屬於初級評估 Secondary 2005 ACL

C 2000 ACLS gold standard 理學檢查 & 觀察 EDD ETCO 2 Bronchoscopy ( 觀看氣管軟骨 ) Bulb type Capnography Detector

Suggest Contents of Special Unit for Difficult Management Rigid laryngoscpe blades - alternate design &

12 如何確定氣管內管的位置? Primary 2005 年的準則已經取消所謂的次級評估也就是全部都是屬於初級評估 Secondary 2005 ACLS Primary 1992 E.C.C 2000 ACLS gold standard 理學檢查 & 觀察 EDD ETCO 2 Bronchoscopy ( 觀看氣管軟骨 ) Bulb type Capnography Detector CxR ( 緩不濟急 ) Tracheal Tube Holders: Adult and Infant ( 市售的專用固定器 ) Secure the endotracheal tube with tape or a commercial device (Class I). These devices may be considered during patient transport (Class IIb). Suggest Contents of Special Unit for Difficult Management Rigid laryngoscpe blades - alternate design & size Endotracheal tubes of assorted sizes Endotracheal tube guides arious supraglottic airway devices-lma/combitube Fiberoptic intubation equipment Retrograde intubation equipment Equipments for transtracheal jet ventilation Equipments suitable for emergency surgical airway accesscricothyrotomy An exhaled CO2 detector 12

急診暨總夜班護理業務觀摩簡介

急診暨總夜班護理業務觀摩簡介呼吸道處置蘇柏樺課程大綱打開呼吸道輔助物使用氣管插管快速插管 (RSI) 氧氣使用呼吸問題 ( 評估三部曲 ) 呼吸道呼吸動力氧氣需求評估呼吸道是否通暢說話清楚? 聲音嘶啞? 無法回應? 已放置的氣管內管, 功能是否正常? Axis of