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1、超声在气道管理中的应用,上 海 交 通 大 学 附 属 第 六 人 民 医 院 麻 醉 科 赵达强,超声在气道管理中的应用,2016-5-27,颈部气道解剖,定位喉上神经,The thyrohyoid membrane as a target for ultrasonography-guided block of the internal branch of the superior laryngeal nerve,Stopar-Pintaric T, Vlassakov K, Azman J. J Clin Anesth.2015 Nov ; 27(7): 548-52.,In conclu
2、sion, we are proposing an anatomical concept for a new, simpler, consistently reproducible US-guided iSLN block technique using the thyrohyoid membrane to define the target plane for low-volume local anesthetic injection.,超声影像舌骨、喉上神经,外侧,过拱桥，甲舌膜里寻喉上,定位环甲膜,The conventional method, inspection and palpa
3、tion, has a low success rate, especially in women (2435%).,Elliott DS, Baker PA, Scott MR, et al. Accuracy of surface landmark identification for cannula cricothyroidotomy.Anaesthesia 2010; 65: 88994 Lamb A, Zhang J, Hung O, et al. Accuracy of identifying the cricothyroid membrane by anesthesia trai
4、nees and staff in a Canadian institution. Can J Anaesth 2015; 62: 495503,Siddiqui N, Arzola C, Friedman Z, et al. Anesthesiology.2015 Nov;123(5):1033-41.,定位环甲膜,Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy,Ultrasound guidance significantly decreased the inci
5、dence of injuries to the larynx and trachea Increased the probability of correct insertion by 5.6 times in cadavers with difficult and impossible landmark palpation.,外侧,甲状软骨,声带,声带,超声影像甲状软骨、环甲膜,外侧,越尖峰，缺口伪影环甲膜,甲状软骨,声带,声带,伪影,超声影像,环状软骨,外侧,气管软骨,甲状腺峡部,外侧,气管软骨,外侧,Ultrasound-guided superior laryngeal nerve
6、block and translaryngeal block for awake tracheal intubation in a patient with laryngeal abscess,Iida T,Suzuki A, Kunisawa T,et al. J Anesth (2013) 27:309310,临床应用1清醒插管,Sonographically Guided Superior Laryngeal Nerve Block During Awake Fiberoptic Intubation,Sawka A, Tang R, Vaghadia H. A A Case Rep.2
7、015 Apr 15; 4(8): 107-10.,Sonographically guided superior laryngeal nerve block may be useful in patients where identification of landmarks in the neck is difficult as a result of patient anatomy,临床应用1清醒插管,临床应用1清醒插管,Ultrasound-guided Cannula Cricothyroidotomy,Suzuki A,Iida T, kunisawa T,et al. Anest
8、hesiology 2012 Nov;117(5):1128,Ultrasound-assisted translaryngeal block for awake fibreoptic intubation,De Oliveira GSJr, Fitzgerald P, Kendall M. Can J Anesth. 2011 58:664665,临床应用1清醒插管,病态肥胖 BMI 60,临床应用1清醒插管,临床应用1清醒插管,临床应用2判断喉镜显露困难,气管软骨,外侧,食管,甲状腺,Wu J,Dong J,Ding Y,et al. Med Sci Monit, 2014; 20: 23
9、43-2350,Role of anterior neck soft tissue quantifications by ultrasound in predicting difficult laryngoscopy,Anterior neck soft tissue thicknesses measured by US at hyoid bone, thyrohyoid membrane, and anterior commissure levels are independent predictors of difficult laryngoscopy. Combinations of t
10、hose screening tests or risk factors with US measurements might increase the ability to predict difficult laryngoscopy.,临床应用2判断喉镜显露困难,气管软骨,外侧,食管,甲状腺,Ultrasonographic measurement of the minimal transverse diameter of the subglottic airway in the transverse plane, typically at the caudal outlet of the
11、 cricoid ring,临床应用3选择适合气管导管,临床应用4判断气管导管位置,气管软骨,外侧,食管,甲状腺,排除食管内插管 证实气管导管在气管内,临床应用4判断气管导管位置,THE SENSITIVITY AND SPECIFICITY OF TRANSCRICOTHYROID ULTRASONOGRAPHY TO CONFIRM ENDOTRACHEAL TUBE PLACEMENT IN A CADAVER MODEL,Dynamic assessment resulted in 97% sensitivity and 100% specificity for detecting e
12、sophageal ET placement. Static assessment resulted in only 51% sensitivity and 91% specificity.,Ma G,Davis DP, Schmitt J, et al. J Emerg Med.2007 May;32(4):405-7.,气管插管过程中环甲膜改变,气管导管气囊充气表现,临床应用5判断喉罩位置,Laryngo-tracheal ultrasonography to confirm correct endotracheal tube and laryngeal mask airway place
13、ment,Sonographic upper airway assessment emerges as a rapid and easily available method to predict difficult intubation, to assess the laryngeal and hypopharyngeal size and visualize the position of the laryngeal mask airway in situ.,Wojtczak JA,Cattano D. Journal of Ultrasonography 2014; 14: 362366
14、,临床应用5判断喉罩位置,蝴蝶征,Unique喉罩的位置E,Supreme喉罩的位置E,临床应用6定位气管切开,Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study,Percutaneous tracheostomy performed under real-time ultrasound guidance is feasible and appears accurate and safe, including in patients with morbid obesity
15、 and cervical spine precautions.,Venkatakrishna Rajajee, Jeffrey J Fletcher, Lauryn R Rochlen, et al. Critical Care 2011, 15:R67,临床应用6定位气管切开,Traditional landmark versus ultrasound guided tracheal puncture during percutaneous dilatational tracheostomy in adult intensive care patients: a randomised co
16、ntrolled trial,Ultrasound guidance significantly improved the rate of first-pass puncture and puncture accuracy. Fewer procedural complications were observed; however, this did not reach statistical significance. These results support wider general use of real-time ultrasound guidance as an addition
17、al tool to improve PDT.,Mt Rudas, Ian Seppelt, Robert Herkes,et al. Critical Care 2014, 18:514,临床应用6定位气管切开,可视化操作才能 有意识避开血管,临床应用6定位气管切开,其他的临床应用1迅速准确建立通气,Mallin M, Curtis K, Dawson M,et al. Am J Emerg Med 2014 Jan;32(1):61-3.,Accuracy of ultrasound-guided marking of the cricothyroid membrane before si
18、mulated failed intubation,Ultrasound marking of the CTM of healthy volunteers before simulated intubation accurately identifies the CTM after neck manipulation expected during a failed intubation.,其他的临床应用2改良Sellick法,向后方压迫 环状软骨 无效,向左后方压迫 环状软骨 有效,其他的临床应用3耐受插管,Advanced Diagnostic Bronchoscopy Using Con
19、scious Sedation and the Laryngeal Nerve Block: Tolerability, Thoroughness, and Diagnostic Yield,Goyal G,Pisani MA,Murphy TE,et al. Lung (2014) 192:905913,如何更好耐受长期气管插管？ 或许喉上神经阻滞是一个选择,1.清醒插管超声引导喉上神经阻滞和环甲膜穿刺 过拱桥，甲舌膜里寻喉上 越尖峰，缺口伪影环甲膜,总 结,4. 判断气管导管的位置环甲膜 气管插管进行时更敏感,5. 判断喉罩位置蝴蝶征,6. 定位气管切开准确定位、避免损伤,7. 迅速建立紧急通气超声引导环甲膜穿刺,8. 改良Sellick法向左后方压迫环状软骨,2. 判断喉镜显露困难颈前部软组织厚度,3. 选择气管导管型号气管最小内径,谢谢聆听,