纖維支氣管鏡的臨床應(yīng)用 Review on Clinical Flexible Bronchoscopy,內(nèi)容綱要, FB簡(jiǎn)介 FB診斷應(yīng)用 FB治療應(yīng)用 FB新進(jìn)展,FB簡(jiǎn)介 Brief Introduction of Flexible Bronchoscopy,1897年德國(guó)醫(yī)師Killian 用硬質(zhì)窺鏡 (Rigid Endoscope) 取出骨性異物; 1964年 日本Olympus公司 Ikeda 制成 標(biāo)準(zhǔn)的光導(dǎo)纖維支氣管鏡，命名為可曲式光導(dǎo)纖維支氣管鏡( Flexible Fiberoptic Bronchoscope )；,發(fā)展史：,3. 硬質(zhì)氣官鏡 (Rigid Bronchoscope) 介入氣管學(xué)(Interventional Bronchology),常規(guī)FB探察氣管范圍（27級(jí)分支）： 氣管 0 主支氣管 葉支氣管 段支氣管 100% 亞段支氣管 74%,摘要幻燈片,RB1: 右上葉尖段 RB1a : 右上葉尖段尖分支 RB1b : 右上葉尖段前分支,禁忌證 ( Contraindications to Bronchoscopy), 絕對(duì)禁忌證 / 相對(duì)禁忌證 1 活動(dòng)性大咯血； 2 嚴(yán)重的上腔靜脈阻塞綜合征； 3 嚴(yán)重的肺動(dòng)脈高壓； 4 氣管部分狹窄/（患側(cè)支氣管）； 5 支氣管哮喘；,禁忌證 (Contraindications to Bronchoscopy),6 全身情況極度衰竭；嚴(yán)重心、肺功能障礙； 7 不能糾正的出血傾向；尿毒癥； 8 嚴(yán)重心律失常；新近發(fā)生的心肌梗死/不穩(wěn)定心絞痛； 9 疑有主動(dòng)脈瘤；,禁忌證 ( Contraindications to Bronchoscopy),絕對(duì)禁忌證 / 相對(duì)禁忌證 1 咯血宜在緩解后兩周再進(jìn)行； 2 新近有較重的支氣管和肺部感染伴發(fā)熱，待炎癥控制后再做檢查； 3 有肺大皰的病人，應(yīng)慎重檢查，避免發(fā)生氣胸； 4 較大的氣管內(nèi)異物，一般活檢鉗難以經(jīng)FB取出；,FB輔助設(shè)備 (Accessories for FB),氧氣 監(jiān)護(hù),FB輔助設(shè)備 (Accessories for FB),氣管內(nèi)套管(endotrcheal tube),支氣管病變的纖維支氣管鏡鏡下分類(lèi) ( JRS分類(lèi) ),支氣管管壁的異常改變 支氣管腔內(nèi)異常 支氣管腔內(nèi)異常物質(zhì) 呼吸動(dòng)力學(xué)改變,1. 支氣管管壁的異常改變 支氣管黏膜腫脹（水腫）,1. 支氣管管壁的異常改變 支氣管黏膜 充血,1. 支氣管管壁的異常改變 支氣管黏膜 萎縮， 綜行皺襞,1. 支氣管管壁的異常改變, 潰瘍,2. 支氣管管腔的異常改變 氣管狹窄,2. 支氣管管腔的異常改變 支氣管狹窄（外壓性）,2.支氣管管壁的異常改變 氣管食道瘺,3. 支氣管管腔的異物 肉芽腫,FB診斷應(yīng)用 Diagnostic Procedures of Flexible Bronchoscopy,適應(yīng)證 (Indications for Diagnostic Bronchoscopy) 不明原因的咯血; 不明原因的的慢性咳嗽； 不明原因的局限性哮鳴音(Unexplained localized wheezing)； 不明原因的聲音嘶??；,5. 痰中發(fā)現(xiàn)癌細(xì)胞或可疑癌細(xì)胞(Roentgenographically occult lung cancer) Tx； 6. CXR、CT提示：肺不張、肺部腫快、阻塞性肺炎、 肺炎不吸收、肺部彌漫性病變、肺門(mén)/縱隔淋巴結(jié) 腫大、氣管支氣管狹窄、原因不明的胸腔積液等；,適應(yīng)證 (Indications for Diagnostic Bronchoscopy),臨床已診斷肺癌的術(shù)前檢查; 胸部外傷、懷疑氣管支氣管挫裂/斷裂、肺移植后氣管支氣管吻合面觀察等； 食道-氣管瘺的確診；,10. 肺/支氣管感染性疾病的病因?qū)W診斷（BAL、PBL）; 11. 引導(dǎo)下的選擇性支氣管造影；,支氣管灌洗（Bronchial Lavage，BL) 支氣管肺泡灌洗（Bronchoalveolar Lavage，BAL) 保護(hù)套管刷（Protected catheter brush） 細(xì)胞刷檢 （Cytology brushing） 氣管內(nèi)鉗取活檢（Endobronchial forceps biopsy） 經(jīng)支氣管肺活檢(Transbronchial Lung Biopsy,TBLB) 經(jīng)支氣管針吸術(shù)(Transbronchial Needle Aspiration,TBNA),診斷應(yīng)用的基本技術(shù) (Basic Techniques in Diagnostic Procedures),并發(fā)癥 (Complications of Bronchoscopy), 麻醉藥物過(guò)敏：丁卡因 麻醉藥物過(guò)量：利多卡因300mg/次 低氧: PaO2 1020mmHg 出血,并發(fā)癥 (Complications of Bronchoscopy), 損傷胸膜 損傷氣管 心血管異常 感染 喉頭水腫、支氣管痙攣：麻醉不充分,并發(fā)癥 (Complications of Bronchoscopy), 輕度并發(fā)癥發(fā)生率 0.01% 0.04% 死亡率 0.01%,經(jīng)支氣管肺活檢 (Transbronchial Lung Biopsy,TBLB),適應(yīng)證 普通FB可見(jiàn)范圍以外的肺組織內(nèi)的孤立性結(jié)節(jié) (solitary pulmonary nodule, SPN); 肺彌漫性病變(interstitial lung disease, ILD)性質(zhì)不明;,經(jīng)支氣管肺活檢 (Transbronchial Lung Biopsy,TBLB),禁忌證 病變不能除外血管畸形所致； 懷疑病變?yōu)榉伟x(chóng)囊腫者； 心肺功能差，預(yù)計(jì)無(wú)法耐受可能發(fā)生的氣胸者； 進(jìn)行機(jī)械通氣者； 有出血傾向者；,經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),Dr. Wang KP 1978年首次開(kāi)展,經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),針吸細(xì)胞標(biāo)本,經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),適應(yīng)證 (Indications for Diagnostic Bronchoscopy),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA) 臨床評(píng)價(jià), 氣胸 縱隔積血 菌血癥、細(xì)菌性心包炎 TBNA 是比TBLB更安全的診斷技術(shù),經(jīng)支氣管針吸術(shù) (Transbronchial Needle Aspiration,TBNA),FB治療應(yīng)用 Therapeutic Procedures of Flexible Bronchoscopy,取出支氣管異物 (Removal of foreign bodies)； 清除氣道內(nèi)異常分泌物(肺不張、肺膿腫)(Bronchial toilet)； 鏡檢中對(duì)咯血的出血部位試行局部止血(冰鹽水、 麻黃素）； 纖支鏡引導(dǎo)下氣管插管(Intubation)； 經(jīng)纖支鏡局部放療 (Brachytherapy) 或 局部注射化療藥物(Intralesional Injection）；,FB治療應(yīng)用,6.纖支鏡對(duì)氣道內(nèi)腫瘤進(jìn)行激光、 微波、 冷凍(Cryotherapy)、 高頻電刀治療(Electrocautery) ；,7. 支氣管肺泡灌洗 (BAL) 治療嚴(yán)重哮喘 祛除黏液栓 治療肺泡蛋白沉 著癥 (PAP) 治療感染性疾病 對(duì)氣道狹窄的治療： 支氣管鏡氣囊擴(kuò)張術(shù) (Balloon Bronchoplasty) 放置氣管內(nèi)支架 (Tracheobronchial stenting),FB治療應(yīng)用,支架種類(lèi) ： 2種 人造金屬內(nèi)支架(Endoprosthetic metal stent) 適應(yīng)證: 各種腫瘤或良性病變引起的 氣管支氣管狹窄 姑息治療 禁忌證 ： 有氣管支氣管瘺者禁用無(wú)膜支架 氣管支氣管狹窄無(wú)法擴(kuò)張或狹窄口直徑過(guò)小( 4mm),FB或硬質(zhì)內(nèi)鏡無(wú)法通過(guò) 存在氣管鏡檢禁忌證,放置支架(Tracheobronchial stenting),1. 人造金屬內(nèi)支架 (Endoprosthetic metal stent),2 . 硅膠內(nèi)支架 (silicone stent),適應(yīng)證: 禁忌證 ： 存在咽喉狹窄或其他硬質(zhì)內(nèi)鏡禁忌證,FB新進(jìn)展, 自發(fā)性熒光纖支鏡(Autofluorescence Bronchoscopy , AFB）/光動(dòng)力治療(Photodynamic therapy，PDT) 氣管鏡超聲 (Endobronchial Ultrasonography, EBUS) 介入氣管學(xué) (Interventional Bronchology) Foreign body removal; Nd YAG Laser(摻汝釔鋁石榴石)/ 氬離子 (Ar)激光; Electrosurgery; Argon plasma coagulation; Balloon Bronchoplasty; Tracheobronchial stenting),自發(fā)性熒光纖支鏡(AFB）,Stage 0, n=3, 100% Stage l ,n=796, 68.5% Stage ll,n=304,46.9% Total, 39.3% Stage llA, n=719, 26.1% Stage lV,n=327, 11.2% Stage lllB,n=233, 9.0% Survival rates for 2,382 patients after resection of lung cancer -Chest 1997;112(4):242,自發(fā)性熒光纖支鏡(AFB）,Although surgery for early stage tumors provides the best prospects of cure, 80% patients already have advanced and inoperable disease when present to their physicians.,自發(fā)性熒光纖支鏡(AFB）,Case Study #1 68 year old male Ex-smoker Presented with a persistent cough and sputum production Sputum cytology showed cells suggestive of squamous carcinoma,自發(fā)性熒光纖支鏡(AFB）,RB8 Image-1(WLB) RB8 Image-2(LIFE) RB8 Image-3(LIFE) Image-1(WLB): In the right lower lobe it was noted that some thickening had occurred in bronchus Image-2,3(LIFE): There was an area of abnormal brownish red fluorescence in the sub-carina,which measured 2 to 3 millimeters in width and was confirmed by biopsy as carcinoma-in-situ with small foci of microinvasion.,Case Study #2 77 year old male Ex-smoker (118 pack-years) Abnormal sputum cytology Chest x-ray indicated Chronic Obstructive Pulmonary Disease (COPD) CT Scan was negative,自發(fā)性熒光纖支鏡(AFB）,LB6 Image-1 (WLB) LB6 Image-2 (LIFE) LB6 Image-1(WLB): no abnormal areas were located. LB6 Image-2(LIFE): There were two areas considered to be suspicious, LB1+2 and LB6, which pathological results indicated carcinoma in-situ for LB1+2 and severe dysplasia for LB6.,AFB定位診斷提高率 (Improved Detection), 每個(gè)患者的診斷率可提高 37%75% On a per-patient basis 每個(gè)活檢標(biāo)區(qū)的診斷率可提高 25%67% On a per-lesion basis,自發(fā)性熒光纖支鏡(AFB),加拿大學(xué)者Lam等設(shè)計(jì)的LIFE系統(tǒng) (Lung Imaging Fluorescence Endoscope system, LIFE) 德國(guó)慕尼黑激光研究院設(shè)計(jì)的D-light Storz系統(tǒng) 日本Pentax 公司生產(chǎn)的SAFE-1000系統(tǒng),自發(fā)性熒光纖支鏡(AFB), 第二代LIFE系統(tǒng),氣管鏡超聲 ( EBUS), 氣管鏡超聲 工作原理模擬,氣管鏡超聲 ( EBUS), 氣管鏡超聲 工作原理模擬,氣管鏡超聲 ( EBUS),氣管鏡超聲 ( EBUS), 氣管鏡超聲探頭 工作狀態(tài)顯示,氣管鏡超聲 ( EBUS), 氣管鏡超聲探頭 工作結(jié)果顯示,You can live without food for weeks. You can live without water for a few days. But if you are deprived of air, you will die within minutes. In terms of survival, Breathing is your most immediate need !,Thanks,后面內(nèi)容直接刪除就行 資料可以編輯修改使用 資料可以編輯修改使用 資料僅供參考，實(shí)際情況實(shí)際分析,主要經(jīng)營(yíng)：課件設(shè)計(jì)，文檔制作，網(wǎng)絡(luò)軟件設(shè)計(jì)、圖文設(shè)計(jì)制作、發(fā)布廣告等 秉著以?xún)?yōu)質(zhì)的服務(wù)對(duì)待每一位客戶(hù)，做到讓客戶(hù)滿(mǎn)意！ 致力于數(shù)據(jù)挖掘，合同簡(jiǎn)歷、論文寫(xiě)作、PPT設(shè)計(jì)、計(jì)劃書(shū)、策劃案、學(xué)習(xí)課件、各類(lèi)模板等方方面面，打造全網(wǎng)一站式需求,感謝您的觀看和下載,The user can demonstrate on a projector or computer, or print the presentation and make it into a film to be used in a wider field,