危重病人的气道处理

1. 危重病人的气道处理 曾其毅

2. 危重病救治程序 • A－airway 建立气道 • B—breathing 维持呼吸 • C—circulation 维持循环 • D—drug 药物疗法 • E—evaluations 病情评估

3. 建立气道 • 面罩－气囊、喉罩 • 气管插管 • 器官切开

4. 面罩气囊 • 注意清除分泌物 • 放置口咽气道-舌后坠 • 注意体位-嗅花位 • 密封效果

5. 喉 罩 • 危急、手术 • 方便快捷 • 危险性大-迷走反射

6. 气道人工 • 气管插管—经口、经鼻 麻醉与肌松 安全快捷有效，并发症少 气道护理要求高

7. 人工气道 • 气管切开 长 效 护理方便 并发症多 可 进 食

8. 气道护理—胸部理疗 • postural drainage 体位引流 • Percussion 叩 拍 • Vibration 振 荡

9. Turning----翻身 • promote unilateral or bilateral lung expansion 促进单侧或双侧肺复张 • improve arterial oxygenation. 改善动脉血氧

10. Turning----翻身 • with the bed at any degree of inclination 床任意角度引流 • Sometimes need a special bed or device 有时需要特殊设备

11. Turning------适应征 • inability or reluctance of patient to change body position. (eg, mechanical ventilation, neuromuscular disease, drug-induced paralysis) 不便于翻身的疾病（如：机械通气、神经肌肉麻痹、药物麻醉）

12. Turning------适应征 • poor oxygenation associated with position (eg, unilateral lung disease) 单侧肺部疾病 • potential for or presence of atelectasis 肺不张 • presence of artificial airway 人工气道

13. 体位引流 • different positions help drain mucus from different sections of the lungs 不同体位对肺部不同部位的引流 • 3 to 15 minutes (longer in special situations) 每种体位15分钟 • modified as the patient's condition and tolerance warrant. 注意病人的适应性

17. 体位引流 -----适应征 • evidence or suggestion of difficulty with secretion clearance • presence of atelectasis caused by or suspected of being caused by mucus plugging

18. 体位引流 -----适应征 • diagnosis of diseases such as cystic fibrosis,bronchiectasis, or cavitating lung disease • presence of foreign body in airway

19. 体位引流 -----禁忌症 • All positions are contraindicated for intracranial pressure (ICP) > 20 mm Hg • head and neck injury until stabilized • active hemorrhage with hemodynamic instability • recent spinal surgery or acute spinal injury • acute spinal injury or active hemoptysis • empyema

20. 体位引流 -----禁忌症 • bronchopleural fistula • pulmonary edema associated with congestive heart failure • large pleural effusions • pulmonary embolism • aged, confused, or anxious patients who do not tolerate position changes • rib fracture, with or without flail chest • surgical wound or healing tissue

21. Percussion 叩拍

22. 振 荡 a fine tremorous action

24. 叩拍 & 振荡-----适应症 sputum volume or consistency suggesting a need for additional manipulation to assist movement of secretions by gravity, in a patient receiving postural drainage

25. 扣拍 & 振荡-----禁忌症 • subcutaneous emphysema • recent epidural spinal infusion or spinal anesthesia • recent skin grafts, or flaps, on the thorax

26. 扣拍 & 振荡-----禁忌症 • recently placed transvenous pacemaker or subcutaneous pacemaker (particularly if mechanical devices are to be used)

27. 扣拍 & 振荡-----禁忌症 • suspected pulmonary tuberculosis • lung contusion • bronchospasm • osteomyelitis of the ribs • coagulopathy • complaint of chest-wall pain

28. 胸部理疗并发症 • Hypoxemia • Increased Intracranial Pressure • Acute Hypotension during Procedure • Pulmonary Hemorrhage • Pain or Injury to Muscles, Ribs, or Spine • Vomiting and Aspiration • Bronchospasm • Dysrhythmias

29. 监 护 • Subjective response--pain, discomfort, dyspnea, response to therapy • Pulse rate, dysrhythmia, and EKG if available

30. 监 护 • Breathing pattern and rate, symmetrical chest expansion, synchronous thoracoabdom-inal movement, flail chest • Sputum production (quantity, color, consistency, odor)

31. 监 护 • Sputum production (quantity, color, consistency, odor) and cough effectiveness • Mental function、 Skin color 、 Breath sounds 、 blood pressure • oxygen saturation by pulse oximetry (if hypoxemia is suspected) • intracranial pressure (ICP)

32. Thank you!