T RT

NI KH QUN

BS. NGUYN HU TUN

VIN TIM MCH

T NI KH QUN L TH THUT
KHNG TH TR HON
TI CC N V CP CU

GII PHU NG TH

Atlat gii phu F. Netter

GII PHU NG TH

Atlat gii phu F. Netter

CH NH
1.

Khai thng v bo v ng th
Tc ng h hp trn cp

Ph n thanh, co tht thanh qun

D vt ng th
Chn thng hm di, thanh qun
Nhim trng: bch hu, p xe thnh sau hng,
vim np thanh mn, vim tc th.qun
Cc khi u
Cc bt thng bm sinh

Procedures, techniques, and minimally invasive monitoring in Intensive care, 4th Ed

CH NH
Mt phn x bo v ng th
Ngng tun hon
Ng c thuc ng
Tai bin mch no, chn thng s no
Bnh nhn suy kit nng, tng tit m di

Procedures, techniques, and minimally invasive monitoring in Intensive care, 4th Ed

CH NH
2. Thng kh nhn to xm nhp

Suy h hp gim oxy ha mu

Vim phi nng, ARDS
Ph phi cp
Suy h hp tng carbonic mu
t cp COPD
Hen ph qun
Cc bnh l thn kinh c
Gy m

Hi sc cp cu ton tp Gs V Vn nh ; NEJM
Procedures, techniques, and minimally invasive monitoring in Intensive care, 4th Ed

CHNG CH NH

Rt him chng ch nh (1)

Tn thng t kh qun
Tn thng ct sng c khng phi l chng ch nh
Chng ch nh NKQ ng ming (2)
Sai khp hm
U vm hng, v xng hm
Phu thut vng hm hng
Chng ch nh vi NKQ ng mi (2)
Chn thng mi, hm mt
R nc no ty qua xoang sng
Ri lon ng mu
(1) ThE NEW ENGLAND JOURNAL of MEDICINE
(2) Hi sc cp cu ton tp Gs V Vn nh
(2) Procedures, techniques, and minimally invasive monitoring in Intensive care, 4th Ed

NH GI NG TH
Cc tnh trng lin quan n NKQ kh
Cc bt thng bm sinh
Hi chng Down
Hi chng Pierre Marry

Tnh trng nhim trng

 Ph i tuyn gip
Chn thng vng hm mt
Bo ph

NH GI NG TH
Di ng xng hm di: > 3cm

NH GI NG TH
Khong cch cm tuyn gip > 6cm

NH GI NG TH

Di ng ca ct sng c

NH GI NG TH
Phn Mallampati
Soft palate
Uvula

CHUN B DNG C

N SOI THANH QUN

LI N
F Li Macintosh and Miller
F Ngi ln dng li Macintosh, tr nh dng
li Miller

Li Miller

Li Macintosh

NG NI KH QUN

High volume
Low pressure cuff

Low volume
High pressure cuff

NG NI KH QUN

NG NI KH QUN
Kch thc ng
Nam 7.5- 8.0- 8.5 mm
N 7.0- 7.5 8.0 mm

Tr s sinh non yu 2,5mm

Tr s sinh

3,0 mm

1- 6 thng

3.5 mm

6 12 thng

4,0mm

12 24 thng

4.5 mm

2- 6 tui

= (tui /3) + 3.5

> 6 tui

= (tui /4) + 4.5

Procedures, techniques, and minimally invasive monitoring in Intensive care, 4th Ed

DNG C KHC

Dy dn

DNG C KHC
Magill forcep

Oral airway

Nasal airway

DNG C KHC
- Syringe 10ml
- Gng sch
- Du bi trn
- Bng dnh c nh NKQ
- ng nghe
Thuc
- Thuc an thn: propofol,midazolam
- Thuc gin c: tracrium
- Thuc t: lidocain 2%
Procedures, techniques, and minimally invasive monitoring in Intensive care, 4th Ed

T TH BN

Trc ca ming
Trc ca hu hng

Trc ca thanh qun

Nga c ti a
Bp bng hoc th oxy
An thn, gin c y
Ly b cc d vt ming
Ht sch m, dch d dy
Mc monitor theo di nhp
tim v SpO2
Procedures, techniques, and minimally invasive monitoring in Intensive care, 4th Ed

K THUT T NKQ NG MING

Th 1 - Bc l thanh mn

- BS ng pha u BN, tay tri cm n, tay phi m ming BN

- n c a t bn phi, y li BN sang tri
- a li n xung pha di np thanh mn (nu dng li thng)

- a li n vo thung lng pha trn np thanh mn (nu dng li cong)

Bc l thanh mn

K THUT T NKQ NG MING

Th 2 - lun ng NKQ

- Tay phi cm u ngoi ng NKQ a vo gc bn phi ca ming, lun

st vo thanh mn
- Ch khi hai dy thanh m m ra, nh nhng lun ng vo thanh qun
- V tr l tng ca NKQ: marker ca NKQ cch dy thanh m 2-3cm
The NEW ENGLAN JOURNAL of MEDICINE

K THUT T NKQ NG MING

Th 3 Kim tra NKQ
- su NKQ: 20-22cm so vi cung rng
- Bm cuff NKQ
- Bp bng ambu v nghe: thng v, hai bn phi
- Ht sch m di trong ng NKQ

- Chp Xquang: u trong ng NKQ ngang mc 2 xng n

(1) Procedures, techniques, and minimally invasive monitoring in Intensive care, 4th Ed

Tng thi gian cho n khi thng kh nhn to

khng c vt qu 30 giy!

Bnh nhn cht do khng c thng kh y

ch khng phi do khng t c NKQ

K THUT T NKQ NG MING

Th 4 C nh NKQ
- Bm cuff :
5 - 10ml kh

p lc 18-25mmHg (*)

- C nh NKQ

(*) Uptodate 2013

The NEW ENGLAN JOURNAL of MEDICINE

BIN CHNG
1. Trong khi lm th thut

Chn thng mi, rng, li

Tng huyt p v nhp tim, lon nhp
Sc phi
Co tht thanh kh qun
Ph n thanh qun

Tng p lc ni s
Sai khp sn nhn
Chn thng ct sng c
t vo thc qun

BIN CHNG
2. Khi lu ng NKQ
Tc NKQ
Tut ng hoc vo ph qun
Tut my th
Sc vo phi
Lot mi, li
Vim xoang

BIN CHNG
3. Khi rt NKQ
Co tht thanh qun
Vim phi do ht
Ph n ng h hp trn

4. Sau rt NKQ
Lot ng th
Hp kh qun
Ni khn
U ht thanh qun

RT NI KH QUN

SN SNG CAI TH MY ???

y oxy:
PaO2 60mmHg/ SaO2 90%, FiO2 0,5
PEEP 8cmH2O
Bnh nhn c th t th (v d th PSV)
Tnh trng tim mch n nh
60HR140
90mmHg SBP 160 mmHg, khng/hoc vn mch liu
thp
Glasgow 13 im, khng dng thuc an thn
Tnh trng chuyn ha n nh
pH 7,25, khng c ri lon in gii nng
Macintyre, Evidence Based Guidelines for Weaning and Discontinouing Ventilatory Support Chest
2001: 120: 375S-396S

CC PHNG THC CAI TH MY

T- piece
H tr p lc thp (5-7 cmH2O) PSV hoc
PEEP
Th CPAP
ng b dng t ng
Tuy nhin khng c s khc bit v t l tht bi
hoc thnh cng gia cc phng php!!!
Boles et. Al, Weaning from mechanical ventilation European Respiratory Journal 2007 29:10331056

TI U HA TRC KHI RT NKQ

BN t th u cao, ht m hu hng sch

Ngng thuc an thn
Ngh ngi
Gii thch tm l cho bnh nhn
Dinh dng y
Dng li tiu gim ph phi
Chng co tht ph qun
iu chnh ri lon in gii c nh hng n c h
hp: PO4, Mg, Ca
H st
iu tr n nh bnh ton thn

THEO DI SAU RT NKQ

Sau rt NKQ, cn kh dung thuc gin ph
qun, ht sch m di, v rung,
Theo di st bnh nhn v tri gic, nhp th,
nhp tim, huyt p, SpO2, kh mu, t nht
trong vng 1 gi sau rt NKQ
Nu BN c du hiu suy h hp tr li, nn
cho bnh nhn th khng xm nhp trc khi
xt t li NKQ.

TIU CHUN TP TH THT BI

Cc du hiu lm sng ch quan
BN bn chn, lo lng
thc xu i
Tot m hi
Tm ti
BN gng sc th: dng c h hp ph, v mt
cng thng, bn thy kh th

Boles et. Al, Weaning from mechanical ventilation European Respiratory

Journal 2007 29:1033-1056

TIU CHUN TP TH THT BI

Cc du hiu khch quan
PaO2 50-60mmHg, FiO20,5 hoc SaO2< 90%
PaCO2>50mmHg hoc tng thm >8mmHg
pH<7,32 hoc gim thm >0,07 n v pH
fR/Vt >105 ln/ lt
fR> 35 ln/pht hoc tng thm >50%
HR> 140 ck/pht hoc tng thm > 20%
SBP > 180mmHg hoc tng thm > 20%
SBP < 90 mmHg
Ri lon nhp tim
Boles et. Al, Weaning from mechanical ventilation European Respiratory
Journal 2007 29:1033-1056

RT NKQ THT BI
Tiu chun rt ng tht bi
fR > 25 ln/ pht lin tc trong 2 gi
HR> 140 ck/ pht hoc lin tc tng/hoc gim > 20%
Triu chng lm sng ca gng sc th hoc mt c h
hp; SaO2 <90%, PaO2<80mmHg vi FiO2>50%
Tng CO2 (PaO2>45mmHg hoc tng 20% so vi trc
khi rt NKQ), pH <7,33

Boles et. Al, Weaning from mechanical ventilation European Respiratory

Journal 2007 29:1033-1056

YU T TIN LNG RT NKQ THT BI

Tui > 70
Tip tc duy tr an thn tnh mch
Thiu mu (Hb<100g/L, hct<0,3)
Thi gian th my ko di ( trn 8-10 ngy)
Tha dch
Tn thng thn kinh trung ng
T rt NKQ
Bnh ni khoa cn cha c kim sot tt
Epstein, Decision to Extubation Intensive Care Medicine 2007 28:535-46

Thank you !

Nguy him qu!

t ni kh qun
kh???

V tai bin ???

Ti liu tham kho

Hi sc cp cu ton tp Gs V Vn nh,
2005 trang 517-527
Orotracheal intubation Christopher kabrhel
MD, NEJM 2007:356:e15
Proceduces, techniques and minimally invasive
monitoring in Intensive Care Medicine
Richard S.Irwin, James M.Rippe, 2008, p4-p18