http://www.bronchoscopy.org/ for training
and maybe even better
need 2mm larger ET tube than diameter of scope, so 8mm tube to use adult size bronchoscope
Anaesthesia 2012, 67, 1042–1056
Procedure from Practical Bronchoscopy
Some bronchoscopists prefer to face the sitting or lying patient whilst others stand behind the head of the lying Of patient (Fig. 3.7). Face to face contact with the frontal approach generally proves valuable to maintain rapport between patient and bronchoscopist. An advantage of standing behind the head of the supine patient is that the spatial orientation of the bronchial tree is then the same for both flexible and rigid bronchoscopes, which may be of importance for bronchoscopists who practise both methods but have difficulty in transposing images.
The patient is seated comfortably with legs horizontal and trunk and head supported at 30‑45′ with a pillow under the head. The bronchoscopist stands to the right of the couch and the assistant behind the patient’s head.
Lignocaine solution (4 or 10%) is sprayed from an atomizer into each nostril, the fauces and posterior pharyngeal wall, the patient having been first warned that the initial effects are an unpleasant stinging and taste. Within 2‑3 minutes the fibrescope lubricated with lignocaine gel can be introduced into the nose or mouth. Once the bronchoscope has passed through the nose or mouth, supplemental oxygen can be given through a nasal cannula into the unoccupied nostril.
The bronchoscopist should wear a clean gown and disposable gloves. If the gloves have been dusted with powder this must first be washed off to prevent starch granules contaminating the trap specimen and causing confusion in interpretation of the speci mens at microscopy.
The fibrescope should be inspected and if necessary the lens cleaned with sterile gauze moistened with sterile saline. The flexible fibrescope is a delicate and expensive apparatus. It must at all times be handled with care to avoid damage to the fibres. Knocking the shaft or tip against furniture and bending or kinking the shaft or tip with undue force must be avoided. The central channel and the polythene connecting tube should be flushed by aspirating sterile saline. To reduce fogging the distal lens can be wiped with silicone or soapy water. The fibrescope shaft should be lubricated with sterile 2% lignocaine jelly and some of this jelly can also be applied into the nostril through which the instrument is to be passed.
The technique of holding the fibrescope depends on the type of instrument available. The Olympus type is most widely used in Britain and can be held and operated by either the left or the right hand (Fig. 3.8). The body of this instrument is held by the 2nd, 3rd and 4th fingers and palm and the control knob can then be moved up and down by the thumb. The index finger is placed near the proximal end of the suction channel to seal it for aspiration as and when necessary. Rotation of the tip is achieved by rotating the wrist and thus the whole instrument (Fig. 3.9). The free hand is used to hold steady, advance and withdraw the shaft as well as to manoeuvre the biopsy forceps and cytology brushes to their targets (Fig. 3. 10). This can greatly reduce nasal discomfort for the patient.
The Machida type of fibrescope is held in the left hand reserving the right hand to operate the various handles at the proximal end as well as supporting, advancing and withdrawing the shaft of the fibrescope. Angulation and rotation of the tip are both achieved by rotating the proximal eyepiece which twists the distal end to the right and anticlockwise twists it to the left. Rotation can also be achieved by rotating the left wrist.
For all types and makes of instrument the bronchoscope tip is inserted gently into the nostril under direct vision and passed into the widest part of the nasal passages. This is usually the inferior meatus between the inferior turbinate and the floor of the nose. Lignocaine does not abolish pressure sensitivity and so the bronchoscope should not be forced as this will cause discomfort. The flexible tip of the bronchoscope is its widest part and once this has passed through any passage the shaft will follow more easily. If the bronchoscope will not pass comfortably through either nasal passage then it should be inserted through the mouth using the guard as described.
Once the posterior pharyngeal wall is reached the fibrescope is angulated downwards following the shape of the pharynx and into the oropharynx behind the uvula. At this stage it should be possible to see the epiglottis and the glottis in the distance. It may be necessary to aspirate secretions obscuring the view. Care should be taken to ensure that the shaft of the instrument is straight and the patient’s chin well forward. Asking the patient to protrude his tongue or to swallow may also help to reveal the epiglottis.
Once the epiglottis has been identified the glottis is usually visible behind and beyond it. If difficulty is encountered in getting behind the epiglottis it may be possible to pass the fibrescope tip laterally and posteriorly alongside the epiglottis and then turn the tip in medially to curl over onto the dorsal surface of the epiglottis. The glottis and the vocal cords are sensitive areas and care should be taken to avoid undue irritation by the bronchoscope tip whilst anaesthetizing this area. Watch for the effects of cardiac dysrhythmias induced by vagal stimulation.
Next, vocal cord mobility should be checked during normal inspiration and expiration by asking the patient to adduct his cords in saying ‘see’. Inequality of movement of the cords suggests recurrent laryngeal nerve palsy. The patient should be warned that the next step will cause coughing. This occurs as the vocal cords are anaesthetized by injecting 2 ml of 4% lignocaine (80 mg) onto them in their adducted position via the central channel of the fibrescope.
For purpose of regional anaesthesia via the fibrescope lignocaine should be drawn up as 2 ml aliquots in 5 ml syringes with 3 ml of air in the syringe. The bronchoscope should be positioned with the suction channel uppermost so that the local anaesthetic is injected first and flushed through the central channel by the following air from the syringe.
Two or three minutes are allowed for the lignocaine to have maximum effect and this time should be spent examining the pyriform fossae and the area between the vocal cords and the ary‑epiglottic folds. During deep inspiration 2 ml of 2% lignocaine (40 mg) is next injected through the vocal cords into the trachea. The fibrescope tip should be quickly withdrawn a few centimetres during the coughing which will follow. Another 2 ml of the 2% lignocaine is usually required to anaesthetize the trachea adequately.
Before the fibrescope is inserted between the cords into the trachea the patient must be warned that this will make him cough, cause transient breathlessness and that he should not attempt to speak. The patient is advised to resist the impulse to take large breaths but rather to continue with shallow breaths which he should be reassured are sufficient.
During quiet inspiration the bronchoscope is passed gently between the cords through the posterior part of the glottis where the opening is the widest (Fig. 3M). The patient should be instructed that although the sensation is odd, he can breathe and swallow normally. A minute or so should be allowed for the patient to become accustomed to the presence of the fibrescope
the trachea. Further boluses of 2% lignocaine may be required if much coughing occurs.
The trachea should be inspected for the appearance of the mucosa and abnormally increased or decreased mobility of the walls should be noted. Similarly the carina should be examined for its sharpness and mobility. Normally the carina becomes shorter and thicker during coughing. Abolition of this variability may indicate infiltration by carcinoma or enlargement of the s ubcarinal lymph glands.
Further boluses of 2 ml of 2% lignocaine are injected through the suction channel as necessary but the total dose administered should be kept to a minimum by avoiding contact with the bronchial walls thus reducing irritation. If the coughing induced is more than slight it is worth withdrawing the bronchoscope and injecting more lignocaine because once coughing is allowed to become severe it is difficult to control. There is considerable variation in sensitivity of the bronchial mucosa between patients and certainly smokers cough more easily and excessively. Encouragement and keeping the patient informed of what is happening with instructions to keep both eyes open will help to make the examination more comfortable for the patient and easier for the operator.
Both right and left bronchial trees must be systematically examined even if the chest radiograph suggests a unilateral lesion. Opinions vary as to whether the normal or abnormal side should be examined first. It is recommended that the normal side should be inspected first. If examined last it is more likely to be inadequately explored as both patient and bronchoscopist may be tired and secretions and blood may have spilled from the abnormal side following inspection and sampling.
To examine the right bronchial tree, the black notch in the visual field is turned to the right side of the patient. This ensures that the fibrescope tip has maximum manoeuvrability for examination of the bronchi on this side. The right upper lobe orifice usually lies just below the carina on the opposite lateral wall; it leads off at an angle of 80‑90′. It is helpful to give an extra 2 ml of 2% lignocaine into the upper lobe before it is inspected as the previous doses of lignocaine frequently fail to reach it due to its angulation. The orifice is now entered and the segments and subsegments are examined. The anterior segment which lies ventrally and the posterior segment lying dorsally are relatively easy to inspect without too much manipulation of the fibrescope tip. The apical segmental bronchus is more difficult to enter. To help this manoeuvre, the patient is asked to take a few deep breaths and then to hold the breath at full inspiration when the apical segmental orifice will be more easily seen with the tip of the fibrescope bent maximally upwards towards the head.
The right middle lobe bronchus arises ventrally from the intermediate bronchus and extends obliquely downwards. The notch in the visual field of the fibrescope should be placed in the anterior position to aid manoeuvrability in this bronchus which can usually be inspected to subsegmental level.
The fibrescope is then withdrawn back into the intermediate bronchus, the notch rotated dorsally until the orifice of the apical, segment of the right lower lobe is seen lying at the same level as the middle lobe. This segmental bronchus branches at 90′ from the intermediate bronchus and once again entry into it can be aided by asking the patient to hold the breath in full inspiration.
The remaining segmental orifices of the right lower lobe lie several centimetres distal to the apical segment. They all extend downwards and really are an extension of the main bronchus so little difficulty is usually encountered in entering them.
After withdrawing the fibrescope back to the carina, the left bronchial tree is next examined by having the notch in the visual field rotated to the left side of the patient. The left main bronchus is longer than the right and also deviates more laterally or horizontally in the erect subject. The secondary carina between the upper and lower lobe orifices is a useful landmark.
The lingular bronchus is usually an extension of the upper lobe bronchus and descends downwards dividing into superior and inferior segments.
The upper division of the upper lobe bronchus is next examined by withdrawing the fibrescope back into the upper lobe bronchus and turning its tip upwards (headwards) with maximum flexion. This is perhaps the most difficult bronchus to enter. This can be made easier by asking the patient to take a deep breath. The anterior and apicoposterior segments are then examined in turn.
The fibrescope is withdrawn back to the secondary carina and the left lower lobe is examined by rotating the notch in the visual field towards it. The apical segmental bronchus arises dorsally almost at the level of the secondary carina. It is located by turning the notch posteriorly and again if difficulty is encountered in entering it, the patient is asked to hold the breath in deep inspiration. The basal segments of the left lower lobe should present no difficulty to examination, noting that the anterior and mediobasal segments are usually combined into a single orifice.
Examination of an average ‘normal’ tracheobronchial. tree has been described. Variations in the branching of the bronchi are frequently encountered and should be borne in mind if apparent abnormalities occur, especially if the mucosa looks normal. At more peripheral levels, individual bronchi or combinations of bronchial orifices cannot be recognized by individual appearances alone because they usually look alike and variations are common. They can only be identified by remembering the route the bronchoscope has taken to get to that point in the bronchial tree. Occasionally it may be necessary to retrace the route to a more central and recognizable bronchus.
A routine of systematic examination of the airways should be adopted to prevent mistakes through omission. In addition to the bronchial tree an orderly inspection of the extrathoracic airways must also be completed. It is valuable to re‑inspect bronchi as the fibrescope is being withdrawn to confirm observations made when the instrument was advancing.
Manipulating the fibrescope
The ability to use a fibrescope comes only with practice. Although many useful hints are often given there is no substitute for time spent handling the instrument. The period of time that the novice can spend on a patient is limited and it can be helpful to use the various lung models available. Eventually, operating the instrument should become a subconscious act, like driving a motor car. The experienced bronchoscopist comes to know the position and orientation of the fibrescope tip as a form of extended proprioception, just as a good motorist knows the limits of the front or back of his car. Similarly guiding the instrument with coordinated movements of the wrist, thumb and fingers of the right hand as well as the forward and backward motion of the left hand will begin to occur at a subconscious level.
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How to Perform Bronchoalveolar Lavage (BAL)
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- Wedge bronch into subsegment
- Instill 120 ml into airways
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