Rigid Bronchoscopy

Dr.Santosh Jha

Rigid Bronchoscopy:Instrumentation• Rigid bronchoscopy is a technique that visualizes the

trachea and proximal bronchi. • Usually performed in the operating room under general

anaesthesia.• Most commonly used to manage patients who have

obstruction of either their trachea or a proximal bronchus, the large lumen facilitates suctioning and the removal of debris, or for interventional procedures such as insertion of airway stents.

Bolliger CT et al. ERS/ATS statement on interventional pulmonology.. Eur Respir J 2002; 19:356. Ernst A ET al Interventional pulmonary procedures: Guidelines from theaccp. Chest 2003; 123:1693.

• The rigid bronchoscope is also known as an open tube bronchoscope, open tube, straight bronchoscope, or ventilating bronchoscope.

• It is a rigid, straight, hollow metal tube that is available in several sizes. Its purpose is to provide access to the airways.

• The rigid bronchoscope, through which a rigid telescope is placed, provides access to the central airways.

• External diameters and lengths vary depending upon the manufacturer.

• The external diameter of a rigid bronchoscope varies from 2 to 14 mm, wall thickness ranges from 2 to 3 mm, and length varies from a very short tube (for pediatric cases) to a long or extra long tube (for adults).

• Tubes with an extra large diameter have been developed for exceptional cases of tracheobronchomalacia, but they are not readily available.

• The distal end of the rigid bronchoscope is usually beveled to facilitate intubation and lifting of the epiglottis; the proximal portion is equipped to accommodate attachments, provide side port ventilation, and permit insertion of ancillary instruments.

• VISUALIZING EQUIPMENT — During rigid bronchoscopy, a rigid telescope and light source are generally inserted through a rigid bronchoscope to visualize the airways.

• A flexible bronchoscope inserted through the rigid bronchoscope is a reasonable alternative.

• Rigid telescopes — Rigid telescopes visualize the airways at angles of 0, 30, 40, 50, 90, 135, and 180 degrees with respect to the axis of the telescope. This facilitates visualization of the upper lobe, lower lobe, and mainstem bronchi bilaterally.

• The Hopkins lens rigid telescope is the most popular type of rigid telescope.

• Light source — Illumination is extremely important during rigid bronchoscopy, A cold light source (ie, xenon and halogen lamps) is the most frequently used illumination device in rigid bronchoscopy.

• Video equipment — ideal for teaching and documenting procedures, as well as allowing viewing by multiple individuals.

• Video imaging is enhanced by the high quality of the optics in a rigid telescope. Single chip or three-chip video cameras can be easily connected to the proximal aspect or eyepiece of a rigid telescope via direct connection devices, Snap-on lenses, or standard C- mounts.

• Alternatively, a flexible bronchoscope with digital video capability can be used.

• ACCESSORY INSTRUMENTS — forceps for biopsy forceps that facilitate foreign-body removal suction tubing Instruments used to insert and remove airway

prostheses (eg, stents).

Rigid bronchoscopy: Intubation techniques

• PATIENT PREPARATION:• Topical anesthesia is applied using lidocaine or tetracaine.

• Patients are oxygenated by mask, and pharyngeal secretions are aspirated.

• Dentures are removed, and the teeth and gums are carefully inspected.

• Depending upon the position of the glottis and the laryngotracheobronchial axis, it may be necessary to use one, two, or no pillows beneath the patient's head.

• Careful attention should be paid to patients with cervical spine disease.

DIRECT INTUBATION

• Direct intubation using a rigid telescope is the method of choice for rigid bronchoscopic intubation.

• With this technique, the rigid telescope is placed inside the bronchoscope, and the laryngeal structures are viewed directly through the telescope.

• Illumination is provided through the distal aspect of the rigid telescope, which is attached via a light cable to a cold light source.

• If a rigid telescope is not used, the bronchoscope is introduced using only the naked eye.

Steps required for direct intubation using a rigid telescope:

• The bronchoscopist stands directly behind the head of

the supine patient.• The rigid bronchoscope is held in the right hand with its

tip uppermost. The middle finger of the left hand is used to protect the upper teeth and gums and to control head movements. The telescope should not extend beyond the edge of the rigid bronchoscope.

• The bronchoscope is inserted with its tip facing forward. Looking through the telescope, the bronchoscopist identifies the uvula posteriorly, and the bronchoscope is advanced along the route of the tongue.

• The rigid bronchoscope is gently lifted upwards and the epiglottis is brought into view . The anterior aspect of the beveled tip of the bronchoscope is then slid under the epiglottis. Gentle advancement of the rigid tube provides further access to the larynx.

• After both arytenoids are identified, the rigid tube is lifted more anteriorly and the vocal cords are seen.

• As the vocal cords are approached, the tip of the bronchoscope is rotated 90 degrees laterally so that the beveled tip lies between them.

• The bronchoscope is advanced and rotated to enter the trachea without traumatizing the larynx.

• Once beyond the level of the cricoid cartilage, the bronchoscope may be rotated so that the beveled tip lies along the posterior wall of the trachea.

• For operators who are uncomfortable with direct intubation but who are adept at laryngoscopy, the vocal cords may be visualized using the rigid laryngoscope alone.

• Intubation through a tracheostomy is a relatively simple technique. the rigid bronchoscope can be inserted directly through the stoma from a lateral position.

SUMMARY AND RECOMMENDATIONS

• The rigid bronchoscope is a potentially dangerous instrument.

• It consists of a hollow stainless steel tube that provides access to the central airways and through which a rigid telescope is placed.

• The technique of rigid bronchoscopic intubation is one that is gradually perfected over time.

• Direct intubation using a rigid telescope is the method of choice for rigid bronchoscopic intubation.

• The bronchoscope can and should be introduced gently, delicately, and with substantial care.

• Most complications of rigid bronchoscopy are related to poor insertion technique, prolonged trauma of the larynx and vocal cords, hypercapnia, hypoxemia, or hemodynamic instability.