Entering The Bronchi

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The lip of the bronchoscope should be turned

in the direction of the bronchus to be explored, and the axis of the

bronchoscope should be made to correspond as nearly as possible to the

axis of this bronchus. The position of the lip is designated by the

direction taken by the handle. Upon entering the right bronchus, the

handle of the bronchoscope is turned horizontally to the right, and at

the same time the assistant deflects the head to the left.

The right upper-lobe bronchus is recognized by its vertical spur;

the orifice is exposed by displacing the right lateral wall of the

right main bronchus at the level of the carina. Usually this orifice

will be thus brought into view. If not the bronchoscope may be

advanced downward 1 or 2 cm., carefully to avoid overriding. This

branch is sometimes found coming off the trachea itself, and even if

it does not, the overriding of the orifice is certain if the right

bronchus is entered before search is made for the upper-lobe-bronchial

orifice. The head must be moved strongly to the left in order to view

the orifice. A lumen image of the right upper-lobe bronchus is not

obtainable because of the sharp angles at which it is given off. The

left upper-lobe bronchus is entered by keeping the handle of the

bronchoscope (and consequently the lip) to the left, and, by keeping

the head of the patient strongly to the right as the bronchoscopist

goes down the left main bronchus. This causes the lip of the

bronchoscope to bear strongly on the left wall of the left main

bronchus, consequently the left upper-lobe-bronchial orifice will not

be overridden. The spur separating the upper-lobe-bronchial orifice

from the stem bronchus is at an angle approximately from two to eight

o'clock, as usually seen in the recumbent patient. A lumen image of a

descending branch of the upper-lobe bronchus is often obtained, if the

patient's head be borne strongly enough to the right.

[FIG. 65.--Schema illustrating the entering of the anteriorly

branching middle lobe bronchus. T, Trachea; B, orifice of left main

bronchus at bifurcation of trachea. The bronchoscope, S, is in the

right main bronchus, pointing in the direction of the right inferior

lobe bronchus, I. In order to cause the lip to enter the middle lobe

bronchus, M, it is necessary to drop the head so that the bronchoscope

in the trachea TT, will point properly to enable the lip of the tube

mouth to enter the middle lobe bronchus, as it is seen to have done at


Branches of the stem bronchus in either lung are exposed, or their

respective lumina presented, by manipulation of the lip of the

bronchoscope, with movement of the head in the required direction.

Posterior branches require the head quite high. A large one in the

left stem just below the left upper-lobe bronchus is often invaded by

foreign bodies. Anterior branches require lowering the head. The

middle-lobe bronchus is the largest of all anterior branches. Its

almost horizontal spur is brought into view by directing the lip of

the bronchoscope upward, and dropping the head of the patient until

the lip bears strongly on the anterior wall of the right bronchus (see

Fig. 65).