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Entering The Bronchi

Source: 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).

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