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Technic Of BronchoscopyCategory: INTRODUCTION OF THE BRONCHOSCOPE Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery Local anesthesia is usually employed in the adult. The patient is placed in the Boyce position shown in Fig. 51, with head and shoulders projecting over the edge of the table and supported by an assistant. The glottis is exposed by left-handed laryngoscopy. The instrument-assistant now inserts the distal end of the bronchoscope into the lumen of the laryngoscope, the handle being directed to the right in a horizontal position. The operator now grasps the bronchoscope, his eye is transferred from the laryngoscope to the bronchoscope, and the bronchoscope is advanced and so directed that a good view of the glottis is obtained. The slanted end of the bronchoscope should then be directed to the left, so as clearly to expose the left cord. In this position it will be found that the tip of the slanted end is in the center of the glottic chink and will slip readily into the trachea. No great force should be used, because if the bronchoscope does not go through readily, either the tube is too large a size or it is not correctly placed (Fig. 60). Normally, however, there is some slight resistance, which in cases of subglottic laryngitis may be considerable. The trained laryngologist will readily determine by sense of touch the degree of pressure necessary to overcome it. When the bronchoscope has been inserted to about the second or third tracheal ring, the heavy laryngoscope is removed by rotating the handle to the left, removing the slide, and withdrawing the instrument. Care must be taken that the bronchoscope is not withdrawn or coughed out during the removal of the laryngoscope; this can be avoided by allowing the ocular end to rest against the gown-covered chest of the operator. If preferred the operator may train his instrumental assistant to take off the laryngoscope, while the operator devotes his attention to preventing the withdrawal of the bronchoscope by holding the handle with his right hand. At the moment of insertion of the bronchoscope through the glottis, an especially strong upward lift on the beak of the spatula will facilitate the passage. It is necessary to be certain that the axis of the bronchoscope corresponds to the axis of the trachea, in order to avoid injury to the subglottic tissue which might be followed by subglottic edema (Fig. 47). If the subglottic region is already edematous and causes resistance, slight rotation to the laryngoscope, and bronchoscope will cause the bronchoscope to enter more easily. [FIG. 59.--Insufflation anesthesia with Elsberg apparatus. Anesthetist has exposed the larynx and is about to introduce the silk-woven catheter. Note the full extension of the head on the table.] [FIG. 60.--Schema illustrating the introduction of the bronchoscope through the glottis, recumbent patient. The handle, H, is always horizontally to the right. When the glottis is first seen through the tube it should be centrally located as at K. At the next inspiration the end B, is moved horizontally to the left as shown by the dart, M, until the glottis shows at the right edge of the field, C. This means that the point of the lip, B, is at the median line, and it is then quickly (not violently) pushed through into the trachea. At this same moment or the instant before, the hyoid bone is given a quick additional lift with the tip of the laryngoscope.] [FIG. 61.--Schema illustrating oral bronchoscopy. The portion of the table here shown under the head is, in actual work, dropped all the way down perpendicularly. It appears in these drawings as a dotted line to emphasize the fact that the head must be above the level of the table during introduction of the bronchoscope into the trachea. A, Exposure of larynx; B, bronchoscope introduced; C, slide removed; D, laryngoscope removed leaving bronchoscope alone in position.] Next: Difficulties In The Introduction Of The Bronchoscope Previous: Introduction Of The Bronchoscope
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