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Technic Of Bronchoscopy

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withdrawn or coughed out during the removal of the laryngoscope; this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.]

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