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Technic Of Bronchoscopy

Sources: 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 p
sition. 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withdrawn or coughed out during the removal of the laryngoscope; this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.]