Mount Sinai Expert Guides. Группа авторов

       Adjust the height of the bed where your non‐dominant hand can reach the point of entry of the bronchoscope (mouth, nose, ETT, or tracheostomy device) and the other arm can be fairly well extended upright to control the bronchoscope.

       Keep the bronchoscope in the center of the airways. If suction is applied while the tip of the bronchoscope is on the airway wall, ecchymosis or erythema will occur.

       Examine the lungs by advancing the lubricated bronchoscope through the nares towards the vocal cords, or threading it through an ETT (Video 5.1). It should be advanced slowly, ensuring that there is no resistance. See Figure 5.1 for the segmental and lobar divisions of the lungs.

       The anterior larynx should be seen with the cartilaginous rings and the posterior should be seen flat.

       The vocal cords should not be seen in an intubated patient since the ETT should be through the vocal cords and the ETT tip sits about 3–4 cm above the main carina. (If the vocal cords are seen, the ETT is above the cords and would need to be advanced.)

       The bronchoscope is advanced to the main carina (Video 5.2). The tracheal rings are on the anterior aspect. If the bronchoscopist is doing the procedure from behind the patient, the right main bronchus will be on the right and the left main bronchus will be on the left, as in Figure 5.1.

       The bronchoscope can then be advanced to the right mainstem bronchus. At this point the bronchus intermedius will be seen at 3 o’clock and the right upper lobe (RUL) bronchus will also be seen (Figure 5.2). In most patients the RUL will have three orifices: the apical, anterior, and posterior segments (called the Mercedes Benz sign). However, in <3% of patients four orifices will be seen.

       Now withdraw the scope from the RUL bronchus and return to the bronchus intermedius. Straight ahead the right lower lobe (RLL) will be seen. The superior segment of the RLL is opposite to the right middle lobe (RML). The RML has the shape of a letter ‘D’ (called the fish mouth sign).

       Withdraw the bronchoscope to the main carina before advancing it towards the left bronchus, which is longer than the right main bronchus. Once in the left mainstem bronchus a ‘secondary carina’ can be seen. This can be distinguished from the main carina by the smaller diameter of the lumens and the absence of tracheal rings.

       The secondary carina divides the left upper lobe and left lower lobe.

       Samples can be collected in the infected lobe/s after visualization of the presumed uninfected lung/lobes/segments. The bronchoscope should be directed to the lobe/segments in question and wedged, then saline squirted in aliquots of 10–15 mL. The saline is then suctioned into the sample containers.

       If a lesion is seen, samples can be obtained by using a brush/forceps. Slides can be made from the samples or the brush can be washed and the sample sent for cultures/cytology. Biopsies of lesions are usually deferred to a pulmonologist.

       If active intrabronchial hemorrhage (Video 5.3) is noted then the source of bleeding can be controlled by squirting epinephrine or ice‐cold saline at the site and holding the bronchoscope to tamponade the bleeding. A catheter with a small balloon can be inserted and inflated at the end of the bronchoscope that may temporize the bleeding. In cases of massive hemoptysis, the non‐bleeding lung can be intubated allowing the bleeding lung to collapse. Rigid bronchoscopy may be required. Options for the control of bleeding include interventional radiologic procedures, bronchial artery embolization, and surgery.

       The flexible bronchoscope fits well in a 7.5 mm ETT and can be used to visualize and be inserted into the trachea for difficult intubation.

       Forceps and basket can be inserted through the flexible bronchoscope working port and this can assist with the removal of small foreign objects in the airway.

       Bedside tracheostomy can be done in the ICU with the aid of bronchoscopic visualization.

       From anesthetic: laryngospasm, bronchospasm.

       From sedative: hypotension, bradycardia (propofol).

       Laryngospasm or bronchospasm.

       Hypoxemia.

       Fever.

       Hemoptysis.

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