Rigid Bronchoscopy

1. Rigid Bronchoscopy
Dr.Santosh Jha

2. Rigid Bronchoscopy:Instrumentation
• Rigid bronchoscopy is a technique that visualizes the
trachea and proximal bronchi.
• Usually performed in the operating room under general
anaesthesia.
• Most commonly used to manage patients who have
obstruction of either their trachea or a proximal
bronchus, the large lumen facilitates suctioning and the
removal of debris, or for interventional procedures such
as insertion of airway stents.
Bolliger CT et al. ERS/ATS statement on interventional pulmonology.. Eur Respir J 2002; 19:356.
Ernst A ET al Interventional pulmonary procedures: Guidelines from theaccp. Chest 2003; 123:1693.

3. • The rigid bronchoscope is also known as an open tube
bronchoscope, open tube, straight bronchoscope, or
ventilating bronchoscope.
• It is a rigid, straight, hollow metal tube that is available
in several sizes. Its purpose is to provide access to the
airways.

4. • The rigid bronchoscope, through which a rigid telescope
is placed, provides access to the central airways.
• External diameters and lengths vary depending upon the
manufacturer.

5. • The external diameter of a rigid bronchoscope varies
from 2 to 14 mm, wall thickness ranges from 2 to 3 mm,
and length varies from a very short tube (for pediatric
cases) to a long or extra long tube (for adults).
• Tubes with an extra large diameter have been developed
for exceptional cases of tracheobronchomalacia, but they
are not readily available.

6. • The distal end of the rigid bronchoscope is usually
beveled to facilitate intubation and lifting of the
epiglottis; the proximal portion is equipped to
accommodate attachments, provide side port ventilation,
and permit insertion of ancillary instruments.

10. • VISUALIZING EQUIPMENT — During rigid
bronchoscopy, a rigid telescope and light source are
generally inserted through a rigid bronchoscope to
visualize the airways.
• A flexible bronchoscope inserted through the rigid
bronchoscope is a reasonable alternative.

11. • Rigid telescopes — Rigid telescopes visualize the
airways at angles of 0, 30, 40, 50, 90, 135, and 180
degrees with respect to the axis of the telescope. This
facilitates visualization of the upper lobe, lower lobe,
and mainstem bronchi bilaterally.
• The Hopkins lens rigid telescope is the most popular
type of rigid telescope.
• Light source — Illumination is extremely important
during rigid bronchoscopy, A cold light source (ie,
xenon and halogen lamps) is the most frequently used
illumination device in rigid bronchoscopy.

12. • Video equipment — ideal for teaching and
documenting procedures, as well as allowing viewing
by multiple individuals.
• Video imaging is enhanced by the high quality of the
optics in a rigid telescope. Single chip or three-chip
video cameras can be easily connected to the proximal
aspect or eyepiece of a rigid telescope via direct
connection devices, Snap-on lenses, or standard C-
mounts.
• Alternatively, a flexible bronchoscope with digital video
capability can be used.

13. • ACCESSORY INSTRUMENTS —
 forceps for biopsy
 forceps that facilitate foreign-body removal
 suction tubing
 Instruments used to insert and remove airway
prostheses (eg, stents).

15. Rigid bronchoscopy: Intubation
techniques
• PATIENT PREPARATION:
• Topical anesthesia is applied using lidocaine or tetracaine.
• Patients are oxygenated by mask, and pharyngeal secretions
are aspirated.
• Dentures are removed, and the teeth and gums are carefully
inspected.

16. • Depending upon the position of the glottis and the
laryngotracheobronchial axis, it may be necessary to use
one, two, or no pillows beneath the patient's head.
• Careful attention should be paid to patients with cervical
spine disease.

17. DIRECT INTUBATION
• Direct intubation using a rigid telescope is the method of
choice for rigid bronchoscopic intubation.
• With this technique, the rigid telescope is placed inside
the bronchoscope, and the laryngeal structures are
viewed directly through the telescope.

18. • Illumination is provided through the distal aspect of the
rigid telescope, which is attached via a light cable to a
cold light source.
• If a rigid telescope is not used, the bronchoscope is
introduced using only the naked eye.

19. Steps required for direct intubation using a rigid
telescope:
• The bronchoscopist stands directly behind the head of
the supine patient.
• The rigid bronchoscope is held in the right hand with its
tip uppermost. The middle finger of the left hand is used
to protect the upper teeth and gums and to control head
movements. The telescope should not extend beyond the
edge of the rigid bronchoscope.

20. • The bronchoscope is inserted with its tip facing forward.
Looking through the telescope, the bronchoscopist
identifies the uvula posteriorly, and the bronchoscope is
advanced along the route of the tongue.

21. • The rigid bronchoscope is gently lifted upwards and the
epiglottis is brought into view . The anterior aspect of the
beveled tip of the bronchoscope is then slid under the
epiglottis. Gentle advancement of the rigid tube provides
further access to the larynx.
• After both arytenoids are identified, the rigid tube is
lifted more anteriorly and the vocal cords are seen.

22. • As the vocal cords are approached, the tip of the
bronchoscope is rotated 90 degrees laterally so that the
beveled tip lies between them.
• The bronchoscope is advanced and rotated to enter the
trachea without traumatizing the larynx.
• Once beyond the level of the cricoid cartilage, the
bronchoscope may be rotated so that the beveled tip lies
along the posterior wall of the trachea.

23. • For operators who are uncomfortable with direct
intubation but who are adept at laryngoscopy, the vocal
cords may be visualized using the rigid laryngoscope
alone.
• Intubation through a tracheostomy is a relatively simple
technique. the rigid bronchoscope can be inserted
directly through the stoma from a lateral position.

26. SUMMARY AND RECOMMENDATIONS
• The rigid bronchoscope is a potentially dangerous
instrument.
• It consists of a hollow stainless steel tube that provides
access to the central airways and through which a rigid
telescope is placed.
• The technique of rigid bronchoscopic intubation is one
that is gradually perfected over time.

27. • Direct intubation using a rigid telescope is the method of
choice for rigid bronchoscopic intubation.
• The bronchoscope can and should be introduced gently,
delicately, and with substantial care.
• Most complications of rigid bronchoscopy are related to
poor insertion technique, prolonged trauma of the larynx
and vocal cords, hypercapnia, hypoxemia, or
hemodynamic instability.