Method of bronchoscopy

For rigid bronchoscopy, metal tubes equipped with artificial lung ventilation (IVL) and equipped with telescopes with a different angle of view, forceps for biopsy, needles and catheters are used. Fibrobronchoscopy is performed using a flexible bronchoscope with an optical system and a biopsy channel for instruments. Possibilities of fibrobronchoscopy allow to see all the bronchi of the IV order, 86% of the bronchi of the V order and 56% of the bronchi of the VI order.

Clinical situations in which preference is given to rigid bronchoscopy:

• acute respiratory failure due to bronchial obstruction;
• childhood;
• intolerance to patients with local anesthetics;
• the patient has epilepsy and other chronic CNS diseases;
• impossibility to establish contact with the patient (deaf-mute patients);
• increased nervous excitability.

Inspection should begin with bronchus of a healthy (or less affected) lung to reduce the likelihood of infection. The fibrobronchoscope is better inserted into the tracheobronchial tree through the nasal passage (the risk of teeth-snacking of the fibroscope is eliminated), if transnasal intubation (curvature of the nasal septum, narrow nasal passage) is impossible, the fibrobronchoscope is inserted through the mouth using a special mouthpiece.

30 minutes before the local anesthesia, 1 ml of 0.1% solution of atropine sulfate is injected subcutaneously (to remove the vagal effect). Patients with glaucoma are examined without prior atropinization. Patients with a tendency to bronchospasm 15 minutes prior to the study, 10 ml of a 2.4% solution of euphyllin per 10 ml of physiological saline are injected intravenously, and 1-2 drops of aerosol used by the patient immediately after the local anesthesia is given.

For anesthesia of the upper respiratory tract and larynx, a 10% solution of lidocaine is applied, applying it on the mucosa using a nebulizer. With the transnasal introduction of the endoscope, the anesthesia of the lower nasal passage is carried out by the application method. Anesthesia of the vocal folds is performed under visual control through a catheter inserted through a biopsy channel during fibrolaringoscopy. Anesthesia of the carina, spur of share and segmental bronchi is carried out with a 2% solution of lidocaine in an amount of 6-8 ml. Anesthetic is administered under the control of vision through a long catheter.

Bronchoconstriction can be performed in two positions of the patient - sitting or lying down. If the patient has a respiratory failure, but there is no danger of complications, it is preferable to carry out the study in the sitting position. Medical bronchoscopy is also convenient to carry out in the patient's sitting position, since it is easier for the patient to cough up the sanitizing solution. The endoscope can be administered transnasal and transoral.

The first anatomical landmark (when performing bronchoscopy with a flexible endoscope) is the epiglottis, which covers the entrance to the larynx. Anesthesia of the epiglottis is not carried out. The end of the endoscope presses the epiglottis to the root of the tongue and examines the larynx. False voice folds look like two horizontally arranged fixed folds of pink color.

The second anatomical landmark is the true vocal folds located under the false ones. They have the appearance of brilliant whitish ribbons. At the rear edge of them are elevations formed by arytenoid cartilage. The space bounded by the inner edge of the true vocal folds and the inner surface of the arytenoid cartilages is called the voice gap.

Before you hold the device below the vocal folds, you need to make sure that the anesthesia performed is sufficient. To do this, the end of the catheter touches the vocal folds. Their immobility indicates adequate anesthesia.

The third anatomical landmark is the keel of the tracheal bifurcation - carina. In the keel of the bifurcation of the trachea, a crest, anterior and posterior triangle are distinguished. Karina can be sharp, like a razor blade, and also flattened, wide, S-shaped, saddle-shaped. Karine should be given special attention, as here various pathological processes are often localized.

The mucous membrane in the anterior and posterior triangles is light red, and the mucosa of the latter is somewhat darker. The size of the front triangle is greater than the rear.

Inspection begins on the side of the bronchial tree, where changes are less pronounced (as determined in advance by X-ray diffraction patterns). If the changes are expressed equally on both sides, then the examination begins with any half of the bronchial tree.

The right upper lobe bronchus begins from the outer surface of the main bronchus and is directed upwards almost at right angles. The diameter of its lumen is 8-10 mm. It is divided into three segmental bronchi.

From the lower edge of the mouth of the upper lobe bronchus, an intermediate bronchus begins, which terminates near the mouth of the mid-lobar bronchus. Its length is 2-3 cm, the diameter of the lumen is 10-11 mm.

The relatively high incidence of isolated lesions in the middle proportion, both in childhood and in the elderly, has long attracted the attention of researchers and made it necessary to look for the cause of such a lesion.

Having carefully studied the anatomy of the tracheobronchial tree, G. Kopstein (1933) and R.Brok (1946) concluded that the mid-lobe bronchus, like the middle lobe, has a number of anatomical and functional features that gave E.Zdansky (1946) bronchus "the place of least resistance". It turned out that the mid-lobe bronchus is the narrowest and longest of all the lobar bronchi. Its diameter varies from 0.5 to 0.7 cm, which corresponds to the size of most segmental bronchi, and its length is from 1.2 to 2.6 cm. The mid-right bronchus extends from the anterior wall of the intermediate bronchus at a sharp (30 °) angle and is divided into two segmental bronchi - lateral and medial. Mid-right bronchus is surrounded by a large number of lymph nodes, which by compression, penetration and perforation can lead to clogging of its lumen. Especially often this is observed in childhood, when the supporting elastic tissue is poorly developed and the bronchial wall is supple, and the lymph nodes are especially developed. In addition, it was proved that the lymph nodes of the middle lobe collect lymph from not only the middle, but also from the lower and the third segment of the upper lobe. Therefore, the cause of the mid-annual syndrome was considered to be lymph node involvement in both nonspecific and tuberculous etiology.

It has also been shown that the median part is under the influence of a mixed rib-diaphragmatic type of respiration and shifts forward with quiet breathing. However, the amplitude of the respiratory movements of the ribs on this segment of the chest is limited. As for the diaphragm, the respiratory movements of its anterior, mostly tendinous areas, to which the median part adjoins, are not very significant and have weaker traction in comparison with the posterior regions. According to AAnthony et al. (1962), the mobility and stretching of the lung segment is the greater, the further it is located from the root. The average proportion is located in close proximity to the lung root and from these positions is in unfavorable conditions. Thus, the conditions for its expansion upon exhalation are inadequate in comparison with other lobes of the lung. E. Stutz and H. Vieten (1955) have indicated an unsatisfactory inspiratory suction of the middle lobe and, in connection with this, they note a difficulty in the outflow of secretion, which facilitates the rapid transition of acute mild to moderate chronic pneumonia. This also explains the low ability to cough up the average proportion of foreign bodies that have fallen into the bronchi. From this point of view, one can explain the propensity to the chronic course of any pathological process in the middle lobe.

An important step forward in the study of median lesions was made by the English surgeon and anatomist R. Brok (1946). In 1948, E. Graham, T. Burford and J. Mayer introduced the term "mid-gender syndrome," meaning wrinkling and atelectasis of the middle lobe of the right lung due to bronchoconstriction of post-tuberculosis etiology, caused by anatomical and topographic features of the middle lobe. In the atelectasis zone, compensatory fluid suppression occurs, segmental and lobar bronchi are filled with mucus, blood filling and expansion of the arteries, veins and capillaries increase. There is a picture of the so-called "obstructive pulmonitis". After 3-6 months, the collagen fibers around the vessels become denser, the connective tissue proliferates, and the atelectasis (carnification) phase begins. Atelectasis is the basis for the development of a secondary inflammatory process. In cases where the cause that caused atelectasis, acts for a short time, it is possible to reactivate the affected area of the lung.

Mid-right bronchus often serves as a site for the localization of benign tumors, which can enclose the bronchus. The cause of atelectasis of the middle lobe can also be foreign bodies.

The intermediate bronchus after the departure from it of the mid-lobe passes into the lower lobe bronchus. Its trunk is very short and difficult to determine. From the posterior surface of the lower lobe bronchus, the upper segmental bronchus, also called the Nelson's bronchus, flows laterally and posteriorly, and the VI segment - the top of Fauvler. The diameter of its lumen is 10 mm. It is divided into three subsegmental bronchi. After departing from the lower lobe, the latter receives the name of the lower zonal and is divided into four basal bronchi.

The mouths of the left upper and lower lobar bronchi are almost at the same level and are separated by a distinct spur. The left upper lobe bronchus departs from the anterior surface of the main bronchus and is directed upwards and outwards. It is divided into four segmental bronchi. The left lower lobe bronchus departs from the posterior surface of the main bronchus and is divided into four segmental bronchi.

To facilitate orientation in the tracheobronchial tree during bronchoconstriction, especially for beginning endoscopists, we developed the following scheme for examining the bronchi.

At the back of the patient - 12 hours, before him - 6 hours, the endoscopist is to the left of the patient at 3 o'clock.

First, examine the right upper lobe bronchus, the mouth of which is determined at 9 o'clock, and its segmental and subsegmental branches. The mouth of the mid-lobar bronchus is at 6 o'clock, while the mouth of the BIV is outside, and the mouth of the BV is inside. A little lower, in front of the mouth of the mid-lobe bronchus at 12 hours, is the mouth of the posterior zona bronchus (BVI), which is divided into two or three subsegmental bronchi. On the medial wall of the lower zonal bronchus is the mouth of the mediobasal bronchus (BVII), and the anterior anterior basal (BVIII), lateral-basal (BIX) and posterior basal (BX) bronchi are located anteriorly backward in a clockwise direction.

On the left, the instrument is held to the spacing of the spine and, unlike the right half of the bronchial tree, the examination begins with the basal bronchi, which are located anteriorly backwards in a counter-clockwise direction. A little above the basal bronchi at 2 hours is determined by the mouth of the posterior zonal bronchus. A little higher, practically on one line, starting from the medial wall towards the lateral, the mouth of segmental bronchus of the anterior zone and the mouth of the segmental bronchial tubes of the upper zone are visible, each of which is divided into two segmental bronchi.

When examining the bronchi, attention is drawn to the shape and size of their mouths, the shape and mobility of the spurs of all visible bronchi, the coloration of the bronchial mucosa, the changes in the cartilaginous rings and vascular pattern, the size of the mouths of the mucous glands, the nature and amount of secretion.

Interpretation of results

Tuberculosis of the trachea and major bronchi is diagnosed in no more than 10-12% of patients. Specific damage to the mucous membranes of the respiratory tract is more often detected in patients with primary, infiltrative and fibrous-cavernous pulmonary tuberculosis. Frequent bronchial involvement with primary tuberculosis (14-15%) is associated with the special reactivity of patients and the proximity of the lesion (lymph nodes) to the bronchus wall. The frequency of detection of bronchial tuberculosis (11-12%) with an infiltrative process is due to the severity of changes in the lungs. The main bronchoscopic forms of tuberculosis of the trachea and bronchi are infiltrate, ulcer and lymphoblocchial fistula. Infiltrative tuberculosis of the trachea and bronchi is characterized by limited; infiltrates have irregular round or elongated shape and are localized in the mouths of the lobar and segmental bronchi.

Lymphobrochial fistulas are formed when necrosis foci are formed in the affected VGLU, which exert mechanical pressure on the bronchi. This causes a narrowing of the lumen or a local bulging of the bronchial wall. At the top of the bulging a hole is formed, from which caseous masses can be emitted independently or with pressure. The edges of the fistula are usually covered with granulation. Sometimes it is possible to find broncholites of various sizes and forms of rocky consistency, "born" from the fistula.

The outcome of tuberculosis of the trachea or bronchus depends on the form of the disease. Infiltrates in most cases are cured without pronounced residual changes, superficial ulcers are scarred without stenosis or with stenosis of I degree. Fistiform forms of tuberculosis of the bronchi lead in the majority of patients to the development of coarse fibrous scars, including cicatricial stenoses.

Nonspecific endobronchitis is the leading concomitant pathology in patients with tuberculosis. Nonspecific inflammation in the large bronchi proceeds with the involvement of only the superficial layers of the bronchial wall, therefore it is usually called endobronchitis. The depth of lesion of small bronchi is greater than that of large ones.

The frequency of detection of nonspecific endobronchitis ranges from 14-20% to 65-70%. In newly diagnosed patients, nonspecific endobronchitis is most common in fibrous-cavernous (61%) and disseminated (57%) pulmonary tuberculosis.

Nonspecific endobronchitis is classified by:

• form of the process: catarrhal, purulent, hypertrophic, atrophic:
• intensity of inflammation: I, II degree:
• localization of the process and its prevalence: one-sided, two-sided, diffuse, limited, drainage.

The form of nonspecific endobronchitis is largely due to the form of pulmonary tuberculosis. Purulent endobronchitis is more often diagnosed with fibro-cavernous tuberculosis (23%), less often - with disseminated (14%) and infiltrative (8%) forms. More often in patients with all forms of pulmonary tuberculosis there are catarrhal endobronchitis of various lengths. Hypertrophic and atrophic nonspecific endobronchitis with pulmonary tuberculosis is rarely detected. For catarrhal endobronchitis is characterized by hyperemia of the mucous membrane of different degrees of severity, the bronchial secretion has a mucous character. Purulent endobronchitis is characterized by hyperemia, thickening of the mucous membrane and its longitudinal folding, the bronchial secretion has a purulent character. At an atrophic nonspecific endobronchitis, the mucosa is thinned, and interchilar gaps are clearly visible.

Post-tubercular cicatricial (fibrous) stenosis of the bronchi is revealed in 2-3% of patients. Significantly less often the outcome of bronchial tuberculosis, especially infiltrative, is the formation of a pigmented spot with a tender scar without stenosis. Posttuberculous cicatricial stenoses of the bronchi are classified:

• by degree of constriction: I degree - bronchus lumen closed by 1/3, II degree - bronchus lumen closed by 2/4 III degree - there is only a narrow slit or small opening:
• in shape: concentric (regular, rounded), eccentric (irregularly shaped, slit-shaped, oval);
• by the degree of compensation: compensated, subcompensated, decompensated.

Endoscopic picture in cicatricial stenoses of the bronchi is characterized by an eccentric arrangement of the bronchus lumen with proliferation of dense whitish tissue. Cicatricial stenosis of the bronchi is formed either by self-healing of the active specific process in the bronchial ways, or at its late detection, or in the prevalent character of tuberculosis lesion.

[1], [2], [3], [4], [5], [6], [7],