Bronchoscopy technique

Rigid bronchoscopy uses metal tubes equipped with artificial lung ventilation (ALV) and supplied with telescopes with different viewing angles, biopsy forceps, needles and catheters. Fiberoptic bronchoscopy is performed using a flexible bronchoscope with an optical system and a biopsy channel for instruments. The capabilities of fiberoptic bronchoscopy allow one to see all IV-order bronchi, 86% of V-order bronchi and 56% of VI-order bronchi.

Clinical situations in which preference is given to rigid bronchoscopy:

• acute respiratory failure due to bronchial obstruction;
• childhood;
• patient intolerance to local anesthetics;
• the patient has epilepsy and other chronic diseases of the central nervous system;
• inability to establish contact with the patient (deaf and dumb patients);
• increased nervous excitability.

The examination should begin with the bronchi of a healthy (or less affected) lung to reduce the likelihood of infection spreading. It is better to insert a fiberoptic bronchoscope into the tracheobronchial tree through the nasal passage (the risk of biting the fiberscope with teeth is eliminated); if transnasal intubation is impossible (deviation of the nasal septum, narrow nasal passage), the fiberoptic bronchoscope is inserted through the mouth using a special mouthpiece.

Thirty minutes before the start of local anesthesia, the patient is given 1 ml of 0.1% atropine sulfate solution subcutaneously (to remove the vagal effect). Patients with glaucoma are examined without preliminary atropinization. Patients with a tendency to bronchospasm are given 10 ml of 2.4% euphyllin solution per 10 ml of physiological solution intravenously 15 minutes before the examination, and immediately before the start of local anesthesia, the patient is given 1-2 doses of the aerosol used by the patient to inhale.

For anesthesia of the upper respiratory tract and larynx, a 10% lidocaine solution is applied to the mucous membrane using a spray. With transnasal insertion of the endoscope, anesthesia of the lower nasal passage is performed using the application method. Anesthesia of the vocal folds is performed under visual control through a catheter inserted through the biopsy channel during fibrolaryngoscopy. Anesthesia of the carina, spurs of the lobar and segmental bronchi is performed with a 2% lidocaine solution in an amount of 6-8 ml. The anesthetic is administered under visual control through a long catheter.

Bronchofibroscopy can be performed with the patient in two positions - sitting or lying down. If the patient has respiratory failure, but there is no risk of complications, it is preferable to perform the examination in a sitting position. Therapeutic bronchoscopies are also conveniently performed with the patient in a sitting position, since it is easier for the patient to cough up the sanitizing solution. The endoscope can be inserted transnasally and transorally.

The first anatomical landmark (when performing bronchoscopy with a flexible endoscope) is the epiglottis, which covers the entrance to the larynx. The epiglottis is not anesthetized. The end of the endoscope is used to press the epiglottis to the root of the tongue and examine the larynx. The false vocal folds look like two horizontally located, motionless, pink folds.

The second anatomical landmark is the true vocal folds, located under the false ones. They look like shiny whitish ribbons. At their posterior edge are elevations formed by the arytenoid cartilages. The space limited by the inner edge of the true vocal folds and the inner surface of the arytenoid cartilages is called the glottis.

Before passing the device below the vocal folds, it is necessary to make sure that the anesthesia is sufficient. To do this, touch the vocal folds with the end of the catheter. Their immobility indicates adequate anesthesia.

The third anatomical landmark is the tracheal bifurcation carina - the carina. In the tracheal bifurcation carina, a crest, anterior and posterior triangle are distinguished. The carina can be sharp, like a razor blade, as well as flattened, wide, S-shaped, saddle-shaped. Special attention should be paid to the carina, since various pathological processes are often localized here.

The mucous membrane in the area of the anterior and posterior triangles is light red, with the mucous membrane of the latter being somewhat darker. The dimensions of the anterior triangle are larger than those of the posterior triangle.

The examination begins on the side of the bronchial tree where the changes are less pronounced (which is determined in advance by X-rays). If the changes are expressed equally on both sides, then the examination begins on any half of the bronchial tree.

The right upper lobe bronchus starts from the outer surface of the main bronchus and goes up almost at a right angle. The diameter of its lumen is 8-10 mm. It is divided into three segmental bronchi.

The intermediate bronchus begins at the lower edge of the mouth of the upper lobe bronchus and ends near the mouth of the middle lobe bronchus. Its length is 2-3 cm, the diameter of the lumen is 10-11 mm.

The relatively high frequency of isolated lesions of the middle lobe both in childhood and in the elderly has long attracted the attention of researchers and forced them to look for the cause of such lesions.

Having carefully studied the anatomy of the tracheobronchial tree, G.Kopstein (1933) and R.Brok (1946) came to the conclusion that the middle lobe bronchus, like the middle lobe, has a number of anatomical and functional features that gave E.Zdansky (1946) the right to consider the middle lobe bronchus the "place of least resistance". It turned out that the middle lobe bronchus is the narrowest and longest of all the lobar bronchi. Its diameter ranges 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 middle lobe bronchus departs from the anterior wall of the intermediate bronchus at an acute (30°) angle and divides into two segmental bronchi - lateral and medial. The middle lobe bronchus is surrounded by a large number of lymph nodes, which can lead to blockage of its lumen by compression, penetration and perforation. This is especially often observed in childhood, when the supporting elastic tissue is poorly developed and the bronchial wall is flexible, and the lymph nodes are especially well developed. In addition, it has been proven that the lymph nodes of the middle lobe collect lymph not only from the middle, but also from the lower and from the third segment of the upper lobe. Therefore, the cause of the middle lobe syndrome began to be considered to be damage to the lymph nodes of both a non-specific nature and tuberculous etiology.

It has also been proven that the middle lobe is influenced by the mixed costal-diaphragmatic type of breathing and shifts forward during quiet breathing. However, the amplitude of the respiratory movements of the ribs in this area of the chest is limited. As for the diaphragm, the respiratory movements of its anterior, mainly tendinous areas, to which the middle lobe is adjacent, are very insignificant and have a weaker pull compared to the posterior areas. According to A. Anthony et al. (1962), the mobility and stretching of a lung area is greater the further it is located from the root. The middle lobe is located in close proximity to the root of the lung and from these positions is in unfavorable conditions. Thus, the conditions for its expansion during exhalation are insufficient compared to other lobes of the lung. E. Stutz and H. Vieten (1955) pointed out the unsatisfactory inspiratory suction of the middle lobe and in this connection noted the difficulty of secretion outflow, which contributes to the rapid transition of acute middle lobe pneumonia to chronic. This also explains the low ability to cough up foreign bodies that have entered the bronchi of the middle lobe. From this point of view, one can explain the tendency for any pathological process in the middle lobe to become chronic.

An important step forward in the study of middle lobe lesions was made by the English surgeon and anatomist R. Brok (1946). In 1948, E. Graham, T. Burford and J. Mayer introduced the term "middle lobe syndrome", meaning wrinkling and atelectasis of the middle lobe of the right lung due to bronchostenosis of post-tuberculous etiology, caused by the anatomical and topographic features of the middle lobe. In the area of atelectasis, compensatory transudation of fluid occurs, segmental and lobar bronchi are filled with mucus, blood filling and dilation of arteries, veins and capillaries increase. A picture of the so-called "obstructive pulmonitis" occurs. After 3-6 months, collagen fibers around the vessels become denser, connective tissue grows, and the induration (carnification) phase of atelectasis begins. Atelectasis serves as the basis for the development of a secondary inflammatory process. In cases where the cause of atelectasis is short-lived, re-aeration of the affected area of the lung is possible.

The middle lobe bronchus is often the site of benign tumors that can obstruct the bronchus. Foreign bodies can also be the cause of middle lobe atelectasis.

The intermediate bronchus, after the middle lobe bronchus branches off from it, passes into the lower lobe bronchus. Its trunk is very short and is difficult to determine. From the posterior surface of the lower lobe bronchus, the upper segmental bronchus, also called Nelson's bronchus, branches off downwards, backwards and laterally, and the sixth segment is called Fowler's apex. The diameter of its lumen is 10 mm. It is divided into three subsegmental bronchi. After branching off from the lower lobe, the latter is called the lower zonal and is divided into four basal bronchi.

The openings of the left upper and lower lobe bronchi are located practically at the same level and are separated by a clearly defined spur. The left upper lobe bronchus departs from the anterior surface of the main bronchus and is directed upward and outward. It divides into four segmental bronchi. The left lower lobe bronchus departs from the posterior surface of the main bronchus and divides into four segmental bronchi.

To facilitate orientation in the tracheobronchial tree during bronchofibroscopy, especially for novice endoscopists, we have developed the following scheme for examining the bronchi.

Behind the patient is 12 o'clock, in front of him is 6 o'clock, the endoscopist is to the left of the patient at 3 o'clock.

First, the right upper lobe bronchus is examined, the opening of which is located at 9 o'clock, and its segmental and subsegmental branches. The opening of the middle lobe bronchus is located at 6 o'clock, with the opening of BIV on the outside and the opening of BV on the inside. Slightly lower, opposite the opening of the middle lobe bronchus at 12 o'clock, the opening of the posterior zonal bronchus (BVI) is determined, which divides into two or three subsegmental bronchi. On the medial wall of the lower zonal bronchus is the opening of the mediobasal bronchus (BVII), and the openings of the anterior basal (BVIII), lateral basal (BIX) and posterobasal (BX) bronchi are located from front to back clockwise.

On the left, the device is carried to the interlobar spur and, unlike the right half of the bronchial tree, the examination begins with the basal bronchi, which are located from front to back counterclockwise. A little higher than the basal bronchi at 2 o'clock, the mouth of the posterior zonal bronchus is determined. A little higher, practically on the same line, starting from the medial wall in the direction of the lateral, the mouths of the segmental bronchi of the anterior zone and the mouths of the segmental bronchi of the upper zone are visible, each of which is divided into two segmental bronchi.

When examining the bronchi, attention is paid to the shape and size of their mouths, the shape and mobility of the spurs of all visible bronchi, the color of the mucous membrane of the bronchi, 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 large bronchi is diagnosed in no more than 10-12% of patients. Specific lesions of the mucous membranes of the respiratory tract are more often detected in patients with primary, infiltrative and fibrous-cavernous pulmonary tuberculosis. Frequent bronchial lesions in primary tuberculosis (14-15%) are associated with the special reactivity of patients and the proximity of the lesion (lymph nodes) to the bronchial wall. The frequency of detection of bronchial tuberculosis (11-12%) in the 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 lymphobronchial fistula. Infiltrative tuberculosis of the trachea and bronchi is characterized by limitation; The infiltrates have an irregular round or elongated shape and are localized in the mouths of the lobar and segmental bronchi.

Lymphobronchial fistulas are formed when foci of necrosis are formed in the affected bronchial lymph nodes, 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 bulge, an opening is formed from which caseous masses can be released independently or under pressure. The edges of the fistula are usually covered with granulation. Sometimes, one can find broncholiths of various sizes and shapes of stony consistency, “born” from the fistula opening.

The outcome of tracheal or bronchial tuberculosis depends on the form of the disease. Infiltrates in most cases are cured without significant residual changes, superficial ulcers are scarred without stenosis or with stenosis of the first degree. Fistulous forms of bronchial tuberculosis lead to the development of coarse fibrous scars in most patients, including cicatricial stenosis.

Non-specific endobronchitis is the leading concomitant pathology in patients with tuberculosis. Non-specific inflammation in large bronchi occurs with the involvement of only the superficial layers of the bronchial wall, so it is commonly called endobronchitis. The depth of damage to small bronchi is greater than to large ones.

The incidence of non-specific endobronchitis ranges from 14-20% to 65-70%. In newly diagnosed patients, non-specific endobronchitis is most often found in fibro-cavernous (61%) and disseminated (57%) pulmonary tuberculosis.

Non-specific endobronchitis is classified according to:

• form of the process: catarrhal, purulent, hypertrophic, atrophic:
• Intensity of inflammation: I, II degree:
• localization of the process and its prevalence: unilateral, bilateral, diffuse, limited, drainage.

The form of nonspecific endobronchitis is largely determined by the form of pulmonary tuberculosis. Purulent endobronchitis is more often diagnosed in fibrous-cavernous tuberculosis (23%), less often in disseminated (14%) and infiltrative (8%) forms. Catarrhal endobronchitis of varying extent is more common in patients with all forms of pulmonary tuberculosis. Hypertrophic and atrophic nonspecific endobronchitis is rarely detected in pulmonary tuberculosis. Catarrhal endobronchitis is characterized by hyperemia of the mucous membrane of varying severity, bronchial secretions are mucous. Purulent endobronchitis is characterized by hyperemia, thickening of the mucous membrane and its longitudinal folding, bronchial secretions are purulent. In atrophic nonspecific endobronchitis, the mucous membrane is thinned and the intercartilaginous spaces are clearly visible.

Post-tuberculous cicatricial (fibrous) stenosis of the bronchi is detected in 2-3% of patients. Much less often, the outcome of bronchial tuberculosis, especially infiltrative, is the formation of a pigment spot with a delicate scar without stenosis. Post-tuberculous cicatricial stenosis of the bronchi is classified:

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

The endoscopic picture of cicatricial bronchial stenosis is characterized by an eccentric location of the bronchial lumen with the growth of dense whitish tissue. Cicatricial bronchial stenosis is formed either with spontaneous healing of an active specific process in the bronchial passages, or with its late detection, or with a widespread nature of tuberculous lesions.

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