Atlas of Flexible Bronchoscopy

Johnny Pujols

Atlas of Flexible Bronchoscopy

Johnny Pujols

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Abstract

I would like to dedicate this book to my family for all their support and encouragement despite the endless evenings and weekends spent on this book. A special thanks to my wife, Mala who created some of the initial anatomical drawing for this book.

Figures (631)

Fig. |.1 Fibreoptic bronchoscope with eyepiece. Fig. |.2 Video bronchoscope. The bronchoscope is essentially a flexible tube consisting of fibreoptic bundles, channels for instruments and a number of wires for manipulating the distal end. The bundles of optical fibres carry light to the distal end in order to illuminate the airways, and further bundles transmit the image back to the eyepiece (Fig. |.1). The modern video bronchoscopes have a charge-coupled device (CCD) chip at the distal end which captures the image and is subsequently transmitted to the monitor (Figs |.2—1.4). The resolution of the image is excellent and continues to improve, with some scopes providing very high-definition images with digital magnification options. There are also hybrid devices for special circumstances, which use the fibreoptic bundle to transmit the image back towards the head of the bronchoscope. In this case, the CCD is located at the head of the bronchoscope, which then transmits the image to the monitor The hybrid setup allows the space of the chip at the distal end to be utilized for

Fig. |.4 Video bronchoscope with connections to image processor and light source.

Fig. |.5 Distal portion of a number of bronchoscopes showing the variety of instruments available with differing external diameters and functional characteristics.

Fig. |.7 Distal tip of the linear array ultrasound bronchoscope. Fig. 1.6 Two bronchoscopes with different sizes of the charge-coupled device video chip, and instrument channel.

The main indications for flexible bronchoscopy are listed in Box |.1. Suspected lung canceris the major indication for bronchoscopy followed by the assessment of pulmonary infiltrates for microbiological sampling. Traditionally bronchoscopy was conducted for diagnostic purposes but the role of therapeutic bronchoscopy is increasing with the development of new endoscopic treatments for respiratory diseases.

Fig. |.8 Room setup with the semi-recumbent patient being approached from the front. Fig. |.9 Bronchoscopic image obtained with the semi- recumbent patient approached from the front.

Fig. |.1 1 Bronchoscopic image obtained with the supine patient approached from the back. Fig. |.10 Room setup with patient being approached from the back in a supine position. The posterior approach with the patient lying flat is also widely used (Fig. 1.10). This approach is also required in a number of procedures such as endobronchial ultrasounc and also the superdimension procedure. With this approach the image obtained is such that the anterior aspect is at the top, the posterior aspect Is the inferior aspect of the image and the left side of the patient is the left sided image and the right side of the patient is the right side of the image (Fig .!.1 1).

A variety of biopsy forceps, from cupped to serrated, are available for obtaining tissue samples. The forceps are inserted through the instrument channel of the bronchoscope. The forceps are just opened, apposed to the area of abnormality and then closed in order to obtain biopsies under direct vision (Fig. 1.12). Several biopsies shou d be obtained to ensure that adequate tissue has been obtained for diagnosis. Crush artefact is the main limiting factor that affects the interpretation of the tissue obtained. A higher yield is obtained from endobronchial biopsies, with an overall sensitivity of 74 ( 48-97) per cent. However, where an exophytic tumour is visible, the diagnostic should be at least 90 per cent. The technique is generally very safe and the range yield main complication is that of bleeding, particularly when vascular lesions are sampled. The bleeding is rarely significant and can usually be controlled with conservative measures. Fig. |.12b Proximal view of the biopsy forceps showing the handle that is used to open and shut them. Fig. |.|2a Distal view of the biopsy forceps in an open and closed position.

Bronchial brushings can be obtained by using the cytology brush to scrape some cells from the surface of any abnormal areas. The brush consists of fine bristles similar to a bottle brush with a protective plastic sheath. The instrument is passed through the instrument channel of the bronchoscope towards the abnormal area. The brush portion is then protruded out of the plastic sheath and brushed against the abnormal mucosa. The brush is then withdrawn back into the plastic sheath (Fig. |.13).The cells are then either smeared on to a slide or rinsed into saline according to local preferences. In some centres, the brushings are rinsed into cytolyte solution for processing. The yield from bronchial brushings is 59 (range 23-93) per cent; the main complication is minor bleeding but there is a risk of a pneumothorax where a brush is advanced blindly beyond a subsegmental bronchus.

The bronchopulmonary segments are numbered according to the relative position of the origin of segmental bronchi. The bronchial segment that originates at the highest position is labelled | (apical segment of the upper lobe); the next bronchial segment that originates is labelled 2, and so on. The bronchial segments are named using Arabic numerals and pulmonary segments with Roman numerals (Figs 2.1a and 2.2a). The bronchial subsegments are subsequently labelled as a, b, c in sequence. In the left lung the labelling is in a clockwise direction, whereas in the right lung the subsegments are labelled in an anticlockwise direction (Figs 2.1b,c and 2.2b,c).

Fig. 2.2e Highlighted area would be denoted as follows: RC RB!—RB2. Fig. 2.2d Highlighted area would be denoted as follows: RC RB!—RB3.

Fig. 2.2j Highlighted area would be denoted as follows: RB3 to RC RB2—RB3

Fig. 2.2g Highlighted area would be_ it denoted as follows: RC RBI—RB2—RB3._ « Fig. 2.2h Highlighted area would be denoted as follows: RB! to RC RB!—RB3

Fig. 2.2f Highlighted area would be denoted as follows: RC RB2—RB3.

Fig. 2.3a Oblique and horizontal fissures in the right lung: lateral or costal view. Fig. 2.3b Oblique and horizontal fissures in the right lung: medial or hilar view. The right lung consists of three lobes separated by the oblique and horizontal fissures The oblique fissure separates the upper and middle lobes from the lower lobes. The horizontal fissure separates the upper and the middle lobes (Fig. 2.3).

Fig. 2.4a Apical segments of the lung. I, apical; Il, posterior; III, anterior pulmonary segments of the right upper lobe: lateral or costal view. Fig. 2.4c Right bronchopulmonary tree showing the apical segments of the lung. Right upper lobe: RB1, apical; RB2, posterior; RB3, anterior bronchial segment.

The apical segment (RB!) of the right upper lobe is the most superior bronchus from the upper lobe branches. Its branches supply the apical portion of the lung (I). The posterior segment of the right upper lobe is lower (RB2) and branches to form the posteroinferior part of the upper lobe (Il). The anterior segment of the right upper lobe is slightly lower (RB3) and branches to form the anterior inferior portion of the upper lobe (Il).

Fig. 2.5b Segments of the right middle lobe. V, medial pulmonary segment. Medial or hilar view.

Fig. 2.5a Segments of the right middle lobe. IV, lateral; V, medial pulmonary segment. Lateral or costal view.

Fig. 2.6b Basal segments of the right lung. VI, superior; VII, medial; VIII, anterior; |X, lateral; X, posterior pulmonary segments of the right lower lobe. Medial or hilar view.

Fig. 2.6a Basal segments of the right lung.VI, superior; VIII, anterior; |X, lateral; X, posterior pulmonary segments of the right lower lobe. Lateral or costal view.

Fig. 2.7b Oblique fissure of the left lung: medial or hilar view. Fig. 2.7a Oblique fissure of the left lung: lateral or costal view. The left lung consists of two lobes which are separated by the oblique fissure (Fig. 2.7). The upper lobe comprises five segments and the lower lobe has four segments.

Fig. 2.9b Basal segments of the lower lobe of the left lung. VI, superior; VIII, anterior; IX, lateral; X, posterior pulmonary segments. Medial or hilar view.

The lower lobe bronchus descends in a posterolateral direction. The apical segmental bronchus LB6 arises from the posterior aspect and forms the apical basal lobe (VI). It then gives off an anterior segmental bronchus (LB7 + 8) from its anterior medial aspect to form the anterior basal segment (VIII). The next is the lateral segmental bronchus (LB9) and finally the airway forms the posterior segment of bronchus LB10.The latter two form the lateral aspects of the inferior lobe (IX) and the posteroinferior part of the lower lobe (X).

The lateral and medial views of the right and left lung, as well as the bronchopulmonary tree, demonstrating all the segments are shown in Figures 2.10 and 2.1 |.

Fig. 2.10b Segments of the right lung. Right upper lobe: I, apical; Il, posterior; Ill, anterior pulmonary segments. Right middle lobe: IV, lateral; V, medial pulmonary segment. Right lower lobe: VI, superior; VII, medial; VIII, anterior; IX, lateral; X, posterior pulmonary segments. Medial or hilar view.

Fig. 2.1 |b Segments of the left lung. Left upper lobe: | + Il, apicoposterior; Ill, anterior; lV, superior lingular;V, inferior lingular pulmonary segments. Left lower lobe:VI, superior; VIII, anterior; IX, lateral; X, posterior pulmonary segments. Medial or hilar view.

Fig. 2.1 la Segments of the left lung. Left upper lobe: | + Il, apicoposterior; Ill, anterior ; IV, superior lingular;V, inferio lingular pulmonary segments. Left lower lobe:VI, superior; VIII, anterior; |X, lateral; X, posterior pulmonary segments. Lateral or costal view.

Fig. 2.12a Cross-sectional CT scans of the thorax at the level of the aortic arch. Correlation of the radiographic changes on a computed tomography (CT) scan to a particular bronchopulmonary segment is important and improves the yield from procedures such as bronchial lavage and transbronchial lung biopsy. The images in Figures 2.12—2.17 are to guide the bronchoscopist as to which areas of a CT scan relate to the various bronchopulmonary segments. | also recommend reviewing the whole CT scan carefully and following the airways sequentially to determine the exact segment involved in a particular patient.

Fig. 2.!2¢ Bronchial tree showing the segments correlating with the CT scan.

Fig. 2. | 4a Cross-sectional CT scans of the thorax at the level of the bronchus intermedius.

Fig. 2.15a Cross-sectional CT scans of the thorax at the level of the origin of the right middle lobe.

Fig. 2.15c Bronchial tree showing the segments correlating with the CT scan.

Fig. 2.1 6a Cross-sectional CT scans of the thorax at the level of the origin of the lower lobe bronchial segments.

Fig. 2.16c Bronchial tree showing the segments correlating with the CT scan.

Fig. 2.1 7a Cross-sectional CT scans of the thorax at the level of the basal pulmonary segments.

Fig. 2.1 7c Bronchial tree showing the segments correlating with the CT scan.

Fig. 3.1b Coronal section CT scan of the vocal cords, which are apposed.

The larynx is composed of a series of cartilages, ligaments and fibrous membranes At bronchoscopy the epiglottis is the more proximal structure. It is a broad leaf- like structure. The sides are attached by the arytenoid cartilages. The cuneiform and corniculate can be seen at the end of the arytenoid cartilage. The cuneiform cartilage is more anterior and superior to the corniculate cartilage. The vocal folds consist of the false cords or vestibular folds and the true vocal folds. They stretch back from the thyroid angle to the vocal processes of the arytenoids. The vocal folds are involved in the production of sound.

Fig. 3.1 Endoscopic view of the epiglottis and vocal cords. Fig. 3.1d Endoscopic view of the vocal cords.

Fig. 3.1f Coronal section CT scan of the vocal cords, which are open.

Fig. 3. le Cross-sectional CT scan at the superior aspect of the thorax at the level of the vocal cords, which are open.

Fig. 3.2¢ Endoscopic view of the trachea from the level of | Fig. 3.2d Endoscopic view of the upper trachea. the subglottis. Fig. 3.2a Cross-sectional CT scan of the thorax at the mid-tracheal level. Fig. 3.2b Coronal sectional CT scan of the thorax through the trachea.

Fig. 3.2j Cross-sectional CT scan showing the tracheal bronchus arising at the distal trachea just above the carina.

Fig. 3.4c Endoscopic view of the right main bronchus visible below the carina. Fig. 3.4d Endoscopic view of the right main bronchus with more of the right upper lobe visible.

Fig. 3.5f Bipartite division of the right upper lobe with division in the vertical axis. Fig. 3.5d Another example of the tripartite right upper lobe arrangement.

Fig. 3.5e Bipartite division of the right upper lobe with division at the horizontal axis. Fig. 3.5c¢ Endoscopic view of the right upper lobe from above with the patient upright being approached from the front.

Fig. 3.5i Four divisions of the right upper lobe.

Fig. 3.5h Bipartite division of the right upper lobe with apical and posterior segments arising together (RB| + 2) and a separate posterior segment (RB3).

Fig. 3.5g Bipartite division of the right upper lobe with apical and anterior segments (RBI + 3 arising together) and a separate posterior segment (RB2).

Fig. 3.6b Coronal sectional CT scan of the thorax through the bronchial tree showing the bronchus intermedius.

Fig. 3.6d Endoscopic view of the distal aspect of the bronchus intermedius.

The bronchus intermedius originates from the right main bronchus and extends frorr the origin of the right upper lobe to the right middle lobe. It is approximately 20 mr long and has a diameter of about 10 mm.The right middle lobe, the apical segment of the lower lobe and the basal segments are visible at the distal end of bronchus intermedius

Fig. 3.7a Cross-sectional CT scan of the thorax at the level Fig. 3 of the right middle lobe. level o evel Fig.3.7b Coronal sectional CT scan of the thorax at the level of the right middle lobe.

Fig. 3.7e Endoscopic view of the right middle lobe subsegments viewed from the origin of the right main bronchus. Fig. 3.7f Close-up endoscopic view of the right middle lobe subsegments. "ig. 3.7d Endoscopic view of right middle lobe.

A bipartite division is occasionally observed where the anterior and lateral segments arise together proximally to the posterior basal segment from a separate branch The position and size of the apical basal segment frequently influence the pattern of branching of the basal segments. For example, in some individuals there is a larger apical bronchus and, as a result, the medial through to posterior segment arises in a tripartite from the same level.

Fig. 3.8l« Cross-sectional CT scan at the level of the basal segments of the right lower lobe. Fig. 3.81 Coronal CT scan showing the basal segments of the right lower lobe.

right lower lobe _ lateral segment right posterior segment right pulmonary artery lower lobe (RB9) lower lobe (RB1I0)

Fig. 3.80 Endoscopic view of the basal segments of the right lower lobe showing a normal variant of a subapical segment.

The left main bronchus is approximately 4 cm long and descends in a gentle lateral curve. At its terminal portion it divides into two main branches: the left lower lobe and the left upper lobe bronchus. There is an obliquely placed sharp carina separating the two bronchi. The upper lobe is joined at a 60° angle to the left main bronchus Occasionally the upper lobe bronchus joins the left main bronchus at an acute angle.

Fig. 3.9a Cross-sectional CT scan of the thorax at the level of the left main bronchus.

Fig. 3.9b Coronal sectional CT scan of the thorax at the level of the left main bronchus.

Fig. 3.9g Endoscopic view of the left secondary carina with both the upper and lower lobes visible.

Fig. 3.9h Endoscopic view of the left lower ana upper lobes, with the apical segment of the left upper lobe arising from the left main bronchus.

Fig. 3.10b Coronal sectional CT scan of the thorax at the level of the left upper lobe bronchus.

Fig. 3.1 0c Endoscopic view of the left superior bronchus from above the left main bronchial carina.

Fig. 3.10a Cross-sectional CT scan of the thorax at the level of the left upper lobe bronchus.

Fig. 3.1 0f Endoscopic view of the apicoposterior segment of the left upper lobe.

Fig. 3.1 1d Endoscopic view of the lingular segments. Fig. 3.1 1c Bronchoscopic view of the lingula and anterior segment of the left upper lobe. Fig. 3.1 1b Coronal sectional CT scan of the thorax at the level of the lingular bronchus. Fig. 3.1 la Cross-sectional CT scan of the thorax at the level of the lingular bronchus.

The lingular bronchus arises from the left upper division bronchus. It divides into superior segmental and inferior segmental branches, which in turn divide into two subsegmental branches. In 25 per cent of individuals, the lingula bifurcates in a lateral and medial fashion. On rare occasions the orifice of the lingula is merged with a segment from the upper lobe.

Fig. 3.12a Cross-sectional CT scan of the thorax at the level of the left lower lobe bronchus. The left lower lobe bronchus descends posterolaterally and divides into four segments to form the left lower lobe. The apical segment arises about | cm after the origin of the left lower lobe bronchus.After a further |—2 cm the inferior bronchus divides into an anterior basal segmental bronchus and a posterolateral basal bronchus which further bifurcates into lateral basal and posterior basal segments. Endoscopically a prominent secondary carina appears to divide into the apical basal bronchus and the other inferior branches. The most common pattern of division of the left lower lobe is into three branches (tripartite) with separate anterior basal, lateral basal and posterior basal divisions. Fig. 3.12b Coronal sectional CT scan of the thorax at the level of the left lower lobe bronchus.

Fig. 3.12 Bronchoscopic view of the basal segments oj the left lower lobe.

Fig. 3.12e Bronchoscopic view of the apical segment of the left lower lobe.

Fig. 3.12c Bronchoscopic view of the left lower lobe viewed from just above the left secondary carina.

Fig. 3.12d Endoscopic view of the left lower lobe.

Fig. 3.1 2g Cross-sectional CT scan of the thorax showing _ the left lower lobe segments.

Fig. 3.12h Coronal sectional CT scan of the thorax showing the left lower lobe segments.

Fig. 4.1b Coronal section CT scan of the vocal cords, which are apposed. Fig. 4. a Cross-sectional CT scan at the superior aspect of the thorax at the level of the vocal cords, which are apposed.

Fig. 4.1 f Coronal section CT scan of the vocal cords, which are open. cords. Fig. 4.1d Endoscopic view of the vocal cords

Fig. 4. |e Cross-sectional CT scan at the superior aspect of the thorax at the level of the vocal cords, which are open.

The trachea is a horseshoe- or D-shaped structure which extends from the cricoid cartilage to the carina. The anterior aspect is composed of |6—-20 incomplete cartilage rings with a flat fibromuscular posterior component. There is also a longitudinal band of connective tissue which runs down the posterior end of the cartilage. At bronchoscopy the cartilage bands on the anterior surface appear as ridges and the posterior wall appears to bulge into the trachea. The posterior bulge is accentuated in expiration. Fig. 4.2b Coronal sectional CT scan of the thorax through the trachea. Fig. 4.2a Cross-sectional CT scan of the thorax at the mid-tracheal level.

Fig. 4.1 g Cross-sectional CT scan at the superior aspect of the thorax at the level of the vocal cords.

Fig. 4.1h Coronal section CT of the vocal cords, which are apposed.

Fig. 4.2c Endoscopic view of the trachea from the level of | Fig. 4.2d Endoscopic view of the upper trachea. the subglottis.

posterior segment of the right upper lobe

Fig. 4.3d Close-up endoscopic view of the carina. Fig. 4.3b Coronal sectional CT scan of the thorax through the trachea. Fig. 4.3a Cross-sectional CT scan of the thorax at the level of the carina.

Fig. 4.4b Coronal sectional CT scan of the thorax showing the right main bronchus. Fig. 4.4a Cross-sectional CT scan of the thorax at the Fi carina, showing the right main lobe. sh The right main bronchus extends from the carina to the origin of the right upper lobe. It then forms the bronchus intermedius. The right main bronchus has a steeper decline from the trachea and hence, in the upright position, foreign bodies tend to fall into the right main bronchus. It is slightly larger in diameter than the left main bronchus, measuring between |0 and |2 mm in external diameter The inferior lip of the upper lobe bronchus is easily visible at the distal end of the right main bronchus. A rare variation is the origin of an airway leading to the upper lobe. This is classified as a pre- eparterial tracheal bronchus. It may be either a supernumerary or a displaced airway. Where the airway is displaced, there is also a missing upper lobe branch. An accessory cardiac bronchus is a supernumerary bronchus arising from the medial aspect of the right main bronchus and leading towards the pericardium.

Fig. 4.4c Endoscopic view of the right main bronchus visible below the carina. Fig. 4.4d Endoscopic view of the right main bronchus which shows more of the right upper lobe origin.

Fig. 4.5a Cross-sectional CT scan of the thorax at the level of the right upper lobe origin.

Fig. 4.5c Endoscopic view of the right upper lobe.

Fig. 4.5h Bipartite division of the right upper lobe with apical and posterior segments arising together (RB! + 2) and a separate posterior segment (RB3). Fig. 4.5f Bipartite division of the right upper lobe with division in the vertical axis.

Fig. 4.5e Bipartite division of the right upper lobe with division at the horizontal axis.

Fig. 4.5g Bipartite division of the right upper lobe with apical and anterior segments (RB! + 3 arising together) and a separate posterior segment (RB2).

ig. 4.5i Four divisions of the right upper lobe.

Fig. 4.6c Endoscopic view of the bronchus intermedius.

The right middle lobe is a semi-lunar (D-shaped) bronchus at the anterior end of the bronchus intermedius. In approximately 70 per cent of cases, there are two distinct segments: lateral and medial. In 23 per cent of normal individuals the middle lobe bifurcates in a superior-inferior fashion, similar to that of the lingula. In up to 20 per cent of individuals there is a main lateral bronchus and a smaller medial bronchus which arises from the lateral segment. Occasionally the reverse is seen, with a larger medial segment and a smaller lateral segment arising from it.

Fig. 4.7e Endoscopic view of right middle lobe subsegments viewed from the origin of the right main bronchus. Fig. 4.7f Close-up endoscopic view of the right middle lobe subsegments. Fig. 4.7¢ Endoscopic view of the right middle and lower lobes. Fig. 4.7d Endoscopic view of the right middle lobe.

A bipartite division is occasionally observed where the anterior and lateral segment: arise together proximally to the posterior basal segment from a separate branct The position and size of the apical basal segment frequently influence the pattern o branching of the basal segments. For example, in some individuals there is a larger apica bronchus and, as a result, the medial through to posterior segment arises in a tripartite from the same level.

Fig. 4.8j Endoscopic view of the basolateral and posterobasal segments of the right lower lobe. In this example a normal variant subapical segment is present. Fig. 4.8h Closer endoscopic view of the basal segments of the right lower lobe.

Fig. 4.8k Endoscopic view of the anterobasal, basolateral and posterobasal segments of the right lower lobe.

Fig. 4.8n Endoscopic view of the basolateral and posterobasal segments of the right lower lobe. Fig. 4.8m Endoscopic view of the anterobasal, basolatera and posterobasal segments of the right lower lobe. Fig. 4.81 Endoscopic view of the basolateral and posterobasal segments of the right lower lobe.

Fig. 4.8p Endoscopic view of the right lower lobe variant with submedial segment.

Fig. 4.9b Coronal sectional CT scan of the thorax at the level of the left main bronchus. Fig. 4.9a Cross-sectional CT scan of the thorax at the level of the left main bronchus.

Fig. 4.9f Endoscopic view of the left main bronchus viewed from two-thirds the way down the left main bronchus, with the left lower lobe visible distally. Fig. 4.9h Endoscopic view of the left lower and upper lobes, with the apical segment of the left upper lobe arising from the left main bronchus. Fig. 4.9g Endoscopic view of the left secondary carina with both the upper and lower lobes visible.

The upper lobe bronchus usually divides into the upper division orifice and the lingual bronchus. The upper division divides into an apicoposterior and anterior bronchus. In the majority of individuals, the apicoposterior bronchus divides into three segmental branches: the apical, posterior and posterolateral branches. In about |5 per cent of individuals the apicoposterior segment has a bipartite structure with the posterolateral subsegment arising from the anterior segment.

Fig. 4.1 0c Endoscopic view of the left superior bronchus from above the left main bronchial carina.

Fig. 4.1 1b Coronal sectional CT scan of the thorax at the level of the lingular bronchus.

Fig. 4.1 1c Bronchoscopic view of the lingula and anterior segment of the left upper lobe. Fig. 4.1 1d Endoscopic view of the lingular segments.

Fig. 4.12b Coronal sectional CT scan of the thorax at the level of the left lower lobe bronchus.

Fig. 4.12a Cross-sectional CT scan of the thorax at the level of the left lower lobe bronchus.

Fig. 4.12g Cross-sectional CT scan of the thorax showing the left lower lobe segments.

Fig. 4.12h Coronal sectional CT scan of the thorax showing the left lower lobe segments.

Fig. 5.1a Relationship to the tracheobronchial tree of the aorta. The aorta is closely related to the anterior and left lateral aspect of the trachea. The aortic root ascends below the carina and then arches over on the distal aspect of the trachea on the left side and curves around the left hilum (Fig. 5.1).

The pulmonary trunk divides at the level of the carina into the right and left pulmonary arteries (Fig. 5.2). The pulmonary artery trunk is lateral to the aorta, and the right pulmonary artery crosses the infracarinal region and is anterior to the trachea. It is located posterior to the aorta. On the left, the pulmonary artery crosses the anterior aspect of the left main bronchus and then advances behind the left upper lobe, where it divides into superior and inferior branches. The superior branch of the left pulmonary artery is located lateral and posterior to the eft upper lobe bronchus. The inferior branch follows the left lower lobe and is lateral and posterior to the left lower lobe The right pulmonary artery crosses anterior to the right main bronchus and divides into superior and inferior branches lateral to 1 the right main bronchus. The superior branch of the right pulmonary artery is located anterolateral to the right upper lobe bronchus. The inferior branch is sent posterio r to the bronchus intermedius and is located posterior and lateral to the right middle lobe and lower lobe branches.

The cross-sectional drawings in Figure 5.3 are from the level of the third to the sixth thoracic vertebral bodies. The drawings give the view that is obtained when looking from above and hence the relationships are those found when performing a bronchoscopy with the patient supine and approached from behind (posterior approach). ® Bronchoscopic views

Fig. 5.4a Station | lymph nodes. These are the low cervical, supraclavicular and sternal notch lymph nodes. The upper border is defined as the lower margin of the cricoid cartilage. The lower border is defined by the clavicles and the upper border of the manubrium. Laterality (right or left side) is determined by the midline of the trachea.

Station 2: Upper paratracheal lymph nodes (F B Superior mediastinal zone

Fig. 5.5a Station 2R lymph nodes. The upper paratracheal lymph nodes are part of the superior mediastinal zone. The upper border is defined by the apex of the lung to the superior border of the clavicles and manubrium bilaterally. On the right side, the lower border is defined by where the inferior aspect of the brachiocephalic vein crosses the trachea. On the left side, the lower border is defined by the superior border of the aortic arch. The lateral margin is determined by the left lateral border of the trachea so that nodes that are in the anterior aspect of the trachea through to the left lateral margin of the trachea are defined as station 2R lymph nodes, whereas nodes on the left lateral aspect of the trachea are defined as station 2L.

The prevascular lymph nodes located on the right side anterior to the superior vena cava up to the sternum. The upper border is defined by the apex of the chest and the lower border at the level of the carina. On the left side, the lymph nodes are anterior to the left carotid artery up to the sternal surface. The upper border is again defined as the apex of the lung and the lower border by the level of the carina. Laterality is defined according to the midline of the trachea. Station 3A: Prevascular and retrosternal lymph nodes (Fig. 5.6

These are the lymph nodes located posterior to the trachea. The upper margin is defined by the apex of the chest and the lower by the carina. Fig. 5.7d Sagittal view (left lateral) of CT scan highlighting the station 3p lymph node area. Fig. 5.7f Axial section of CT scan depicting the lower border of the station 3p lymph node zone. Fig. 5.7e Axial section of CT scan depicting the upper border of the station 3p lymph node zone.

Fig. 5.8b Station 4L lymph nodes. Fig. 5.8a Station 4R lymph nodes (azygos vein showing lower border). The lower right paratracheal lymph nodes include the right paratracheal and anterior carinal lymph nodes. Laterality is defined by the left lateral border of the trachea (2 o'clock position if the midline is considered to be |2 o'clock through to 6 o'clock). The upper border of the 4R lymph nodes is at the level where the lower border of the brachiocephalic vein crosses the trachea. The lower border is defined by the azygos vein. On the left side, the left paratracheal or 4L lymph node is on the left lateral aspect of the trachea from the 2 o'clock position. Its upper border is the upper margin of the aortic arch and the lower border is the upper rim of the left main pulmonary artery,

Fig. 5.8c Axial section of CT scan depicting the upper margins of the station 4 lymph node zone. Fig. 5.8d Axial section of CT scan depicting the lower margin of the station 4 lymph node zone.

Fig. 5.9b coronal section of CT scan depicting station 5 lymph nodes.

Fig. 5.9c Sagittal section of CT scan demonstrating station 5 lymph node: left. Fig. 5.9d Axial section of CT scan demonstrating station 5 lymph node.

Station 6: Para-aortic lymph nodes (Fig.

Fig. 5.10a Station 6 lymph nodes: anterior view. The para-aortic lymph nodes are located on the left side and found anterolateral to the ascending aorta and the aortic arch. The upper border is a horizontal line through the upper border of the aortic arch and the lower border defined by the lower level of the aortic arch.

Station 8: Para-oesophageal lymph nodes (Fig. !

Fig. 5.12a Station 8 lymph nodes. Fig. 5.12b Coronal section of CT scan depicting the margins of the station 8 lymph node zone. These are lymph nodes lying adjacent to the wall of the oesophagus. They are the nodes located below the sub-carinal lymph nodes. Hence the upper border on the right side is defined by the lower border of the bronchus intermedius and the left by the lower border of the left main bronchus. The inferior extent of the lymph nodes is the dome of the diaphragm.

Station 10 or hilar lymph nodes are found adjacent to the right and left main bronchi and the main pulmonary artery and pulmonary vein. On the right side, the upper border is determined by the lower rim of the azygos vein down to the distal margin of the right main bronchus. On the left side, the lymph nodes are located between the upper rim of the pulmonary artery and the lower aspect of the left main bronchus. Station 10: Main bronchial lymph nodes (Fig. . B Hilar/interlobar zone (hilar nodes)

These interlobar lymph nodes are located between the origin of the lobar bronchus On the right side are the superior station || lymph nodes (| 1Rs), which are locatec between the right upper lobe and the bronchus intermedius. The inferior station | | lymph nodes (I | Ri) are located between the middle lobe bronchus and the lower lobe bronchus. On the left side, the station || lymph nodes (| 1L) are located between the left superior division bronchus and the left lower lobe bronchus. Station | |: Interlobar lymph nodes (Fig.

Fig. 5.15g Axial sections of CT scan depicting: station | IL lymph node. Fig. 5.15e Axial section of CT scan depicting Station | |Rs lymph node. Fig. 5.15f Axial sections of CT scan depicting: station | | Ri lymph node.

» Peripheral zone Stations 12,13 and 14 These are the lymph nodes located adjacent to the lobar bronchi (station 12) nodes, adjacent to the upper lobes (| 2u), middle lobe (| 2m) and lower lobes (1 2I).The station |3 lymph nodes are segmental nodes and the station |4 nodes are located adjacent to the subsegmental bronchi. These lymph nodes are not accessible at bronchoscopy and are therefore not discussed further

Transbronchial fine-needle aspiration (TBNA) Is a simple, cheap technique for sampling mediastinal nodes. Hilar lymph nodes, masses adjacent to the airways and submucosal disease may also be sampled with this technique. A variety of needles are available but the needle should be retractable with a length of between |3 and 15 mm and a gauge of between |8 and 22 (Fig. 6.1). Planning/site selection

Fig. 6.2b CT scan with the right paratracheal lymph node highlighted in yellow and the clock face showing that the lymph node is in 10-1 | o’clock position.

Fig. 6.2a CT scan with right paratracheal lymph node present.

Fig. 6.2¢ Cross-sectional CT scan of the thorax; note the relative position of the anterior and posterior aspects of the patient. Fig. 6.2d Bronchoscopic view; note the relative position of the anterior and posterior aspects of the patient.

Fig. 6.2f Coronal CT reformat to help determine the vertical position of the lymph node in relation to the carina.

Fig. 6.2h Virtual bronchoscopy derived from CT scanning with lymph node highlighting.

Fig. 6.2g Virtual bronchoscopy derived from CT scanning. Fig. 6.2e Cross-sectional CT scan of the thorax flipped on the horizontal axis so as to align the anterior and posterior aspects of the patient with the bronchoscopic view.

Fig. 6.3a Transbronchial needle apposed on to the airway wall at an angle of at least 45° in the anterior carinal position.

Fig. 6.3b Transbronchial needle penetrating through the airway wall in the anterior carinal position.

Fig. 6.3c¢ Cytology slides being prepared from aspirates. The aspirate is first sprayed on to the slides and then thin smears are made.

Fig. 6.4a Cross-sectional CT scan of the thorax at the level of the aortic arch showing a station 4R lymph node Fig. 6.4b Cross-sectional CT scan with a superimposed clock face and a station 4R lymph node highlighted in yellow. The station 4R or right paratracheal lymph node is classically located in the right anterior aspect of the trachea. The exact position should be predetermined from the CT scan. Usually on the CT scan the right paratracheal lymph node is located in the 10-1 | o'clock position, if the anterior midline is considered to be |2 o'clock. However, one should note that the CT scans are obtained by looking at the patient from the feet upwards; but when patients undergo a bronchoscopy, the airways are viewed with the head downwards. When the patient is approached from the front, with the patient in a semi-recumbent position, the posterior wall is now at the 12 o'clock position and the anterior wall at the 6 o'clock position. Hence, in this position the right paratracheal lymph node is now positioned between the seven and 8 o'clock positions. The simplest way is to flip the CT scan in the horizontal axis. The bronchoscopic position of the right paratracheal lymph node is between seven and 8 o'clock. Bending the bronchoscope posteriorly in this position is more difficult. Easier and more accurate access can be achieved by rotating the bronchoscope by about |80°.The lymph node is now in the one to 2 o'clock position. The vertical position of the right paratracheal lymph node is about two to four intercartilage spaces above the carina.

Fig. 6.4d Coronal section of CT scan showing the vertical position of the lymph node, which is usually about two to four rings above the carina.

Fig. 6.4c Cross-sectional CT scan of the thorax flipped on the horizontal axis. The 4R lymph node is in the 7-8 o'clock position.

Fig. 6.4i Cross-sectional CT scan of anterior carinal lymph node (station 4R) anterior to the carina.

Fig. 6.4|« Cross-sectional CT scan flipped on the horizontal axis.The anterior carinal lymph node (station AR) is in the 6—6.30 o’clock position.

Fig. 6.41 Coronal section of CT scan showing the vertical position of the anterior carinal lymph node which is usually at the level of the carina.

Fig. 6.5d Coronal section of CT scan showing the vertical position of the station 4L lymph node, which is usually at one intercartilage space above the carina.

Fig. 6.5b Cross-sectional CT scan with a superimposed clockface and a station 4L lymph node highlighted in yellow. The station 4L or left paratracheal lymph node is located on the left lateral position of the trachea at or above the level of the carina. On the CT scan the lymph node is located in the 3 o'clock position. When the patient is being approached from the front at bronchoscopy, the lymph node is located at the same 3 o'clock position. The vertical position of the lymph node is at the level of the carina or one space above. In practice this lymph node is more easily accessed by rotating the bronchoscope 90° in an anticlockwise direction. Once the needle has penetrated the airway wall, the torsion on the bronchoscope can be relaxed and the needle moved back while the bronchoscope is in the neutral position (as in Fig. 6.5h).

Fig. 6.5a Cross-sectional CT scan of the thorax showing a station 4L lymph node.

Fig. 6.5c Cross-sectional CT scan of the thorax flipped on the horizontal axis. The 4L lymph node is in the 3 o’clock position.

Fig. 6.6b Cross-sectional CT scan with a superimposed clockface and a station 3p lymph node highlighted in yellov

Fig. 6.6a Cross-sectional CT scan of the thorax showing a station 3p lymph node.

Fig. 6.6d Coronal section of CT scan showing the vertical position of the station 3p lymph node, which is usually at the level of the carina.

Fig. 6.6e Bronchoscopic view of the station 3p lymph node which is in the | 2—12.30 o'clock position about one intercartilage space above the carina.

Fig. 6.6c Cross-sectional CT scan of the thorax flipped on the horizontal axis.The 3p lymph node is in the | 2—12.30 o'clock position.

Fig. 6.6f Bronchoscopic view of needle inserted into a 3p lymph node in the |2 o’clock position with the scope in the neutral position.

Fig. 6.7¢ Cross-sectional CT scan of the thorax flipped on the horizontal axis.The station 7 lymph node is in the 3 o’clock position.

Fig. 6.7b Cross-sectional CT scan with a superimposed clock face and a station 7 lymph node highlighted in yellow. Fig. 6.7a Cross-sectional CT scan of the thorax showing a station 7 lymph node. The station 7 or subcarinal lymph nodes are located just inferior to the carina. The carina is composed of three bundles of cartilage and ligament and hence direct puncture through the carina tends to be unsuccessful. The subcarinal lymph nodes should be approached in the right main bronchus by one space below the carina. On the CT scan this translates to the 3 o’clock position and is the same if the patient is being approached from the front. Easier and more accurate access is facilitated by rotating the bronchoscope by 90° anticlockwise.

Fig. 6.7d Coronal section of CT scan showing the vertical position of the station 7 lymph node which is usually one intercartilage space below the carina in the right main bronchus.

Fig. 6.8b Cross-sectional CT scan with a superimposed clock face and a station | OR lymph node highlighted in yellow.

Fig. 6.8a Cross-sectional CT scan of the thorax showing a station 1OR lymph node.

Fig. 6.8d Coronal section of CT scan showing the vertical position of the station |OR lymph node which is usually one intercartilage space below the carina in the right main bronchus.

Fig. 6.8c¢ Cross-sectional CT scan of the thorax flipped or the horizontal axis.The |OR lymph node is in the 6 o’clock position in the right main bronchus.

Fig. 6.9b Cross-sectional CT scan with a superimposed clock face and a station | OL lymph node highlighted in yellow in the 6 o’clock position.

Fig. 6.9a Cross-sectional CT scan of the thorax showing a station | OL lymph node.

Fig. 6.9c Cross-sectional CT scan of the thorax flipped on the horizontal axis.The | OL lymph node is in the | 2 o'clock position.

Fig. 6.9d Coronal section of CT scan showing the vertical position of the station | OL lymph node which is usually one intercartilage space below the carina.

Fig. 6.|0b Cross-sectional CT scan with a superimposed clock face and a station | 1 Rs (right upper hilar) lymph node highlighted in yellow.

Fig. 6.10a Cross-sectional CT scan of the thorax showing a station | | Rs (right upper hilar) lymph node. The station | IR includes the right upper and right lower hilar nodes. The right upper hilar node is located on the CT scan between the right upper lobe bronchus and the bronchus intermedius. On the CT cross-section it relates to the 9 o'clock position just below the origin of the bronchus intermedius. At bronchoscopy this relates to the anterior spur of the right upper lobe carina and the optimal approach is to insert the needle just below the spur of the upper lobe carina. When the patient is approached from the front, this is just below the origin of the bronchus intermedius in the 9-10 o'clock position. It is in the proximal portion of the bronchus intermedius.

Fig. 6.|0c Cross-sectional CT scan of the thorax flipped on the horizontal axis.The station | | Rs (right upper hilar lymph node is in the 9 o’clock position.

Fig. 6.10d Coronal section of CT scan showing the vertical position of the station | IRs (right upper hilar) lymph node, which is usually located at the right upper lobe carina.

Fig. 6.1 1b Cross-sectional CT scan with a superimposed clock face and a station | | Ri (right lower hilar) lymph node highlighted in yellow.

Fig. 6.1 la Cross-sectional CT scan of the thorax showing a station | | Ri (right lower hilar) lymph node.

Fig. 6.1 1d Coronal section of CT scan showing the vertical position of the station | | Ri (right lower hilar) lymph node, which is usually just higher than the right middle lobe origin.

Fig. 6.| | ¢ Cross-sectional CT scan of the thorax flipped on the horizontal axis.The station | | Ri (right lower hilar) lymph node is in the 9 o’clock position.

Fig. 6.1 2b Cross-sectional CT scan with a superimposed clock face and a station | | L lymph node highlighted in yellow.

Fig. 6.|2d Coronal section of CT scan showing the vertical position of the station | 1L lymph node which is usually at the level of the carina between the left upper and lower lobes.

Fig. 6.1 2a Cross-sectional CT scan of the thorax showing a station | 1L lymph node.

Fig. 6.| 2c Cross-sectional CT scan of the thorax flipped on the horizontal axis.The | 1L lymph node is in the 6—7 o'clock position when approached from the left lower lobe

Fig 7.2a CT scan with the right paratracheal lymph node present. Fig 7.2b CT scan with the right paratracheal lymph node highlighted in yellow and the clock face showing that the lymph node is in |0—1 | o’clock position.

Fig 7.2d Bronchoscopic view; note the relative position of the anterior and posterior aspects of the patient.

Fig 7.2c Cross-sectional CT scan of the thorax; note the relative position of the anterior and posterior aspects of the patient.

Fig 7.2f Coronal CT reformat to help determine the vertical position of the lymph node in relation to the carina.

Fig 7.2h Virtual bronchoscopy derived from CT scanning with lymph node highlighting.

Fig 7.2g Virtual bronchoscopy derived from CT scanning.

Fig 7.2e Cross-sectional CT scan of the thorax flipped o! the vertical axis so as to align the right and left aspects o the patient with the bronchoscopic view.

Fig. 7.3b Transbronchial needle penetrating the airway wall in the anterior carinal position.

Fig. 7.3a Transbronchial needle apposed on to the airway wall at an angle of a least 45° in the anterior carinal position

Fig. 7.3c Cytology smears prepared by spraying aspirate on to the slides.

Fig. 7.4a Cross-sectional CT scan of the thorax at the level of the aortic arch showing a station 4R lymph node.

Fig. 7.4c Cross-sectional CT scan of the thorax flipped on the vertical axis. The 4R lymph node is in the !—2 o’clock position.

Fig. 7.4d Coronal section of CT scan showing the vertical position of the lymph node, which is usually about two to four rings above the carina.

Fig. 7.4f Bronchoscopic view of the needle inserted into a 4R lymph nod. in the 2 o’clock position. Fig. 7.4e Bronchoscopic view of the station 4R lymph node which is in the !—2 o’clock position about two to four intercartilage spaces above the carina.

Fig. 7.4i Cross-sectional CT scan of the thorax at the level of the carina with a superimposed clock face and highlighting an anterior carinal lymph node (station 4R lymph node).

Fig. 7.4g Further example of needle inserted into the 4R lymph node.

Fig. 7.4k Coronal section of CT scan showing the vertical position of the lymph node, which is usually at the level of the carina.

Fig. 7.4j Cross-sectional CT scan of the thorax flipped on the vertical axis. The anterior carinal lymph node is in the ! 2-12.30 o'clock position.

Fig. 7.4m Bronchoscopic view of the needle inserted into the anterior carinal lymph node in the 12 o'clock position. Fig. 7.41 Bronchoscopic view of the anterior carinal (station 4R) lymph node which is in the 6 o’clock positior at the level of the carina.

Fig. 7.5c Cross-sectional CT scan of the thorax flipped on the vertical axis. The 4L lymph node is in the 9 o’clock position.

Fig. 7.5b Cross-sectional CT scan with a superimposed clock face and a station 4L lymph node highlighted in yellow.

Fig. 7.5d Coronal section of CT scan showing the vertica position of the station 4L lymph node which is usually at one intercartilage space above the carina.

Fig. 7.5a Cross-sectional CT scan of the thorax showing a_ | station 4L lymph node. (

Fig. 7.6b Cross-sectional CT scan with a superimposed clock face and a station 3p lymph node highlighted in yellow

Fig. 7.6a Cross-sectional CT scan of the thorax showing a station 3p lymph node.

The posterior carinal lymph node is located at the level of the carina on the posterior aspect of the trachea. On CT terms it can be considered to be in the 5.30—6 position At bronchoscopy when the patient is approached from behind, the lymph nodes are now located at the 6-630 o'clock position. The forward angulation of the bronchoscope Is greater in the anterior direction and therefore access for TBNA is improved by rotating the scope to | 80° so that the lymph nodes are now anterior in the | |.30-|2 o'clock position.

Fig. 7.6c Cross-sectional CT scan of the thorax flipped on the vertical axis. The 3p lymph node is in the 6—6.30 o'clock position.

Fig. 7.6d Coronal section of CT scan showing the vertical position of the station 3p lymph node which is usually at the level of the carina.

Fig. 7.7d Coronal section of CT scan showing the vertical position of the station 4L lymph node, which is usually at one intercartilage space above the carina.

Fig. 7.7 Cross-sectional CT scan of the thorax flipped on the vertical axis. The station 7 lymph node is in the 9 o'clock position.

Fig. 7.7a Cross-sectional CT scan of the thorax showing a station 7 lymph node. Fig. 7.7b Cross-sectional CT scan with a superimposed clock face and a station 7 lymph node highlighted in yellov The subcarinal lymph nodes are located just inferior to the carina. The carina Is composed of three bundles of cartilage and ligament, and hence direct puncture through the carina tends to be unsuccessful. The subcarinal lymph nodes should be approached in the right main bronchus at one space below the carina. On the CT scan this translates to the 3 o'clock position and it is at the 9 o'clock position (medially in the right main bronchus one space below the carina) when the patient is being bronchoscoped from behind.

Fig. 7.8b Cross-sectional CT scan with a superimposed clock face and a station | OR lymph node highlighted in yellow.

Fig. 7.8a Cross-sectional CT scan of the thorax showinga__ Fig station |OR lymph node. face The right main bronchial node is located anterior to the right main bronchus about one intercartilage space below the carina at the 12 o'clock position on the CT scan. When the patient is being approached from behind, the lymph node is also located in the |2 o'clock position in the right main bronchus one space below the carina.

Fig. 7.8d Coronal section of CT scan showing the vertical position of the station |OR lymph node which is usually one intercartilage space below the carina in the right main bronchus.

Fig. 7.8c Cross-sectional CT scan of the thorax flipped or the vertical axis. The |OR lymph node is in the 12 o’clock position in the right main bronchus.

Fig. 7.8f Bronchoscopic view of the needle inserted into a !OR lymph node.

Fig. 7.8e Bronchoscopic view of the station | OR lymph node which is in the 12 o’clock position about one intercartilage space below the carina in the right main bronchus.

Fig. 7.9b Cross-sectional CT scan with a superimposed clock face and a station | OL lymph node highlighted in yellow in the 6 o’clock position.

Fig. 7.9a Cross-sectional CT scan of the thorax showing a station | OL lymph node.

Fig. 7.9d Coronal section of CT scan showing the vertical position of the station | OL lymph node which is usually one intercartilage space below the carina.

Fig. 7.9c Cross-sectional CT scan of the thorax flipped on the vertical axis.The | OL lymph node is in the 12 o’clock position.

Fig. 7.9f Bronchoscopic view of the needle inserted into c OL lymph node.

Fig. 7.9e Bronchoscopic view of the station | OL lymph node which is in the 12 o’clock position about one intercartilage space below the carina in the left main bronchus.

Fig. 7.1 0b Cross-sectional CT scan with a superimposed clock face and a station | | Rs (right upper hilar) lymph node highlighted in yellow. The right upper hilar node is located on the CT scan between the right upper lobe bronchus and the bronchus intermedius. On the CT cross-section it relates to the 9 o'clock position just below the origin of the bronchus intermedius. At bronchoscopy this relates to the anterior spur of the right upper lobe carina and the optimal approach is to insert the needle just below the spur of the upper lobe carina. When the patient is approached from behind, the right hilar node is located at the right side towards the 2—3 o'clock position in the anterior spur of the right upper lobe carina. It is in the proximal portion of the bronchus intermedius.

Fig. 7.10a Cross-sectional CT scan of the thorax showing a station | | Rs (right upper hilar) lymph node.

Fig. 7.10d Coronal section of CT scan showing the vertical position of the station | IRs (right upper hilar) lymph node, which is usually located at the right upper lobe carina.

Fig. 7.|0c Cross-sectional CT scan of the thorax flipped on the vertical axis. The station | IRs (right upper hilar) lymph node is in the 2—3 o’clock position.

Fig. 7.! |b Cross-sectional CT scan with a superimposed clock face and a station | | Ri (right lower hilar) lymph node highlighted in yellow. On the CT scan the right lower hilar lymph node is located lateral to the bronchus intermedius in the 9 o'clock position at the level of the right middle lobe. At bronchoscopy the needle should be inserted in the 3 o'clock position in the distal aspect of the bronchus intermedius at the level of the right middle lobe origin.

Fig. 7.1 1d Coronal section of CT scan showing the vertical position of the station | | Ri (right lower hilar) lymph node, which is usually just higher than the right middle lobe origin.

Fig. 7.1 | ¢ Cross-sectional CT scan of the thorax flipped on the vertical axis. The station | | Ri (right lower hilar) lymph node is in the 3 o’clock position.

Fig. 7.1 la Cross-sectional CT scan of the thorax showing a station | | Ri (right lower hilar) lymph node.

Fig. 7.1 2b Cross-sectional CT scan with a superimposed clock face and a station | 1L lymph node highlighted in yellow

Fig. 7.1 2a Cross-sectional CT scan of the thorax showing a station | 1L lymph node.

Station | |L: Left hilar lymph node (Fig. 7.

Fig. 7.|2d Coronal section of CT scan showing the vertical position of the station | 1L lymph node, which is usually at level of the carina between the left upper and lower lobe.

Fig. 7.12 Bronchoscopic view of the needle inserted into an I IL lymph node in the | |—12 o'clock position.

Fig. 7.| 2c Cross-sectional CT scan of the thorax flipped on the horizontal axis. The | 1L lymph node is in the | 1-12 o’clock position.

Fig. 7.12e Bronchoscopic view of the station | 1L lymph node which is in the | 1-12 o’clock position about one intercartilage space above the carina.

The ultrasound image obtained can be improved by applying a water-filled balloon to the ultrasound transducer This can be attached onto the distal end of the endobronchial ultrasound bronchoscope with a specific applicator This water-filled balloon improves the acoustic contact but air bubbles within it may cause some artefacts.

Fig. 8.1f Artefact on ultrasound image due to air bubbles within the water-filled balloon. Fig. 8.1a Endobronchial ultrasound bronchoscope.

Fig. 8.3a Ultrasound appearance of the aortic arch. Fig. 8.3b Bronchoscopic view of the trachea with the left lateral wall marked corresponding to the aortic arch.

Fig. 8.4c Coronal section of CT scan showing the 2R lymph node. Note that the node is above the level of the brachiocephalic vein crossing the trachea. Fig. 8.4a Cross-sectional CT scan of the thorax showing a station 2R lymph node.

Fig. 8.4b Cross-sectional CT scan flipped left to right with the station 2R lymph node highlighted in blue. The upper margin of station 2R is difficult to define at endobronchial ultrasound but is primarily at the level of the clavicle. The lower border is defined by the inferior aspect of the left brachiocephalic vein crossing the trachea. Anterolateral in this area, the right subclavian artery and right common carotid artery are visible on endobronchial ultrasound. More anterior to these blood vessels are the right brachiocephalic vein and the right external jugular vein. The endobronchial position is difficult to estimate accurately but is about one-third of the distance of the trachea from the vocal cords.

Fig. 8.4d Bronchoscopic view of where the ultrasound probe should be placed to view the station 2R lymph nodes highlighted.

Fig. 8.4e Ultrasound image of the station 2R lymph node in a central position with the right common carotid artery superior to the node and the right subclavian artery inferior.

Fig. 8.4f Ultrasound image of the station 2R lymph node and the right common carotid artery more superior.

Fig. 8.5e Ultrasound image of the station 2L lymph node. Fig. 8.5d Bronchoscopic view of where the ultrasound probe should be placed to view the station 2L lymph nodes highlighted.

Fig. 8.5b Cross-sectional CT scan flipped left to right with the station 2L lymph node highlighted in blue.

Fig. 8.5a Cross-sectional CT scan of the thorax showing a station 2L lymph node. Fig. 8.5c Coronal section of CT scan showing the 2L lymph node. Note the node is above the level of the aortic arch.

Fig. 8.6e Ultrasound image of the station 3a lymph node. Fig. 8.6c Coronal section of CT scan showing the station 3a lymph node.

Fig. 8.6a Cross-sectional CT scan of the thorax showing « station 3a lymph node.

Fig. 8.6d Bronchoscopic view of where the ultrasound probe should be placed to view the station 3a lymph nodes highlighted.

Fig. 8.6b Cross-sectional CT scan flipped left to right wit the station 3a lymph node highlighted.

The upper border is demarcated by the clavicle and the lower border by the carine which is visible on the endobronchial image. These nodes are usually located anterior tc the great vessels, i.e. the left common carotid and subclavian artery, and hence canno be sampled by endobronchial ultrasound.

Fig. 8.7b Cross-sectional CT scan flipped left to right with the station 3p lymph node highlighted. The upper border is at the level of the clavicle and the lower border is at the carina, which can be confirmed by the bronchoscopic image. These nodes are located on the posterior aspect of the trachea.

Fig. 8.7d Bronchoscopic view of where the ultrasound probe should be placed to view the station 3p lymph nodes highlighted. Fig. 8.7e Ultrasound image of the station 3p lymph node.

Fig. 8.7c Coronal section of CT scan showing the station 3p lymph node. Fig. 8.7a Cross-sectional CT scan of the thorax showing a station 3p lymph node.

Fig. 8.8d Bronchoscopic view of where the ultrasound probe should be placed to view the station 4R lymph nodes highlighted. Fig. 8.8b Cross-sectional PET-CT scan flipped left to right with the active station 4R lymph node.

Fig. 8.8c Coronal section of PET-CT scan showing the 4R lymph node. Fig. 8.8a Cross-sectional PET-CT scan of the thorax showing an active station 4R lymph node.

Fig. 8.8e Ultrasound image of the station 4R lymph nod with the brachiocephalic vein demarcating the border between stations 4R and 2R.

Fig. 8.8f Ultrasound image of the station 4R lymph node

The upper border is identified on endobronchial ultrasound as the inferior margir of the brachiocephalic vein crossing the trachea. The lower border is defined by the azygos vein, which should be identified at ultrasound.

Fig. 8.8j Ultrasound image of the azygos vein at a lower level with the superior vena cava visible distally. Fig. 8.8h Ultrasound image of the station 4R lymph node with the azygos vein demarcating the border between station 4R and | OR lymph nodes.

Fig. 8.8g Ultrasound image of the station 4R lymph node with the superior vena cava more distal to the lymph node.

Fig. 8.8] Ultrasound image of the azygos vein at a lower level draining into the superior vena cava.

Fig. 8.8k Ultrasound image of the azygos vein a few mn further distal.

Fig. 8.8i Ultrasound image of the azygos vein.

Fig. 8.8q Ultrasound image of the station 4R (anterior carinal, acn) lymph node.

Fig. 8.8r Ultrasound image of the station 4R (anterior carinal, acn) lymph node with the aorta visible just inferior! Fig. 8.8p Bronchoscopic view of where the ultrasound probe should be placed to view the station 4R (anterior carinal node) lymph nodes highlighted.

Fig. 8.80 Coronal CT scan of the thorax showing an anterior carinal lymph node (station 4R lymph node). Fig. 8.8m Further example of cross-sectional CT scan of the thorax showing a station 4R lymph node (anterior carinal lymph node).

Fig. 8.8n Cross-sectional CT scan flipped left to right with the station 4R (anterior carinal) lymph node highlighted.

Fig. 8.8s Ultrasound image of the station 4R (anterior carinal acn) lymph node with a greater aspect of the aorta visible.

Fig. 8.9b Cross-sectional PET-CT scan flipped left to right with the active station 4L lymph node. The location of the lymph node is between the ascending aorta and the pulmonary trunk. The upper border is defined by the aortic arch and the lower border by the pulmonary artery. The classical image visible at ultrasound consists of the lymph node identified in between the aorta which is on the right of the image and the pulmonary artery on the left of the image. The bronchoscopic location of this station is the left lateral aspect of the trachea at the level of the carina or one space above the carina.

Fig. 8.9a Cross-sectional PET-CT scan of the thorax showing an active station 4L lymph node.

Fig. 8.9c Coronal section of PET-CT scan showing the 4L lymph node.

Fig. 8.9e Ultrasound images of the station 4L lymph nodes.

Fig. 8.9d Bronchoscopic view of where the ultrasound probe should be placed to view the station 4L lymph nodes highlighted.

Fig. 8.9h Ultrasound images of the station 4L lymph nodes with a greater portion of the pulmonary trunk visible Fig. 8.9f Ultrasound images of the station 4L lymph node: with the aorta visible superior and distal to the nodes.

Fig. 8.9g Ultrasound images of the station 4L lymph nodes with the aorta visible superior to, and the pulmonar) trunk on the inferior aspect of, the nodes.

Fig. 8.10e Ultrasound image of the station 5 lymph node visible distal to the pulmonary artery. The aorta is partly visible superiorly. Fig. 8.10d Bronchoscopic view of where the ultrasound probe should be placed to view the station 5 lymph nodes highlighted.

Fig. 8.|0b Cross-sectional CT scan flipped left to right with the active station 5 lymph node highlighted.

Fig. 8.10c Coronal section of CT scan showing the station 5 lymph node highlighted. Fig. 8.1 0a Cross-sectional CT scan of the thorax showing a station 5 lymph node.

Fig. 8.1 1c Coronal section of PET-CT scan showing the station 6 lymph node. Fig. 8.1 le Ultrasound image of the station 6 lymph node.

Fig. 8.1 la Cross-sectional CT scan of the thorax showing a station 6 lymph node.

Fig. 8.1 |b Cross-sectional CT scan flipped left to right with the active station 6 lymph node highlighted. Fig. 8.1 1d Bronchoscopic view of where the ultrasound probe should be placed to view the station 6 lymph nodes highlighted.

Fig. 8.1 2b Cross-sectional PET-CT scan flipped left to right with the active station 7 lymph node. The borders of station 7 are more clearly defined by the bronchoscopic view. It represents the nodal area inferior to the carina and down to the level where the right middle lobe bronchus originates on the right side and the secondary carina on the left side. The ultrasound transducer may be applied to the medial aspect of either the right or the left main bronchus. At this level, anterior movement of the transducer demonstrates the pulmonary artery and pulmonary trunk.

Fig. 8.12d Bronchoscopic view of where the ultrasound probe should be placed to view the station 7 lymph nodes highlighted.

Fig. 8.12c Coronal section of PET-CT scan showing the station 7 lymph node.

Fig. 8.1 2a Cross-sectional PET-CT scan of the thorax showing a station 7 lymph node.

Fig. 8.13b Cross-sectional CT scan flipped left to right with the station 1OR lymph node highlighted.

Fig. 8.|3a Cross-sectional CT scan of the thorax showing a station 1OR lymph node.

Fig. 8.13e Ultrasound images of the station |OR lymph node: with the azygos visible, which delineates the border between station 4R and | OR. Fig. 8.13g Ultrasound images of the station |OR lymph node: with the right pulmonary artery inferior and distal to the node. Fig. 8.13f Ultrasound images of the station |OR lymph node: in a more central position. Fig. 8.13d Bronchoscopic view of where the ultrasound probe should be placed to view the station |OR lymph nodes highlighted.

Fig. 8.13c Coronal section of CT scan showing the |0R lymph node.

Fig. 8.1 4b Cross-sectional CT scan flipped left to right with the station | OL lymph node highlighted. These are lymph nodes located on the left main bronchus. The upper border is again just below the carina on the left side and on ultrasound image is defined by the superior aspect of the pulmonary artery. The lower margin is indicated by the bifurcation of the left main bronchus into the superior lobar bronchus and the left lower lobe. The transducer should usually be applied to the anterior aspect of the left main bronchus and advanced slowly down towards the secondary carina. The structure visible anterior to the left main bronchus consists of the left pulmonary artery and trunk, and more inferiorly the left atrium may also be visible. On the medial aspect of the left main bronchus, the descending aorta may also be visible.

Fig. 8.1 4a Cross-sectional CT scan of the thorax showing a station | OL lymph node.

Fig. 8.1 4c Coronal section of CT scan showing the 1 OL lymph node.

Fig. 8.1 4d Bronchoscopic view with the location of station OL lymph nodes highlighted.

Fig. 8.|5e Ultrasound images of the station | 1Rs lymph node: with the superior vena cava visible superior and distal to the nodes.

Fig. 8.15a Cross-sectional PET-CT scan of the thorax showing a station | | Rs (right upper hilar) lymph node. These are located at the upper lobe carina. The ultrasound transducer Is applied just below the upper lobe origin in the bronchus intermedius. Superior to the |1R lymp node, the right upper lobe bronchus and pulmonary artery may be visible. Inferiorly the pulmonary artery branch and, more distally, the right pulmonary vein and superior vena cava are visible.

Fig. 8.1 5b Cross-sectional PET-CT scan of the thorax flipped left to right showing the station | | Rs lymph node Fig. 8.15d Bronchoscopic view of where the ultrasound probe should be placed to view the station | 1Rs lymph nodes highlighted.

Fig. 8.1 5c Coronal section of PET-CT scan showing the 1 1Rs lymph node.

Fig. 8.16b Cross-sectional PET-CT scan of the thorax flipped left to right showing the station | | Ri lymph node. Fig. 8.16d Bronchoscopic view of where the ultrasound probe should be placed to view the station | | Ri lymph nodes highlighted.

Fig. 8.1 6f Station | |Ri lymph node with the pulmonary vein which leads to the left atrium.

Fig. 8.1 6c Coronal section of PET-CT scan showing the 1 1Ri lymph node. Fig. 8.1 6a Cross-sectional PET-CT scan of the thorax showing a station | | Ri (right lower hilar) lymph node.

Fig. 8.1 6e Ultrasound image of the station | | Ri lymph node.

Fig. 8.1 7e Ultrasound images of the station | 1L lymph node: with left pulmonary artery and left upper lobe bronchus more superior.

Fig. 8.17d Bronchoscopic view of where the ultrasound probe should be placed to view the station | IL lymph nodes highlighted. Fig. 8.17f Ultrasound images of the station | 1L lymph node: with the lingular bronchus visible inferior to the node.

Fig. 8.1 7c Coronal section of PET-CT scan showing the IIL lymph node. Fig. 8.1 7a Cross-sectional PET-CT scan of the thorax showing a station | |L lymph node.

Fig. 8.1 7b Cross-sectional PET-CT scan of the thorax flipped left to right showing a station | |L lymph node.

Fig. 8.18d Bronchoscopic image showing the significant length of the visible sheath. This greater distance may impair acoustic contact and hence the ultrasound image. Fig. 8.1 8b Close-up of the handle of the needle showing the mechanism for the adjustment of the needle sheath.

Fig. 8.18a Specific needle for the Olympus endobronchial bronchoscope.

Fig. 8.19a Endobronchial ultrasound bronchoscope with the needle fixed in position on the scope. The needle should be introduced into the bronchoscope straight into the trachea. The needle tip should be adjusted so that a very small crescent Is visible in the endoscopic image on the top right-hand corner Once the lymph node or mass is identified in the ultrasound field, an assistant is asked to secure the bronchoscope and hold it in position. The central stylet is then withdrawn about 3 mm so that the needle point is sharp. The safety lock for the needle is lowered to the required distance and the needle gently inserted through the airway wall whilst maintaining the ultrasound image at all times (Figs 8.19 and 8.20). Once the needle is through the airway wall into the lymph node, the stylet is jiggled back and forth in order to remove any cartilage or airway wall plug from the needle. The stylet is then removed and the aspiration syringe connected. The syringe is preset with suction and, providing it is within the lymph node, the three-way tap is opened and the needle moved gently back and forth through the lymph node. This allows cellular material from the lymph node to be aspirated. The bronchoscope can be gently manipulated so that material from different parts of the lymph node is aspirated. The three-way tap is then closed and the needle withdrawn back into the sheath and the needle removed.

Fig. 8.19b Endobronchial ultrasound bronchoscope with the needle protruding out at the distal tip of the bronchoscope.

Fig. 8.20a Bronchoscopic view of the needle sheath and ultrasound image of the lymph node.

Fig. 8.20b Bronchoscopic view of the needle tip and ultrasound image of the lymph node showing initial penetration of the needle.

Fig. 8.20c Bronchoscopic view of the needle tip and sheath with the corresponding ultrasound image of the lymph node showing needle aspiration of the lymph node.

Fig. 8.21c The glass slide with cellular material is gently apposed to another glass slide and then slid apart to create a thin smear on the slide. Fig. 8.2!a Lymph node aspirate is injected on to a glass slide.

Fig. 8.21b Glass slide with cellular material from lymph node aspiration.

This chapter consists mainly of bronchoscopic images of the various pathological conditions encountered during bronchoscopy. The sections cover pathology seen on the vocal cords through to the trachea, lobar bronchi and bronchial segments.

Fig. 9.5b Small cell carcinoma involving the right upper lobe with increased tortuosity of blood vessels and blind- ending punctate vessels.

Fig. 9.5a Polypoid necrotic tumour originating from the posterior segment of the right upper lobe (RB2) and extrinsic compression of the anterior segment of the right upper lobe (RB3). Left: video bronchoscopy image; right: narrow-band imaging. Increased vascularity is evident in the extrinsic lesion and lack of blood vessels in the necrotic tumour.

Fig. 10.1 d Abnormal fluorescence of the left main carina showing subtle abnormality not visible on video bronchoscopy. Fig. 10. 1b Mucus secretions in the right middle lobe which appear pink and can be easily mistaken for an abnormal area.

Fig. 10.1 Loss of fluorescence in the inflammatory nodule in the lower trachea. Fig. |0.!a Video bronchoscopy and fluorescence bronchoscopy image of the left lower lobe.

All epithelial tissue has an innate fluorescence but this is not discernible without some enhancement. With autofluorescence bronchoscopy the airways are illuminated with ; blue light (395-445 nm). The autofluorescence signal (550 nm) is incorporated in the video processor with the other reflected light to form a composite image where norma tissue appears as green (fluorescent tissue). Any reduction in fluorescence shows uf as a pink through to magenta colour Blood appears dark green (Fig. 10.1). Care shoul be taken as any mucus or secretions overlying the epithelial tissue conceal the norme fluorescent epithelial and falsely appear pink. Autofluorescence bronchoscopy require a special bronchoscope and usually the mode can be switched from white light tc fluorescence by simply pressing a remote button on the bronchoscope or a foot peda

Fig. |0.2a Thickening of the carina with abnormal fluorescence between the lateral segment of the left lower lobe (LB9) and the posterior segment of the left lower lobe (LB10) due to mild dysplasia. Fluorescence bronchoscopy is used primarily as a research tool. ln some cases, where a patient has had multiple cancers (head and neck or lung cancer) or where there are multiple areas of field effect (patchy change in airways from metaplasia through to carcinoma in situ), the patients undergo regular fluorescence bronchoscopy for clinical surveillance. These patients may undergo repeated bronchoscopy over several years and possibly by several operators. Hence, careful documentation is essential and standard nomenclature is required to describe the location and extent of the abnormalities (Fig. 10.2). We would recommend use of nomenclature as in Chapter 2.

Fig. 10.1g Inflammatory web with normal fluorescence in the left lower lobe. Fig. 10.1 f Cartilage nodule in the right lower lobe segment with normal fluorescence.

Fig. |0.2b Thickening of the carina with abnormal fluorescence between the anterior segment of the right lower lobe (RB8) and the lateral segment of the right lower lobe (RB9) due to moderate dysplasia.

Fig. |0.2¢ Nodularity with abnormal fluorescence in the inferior aspect of the right upper lobe carina due to severe dysplasia.

Fig. 10.2d Thickening of the segmental carina with abnormal fluorescence in the right lower lobe due to carcinoma in situ.

Fig. !0.2g Tumour with abnormal fluorescence around the anterior segment of the right upper lobe. Fig. 10.2e Abnormal fluorescence of polypoid tumour in the apical segment of the left lower lobe.

Fig. |0.2h Right lower lobe sleeve resection with nodularity which appears suspicious on white light but has normal fluorescence. Patchy abnormal fluorescence due to secretions. Fig. |0.2f Tumour around the apical segment of the right upper lobe and some narrowing of the anterior segment of the right upper lobe.

Confocal endomicroscopy is a fluorescence-based imaging technique which illuminates the airways or lung parenchyma with a blue argon laser light at a wavelength of 488 nm. The probe, which consists of a bundle of optical fibres, is inserted through the instrument channel of the bronchoscope (Fig. 10.3). The probe can be applied to the proximal airways for evaluating the trachea, main bronchi and bronchial segments (Fig. | 0.4). The elastin, which is found in the basement membrane, provides information on the bronchial tree. The probe can be easily passed into a subsegment and slowly advanced from the lobular bronchus to the terminal bronchiole, the respiratory bronchiole and then to the alveolar acinus. Elastin is a structural connective tissue component of the alveolar walls and the confocal probe detects the fluorescent elastin scaffold of the lobule used to image the proximal airways and down to the alveoli.

Fig. 10.4h Normal pleura with longitudinal elastin network and fewer cross-linking fibres.

Fig. |0.4b Confocal microscopy images of the bronchial segments showing the lattice network of elasti in the basement membrane. Fig. |0.4¢ Confocal microscopy of a bronchial segment with an area without fluorescence due to a bronchial gland. Fig. |0.4e Confocal microscopy image of a bronchiole. Fig. 10.4f Normal alveoli with elastin scaffolding visible with confocal microscopy.

Light radiating back from the fluorescing tissue between 500 and 650 nm is collecte at |2 frames/second. This creates a high-quality real-time image with a diameter fiel of view of 600 um but a depth of penetration of approximately 50 um and a laters resolution of 3.5 um.This is a developing field and the images shown in Figs 10.5—10. are from the early research. Fig. 10.6b Disruption of elastin alveolar structure with large cystic areas in emphysema. Fig. 10.6a Confocal microscopy in a patient with moderate emphysema. Note the large cystic spaces. Fig. |0.5d Loss of fluorescence from the alveolar architecture due to non- small cell lung cancer.

Fig. |0.7a Thickened interstitium and increased elastin network in interstitial pneumonitis (pulmonary fibrosis). Fig. 10.6d Fluorescent macrophages in the alveoli in a smoker with chronic obstructive pulmonary disease.

Fig. |0.6c Large bulla in a patient with severe emphysema with some remaining alveolar structure in the superior aspect.

Fig. 10.7g Drug-related hypersensitivity pneumonitis with normal elastin alveolar architectur and increased cellularity. Fig. |0.7f Increased fluorescent cells within normal elastin alveolar architecture in drug-related hypersensitivity pneumonitis. Fig. 10.7e Further example of abnormal spiral loops of elastin in a granuloma due to sarcoidosis.

Fig. |0.8b Alveolar architecture obscured by cells with low fluorescence in pneumonia. Fig. 10.8a Reduced fluorescence of alveolar architecture due to consolidation from pneumonia.

Fig. |0.8d Increased fluorescent cells adjacent to a blood vessel in organizing pneumonia. Fig. 10.8c Increased fluorescent cells in organizing pneumonia.

Fig. | |.2a SuperDimension® CT planning module. Virtual bronchoscopy mode showing: carina.

Fig. | |.2b SuperDimension® CT planning module.Virtual bronchoscopy mode showing: close-up of carina.

Fig. | |.2c SuperDimension® CT planning module.Virtual bronchoscopy mode showing: right upper lobe. (RC!)

Fig. | |.2d SuperDimension® CT planning module.Virtual bronchoscopy mode showing: right middle lobe (RC2).

Fig. | |.2e SuperDimension® CT planning module.Virtual bronchoscopy mode showing: left mair carina (LC2).

Fig. | 1.2f SuperDimension® CT planning module.Virtual bronchoscopy mode showing: carina of the left apical basal segment (LC LB6—LB8).

Fig. | |.2g SuperDimension® CT planning module. Virtual bronchoscopy mode showing: the target located.

Fig. | 1.3a Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning module: main carina.

Fig. | 1.3b Marking of landmarks during virtual bronchoscopy on the superDimension® CT plannin; module: right upper lobe carina (RC!).

Fig. | 1.3 Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning module: right middle lobe carina (RC2).

Fig. | 1.3d Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning module: carina of the right apical basal segment marked (RC RB6—RB8).

Fig. | 1.3e Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning module: left secondary carina (LC2).

Fig. | 1.3 Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning module: carina between the left apical basal (LB6) and basal segments (LC LB6—LB8).

Fig. | |.5a Registration process with the module showing virtual bronchoscopy and locatable guide on a real-time bronchoscopic image co-registering the following: the main carina (MC). Fig. | 1.4 Electromagnetic board with the field depicted with white arrows and the locatable guide as a black arrow moving through the field.

The bronchoscopy is performed with the patient lying flat on an electromagnetic board (Fig, | 1.4). This creates a magnetic field, and the electromagnetic tracker placed through the instrument channel of the bronchoscope can be used to detect the position of the tip in this electromagnetic field. The navigation phase involves registering the same andmarks marked on the navigation module in the patient. The magnetic tracking guide is inserted through the bronchoscope, and at the procedure the same landmarks are marked, i.e. the main carina, the right upper lobe carina, the middle lobe carina, the left main carina and the carina between the left basal segments and the apical segment of the left lower lobe (Fig. 11.5). This is achieved by applying the magnetic locator guide at the carina and using a foot pedal to mark this point. The system then correlates the two pieces of data and co-registers the information.

Fig. | 1.5b Registration process with the module showing virtual bronchoscopy and locatable guide on a real-time bronchoscopic image co-registering the following: the right upper lobe carina.

Fig. | 1.5c Registration process with the module showing virtual bronchoscopy and locatable guide on a real-time bronchoscopic image co-registering the following: the right middle lobe carina (RC2).

Fig. | |.5d Registration process with the module showing virtual bronchoscopy and locatable guide on a real-time bronchoscopic image co-registering the following: the carina between the apical basal segment (RB6) and basal segments.

Fig. | 1.5e Registration process with the module showing virtual bronchoscopy and locatable guide on a real-time bronchoscopic image co-registering the following: the left secondary carina (LC1!).

Fig. | |.5f Registration process with the module showing virtual bronchoscopy and locatable guide on a real-time bronchoscopic image co-registering the following: the carina between the apical basal segment (LB6) and basal segments.

Fig. | 1.7a Navigation module showing the positions of the locatable guide on the CT sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the steerable catheter: | 0 o’clock position. After inserting the catheter with the locatable guide to the appropriate bronchial segment, the navigation system can be used to guide it to the target location. The system shows the location of the guide on coronal, axial and sagittal CT sections (Fig | 1.7). There is also a screen which advises the operator in which direction, i.e. | o'clock or 2 o'clock etc., to manipulate the steerable catheter A ‘bull’s eye’ appears when the locatable guide is within 10 mm of the target location. Once the target is reached the catheter is locked into position. The scope is held firmly in position, the locatable guide is removed and instruments such as cytology brushes, transbronchial needles and biopsy forceps can be passed through the steerable catheter in order to obtain samples from the target location. Where facilities exist, radial ultrasound probes or fluoroscopy can be used to verify the location of the catheter tip or locatable guide.

Fig. | 1.7b Navigation module showing the positions of the locatable guide on the CT sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the steerable catheter: 8 o’clock position, guiding the catheter towards the right upper lobe.

Fig. | 1.7¢ Navigation module showing the positions of the locatable guide on the CT sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the steerable catheter: 5 o’clock position guiding the catheter towards the right upper lobe.

Fig. | 1.7d Navigation module showing the positions of the locatable guide on the CT sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the steerable catheter: locatable guide close to the target site — the green dot appears close ‘o the steering guide (orange circle).

Fig. | 1.7e Navigation module showing the positions of the locatable guide on the CT sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the steerable catheter: locatable guide within | | mm of the target site as indicated by green dot being close to the steering guide.

With the latest iLogic™ software, the navigation module now has six possible screen modes It creates a bronchial tree diagram with a route map to the target. After the registration process, the virtual bronchoscopy image displays the pathway to the target (Fig. | 1.8). This facilttates navigation of the bronchoscope to the wedge position. From that point onwards the images can be set to display the clock face with CT sections to guide the steerable catheter to the target site. A close-up image can be selected when the locatable guide is within 10 mm of the target site to guide the optimal position for sampling.

Fig. | |.8c Latest iLogic™ software showing the six-screen mode with axial, coronal and sagittal CT views, with the position of the locatable guide and the virtual bronchoscopy with the route to the target.

Fig. | |.8d Latest iLogic™ software showing the six-screen mode with close-up CT views when the locatable guide is close to the target.

Fig. |2.1d Uncuffed endotracheal tube slid over to the proximal aspect of the bronchoscope. Fig. |2.1¢ Uncuffed endotracheal tube with Murphy eye slid over the distal aspect of the bronchoscope. Fig. |2.la Uncuffed endotracheal tube (size 8.0, full length 32 cm). Fig. |2.1b Endotracheal tube cut to marker for oral intubation (25 cm).

An endotracheal tube with a Murphy eye may be useful in some circumstances. Depending on the position it may allow ventilation of the contralateral lung during interventional procedures. Furthermore, any debris or tumour fragments would then tend to fall back into the lung being treated and not into the contralateral lung.

Fig. 12.2a Sequence of images demonstrating intubation: topical lidocaine 2 per cent applied to the vocal cords. The endotracheal tube is moved to the distal aspect of the bronchoscope and over the vocal cords. The images in Figure | 2.2 show the sequence of steps involved in intubation from topical application of lidocaine to the vocal cords through to insertion of the endotracheal tube through the vocal cords and into the trachea.

Fig. |2.2b Sequence of images demonstrating intubation: uncuffed endotracheal tube inserted through the vocal cords and into the trachea.

Fig. 12.2¢ Sequence of images demonstrating intubation: endotracheal tube inserted into the trachea

Fig. |2.3a Sequence of images showing common problems with intubation: endotracheal tube caugh on arytenoid cartilage.

Fig. |2.3b Sequence of images showing common problems with intubation: endotracheal tube caugh on corniculate cartilage.

The Cohen endobronchial balloon blocker has a tip that can be deflected (Fig. | 2.4). | can be inserted through an adaptor which attaches to the distal end of the endotrachea tube. The balloon catheter is inserted through the side-angled port of this adaptor anc through the endotracheal tube into the right or left main bronchus. It naturally tend to go down the right main bronchus but can be manipulated or steered by a smal degree in order to place the balloon in the left side. There is a gauge on the proxima end which, when turned, pulls on an in-built thread-wire and causes the distal tip o the catheter to bend (Fig. 12.5). The proximal and distal aspects of the catheter are marked with an arrow in the direction in which the tip tends to deflect. Therefore the blocker should be inserted through the endotracheal tube so that the arrows denotins direction of deflection are in the appropriate position. Fig. |2.5b Cohen tip deflecting balloon catheter shown ir various positions: dial moved by 45° anticlockwise causing a small deflection in the balloon tip. Fig. |2.5a Cohen tip deflecting balloon catheter shown in various positions: neutral position.

Fig. |2.5e Cohen tip deflecting balloon catheter shown i various positions: inserted into the left main bronchus with the balloon inflated. Fig. |2.5c Cohen tip deflecting balloon catheter shown in various positions: dial moved by 90° anticlockwise causing a deflection in the balloon tip.

Fig. |2.6a Sequences showing the insertion of a Cohen tip deflecting balloon catheter into the left main bronchus: inserted into the right main bronchus. The sequence of images in Figures | 2.6 and | 2.7 shows insertion of the balloon catheter into the left main bronchus. Occasionally the balloon catheter tip has a tendency to repeatedly go down the right side and then catch on the cartilage rings or carina preventing correct placement. Figure |2.8 demonstrates this problem and also how it can be overcome by manipulation of the balloon tip and applying gentle torsion to the balloon catheter. Inflation of the balloon may also help when a balloon is partly inserted into the desired airway but stuck on a cartilage ring.

Fig. |2.6d Sequences showing the insertion of a Cohen tip deflecting balloon catheter into the left main bronchus: positioned in the left main bronchus with balloon being inflated. Fig. |2.6c Sequences showing the insertion of a Cohen tip deflecting balloon catheter into the left main bronchus: being manipulated into the left main bronchus. Note the arrow at the tip of the catheter, which indicates the direction of deflection.

Fig. |2.6b Sequences showing the insertion of a Cohen tip deflecting balloon catheter into the left main bronchus: being withdrawn from the right main bronchus to the carina and then being manipulated into the left main bronchus.

Fig. |2.7a Cohen tip deflecting balloon catheter: being inserted via the endotracheal tube and into the lower trachea — the tip is directed into left main bronchus.

Fig. |2.7¢ Cohen tip deflecting balloon catheter: in the left main bronchus with the balloon being inflated. Fig. |2.7b Cohen tip deflecting balloon catheter: in the left main bronchus.

Fig. |2.8a Sequence showing difficult insertion of the Cohen tip deflecting balloon catheter into the left main bronchus: the balloon catheter first enters the right main bronchus.

Fig. |2.8b Sequence showing difficult insertion of the Cohen tip deflecting balloon catheter into the left main bronchus: the balloon catheter is withdrawn from the right main bronchus.

Fig. |2.8c¢ Sequence showing difficult insertion of the Cohen tip deflecting balloon catheter into the left main bronchus: the catheter tip is caught on the cartilage ring above the carina.

Fig. 12.8d Sequence showing difficult insertion of the Cohen tip deflecting balloon catheter into the left main bronchus: the balloon catheter inserted in an inverted position into the left main bronchus. Balloon inflation is being attempted to try to push the tip down into the left main bronchus. The balloon is finally inserted down into the left main bronchus. The balloon is then inflated to check position.

Fig. |2.9a Sequence of images showing effects of inflating a balloon that is too proximal, with the tendency for the balloon to pop out of the left main bronchus. The series of images in Figure 12.9 shows the problems of overinflation or incorrec fixation of the balloon.This emphasizes the need to check placement by inflation of the balloon prior to commencing the interventional procedure.

Fig. |2.9b The problem is corrected by inserting the balloon further into the left main bronchus.

Fig. 12.1 le Arndt balloon catheter and bronchoscope: bronchoscope being withdrawn after positioning the Arndt balloon catheter in the left main bronchus and inflating it. Fig. 12.1 | Arndt balloon catheter and bronchoscope: being directed into left main bronchus.

Fig. 12.1 1d Arndt balloon catheter and bronchoscope: positioned in the left main bronchus. Fig. 12.1 1b Arndt balloon catheter and bronchoscope: being directed into left main bronchus.

Fig. |2.1 la Arndt balloon catheter and bronchoscope: in neutral position in the trachea.

Fig. 12.1 2a Active brisk bleeding from right lower lobe managed with a cycle of suction, ice-cold saline and dilute adrenaline. The Cohen balloon blocker is inflated to isolate the right lung.

Fig. 12.12b Cohen balloon blocker inflated to isolate right lung with suction of blood from the remaining airways.The balloon is deflated after 2 minutes. Saline is instilled and gentle suction is applied proximally in the right lower lobe after deflation and removal of the Cohen balloon.

Fig. 13.2a Coagulation probe and tumour visible in the left main bronchus. Note the green band protruding from the bronchoscope. The coagulation probe is inserted into the centre of the tumour. Low-voltage, high-amperage current leads to coagulation, whereas cutting involves high voltage and low amperage. A blend of these two modes is used to achieve tissue destruction with coagulation. Electrocautery allows rapid ablation of the tumour and restoration of airway patency. Hence, electrocautery can be used in an acute setting where rapid restoration of airway patency is required. A coagulation probe is a blunt probe and is usually the first tool used (Fig. 13.2). A test patch on normal mucosa derives some information and allows the power setting to be adjusted so that a small white blanched area is obtained on application of the electrocautery probe (usually 10-30 watts). Contact with the tumour with a 3-5 second activation should also provide some information about tumour susceptibility, friability and potential bleeding risk. Elongated or plaque-like lesions are amenable to treatment with a coagulation probe. It may also be used to free up tumour from edges of the airway wall.

Fig. 13.2 The coagulation probe is activated in a blend mode (combination of coagulation and cut) and moved from side to side to free the tumour from the airway wall. There is some debulking of tumour with the distal airway visible in the superolateral aspect. Fig. |3.2b The edge of the tumour being treated with the coagulation probe in order to free the tumour from the airway.The coagulation probe is being used to free the lateral edge of the tumour and then the superior margin.

Fig. |3.3a Electrosurgical snare placed around polypoid tumour originating from the left main bronchus into the trachea.

Fig. 13.3d Resected tumour being withdrawn through the endotracheal tube with the bronchoscopic view from the trachea showing complete resection of tumour from the left main bronchus. Fig. 13.3 Snare opened and looped over residual tumour.

Fig. 13.3b Once the snare is around tumour, the electrocautery is activated in 2-second bursts while the snare is slowly tightened around the tumour. The snare cuts through the tumour and is removed.

Fig. |3.4a Argon plasma coagulation activated in the airway. Note that the first black marking band is visible, indicating that the catheter is a safe distance from the tip of the bronchoscope.A test area of coagulation is performed in the airway to check the energy level selected.

Fig. 13.4c¢ Vascular right middle lobe tumour treated with spray coagulation to the surface. The whole surface of tumour in the right middle lobe is coagulated. Fig. 13.4b Argon plasma coagulation of the vascular right middle lobe tumour.

Fig. |3.5a Cryoprobe activated while in contact with tumour and with an ice ball formed around the tip of the cryoprobe.

Fig. |3.5b The probe is allowed to thaw and then the cryoprobe is moved a few mm to the side anc activated again.

Fig. 13.5d The cryoprobe again moved a few mm and activated to create multiple overlapping area of treatment. Fig. |3.5c Note the formation of the ice-front around the tip of the probe. The ice-front enlarges with continued application of the cryoprobe. Regression of the ice-front is observed after switching off the probe.

Fig. 13.6a Necrotic tumour almost completely occluding the right main bronchus.The cryoprobe is activated after contact with the tumour.

Fig. |3.6e Significant debulking of the tumour with cyclical freezing and breaking off adherent frozen tumour. Fig. 13.6d A further piece of tumour in contact with the cryoprobe is frozen and pulled off.

Fig. |3.6f Restoration of patency in the right main bronchus with pus arising through the reopened airway.

Fig. |3.6c Ice-front formed in the tumour in the area of contact with the cryoprobe. The adherent tumour is being gently pulled to detach another piece of tumour. Fig. 13.6b The tumour adheres to the tip of the cryoprobe and the adherent tumour is broken off. The cryoprobe with adherent tumour and bronchoscope are removed as one unit via the endotracheal tube.

Endobronchial or endotracheal stents are used where airway obstruction is caused by extrinsic compression from a tumour They may also be required after endobronchial tumour debulking if the airway has lost its support structure and also if the tumour is prolapsing through a lobar bronchus and occluding the main bronchus. A variety of different stents exist, but the main group are metallic or non-metallic stents. Metallic stents themselves are subdivided into covered and uncovered stents. Non-metallic stents usually require insertion with a rigid bronchoscope and are not discussed further here. Metallic stents are usually made from nitinol (a nickel titanium alloy) (Fig. 14.1). B Direct vision

Fig. |4.2g Full deployment of the stent under bronchoscopic control. The patient is then re-bronchoscoped by inserting the bronchoscope through the vocal cords via the oral route adjacent to the endotracheal tube. This allows the stent to be passed through the endotracheal tube and manipulated in the trachea or bronchi while maintaining vision with the bronchoscope (Fig. 14.3). The stent is fed over the guidewire through the endotracheal tube and into the desired location in the airways. The stents have markers highlighting the proximal end of the stent within the delivery catheter. Before the procedure, a CT scan of the thorax should be carefully studied to ensure that stenting is a suitable treatment option. For example it is important to ascertain that there is a good patency of the airways beyond the stenosis. The size and length of the stents required can also be determined by the CT scan. This is complemented by careful examination of the airways at bronchoscopy.

Fig. | 4.3h, i Covered nitinol stent in the airway with a proximal silk thread which can be used to grab the stent and manipulate it into a more proximal position (the stent should not be pushed distally). Fig. | 4.3g Silicon-coated nitinol stent with a suture in the proximal aspect. Fig. 14.3e Delivery catheter with the stent positioned so that the yellow markers for the proximal limits of the stent are above the area of stenosis. Distal and proximal aspects of the stent are inspected.

Fig. |4.3d Guidewire advanced distally into the right main bronchus while sequentially withdrawing the bronchoscope. Delivery catheter with the stent advanced over the guidewire under bronchoscopic vision with 2.8 mm hybrid fibrescope (round images).

Fig. |4.3¢ Concentric infiltration and narrowing of the right main bronchus. Guidewire inserted into the right main bronchus.

Fig. | 4.4a Following intubation, the guidewire is inserted into the narrowed right main bronchus. The stent is carefully positioned so that the proximal marker is visible proximal to the area of narrowing under direct vision and the stent is carefully deployed. A variety of deployment mechanisms exist and in principle all use the technique of withdrawing the overlying protective catheter (Figs 14.4 and 14.5). Please check and familiarize yourself with the manufacturer's instructions. We recommend fixing the position of your arm, for example, holding the elbow fixed over your abdomen and then pulling back the overlying sheath over the stent. This is an important step for correct placement as there is a tendency to push forward during deployment and this leads to the stent being deployed further into the airways than desired. The stent should be deployed in a steady manner under direct vision so that any small adjustments can be made to ensure that the stent is optimally positioned prior to full deployment.

Fig. |4.4c An uncovered nitinol stent which has been fully deployed with an improvement in the calibre of the right main bronchus. Fig. |4.4b The stent is inserted through the narrowed right main bronchus and gradually deployed by removing the silk thread around the stent.

Fig. |4.5d Covered nitinol stent being positioned in the trachea.The yellow marker defines the proximal limit of the stent and the stent is carefully positioned in the trachea to fully seal the tracheo- oesophageal fistula. Fig. 1 4.5c Tracheo-oesophagedl fistula visible in the posterior aspect of the upper trachea. Stent inserted over the guidewire under visual control with a thin hybrid bronchoscope.

Fig. 14.5e Steady deployment of stent in the trachea with repositioning of the stent in order to ensure an adequate seal of the tracheo-oesophageal fistula.

Complications of stents Endotracheal and endobronchial stents can also be positioned and deployed under fluoroscopic guidance (Figs. 14.6 and 14.7). The initial steps are similar to deployment of the stents under direct vision. Once the guidewire is placed through the appropriate narrowed lobar bronchus, the stent is fed over the guidewire and through the endotracheal tube. Under fluoroscopic guidance the stent is advanced and positioned over the desired area. The stents usually have proximal and distal radiological markers, which allow the accurate positioning of the stent under fluoroscopic control. The deployment of the stent is again the same as with direct vision except on this occasion the fluoroscopy provides the visual guidance. Stents can also be placed with a combination of direct visual guidance and fluoroscopy. This may be more appropriate in circumstances where the distal aspect cannot be visualized at bronchoscopy even with an ultra-fine bronchoscope. Malignant endobronchial tumour involvement is the most common indication for tracheal or bronchial stents. Hence the covered variety is more frequently utilized. However, these stents impair normal mucociliary clearance and hence are prone to complications such as mucus retention and bio-fouling of the stents. This is where bacteria grow mucoid biofilms on the inner surface of the stent (Fig. 14.8). A further complication of this phenomena Is halitosis. These stents are also prone to displacement.

Fig. 14.9b The stent has migrated to the trachea and is then removed by grasping with biopsy forceps. Fig. |4.9a Migration of stent inserted into the right main bronchus.With coughing the stent moves up into the trachea.

Other complications of stents include development of granulation tissue and overgrowth from the tumour itself at the proximal and distal margins. The stents are exposed to significant forces during coughing and also through the respiratory cycle (Fig. 14.9). Stent fractures are a potential complication and a difficult problem as the stent needs to be removed, usually piecemeal by removing the individual wires carefully with a rigid bronchoscope.

Fig. 14.10a CT scan in a patient with left pneumonectomy and narrowed right main bronchus.

Fig. |4.10b Circumferential narrowing of the right main bronchus in a patient with left-sided pneumonectomy. Insertion of balloon dilator through the narrowed right main bronchus.

Fig. 14.10c Inflation of a balloon dilator which has been inserted through the narrowed right main bronchus. There is partial improvement in calibre in the right main bronchus.

This is defined as greater than |0 per cent variation in the emphysematous destruction between the upper and lower lobes.A more accurate way of assessing this is by applying a density mask to lung windows and areas with an attenuation value of less than 910 Houndsfield units on 10 mm computed tomography (CT) sections (Fig. 15.1).

Fig. |5.3a Delivery catheter for the Zephyr valve with blue side flanges measuring 4 mm (smallest flange) and 7 mm (largest flange). Measurement of the airway segment with a 4 mm catheter demonstrates that the segment diameter is larger than the small flange (4 mm) and smaller than the larger (7 mm) flange and hence suitable for a 4 mm valve, which has a range of 4—7mm.The delivery catheter with a blue margin demarcating the proximal limit of the valve. Once the valve is loaded into the delivery catheter, it is manoeuvred into the appropriate airway segment (Figs 15.2 and 15.3).We recommend using the technique of partial deployment. The valve is very slightly deployed so that it protrudes through the distal tip of the delivery catheter The valve can then be wedged against the carina within the segment to be treated and deployed. This ensures that the valve is correctly positioned so as to occlude the whole segment. Full deployment in a single manoeuvre can sometimes force the valve into a particular subsegment leading to only partial closure of the segment and this in turn will prevent full lobar atelectasis.

Fig. |15.3b Slow deployment of the Zephyr valve after wedging against a subsegmental carina.

Fig. |5.3c The Zephyr valve which is closed in inspiration and open in expiration, therefore allowing air out.

he main complications observed are acute exacerbations. Other acute complication iclude a pneumothorax. In the long term, development of granulation tissue aroun ne valves has been observed. In some cases, there may be secondary colonizatio! f the valves with bacteria such as Pseudomonas or fungal species such as Aspergillu Fig. 15.4). B Intrabronchial valve The intrabronchial valve is an umbrella-shaped device, which is available in sizes of 5, 6 and 7 mm (Fig. 15.5). The manufacturers have been promoting the strategy of airflow re-direction and hence recommend that one subsegment is left patent on the right side and the lingular is untreated on the left side. The valves have a lower margin of error as oversizing causes ruffling of the valve and hence incompetence. Undersizing does not allow a proper seal of the airway either. The valve therefore requires accurate sizing of the airways using a balloon sizing kit. The valves can be easily removed with grasping forceps. The proximal duck-billed valve can be grasped with the forceps and the valve pulled out as a whole unit with the bronchoscope.

Intubation of all patients undergoing the procedure is recommended. This provides a secure airway but also facilitates removal of valves if required during the procedure. The treatment sites are usually planned according to the findings of a spiral CT scan and a ventilation- perfusion scan.The lobes with the greatest destruction are targeted. The calibration balloon is inserted through the instrument channel and inflated in the target segments until the balloon fits snugly in the segment (Fig. 15.8). The balloon is then moved back and forth in order to determine whether the balloon is correctly inflated. Overinflation leads to some indentation in the balloon.Where there is underinflation a gap may be visible.

The syringe is then exchanged for a 500 uL glass syringe and filled with exactly 500 uL of normal saline. The saline-filled balloon is then calibrated using a sizing template. The balloon is carefully inserted and inflated to fit different-sized templates from 3,5, 7 and 9 mm holes and the volume of saline in the glass syringe is recorded for each size (Fig. [5.7). In this way a calibration curve for the particular balloon is produced which can then be used to size the airways in a patient. Patient preparation

Fig. 15.10a Delivery catheter inserted into the left main bronchus. There is a small gap between the delivery rod and the valve that is closed in the delivery catheter. The catheter is advanced into the left apicoposterior segment (LB| + 2) of the upper lobe.

Fig. 15.10b The delivery catheter is slowly withdrawn back and the yellow line (proximal marker for valve leaflet) is positioned at the origin of the bronchial segment. The valve deployed in left apicoposterior segment (LB| + 2) of the upper lobe.

Fig. |5.!0c Catheter tip inserted into the anterior segment of the left upper lobe (LB3).

Fig. 15.10d Valve in the subsegment of the left anterior upper lobe (LB3).

Fig. 15.1! la Incorrectly positioned intrabronchial valve. Removal of valve using biopsy forceps which are first positioned over the intrabronchial valve. The intrabronchial valve can be easily removed if it has been incorrectly positioned ot if the valve size is incorrect (Fig. 15.11). It can also be removed if the patient does not improve with intervention or ifthey develop any complications such as post-obstructive infection. The biopsy forceps are inserted through the instrument channel and used tc grasp the central rod located on the valve. The valve is then pulled close towards the bronchoscope and the unit is removed in its entirety. Do not attempt to pull the valve through the instrument channel as it will not be possible and there is a risk of damagins the distal portion of the bronchoscope.

Fig. 15.1 1b Biopsy forceps grasp the central rod on the intrabronchial valve. The intrabronchial valve is pulled closer to the bronchoscope and removed through the endotracheal tube as one unit.

The most common complication is exacerbation of chronic obstructive pulmonary disease (COPD) which occurs in up to |0 per cent of patients following insertion of end spe obronchial valves. The patient presents with increased breathlessness, cough, wheezy Is or even mucous hypersecretion. Treatment is with steroids and antibiotics. The other acute complication is that of pneumothorax. It usually resolves with conservative management, requiring intercostal drainage, but only in a small proportion is there ap rolonged air leak of more than 7 days. Haemoptysis and haemorrhage are less common and are usually related to incorrect placement of the valve where the + pro truding section of the valve is rubbing against the airway mucosa. Similarly, valve displacement can occasionally occur but the incidence can be reduced by correct valve replacement. Granulation tissue also develops in some patients with endobronchial valves. We have observed chronic infection such as Aspergillus infection around the valve, which usually resolves with removal of the valves.

Fig. |5.14a Catheter inserted into the apicoposterior (LB! + 2) segment of the left upper lobe. Note the radio-opaque tip of the catheter. PheumRx® coil being advanced through the catheter.

Fig. |5.14b Overlying catheter being steadily withdrawn with the PneumRx® coil reverting to its original shape. Grasping forceps are visible at the distal end of the bronchoscope.

Fig. 15.1 4c Grasping forceps are opened releasing the PheumRx® coil. The forceps are then withdrawn. The catheter is repositioned in another airway subsegment and the guidewire is advanced into the bronchial segment.

Fig. 15.14d The guidewire and overlying catheter advanced into the bronchial subsegment.

Fig. |5.14e The catheter being advanced over the guidewire until resistance is felt or the catheter tip is about 3 cm from the pleural edge. The guidewire is withdrawn to the tip of the catheter and the length is estimated with the guidewire which has radio-opaque markers every 25 mm.The guidewire is completely withdrawn leaving the catheter in place.

Fig. 15.1 4f The PneumRx® coil being advanced through the catheter.The overlying catheter is fully withdrawn with the PneumRx® coil being fully deployed. The distal aspect of the PheumRx® coil is still grasped by forceps.

Fig. 15.1 4g The grasping forceps are opened to release the PneumRx® coil with the distal tip of PneumRx® coil visible in the airway.

The area around the newly created passage between the airway and alveolar parenchyma is carefully re-inspected with the Doppler probe to ensure that there are no blood vessels in close proximity to the passage. This is important as release of trapped gas when the hole is made might bring vessels closer than would be safe for stent insertion.

Fig. |5.16a Exhale® Doppler catheter first identifies a blood vessel (positive control signal to ensure the Doppler probe is functioning). The Exhale® transbronchial dilation needle is inserted through the avascular area identified by the Doppler probe.

Fig. |5.16¢ Hole created by the Exhale® transbronchial needle. The Exhale® Doppler probe checking around the hole created to ensure that it is still free of blood vessels. Fig. 15.16b Balloon dilatation with the Exhale® transbronchial needle after insertion of the needle through the airway into the lung parenchyma.

Fig. |5.16e The stent visible through the dilated balloon.The balloon is deflated after deployment of the stent followed by removal of the delivery catheter. The Exhale® drug-eluting stent supporting the hole that was created. Emphysematous lung is visible through the stent. Fig. |5.!6d Exhale® drug-eluting stent on the delivery catheter inserted through the hole created and positioned midway through the stent before balloon inflation. Deployment of the stent by inflation of the balloon catheter. It is important to ensure that black marker on the balloon catheter is visible ir order to ensure correct inflation of the balloon.

The main limitation of the stents is that they become occluded over time (usually within 3 months). Figure 15.17 shows epithelialization of the stents in various stages.

The patient has an earthing plate attached to the thigh or lower back. The Alair catheter is introduced through the instrument channel of the bronchoscope and inserted into the most distal accessible airway. Success of the treatment depends on comprehensive treatment of the airway, with care taken not to apply repeated treatments to the same airway. This relies on a systematic approach. In the clinical trials the treatments were administered over three sessions, treating the right lower lobe, the left lower lobe and then the two upper lobes anc lingula by bronchoscopy every 3 weeks. Our approach, for example, for the right lower lobe is to treat RB|0 (right posterior basal bronchus) first, using the BF260 bronchoscope (external diameter 4.3 mm) so that the distal subsegments can be assessed. The technique uses the Alair radiofrequency controller and Alair catheter, which delivers the energy to the airways (Fig. 15.18). The energy delivered heats up the local tissue to around 65°C and selectively reduces the airway smooth muscle bulk. There is some mucosal oedema which recovers over the next 7—|4 days.

Fig. 15.19a Alair catheter opened in the distal aspect of the airway.The energy is delivered when the catheter is expanded and in full contact with the airways. The catheter is partially closed and moved proximally by about 4 mm.The catheter is then re-expanded and a further cycle of energy is delivered. In this stepwise manner, the whole length of the airway and any side branches are treated.

Fig. 15.19b Alair catheter in contact with the airways.The bare section through which the energy is delivered can be seen.The catheter is fully expanded against the airways. Note the central green wire and four equally spaced, partially insulated wires. The radiofrequency controller delivers the energy over a |0-second period and any loss of contact of the catheter from the airway wall, due to coughing etc., will cause the radiofrequency controller to cut out with incomplete delivery of the energy.A further cycle can be delivered at the same site, but if there are two incomplete activations at one individual site then the catheter should be moved more proximally before further treatment.

To save space in the index, the following abbreviations have been used:

Kamal Singhal

The Indian Journal of Pediatrics, 2015

Bronchoscopes have markedly improved the diagnosis as well as therapy in pediatric pulmonary disorders. Two types of bronchoscopes are available; flexible and rigid, with their own advantages and disadvantages. Depending on the clinical need and availability of skills, choice is made between the two. Typically, rigid scopes are largely used by the surgeons (pediatric or otolayngologists) while flexible bronchoscope stays in the domain of the pediatric pulmonologist and intensivists. Rigid scopes may be more versatile than flexible bronchoscopes in removing the foreign bodies from the airway. Flexible bronchoscopes on the other hand can even be introduced through an endotracheal tube. At times, use of both scopes may be required in a given patient for optimal results. Bronchoscopes give us a means to visualize the inside of the airway, which can be very informative for assessing various pathologies affecting the airways. Apart from the visualization of the parts of the airway tree and their structure as well as patency, it can also be used to take tissue biopsy specimens, collect secretions from the airways and bronchoalveolar lavage which can also get cellular elements from the distal alveoli. In the past few decades, more and more instruments are being used for expanding the utility of flexible bronchoscope for interventions ranging from bronchial toilet, foreign body removal, airway stenting and lasers or cryotherapy for airway lesions. The perinatologists have opened up more vistas and thrown newer challenges for using fiberoptic bronchoscopy (FB) for in utero tracheal occlusion in cases with diaphragmatic hernia. The vast applications of this tool makes it very relevant to pulmonary investigations and therapeutics.

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Flexible bronchoscopy

Pallav Shah

Medicine, 2008

Bronchoscopy is an essential tool in respiratory medicine, which allows visualization and sampling from the main airways. It has an important role in the evaluation of suspected lung cancer, interstitial lung disease, persistent infection and the assessment of new pulmonary infiltrates in immunocompromised patients. It is a very safe technique which can be performed with or without conscious sedation. Recent developments have ranged from the improvement in image quality to integration of ultrasound. this has increased diagnostic sensitivity and facilitated imageguided biopsies of masses beyond the airways. the therapeutic role of bronchoscopy is also expanding from lung cancer to airways disease.

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Indications for performing flexible bronchoscopy: Trends over 34 years at a tertiary care hospital

inderpaul sehgal

Lung India, 2015

deployment of metallic stents and others) procedures. FB is an easy to perform and a safe procedure. [2,3] Unlike its rigid counterpart, FB can be performed under conscious sedation and local anesthesia thereby avoiding the attendant complications of general anesthesia. Moreover, FB is an outpatient procedure, thus obviating the need for hospitalization. Furthermore, FB can be used to observe upper lobes and bronchial subsegments that are not easily visualized by a rigid bronchoscope. [4-9] FB is now widely performed in India and is considered an essential requirement for a pulmonologist. Herein, we describe our experience of performing FB over the last three-and-a-half decades.

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Indications, clinical outcomes and complications of 1,949 flexible bronchoscopies

Marcia Jacomelli

Einstein (São Paulo)

Objective: To describe indications, clinical outcomes and complications of flexible bronchoscopy. Methods: A descriptive observational study of bronchoscopies performed at the endoscopy service of Hospital Israelita Albert Einstein. Demographic (age, gender and origin) and medical (indications and results of endoscopy and diagnostic tests, such as biopsy collection, lavage, cytology and culture) data were analyzed. Electronic medical records with incomplete data or reporting interventional procedures were excluded. Results: Over a three-year period (2013 to 2016), a total of 1,949 bronchoscopies were performed by respiratory endoscopy team and anesthesia specialists of the hospital. The mean age of patients was 57.7±21.9 years (range of 3 days to 99 years), with prevalence of males (56.4%). The procedures were mostly (86.3%) elective and 30.7% were carried out in the intensive care unit. Major indications for bronchoscopy were infection or secretion (42.4%), followed by suspected neoplasm (10.8%). Endoscopic changes were reported in 91.9% of cases, with more than one change described in approximately 6.9% of patients. Positive results were obtained via direct testing or culture in 36.3% and 53.9% of 1,399 bronchoalveolar lavages, respectively. The overall diagnostic yield (bronchoalveolar lavage and biopsy) was 72.6%. Mild adverse event rate was 7.2%. The rate of severe adverse events requiring additional intervention was 0.5% (pneumothorax, 0.4%; severe bleeding with patient death, 0.1%). Conclusion: Lower airway endoscopy is critical for respiratory disease assessment, diagnosis and treatment. Flexible bronchoscopy is associated with good diagnostic yield and minimal inherent risk.

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Rigid Bronchoscopy

Hervé Dutau

Clinics in Chest Medicine, 2013

Interventional pulmonology Interventional bronchoscopy Rigid bronchoscopy Flexible bronchoscopy Airway stenting Airway obstruction Airway stenosis

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Inexpensive anatomical trainer for bronchoscopy

Stefano di domenico

Interactive CardioVascular and Thoracic Surgery, 2007

Flexible fiberoptic bronchoscopy is an indispensable tool for optimal management of intensive care unit patients. However, the acquisition of sufficient training in bronchoscopy is not straightforward during residency, because of technical and ethical problems. Moreover, the use of commercial simulators is limited by their high cost. In order to overcome these limitations, we realized a low-cost anatomical simulator to acquire and maintain the basic skill to perform bronchoscopy in ventilated patients. We used 1.5 mm diameter iron wire to construct the bronchial tree scaffold; glazier-putty was applied to create the anatomical model. The model was covered by several layers of newspaper strips previously immersed in water and vinilic glue. When the model completely dried up, it was detached from the scaffold by cutting it into six pieces, it was reassembled, painted and fitted with an endotracheal tube. We used very cheap material and the final cost was 716. The trainer resulted in real-scale and anatomically accurate, with appropriate correspondence on endoscopic view between model and patients. All bronchial segments can be explored and easily identified by endoscopic and external vision. This cheap simulator is a valuable tool for practicing, particularly in a hospital with limited resources for medical training.

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Flexible Bronchoscopy Assisted by Noninvasive Positive Pressure Ventilation

Henri Colt

Critical Care Nurse, 2011

endotracheal intubation in order to ensure airway patency and minimize risks of procedure-related respiratory insufficiency. 4-7 In many instances, however, bronchoscopy can be safely performed while the patient receives NPPV, sparing patients the discomfort and risks of refractory hypoxemia, intubation, and mechanical ventilation. The limited available published evidence indicates that NPPVassisted flexible bronchoscopy is used about 3 times per month in tertiary academic centers. Critical care nurses have an essential role in the preparation and performance of this procedure, as well as in surveillance after the procedure, and, as part of the multidisciplinary health care team, in patient care decisions. The objectives of this article, therefore, are to review the physiological basis for NPPV-assisted bronchoscopy; describe its indications, contraindications, and techniques; and identify ways in which critical care nurses can further influence patient care before, during, and after this airway procedure.

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Operative rigid bronchoscopy: indications, basic techniques and results

Domenico Galetta

Multimedia Manual of Cardiothoracic Surgery

Palliative airway treatments are essential to improve quality and length of life in lung cancer patients with central airway obstruction. Rigid bronchoscopy has proved to be an excellent tool to provide airway access and control in this cohort of patients. The main indication for rigid bronchoscopy in adult bronchology remains central airway obstruction due to neoplastic or non-neoplastic disease. We routinely use negative pressure ventilation (NPV) under general anaesthesia to prevent intraoperative apnoea and respiratory acidosis. This procedure allows opioid sparing, a shorter recovery time and avoids manually assisted ventilation, thereby reducing the amount of oxygen needed, while maintaining optimal surgical conditions. The major indication for NPV rigid bronchoscopy at our institution has been airway obstruction by neoplastic tracheobronchial tissue, mainly treated by laser-assisted mechanical dissection. When strictly necessary, we use silicone stents for neoplastic or cicat...

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Flexible Bronchoscopy Assisted by Noninv

Henri Colt

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Pediatric flexible and rigid bronchoscopy in European centers-Availability and current practice

Kostas Priftis

Pediatric Pulmonology, 2017

Aim: Eighteen years have passed since the last European survey concerning practices in pediatric bronchoscopy was conducted. Therefore, members of the European Respiratory Society (ERS) Pediatric Bronchology Group 7.7, initiated the "European Pediatric Bronchoscopy Survey 2015," which aimed to assess the current state of this evolving diagnostic and therapeutic procedure in the field of pediatric respiratory medicine. Method: A questionnaire was sent to national representatives of 44 European countries with the request to distribute it to all centers performing pediatric bronchoscopies. Questions concerned the following areas of interest: number of procedures, personnel and technical equipment, indications, complications, anesthesia, and diagnostic possibilities. Results: In total, 198 European centers from 33 European countries participated in the survey. From 2012 to 2014 a total of 57 145 bronchoscopies were reported. Both flexible and rigid techniques were available at most of the centers. The most frequently mentioned indications were suspected aspiration, infection, radiographic abnormalities, airway obstruction, and cough. Hypoxemia, airway obstruction, and cough were the most common complications mentioned, followed by airway hemorrhage. Most centers were able to perform bronchoalveolar lavage (BAL) and endobronchial biopsies and some performed more special procedures, such as transbronchial biopsies. Interventions like balloon dilation, laser procedures, or stent placement were less common and rarely available. Conclusion: Compared to the 1997 survey, our results suggest that pediatric bronchoscopy has become more widely available and established in Europe. Different practices in individual countries suggest that more effort should be put on standardizing bronchoscopic procedures across Europe.

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Gilda Diaz-Fuentes

Global Perspectives on Bronchoscopy, 2012

A recent trend has been the emergence of "interventional bronchoscopy" and the "interventional bronchoscopist". These phrases denote a two-tier system in which one group of bronchoscopists perform "routine bronchoscopy" and the other performs special bronchoscopic procedures. Disease processes encompassed within this discipline include complex airway management problems, benign and malignant central airway obstruction, pleural diseases, and pulmonary vascular procedures. Diagnostic and therapeutic procedures pertaining to these areas include, but are not limited to, rigid bronchoscopy, transbronchial needle aspiration (TBNA), auto fluorescence bronchoscopy, endobronchial ultrasound (EBUS), transthoracic needle aspiration (TTNA) and biopsy, laser bronchoscopy, endobronchial electrosurgery, argon-plasma coagulation, cryotherapy, airway stent insertion, balloon bronchoplasty and dilatation techniques, endobronchial radiation, photodynamic therapy, percutaneous dilatational tracheotomy, transtracheal oxygen catheter insertion, medical thoracoscopy, and imaging-guided thoracic interventions. (Anders et al. 1988) Considering the prominence of FFB in the procedural armamentarium of pulmonary physicians (among other specialties) and the new developments of interventional bronchoscopy, it is important for the non-interventional pulmonologist and physician in pulmonary training to have a clear understanding of the role of FFB.

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Flexible bronchoscopy in a tertiary healthcare facility: a review of indications and outcomes

Ernest Kwarteng

Ghana Medical Journal, 2021

Objectives: Flexible Fibreoptic bronchoscopy (FFB) is a major diagnostic and therapeutic tool employed largely in respiratory medicine but its use in our country has been quite limited. We performed a retrospective review of the indications, overall diagnostic yield and safety of FFB at the Korle-Bu Teaching Hospital (KBTH).Study Design: Retrospective studyStudy Setting: Cardiothoracic Unit, Korle-Bu Teaching HospitalStudy Participants: All bronchoscopy records from January 2017 - December 2018Interventions: Eight-five bronchoscopy reports generated over a 2-year period were reviewed. Using a data extraction form, patient’s demographic details, indications for FFB, sedation given, specimen obtained and results of investigation, and complications encountered were recorded and entered into SPSS version 22. Descriptive analysiswas performed and presented as means and percentages.Results: Suspected lung cancer was the predominant indication for bronchoscopy requests (55.3%). Diagnostic ...

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Innovation in rigid bronchoscopy—past, present, and future

Thomas Gildea

Journal of Thoracic Disease

German laryngologist Gustav Killian performed the first "Direkte Bronchoskopie" using a rigid bronchoscope to extract a foreign airway body from the right main bronchus over a hundred years ago, transforming the practice of respiratory medicine. The procedure instantaneously became popular throughout the world. Chevalier Jackson Sr from the United States further advanced the instrument, technique, safety, and application. In the 1960s, Professors Harold H. Hopkins and N.S. Kapany introduced optical rods as well as fiberoptics that led Karl Storz to develop the cold light system improving endoluminal illumination, achievements that ushered in the modern era of flexible endoscopy. Several diagnostic and therapeutic procedures became possible such as transbronchial needle biopsy, transbronchial lung biopsy, airway electrosurgery, or cryotherapy. Dr. Jean-François Dumon from France advanced the use of Nd-YAG laser in the endobronchial tree and created the dedicated Dumon silicone stent introducing the whole new field of interventional pulmonology (IP). This major milestone revitalized interest in rigid bronchoscopy (RB). Now, advancements are being made in stenting, instrumentation, and education. RB robotic technology advancements are currently anticipated and can potentially revolutionize the practice of pulmonary medicine. In this review, we describe some of the most substantial advances related to RB from its beginning to the modern era.

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Competence in flexible bronchoscopy and basic biopsy technique

Annamaria Romano

Panminerva Medica, 2019

Diagnostic bronchoscopy and tissue sampling techniques using forceps (endobronchial biopsy [EBB] and transbronchial biopsies [TBB]) or needle aspiration (transbronchial needle aspiration-TBNA), all performed with a flexible bronchoscope, are the basic elements of any interventional procedure. The flexible fibrobronchoscopy allows the visualization of the airways and is used both for diagnostic and therapeutic purposes. The working channel of both fibrobronchoscopes with optical fibers and videobronchoscopes, even if of relatively small diameter, allows the insertion of various diagnostic and therapeutic accessories. Fiber optic systems have been widely replaced by video cameras using a miniaturized charge-coupled device camera positioned at the end of the scope that provides electronic transmission of images to a monitor. The indications for both diagnostic and therapeutic fibrobronchoscopy derive from a correct evaluation of symptoms and objective signs of the patient and from the correct interpretation of imaging methods. Although bronchoscopy techniques keep evolving at a rapid pace, basic procedures such as bronchoalveolar lavage, transbronchial lung biopsy, and transbronchial needle aspiration still play a key role in pulmonary disease diagnostics, and therefore, these methods must still be part of the training of interventional pulmonologists. Trainees will acquire a thorough knowledge of thoracic anatomy and become skilled in the interpretation of thoracic imaging, after which they will be given a theoretical and practical training course on virtual reality simulators, on animal or cadaver models, the effectiveness of which has been fully demonstrated by scientific studies. Specific DOPS tests have been developed for a qualitative evaluation of procedures on simulators, on animal models and on the patient.

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Loss of flexion during bronchoscopy: a physical experiment and case study of commercially available systems

Kashif Khan

Lung Cancer Management, 2017

During routine endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) procedures, especially with biopsy of lymph nodes in or around the left upper lobe, frequent reports have noted the loss of ultrasound image and needle angulation leading to an inability to biopsy nodes visualised by EBUS. The aim of this research was to investigate and compare this loss of angulation with commercially available scopes. Bench-top experiments and a clinical case study demonstrated the varying loss of scope angulation, flexibility and manoeuvrability with different scopes and biopsy instruments leading to procedural implications. Improvements in both the EBUS scope and needle characteristics are required to overcome this limitation which has implications in bronchoscope navigation and the diagnostic yield of EBUS-TBNA.

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Flexible bronchoscopy in children: Utility and complications ScienceDirect

Khalid Altirkawi

Background and objectives: The flexible bronchoscope has become widely used by pediatric pulmonologists as a diagnostic and therapeutic tool. Nevertheless, there are several gaps in our knowledge to help refine its use and reduce its complications. In this study, we aimed to evaluate the utility and complications of pediatric bronchoscopy. Design and setting: We conducted a retrospective review of bronchoscopy cases between March 2006 and April 2015 at a tertiary care medical center (King Fahad Medical City). One-hundred forty nine patients were studied. Patients and methods: We evaluated how bronchoscopy contributed to the patients' diagnosis, assessed the accuracy of bronchoalveolar lavage white blood cell count (BAL WBC) to differentiate between infectious and non-infectious conditions, assessed the ability of clinical factors to predict high risk of desaturation during bronchoscopy, and finally summarized the reported procedural complications. Results: We found pediatric bronchoscopy was a crucial diagnostic (confirming, ruling out, and discovering unexpected diagnosis) and therapeutic tool. The accuracy of BAL WBC counts is poor (AUC (95% CI) Z 0.609 (0.497e0.712)); however, using two cutoff values (10 WBCs (sensitivity Z 84.44% and specific ity Z 2 9.27%) to rule out, and !400 WBCs (sensitivity Z 33.33% and specificity 81.49%) to rule in infection) helped in early differentiation between infectious and non-infectious conditions. From the factors that we test, none we found predictive of desaturation. The most common procedural complication was International Journal of Pediatrics and Adolescent Medicine (2016) 3, 18e27 desaturation (pooled incidence (95% CI) Z 13 (8e19)%) followed by cough, mild airway bleeding, and spasm. Conclusions: Flexible bronchoscopy is an important and relatively safe diagnostic and therapeutic tool in pediatric medicine, and utilization of this service should be encouraged after a careful consideration of which patient needs this procedure and a rigorous estimate of its pros and cons.

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Flexible bronchoscopy through Rigid bronchoscope for airway foreign body: a good marriage of convenience!

Kamal Singhal

2020

A 12-year-old girl presented with chronic suppurative lung disease secondary to an old forgotten, foreign body (plastic whistle) in the right lower lobe bronchus, confirmed by Contrast enhanced computer tomography (CECT) chest. Rigid bronchoscopic removal was attempted twice but the foreign body could not be removed. Under general anesthesia, a flexible bronchoscope was inserted through the rigid bronchoscope and the foreign body was grasped and removed using rat-toothed forceps inserted through the suction channel of the flexible scope. Although there are a few reports of sequential use of flexible and rigid bronchoscopies, this report highlights the feasibility and utility of flexible through rigid bronchoscopy technique for foreign body removal in the distal airways.

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Bronchoscopes of the Twenty-First Century

David Feller-kopman

Clinics in Chest Medicine, 2010

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Local experience in paediatric flexible bronchoscopy

Alok Jayant

The Medical journal of Malaysia, 2003

All children who underwent flexible bronchoscopy in the respiratory unit at Paediatric Institute, Hospital Kuala Lumpur from June 1997 to June 2002 were reviewed. A hundred and ten children underwent the procedure under sedation or general anaesthesia. The median age of these children was eight months. (Q1 3, Q3 30) The commonest indication for performing flexible bronchoscopy was for chronic stridor (50 cases) followed by persistent or recurrent changes such as lung infiltrates, atelectasis and consolidation on the chest radiographs (22). Laryngomalacia was found to be the commonest cause of stridor in 29 children. Two patients were diagnosed with pulmonary tuberculosis. With regard to safety, three procedures were abandoned due to recurrent desaturation below 85%. One of these patients had severe laryngospasm that required ventilation for 48 hours but recovered fully. Two neonates developed pneumonia requiring antibiotics following bronchoscopy. No patients developed pneumothorax ...

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Bronchoscopy, indications, safety and complications

Omer Alamoudi

Saudi medical journal

lexible fiber optic bronchoscopy (FFB) was introduced by S. Ikeda in 1964. Since then bronchoscopy has become an important diagnostic and therapeutic tool for management of chest disease. The indications of bronchoscopy are numerous and usually based on the presence of respiratory symptoms and abnormal chest radiograph or both. 1 Common indications include peripheral pulmonary nodule, hemoptysis, chronic cough, pleural effusion, recent or unresolved pneumonia, pulmonary tuberculosis, and lung collapse. 2-9 Bronchoscopy can be used in the intensive care units as an aid for intubation, positioning of double lumen tubes for surgery, and in the diagnosis of ventilation-Objectives: To review the safety, indications, complications of flexible fiberoptic bronchoscopies performed at university teaching hospital, and to correlate the bronchoscopic findings with radiology, histology, and history of smoking.

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