Chapter 2
Rigid bronchoscopy
Maren Schuhmann
Dept of Respiratory and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany.
Correspondence: Maren Schuhmann, Dept of Respiratory and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Röntgenstrasse 1, 69126 Heidelberg, Germany. E-mail: maren.schuhmann@med.uni-heidelberg.de
Rigid bronchoscopy was first introduced in the late 1890s, but its use declined in the 1960s with the development of flexible bronchoscopy. However, due to its many new applications and indications, it has seen a revival in recent years. Management of severe haemoptysis, stent placement and recanalisation are some of the many indications for rigid bronchoscopy, often used in combination with a flexible bronchoscope. Its main disadvantages are the need for general anaesthesia and limited opportunities for training due to a relatively low number of departments worldwide performing rigid bronchoscopy on a regular basis.
Cite as: Schuhmann M. Rigid bronchoscopy. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 19–28 [https://doi.org/10.1183/2312508X.10002417].
In 1897, the ENT surgeon Gustav Kilian from Freiburg, Germany, was the first person to perform a rigid bronchoscopy to remove a piece of pork bone from the right main bronchus of a patient [1]. At the time, he used a Mikulicz–Rosenheim oesophagoscope combined with a rigid forceps and was able to avoid a tracheotomy for the patient. Aspiration of foreign bodies at that time meant falling ill because of atelectasis, chronic pneumonia or haemorrhage.
In 1904, Chevalier Jackson was able to use a rigid bronchoscope with a small light source for the first time in the USA. The development of rigid lenses led to further development of the technique and its use in foreign body retrieval and to treat central airway obstruction [2].
In the 1970s, the flexible bronchoscope was developed and has seen rapid development and improvements in recent years. Several techniques were adapted and invented to be used with the flexible bronchoscope. In many areas, this has led to a reduction in rigid bronchoscopy procedures, but more recently, the technique has seen a revival due to its advantage of securing a large airway, and allowing ventilation and the introduction of large instruments into the central airways [3]. The bronchoscopist Jean-Francois Dumon in Marseille, France, in particular developed the technique and the rigid scope further, and in combination with silicone stenting, laser vaporisation and photocoagulation brought the technique back to the general interest of pulmonologists worldwide [4]. In larger respiratory centres in particular, the ability to perform rigid bronchoscopy is invaluable for diagnostic as well as all available therapeutic procedures within the airways, often in combination with a flexible bronchoscope. The increased performance of cryobiopsies has also led to an increased interest in rigid bronchoscopy, as the procedure can be performed in a safe fashion with a rigid bronchoscope in place. More junior interventional bronchoscopists now have a keen interest in learning and applying this technique again, and guidelines indicate the need for training in rigid bronchoscopy [5].
This chapter focuses on the indications for and technique of rigid bronchoscopy, and will also discuss the aspects of sedation for rigid bronchoscopy and the limitations of the technique.
Equipment
Briefly, there are three main components to a rigid bronchoscope. The first is the scope itself, which is a straight, hollow, metal tube with a bevelled distal tip. This allows atraumatic intubation through the vocal cords, as well as through a stenosis or when used for recanalisation. Depending on the manufacturer, the length varies between 33 and 43 cm with an outer diameter of 6–14 mm. Thinner bronchoscopes facilitate reaching the main bronchi, whereas the larger scopes allow larger instruments to be passed through, as well as the placement of silicone stents. The choice of bronchoscope depends on the planned intervention. The use of scopes ascending in diameter also allows the dilatation of central stenoses.
There are generally two different types of scopes, the longer bronchoscope and the shorter tracheoscope (figure 1a and b). The bronchoscope is intended to be used all the way to the main bronchi, with slits in the distal end to facilitate ventilation as the bronchoscope is advanced into the contralateral main bronchus. The tracheoscope is shorter and is used instead for interventions in the trachea and at the level of the vocal cords. There are no ventilation fenestrations in the tracheoscope. The EFER-Dumon (La Ciotat, France) and the Dutau-Novatech (La Ciotat, France) rigid scopes are modular systems that allow smaller rigid scopes to be passed through the introducing tracheoscopes. This is particularly useful in the dilatation of stenosis and for recanalisation (coaxial bronchial dilatation).
Figure 1. A selection of bronchoscopes and tracheoscopes of differing diameters, showing the ventilation slits in the rigid bronchoscopes.
The second component is an adapter head at the proximal end, which is made up of a central opening, as well as differing side ports, depending on the manufacturer (figure 2). The light source can be attached to the proximal end or to the telescopic lens. The illumination is usually provided by a xenon light source with a light deflector. On one of the lateral ports, the jet ventilation can be attached; otherwise, it is also possible to attach continuous mechanical ventilation. Manufacturers of the currently available rigid scopes include Karl Storz (Tuttlingen, Germany), Richard Wolf (Knittlingen, Germany), EFER-Dumon and Dutau-Novatech.
Figure 2. Adapter head of a Karl Storz (Tuttlingen, Germany) bronchoscope.
For intubation, the operator can look either directly down the bronchoscope through the eyepiece or through an optical lens with an attached chip video camera for easier intubation. These rigid lenses can be attached to a camera, which transmits the picture to a monitor in order to demonstrate the intubation to observers.
Ventilation during bronchoscopy is delivered by either conventional or jet ventilation. The rigid scope is uncuffed, thus leading to a significant amount of air leakage during the procedure. The Richard Wolf bronchoscope has been further developed into the so-called Hemer bronchoscope, allowing the measurement of inspiratory and expiratory pressures, as well as carbon dioxide and oxygen concentrations.
When the airway is secured with the rigid scope, the rigid camera can be advanced further into the main bronchi for inspection, or rigid forceps can be mounted on the camera for biopsy. Alternatively, the bronchoscopist can use a flexible bronchoscope via the rigid scope for inspection of the entire bronchial tree prior to any planned intervention.
Technique
When using a rigid bronchoscope, the bronchoscopist, as well as the assisting nursing team and anaesthetist, should be familiar with this technique and trained accordingly. Usually, the rigid bronchoscope is inserted under direct vision, but a laryngoscope can additionally be used. Using the telescope and camera facilitates the view and allows a more comfortable body position for the examiner. It is mandatory that the camera always remains within the barrel of the rigid scope to avoid damage to the airways (figure 3).
Figure 3. Hand position for a rigid bronchoscope for intubation.
The patient is positioned on their back in an improved Jackson position (slight head elevation for improved laryngeal exposure). The mouth of the patient is opened with one hand and the rigid scope is inserted with the other. The middle finger rests on the hard palate, while the index finger opens the lower jaw and pushes the lower lip out of harm’s way. Care must be taken to avoid damage to the teeth and other structures, and the rigid scope should always be guided by the thumb of the opposite hand, acting as a fulcrum. By pushing up the thumb, the upper teeth and upper lip are protected (figure 4). An additional tooth guard can be placed in the mouth; however, this significantly limits the opening area of the mouth, sometimes making intubation more difficult. The scope is inserted centrally over the tongue until the uvula is reached (figure 5a). At a steeper angle, the epiglottis is visualised (figure 5b). The epiglottis is subsequently lifted up with the longer end of the distal tip to fully view the vocal cords (figure 5c). The scope is now rotated 90° to the right and the right vocal cord is gently pushed aside while passing through the vocal cords (figure 5d). Once the cords have been passed, the scope is rotated another 90° and advanced to the mid-trachea. The ventilation can now be attached.
