Rigid Bronchoscopy
Background
Rigid bronchoscopy has seen a recent resurgence, primarily for therapeutic indications, in management of patients with complex airway disorders. The rigid bronchoscope owes its conceptualization to Gustav Killian, a German otolaryngologist, who adapted an esophagoscope for evaluation of the trachea and mainstem bronchi, and performed the first documented successful removal of an airway foreign body, a pork bone fragment, in 1897. Since then, evolution in bronchoscope technology and advancements of flexible bronchoscopic techniques have catapulted bronchoscopy into the mainstream for the general practicing pulmonologist; however, the rigid bronchoscope retains several specific indications and skills that will be discussed in this chapter.
Indications
Evaluation of the airways via bronchoscopy serves two primary purposes: diagnostic evaluation and therapeutic intervention. While there have been numerous technological advances in the flexible bronchoscope and many instruments adapted for use with it, the rigid bronchoscope remains the tool of choice for therapeutic interventions as it simultaneously provides a large conduit for ventilation and instruments. Specifically, the primary indications for rigid bronchoscopy include therapeutic intervention for benign and malignant central airway obstruction (CAO), including applications such as cryotherapy, heat ablative therapies, stent deployment, foreign body removal, management of massive hemoptysis, and large diagnostic tissue biopsy ( Box 6.1 ). The use of the rigid bronchoscope is generally combined with the flexible bronchoscope, allowing for simultaneous therapeutic intervention in the large, central airways as well as smaller, distal airways.
Therapeutic Management of Malignant Central Airway Obstruction
Debridement
Core debulking using rigid bronchoscope
Forceps debulking
Microdebrider
Heat ablative therapies
Argon plasma coagulation
Electrocautery
Laser therapies
Cryotherapy/cryodebridement
Stent deployment, especially silicone stents
Therapeutic Intervention for Benign Central Airway Obstruction
Direct and balloon airway dilation
Heat ablative therapies or cryotherapy
Stent deployment, especially silicone stent
Complex Foreign Body Removal
Management of Massive Hemoptysis
Direct tissue tamponade
Airway isolation
Large Diagnostic Tissue Biopsy
Preprocedural Planning
Patient Assessment
A thorough history and physical examination is paramount when evaluating a patient for rigid bronchoscopy to review the indication, plan the procedure, and assess and mitigate risks. Patients undergoing rigid bronchoscopy may carry significant cardiopulmonary comorbidities that can adversely affect procedural outcomes if not carefully considered. It is recommended that rigid bronchoscopy be performed under general anesthesia, and thus all patients being considered for the procedure should undergo a standard cardiopulmonary preoperative assessment and optimization as the clinical situation allows. Basic laboratory tests including a complete blood count, chemistries, and coagulation studies may be considered prior to the procedure.
During the physical examination, special attention should be paid to the following upper airway examination parameters ( Box 6.2 ):
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Oral cavity and Mallampati score
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Degree of mouth opening
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Thyromental distance
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Neck mobility
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Teeth and dentures.
Modified Mallampati Score
(Assessed by asking the patient, preferably in a sitting posture, to open the mouth and protrude the tongue as much as possible, without phonation)
Class 1: Soft palate, uvula, fauces, pillars visible
Class 2: Soft palate, uvula, fauces visible
Class 3: Soft palate, base of uvula visible
Class 4: Only hard palate visible
Mouth Opening
(Distance between incisors)
Normal: Three or more fingers
Narrow: Less than three fingers
Thyromental Distance
(Measured from the thyroid notch to the tip of the jaw with the head extended and mouth closed)
Normal: Equal or more than three fingers’ breadth
Limited: Less than three fingers’ breadth
Neck Range of Motion
Normal (>90 degrees)
Limited (<90 degrees)
Teeth
Full
Absent
Missing/loose
Buck teeth (Prominent upper incisors/upper incisors protrude >0.5 cm from the lower incisors when teeth put together)
Limitations in mouth opening, neck mobility, or a high Mallampati score should alert the proceduralist to the potential for a more challenging intubation with the rigid bronchoscope. The patient should be evaluated for any loose teeth and removal of any dentures or other removable dental apparatus. In addition, all patients being considered for rigid bronchoscopy require an evaluation of neck mobility, both flexion and extension as well as lateral head movements, as appropriate positioning during both the initial rigid bronchoscope intubation and subsequent maneuvering of the rigid bronchoscope into the right and left mainstem requires neck hyperextension and lateral rotational movements of the head, respectively. This is easily accomplished by asking the patient to touch their chin to chest, then raise the chin to extend the neck back as far as possible, and finally to return the chin to a neutral position and rotate the head 90 degrees to look toward each shoulder. Should a patient demonstrate severe limitations in neck mobility, or cervical spine instability is suspected, as with rheumatoid arthritis or cervical spine trauma, rigid bronchoscopy should be avoided in favor of alternative techniques. If a patient’s examination is concerning for a higher risk intubation, these issues as well as possible alternative plans for airway management and intubation should be discussed with the anesthesiologist prior to the procedure.
Equipment
The rigid bronchoscope is a rather simple but versatile tool, not having changed much in basic design from the time of its original design in the early 20th century. While there are several manufacturers of rigid bronchoscopes, the three essential components of the rigid bronchoscope remain consistent: the barrel; the multifunctional head connector(s); and the rigid telescope, light source, and/or video optics ( Box 6.3 ). Numerous additional tools and accessories have been developed to work within the working channel of the rigid bronchoscope during the procedure:
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Barrel : Barrels are manufactured in two general lengths: shorter rigid tracheoscopes and longer rigid bronchoscopes ( Figs. 6.1 and 6.2 ). While the tracheoscope is made to simply intubate to the mid to distal trachea, the longer rigid bronchoscope allows access for intubation of the right or left mainstem and has fenestrations in the distal portion of the barrel to allow for contralateral lung ventilation during the procedure. Rigid bronchoscopes typically range in outer diameter from 7 mm to 14 mm for general adult applications, with a wall thickness of 1–2 mm and, due to variations between manufacturers, lengths will vary typically between 33 and 43 cm. Some companies color code the size of the barrels making it easier for the proceduralist to identify the size on basic inspection. The barrel itself is essentially a hollow metal tube with a beveled distal tip, which helps with lifting the tongue and epiglottis, and atraumatic passage between the vocal cords during intubation. Further, the beveled tip itself can be used for coring the endobronchial central airway tumors. The proximal end of the rigid barrel can connect to the multifunctional head, allowing for ventilation connections, passage of instruments, and support for the light source and video optics. Selection of the appropriately sized barrel(s) is critical, as different-sized barrels will accommodate different needs and instruments, and multiple-sized barrels may be necessary for a single case. For example, a smaller barrel may be necessary in the case of initially securing the airway during the management of a severe tracheal stenosis; however, a larger barrel will be necessary later if silicone stent placement is planned.
Fig. 6.1
Rigid telescope (a) . Rigid bronchoscope with side fenestrations attached to the head connector (b) . Jet ventilator connector (c) . Rigid tracheoscope (d) .
Fig. 6.2
Rigid telescope (a) connected to camera head (b) and light source (c) inserted in the rigid bronchoscope. Jet ventilator connector (d) and suction catheter (e) are attached to the rigid bronchoscope.
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Multifunctional head connectors : The head is a small, separate piece that attaches to the proximal end of the barrel and generally houses multiple ports ( Figs. 6.1 and 6.2 ). The side port allows for attachment of a standard ventilator or self-inflating ventilation bag while still accommodating for passage of multiple tools through the main working channel. Most head connectors include an additional port for a jet ventilator attachment. Silicone caps can be attached to the proximal end of the head connectors to minimize the leak in the system and have ports for passage of tools and a light source.
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Light source and optics: Most modern rigid bronchoscopes use a long, rigid telescope with a camera head attached proximally, and the image is displayed on a video monitor ( Figs. 6.1 and 6.2 ). Several integrated rigid bronchoscopes have more recently been developed that include optics embedded in the distal end of the rigid bronchoscope barrel. Further during the procedure, visualization can be accomplished using a host of alternative visualization tools including a flexible bronchoscope, optical forceps, etc.
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Additional tools and accessories : Numerous additional tools and accessories have been developed to work within the rigid bronchoscope to aid in the procedure, including rigid forceps, dilators, graspers, scissors, suction catheters, stents and stent deployers, and many others limited only by the imagination of the proceduralist ( Fig. 6.3 ). All equipment for any anticipated adjunct procedures including cryotherapy, heat therapies, and stents should be available at the time of the procedure. We would suggest including a flexible bronchoscope in this arsenal to complement the rigid bronchoscope during the procedure. Gathering and assembling all necessary equipment prior to induction of anesthesia and beginning the procedure will allow for optimization of the procedure for both the proceduralist and the patient ( Box 6.3 ).
Fig. 6.3
Instruments that are used during rigid bronchoscopy. Rigid forceps (a) . Rigid electrocautery (b) . Rigid forceps with rotatable jaws (c) . Silicone stent deployers (d) . Silicone stent loaders (e) .
Rigid Barrel(s)
Consider different sizes and lengths depending on indication
Multifunctional Head Connector(s)
Rigid Telescope
Light Source and Video Optics
Tooth Guard
Adjunct Tools
Rigid or flexible suction catheter
Rigid forceps
Stent deployer
Airway stents
Cryoprobe
Electrocautery
Argon plasma coagulation
Microdebrider
Ventilation Equipment
Traditional or jet ventilator
Gauze for airway packing
Silicone caps for rigid bronchoscope
Self-inflating bag-valve-mask for manual ventilation
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