Rigid Bronchoscopy

Key Points

• Open communication between the surgeon and the anesthesiologist is of the highest importance during rigid bronchoscopy.

• Inspect the equipment before the procedure; ensure that the bronchoscopes, light sources, light carriers, and connectors are all in working order.

• Check that instruments (suction, graspers, telescopes) are the appropriate length for the selected bronchoscopes.

• Have a backup set that is a size smaller than what you plan to use with appropriate instruments at the ready.

• For pediatric patients, calculate the safe maximum dose of each topical medication (e.g., lidocaine), and restrict their presence in the operative field.

• Place dental/gingival protection, and never leave the bronchoscope on the teeth.

• Advance the scope only when there is an identifiable lumen.

Introduction

Rigid bronchoscopy is a surgical technique that is used to visualize the oropharynx, larynx, vocal cords, trachea, and proximal pulmonary branches. The origin of rigid bronchoscopy can be traced back to Hippocrates (460–370 BCE), who advised introducing a pipe into the larynx in a suffocating patient to assess the airways. Because of limitations in light delivery, the field was largely dormant until the 1800s, when incandescent lightbulbs were invented. The development of local anesthesia in 1880 also made bronchoscopy more tolerable. In 1897 Gustave Killian passed an endoscope through the larynx and removed a piece of pork bone from the right mainstem bronchus using cocaine as topical anesthesia. Chevalier Jackson further advanced the field of rigid endoscopy by improving lighting, developing auxiliary instrumentation for the removal of foreign objects, and implementing rigid bronchoscopy training programs. As a result of these and other efforts, he is recognized as the father of contemporary rigid endoscopy. Since Jackson’s time, instrumentation has continued to advance, such that current rigid instrumentation and ventilation systems allow for more precise assessment of and intervention within the respiratory tract. HH Hopkins of England invented the first conventional lens system by using glass rods instead of small lenses, which produced a significantly brighter image, occupied less space, and allowed for greater visualization of an object in a single field. This provided the basis for modern fiberoptic bronchoscopy.

Indications and Contraindications

The tracheobronchial tree can be directly observed using either rigid or flexible bronchoscopy. Although the advent of flexible bronchoscopy has given physicians improved access to more distal portions of the tracheobronchial tree with a more rapid learning curve and less patient discomfort compared with rigid bronchoscopy, there are still clinical situations in which rigid bronchoscopy is more appropriate. The larger working port and defined structure of the instrument make rigid bronchoscopy useful for surgical interventions within the airway, such as the removal of foreign bodies and masses. At the same time, the bronchoscope can be used to establish and maintain the airway in patients presenting with ventilation difficulty, including obstructing masses, external compression, and hemorrhage. In contrast to the flexible apparatus, the rigid bronchoscope has a ventilation port that can be connected directly to the anesthesia circuit, allowing for ventilation while airway procedures are performed. In fact, earlier iterations of the American Society of Anesthesiologists (ASA) Practice Guidelines for Management of the Difficult Airway included the use of rigid bronchoscopy under techniques for difficult ventilation; however, it was removed from the 2013 revision. Other instances in which rigid bronchoscopy may be preferred include deep and/or large diagnostic biopsies when a fiberoptic specimen would be inadequate, dilatation of stenosis, bronchial stenting, reduction of fractures, application of laser therapy or cryotherapy, tumor removal, and diagnosis of vascular rings. A summary of the indications for rigid bronchoscopy is presented in Box 27.1 .

There are few contraindications to rigid bronchoscopy. In practice, most of the factors limiting rigid bronchoscopy are related to the need for general anesthesia, such as an unstable cardiovascular or respiratory status. One absolute contraindication to rigid bronchoscopy is an unstable cervical spine, because of the hyperextension of the head required during the performance of the procedure. In this instance, flexible bronchoscopy is indicated to avoid further spinal injury. Other contraindications include laryngeal stenosis that prevents the passage of the bronchoscope, limited range of motion of the mandible, severe kyphoscoliosis, uncontrolled coagulopathy, and extreme ventilatory/oxygenation demands. ^,