EMCrit.org | Emergency Critical Care - Critical Care Procedures

1 unit/cc of heparin, take air out of IV bag first. Must have line open to air in order to zero.

SPV systolic pressure variation examines the min to max variation is one respiratory cycle. The change down pressure is the 1st drop with inspiration. The change u

In conclusion, there is no significant difference between heparinized and nonheparinized flush solutions for the maintenance of perioperative radial artery catheter patency. (Anesth Analg 2005;100:1117-1112)

Intraaortic Balloon Pump

inflation during early diastole increases coronary artery perfusion pressure, increases diastolic BP by 15-30% and increases SBP as well

advance the radioopaque marker to just distal to the takeoff of the left subclavian

never pull a balloon back through the sheath if it has been inflated, even after deflation

contraindicated in aortic regurgitation, aortic dissection, PDA, and aortic aneurysm

Tracheostomy

Portex trach tube is far superior to the Shiley trach tube which comes in the Cook kit, and, at least to me, the

superiority of Portex's trach tube outweighs the superiority of the Cook/Shiley Blue Rhino PDT kit.

The solution may be that Portex is already marketing a 'White Rhino' kit in Europe, and we're hoping to see it here soon, so that will allow us the best of both worlds.

Severe reactive airway disease: use pretreatment

Coagulopathy

Keep extra clamp to pull out dilator

Early may be better (Crit Care Med 2004 Vol 32 #8 1689-1693)

Change tubes over 4.5 pediatric endotracheal tube

Technique for Crash Trach (Injury 2008;39:375)

Percutaneous Tracheostomy

We tried the Ciaglia and the Fantoni techniques and we prefer the Ciaglia/
Blue Rhino set.

Changing a Perc Trach

1. Check the size currently in situ and ensure that you have the correct size and one size smaller, just in case.
2. Mentally walk through the procedure, like say oxygenate, deflate the cuff, remove and suction........
3. Demonstrate to all what a magnificent operation has taken place, that one can see with a light into the trachea and that the patient can easily breath through the hole.

there is no need for positive pressure then there is no need for a cuff, and I try to change tubes to uncuffed before the patient leaves ICU. It is pretty clear that cuffs do NOT prevent aspiration - we know that one factor in VAP is continuous microaspiration past the cuff, and we deliberately keep cuff pressure less than mucosal capillary pressures so a good vomit will go past the cuff anyway. Cuffs do interfere with swallowing, however because of pressure on the cricopharyngeus. I find that if I don't aggressively change to uncuffed tubes before the patients goes to the ward the patient gets caught in a vicious cycle of 'leave the cuff up to prevent aspiration ..... look he has failed his swallow test you had better leave the cuff up to protect his airway ...." and nobody every gets around to taking the rotten tube out.

Just below thryoid for incision. Can enter sub-cricoid

Cut trach tie 1/3 and 2/3 then put slit 1 cm down to pull end through

can put saline into angio to see if it sprays when pt ventilated

put finger in hole, use it to guide the needle

Details on technique by the man, Ciaglia (Chest 1996;110(3):762)

Perc Trach without Bronch (Chest 2004;126(3):869)

The use of the bronchoscope is felt by some to be mandatory but many including myself, Sedar, and some of the Intensivists in the Silvester series prefer to perform the procedure with the bronchoscope on standby only to be used if needed. We have developed a technique using a bronchoscopy adapter on the endotracheal tube through which we place a 5 mm Cook tube changer which extends 10 cm beyond the tip of the endotracheal tube allowing easy rescue of the air way if needed. The tube changer is small enough not to impair ventilation (important for ICP control) during the procedure or interfere with accessing the trachea and placing the tracheostomy. PT is now really a misnomer since most operators use a modified technique creating a 1.5–2 cm horizontal incision a fingers breadth below the cricoid cartilage. Blunt dissection is carried out to the anterior tracheal wall with a hemostat and gloved finger. Our preference is to leave the cuff on the endotracheal tube inflated as it is drawn back 8 cm from its original position.
We place the needle for canulation on the trachea while it is splinted by the cuff of the endotracheal tube. When the cuff passes under the gloved finger held on the trachea beside the needle, the needle is inserted and air is aspirated and the guide wire is passed, etc.

(Curr Opin in Crit Care 2005;11:326)

We buy the small Blue Rhino kit without the Shiley Trach tube, and use the Portex Trach tube separately. I do not like the Shiley tube - if you don't position it properly on the loading dilator, there is a gap between the tube and the dilator. I have had this rip on the tracheal ring, making it impossible to advance and having to get a new tube. It just does not slide in nearly as easily as the Portex. So, by unbundling, we are able to get the best of both worlds. It does cause us to have to scurry around sometimes to make sure that all the things we need are present, but it is much more preferable than having to use a sub-standard Trach tube. What bothers me is that I have many times talked to both the Cook and Shiley people about it - they each point a finger and blame the other company, then point the finger at me and tell me that we are doing something wrong because "nobody else complains about the trach tube!!". If the Blue Rhino were not so superior, I would stop using it also, based on their attitude!

Go down to strap muscles using a small kelly or right angles to spread for the bovie

Place straight clamp with jaws facing up. Put two kellys in jaws with concave facing in

Mark Cricoid and sternal notch. Entry point is usally two finger breadths above notch

Laryngoscope. 2005 Oct;115(10 Pt 2):1-30. Related Articles, Links

Endoscopic percutaneous dilatational tracheotomy: a prospective
evaluation of 500 consecutive cases.

Kost KM.

Department of Otolaryngology, McGill University, Montreal, Quebec,
Canada. kmkost@yahoo.com

OBJECTIVES/HYPOTHESIS: An evaluation of 500 adult, intubated,
intensive care unit patients undergoing endoscopic percutaneous
tracheotomy using the multiple and single dilator techniques was
conducted to assess the feasibility and safety of the procedure as it
compares with surgical tracheotomy. Endoscopy was used in all cases
and evaluated as an added safety measure in reducing complications.
STUDY DESIGN: A prospective evaluation of endoscopic percutaneous
dilatational tracheotomy in 500 consecutive adult, intubated intensive
care unit patients. METHODS: Between 1990 and 2003, endoscopically
guided percutaneous dilatational tracheotomy (PDT) was performed in
500 consecutive adult, intubated patients in the intensive care units
(ICU) of three tertiary care adult hospitals. The first 191 patients
underwent PDT using the Ciaglia Percutaneous Tracheostomy Introducer
Kit (Cook Critical Care Inc., Bloomington, Indiana) and in the
remaining 309 patients the Ciaglia Blue Rhino Single Dilator Kit (Cook
Critical Care Inc., Bloomington, Indiana) was used. The procedure was
contraindicated in the following situations: 1) children, 2)
unprotected airway, 3) emergencies, 4) presence of a midline neck
mass, 5) inability to palpate the cricoid cartilage, and 6)
uncorrectable coagulopathy. The following parameters were recorded
preoperatively: age, sex, diagnosis, American Society of Anesthesia
(ASA) class, body mass index (BMI), and number of days intubated.
Recorded hematologic parameters included hemoglobin (Hgb), platelets,
prothrombin time (PT), partial thromboplastin time (PTT), and the
international normalized ratio (INR) since it became available in
1998. All patients were ventilated on 100% oxygen and vital signs were
continuously monitored. Tracheotomy was carried out under continuous
endoscopic guidance using a series of graduated dilators in the first
191 cases, and a single, tapered dilator in the remaining 309
patients. The preoperative data on each patient, along with the type
of dilator used, the size of the tube, the intraoperative and
postoperative complications, and blood loss information were recorded
prospectively and maintained in a computer spreadsheet. Univariate
analyses were used in each group separately for each type of dilator
to assess the risks of a complication within subgroups defined by each
parameter/characteristic, and the statistical significance assessed
with a chi test, or Fisher exact test. RESULTS: The total complication
rate was 9.2% (13.6% in the multiple dilator group, and 6.5% in the
single dilator group), with more than half of these considered minor.
Overall, the two most common complications were oxygen desaturation in
14 cases and bleeding in 12 cases. The absence of serious
complications such as pneumothorax and pneumomediastinum are
attributable to the use of bronchoscopy. There was no significant
association between the rate of complications and age, gender, ASA,
weeks intubated, tracheostomy tube size, Hgb levels, platelets, PT,
PTT, or INR. There was a statistically significant relationship
between experience and the likelihood of complications in the multiple
dilator group (P < .0001), with a higher rate of complications in the
first 30 patients (40%) compared with 8.7% in the remaining 161
patients. This relationship did not exist for the first 30 patients in
the single dilator group. Patients with a BMI of 30 or higher
experienced a significantly greater (P < .05) number of complications
(15%), compared with an 8% complication rate in patients with a BMI of
less than 30. This risk was even more significant for patients with a
BMI of 30 or greater who were also in ASA class 4 (11/56 or 20%) (P <
.02). CONCLUSIONS: Endoscopic PDT is associated with a low
complication rate and is at least as safe as surgical tracheotomy in
the ICU setting. Bronchoscopy significantly decreases the incidence of
complications and should be used routinely. While embraced by critical
care physicians, endoscopic PDT has been infrequently performed by
otolaryngologists. As the airway experts, otolaryngologists are in the
best position to learn and teach the procedure as it should be done.

Publication Types:
2006/2/14, Marek Nalos <mareknalos@mediclub.cz>:
> Chest. 2004 Aug;126(2):547-51. Related Articles, Links

Percutaneous tracheostomy is safe in patients with severe thrombocytopenia.

Kluge S, Meyer A, Kuhnelt P, Baumann HJ, Kreymann G.

Department of Medicine, University Hospital Eppendorf, Martinistrasse
52, 20246 Hamburg, Germany. skluge@uke.uni-hamburg.de

STUDY OBJECTIVES: Severe thrombocytopenia has been described as a
contraindication for percutaneous tracheostomy (PT). The objective of
this study was to assess the safety of PT in mechanically ventilated
patients with severe thrombocytopenia (defined by a platelet count of
< 50 x 10(9) cells/L). DESIGN: Retrospective, single-center cohort
study. SETTING: Medical ICU of the University Hospital
Hamburg-Eppendorf, Germany. PATIENTS: Forty-two medical patients with
acute respiratory failure and severe thrombocytopenia. INTERVENTIONS:
Bedside PT under bronchoscopic guidance using the Griggs guidewire
forceps technique.Measurements and main results: The mean (+/- SD)
intubation time prior to undergoing PT was 6.7 +/- 3.9 days (range, 1
to 20 days). The mean platelet count was 26.4 +/- 11.6 x 10(9) cells/L
(range, 1 x 10(9) to 47 x 10(9) cells/L). The median transfusion of
platelets before the procedure in 40 of the 42 patients was 6 +/- 2.5
U (range, 3 to 12 U). Twenty-two patients (52%) had an additional
coagulopathy (activated partial thromboplastin time [APTT], > 40 s;
international normalized ratio, > 1.5). PT was safely performed in all
42 patients. Only two (5%) patients developed major postprocedural
bleeding complications that required suturing. Both of these patients
had an elevated APTT due to heparin therapy. CONCLUSIONS: When
performed by experienced personnel, PT with bronchoscopic guidance has
a low complication rate in patients with severe thrombocytopenia,
provided that platelets are administered beforehand. However, in order
to minimize bleeding complications heparin infusions should be
temporarily interrupted during the procedure.

PMID: 15302743 [PubMed - indexed for MEDLINE]

Chest. 2003 May;123(5):1595-602. Related Articles, Links

Comment in:
Chest. 2003 May;123(5):1336-8.

Percutaneous dilatational tracheostomy in the ICU: optimal
organization, low complication rates, and description of a new
complication.

Polderman KH, Spijkstra JJ, de Bree R, Christiaans HM, Gelissen HP,
Wester JP, Girbes AR.

Departments of Intensive Care, University Medical Center, Amsterdam,
the Netherlands. k.polderman@tip.nl

STUDY OBJECTIVES: To assess short-term and long-term complications of
bronchoscopy-guided, percutaneous dilatational tracheostomy (PDT) and
surgical tracheostomy (ST) and to report a complication of PDT that
has not been described previously. DESIGN: Prospective survey.
SETTING: University teaching hospital. PATIENTS: Two hundred eleven
critically ill patients in our ICU. INTERVENTIONS: PDT was performed
in 174 patients, under bronchoscopic guidance in most cases. ST was
performed in 40 patients. RESULTS: No procedure-related fatalities
occurred during PDT or ST. The incidence of significant complications
(eg, procedure-related transfusion of fresh-frozen plasma, RBCs, or
platelets, malpositioning or kinking of the tracheal cannula,
deterioration of respiratory parameters lasting for > 36 h following
the procedure, or stomal infection) in patients undergoing PDT was
4.0% overall and 3.0% when bronchoscopic guidance was used. No cases
of paratracheal insertion, pneumothorax, pneumomediastinum, tracheal
laceration, or clinically significant tracheal stenosis occurred in
patients undergoing PDT. We attribute this low rate of complications
to procedural and organizational factors such as bronchoscopic
guidance, performance by or supervision of all PDTs by physicians with
extensive experience in this procedure, and airway management by
physicians who were well-versed in (difficult) airway management. In
addition, an ear-nose-throat surgeon participated in the procedure in
case conversion of the procedure to an ST should become necessary. We
observed a complication that, to our knowledge, has not been reported
previously. Five patients developed intermittent respiratory
difficulties 2 to 21 days (mean, 8 days) after undergoing PDT. The
cause turned out to be the periodic obstruction of the tracheal
cannula by hematoma and the swelling of the posterior tracheal wall,
which had been caused by intermittent pressure and chafing of the
cannula on the tracheal wall. In between the episodes of obstruction,
the cannula was open and functioning normally, which made the
diagnosis difficult to establish. CONCLUSIONS: Bronchoscopy-assisted
PDT is a safe and effective procedure when performed by a team of
experienced physicians under controlled circumstances. The
intermittent obstruction of the cannula caused by swelling and
irritation of the posterior tracheal wall should be considered in
patients who develop unexplained paroxysmal respiratory problems some
time after undergoing PDT or ST.

Meta Analysis of Early Trach shows reduced ICU time and Vent days (BMJ 2005 Griffiths J, Barber VS, Morgan L)

Canadian Journal of Anesthesia 54:321-322 (2007)
Use of the "Aretube" to facilitate ventilation during percutaneous tracheostomy

The PWA is performed by the nursing and respiratory therapy staff and determines whether a patient’s level of ventilatory support is appropriate for weaning attempts (i.e., Fio2 <=0.5, positive end-expiratory pressure <=8 cm H2O, minute volume <15 L/min) and whether acute physiologic derangements (i.e., increased intracranial pressure, significant hemoptysis, active gastrointestinal hemorrhage, evolving myocardial infarction, elevated minute ventilation) might preclude successful weaning. Ventilator settings are then adjusted to provide a continuous positive airway pressure of 5 cm H2O and Fio2 = 0.4. If after 2 mins patients manifest no evidence of respiratory or hemodynamic derangement (i.e., dyspnea, use of accessory muscles, SpO2 <92%, tachypnea, tachycardia, bradycardia, hypotension), SBT is performed. Patients displaying evidence of respiratory or hemodynamic distress during this 2-min trial are categorized as PWA failures and returned to pretrial ventilatory support. During SBT, patients receive minimal ventilatory support (pressure support 5–8 cm H2O, positive end-expiratory pressure 5 cm H2O, Fio2 = 0.4) for 30 mins. Patients exhibiting signs of respiratory or hemodynamic distress are categorized as SBT failures and returned to pretrial ventilatory support. Patients passing the SBT are considered extubation candidates. SBT results are conveyed to the physician staff responsible for decision for extubation. Timing of extubation following successful SBT completion is at the discretion of the physician staff.

Extracorporeal Support (ECMO) and Bypass

venous-venous is usually done with inflow to pump from IVC and blood retrun via the femoral vein

Bronchoscopy

need 2mm larger ET tube than diameter of scope, so 8mm tube to use adult size bronchoscope

Procedure from Practical Bronchoscopy

Some bronchoscopists prefer to face the sitting or lying patient whilst others stand behind the head of the lying Of patient (Fig. 3.7). Face to face contact with the frontal approach generally proves valuable to maintain rapport between patient and bronchoscopist. An advantage of standing behind the head of the supine patient is that the spatial orientation of the bronchial tree is then the same for both flexible and rigid bronchoscopes, which may be of importance for bronchoscopists who practise both methods but have difficulty in transposing images.

The patient is seated comfortably with legs horizontal and trunk and head supported at 30‑45' with a pillow under the head. The bronchoscopist stands to the right of the couch and the assistant behind the patient's head.

Lignocaine solution (4 or 10%) is sprayed from an atomizer into each nostril, the fauces and posterior pharyngeal wall, the patient having been first warned that the initial effects are an unpleasant stinging and taste. Within 2‑3 minutes the fibrescope lubricated with lignocaine gel can be introduced into the nose or mouth. Once the bronchoscope has passed through the nose or mouth, supplemental oxygen can be given through a nasal cannula into the unoccupied nostril.

The bronchoscopist should wear a clean gown and disposable gloves. If the gloves have been dusted with powder this must first be washed off to prevent starch granules contaminating the trap specimen and causing confusion in interpretation of the speci mens at microscopy.

The fibrescope should be inspected and if necessary the lens cleaned with sterile gauze moistened with sterile saline. The flexible fibrescope is a delicate and expensive apparatus. It must at all times be handled with care to avoid damage to the fibres. Knocking the shaft or tip against furniture and bending or kinking the shaft or tip with undue force must be avoided. The central channel and the polythene connecting tube should be flushed by aspirating sterile saline. To reduce fogging the distal lens can be wiped with silicone or soapy water. The fibrescope shaft should be lubricated with sterile 2% lignocaine jelly and some of this jelly can also be applied into the nostril through which the instrument is to be passed.

The technique of holding the fibrescope depends on the type of instrument available. The Olympus type is most widely used in Britain and can be held and operated by either the left or the right hand (Fig. 3.8). The body of this instrument is held by the 2nd, 3rd and 4th fingers and palm and the control knob can then be moved up and down by the thumb. The index finger is placed near the proximal end of the suction channel to seal it for aspiration as and when necessary. Rotation of the tip is achieved by rotating the wrist and thus the whole instrument (Fig. 3.9). The free hand is used to hold steady, advance and withdraw the shaft as well as to manoeuvre the biopsy forceps and cytology brushes to their targets (Fig. 3. 10). This can greatly reduce nasal discomfort for the patient.

The Machida type of fibrescope is held in the left hand reserving the right hand to operate the various handles at the proximal end as well as supporting, advancing and withdrawing the shaft of the fibrescope. Angulation and rotation of the tip are both achieved by rotating the proximal eyepiece which twists the distal end to the right and anticlockwise twists it to the left. Rotation can also be achieved by rotating the left wrist.

For all types and makes of instrument the bronchoscope tip is inserted gently into the nostril under direct vision and passed into the widest part of the nasal passages. This is usually the inferior meatus between the inferior turbinate and the floor of the nose. Lignocaine does not abolish pressure sensitivity and so the bronchoscope should not be forced as this will cause discomfort. The flexible tip of the bronchoscope is its widest part and once this has passed through any passage the shaft will follow more easily. If the bronchoscope will not pass comfortably through either nasal passage then it should be inserted through the mouth using the guard as described.

Once the posterior pharyngeal wall is reached the fibrescope is angulated downwards following the shape of the pharynx and into the oropharynx behind the uvula. At this stage it should be possible to see the epiglottis and the glottis in the distance. It may be necessary to aspirate secretions obscuring the view. Care should be taken to ensure that the shaft of the instrument is straight and the patient's chin well forward. Asking the patient to protrude his tongue or to swallow may also help to reveal the epiglottis.

Once the epiglottis has been identified the glottis is usually visible behind and beyond it. If difficulty is encountered in getting behind the epiglottis it may be possible to pass the fibrescope tip laterally and posteriorly alongside the epiglottis and then turn the tip in medially to curl over onto the dorsal surface of the epiglottis. The glottis and the vocal cords are sensitive areas and care should be taken to avoid undue irritation by the bronchoscope tip whilst anaesthetizing this area. Watch for the effects of cardiac dysrhythmias induced by vagal stimulation.

Next, vocal cord mobility should be checked during normal inspiration and expiration by asking the patient to adduct his cords in saying 'see'. Inequality of movement of the cords suggests recurrent laryngeal nerve palsy. The patient should be warned that the next step will cause coughing. This occurs as the vocal cords are anaesthetized by injecting 2 ml of 4% lignocaine (80 mg) onto them in their adducted position via the central channel of the fibrescope.

For purpose of regional anaesthesia via the fibrescope lignocaine should be drawn up as 2 ml aliquots in 5 ml syringes with 3 ml of air in the syringe. The bronchoscope should be positioned with the suction channel uppermost so that the local anaesthetic is injected first and flushed through the central channel by the following air from the syringe.

Two or three minutes are allowed for the lignocaine to have maximum effect and this time should be spent examining the pyriform fossae and the area between the vocal cords and the ary‑epiglottic folds. During deep inspiration 2 ml of 2% lignocaine (40 mg) is next injected through the vocal cords into the trachea. The fibrescope tip should be quickly withdrawn a few centimetres during the coughing which will follow. Another 2 ml of the 2% lignocaine is usually required to anaesthetize the trachea adequately.

Before the fibrescope is inserted between the cords into the trachea the patient must be warned that this will make him cough, cause transient breathlessness and that he should not attempt to speak. The patient is advised to resist the impulse to take large breaths but rather to continue with shallow breaths which he should be reassured are sufficient.

During quiet inspiration the bronchoscope is passed gently between the cords through the posterior part of the glottis where the opening is the widest (Fig. 3M). The patient should be instructed that although the sensation is odd, he can breathe and swallow normally. A minute or so should be allowed for the patient to become accustomed to the presence of the fibrescope

the trachea. Further boluses of 2% lignocaine may be required if much coughing occurs.

The trachea should be inspected for the appearance of the mucosa and abnormally increased or decreased mobility of the walls should be noted. Similarly the carina should be examined for its sharpness and mobility. Normally the carina becomes shorter and thicker during coughing. Abolition of this variability may indicate infiltration by carcinoma or enlargement of the s ubcarinal lymph glands.

Further boluses of 2 ml of 2% lignocaine are injected through the suction channel as necessary but the total dose administered should be kept to a minimum by avoiding contact with the bronchial walls thus reducing irritation. If the coughing induced is more than slight it is worth withdrawing the bronchoscope and injecting more lignocaine because once coughing is allowed to become severe it is difficult to control. There is considerable variation in sensitivity of the bronchial mucosa between patients and certainly smokers cough more easily and excessively. Encouragement and keeping the patient informed of what is happening with instructions to keep both eyes open will help to make the examination more comfortable for the patient and easier for the operator.

Both right and left bronchial trees must be systematically examined even if the chest radiograph suggests a unilateral lesion. Opinions vary as to whether the normal or abnormal side should be examined first. It is recommended that the normal side should be inspected first. If examined last it is more likely to be inadequately explored as both patient and bronchoscopist may be tired and secretions and blood may have spilled from the abnormal side following inspection and sampling.

To examine the right bronchial tree, the black notch in the visual field is turned to the right side of the patient. This ensures that the fibrescope tip has maximum manoeuvrability for examination of the bronchi on this side. The right upper lobe orifice usually lies just below the carina on the opposite lateral wall; it leads off at an angle of 80‑90'. It is helpful to give an extra 2 ml of 2% lignocaine into the upper lobe before it is inspected as the previous doses of lignocaine frequently fail to reach it due to its angulation. The orifice is now entered and the segments and subsegments are examined. The anterior segment which lies ventrally and the posterior segment lying dorsally are relatively easy to inspect without too much manipulation of the fibrescope tip. The apical segmental bronchus is more difficult to enter. To help this manoeuvre, the patient is asked to take a few deep breaths and then to hold the breath at full inspiration when the apical segmental orifice will be more easily seen with the tip of the fibrescope bent maximally upwards towards the head.

The right middle lobe bronchus arises ventrally from the intermediate bronchus and extends obliquely downwards. The notch in the visual field of the fibrescope should be placed in the anterior position to aid manoeuvrability in this bronchus which can usually be inspected to subsegmental level.

The fibrescope is then withdrawn back into the intermediate bronchus, the notch rotated dorsally until the orifice of the apical, segment of the right lower lobe is seen lying at the same level as the middle lobe. This segmental bronchus branches at 90' from the intermediate bronchus and once again entry into it can be aided by asking the patient to hold the breath in full inspiration.

The remaining segmental orifices of the right lower lobe lie several centimetres distal to the apical segment. They all extend downwards and really are an extension of the main bronchus so little difficulty is usually encountered in entering them.

After withdrawing the fibrescope back to the carina, the left bronchial tree is next examined by having the notch in the visual field rotated to the left side of the patient. The left main bronchus is longer than the right and also deviates more laterally or horizontally in the erect subject. The secondary carina between the upper and lower lobe orifices is a useful landmark.

The lingular bronchus is usually an extension of the upper lobe bronchus and descends downwards dividing into superior and inferior segments.

The upper division of the upper lobe bronchus is next examined by withdrawing the fibrescope back into the upper lobe bronchus and turning its tip upwards (headwards) with maximum flexion. This is perhaps the most difficult bronchus to enter. This can be made easier by asking the patient to take a deep breath. The anterior and apicoposterior segments are then examined in turn.

The fibrescope is withdrawn back to the secondary carina and the left lower lobe is examined by rotating the notch in the visual field towards it. The apical segmental bronchus arises dorsally almost at the level of the secondary carina. It is located by turning the notch posteriorly and again if difficulty is encountered in entering it, the patient is asked to hold the breath in deep inspiration. The basal segments of the left lower lobe should present no difficulty to examination, noting that the anterior and mediobasal segments are usually combined into a single orifice.

Examination of an average 'normal' tracheobronchial. tree has been described. Variations in the branching of the bronchi are frequently encountered and should be borne in mind if apparent abnormalities occur, especially if the mucosa looks normal. At more peripheral levels, individual bronchi or combinations of bronchial orifices cannot be recognized by individual appearances alone because they usually look alike and variations are common. They can only be identified by remembering the route the bronchoscope has taken to get to that point in the bronchial tree. Occasionally it may be necessary to retrace the route to a more central and recognizable bronchus.

A routine of systematic examination of the airways should be adopted to prevent mistakes through omission. In addition to the bronchial tree an orderly inspection of the extrathoracic airways must also be completed. It is valuable to re‑inspect bronchi as the fibrescope is being withdrawn to confirm observations made when the instrument was advancing.

The ability to use a fibrescope comes only with practice. Although many useful hints are often given there is no substitute for time spent handling the instrument. The period of time that the novice can spend on a patient is limited and it can be helpful to use the various lung models available. Eventually, operating the instrument should become a subconscious act, like driving a motor car. The experienced bronchoscopist comes to know the position and orientation of the fibrescope tip as a form of extended proprioception, just as a good motorist knows the limits of the front or back of his car. Similarly guiding the instrument with coordinated movements of the wrist, thumb and fingers of the right hand as well as the forward and backward motion of the left hand will begin to occur at a subconscious level.

This service is a free not-for-profit continuing medical education activity which is offered to all practitioners of Anesthesia and related areas of Medicine and Surgery. By clicking on the "Bronchial Anatomy Quiz" tab readers can complete a needs assessment of their knowledge of tracheo-bronchial anatomy

Critical Care Procedures

Arterial Lines

Intraaortic Balloon Pump

Tracheostomy

Percutaneous Tracheostomy

Extracorporeal Support (ECMO) and Bypass

Bronchoscopy

Procedure from Practical Bronchoscopy