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Pallav Shah md frcpConsultant Physician and Honorary Senior LecturerRoyal Brompton Hospital, Chelsea and WestminsterHospital and Imperial College London, UK

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Page 1: Atlas of Flexible Bronchoscopy
Page 2: Atlas of Flexible Bronchoscopy

AtlasofFlexibleBronchoscopy

Page 3: Atlas of Flexible Bronchoscopy

Iwouldliketodedicatethisbooktomyfamilyforalltheirsupportandencouragementdespitetheendlesseveningsandweekendsspentonthisbook.Aspecialthankstomywife,Malawhocreatedsomeoftheinitialanatomicaldrawingforthisbook.

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AtlasofFlexibleBronchoscopy

Pallav Shah md frcpConsultantPhysicianandHonorarySeniorLecturerRoyalBromptonHospital,ChelseaandWestminsterHospitalandImperialCollegeLondon,UK

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FirstpublishedinGreatBritainin2012byHodderArnold,animprintofHodderEducation,anHachetteUKcompany,338EustonRoad,LondonNW13BH

http://www.hodderarnold.com

©2012PallavShah

Allrightsreserved.ApartfromanyusepermittedunderUKcopyrightlaw,thispublicationmayonlybereproduced,storedortransmitted,inanyform,orbyanymeanswithpriorpermissioninwritingofthepublishersorinthecaseofreprographicproductioninaccordancewiththetermsoflicencesissuedbytheCopyrightLicensingAgency.IntheUnitedKingdomsuchlicencesareissuedbytheCopyrightLicensingAgency:SaffronHouse,6–10KirbyStreet,LondonEC1N8TS.

Whilsttheadviceandinformationinthisbookarebelievedtobetrueandaccurateatthedateofgoingtopress,neithertheauthornorthepublishercanacceptanylegalresponsibilityorliabilityforanyerrorsoromissionsthatmaybemade.Inparticular,(butwithoutlimitingthegeneralityoftheprecedingdisclaimer)every effort hasbeenmade to checkdrugdosages; however it is still possible that errors havebeenmissed.Furthermore,dosageschedulesareconstantlybeingrevisedandnewsideeffectsrecognized.Forthese reasons the reader is stronglyurged to consult thedrug companies’printed instructionsbeforeadministeringanyofthedrugsrecommendedinthisbook.

British Library Cataloguing in Publication DataAcataloguerecordforthisbookisavailablefromtheBritishLibrary

Library of Congress Cataloging-in-Publication DataAcatalogrecordforthisbookisavailablefromtheLibraryofCongress

ISBN-13 978-0-340-96832-1

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Publisher : CarolineMakepeaceEditorialManager: JoannaSilmanProductionController : KateHarrisCoverDesign: HelenTownson

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Whatdoyouthinkaboutthisbook?OranyotherHodderArnoldtitle?Pleasevisitourwebsite:www.hodderarnold.com

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ContentsPreface vii

1 Introduction 1

2 Bronchopulmonarysegments 11

3 Normalanatomy(anteriorapproach) 28

4 Normalanatomy(posteriorapproach) 53

5 Vascularrelationshipsandlymphnodestations 78

6 Transbronchialfine-needleaspiration(anteriorapproach) 94

7 Transbronchialfine-needleaspiration(posteriorapproach) 113

8 Endobronchialultrasoundbronchoscopy 133

9 Pathology 158

10 Fluorescence-basedimaging 164

11 Electromagneticnavigation 172

12 Intubationandmanagementofairwayhaemorrhage 189

13 Endobronchialtumourdebulking 202

14 Stents 211

15 Bronchoscopictreatmentforemphysemaandasthma 220

Index 238

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Preface ‘Strivingforexcellenceinthecareofourpatients’.

My ambition for this book is to provide a simple step wise approach to flexiblebronchoscopy. I have linked gross anatomy with the radiology and correlated it tothebronchoscopicfindingsandview.Thisapproachshouldassistthebronchoscopistwithbothdiagnosticandtherapeuticprocedures.Safepractice isalsoofparamountimportanceandisakeythemethroughoutthisbook.

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CHAPTER

1Introduction

Bronchoscopyhasbecomeanessentialtoolfortherespiratoryphysician.Theoriginalfibreopticbronchoscopeswereprimarilyutilized for visualizing theairwaysandalsoforsampling.Themodernvideobronchoscopesprovidehigh-definitionimagesoftheairwayssothatevensubtlelesionsarerecognized.Theprocedurehasalsoexpandedfromsimplediagnosticprocedurestotherapeuticprocedures.Thedevelopmenthasseenthetherapeuticcapabilitiesprogressfrompalliativetreatmentofendobronchialtumourstoasthmaandemphysema.

EquipmentThebronchoscopeisessentiallyaflexibletubeconsistingoffibreopticbundles,channelsfor instrumentsandanumberofwires formanipulating thedistalend.Thebundlesofoptical fibres carry light to thedistal end inorder to illuminate theairways, andfurtherbundlestransmittheimagebacktotheeyepiece(Fig.1.1).Themodernvideobronchoscopes have a charge-coupled device (CCD) chip at the distal end whichcaptures the image and is subsequently transmitted to the monitor (Figs 1.2–1.4).Theresolutionoftheimageisexcellentandcontinuestoimprove,withsomescopesprovidingveryhigh-definitionimageswithdigitalmagnificationoptions.Therearealsohybriddevicesforspecialcircumstances,whichusethefibreopticbundletotransmittheimagebacktowardstheheadofthebronchoscope.Inthiscase,theCCDislocatedat 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.1.1Fibreoptic bronchoscope with eyepiece.

Fig.1.2Video bronchoscope.

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otherpurposes,i.e.largerinstrumentchannels,dualchannelsorsimplytofacilitatethemanufactureofslimmerbronchoscopes.

Thedistalendof thebronchoscopecanberotatedthrough160°bya leverat theendofthescope.This,incombinationwithmanualrotationofthescope,allowsittobemanipulatedduring examinationof the airways.Thenew rangeof scopes beingdevelopedalsohavearotatingfunctionwiththeabilitytolockthedegreeofrotationin a specific position.This development increases the range of movement of thebronchoscopeandfacilitatesaccesstosomeoftheareasinthelung.

Awiderangevarietyofbronchoscopesareavailablewithdifferentexternaldiametersrangingfrom2.2to6.3mm(Fig.1.5).Theinstrumentchannelsandthequalityofthevideochipandimagesalsovaryaccordingly(Fig.1.6).Astandardbronchoscopeshouldbeabletoundertakethemajorityoftasks(goodCCD,instrumentchannelofatleast2.2mmandexternaldiameterofabout4.6mm).Slimmerbronchoscopescanallowforsmallerairwaystobeinspectedandsampled.Anultra-finebronchoscopecanexaminemuchsmallerairwaysbutcanalsofacilitateotherproceduressuchasinsertionofstentsetc.underdirectvision.Alargerbronchoscopewithalargeinstrumentchannelwouldbemoreappropriateforinterventionalprocedureswherealargechannelforsuctionandintroductionofinstrumentsisrequired.Bronchoscopeswithabuilt-inlineararrayultrasound probe are also availablewhich allow sampling of lymph nodes and lungmassesadjacenttothecentralairways(Fig.1.7).

Fig.1.3Distal tip of a video bronchoscope showing the instrument channel, fibreoptics and charge-coupled device video chip.

Fig.1.4Video bronchoscope with connections to image processor and light source.

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DisinfectionManualcleaningofthebronchoscopeisanessentialstep,asanybiologicaldebrisleftbehindwouldnotbeadequatelysterilizedbyanydisinfectantliquid.Thesuctionpartsand instrumentchannelsaresusceptibleareaswheredebrismaynotbecompletelyremovedandcanthenbecomecolonizedbybacteria.Manualcleaningwithabrushisthemostimportantfirststepandthisisusuallyfollowedbyautomaticdisinfection.Instrumentsareplaced inspecializedwashersandcleanedwithdisinfectionsolutionsuchas0.2percentpara-aceticacid.Themethodofdisinfectinginstrumentsbyhandandplacingtheminadisinfectionsolutionsuchas2percentalkalineglutaraldehydeisbeingphasedoutduetotheriskstostafffromoccupationalexposuretothefumesfromthecleaningliquids.Mostmodernsystemscancleanseveralscopesinonecycleandawashcycleusuallylasts40minutes.

Cross-infectionhasbeenobservedwithorganismssuchasenvironmentalMycobacteriumandPseudomonasspecies.Henceprocessesshouldbeinplacetoensurethatrecordsofdisinfectionbeforeuseinapatientandtheserialnumbersofbronchoscopesusedinindividualpatientsaremaintained.Thisisessentialfortracingpatientsintheeventofsuspectedcross-infection.Again,inthemajorityofcases,inadequatemanualcleaningofthebronchoscopes,particularlyofthesuctionportshasbeenakeyfactor.

Biopsyforcepsandneedlesaremoreinvasiveandhenceneedtobesterilizedratherthansimplydisinfected.Thepotentialriskofinfectionwithvirusesandprionshasdriven

Fig.1.5Distal portion of a number of bronchoscopes showing the variety of instruments available with differing external diameters and functional characteristics.

Fig.1.6Two bronchoscopes with different sizes of the charge-coupled device video chip, and instrument channel.

Fig.1.7Distal tip of the linear array ultrasound bronchoscope.

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thedevelopmentofsingle-usedisposableinstruments.Hence,inmostbronchoscopyunits,thebiopsyforceps,transbronchialaspirationneedlesandsoonarenowdisposablesingle-useinstruments.Bronchoscopesthatcanbesterilizedratherthandisinfectedarealsoindevelopment,whichwouldfurtherreducetheriskfromprions,butthesewouldrequiremostbronchoscopyunitstosignificantlyincreasethenumberofinstrumentstheyhaveinordertomanageabronchoscopylist.Single-usebronchoscopesarealsoindevelopmentwhichemployLEDlightsourcesandsmalldistalchipswithinasimpleplastictubing.However,thusfartheyhavelimitedfunctionality.

IndicationsThemain indications forflexiblebronchoscopyare listed inBox1.1.Suspected lungcanceristhemajorindicationforbronchoscopyfollowedbytheassessmentofpulmonaryinfiltratesformicrobiologicalsampling.Traditionallybronchoscopywasconductedfordiagnosticpurposesbuttheroleof therapeuticbronchoscopy is increasingwiththedevelopmentofnewendoscopictreatmentsforrespiratorydiseases.

BOX1.1Indications for bronchoscopy

●● Investigationsofsymptoms– haemoptysis– persistentcough– recurrentinfection

●● Suspectedneoplasia– unexplainedparalysisofvocalcords– stridor– localizedmonophonicwheeze– segmentalorlobarcollapse– assessmentofnodulesormassesidentifiedonradiology– unexplainedparalysisofhemi-diaphragmorraisedrighthemi-diaphragm– suspicioussputumcytology– unexplainedpleuraleffusions– mediastinaltissuediagnosisandstaging– assesssuitabilityforsurgery– stagingoflungcancer

●● Infection– assessmentofpulmonaryinfiltrates– identificationoforganisms– evaluateairwaysifrecurrentorpersistentinfection– clinicalorradiologicalfeaturesofenvironmentalmycobacterialinfection

●● Diffuselungdisease– differentialcellcountsandcytology– transbronchiallungbiopsy

●● Therapeutic– clearanceofairwaysecretions– recurrentmucouspluggingcausinglobarcollapseandatelectasisinpatients

onmechanicalventilators– foreignbodyremoval– palliationofneoplasm– endobronchialablationoftumour(cryotherapy,electrocautery,laser)– insertionofairwaystents– insertionofbrachytherapycatheters– insertionoffiducialmarkersforthegamma/cyberknife– bronchoscopiclungvolumereduction– bronchialthermoplastyforasthma– treatmentofbronchopleuralfistula

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ContraindicationsFailure of the patient or their representative (in special circumstances) to provideconsent isacontraindication,andwrittenconsent isrequiredbeforetheprocedure.Themaincontraindicationsforbronchoscopyarehypoxiathatcannotbeadequatelycorrectedbyoxygensupplementationandableedingdiathesis.However,eveninthesecircumstances, firm cut-offs are not given as the risk–benefit should be evaluatedon an individual-patient basis. Full resuscitation equipment should be available inthebronchoscopy suite and the staff should have the appropriate level of skill andexperiencetodealwithanypotentialcomplications.Theseincluderespiratoryfailure,cardiacarrhythmias,haemorrhageandintercostaldraininsertion.

PatientpreparationAllpatientsneedtoprovideinformedconsentpriortotheprocedure.Theyshouldbeprovidedwithwritteninformationinadvanceoftheprocedureandthekeyaspects,such as risks of the procedure and alternative approaches, should be discussedbeforefinalconsent.Theprocedureisusuallyperformedonanoutpatientbasiswithconscioussedation.Patientsshouldbeadvisednottoeatforatleast6hoursbeforetheprocedurebuttheymaybeallowedtodrinkwaterforupto2hoursbeforetheprocedure.Box1.2providesasimplechecklist forpatientpreparationprior totheprocedure.

BOX1.2Preparation for bronchoscopy

●● Patientinformation–verbalandwritten●● Fullbloodcountandclottingpriortotransbronchiallungbiopsyand

interventionalproceduressuchastumourablation●● Informedconsent●● Spirometryifoxygensaturations<95percent●● Arterialbloodgasesifoxygensaturations<92percent●● Baselineelectrocardiogram(ECG)ifthereisahistoryofcardiacdisease●● Ifpatientsaretohaveanysedation,ensurethatsomeoneisgoingto

accompanythemhomeaftertheprocedure●● Remindpatientsthatiftheyaresedatedtheywillbeunabletodriveor

operatemachineryforatleast24hours●● Intravenousaccess●● Considerbronchodilatorsifthereisevidenceofbronchospasm●● Considerprophylacticantibioticsifatveryhighriskofendocarditis:asplenia,

heartvalveprosthesisorprevioushistoryofendocarditis

Computedtomography(CT)scanshouldbeperformedpriortobronchoscopyandthereisgoodevidencethatreviewingCTscansofthethoraxbeforeflexiblebronchoscopysignificantly improves the yield from the procedure. It allows the bronchoscopist toselectmore accurately the segment of the lung that should be sampled and henceimprovethediagnosticaccuracyoftheinvestigation.TheCTscanmayalsodemonstratethepresenceofmediastinallymphnodesandhenceallowadditionalproceduressuchastransbronchialfine-needleaspirationtobeperformedatthesametimeasthediagnosticbronchoscopy.

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SedationBronchoscopy can be easily performed without any sedation providing the patientisrelaxedandfully informedabouttheprocedureandwhattoexpect.Short-actingsedativesthatarecommonlyusedincludeashort-actingintravenous(IV)benzodiazepine,suchas IVmidazolam,oranopiatesuchas fentanyloralfentanil.Midazolamhastheadvantageofamnesicpropertieswhereasfentanyloralfentanilhavegoodantitussiveproperties. In some institutions, low-dose propofol infusion is used to induce andmaintainsedation.

Patientswhohavebeengivensedationshouldbeadvisednottodriveorhandleanymachineryforatleast24hoursaftertheprocedure.Patientswhoaregivensedativesneedtobecollectedandaccompaniedhomeaftertheprocedure.

RoomergonomicsandapproachtotheprocedureTheprocedurecanbeperformedwiththepatientsittinguprightinasemi-recumbentpositionbeingapproachedfromthefront(Fig.1.8).Thishastheadvantageofallowingittobecarriedoutinsickerpatientswhodesaturateuponlyingflat.Forthissetupthebronchoscopeimageobtainedissuchthattheposterioraspectisvisibleatthetop,theanterioraspectisbelow,therightisontheleftpartoftheimageandtheleftisontherightpartoftheimage(Fig.1.9).

Fig.1.9Bronchoscopic image obtained with the semi-recumbent patient approached from the front.

Fig.1.8Room setup with the semi-recumbent patient being approached from the front.

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Theposteriorapproachwiththepatientlyingflatisalsowidelyused(Fig.1.10).Thisapproachisalsorequiredinanumberofproceduressuchasendobronchialultrasoundandalsothesuperdimensionprocedure.Withthisapproachtheimageobtainedissuchthattheanterioraspectisatthetop,theposterioraspectistheinferioraspectoftheimageandtheleftsideofthepatientistheleftsidedimageandtherightsideofthepatientistherightsideoftheimage(Fig.1.11).

Fig.1.10Room setup with patient being approached from the back in a supine position.

Fig.1.11Bronchoscopic image obtained with the supine patient approached from the back.

The different approaches have their own merits and limitations and we wouldadvocatethatthebronchoscopistbecomesfamiliarwithbothapproachesandhencebecomesflexibleandadaptivetothecircumstances.Inordertosimplifytheanatomyforbeginners,thisisdiscussedseparatelyinthefollowingchapters,dependingontheapproach.Chapter3demonstratestheanatomyaccordingtotheanteriorapproachandChapter4theanatomyaccordingtotheposteriorapproach.

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Basictechniquesandsampling

●● Bronchial washingsBronchial washings allow targeted sampling of proximal or segmental airways.Thebronchoscopeisheldproximal,butclose,tothesiteofabnormality.About10–20mLaliquotsofsalineareinstilledandaspiratedback.Thesensitivityofbronchialwashingsisveryvariable(average50percent;range21–76percent).

●● Bronchial biopsiesAvarietyofbiopsyforceps,fromcuppedtoserrated,areavailableforobtainingtissuesamples.Theforcepsareinsertedthroughtheinstrumentchannelofthebronchoscope.Theforcepsarejustopened,apposedtotheareaofabnormalityandthenclosedinorder to obtain biopsies under direct vision (Fig. 1.12). Several biopsies should beobtainedtoensurethatadequatetissuehasbeenobtainedfordiagnosis.Crushartefactisthemainlimitingfactorthataffectstheinterpretationofthetissueobtained.Ahigheryieldisobtainedfromendobronchialbiopsies,withanoverallsensitivityof74(range48–97)percent.However,whereanexophytictumourisvisible,thediagnosticyieldshould be at least 90 per cent.The technique is generally very safe and the maincomplication is thatofbleeding,particularlywhenvascular lesions are sampled.Thebleedingisrarelysignificantandcanusuallybecontrolledwithconservativemeasures.

Fig.1.12bProximal view of the biopsy forceps showing the handle that is used to open and shut them.

Fig.1.12aDistal view of the biopsy forceps in an open and closed position.

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●● Bronchial brushingsBronchialbrushingscanbeobtainedbyusingthecytologybrushtoscrapesomecellsfromthesurfaceofanyabnormalareas.Thebrushconsistsoffinebristlessimilartoabottlebrushwithaprotectiveplasticsheath.Theinstrumentispassedthroughtheinstrumentchannelofthebronchoscopetowardstheabnormalarea.Thebrushportionisthenprotrudedoutoftheplasticsheathandbrushedagainsttheabnormalmucosa.Thebrushisthenwithdrawnbackintotheplasticsheath(Fig.1.13).Thecellsaretheneither smearedon toa slideor rinsed into salineaccording to localpreferences. Insomecentres,thebrushingsarerinsedintocytolytesolutionforprocessing.Theyieldfrombronchialbrushingsis59(range23–93)percent;themaincomplicationisminorbleeding but there is a risk of a pneumothoraxwhere a brush is advanced blindlybeyondasubsegmentalbronchus.

Fig.1.13aClose-up of a bronchial brush (left) and handle (right): when the brush is protruding out of the sheath.

Fig.1.13bClose-up of a bronchial brush (left) and handle (right): when the brush is retracted.

●● Bronchoalveolar lavageBronchoalveolarlavageenablessamplingofthedistalairwaysandalveolarspaces.Itisparticularlyusefulintheassessmentof:

●● diffuseinterstitiallungdisease●● parenchymalinfiltrates●● pulmonaryinfiltratesinimmunocompromisedpatients●● assessmentofoccupationaldustexposure.

Theprocedureisperformedbywedgingthebronchoscopeinthedesiredsubsegment.Indiffuselungdisease,therightmiddlelobeisthesegmentofchoiceasitdrainswellandhenceprovidesthebestyield.Otherwisetheoptimalsegmentisselectedonthebasisofradiologicalfindings.Oncethebronchoscopeiswedgedintothesubsegment,50–60mLaliquotsofnormalsalineare instilledandaspiratedbackeitherbygentlehandsuctionorwithlow-pressuresuctionintoacollectingbottle.Thetotalfluidinstilledrangesfrom100to250mLdependingontheexactindicationandlocalcircumstances.Thekeyaspectofthetechniqueistomaintainthepositionofthebronchoscopeinthe bronchial segment and also to maintain low suction pressure. Displacement ofthebronchoscopeandhighersuctionpressurecausingairwaycollapsearethemainfactorsthatleadtoloweryieldsfrombronchoalveolarlavage.Patientswithobstructive

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airwaysdiseaseandemphysemaalsotendtohavelowyields.Themainadverseeventsinbronchoalveolarlavageareusuallycough,dyspnoea,wheezingandtransientfevers.Asignificantproportionofthepatientswhoaresampledarehypoxicduetounderlyingdisease,andinstillationofsignificantvolumesofsalinecanprecipitatehypoxiaandinsomepatientswithpulmonaryoedema.

The sampling provides information on the cellular composition of the pulmonaryinfiltrates, types of infective organisms, and presence of particulate and acellularmaterial in the alveolar spaces. Identification of specific bacteria, fungi and acid-fastbacillimaybediagnostic.Malignantcellscanbeidentifiedinthelavageinpatientswithbronchioloalveolar cell carcinoma, lymphangitis carcinomatosis or diffuse metastaticdisease.Milkyproteinaceouslavagewhichisladenwithamorphousperiodicacid-Schiff(PAS)-positivestainingtothedebrisisalmostpathognomonicofpulmonaryalveolar-proteinosis.

●● Transbronchial lung biopsyTransbronchiallungbiopsyisutilizedintheassessmentofdiffuselungdiseaseandinpatientswherethereisalocalizedparenchymalshadow(atleastinvolvingapulmonarysegment).The yield is greater in bronchocentric conditions such as sarcoidosis. Italso has a useful role in the diagnosis of diffuse lung diseases, such as lymphangitiscarcinomatosis,disseminatedmalignancy, interstitialpneumonitisandextrinsicallergicalveolitis.

Thebiopsyforcepsareinsertedthroughtheinstrumentchannelofthebronchoscopeintothedesiredsegment. Ideallythebronchoscopeshouldalsobewedgedintothisarea,sothatifthereisanybleedingitcanbecontainedwithinasmallareaofthelung.Theforcepsshouldbeadvanceduntilthereisresistanceduringinspiration.Theforcepsare thenwithdrawn1–2cmandopened.Thepatient is thenasked tobreatheoutwhilsttheforcepsareadvancedduringexpiration.Whenresistanceisfelt,theforcepsareclosedandgentlytugged.Thisisusuallyrepeateduntilfourbiopsiesareobtainedforpathologicalanalysis.

Thetwomainadverseeventsfromtransbronchiallungbiopsyarehaemorrhageandpneumothorax.The risk of a pneumothorax is between 5 and 10 per cent, but aclinicallysignificantpneumothoraxrequiringinterventionoccursinabout1percentofcases.Thedegreeofbleedingisveryvariablebutbloodlossofmorethan250mLisinfrequent.Anysignificantbleedingismanagedwithsuctioningofanyblood,combinedwith instillation of ice-cold saline and diluted adrenaline (1:100000).As describedearlier,wedgingofthebronchoscopeinthesegmentwherethebiopsyisobtainedalsocontainsthebleeding.Foradditionalinformationregardingmanagement,pleaseseethesectiononairwayhaemorrhage(Chapter12).

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Chapter

2Bronchopulmonary

segmentsThe lungsaremadeupof the rightand left lung, three lobes in the right lung, twolobesintheleftlung,10segmentsintherightlungandninesegmentsintheleftlung.Thetracheadividesintotwomainbronchi,whichinturndivideintothelobarbronchiandthenthesegmentalbronchi.Thesegmentalbronchicontinuetodivideintosmallerairways.Thepatencyoftheseairwaysismaintainedbythesectionsofcartilagewithintheairway.Thecartilaginouscomponentoftheairwaydecreaseswithmoreprogressivedivisionsofairwaysandtheairwaysalsobecomeprogressivelynarrow.

NomenclatureThebronchopulmonarysegmentsarenumberedaccordingtotherelativepositionoftheoriginofsegmentalbronchi.Thebronchialsegmentthatoriginatesatthehighestpositionislabelled1(apicalsegmentoftheupperlobe);thenextbronchialsegmentthatoriginatesislabelled2,andsoon.ThebronchialsegmentsarenamedusingArabicnumerals and pulmonary segmentswithRoman numerals (Figs 2.1a and 2.2a).Thebronchialsubsegmentsaresubsequentlylabelledasa,b,cinsequence.Intheleftlungthelabellingisinaclockwisedirection,whereasintherightlungthesubsegmentsarelabelledinananticlockwisedirection(Figs2.1b,cand2.2b,c).

Fig.2.1aRight bronchopulmonary tree with numbering of segments.

RB1RB2

RB6

RB3

RB4

RB5

RB8

RB9

RB10

RB7

RB6a

RB6b

RB6c

RB10a

RB10b RB10c

Fig.2.1bExample of labelling of subsegments in the right bronchopulmonary tree: segments of the apical segment of the right lower lobe, labelled a, b and c in an anticlockwise direction.

Fig.2.1cExample of labelling of subsegments in the right bronchopulmonary tree: segments of the posterior segment of the right lower lobe, labelled a, b and c in an anticlockwise direction.

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The carina are also denoted in a systematicmanner.Themain carina is labelled asMC.Ontherightside,thefirstcarinaisatthejunctionoftherightupperlobeandthebronchusintermedius(labelledasRC1).ThenextcarinaisatthejunctionoftherightmiddleandtherightlowerlobeandislabelledasRC2.Intheleftlung,themainsecondarycarinaisthedivisionbetweentheleftupperlobeandtheleftlowerlobeandistermedLC2.ThecarinabetweentheleftupperlobeandthelingulaisinamoresuperiorpositionandisdenotedbyLC1.Othercarinacanbedenotedaccordingtothesegmentsthatformthecarina,e.g.thecarinabetweentheposteriorandanteriorsegmentsoftherightupperlobemaybedescribedasRCRB2–RB3(Figs2.2d–2.2j).

Fig.2.2cExample of labelling of subsegments in the left bronchopulmonary tree: segments of the apical segment of the left lower lobe, denoted a, b and c in a clockwise direction.

Fig.2.2bExample of labelling of subsegments in the left bronchopulmonary tree: segments of the anterior segment of the left upper lobe, denoted a, b and c in a clockwise direction.

Fig.2.2aLeft bronchopulmonary tree with numbering of segments.

LB1+2LB3

LB4

LB5

LB6

LB10LB8

LB9

LB3c

LB3b

LB3a

LB6a

LB6b

LB6c

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Fig.2.2dHighlighted area would be denoted as follows: RC RB1–RB3.

Fig.2.2gHighlighted area would be denoted as follows: RC RB1–RB2–RB3.

Fig.2.2jHighlighted area would be denoted as follows: RB3 to RC RB2–RB3.

Fig.2.2eHighlighted area would be denoted as follows: RC RB1–RB2.

Fig.2.2hHighlighted area would be denoted as follows: RB1 to RC RB1–RB3.

Fig.2.2fHighlighted area would be denoted as follows: RC RB2–RB3.

Fig.2.2iHighlighted area would be denoted as follows: RB3.

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RightlungTherightlungconsistsofthreelobesseparatedbytheobliqueandhorizontalfissures.Theobliquefissureseparatestheupperandmiddlelobesfromthelowerlobes.Thehorizontalfissureseparatestheupperandthemiddlelobes(Fig.2.3).

Fig.2.3aOblique and horizontal fissures in the right lung: lateral or costal view.

Fig.2.3bOblique and horizontal fissures in the right lung: medial or hilar view.

Oblique �ssure

Anteriorborder

Posteriorborder

Horizontal�ssure Pulmonary

hilum

Oblique �ssure

Posterioraspect

Anterioraspect

Horizontal�ssure

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●● Right upper lobe (Fig.2.4)

Theapicalsegment(RB1)oftherightupperlobeisthemostsuperiorbronchusfromtheupperlobebranches.Itsbranchessupplytheapicalportionofthelung(I).Theposteriorsegmentoftherightupperlobeislower(RB2)andbranchestoformtheposteroinferiorpartoftheupperlobe(II).Theanteriorsegmentoftherightupperlobeisslightlylower(RB3)andbranchestoformtheanteriorinferiorportionoftheupperlobe(III).

Fig.2.4aApical segments of the lung. I, apical; II, posterior; III, anterior pulmonary segments of the right upper lobe: lateral or costal view.

Fig.2.4bApical segments of the lung. I, apical; II, posterior; III, anterior pulmonary segments of the right upper lobe: medial or hilar view.

III

I

IIIII

I

II

RB1

RB1bRB1a

RB2

RB2bRB2a RB3

RB3aRB3b

Fig.2.4cRight bronchopulmonary tree showing the apical segments of the lung. Right upper lobe: RB1, apical; RB2, posterior; RB3, anterior bronchial segment.

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●● Right middle lobe (Fig.2.5)

Therightmiddlelobeisabranchfromtheanteriorportionoftherightmainbronchus.Itdivides intoa lateralsegment(RB4)andamedialsegment(RB5).Thesesegmentsformthelateral(IV)andmedialportions(V)ofthemiddlelobe.

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

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

V

IVV

Fig.2.5cRight bronchopulmonary tree showing the right middle lobe: RB4, lateral; RB5, medial bronchial segment.

RB4RB4a

RB4b

RB5b

RB5RB5a

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●● Right lower lobe (Fig.2.6)

The right lower lobe bronchus gives off a posterior branch (RB6) a short distancefrom the right middle lobe origin.This supplies the apical portion to the lower lobe(VI).Themainairwaycontinuesposterolaterallyfromitsanteriormedialaspecttoformtheoriginof themedial segment (RB7),which supplies the inferiormedial portionofthelung(VII).Itcontinuestogiveofftheanteriorsegment(RB8)andsuppliestheanteriorportionofthelowerlobe(VIII).Theairwaycontinuesposterolaterallyandalsogivesoffalateralsegment(RB9)andthenformstheposteriorbasalsegment(RB10).Theseformthelateral(IX),andposteriorinferior(X)pulmonarysegmentsoftherightlung,respectively.

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

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

IX

VIII

VI

X

VI

X

IXVIII

VII

RB6

RB6a

RB6b

RB6c

RB8

RB8a

RB8b

RB9RB9a

RB9b

RB10

RB10a

RB10b

RB10c

RB7

Fig.2.6cRight bronchopulmonary tree showing the basal segments. VI, superior; VII, medial; VIII, anterior; IX, lateral; X posterior bronchial segments of the right lower lobe.

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LeftlungTheleftlungconsistsoftwolobeswhichareseparatedbytheobliquefissure(Fig.2.7).Theupperlobecomprisesfivesegmentsandthelowerlobehasfoursegments.

Fig.2.7aOblique fissure of the left lung: lateral or costal view.

Fig.2.7bOblique fissure of the left lung: medial or hilar view.

Oblique �ssure

Posterioraspect

Anterioraspect

Pulmonaryhilum

Oblique�ssure

Posterioraspect

Anterioraspect

●● Left upper lobe (Fig.2.8)

Theleftupperlobehasasuperiorandaninferiordivision.Fromthesuperiordivision,thehighestbranchistheapicoposteriorsegment(LB1+2),whichinturnseparatestoformtheapicalsegmentalbronchus(LB1)andtheposteriorsegmentalbronchus(LB2).Theseformtheapicalsegment(I)andtheposteriorsegment(II)oftheupperlobe.Justbelowtheoriginoftheapicoposteriorbranchistheanteriorbranch(LB3)andthisformstheanteriorsegment(III).Theinferiordivisionoftheleftupperlobeformsthelingularsegments,thesuperiorbranchLB4formsthesuperiorsegment(IV)andthesubsequentslightlyinferiordivision(LB5)formstheinferiorsegmentofthelingula(V).

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Fig.2.8aSegments of the upper lobe of the left lung. I + II, apicoposterior; III, anterior ; IV, superior lingular; V, inferior lingular pulmonary segments. Lateral or costal view.

Fig.2.8bSegments of the upper lobe of the left lung. I + II, apicoposterior; III, anterior ; IV, superior lingular; V, inferior lingular pulmonary segments. Medial or hilar view.

I + II

IV

III

V

I + II

IV

III

V

Fig.2.8cLeft bronchopulmonary tree showing the segments of the upper lobe. I + II, apicoposterior; III, anterior; IV, superior lingular; V, inferior lingular bronchial segments.

LB1+2c

LB3a

LB3c

LB3b

LB4aLB4b

LB5a

LB5b

LB1+2aLB1+2b

LB1+2LB3

LB4

LB5

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●● Left lower lobe (Fig.2.9)

Thelowerlobebronchusdescendsinaposterolateraldirection.TheapicalsegmentalbronchusLB6arisesfromtheposterioraspectandformstheapicalbasallobe(VI).Itthengivesoffananteriorsegmentalbronchus(LB7+8)fromitsanteriormedialaspecttoformtheanteriorbasalsegment(VIII).Thenextisthelateralsegmentalbronchus(LB9)andfinallytheairwayformstheposteriorsegmentofbronchusLB10.Thelattertwoformthelateralaspectsoftheinferiorlobe(IX)andtheposteroinferiorpartofthelowerlobe(X).

Fig.2.9aBasal segments of the lower lobe of the left lung. VI, superior; VIII, anterior; IX, lateral; X, posterior pulmonary segments. Lateral or costal view.

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

VI

X

IXVIII

VI

X

IX VIII

Fig.2.9cLeft bronchopulmonary tree showing the basal segments of the left lower lobe. VI, superior; VIII, anterior; IX, lateral; X, posterior bronchial segments.

LB10a

LB9a

LB6a

LB6b

LB6c

LB9b

LB8bLB8a

LB10b

LB10c

LB6

LB10

LB8

LB9

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OverallviewofsegmentsThelateralandmedialviewsoftherightandleftlung,aswellasthebronchopulmonarytree,demonstratingallthesegmentsareshowninFigures2.10and2.11.

Fig.2.10aSegments of the right lung. Right upper lobe: I, apical; II, posterior; III, anterior pulmonary segments. Right middle lobe: IV, lateral; V, medial pulmonary segment. Right lower lobe: VI, superior; VIII, anterior; IX, lateral; X, posterior pulmonary segments. Lateral or costal view.

Fig.2.10bSegments of the right lung. Right upper lobe: I, apical; II, posterior; III, 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.

V

IV

IX

VIII

III

I

II

VI

X

III

I

II

VI

X

IXVIII

V

VII

RB6a

RB6b

RB6c

RB8a

RB8b

RB9a

RB9b

RB10a

RB10b

RB10c

RB7

RB4a

RB4bRB5a

RB5b

RB1bRB1a

RB2b

RB2a

RB3a

RB3b

Fig.2.10cRight bronchopulmonary tree showing all the segments of the right lung. Right upper lobe: I, apical; II, posterior; III anterior bronchial segments. Right middle lobe: IV, lateral; V, medial bronchial segment. Right lower lobe: VI, superior; VII, medial; VIII, anterior; IX, lateral; X, posterior bronchial segments.

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Fig.2.11aSegments of the left lung. Left upper lobe: I + II, apicoposterior; III, anterior ; IV, superior lingular; V, inferior lingular pulmonary segments. Left lower lobe: VI, superior; VIII, anterior; IX, lateral; X, posterior pulmonary segments. Lateral or costal view.

Fig.2.11bSegments of the left lung. Left upper lobe: I + II, apicoposterior; III, anterior; IV, superior lingular; V, inferior lingular pulmonary segments. Left lower lobe: VI, superior; VIII, anterior; IX, lateral; X, posterior pulmonary segments. Medial or hilar view.

VI

X

IXVIII

I + II

IV

III

V

VI

X

IX VIII

I + II

IV

III

V

LB10a

LB9a

LB1+2c

LB3a

LB3c

LB3b

LB4aLB4b

LB5a

LB5b

LB1+2aLB1+2b

LB6a

LB6b

LB6c

LB9b

LB8bLB8a

LB10b

LB10c

Fig.2.11cLeft bronchopulmonary tree showing all segments of the left lung. Left upper lobe: I + II, apicoposterior; III, anterior ; IV, superior lingular; V, inferior lingular bronchial segments. Left lower lobe: VI, superior; VIII, anterior; IX, lateral; X, posterior bronchial segments.

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CorrelationofCTscansandbronchopulmonarysegmentsCorrelationof the radiographic changeson a computed tomography (CT) scan toa particular bronchopulmonary segment is important and improves the yield fromprocedures such as bronchial lavage and transbronchial lung biopsy.The images inFigures2.12–2.17 are to guide thebronchoscopist as towhich areasof aCT scanrelate tothevariousbronchopulmonarysegments. IalsorecommendreviewingthewholeCTscancarefullyandfollowingtheairwayssequentiallytodeterminetheexactsegmentinvolvedinaparticularpatient.

Fig.2.12aCross-sectional CT scans of the thorax at the level of the aortic arch.

Fig.2.12bCross-sectional CT scans of the thorax at the level of the aortic arch; the overlay shows the margins of the pulmonary segments.

Fig.2.12cBronchial tree showing the segments correlating with the CT scan.

Atlas of Flexible BronchoscopyShah

2_12c

FOR PROOFING ONLY – Jane Fallows

RB6 LB6

LB3

LB1+2

RB3

RB2 RB1

anterior segmentright upper lobe (RB3)

anterior segmentleft upper lobe (LB3)

apico-posterior segment of theleft upper lobe (LB1+2)

apicalsegmentleft lowerlobe (LB6)

posteriorsegmentright upperlobe (RB2)

apical segmentright upper lobe (RB2)

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Fig.2.13aCross-sectional CT scans of the thorax at the level of the right upper lobe origin.

Fig.2.13bCross-sectional CT scans of the thorax at the level of the right upper lobe origin; the overlay shows the margins of the pulmonary segments.

Fig.2.13cBronchial tree showing the segments correlating with the CT scan.

anterior segmentright upper lobe (RB3)

anterior segmentleft upper lobe (LB3)

apico-posterior segment of theleft upper lobe (LB1&2)

apical segmentleft lower lobe (LB8)

apical segmentright lower lobe (RB8)

posterior segmentright upper lobe (RB2)

Atlas of Flexible BronchoscopyShah

2_13c

FOR PROOFING ONLY – Jane Fallows

RB6 LB6

LB3

LB1+2

RB3

RB2

Fig.2.14aCross-sectional CT scans of the thorax at the level of the bronchus intermedius.

Fig.2.14bCross-sectional CT scans of the thorax at the level of the bronchus intermedius; the overlay shows the margins of the pulmonary segments.

Fig.2.14cBronchial tree showing the segments correlating with the CT scan.

Atlas of Flexible BronchoscopyShah

2_14c

FOR PROOFING ONLY – Jane Fallows

RB6 LB6

LB3

RB3

posteriorsegmentright upper lobe (RB2)

apicalsegmentright lowerlobe (RB6)

posteriorsegmentleft upper lobe (LB2)

apicalsegmentleft lowerlobe (LB6)

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

Fig.2.15bCross-sectional CT scans of the thorax at the level of the origin of the right middle lobe; the overlay shows the margins of the pulmonary segments.

Fig.2.15cBronchial tree showing the segments correlating with the CT scan.

RB6 LB6 LB4

LB5RB5

RB4

lateralsegmentright middlelobe (RB4)

superiorsegmentof lingula (LB4)

inferior segment of lingula (LB5)

apicalsegment ofleft lowerlobe (LB6)

apicalsegmentright lowerlobe (RB6)

medial segmentright middle lobe (RB5)

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Fig.2.16aCross-sectional CT scans of the thorax at the level of the origin of the lower lobe bronchial segments.

Fig.2.16bCross-sectional CT scans of the thorax at the level of the origin of the lower lobe bronchial segments; the overlay shows the margins of the pulmonary segments.

Fig.2.16cBronchial tree showing the segments correlating with the CT scan.

Atlas of Flexible BronchoscopyShah

2_16c

FOR PROOFING ONLY – Jane Fallows

RB10

LB8

LB5

LB9

LB10

RB5

RB4

RB8

RB9

lateralsegment ofright middlelobe (RB4)

anterior segment ofleft lowerlobe (LB8)

lateral segment of left lowerlobe (LB9)

posteriorsegment ofleft lowerlobe (LB10)

lateralsegment ofright lowerlobe (RB9)

medial segment ofright middle lobe (RB5)

inferior segmentof lingula (LB5)

posterior segment ofleft lower lobe (RB10)

anterior segment ofright lowerlobe (RB8)

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Fig.2.17aCross-sectional CT scans of the thorax at the level of the basal pulmonary segments.

Fig.2.17bCross-sectional CT scans of the thorax at the level of the basal pulmonary segments; the overlay shows the margins of the pulmonary segments.

Atlas of Flexible BronchoscopyShah

2_17c

FOR PROOFING ONLY – Jane Fallows

RB10

RB7 LB8

LB5

LB9

LB10

RB5

RB4

RB8

RB9

Fig.2.17cBronchial tree showing the segments correlating with the CT scan.

anterior segment ofright lowerlobe (RB8)

inferiorsegmentlingula (LB5)

anterior segment of left lowerlobe (LB8)

lateralsegment ofleft lowerlobe (LB9)

lateralsegment ofright lowerlobe (RB9)

medial segmentright middle lobe (RB5)

lateral segment ofright middle lobe (RB4)

posterior segment ofright lower lobe (RB10)

posterior segment ofleft lower lobe (LB10)

medialsegment ofright lowerlobe (RB7)

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CHAPTER

3Normal anatomy (anterior approach)In this chapter the endoscopic images are related to the computed tomography(CT) images.Theoverall appearance,maincharacteristics andnormal variationsaredescribed.Theanatomicalimagesinthischapterarepresentedastheyappearwhenthe procedure is performed with the patient in a semi-recumbent position beingapproachedfromthefront.

Inorder tominimize confusion, thenormal anatomy is described again in thenextchapterbutthebronchoscopicimagesarepresentedastheyappearwhenthepatientisbronchoscopedinasupinepositionandapproachedfrombehind.

Vocalcords(Fig.3.1)

The larynx is composedofa seriesof cartilages, ligamentsandfibrousmembranes.At bronchoscopy the epiglottis is the more proximal structure. It is a broad leaf-likestructure.Thesidesareattachedbythearytenoidcartilages.Thecuneiformandcorniculatecanbeseenattheendofthearytenoidcartilage.Thecuneiformcartilageismoreanteriorandsuperiortothecorniculatecartilage.Thevocal foldsconsistofthefalsecordsorvestibularfoldsandthetruevocalfolds.Theystretchbackfromthethyroidangletothevocalprocessesofthearytenoids.Thevocalfoldsareinvolvedintheproductionofsound.

cuneiform tubercle corniculate tubercle

left vocal cord aryepiglottic fold

LR

vocal fold hyoid bone cricoid cartilage

Fig.3.1aCross-sectional CT scan at the superior aspect of the thorax at the level of the vocal cords, which are apposed.

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

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right aryepiglottic fold posterior pharyngeal wall

right vallecula epiglottis left vallecula

hyoid bone open vocal foldsvocal folds

right cuneiform tubercle

right corniculate tubercle

posteriorpharyngeal wall

left aryepiglottic foldleft vocal cord epiglottis

Fig.3.1cEndoscopic view of the epiglottis and vocal cords.

Fig.3.1eCross-sectional CT scan at the superior aspect of the thorax at the level of the vocal cords, which are open.

Fig.3.1dEndoscopic view of the vocal cords.

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

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open vocal cords

aryepiglottic fold epiglottis

corniculate tubercle apposed vocal cords

cuneiform tubercle

Fig.3.1gEndoscopic view of the open vocal cords. Fig.3.1hEndoscopic view of apposed vocal cords.

Trachea(Fig.3.2)

Thetrachea isahorseshoe-orD-shapedstructurewhichextends fromthecricoidcartilagetothecarina.Theanterioraspectiscomposedof16–20incompletecartilageringswithaflatfibromuscularposteriorcomponent.Thereisalsoalongitudinalbandofconnectivetissuewhichrunsdowntheposteriorendofthecartilage.Atbronchoscopythecartilagebandson theanterior surfaceappearas ridgesand theposteriorwallappearstobulgeintothetrachea.Theposteriorbulgeisaccentuatedinexpiration.

Thetracheameasuresapproximately110mminlengthwithanexternaldiameterthatrangesfrom15mminwomento20mminmen.Theinternaldiameterofthetracheaisabout12–14mm.

Thetracheadividesintotherightandleftmainbronchiatthelevelofthesternomanubrialjunctionorthebodyofthefourththoracicvertebrae.

Atrachealbronchusisararenormalvariantandoriginatesfromthelateralwallofthetracheaandintotheupperlobeontherightsideinabout0.1–2percentofindividualsandontheleftsidein0.3–1percentofindividuals.Thetermtrachealbronchusisalsousedforotheranomalousairwaysarisingfromthemainbronchianddirectedtotheupperlobes.

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superior vena cava

trachea oesophagus

fat aorta right pulmonaryartery trachea

left atrium left inferior pulmonary vein

aortic archleft pulmonaryartery

posterior membranous trachea

anterior aspectcartilage rings

carina

Rt Lt

cartilage rings anterior wall

posterior tracheal wall

Fig.3.2cEndoscopic view of the trachea from the level of the subglottis.

Fig.3.2aCross-sectional CT scan of the thorax at the mid-tracheal level.

Fig.3.2dEndoscopic view of the upper trachea.

Fig.3.2bCoronal sectional CT scan of the thorax through the trachea.

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anteriortrachealwall

leftmainbronchus

rightmainbronchus

posteriortrachealwall carina (mc)

Rt Lt

anterior

rightmainbronchus

Rt Lt

membranousposteriorwall

leftmainbronchus

carina (mc) rightupperlobe

anterioraspectof trachea

trachealbronchus

posterior wallof trachea

rightmainbronchus

right mainbronchus

posteriorwall oftrachea

right upperlobe

trachealbronchus

posterior segment

anterior segment tracheal bronchus trachea

Fig.3.2eEndoscopic view of the trachea from the mid-tracheal level.

Fig.3.2fEndoscopic view of the distal portion of the trachea.

Fig.3.2gEndoscopic view of a tracheal bronchus as viewed from above with the patient upright and approached from the front. The right upper lobe arises from the right main bronchus.

Fig.3.2hEndoscopic view of a tracheal bronchus as seen at the distal trachea just above the carina. The right upper lobe and bronchus intermedius are visible below.

Fig.3.2iBipartite division of the upper lobe in the presence of a tracheal bronchus.

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

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Carina(Fig.3.3)

Thecarinaisaconcavespurofcartilagelocatedwherethedistaltracheadividesintotherightandleftmainbronchi.Thecarinanormallyappearsasasharpstructureandformsthemedialbordersoftheoriginoftherightandleftmainbronchi.Thesharpangle is maintained as it is primarily composed of cartilage (carinal) and ligaments(interbronchial).Enlargementofthesubcarinalstructures,suchasthesubcarinallymphnodes or the left atrium, may lead to blunting or widening of the carina. It usuallymeasuresabout12mmindiameterandstretchesinthemidlineintheanteroposteriordimension.Veryrarelythereisanaccessorybronchusopeningfromthelateralwallsdirectedtowardstheupperlobe.

superiorpericardialrecess

posterior segment of right upperlobe (RB2)

carina

superiorvena cava

ascending aorta

pulmonaryartery

anterior segmentof the left upperlobe (LB3)

oblique �ssure

apical segment of right upper lobe (RB1)

descending aorta

apicoposterior segment of the left upper lobe (LB1+2)

right upper lobe

right pulmonary artery

apicoposterior segment of the left upper lobe (LB1+2)trachea

aortic arch

anterior segment of the left upperlobe (LB3)

left atrium left pulmonary artery

left inferiorpulmonary vein

Fig.3.3aCross-sectional CT scan of the thorax at the level of the carina.

Fig.3.3bCoronal sectional CT scan of the thorax through the trachea.

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Rightmainbronchus(Fig.3.4)

Therightmainbronchusextendsfromthecarinatotheoriginoftherightupperlobe.Itthenformsthebronchusintermedius.Therightmainbronchushasasteeperdeclinefromthe tracheaandhence, in theuprightposition, foreignbodies tend to fall intotherightmainbronchus. It is slightly larger indiameter thanthe leftmainbronchus,measuringbetween10and12mminexternaldiameter.Theinferiorlipoftheupperlobe bronchus is easily visible at the distal end of the right main bronchus.A rarevariationistheoriginofanairwayleadingtotheupperlobe.Thisisclassifiedasapre-eparterialtrachealbronchus.Itmaybeeitherasupernumeraryoradisplacedairway.Wheretheairwayisdisplaced,thereisalsoamissingupperlobebranch.Anaccessorycardiacbronchusisasupernumerarybronchusarisingfromthemedialaspectoftherightmainbronchusandleadingtowardsthepericardium.

left main bronchus

right main bronchus carina (mc)posterior membranous wall of trachea

posterior membranous wall of trachea

right main bronchus left main bronchus

carina (mc)

Fig.3.3cEndoscopic view of the carina. Fig.3.3dClose-up endoscopic view of the carina.

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anterior segmentalbronchus of rightupper lobe (RB3)

posterior segmentalbronchus of rightupper lobe (RB2)

right mainbronchus

azygosvein

descendingaorta

leftmainbronchusoesophagus

apical segmentalbronchus of rightupper lobe (RB1)

superiorvenacava carina

leftpulmonaryartery

right upper lobe bronchus

right upper lobe spur (RC1)

azygos arch trachea

main carina (mc)

left main bronchus

right main bronchus

right upperlobe spur (RC1)

bronchusintermedius

anterior wall of right main bronchus

medial wall of right main bronchus

right upper lobe posterior wall of right main bronchus

right upper lobespur (RC1)

right upper lobe origin basal segmentsposterior wall ofright main bronchus

right middlelobe

anterior wall ofright mainbronchus

medial wall ofright main bronchus

Fig.3.4cEndoscopic view of the right main bronchus visible below the carina.

Fig.3.4aCross-sectional CT scan of the thorax at the carina, showing the right main bronchus.

Fig.3.4dEndoscopic view of the right main bronchus with more of the right upper lobe visible.

Fig.3.4bCoronal sectional CT scan of the thorax showing the right main bronchus.

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Rightupperlobe(Fig.3.5)

The right upper lobe has three main segmental divisions: the apical, anterior andposteriorsegments.Theupperlobesegmentsdivideintosegmentsabout10mmfromtheorigin.Theupperlobeissubjecttoconsiderablenormalvariation:

●● In40percentthesegmentalbronchiariseindependently.●● In24percent there isacommonapicalandanterior trunkandan independentposterior-segmentalbronchus.(seeFig.3.5g)

●● In14percentthereisacommonapicalandposteriortrunkandanindependentanteriorsegment.(seeFig3.5h)

●● In10percentthereisacommonanteriorandposteriortrunkwithanindependentapicalsegment.

●● In10percenttheposteriorsegmentalbronchusisabsent.●● In2percenttheapicalsegmentisabsent.●● In <1 per cent of patients there is a tracheal bronchus which originates eitherdirectly from the tracheaor at the levelof thecarina. In somecases there is anadditionalbranchtotheupperlobe,whichoriginatesfromtherightmainbronchus.

superior branch ofright pulmonary artery

superior vena cava

right main bronchus

pulmonary artery trunk

right upper lobebronchus

anterior segment of theleft upper lobe (LB3)

apico posterior segment of the left upper lobe (LB1+2)

anterior branch ofright upper lobebronchus (RB3)

bronchus intermedius right main bronchus

apical branch ofright upper lobebronchus (RB1)

apical segment ofthe left upper lobe (LB1)

right upper lobe

Fig.3.5aCross-sectional CT scan of the thorax at the level of the right upper lobe origin.

Fig.3.5bCoronal sectional CT scan of the thorax showing the right upper lobe.

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anterior segment of the right upper lobe (RB3)

posterior segment of the right upper lobe (RB2)

apical segment of theright upper lobe (RB1) RB2b RB2a

apical segment of the right upper lobe (RB1)

anterior segment of the right upper lobe (RB3)

posterior segment of the right upper lobe (RB2)

Fig.3.5cEndoscopic view of the right upper lobe from above with the patient upright being approached from the front.

Fig.3.5dAnother example of the tripartite right upper lobe arrangement.

Fig.3.5eBipartite division of the right upper lobe with division at the horizontal axis.

Fig.3.5fBipartite division of the right upper lobe with division in the vertical axis.

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anterior segment (RB3)

apicoanterior segment of the right upper lobe (RB1+3) apical segment (RB1)

posterior segment of the right upper lobe (RB2)

RB2b

anterior segment of the right upper lobe (RB3)

apicoposterior segment of the right upper lobe (RB1+2)

apical segment (RB1)

posterior segment (RB2)

RB2a

Fig.3.5gBipartite division of the right upper lobe with apical and anterior segments (RB1 + 3 arising together) and a separate posterior segment (RB2).

Fig.3.5iFour divisions of the right upper lobe.

Fig.3.5hBipartite division of the right upper lobe with apical and posterior segments arising together (RB1 + 2) and a separate posterior segment (RB3).

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Bronchusintermedius(Fig.3.6)

Thebronchusintermediusoriginatesfromtherightmainbronchusandextendsfromtheoriginoftherightupperlobetotherightmiddlelobe.Itisapproximately20mmlongandhasadiameterofabout10mm.Therightmiddlelobe,theapicalsegmentofthelowerlobeandthebasalsegmentsarevisibleatthedistalendofbronchusintermedius.

right superior pulmonary vein

bronchus intermedius

left ventricular outow tract

pulmonary trunk

left main bronchus

left superiorpulmonary vein

right pulmonary artery

azygos vein

left lower lobe pulmonary artery

left upper lobe bronchus

right upper lobe bronchus

right lower lobe pulmonary artery

bronchus intermedius

right mainbronchus

left upper lobe bronchus

apicoposterior segment of left upper lobe (LB1+2)

anterior segment ofthe left bronchus (LB3)

apical segment of right lower lobe (RB6)

carina between right middle lobe and lower lobe (RC2)

right middle lobe bronchus (RB4+5)

basal segments ofthe right lower lobe

Fig.3.6aCross-sectional CT scan of the thorax at the level of the bronchus intermedius (distal to the right upper lobe origin).

Fig.3.6cEndoscopic view of the bronchus intermedius.

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

Fig.3.6dEndoscopic view of the distal aspect of the bronchus intermedius.

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Rightmiddlelobe(Fig.3.7)

Therightmiddlelobeisasemi-lunar(D-shaped)bronchusattheanteriorendofthebronchus intermedius. Inapproximately70percentofcases, thereare twodistinctsegments: lateral and medial. In 23 per cent of normal individuals the middle lobebifurcates inasuperior-inferior fashion,similartothatofthe lingula. Inupto20percentofindividualsthereisamainlateralbronchusandasmallermedialbronchuswhicharisesfromthelateralsegment.Occasionallythereverseisseen,withalargermedialsegmentandasmallerlateralsegmentarisingfromit.

right lower lobe pulmonary artery

lateral segment of right middle lobe (RB4)

right middle lobe

medial segment of right middle lobe (RB5)

right lower lobe

left atrium

left lower lobepulmonary artery

superior pulmonaryvein

rightatrium

left inferior pulmonary vein

right upper lobe segment

right middle lobe pulmonary artery

right middle lobe

right inferior pulmonary vein

left atrium

left ventricle

right superior pulmonary vein

Fig.3.7aCross-sectional CT scan of the thorax at the level of the right middle lobe.

Fig.3.7bCoronal sectional CT scan of the thorax at the level of the right middle lobe.

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RB4a

RB5a medial segment of the right lower lobe (RB5)

lateral segment of the right lower lobe (RB4) RB4b

RB5b

lateral segment of theright middle lobe (RB4) RB4bRB4a

RB5a medial segment of the right middle lobe (RB5)

RB5b posterior wall

basal segments of the right lower lobe

apical segment of theright lower lobe (RB6)

carina between right middle lobe and lowerlobe (RC2)

right middle lobe

medial segment of the right lower lobe (RB7)

right lower lobe segments

carina between right middle lobe and right lower lobe (RC2)

right middle lobe bronchus (RB4+5)

Fig.3.7cEndoscopic view of the right middle and lower lobes.

Fig.3.7eEndoscopic view of the right middle lobe subsegments viewed from the origin of the right main bronchus.

Fig.3.7dEndoscopic view of right middle lobe.

Fig.3.7fClose-up endoscopic view of the right middle lobe subsegments.

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Rightlowerlobe(Fig.3.8)

Therightlowerlobecomprisesfivemainsegments:apicalbasal,medialbasal,anteriorbasal,lateralbasalandposteriorbasal.Inabout40–60percentofindividualsthereisanadditionalsubapicalbasalsegment.Theapicalbasalsegmentoftherightlowerlobeispositionedposteriorlyattheendofthebronchusintermedius.Theapicalsegmentdivides immediately into three subsegmental bronchi.Thenormal patternobservedinthelowerlobebronchialsegmentsarealargemedialbasalsegment(RB7),whichisproximal totheotherbasalsegments.Theanteriorbasalsegment is in the lateralposition,withthelowerbronchusdividingfurtherintolateralandposteriorsegments.Thispattern isseen inover70percentof individuals.Theothercommonvariationobserved iswhere the anterior basal, lateral basal andposterior basal segments alloriginateindependentlyatthesamelevel.

Abipartitedivisionisoccasionallyobservedwheretheanteriorandlateralsegmentsarise together proximally to the posterior basal segment from a separate branch.Thepositionandsizeoftheapicalbasalsegmentfrequentlyinfluencethepatternofbranchingofthebasalsegments.Forexample,insomeindividualsthereisalargerapicalbronchusand,asaresult,themedialthroughtoposteriorsegmentarisesinatripartitefromthesamelevel.

Fig.3.8aCross-sectional CT scan of the thorax at the level of the basal segments of the right lower lobe.

Fig.3.8bCoronal sectional CT scan showing the right lower lobe.

right atriumsuperior pulmonary vein

right lower lobepulmonary artery

right lower lobe bronchus

left atrium

inferior pulmonary vein

left lower lobepulmonary artery

left lower lobe bronchus bronchus intermedius

anterior segment of right lower lobe (RB8)

right lower lobe bronchus

left atrium inferior pulmonaryvein

left pulmonary artery

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apical segment of the right lower lobe (RB6)

anterior segment of the right lower lobe (RB8)

medial segmentof the rightlower lobe (RB7)

apical segment of the right lower lobe (RB6)

basal segments of the right lower lobe

RB6b RB6a

RB6ci RB6cii

RB6b

RB6a

subsegments of the apical segments of the right lower lobe (RB6)

lateral basal segment of the right lower lobe (RB9)

RB8a

RB8b medial basal segment of the right lower lobe (RB7)

anterior basal segment of the right lower lobe (RB8)

posterior basal segment of the right lower lobe (RB10)

lateral segment of the right lower lobe (RB9)

RB8a

anterior segment of the right lower lobe (RB8)

RB8b medial segment of the right lower lobe (RB7)

posterior segment of the right lower lobe (RB10)

lateral segment of the right lower lobe (RB9)

RB8a

anterior segment of the right lower lobe (RB8)

RB8b lateral wall of medial segment of the right lower lobe

posterior segment of the right lower lobe (RB10)

RB10c

RB10a

accessory subapical bronchusof the right lower lobe

posterior segment of the right lower lobe (RB10)RB10a

RB10b lateral basal segment of the right lower lobe (RB9)

RB10c

Fig.3.8cEndoscopic view of the basal segments of the right lower lobe.

Fig.3.8dEndoscopic view of the right apicobasal segment.

Fig.3.8eEndoscopic view of the apicobasal segments of the right lower lobe.

Fig.3.8fClose-up endoscopic view of the right apicobasal subsegments.

Fig.3.8gEndoscopic view of the basal segments of the right lower lobe.

Fig.3.8hCloser endoscopic view of the basal segments of the right lower lobe.

Fig.3.8iEndoscopic view of the anterobasal, basolateral and posterobasal segments of the right lower lobe.

Fig.3.8jEndoscopic view of the basolateral and posterobasal segments of the right lower lobe. In this example a normal variant subapical segment is present.

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anterior segment right lower lobe (RB8)

right lower lobe pulmonary artery

lateral segment right lower lobe (RB9)

posterior segment right lower lobe (RB10)

inferior pulmonary vein

posterior segment of the right lower lobe (RB10)

anterior segment of the right lower lobe (RB8)

lateral segment of the right lower lobe (RB9)

anterior segment of theright lower lobe (RB8)

posterior segment of the right lower lobe (RB10)

accessory subapical segment of the right lower lobe

lateral segment of the right lower lobe (RB9)

posterior segment of the right lower lobe (RB10)

Fig.3.8kCross-sectional CT scan at the level of the basal segments of the right lower lobe.

Fig.3.8mEndoscopic view of the anterobasal, basolateral and posterobasal segments of the right lower lobe.

Fig.3.8lCoronal CT scan showing the basal segments of the right lower lobe.

Fig.3.8nEndoscopic view of the basolateral and posterobasal segments of the right lower lobe.

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lateral segment of theright lower lobe (RB9)

anterior segment of the right lower lobe (RB8)

RB7b medial segment of the right lower lobe (RB7)

RB7a

accessory subapicalsegment of the rightlower lobe

posterior segment of the right lower lobe (RB10)

lateral segment of the right lower lobe (RB9)

anterior segment of the right lower lobe (RB8)

accessory segment ofthe right lower lobe

medial segment of the right lower lobe (RB7)

posterior segment of the right lower lobe (RB10)

lateral segment of the right lower lobe (RB9)

posterior segment of the right lower lobe (RB10)

anterior segment of the right lower lobe (RB8)

accessory segment of the right lower lobe

medial segment of the right lower lobe (RB7)

Fig.3.8oEndoscopic view of the basal segments of the right lower lobe showing a normal variant of a subapical segment.

Fig.3.8qClose-up of the right lower lobe variant with a submedial segment.

Fig.3.8pEndoscopic view of the right lower lobe variant with submedial segment.

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Leftmainbronchus(Fig.3.9)

The leftmainbronchus isapproximately4cmlonganddescends inagentle lateralcurve.At its terminalportion itdivides into twomainbranches: the left lower lobeandtheleftupperlobebronchus.Thereisanobliquelyplacedsharpcarinaseparatingthetwobronchi.Theupper lobe is joinedata60°angletothe leftmainbronchus.Occasionallytheupperlobebronchusjoinstheleftmainbronchusatanacuteangle.

right pulmonary artery pulmonary artery

left main bronchus left lower lobe pulmonary artery

left superior pulmonary vein left pulmonary artery

lower lobe pulmonary artery

left lower lobe bronchus

inferior pulmonary vein

left main bronchus

anterior wall of trachea

left mainbronchus

carina posterior wall of trachea

right main bronchus

medial wall of left main bronchus

left main bronchus

posterior wall of left main bronchus

lateral curve of left main bronchus

medial wall of left main bronchus

left main bronchus

posterior wall of left main bronchus

secondary carina of left main bronchus (LC2)

anterior aspect of left mainbronchus

left upperlobe bronchus

apical segment of left lowerlobe (LB6)

left lower lobe segments

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

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

Fig.3.9cEndoscopic view of the left main bronchus from the carina.

Fig.3.9dEndoscopic view of the curve in the left main bronchus.

Fig.3.9eEndoscopic view of the left main bronchus viewed from halfway down the left main bronchus with the left lower lobe visible distally.

Fig.3.9fEndoscopic view of the left main bronchus viewed from two-thirds the way down the left main bronchus, with the left lower lobe visible distally.

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Leftupperlobe(Fig.3.10)

Theupperlobebronchususuallydividesintotheupperdivisionorificeandthelingularbronchus.Theupperdivisiondividesintoanapicoposteriorandanteriorbronchus.Inthemajorityof individuals,theapicoposteriorbronchusdivides intothreesegmentalbranches: theapical,posteriorandposterolateralbranches. In about15percentofindividualstheapicoposteriorsegmenthasabipartitestructurewiththeposterolateralsubsegmentarisingfromtheanteriorsegment.

secondary carinaof left main bronchus (LC2)

lingular bronchus (LB4+5)

LC1 left upper division bronchus

left upper lobe

apical segmentof left lowerlobe (LB6)

basal segments of left lower lobe

left lower lobe

left upper lobe

accessory bronchus

posterior wallof left mainbronchus

medial wall of left main bronchus

secondarycarina left lower lobe

left upper lobebronchus

accessory bronchus

left lower lobesecondarycarina

left upper lobe accessorybronchus

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

Fig.3.9hEndoscopic view of the left lower and upper lobes, with the apical segment of the left upper lobe arising from the left main bronchus.

Fig.3.9iEndoscopic view of the left lower and upper lobes with a close view of the apical segment of the left upper lobe arising from the left main bronchus.

Fig.3.9jEndoscopic view of the left lower and upper lobes with a view of the apical segment of the left upper lobe arising from the left main bronchus, just from above its origin.

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left pulmonary artery

left main bronchus apicoposterior segmentof the left upper lobe (LB1+2)

left upper lobe bronchus anterior segment (LB3)

posterior segment of the right lower lobe (RB10)

lateral segment of the right lower lobe (RB9)

medial segment of the right lower lobe (RB7)

inferior pulmonary vein

anterior segmentof the leftlowerlobe (LB7+8)

lateral segmentof the left lowerlobe (LB9)

superior bronchuspulmonary artery

left upper lobe bronchus

secondarycarina (LC2)

lingula (LB4+5)

anterior segment of the left upper lobe (LB3)

apicoposterior segment of the left upper lobe (LB1+2)

left superiordivisionbronchus

left lower lobe bronchial segments

apical segment of left lower lobe bronchus (LB6) lingula (LB4+5)

anterior segment of the left upper lobe (LB3)

apicoposterior segment of the left upper lobe (LB1+2)

lingula

LB3a

LB3b

apicoposterior segment of the left upper lobe (LB1+2)

anterior segment of the left upper lobe (LB3)

anterior segment of the left upper lobe (LB3)

apicoposterior segment of the left upper lobe (LB1+2)

posterior segment of the left upper lobe (LB2)

apical segment of the left upper lobe (LB1)

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

Fig.3.10cEndoscopic view of the left superior bronchus from above the left main bronchial carina.

Fig.3.10dClose-up of the left superior bronchus showing the lingula and left upper lobe segments.

Fig.3.10eLeft upper lobe segments showing anterior and apicoposterior segments.

Fig.3.10fEndoscopic view of the apicoposterior segment of the left upper lobe.

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

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Lingula(Fig.3.11)

Thelingularbronchusarisesfromtheleftupperdivisionbronchus.Itdividesintosuperiorsegmentalandinferiorsegmentalbranches,whichinturndivideintotwosubsegmentalbranches.In25percentofindividuals,thelingulabifurcatesinalateralandmedialfashion.Onrareoccasionstheorificeofthelingulaismergedwithasegmentfromtheupperlobe.

lingular bronchus

left lower lobe bronchus

apical segment of the left lower lobe (LB6)

lower lobe pulmonary artery

superior segmentof the lingula (LB4)

inferior segment ofthe lingula (LB5) superior pulmonary vein

pulmonary artery

left atrium inferior pulmonary vein

lingular bronchus

left upper lobe

lingular ori�ce

LB3a anterior segment of the left upper lobe (LB3)

LB3b apicoposterior segment of the left upper lobe (LB1+2)

inferior segment of the lingula (LB5)

superior segment of the lingula (LB4)

Fig.3.11aCross-sectional CT scan of the thorax at the level of the lingular bronchus.

Fig.3.11cBronchoscopic view of the lingula and anterior segment of the left upper lobe.

Fig.3.11bCoronal sectional CT scan of the thorax at the level of the lingular bronchus.

Fig.3.11dEndoscopic view of the lingular segments.

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Leftlowerlobe(Fig.3.12)

Theleftlowerlobebronchusdescendsposterolaterallyanddividesintofoursegmentstoformtheleftlowerlobe.Theapicalsegmentarisesabout1cmaftertheoriginoftheleftlowerlobebronchus.Afterafurther1–2cmtheinferiorbronchusdividesintoananteriorbasalsegmentalbronchusandaposterolateralbasalbronchuswhichfurtherbifurcatesinto lateralbasalandposteriorbasalsegments.Endoscopicallyaprominentsecondarycarinaappearstodivideintotheapicalbasalbronchusandtheotherinferiorbranches.The most common pattern of division of the left lower lobe is into three branches(tripartite)withseparateanteriorbasal,lateralbasalandposteriorbasaldivisions.

Fig.3.12aCross-sectional CT scan of the thorax at the level of the left lower lobe bronchus.

Fig.3.12bCoronal sectional CT scan of the thorax at the level of the left lower lobe bronchus.

left inferior pulmonary vein

left lower lobe bronchus

lower lobe pulmonary artery

inferior segment of the lingula(LB5)

superior segment of the lingula (LB4) left pulmonary artery

left main bronchus

left lower lobe bronchus

left lower lobe pulmonary artery

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basal segments of the left lower lobe

left upper lobe secondary carina (LC2)

apical segment of the left lower lobe (LB6)

basal segments of the left lower lobe

LB6a apical segment of the left lower lobe (LB6)

LB6b

basal segments of the left lower lobe

LB6a apical segment of the left lower lobe (LB6)

LB6b

lateral segment of the left lower lobe (LB9)

posterior segment of the left lower lobe (LB1)

LB7+8a anterior segment of the left lower lobe (LB7+8)

LB7+8b

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

Fig.3.12dEndoscopic view of the left lower lobe.

Fig.3.12eBronchoscopic view of the apical segment of the left lower lobe.

Fig.3.12fBronchoscopic view of the basal segments of the left lower lobe.

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left lower lobe pulmonary artery

lingular inferior segmental bronchus (LB5)

inferior pulmonary vein

posterior segment of the left lower lobe (LB10)

lateral segment of the left lower lobe (LB9)

anterior segmentof the left lowerlobe (LB8)

lateral segment ofleft lower lobe (LB9)left main bronchus left pulmonary

left lower lobeinferior pulmonary

Fig.3.12gCross-sectional CT scan of the thorax showing the left lower lobe segments.

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

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CHAPTER

4Normal anatomy

(posterior approach)Inthischaptertheendoscopicimagesarerelatedtothecomputedtomography(CT)images.Theoverallappearance,maincharacteristicsandnormalvariationsaredescribed.Here,incontrasttoChapter3,theendoscopicimagesarepresentedastheyappearwhenthepatientisbronchoscopedinasupinepositionandapproachedfrombehind.

Vocalcords(Fig.4.1)

The larynx is composedofa seriesof cartilages, ligamentsandfibrousmembranes.At bronchoscopy the epiglottis is the more proximal structure. It is a broad leaf-likestructure.Thesidesareattachedbythearytenoidcartilages.Thecuneiformandcorniculatecanbeseenattheendofthearytenoidcartilage.Thecuneiformcartilageismoreanteriorandsuperiortothecorniculatecartilage.Thevocal foldsconsistofthefalsecordsorvestibularfoldsandthetruevocalfolds.Theystretchbackfromthethyroidangletothevocalprocessesofthearytenoids.Thevocalfoldsareinvolvedintheproductionofsound.

left vocal cord

cuneiform tubercle

aryepiglottic fold

corniculate tubercle

vocal fold hyoid bone cricoid cartilage

Fig.4.1aCross-sectional CT scan at the superior aspect of the thorax at the level of the vocal cords, which are apposed.

Fig.4.1bCoronal section CT scan of the vocal cords, which are apposed.

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open vocal foldshyoid bone vocal folds

left vallecula epiglottis right vallecula

posterior pharyngeal wall right aryepiglottic fold

left vocal cord

left aryepiglottic fold

posterior pharyngeal wall

right corniculate tubercle

right cuneiform tubercle

epiglottis

Fig.4.1cEndoscopic view of the epiglottis and vocal cords. Fig.4.1dEndoscopic view of the vocal cords.

Fig.4.1eCross-sectional CT scan at the superior aspect of the thorax at the level of the vocal cords, which are open.

Fig.4.1fCoronal section CT scan of the vocal cords, which are open.

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Trachea(Fig.4.2)

Thetrachea isahorseshoe-orD-shapedstructurewhichextends fromthecricoidcartilagetothecarina.Theanterioraspectiscomposedof16–20incompletecartilageringswithaflatfibromuscularposteriorcomponent.Thereisalsoalongitudinalbandofconnectivetissuewhichrunsdowntheposteriorendofthecartilage.Atbronchoscopythecartilagebandson theanterior surfaceappearas ridgesand theposteriorwallappearstobulgeintothetrachea.Theposteriorbulgeisaccentuatedinexpiration.

epiglottis open vocal cords aryepiglottic foldapposed vocal cords corniculate tubercle cuneiform tubercle

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

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

superior vena cava

trachea oesophagus

fat aorta trachea

right pulmonary artery left atrium left inferior pulmonary vein

aortic arch left pulmonary artery

Fig.4.2aCross-sectional CT scan of the thorax at the mid-tracheal level.

Fig.4.2bCoronal sectional CT scan of the thorax through the trachea.

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cartilage rings anterior aspect

posterior membranous trachea

carina anterior wall

posterior tracheal wall

cartilage rings

anterior tracheal wall

left main bronchus

carina (mc)posteriortracheal wall

right main bronchus

left main bronchus

anterior aspect

right main bronchus

carina (mc)membranous posterior wall

anterior aspect of trachea

right upper lobe

right mainbronchus

posterior wall of trachea

tracheal bronchus

right mainbronchus

posterior wallof trachea

right upperlobe

tracheal bronchus

Fig.4.2eEndoscopic view of the trachea from the mid-tracheal level.

Fig.4.2fEndoscopic view of the distal portion of the trachea.

Fig.4.2gEndoscopic view of a tracheal bronchus as viewed from above with the patient supine and approached from behind. The right upper lobe arises from the right main bronchus.

Fig.4.2hEndoscopic view of a tracheal bronchus as seen at the distal trachea just above the carina. The right upper lobe and bronchus intermedius are visible below.

Fig.4.2cEndoscopic view of the trachea from the level of the subglottis.

Fig.4.2dEndoscopic view of the upper trachea.

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Thetracheameasuresapproximately110mminlengthwithanexternaldiameterthatrangesfrom15mminwomento20mminmen.Theinternaldiameterofthetracheaisabout12–14mm.

Thetracheadividesintotherightandleftmainbronchiatthelevelofthesternomanubrialjunctionorthebodyofthefourththoracicvertebrae.

Atrachealbronchusisararenormalvariantandoriginatesfromthelateralwallofthetracheaandintotheupperlobeontherightsideinabout0.1–2percentofindividualsandontheleftsidein0.3–1percentofindividuals.Thetermtrachealbronchusisalsousedforotheranomalousairwaysarisingfromthemainbronchianddirectedtotheupperlobes.

anterior segment of the right upper lobe

posterior segment of the right upper lobe

tracheal bronchus trachea

Fig.4.2iBipartite division of the upper lobe in the presence of a tracheal bronchus.

Fig.4.2jCross-sectional CT scan showing the tracheal bronchus arising at the distal trachea just above the carina.

Carina(Fig.4.3)

Thecarinaisaconcavespurofcartilagelocatedwherethedistaltracheadividesintotherightandleftmainbronchi.Thecarinanormallyappearsasasharpstructureandformsthemedialbordersoftheoriginoftherightandleftmainbronchi.Thesharpangle is maintained as it is primarily composed of cartilage (carinal) and ligaments(interbronchial).Enlargementofthesubcarinalstructures,suchasthesubcarinallymphnodes or the left atrium, may lead to blunting or widening of the carina. It usuallymeasuresabout12mmindiameterandstretchesinthemidlineintheanteroposteriordimension.Veryrarelythereisanaccessorybronchusopeningfromthelateralwallsdirectedtowardstheupperlobe.

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apical segment of the right upper lobe (RB1)

superior pericardialrecess

posterior segmentof the right upperlobe (RB2)

carina descendingaorta

apicoposterior segment of the left upper lobe (LB1+2)

superiorvena cava

ascendingaorta

pulmonaryartery

anterior segment of the left upper lobe (LB3)

oblique �ssure

right pulmonary artery

left atrium left pulmonary artery

left inferior pulmonary vein

anterior segment ofthe left upper lobe (LB3)

right upper lobe

apicoposterior segmentof the left upper lobe (LB1+2)

left main bronchus

posterior membranous wall of trachea

carina (mc) right main bronchus

left main bronchus carina (mc) right main bronchus

posterior membranous wall of trachea

Fig.4.3cEndoscopic view of the carina. Fig.4.3dClose-up endoscopic view of the carina.

Fig.4.3aCross-sectional CT scan of the thorax at the level of the carina.

Fig.4.3bCoronal sectional CT scan of the thorax through the trachea.

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Rightmainbronchus(Fig.4.4)

Therightmainbronchusextendsfromthecarinatotheoriginoftherightupperlobe.Itthenformsthebronchusintermedius.Therightmainbronchushasasteeperdeclinefromthe tracheaandhence, in theuprightposition, foreignbodies tend to fall intotherightmainbronchus. It is slightly larger indiameter thanthe leftmainbronchus,measuringbetween10and12mminexternaldiameter.Theinferiorlipoftheupperlobe bronchus is easily visible at the distal end of the right main bronchus.A rarevariationistheoriginofanairwayleadingtotheupperlobe.Thisisclassifiedasapre-eparterialtrachealbronchus.Itmaybeeitherasupernumeraryoradisplacedairway.Wheretheairwayisdisplaced,thereisalsoamissingupperlobebranch.Anaccessorycardiacbronchusisasupernumerarybronchusarisingfromthemedialaspectoftherightmainbronchusandleadingtowardsthepericardium.

posterior segmental bronchus of right upper lobe (RB2)

azygos vein

anterior segmentalbronchus of rightupper lobe (RB3)

apical segmental bronchus of right upper lobe (RB1)

carina (mc)

left pulmonary artery

superiorvenacava

descending aorta

left main bronchus

azygos arch

right upper lobe bronchus

right upper lobe spur (RC1)

right main bronchus

trachea carina (mc) left main bronchus

Fig.4.4aCross-sectional CT scan of the thorax at the carina, showing the right main lobe.

Fig.4.4bCoronal sectional CT scan of the thorax showing the right main bronchus.

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Rightupperlobe(Fig.4.5)

The right upper lobe has three main segmental divisions: the apical, anterior andposteriorsegments.Theupperlobesegmentsdivideintosegmentsabout10mmfromtheorigin.Theupperlobeissubjecttoconsiderablenormalvariation:

●● In40percentthesegmentalbronchiariseindependently.●● In24percent there isacommonapicalandanterior trunkandan independentpost-segmentalbronchus.(SeeFig4.5g)

●● In14percentthereisacommonapicalandposteriortrunkandanindependentanteriorsegment.(SeeFig4.5h)

●● In10percentthereisacommonanteriorandposteriortrunkwithanindependentapicalsegment.

●● In10percenttheposteriorsegmentalbronchusisabsent.●● In2percenttheapicalsegmentisabsent.●● In <1 per cent of patients there is a tracheal bronchus which originates eitherdirectly from the tracheaor at the levelof thecarina. In somecases there is anadditionalbranchtotheupperlobe,whichoriginatesfromtherightmainbronchus.

Fig.4.4cEndoscopic view of the right main bronchus visible below the carina.

Fig.4.4dEndoscopic view of the right main bronchus which shows more of the right upper lobe origin.

anterior wall of right main bronchus

right upper lobe spur (RC1) right upper lobe

posterior wall of right main bronchus

bronchus intermedius

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superior branch of pulmonary artery

superior vena cava

right upper lobe bronchus apicoposterior segment of the left upper lobe (LB1+2)

right main bronchus

pulmonary arterytrunk

anterior segment of the left upper lobe (LB3)

anterior branch of right upper lobebronchus (RB3)

apical branch ofright upper lobebronchus (RB1)

bronchus intermedius right main bronchus

right upper lobe

apical segment of left upper lobe (LB1)

apical segment of the right upper lobe (RB1)

anterior segment of the right upper lobe (RB3)

posterior segment of the right upper lobe (RB2)

RB2b RB2a

apical segment of the right upper lobe (RB1)

anterior segment of the right upper lobe (RB3)

posterior segment of the right upper lobe (RB2)

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

Fig.4.5bCoronal sectional CT scan of the thorax showing the right upper lobe.

Fig.4.5cEndoscopic view of the right upper lobe. Fig.4.5dAnother example of the tripartite right upper lobe arrangement.

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apical segment of the right upper lobe (RB1)

RB3b anterior segment of the right upper lobe (RB3)

RB3a

apicoposterior segment of the right upper lobe (RB1+2)

posterior segment of the right upper lobe (RB2)

anterior segment of the right upper lobe (RB3)

apical segment of the right upper lobe (RB1)

apicoanterior segment of the right upper lobe (RB1+3)

posterior segment of the right upper lobe (RB2)

apicoanterior segment of the right upper lobe (RB1+3) apical segment (RB1)

anterior segment (RB3) posterior segment of the right upper lobe (RB2)

anterior segment of the right upper lobe (RB3)

RB2b posterior segment (RB2) RB2a

apicoposterior segment of the right upper lobe (RB1+2) apical segment (RB1)

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

Fig.4.5fBipartite division of the right upper lobe with division in the vertical axis.

Fig.4.5gBipartite division of the right upper lobe with apical and anterior segments (RB1 + 3 arising together) and a separate posterior segment (RB2).

Fig.4.5hBipartite division of the right upper lobe with apical and posterior segments arising together (RB1 + 2) and a separate posterior segment (RB3).

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anterior segment of the right upper lobe (RB3)

RB3a RB3b posterior segment of the right upper lobe (RB2)

apical segment of the right upper lobe (RB1)

apicoposterior segment of the right upper lobe (RB1+2)

Fig.4.5iFour divisions of the right upper lobe.

Bronchusintermedius(Fig.4.6)

Thebronchusintermediusoriginatesfromtherightmainbronchusandextendsfromtheoriginoftherightupperlobetotherightmiddlelobe.Itisapproximately20mmlongandhasadiameterofabout10mm.Therightmiddlelobe,theapicalsegmentof the lower lobe and thebasal segments are visible at thedistal endofbronchusintermedius.

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right superior pulmonary vein

bronchus intermedius

left ventricular outow tract

right pulmonary artery

azygos vein

left lobe pulmonary artery

left upper lobe bronchus

pulmonary trunk

left main bronchus

left superior pulmonary vein

right upper lobe bronchus

right lower lobe pulmonary artery

bronchus intermedius

right main bronchus

left upper lobe bronchus

apicoposterior segment of the left upper lobe (LB1+2)

anterior segment of the left upper lobe (LB3)

right middle lobe (RB4+5)

basal segments of the right lower lobe

apical segment of the right lower lobe (RB6)

right middle lobe bronchus (RB4+5)

carina between right middle lobe and lower lobe (RC2)

basal segments of lower lobe apical segment of right upper lobe (RB6)

Fig.4.6aCross-sectional CT scan of the thorax at the level of the bronchus intermedius (distal to the right upper lobe origin).

Fig.4.6cEndoscopic view of the bronchus intermedius.

Fig.4.6bCoronal sectional CT scan of the thorax through the bronchial tree showing the bronchus intermedius.

Fig.4.6dEndoscopic view of the distal aspect of the bronchus intermedius.

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Rightmiddlelobe(Fig.4.7)

Therightmiddlelobeisasemi-lunar(D-shaped)bronchusattheanteriorendofthebronchus intermedius. Inapproximately70percentofcases, thereare twodistinctsegments: lateral and medial. In 23 per cent of normal individuals the middle lobebifurcates inasuperior-inferior fashion,similartothatofthe lingula. Inupto20percentofindividualsthereisamainlateralbronchusandasmallermedialbronchuswhicharisesfromthelateralsegment.Occasionallythereverseisseen,withalargermedialsegmentandasmallerlateralsegmentarisingfromit.

right lower lobe pulmonary artery

superior pulmonary vein

lateral segment of right middle lobe (RB4)

right middle lobe

right lower lobe

left atrium left lower lobe pulmonary artery

right atrium

left inferior pulmonary vein

right upper lobe segment

right middle lobe pulmonary artery

right middle lobe

right inferior pulmonary vein

left atrium

left ventricle

right superior pulmonary vein

Fig.4.7aCross-sectional sectional CT scan of the thorax at the level of the right middle lobe.

Fig.4.7bCoronal sectional CT scan of the thorax at the level of the right middle lobe.

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RB5bmedial segment of the right lower lobe (RB5)

RB4b lateral segment of right lower lobe (RB4)

RB4a

RB5a RB5b

RB4b lateral segment of the right middle lobe (RB4)

RB4a

RB5amedial segment of the right middle lobe (RB5)

right middle lobecarina between right middle lobe and lower lobe (RC2)

medial segment of right lower lobe (RB7)

basal segments of right lower lobe

apical segment of the right lower lobe (RB6)

right middle lobe

right lower lobe segments

carina between right middle lobe and right lower lobe (RC2)

Fig.4.7cEndoscopic view of the right middle and lower lobes.

Fig.4.7eEndoscopic view of right middle lobe subsegments viewed from the origin of the right main bronchus.

Fig.4.7dEndoscopic view of the right middle lobe.

Fig.4.7fClose-upendoscopic view of the right middle lobe subsegments.

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Rightlowerlobe(Fig.4.8)

Therightlowerlobecomprisesfivemainsegments:apicalbasal,medialbasal,anteriorbasal,lateralbasalandposteriorbasal.Inabout40–60percentofindividualsthereisanadditionalsubapicalbasalsegment.Theapicalbasalsegmentoftherightlowerlobeispositionedposteriorlyattheendofthebronchusintermedius.Theapicalsegmentdivides immediately into three subsegmental bronchi.Thenormal patternobservedinthelowerlobebronchialsegmentsarealargemedialbasalsegment(RB7),whichisproximal totheotherbasalsegments.Theanteriorbasalsegment is in the lateralposition,withthelowerbronchusdividingfurtherintolateralandposteriorsegments.Thispattern isseen inover70percentof individuals.Theothercommonvariationobserved iswhere the anterior basal, lateral basal andposterior basal segments alloriginateindependentlyatthesamelevel.

Abipartitedivisionisoccasionallyobservedwheretheanteriorandlateralsegmentsarise together proximally to the posterior basal segment from a separate branch.Thepositionandsizeoftheapicalbasalsegmentfrequentlyinfluencethepatternofbranchingofthebasalsegments.Forexample,insomeindividualsthereisalargerapicalbronchusand,asaresult,themedialthroughtoposteriorsegmentarisesinatripartitefromthesamelevel.

right atrium

right lower lobe pulmonary artery

right lower lobe bronchus

left inferior pulmonary vein

left lower lobe pulmonary artery

left atrium left lower lobe bronchusbronchus intermedius

anterior segment of the right lower lobe (RB8)

right lower lobe bronchus

left atrium left inferior pulmonary vein

left pulmonary artery

Fig.4.8aCross-sectional CT scan of the thorax at the level of the right lower lobe.

Fig.4.8bCoronal sectional CT scan showing the right lower lobe.

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medial segment of right lower lobe (RB7)

apical segment of the right lower lobe (RB6)

anterior segment of the right lower lobe (RB8)

RB6ci

RB6a RB6b

RB6ciiBasal segment of right lower lobe

apical segment of right lower lobe (RB6)

RB6a RB6b

Subsegments of the apical segment of the right lower lobe (RB6)

medial basal segment of the right lower lobe (RB7)

posterior basal segment of the right lower lobe (RB10)

lateral basal segment of the right lower lobe (RB9)

RB8a

RB8banterior basal segment of the right lower lobe (RB8)

medial basal segment of the right lower lobe (RB7)

posterior basal segment of the right lower lobe (RB10)

lateral basal segment of the right lower lobe (RB9)

anterior basal segment of the right lower lobe (RB8)RB8b

RB8a

lateral wall of the medial segment of the right lower lobe

RB10c

posterior basal segment of the right lower lobe (RB10)

lateral basal segment of the right lower lobe (RB9)

RB10a

anterior basal segment ofthe right lower lobe (RB8)RB8b

RB8a

lateral basal segment of the right lower lobe (RB9)

RB10c

RB10a

RB10bposterior basal segment of the right lower lobe (RB10)

accessory subapical segment of the right lower lobe

Fig.4.8gEndoscopic view of the basal segments of the right lower lobe.

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

Fig.4.8hCloser endoscopic view of the basal segments of the right lower lobe.

Fig.4.8jEndoscopic view of the basolateral and posterobasal segments of the right lower lobe. In this example a normal variant subapical segment is present.

Fig.4.8cCross-sectional CT scan of the thorax at the level of the basal segments of the right lower lobe, showing the right basal segments.

Fig.4.8dEndoscopic view of the right apicobasal segment.

Fig.4.8eEndoscopic view of the apicobasal segments of the right lower lobe.

Fig.4.8fClose-up endoscopic view of the right apicobasal subsegments.

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anterior segment right lower lobe (RB8)

right lower lobe pulmonary artery

lateral segment of the right lower lobe (RB9)

posterior segment of right lower lobe(RB10)

inferior pulmonary vein

posterior segment of the right lower lobe (RB10)

anterior segment of the right lower lobe (RB8)

posterior segment of the right lower lobe (RB10)

lateral basal segment of the right lower lobe (RB9)

anterior basal segment of the right lower lobe (RB8)

lateral segment of the right lower lobe (RB9)

subapical segment of the right lower lobe

posterior segment of the right lower lobe (RB10)

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

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

Fig.4.8lEndoscopic view of the basolateral and posterobasal segments of the right lower lobe.

Fig.4.8nEndoscopic view of the basolateral and posterobasal segments of the right lower lobe.

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medial segment of the right lower lobe

RB7a posterior segment of the right lower lobe (RB10)

accessory subapical segment of the right lower lobe

lateral segment of the right lower lobe (RB9)

RB7aanterior segment of the right lower lobe (RB8)

medial segment of the right lower lobe (RB7)

posterior segment of the right lower lobe (RB10)

lateral segment of the right lower lobe (RB9)

accessory segment of the right lower lobe

anterior segment of the right lower lobe (RB8)

medial segment of the right lower lobe (RB7)

accessory segment of the right lower lobe

posterior segment of the right lower lobe (RB10)

lateral segment of the right lower lobe (RB9)

anterior segment of the right lower lobe (RB8)

Fig.4.8oEndoscopic view of the basal segments of the right lower lobe showing a normal variant of a subapical segment.

Fig.4.8qClose-up of the right lower lobe variant with a submedial segment.

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

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Leftmainbronchus(Fig.4.9)

The leftmainbronchus isapproximately4cmlonganddescends inagentle lateralcurve.At its terminalportion itdivides into twomainbranches: the left lower lobeandtheleftupperlobebronchus.Thereisanobliquelyplacedsharpcarinaseparatingthetwobronchi.Theupper lobe is joinedata60oangle tothe leftmainbronchus.Occasionallytheupperlobebronchusjoinstheleftmainbronchusatanacuteangle.

right pulmonary artery

left main bronchus left lower lobe pulmonary artery

pulmonary arteryleft superiorpulmonary vein left main bronchus

left lower lobe bronchus

inferior pulmonary vein left lower lobe pulmonary artery

left pulmonary artery

left main bronchus

carina (mc) right main bronchus

anterior wall of trachea

left main bronchus

posterior wall of left main bronchus

lateral curve of left main bronchus

medial wall of left main bronchus

left main bronchus

medial wall of left main bronchus

posterior wall of left main bronchus

Fig.4.9aCross-sectional CT scan of the thorax at the level of the left main bronchus.

Fig.4.9bCoronal sectional CT scan of the thorax at the level of the left main bronchus.

Fig.4.9cEndoscopic view of the left main bronchus from the carina.

Fig.4.9dEndoscopic view of the curve in the left main bronchus.

Fig.4.9eEndoscopic view of the left main bronchus viewed from halfway down the left main bronchus with the left lower lobe visible distally.

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upper left lobe

lingular bronchus

secondary carina of left main bronchus (LC2)

left lower lobe basal segments

apical segment of left lower lobe (LB6)

accessory bronchus

posterior wall of left main bronchus

left lower lobe

left upper lobe

accessory bronchus

left upper lobe bronchus

left lower lobe

secondary carina (LC2)

accessory bronchus

left upper lobe bronchus

left lower lobe secondary carina (LC2)

left upper lobebronchus

secondary carina of left main bronchus (LC2)

anterior aspect of left main bronchus

apical segment of left lower lobe (LB6)

left lower lobe segments

Fig.4.9fEndoscopic 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.4.9gEndoscopic view of the left secondary carina with both the upper and lower lobes visible.

Fig.4.9hEndoscopic view of the left lower and upper lobes, with the apical segment of the left upper lobe arising from the left main bronchus.

Fig.4.9iEndoscopic view of the left lower and upper lobes with a close view of the apical segment of the left upper lobe arising from the left main bronchus.

Fig.4.9jEndoscopic view of the left lower and upper lobes with a view of the apical segment of the left upper lobe arising from the left main bronchus, from just above its origin.

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Leftupperlobe(Fig.4.10)

Theupperlobebronchususuallydividesintotheupperdivisionorificeandthelingualbronchus.Theupperdivisiondividesintoanapicoposteriorandanteriorbronchus.Inthemajorityof individuals,theapicoposteriorbronchusdivides intothreesegmentalbranches: theapical,posteriorandposterolateralbranches. In about15percentofindividualstheapicoposteriorsegmenthasabipartitestructurewiththeposterolateralsubsegmentarisingfromtheanteriorsegment.

left pulmonary artery

left main bronchus apicoposterior segment of the left lower lobe (LB1+2)

anterior segment of left upper lobe (LB3)

posterior segment of the right lower lobe (RB10)

inferior pulmonary vein

anterior segment of the left lower lobe (LB7+8)

lateral segment of the left lower lobe (LB9)

lateral segment of the right lower lobe (RB8)

medial segment of the right lower lobe bronchus (RB7)

superior bronchus pulmonary artery

left superior division bronchus

apical segment of left lower lobe (LB6)

left lower lobe bronchus

secondary carina (LC2)

apicoposterior segment of left upper lobe (LB1+2)

anterior segment of left upper lobe (LB3)

lingula (LB4+5)

apicoposterior segment of left upper lobe (LB1+2)

anterior segment of the left upper lobe (LB3)

lingula (LB4+5)

Fig.4.10aCross-sectional CT scan of the thorax at the level of the left upper lobe bronchus.

Fig.4.10cEndoscopic view of the left superior bronchus from above the left main bronchial carina.

Fig.4.10dClose-up of the left superior bronchus showing the lingula and left upper lobe segments.

Fig.4.10bCoronal sectional CT scan of the thorax at the level of the left upper lobe bronchus.

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Lingula(Fig.4.11)

Thelingularbronchusarisesfromtheleftupperdivisionbronchus.Itdividesintosuperiorsegmentalandinferiorsegmentalbranches,whichinturndivideintotwosubsegmentalbranches. In 25per centof individuals, the lingulabifurcates in a lateral andmedialfashion.Onrareoccasionstheorificeofthelingulaismergedwithasegmentfromtheupperlobe.

apicoposterior segment of the left upper lobe (LB1+2) LB3a

LB3b lingulaanterior segment of the upper lobe (LB3)

anterior segment of the left upper lobe (LB1)

posterior segment of the left upper lobe (LB2)

apicoposterior segment of the left upper lobe (LB1+2)

anterior segment of the left upper lobe (LB3)

Fig.4.10eLeft upper lobe segments showing anterior and apicoposterior segments.

Fig.4.10fEndoscopic view of the apicoposterior segment of the left upper lobe.

lingular bronchus

lower lobe pulmonary artery

superior segment of the lingula (LB4)

inferior segment of the lingula (LB5)

Fig.4.11aCross-sectional CT scan of the thorax at the level of the lingular bronchus.

Fig.4.11bCoronal sectional CT scan of the thorax at the level of the lingular bronchus.

superior pulmonary vein

pulmonary artery

left atrium inferior pulmonary vein

lingular bronchus

left upper lobe

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apicoposterior segment of the left upper lobe (LB1+2)

lingular bronchus

LB3b

anterior segment of left upper lobe (LB3) LB3a

superior segment of lingula (LB4)

inferior segment of lingula (LB5)

Fig.4.11cBronchoscopic view of the lingula and anterior segment of the left upper lobe.

Fig.4.11dEndoscopic view of the lingular segments.

Leftlowerlobe(Fig.4.12)

Theleftlowerlobebronchusdescendsposterolaterallyanddividesintofoursegmentstoformtheleftlowerlobe.Theapicalsegmentarisesabout1cmaftertheoriginofthe left lower lobe bronchus.After a further 1–2 cm the inferior bronchus dividesintoananteriorbasalsegmentalbronchusandaposterolateralbasalbronchuswhichfurther bifurcates into lateral basal and posterior basal segments. Endoscopically aprominentsecondarycarinaappearstodivideintotheapicalbasalbronchusandtheotherinferiorbranches.Themostcommonpatternofdivisionoftheleftlowerlobeisintothreebranches(tripartite)withseparateanteriorbasal,lateralbasalandposteriorbasaldivisions.

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secondary carina (LC2)

apical segment of the left lower lobe (LB6)

basal segments of the left lower lobe

left upper lobe LB6b LB6a

apical segment of the left lower lobe (LB6)

basal segments of the left lower lobe

LB6b

apical segment of the left lower lobe (LB6)

basal segments of left lower lobe

LB6a

lateral segment of left lower lobe (LB9)

posterior segment of left lower lobe (LB10)

LB8b

anterior segment of left lower lobe (LB7+8) LB8a

left pulmonary artery

left main bronchus left lower lobe bronchus

left lower lobe pulmonary artery

Fig.4.12cBronchoscopic view of the left lower lobe viewed from just above the left secondary carina.

Fig.4.12dEndoscopic view of the left lower lobe.

Fig.4.12eBronchoscopic view of the apical segment of the left lower lobe.

Fig.4.12fBronchoscopic view of the basal segments of the left lower lobe.

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

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

left inferior pulmonary vein

left lower lobe bronchus

lower lobe pulmonary artery

inferior segment of the lingula(LB5)

superior segment of the lingula (LB4)

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left lower lobe pulmonary artery

inferior pulmonary vein

posterior segment of the left lower lobe (LB10)

lateral segment of the left lower lobe (LB9)

anterior segment of the left lower lobe (LB8)

inferior segment of lingula (LB5)

lateral segment ofleft lower lobe (LB9)left main bronchus left pulmonary

left lower lobeinferior pulmonary

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

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

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CHAPTER

5Vascular relationships and lymph node stationsAgoodknowledgeofthemediastinalanatomy,particularlytherelationshipbetweenthe trachea, bronchial tree and the major vessels, is essential for procedures suchas transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guidedtransbronchialneedleaspiration(EBUS-TBNA).Thethoracic lymphnodesalsohaveanimportantroleinthestaging,andhencetreatment,oflungcancer.TheanatomyisdescribedinrelationtothenewInternationalAssociationfortheStudyofLungCancer(IASLC)lymphnodemap.

VascularrelationshipsTheaortaiscloselyrelatedtotheanteriorandleftlateralaspectofthetrachea.Theaorticrootascendsbelowthecarinaandthenarchesoveronthedistalaspectofthetracheaontheleftsideandcurvesaroundthelefthilum(Fig.5.1).

Fig.5.1bRelationship to the tracheobronchial tree of the brachiocephalic veins, the superior vena cava and the aorta.

Fig.5.1aRelationship to the tracheobronchial tree of the aorta.

Theleftbrachiocephalicveincrossestheanterioraspectofthetrachea,anditsinferiorborderontherightsideofthetracheaisatthesamelevelastheaorticarch.Itjoinswith therightbrachiocephalicveinand forms thesuperiorvenacava.Thesuperiorvenacavacrossestheanterioraspectoftherightmainbronchusanddrainsintotherightatrium.

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Thepulmonarytrunkdividesatthelevelofthecarinaintotherightandleftpulmonaryarteries (Fig. 5.2).Thepulmonary artery trunk is lateral to the aorta, and the rightpulmonaryarterycrosses the infracarinal regionand isanterior to the trachea. It islocatedposteriortotheaorta.Ontheleft,thepulmonaryarterycrossestheanterioraspectoftheleftmainbronchusandthenadvancesbehindtheleftupperlobe,whereitdividesintosuperiorandinferiorbranches.Thesuperiorbranchoftheleftpulmonaryartery is located lateral andposterior to the leftupper lobebronchus.The inferiorbranchfollowstheleftlowerlobeandislateralandposteriortotheleftlowerlobe.Therightpulmonaryarterycrossesanteriortotherightmainbronchusanddividesinto superiorand inferiorbranches lateral to the rightmainbronchus.Thesuperiorbranchoftherightpulmonaryarteryislocatedanterolateraltotherightupperlobebronchus.The inferior branch is sent posterior to the bronchus intermedius and islocatedposteriorandlateraltotherightmiddlelobeandlowerlobebranches.

Fig.5.2fRelationship to the tracheobronchial tree of the left pulmonary artery (blue) and pulmonary vein (red).

Fig.5.2gRelationship to the tracheobronchial tree of the right pulmonary artery (blue) and pulmonary vein (red).

Fig.5.2cRelationship to the tracheobronchial tree of the left pulmonary artery.

Fig.5.2dRelationship to the tracheobronchial tree of the right pulmonary artery.

Fig.5.2eRelationship to the tracheobronchial tree of the aorta, pulmonary arteries and pulmonary veins.

Fig.5.2aRelationship to the tracheobronchial tree of the pulmonary arteries.

Fig.5.2bRelationship to the tracheobronchial tree of the aorta and the pulmonary arteries.

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Atlas of Flexible BronchoscopyShah

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The pulmonary veins are located anterior and inferior to the pulmonary artery.Thesuperiorpulmonaryveinisinferiorandanteriortothepulmonaryartery.Ontheleftside,thesuperiorpulmonaryveinisanteriortotheleftmainbronchus,andthebranchesarepredominantlyanteriortothebronchi.Theinferiorpulmonaryveinarisesinbranchesthatarepredominantlyposteriortothebronchusandpulmonaryarteries,andformstheinferiorpulmonaryveinmedialtotheleftlowerlobe.Ontherightside,thesuperiorpulmonaryveincrossesoveranteriortotherightmainbronchusandthebranchesarisefromtheupperandmiddlelobes.Theinferiorpulmonaryveinontherightsidecrossesthebronchusintermediusandthentravelsposteriortothebronchusandpulmonaryarterybranches.

●● Bronchoscopic viewsThecross-sectionaldrawingsinFigure5.3arefromthelevelofthethirdtothesixththoracicvertebralbodies.Thedrawingsgivetheviewthatisobtainedwhenlookingfromaboveandhencetherelationshipsarethosefoundwhenperformingabronchoscopywiththepatientsupineandapproachedfrombehind(posteriorapproach).

Fig.5.3aCross-sectional view at the level of the third vertebral body as viewed from above, showing the main vascular relationships to the trachea.

Fig.5.3dCross-sectional view at the level of the fifth vertebral body as viewed from above, showing the main vascular relationships to the main bronchi.

Fig.5.3bCross-sectional view at the upper level of the fourth vertebral body as viewed from above, showing the main vascular relationships to the trachea.

Fig.5.3eCross-sectional view at the level of the sixth vertebral body as viewed from above, showing the main vascular relationships to the main bronchi.

Fig.5.3cCross-sectional view at the lower level of the fourth vertebral body as viewed from above, showing the main vascular relationships to the trachea.

T3

left phrenic nerve

left commoncorotid artery

left recurrentlaryngeal nerve

left subclavianartery

oesophagus

right vagnusnerve

right brachiocephalicvein

brachiocephalic artery

left brachiocephalic vein

T4

aortic arch

superiorvena cava

azygos vein

T4 T5 T6

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LymphnodestationsThemediastinalandhilarlymphnodesaredescribedinthissectionaccordingtothenewIASLCclassification.

●● Superclavicular zoneStation1(Fig.5.4)Thesearethelowcervical,supraclavicularandsternalnotchlymphnodes.Theupperborder is defined as the lowermarginof the cricoid cartilage.The lowerborder isdefinedbytheclaviclesandtheupperborderofthemanubrium.Laterality(rightorleftside)isdeterminedbythemidlineofthetrachea.

Fig.5.4aStation 1 lymph nodes. Fig.5.4bCoronal section of CT scan depicting margins of the station 1 lymph node zone.

Fig.5.4cAxial sections of CT scan depicting the margins of the station 1 lymph node zone: upper margins.

Fig.5.4dAxial sections of CT scan depicting the margins of the station 1 lymph node zone: lower margin.

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●● Superior mediastinal zoneStation2:Upperparatracheallymphnodes(Fig.5.5)Theupperparatracheallymphnodesarepartofthesuperiormediastinalzone.Theupperborder isdefinedbytheapexofthe lungtothesuperiorborderoftheclaviclesandmanubriumbilaterally.Ontherightside,thelowerborderisdefinedbywheretheinferioraspectofthebrachiocephalicveincrossesthetrachea.Ontheleftside,thelowerborderisdefinedbythesuperiorborderoftheaorticarch.Thelateralmarginisdeterminedbytheleftlateralborderofthetracheasothatnodesthatareintheanterioraspectofthetracheathroughtotheleftlateralmarginofthetracheaaredefinedasstation2Rlymphnodes,whereasnodesontheleftlateralaspectofthetracheaaredefinedasstation2L.

Fig.5.5aStation 2R lymph nodes. Fig.5.5bStation 2L lymph nodes.

Fig.5.5cAxial sections of CT scan depicting the margins of the station 2 lymph node zone: upper margins.

Fig.5.5dAxial sections of CT scan depicting the margins of the station 2 lymph node zone: lower margin.

Fig.5.5eCoronal section of CT scan depicting the margins of the station 2 lymph node zone.

Fig.5.5fSagittal views of CT scan highlighting the station 2 lymph node area: left lateral.

Fig.5.5gSagittal views of CT scan highlighting the station 2 lymph node area: right lateral.

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Station3

Station 3A: Prevascular and retrosternal lymph nodes (Fig.5.6)Theprevascularlymphnodeslocatedontherightsideanteriortothesuperiorvenacavauptothesternum.Theupperborderisdefinedbytheapexofthechestandthelowerborderatthelevelofthecarina.Ontheleftside,thelymphnodesareanteriortotheleftcarotidarteryuptothesternalsurface.Theupperborderisagaindefinedastheapexofthelungandthelowerborderbythelevelofthecarina.Lateralityisdefinedaccordingtothemidlineofthetrachea.

Fig.5.6dSagittal views of CT scan highlighting the station 3a lymph node area: left lateral.

Fig.5.6aStation 3a lymph nodes: anterior view.

Fig.5.6eAxial sections of CT scan depicting the borders of the station 3a lymph node zone: upper border.

Fig.5.6bStation 3a lymph nodes: coronal view.

Fig.5.6fAxial sections of CT scan depicting the borders of the station 3a lymph node zone: lower border.

Fig.5.6cSagittal views of CT scan highlighting the station 3a lymph node area: right lateral.

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Station 3P: Posterior or retrotracheal lymph nodes (Fig.5.7)These are the lymph nodes located posterior to the trachea.The upper margin isdefinedbytheapexofthechestandthelowerbythecarina.

Fig.5.7aStation 3p lymph nodes (lateral view).

Fig.5.7bCoronal view of CT scan depicting the area of the station 3p lymph node.

Fig.5.7cSagittal view (right lateral) of CT scan highlighting the station 3p lymph node area.

Fig.5.7dSagittal view (left lateral) of CT scan highlighting the station 3p lymph node area.

Fig.5.7eAxial section of CT scan depicting the upper border of the station 3p lymph node zone.

Fig.5.7fAxial section of CT scan depicting the lower border of the station 3p lymph node zone.

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Station4:Lowerparatracheallymphnodes(Fig.5.8)Thelowerrightparatracheallymphnodesincludetherightparatrachealandanteriorcarinal lymph nodes. Laterality is defined by the left lateral border of the trachea(2o’clockpositionifthemidlineisconsideredtobe12o’clockthroughto6o’clock).Theupperborderofthe4Rlymphnodesisatthelevelwherethelowerborderofthebrachiocephalicveincrossesthetrachea.Thelowerborderisdefinedbytheazygosvein.Ontheleftside,theleftparatrachealor4Llymphnodeisontheleftlateralaspectofthetracheafromthe2o’clockposition.Itsupperborderistheuppermarginoftheaorticarchandthelowerborderistheupperrimoftheleftmainpulmonaryartery.

Fig.5.8aStation 4R lymph nodes (azygos vein showing lower border).

Fig.5.8bStation 4L lymph nodes.

Fig.5.8cAxial section of CT scan depicting the upper margins of the station 4 lymph node zone.

Fig.5.8eCoronal section of CT scan depicting the margins of the station 2 lymph node zone.

Fig.5.8fSagittal views of CT scan highlighting the margins of the station 4 lymph node zone: right lateral.

Fig.5.8gSagittal views of CT scan highlighting the margins of the station 4 lymph node zone: left lateral.

Fig.5.8dAxial section of CT scan depicting the lower margin of the station 4 lymph node zone.

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Station5:Aorticlymphnodes(Fig.5.9)Theselymphnodesarelocatedontheleftsidelateraltotheligamentumarteriosum.Theuppermargin isdefinedbythe lowerborderof theaorticarchandthe lowermarginbytheupperborderoftheleftmainpulmonaryartery.

Fig.5.9aStation 5 lymph notes: anterior view (nodes in brown).

Fig.5.9cSagittal section of CT scan demonstrating station 5 lymph node: left.

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

Fig.5.9dAxial section of CT scan demonstrating station 5 lymph node.

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Station6:Para-aorticlymphnodes(Fig.5.10)Thepara-aorticlymphnodesarelocatedontheleftsideandfoundanterolateraltotheascendingaortaandtheaorticarch.Theupperborderisahorizontallinethroughtheupperborderoftheaorticarchandthelowerborderdefinedbythelowerleveloftheaorticarch.

Fig.5.10cSagittal view (left lateral) of CT scan depicting the station 6 lymph node.

Fig.5.10dAxial view of CT scan depicting the station 6 lymph node.

Fig.5.10aStation 6 lymph nodes: anterior view.

Fig.5.10bStation 6 lymph nodes: coronal view.

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●● Inferior mediastinal nodesStation7:Subcarinallymphnodes(Fig.5.11)Thesearethelymphnodeslocatedbelowthemaincarinaofthetrachea.Thelowerborderisdefinedbythelowerborderofthebronchusintermediusontherightsideandthelowerborderoftheleftmainbronchusontheleftside.

Fig.5.11aStation 7 lymph nodes.

Fig.5.11dSagittal views of CT scan depicting the station 7 lymph node: left lateral.

Fig.5.11bCoronal section of CT scan depicting the margins of the station 7 lymph node zone.

Fig.5.11eAxial section of CT scan depicting the upper margins of the station 7 lymph node zone.

Fig.5.11cSagittal views of CT scan depicting the station 7 lymph node: right lateral.

Fig.5.11fAxial section of CT scan depicting the lower margins of the station 7 lymph node zone.

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●● Lower zoneStation8:Para-oesophageallymphnodes(Fig.5.12)These are lymphnodes lying adjacent to thewall of theoesophagus.They are thenodes locatedbelowthesub-carinal lymphnodes.Hence theupperborderon therightsideisdefinedbythelowerborderofthebronchusintermediusandtheleftbythelowerborderoftheleftmainbronchus.Theinferiorextentofthelymphnodesisthedomeofthediaphragm.

Fig.5.12aStation 8 lymph nodes.

Fig.5.12dAxial section of CT scan depicting the lower margins of the station 8 lymph node zone.

Fig.5.12bCoronal section of CT scan depicting the margins of the station 8 lymph node zone.

Fig.5.12eSagittal views of CT scan depicting the station 8 lymph node: left lateral.

Fig.5.12cAxial section of CT scan depicting the upper margins of the station 8 lymph node zone.

Fig.5.12fSagittal views of CT scan depicting the station 8 lymph node: right lateral.

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Station9:Pulmonaryligamentlymphnodes(Fig.5.13)Thepulmonaryligamentlymphnodesarelocatedalongthepulmonaryligament.Theupperborderof station9 isdefinedby the inferiorpulmonary vein and the lowerborderbythediaphragm.

Fig.5.13dAxial section of CT scan depicting the lower margins of station 9 lymph node zone.

Fig.5.13aStation 9 lymph nodes.

Fig.5.13eSagittal views of CT scan depicting the station 9 lymph node: left lateral.

Fig.5.13bCoronal section of CT scan depicting the lower margins of the station 9 lymph node zone.

Fig.5.13fSagittal views of CT scan depicting the station 9 lymph node: right lateral.

Fig.5.13cAxial section of CT scan depicting the upper margins of the station 9 lymph node zone.

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●● Hilar/interlobar zone (hilar nodes)Station10:Mainbronchiallymphnodes(Fig.5.14)Station10orhilarlymphnodesarefoundadjacenttotherightandleftmainbronchiand the main pulmonary artery and pulmonary vein. On the right side, the upperborderisdeterminedbythelowerrimoftheazygosveindowntothedistalmarginoftherightmainbronchus.Ontheleftside,thelymphnodesarelocatedbetweentheupperrimofthepulmonaryarteryandtheloweraspectoftheleftmainbronchus.

Fig.5.14aStation 10R lymph nodes (azygos vein depicting upper margin).

Fig.5.14bStation 10L lymph nodes.

Fig.5.14dAxial sections of CT scan depicting the margins of the station 10 lymph node zone: upper margins.

Fig.5.14eAxial sections of CT scan depicting the margins of the station 10 lymph node zone: lower margins.

Fig.5.14fSagittal section of CT scan depicting the station 10R (right) lymph node.

Fig.5.14gSagittal section of CT scan (left lateral) depicting the station 10L (left) lymph node zone.

Fig.5.14cCoronal view of CT scan depicting the margins of the station 10 lymph node zone.

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Station11:Interlobarlymphnodes(Fig.5.15)Theseinterlobarlymphnodesarelocatedbetweentheoriginofthelobarbronchus.Ontherightsidearethesuperiorstation11lymphnodes(11Rs),whicharelocatedbetweentherightupper lobeandthebronchus intermedius.Theinferiorstation11lymphnodes(11Ri)arelocatedbetweenthemiddlelobebronchusandthelowerlobebronchus.Ontheleftside,thestation11lymphnodes(11L)arelocatedbetweentheleftsuperiordivisionbronchusandtheleftlowerlobebronchus.

Fig.5.15aStation 11Rs lymph nodes. Fig.5.15bStation 11Ri lymph nodes.

Fig.5.15cStation 11L lymph nodes. Fig.5.15dCoronal view of CT scan depicting the station 11 lymph nodes.

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●● Peripheral zoneStations12,13and14Thesearethelymphnodeslocatedadjacenttothelobarbronchi(station12)nodes,adjacenttotheupperlobes(12u),middlelobe(12m)andlowerlobes(12l).Thestation13lymphnodesaresegmentalnodesandthestation14nodesarelocatedadjacenttothesubsegmentalbronchi.Theselymphnodesarenotaccessibleatbronchoscopyandarethereforenotdiscussedfurther.

Fig.5.15eAxial section of CT scan depicting Station 11Rs lymph node.

Fig.5.15fAxial sections of CT scan depicting: station 11Ri lymph node.

Fig.5.15gAxial sections of CT scan depicting: station 11L lymph node.

Fig.5.15hSagittal section of CT scan (right lateral) depicting the station 11Rs (right) lymph node.

Fig.5.15iSagittal section of CT scan (right lateral) depicting the station 11R (right) lymph node.

Fig.5.15jSagittal section of CT scan (left lateral) depicting the station 11L (left) lymph node.

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CHAPTER

6Transbronchial fine-needle aspiration (anterior approach)Transbronchialfine-needleaspiration(TBNA)isasimple,cheaptechniqueforsamplingmediastinalnodes.Hilarlymphnodes,massesadjacenttotheairwaysandsubmucosaldiseasemayalsobesampledwiththistechnique.Avarietyofneedlesareavailablebuttheneedleshouldberetractablewithalengthofbetween13and15mmandagaugeofbetween18and22(Fig.6.1).

Fig.6.1aBronchoscope with transbronchial fine-needle aspiration needle: withdrawn into the sheath.

Fig.6.1bBronchoscope with transbronchial fine-needle aspiration needle: extended out of the sheath.

Planning/siteselectionThe computed tomography (CT) scanof the thorax should be examinedprior toTBNA and the site of aspiration should be predetermined (Fig. 6.2a).The simplestapproachistorelatetheairwaytoaclockfaceandplanthepositionoftargetsitesinthismanner(Fig.6.2b).TheCTscanisobtainedbyimagingfromthefeetupwards(Fig.6.2c),whereasatbronchoscopythepatientisapproachedfromtheheaddownwards(Fig.6.2d).Itisthereforeimportanttoaccountforthesedifferences.Forpatientswhoarebeingapproachedfromtheanteriorside, thesimpletrick is toflipthe image inthehorizontalaxis(Fig.6.2e).Theverticalpositionalsoneedstobedeterminedandcanbedescribed in termsof cartilage spacesor rings aboveandbelow the carina(Fig. 6.2f). In some cases itmay be necessary to relate the vertical position to theoriginofthesegmentalbronchi.Moredetaileddescriptionsaregivenfortheexamplelymphnodestations in thischapter,but it shouldbeemphasized that this ismerelya guideand individual sites for aspirationaredeterminedaccording to thepatient’sCTscan.Modernmulti-planarreformattingofCTsandsoftwaremoduleswithvirtualbronchoscopy(Fig.6.2g)andlymphnodehighlighting(Fig.6.2h)mayhelptodeterminethesiteofneedleaspiration.

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Fig.6.2aCT scan with right paratracheal lymph node present.

Fig.6.2cCross-sectional CT scan of the thorax; note the relative position of the anterior and posterior aspects of the patient.

Fig.6.2bCT scan with the right paratracheal lymph node highlighted in yellow and the clock face showing that the lymph node is in 10–11 o’clock position.

Fig.6.2dBronchoscopic view; note the relative position of the anterior and posterior aspects of the patient.

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Fig.6.2eCross-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.6.2gVirtual bronchoscopy derived from CT scanning.

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

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

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TechniqueTransbronchialfine-needleaspirationshouldbeperformedfirstduringthebronchoscopyand,inthecaseofmediastinallymphnodesampling,beforeinspectionoftheairways.Minimaluseofsuctionshouldbeemployedinordertominimizetheriskofaspiratingcellularmaterialfromthedistalairways,whichmayleadtofalse-positiveresults.Thesesimpleprecautionsvirtuallypreventanyfalse-positiveresults.Thisisimportantinthestagingoflungcancerwhereafalse-positiveresultwouldupstageapatientanddenyhim or her potentially curative surgery. It is also important to sample the highest-stagelymphnodesfirst,e.g.N3lymphnodesfollowedbyN2lymphnodesandfinallyN1 lymphnodes.Theneedleshouldbe insertedthroughthe instrumentchannelofthebronchoscopewiththebronchoscopeasstraightaspossibleinthetrachea.Anyflexionorextensionof thedistalportionof the scope shouldbeavoideduntil thehuboftheneedleisoutsidethebronchoscope.Thisisessentialinordertominimizebronchoscopedamage.

Anumberoftechniquescanbeusedtosamplethelymphnode(Fig.6.3):

●● jabbing●● piggyback●● cough.

●● Jabbing techniqueThisinvolvesguidingthebronchoscopetothetargetareaandthenapposingthedistalhuboftheneedletotheairwaywall.Thedistalportionofthescopeshouldbeangulatedtoensurethattheneedlepenetratesthroughtheairwayasperpendicularaspossible.Thereshouldbeanangleofatleast45°betweentheairwaywallandtheneedle.The

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

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

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needleisthenpushedthroughtheairwaywallandgentlymanipulatedbackandforth.Atthesametime,anassistantshouldapplysuctionattheproximalendoftheTBNAneedlewith a20mL syringe.The samples collectedare then smearedon to slidesand sprayedwith a fixative, or alternatively injected into salineor cytolyte solution,depending on the preference of the local site pathologist.Any tissue fragments orsliversobtainedareplacedinformalinandsentforhistologicalanalysis.Theavailabilityof rapid on-site cytological evaluation (ROSE) significantly reduces the time of theprocedureandimprovesdiagnosticyield.

IntheabsenceofaROSE,atleastfourneedlepassesaremadeateachtargetsitewhenassessingpatientswithsuspectedlungcancer.Thesitewiththehighestpossiblelymphnodestageshouldbesampledfirst,thenmovingprogressivelydowntothelowersite.

●● Piggyback methodWiththismethodtheneedleisadvanced,andoncethehubisprotrudingthroughthedistalend,theneedleisfixedbypressingtheinsertionportofthebronchoscopewithanindexfinger.Thisdoescausethecathetertobendatthispointandthetechniqueis better reserved for single-use disposable needles. Once the needle is fixed intoposition,thescopeandtheneedlecanbemovedinunisonandpushedforwardatthedesiredlocationuntiltheneedlepenetratestheairwaywall.Theneedleismovedbackandforthwithanassistantapplyingsuctionasdescribedforthejabbingtechnique.

●● Cough techniqueThismethodemployseitheroftheaboveapproachesinconjunctionwithacontrolledcoughtofacilitatepenetrationoftheneedlethroughtheairwaywall.Itreliesonpatientcooperationandmaynotalwaysbesuccessful.

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

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LymphnodestationsItispossibletosampleanyofthelymphnodesthatareadjacenttotheairwaysusingTBNA.The lymph node stations are described according to the new InternationaIAssociationfortheStudyofLungCancer(IASLC)classification.

●● Superior mediastinal lymph nodes: upper zoneStation4R:Lowerrightparatracheallymphnode(Fig.6.4)The station 4R or right paratracheal lymph node is classically located in the rightanterioraspectofthetrachea.TheexactpositionshouldbepredeterminedfromtheCTscan.UsuallyontheCTscantherightparatracheallymphnodeislocatedinthe10–11o’clockposition,iftheanteriormidlineisconsideredtobe12o’clock.However,oneshouldnotethattheCTscansareobtainedby lookingatthepatient fromthefeetupwards;butwhenpatientsundergoabronchoscopy,theairwaysareviewedwiththeheaddownwards.Whenthepatientisapproachedfromthefront,withthepatientinasemi-recumbentposition,theposteriorwallisnowatthe12o’clockpositionandtheanteriorwallatthe6o’clockposition.Hence,inthispositiontherightparatracheallymphnodeisnowpositionedbetweenthesevenand8o’clockpositions.ThesimplestwayistofliptheCTscaninthehorizontalaxis.Thebronchoscopicpositionoftherightparatracheallymphnodeisbetweensevenand8o’clock.Bendingthebronchoscopeposteriorly inthisposition ismoredifficult.Easierandmoreaccurateaccesscanbeachievedbyrotatingthebronchoscopebyabout180°.Thelymphnodeisnowintheoneto2o’clockposition.Theverticalpositionoftherightparatracheallymphnodeisabouttwotofourintercartilagespacesabovethecarina.

Fig.6.4aCross-sectional CT scan of the thorax at the level of the aortic arch showing a station 4R lymph node.

Fig.6.4bCross-sectional CT scan with a superimposed clock face and a station 4R lymph node highlighted in yellow.

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

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

Fig.6.4eBronchoscopic view of the station 4R lymph node which is in the 7–8 o’clock position about two to four intercartilage spaces above the carina.

Fig.6.4fRotation of the bronchoscope by 180° facilitates access of the station 4R lymph node which is now in the 1–2 o’clock position.

Fig.6.4gBronchoscopic view of the needle inserted into a 4R lymph node in the 2 o’clock position with the scope rotated anteriorly by 180°.

Fig.6.4hBronchoscopic view of the needle inserted into a 4R lymph node in the 8 o’clock position with the scope in the neutral position.

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

Fig.6.4jCross-sectional CT scan with a superimposed clock face and anterior carinal lymph node (station 4R) highlighted in yellow.

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Fig.6.4kCross-sectional CT scan flipped on the horizontal axis. The anterior carinal lymph node (station 4R) is in the 6–6.30 o’clock position.

Fig.6.4lCoronal section of CT scan showing the vertical position of the anterior carinal lymph node which is usually at the level of the carina.

Fig.6.4mBronchoscopic view of the station 4R (anterior carinal) lymph node which is in the 6 o’clock position at the level of the carina.

Fig.6.4nRotation of the bronchoscope by 180° facilitates access of the station 4R (anterior carinal) lymph node, which is now in the 12 o’clock position.

Fig.6.4oBronchoscopic view of needle inserted into a 4R lymph node in the 12 o’clock position with the scope rotated anteriorly by 180°.

Fig.6.4pBronchoscopic view of the needle inserted into a 4R lymph node in the 6 o’clock position with the scope in the neutral position.

AsdescribedinChapter5,station4Rcanextendanteriortothetracheathroughtothe2o’clockposition.Nodeslocatedanteriortothetracheawerepreviouslydescribedasanteriorcarinal lymphnodes.Theyareusually located in the11.30 to12o’clockpositionontheCTscan.Atbronchoscopythisrelatestothe6–6.30positionwhenthepatient isbeingapproachedfromthefront.DuringTBNAwhenthepatient isbeingapproachedfromthefront,itiseasiertosamplethelymphnodesifthescopeisrotatedby180°sothatthelymphnodeisnowinananteriordirectionofthebronchoscope.

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Station4L:Lowerleftparatracheallymphnode(Fig.6.5)Thestation4Lorleftparatracheallymphnodeislocatedontheleftlateralpositionofthetracheaatorabovethelevelofthecarina.OntheCTscanthelymphnodeis located inthe3o’clockposition.Whenthepatient isbeingapproachedfromthefrontatbronchoscopy,thelymphnodeislocatedatthesame3o’clockposition.Theverticalpositionofthelymphnodeisatthelevelofthecarinaoronespaceabove.Inpracticethislymphnodeismoreeasilyaccessedbyrotatingthebronchoscope90°in an anticlockwise direction. Once the needle has penetrated the airway wall, thetorsiononthebronchoscopecanberelaxedandtheneedlemovedbackwhilethebronchoscopeisintheneutralposition(asinFig.6.5h).

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

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

Fig.6.5dCoronal 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.6.5bCross-sectional CT scan with a superimposed clockface and a station 4L lymph node highlighted in yellow.

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Fig.6.5eBronchoscopic view of the station 4L lymph node which is in the 3 o’clock position about one intercartilage space above the carina.

Fig.6.5fRotation of the bronchoscope by 90° anticlockwise facilitates access of the station 4L lymph node.

Fig.6.5gBronchoscopic view of the needle inserted into a 4L lymph node with the scope rotated anticlockwise by 90°.

Fig.6.5hBronchoscopic view of the needle inserted into a 4L lymph node in the 3 o’clock position with the scope in the neutral position.

Station3P:Posteriortracheallymphnode(Fig.6.6)Theposteriorcarinal lymphnodeisusually locatedatthelevelofthecarinaontheposterioraspectofthetrachea.OnCTtermsitcanbeconsideredtobeinthe5.30–6o’clockposition.Atbronchoscopyitislocatedatthelevelofthecarinainthe12–12.30o’clockpositionwhenthepatientisapproachedfromthefront.TheforwardangulationofthebronchoscopeisgreaterintheanteriordirectionandthereforeaccessforTBNAisimprovedbyrotatingthescopeto180°sothatthelymphnodesarenowanteriorinthe12–12.30o’clockposition.TheseventheditionoftheIASLCstagingclassificationregardsall lymphnodesposteriortothetracheaasstation3p,sothesiteofneedlesamplingshouldbeplannedfromtheCTscanofthethorax.

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

Fig.6.6bCross-sectional CT scan with a superimposed clockface and a station 3p lymph node highlighted in yellow.

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Fig.6.6cCross-sectional CT scan of the thorax flipped on the horizontal axis. The 3p lymph node is in the 12–12.30 o’clock position.

Fig.6.6eBronchoscopic view of the station 3p lymph node which is in the 12–12.30 o’clock position about one intercartilage space above the carina.

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

Fig.6.6fBronchoscopic view of needle inserted into a 3p lymph node in the 12 o’clock position with the scope in the neutral position.

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●● Inferior mediastinal lymph nodesStation7:Subcarinallymphnode(Fig.6.7)Thestation7orsubcarinallymphnodesarelocatedjustinferiortothecarina.Thecarinais composedof threebundlesof cartilage and ligament andhencedirect puncturethrough thecarina tends tobeunsuccessful.The subcarinal lymphnodes shouldbeapproached in therightmainbronchusbyonespacebelowthecarina.OntheCTscan this translates to the3o’clockpositionand is the same if thepatient isbeingapproachedfromthefront.Easierandmoreaccurateaccessisfacilitatedbyrotatingthebronchoscopeby90°anticlockwise.

Fig.6.7aCross-sectional CT scan of the thorax showing a station 7 lymph node.

Fig.6.7bCross-sectional CT scan with a superimposed clock face and a station 7 lymph node highlighted in yellow.

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

Fig.6.7dCoronal 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.

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Fig.6.7eBronchoscopic view of the station 4L lymph node which is in the 3 o’clock position one intercartilage space below the carina in the right main bronchus.

Fig.6.7fRotation of the bronchoscope by 90° anticlockwise facilitates access of the station 7 lymph node.

Fig.6.7gBronchoscopic view of needle inserted into a station 7 lymph node with the scope rotated anticlockwise by 90°.

Fig.6.7hBronchoscopic view of the needle inserted into a station 7 lymph node in the 3 o’clock position with the scope in the neutral position.

●● Hilar zone lymph nodesStation10R:Rightmainbronchiallymphnode(Fig.6.8)Thestation10Rorrightmainbronchiallymphnodeislocatedanteriortotherightmain bronchus about one intercartilage space below the carina in the 12 o’clockpositionontheCTscan.Wherethepatientisbeingbronchoscopedfromthefront,thisisequivalenttothe6o’clockpositionintherightmainbronchusonespacebelowthe carina.Again, for improved access when performingTBNA, the bronchoscopeshouldberotatedby180°sothatthelymphnodeisnowpositionedanteriorlyatthe12o’clockposition.

Fig.6.8aCross-sectional CT scan of the thorax showing a station 10R lymph node.

Fig.6.8bCross-sectional CT scan with a superimposed clock face and a station 10R lymph node highlighted in yellow.

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Station10L:Leftmainbronchiallymphnode(Fig.6.9)Theleftmainbronchiallymphnodeislocatedontheanterioraspectoftheleftmainbronchusapproximatelyone interspacebelowthecarina in the12o’clockposition.Duringbronchoscopywhenthepatientisbeingapproachedfromthefront,thelymphnode is in the 6 o’clock position and again access improved by rotating the scopethrough180°sothattheapproachisnowinthe12o’clockposition.

Fig.6.8cCross-sectional CT scan of the thorax flipped on the horizontal axis. The 10R lymph node is in the 6 o’clock position in the right main bronchus.

Fig.6.8eBronchoscopic view of the station 10R lymph node which is in the 6 o’clock position about one intercartilage space below the carina in the right main bronchus.

Fig.6.8fRotation of the bronchoscope by 180° clockwise facilitates access of the station 10R lymph node.

Fig.6.8gBronchoscopic view of the needle inserted into a 10R lymph node with the scope rotated clockwise by 180°.

Fig.6.8hBronchoscopic view of the needle inserted into a station 10R lymph node in the 6 o’clock position with the scope in the neutral position.

Fig.6.8dCoronal section of CT scan showing the vertical position of the station 10R lymph node which is usually one intercartilage space below the carina in the right main bronchus.

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Fig.6.9aCross-sectional CT scan of the thorax showing a station 10L lymph node.

Fig.6.9bCross-sectional CT scan with a superimposed clock face and a station 10L lymph node highlighted in yellow in the 6 o’clock position.

Fig.6.9dCoronal section of CT scan showing the vertical position of the station 10L lymph node which is usually one intercartilage space below the carina.

Fig.6.9cCross-sectional CT scan of the thorax flipped on the horizontal axis. The 10L lymph node is in the 12 o’clock position.

Fig.6.9eBronchoscopic view of the station 10L lymph node which is in the 6 o’clock position about one intercartilage space below the carina in the left main bronchus.

Fig.6.9fRotation of the bronchoscope by 180° clockwise facilitates access of the station 10L lymph node.

Fig.6.9gBronchoscopic view of the needle inserted into a 10L lymph node with the scope rotated clockwise by 180°.

Fig.6.9hBronchoscopic view of the needle inserted into a 10L lymph node in the 6 o’clock position with the scope in the neutral position.

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Station11Rs:Rightupperhilarlymphnode(Fig.6.10)Thestation11Rincludestherightupperandrightlowerhilarnodes.TherightupperhilarnodeislocatedontheCTscanbetweentherightupperlobebronchusandthebronchusintermedius.OntheCTcross-sectionitrelatestothe9o’clockpositionjustbelow theorigin of the bronchus intermedius.At bronchoscopy this relates to theanteriorspuroftherightupperlobecarinaandtheoptimalapproachistoinserttheneedlejustbelowthespuroftheupperlobecarina.Whenthepatientisapproachedfromthefront,thisisjustbelowtheoriginofthebronchusintermediusinthe9–10o’clockposition.Itisintheproximalportionofthebronchusintermedius.

Fig.6.10aCross-sectional CT scan of the thorax showing a station 11Rs (right upper hilar) lymph node.

Fig.6.10bCross-sectional CT scan with a superimposed clock face and a station 11Rs (right upper hilar) lymph node highlighted in yellow.

Fig.6.10cCross-sectional CT scan of the thorax flipped on the horizontal axis. The station 11Rs (right upper hilar) lymph node is in the 9 o’clock position.

Fig.6.10dCoronal section of CT scan showing the vertical position of the station 11Rs (right upper hilar) lymph node, which is usually located at the right upper lobe carina.

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Fig.6.10eBronchoscopic view of the station 11Rs (right upper hilar) lymph node which is in the 9 o’clock position in the anterior spur of the right upper lobe carina.

Fig.6.10fRotation of the bronchoscope by 90° clockwise facilitates access of the station 11Rs (right upper hilar) lymph node.

Fig.6.10gBronchoscopic view of the needle inserted into a station 11Rs (right upper hilar) lymph node with the scope rotated clockwise by 90°.

Fig.6.10hBronchoscopic view of the needle inserted into a station 11Rs (right upper hilar) lymph node in the 9 o’clock position with the scope in the neutral position.

Station11Ri:Rightlowerhilarlymphnode(Fig.6.11)OntheCTscan,therightlowerhilarlymphnodeis locatedlateraltothebronchusintermediusinthe9o’clockpositionattheleveloftherightmiddlelobe.Atbronchoscopytheneedleshouldbe inserted inthedistalpartof thebronchus intermedius inthe9o’clockpositionattheleveloftherightmiddlelobeorigin.Accessintothis lymphnodeisalsofacilitatedbyrotationofthescopeby90°.

Fig.6.11aCross-sectional CT scan of the thorax showing a station 11Ri (right lower hilar) lymph node.

Fig.6.11bCross-sectional CT scan with a superimposed clock face and a station 11Ri (right lower hilar) lymph node highlighted in yellow.

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Station11L:Lefthilarlymphnode(Fig.6.12)Thestation11Lorlefthilarlymphnodeislocatedatthebifurcationoftheleftmainbronchus.It isaccessedfromtheleftlowerlobetowardstheupperlobeinthe6–7o’clockposition.Needleinsertioniseasierifthebronchoscopeisrotatedby180°andtheneedleisinsertedintothe12–1o’clockpositionfromtheleftlowerlobetotheleftupperlobe.

Fig.6.11eBronchoscopic view of the station 11Ri (right lower hilar) lymph node which is in the 9 o’clock position in the bronchus intermedius just above the origin of the right middle lobe.

Fig.6.11fRotation of the bronchoscope by 90° clockwise facilitates access of the station 11Ri (right lower hilar) lymph node.

Fig.6.11gBronchoscopic view of the needle inserted into a station 11Ri (right lower hilar) lymph node with the scope rotated clockwise by 90°.

Fig.6.11hBronchoscopic view of the needle inserted into a station 11Ri (right lower hilar) lymph node in the 9 o’clock position with the scope in the neutral position.

Fig.6.11cCross-sectional CT scan of the thorax flipped on the horizontal axis. The station 11Ri (right lower hilar) lymph node is in the 9 o’clock position.

Fig.6.11dCoronal section of CT scan showing the vertical position of the station 11Ri (right lower hilar) lymph node, which is usually just higher than the right middle lobe origin.

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Fig.6.12aCross-sectional CT scan of the thorax showing a station 11L lymph node.

Fig.6.12cCross-sectional CT scan of the thorax flipped on the horizontal axis. The 11L lymph node is in the 6–7 o’clock position when approached from the left lower lobe.

Fig.6.12bCross-sectional CT scan with a superimposed clock face and a station 11L lymph node highlighted in yellow.

Fig.6.12dCoronal section of CT scan showing the vertical position of the station 11L lymph node which is usually at the level of the carina between the left upper and lower lobes.

Fig.6.12eBronchoscopic view of the station 11L lymph node which is in the 6–7 o’clock position when approached from the left lower lobe and about one intercartilage space below the left main bronchial carina.

Fig.6.12fRotation of the bronchoscope by 180° clockwise facilitates access of the station 11L lymph node and the lymph node is in the 12 to 1 o’clock position when approached from the left lower lobe and about one intercartilage space below the left main bronchial carina.

Fig.6.12gBronchoscopic view of the needle inserted into an 11L lymph node with the scope rotated anticlockwise by 90°.

Fig.6.12hBronchoscopic view of the needle inserted into an 11L lymph node in the 3 o’clock position with the scope in the neutral position.

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CHAPTER

7Transbronchial fine-

needle aspiration (posterior approach)

Transbronchialfine-needleaspiration(TBNA)isasimple,cheaptechniqueforsamplingmediastinalnodes.Hilarlymphnodes,massesadjacenttotheairwaysandsubmucosaldiseasemayalsobesampledwiththistechnique.Avarietyofneedlesareavailablebuttheneedleshouldberetractablewithalengthofbetween13and15mmandagaugeofbetween18and22(Fig.7.1).

Fig7.1aBronchoscope with transbronchial fine-needle aspiration needle: withdrawn into the sheath.

Fig7.1bBronchoscope with transbronchial fine-needle aspiration needle: extended out of the sheath.

Planning/siteselectionThe computed tomography (CT) scanof the thorax should be examinedprior toTBNA and the site of aspiration should be predetermined (Fig. 7.2a).The simplestapproachistorelatetheairwaytoaclockfaceandplanthepositionoftargetsitesinthismanner(Fig.7.2b).TheCTscanisobtainedbyimagingfromthefeetupwards(Fig.7.2c),whereasatbronchoscopythepatientisapproachedfromtheheaddownwards(Fig.7.2d).Itisthereforeimportanttoaccountforthesedifferences.Forpatientswhoarebeing approached from theposterior side, the simple trick is to flip the imageintheverticalaxis(Fig.7.2e).Theverticalpositionalsoneedstobedeterminedandcanbedescribed in termsof cartilage spacesor rings aboveandbelow the carina(Fig. 7.2f). In some cases itmay be necessary to relate the vertical position to theoriginofthesegmentalbronchi.Moredetaileddescriptionsaregivenfortheexamplelymphnodestations in thischapter,but it shouldbeemphasized that this ismerelya guideand individual sites for aspirationaredeterminedaccording to thepatient’sCTscan.Modernmulti-planarreformattingofCTsandsoftwaremoduleswithvirtualbronchoscopy(Fig.7.2g)andlymphnodehighlighting(Fig.7.2h)mayhelptodeterminethesiteofneedleaspiration.

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Fig7.2cCross-sectional CT scan of the thorax; note the relative position of the anterior and posterior aspects of the patient.

Fig7.2aCT scan with the right paratracheal lymph node present.

Fig7.2dBronchoscopic view; note the relative position of the anterior and posterior aspects of the patient.

Fig7.2bCT scan with the right paratracheal lymph node highlighted in yellow and the clock face showing that the lymph node is in 10–11 o’clock position.

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Fig7.2eCross-sectional CT scan of the thorax flipped on the vertical axis so as to align the right and left aspects of the patient with the bronchoscopic view.

Fig7.2gVirtual bronchoscopy derived from CT scanning.

Fig7.2fCoronal CT reformat to help determine the vertical position of the lymph node in relation to the carina.

Fig7.2hVirtual bronchoscopy derived from CT scanning with lymph node highlighting.

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TechniqueTransbronchialfine-needleaspirationshouldbeperformedfirstduringthebronchoscopyand,inthecaseofmediastinallymphnodesampling,beforeinspectionoftheairways.Minimaluseofsuctionshouldbeemployedinordertominimizetheriskofaspiratingcellularmaterialfromthedistalairways,whichmayleadtofalse-positiveresults.Thesesimpleprecautionsvirtuallypreventanyfalse-positiveresults.Thisisimportantinthestagingoflungcancerwhereafalse-positiveresultwouldupstageapatientanddenyhim or her potentially curative surgery. It is also important to sample the highest-stagelymphnodesfirst,e.g.N3lymphnodesfollowedbyN2lymphnodesandfinallyN1 lymphnodes.Theneedleshouldbe insertedthroughthe instrumentchannelofthebronchoscopewiththebronchoscopeasstraightaspossibleinthetrachea.Anyflexionorextensionof thedistalportionof the scope shouldbeavoideduntil thehuboftheneedleisoutsidethebronchoscope.Thisisessentialinordertominimizebronchoscopedamage.

Anumberoftechniquescanbeusedtosamplethelymphnode:

●● jabbing●● piggyback●● cough.

●● Jabbing techniqueThis involves guiding the bronchoscope to the target area and then apposing thedistalhuboftheneedletotheairwaywall.Thedistalportionofthescopeshouldbeangulatedtoensurethattheneedlepenetratesthroughtheairwayasperpendicularas possible.There should be an angle of at least 45° between the airwaywall andtheneedle (Fig.7.3).Theneedle is thenpushed through theairwaywall andgentlymanipulatedbackandforth.Atthesametime,anassistantshouldapplysuctionatthe

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

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

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proximalendoftheTBNAneedlewitha20mLsyringe.Thesamplescollectedarethensmearedontoslidesandsprayedwithafixative,oralternativelyinjectedintosalineorcytolytesolution,dependingonthepreferenceofthelocalsitepathologist.Anytissuefragmentsorsliversobtainedareplacedinformalinandsentforhistologicalanalysis.Theavailabilityofrapidon-sitecytologicalevaluation(ROSE)significantlyreducesthetimeoftheprocedureandimprovesdiagnosticyield.

IntheabsenceofaROSE,atleastfourneedlepassesaremadeateachtargetsitewhenassessingpatientswithsuspectedlungcancer.Thesitewiththehighestpossiblelymphnodestageshouldbesampledfirst,thenmovingprogressivelydowntothelowersite.

●● Piggyback methodWiththismethodtheneedleisadvanced,andoncethehubisprotrudingthroughthedistalend,theneedleisfixedbypressingtheinsertionportofthebronchoscopewithanindexfinger.Thisdoescausethecathetertobendatthispointandthetechniqueis better reserved for single-use disposable needles. Once the needle is fixed intoposition,thescopeandtheneedlecanbemovedinunisonandpushedforwardatthedesiredlocationuntiltheneedlepenetratestheairwaywall.Theneedleismovedbackandforthwithanassistantapplyingsuctionasdescribedforthejabbingtechnique.

●● Cough techniqueThismethodemployseitheroftheaboveapproachesinconjunctionwithacontrolledcoughtofacilitatepenetrationoftheneedlethroughtheairwaywall.Itreliesonpatientcooperationandmaynotalwaysbesuccessful.

Fig.7.3cCytology smears prepared by spraying aspirates on to the slides.

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LymphnodestationsItispossibletosampleanyofthelymphnodesthatareadjacenttotheairwaysusingTBNA.The lymph node stations are described according to the new InternationaIAssociationfortheStudyofLungCancer(IASLC)classification.

●● Superior mediastinal lymph nodes: upper zoneStation4R:Lowerrightparatracheallymphnode(Fig.7.4)Therightparatracheallymphnodeisclassicallylocatedintherightanterioraspectofthetrachea.TheexactpositionshouldbepredeterminedfromtheCTscan.UsuallyontheCTscantherightparatracheallymphnodeislocatedinthe10–11o’clockpositioniftheanteriormidlineisconsideredtobe12o’clock.However,oneshouldnotethattheCTscansareobtainedbylookingatthepatientfromthefeetupwards;butwhenpatientsundergoabronchoscopy,theairwaysareviewedwiththeheaddownwards.Whenthepatientisapproachedfromthebackwiththepatientsupine,theirrightsideisnowatthe3o’clockpositionandtheleftsideatthe9o’clockposition.Hence,inthispositiontherightparatracheallymphnodeisactuallypositionedbetweenthe1and2o’clockposition.ThesimplestwayistofliptheCTscanontheverticalaxis.Theverticalpositionoftherightparatracheallymphnodeisabouttwotofourintercartilagespacesabovethecarina.

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

Fig.7.4bCross-sectional CT scan with a superimposed clock face and a station 4R lymph node highlighted in yellow.

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Fig.7.4cCross-sectional CT scan of the thorax flipped on the vertical axis. The 4R lymph node is in the 1–2 o’clock position.

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

Fig.7.4eBronchoscopic view of the station 4R lymph node which is in the 1–2 o’clock position about two to four intercartilage spaces above the carina.

Fig.7.4fBronchoscopic view of the needle inserted into a 4R lymph node in the 2 o’clock position.

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

Fig.7.4hCross-sectional CT scan of the thorax at the level of the carina showing an anterior carinal lymph node (station 4R lymph node).

Fig.7.4iCross-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).

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Fig.7.4jCross-sectional CT scan of the thorax flipped on the vertical axis. The anterior carinal lymph node is in the 12–12.30 o’clock position.

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

Fig.7.4lBronchoscopic view of the anterior carinal (station 4R) lymph node which is in the 6 o’clock position at the level of the carina.

Fig.7.4mBronchoscopic view of the needle inserted into the anterior carinal lymph node in the 12 o’clock position.

Fig.7.4nBronchoscopic view of the needle inserted into the anterior carinal lymph node in the 12.30 o’clock position.

AsdescribedinChapter5,thestation4Rcanextendanteriortothetracheathroughto the 2 o’clock position. Nodes located anterior to the trachea were previouslydescribedasanteriorcarinallymphnodes.Itisusuallylocatedinthe11.30–12o’clockposition on the CT scan. In patients being bronchoscoped from behind, this is the12–12.30position.

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Station4L:Lowerleftparatracheallymphnode(Fig.7.5)Theleftparatracheallymphnodeislocatedontheleftlateralpositionofthetracheaatorabovethelevelofthecarina.OntheCTscanthelymphnodeislocatedatthe3o’clockposition.Whenthepatientisbeingapproachedfrombehind,atbronchoscopythelymphnodeislocatedatthe9o’clockposition.Theverticalpositionofthelymphnodeisatthelevelofthecarinaoronespaceabove.Inpracticethislymphnodeismoreeasilyaccessedbyrotatingthebronchoscope90°inaclockwisedirection.Oncetheneedlehaspenetratedtheairwaywall,thetorsiononthebronchoscopecanberelaxedandtheneedlemovedbackwhilethebronchoscopeisintheneutralposition(asinFig.7.5h).

Fig.7.5aCross-sectional CT scan of the thorax showing a station 4L lymph node.

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

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.7.5d 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.

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Station3P:Posteriortracheallymphnode(Fig.7.6)Theposteriorcarinallymphnodeislocatedatthelevelofthecarinaontheposterioraspectofthetrachea.OnCTtermsitcanbeconsideredtobeinthe5.30–6position.At bronchoscopywhen the patient is approached frombehind, the lymph nodesare now located at the 6–6.30 o’clock position.The forward angulation of thebronchoscopeisgreaterintheanteriordirectionandthereforeaccessforTBNAisimprovedbyrotatingthescopeto180°sothatthelymphnodesarenowanteriorinthe11.30–12o’clockposition.

Fig.7.5e Bronchoscopic view of the station 4L lymph node, which is in the 9 o’clock position about one intercartilage space above the carina.

Fig.7.5f Rotation of the bronchoscope by 90° clockwise facilitates access to the station 4L lymph node.

Fig.7.5g Bronchoscopic view of the needle inserted into a 4L lymph node with the scope rotated clockwise by 90°.

Fig.7.5h Bronchoscopic view of the needle inserted into a 4L lymph node in the 9 o’clock position with the scope in the neutral position.

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

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

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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.7.6e Bronchoscopic view of the station 3p lymph node which is in the 6–6.30 o’clock position about one intercartilage space above the carina.

Fig.7.6f Rotation of the bronchoscope by 180° facilitates access to the station 3p lymph node.

Fig.7.6g Bronchoscopic view of the needle inserted into a 3p lymph node with the scope rotated clockwise by 180°.

Fig.7.6h Bronchoscopic view of the needle inserted into a 3p lymph node in the 6 o’clock position with the scope in the neutral position.

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●● Inferior mediastinal lymph nodesStation7:Subcarinallymphnode(Fig.7.7)The subcarinal lymph nodes are located just inferior to the carina.The carina iscomposed of three bundles of cartilage and ligament, and hence direct puncturethroughthecarinatendstobeunsuccessful.Thesubcarinal lymphnodesshouldbeapproached intherightmainbronchusatonespacebelowthecarina.OntheCTscanthistranslatestothe3o’clockpositionanditisatthe9o’clockposition(mediallyin the rightmainbronchusonespacebelowthecarina)when thepatient isbeingbronchoscopedfrombehind.

Fig.7.7c 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.7.7d 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.7.7a 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 yellow.

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●● Hilar zone lymph nodesStation10R:Rightmainbronchiallymphnode(Fig.7.8)Therightmainbronchialnodeis locatedanteriortotherightmainbronchusaboutoneintercartilagespacebelowthecarinaatthe12o’clockpositionontheCTscan.Whenthepatientisbeingapproachedfrombehind,thelymphnodeisalsolocatedinthe12o’clockpositionintherightmainbronchusonespacebelowthecarina.

Fig.7.7e Bronchoscopic view of the station 7 lymph node which is in the 9 o’clock position one intercartilage space below the carina in the right main bronchus.

Fig.7.7f Rotation of the bronchoscope 90° clockwise facilitates access to the station 7 lymph node.

Fig.7.7g Bronchoscopic view of the needle inserted into a station 7 lymph node with the scope rotated 90° clockwise.

Fig.7.7h Bronchoscopic view of the needle inserted into a station 7 lymph node in the 9 o’clock position with the scope in the neutral position.

Fig.7.8aCross-sectional CT scan of the thorax showing a station 10R lymph node.

Fig.7.8bCross-sectional CT scan with a superimposed clock face and a station 10R lymph node highlighted in yellow.

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Fig.7.8cCross-sectional CT scan of the thorax flipped on the vertical axis. The 10R lymph node is in the 12 o’clock position in the right main bronchus.

Fig.7.8eBronchoscopic view of the station 10R lymph node which is in the 12 o’clock position about one intercartilage space below the carina in the right main bronchus.

Fig.7.8dCoronal section of CT scan showing the vertical position of the station 10R lymph node which is usually one intercartilage space below the carina in the right main bronchus.

Fig.7.8fBronchoscopic view of the needle inserted into a 10R lymph node.

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Station10L:Leftmainbronchiallymphnode(Fig.7.9)Theleftmainbronchiallymphnodeislocatedontheanterioraspectoftheleftmainbronchusapproximatelyone interspacebelowthecarina in the12o’clockposition.Thisisnaturallythepositioninwhichthelymphnodeislocatedwhenthepatientisbeingbronchoscopedfrombehind.

Fig.7.9a Cross-sectional CT scan of the thorax showing a station 10L lymph node.

Fig.7.9bCross-sectional CT scan with a superimposed clock face and a station 10L lymph node highlighted in yellow in the 6 o’clock position.

Fig.7.9c Cross-sectional CT scan of the thorax flipped on the vertical axis. The 10L lymph node is in the 12 o’clock position.

Fig.7.9dCoronal section of CT scan showing the vertical position of the station 10L lymph node which is usually one intercartilage space below the carina.

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Station11Rs:Rightupperhilarlymphnode(Fig.7.10)TherightupperhilarnodeislocatedontheCTscanbetweentherightupperlobebronchusandthebronchusintermedius.OntheCTcross-sectionitrelatestothe9o’clockpositionjustbelowtheoriginofthebronchusintermedius.Atbronchoscopythisrelatestotheanteriorspuroftherightupperlobecarinaandtheoptimalapproachistoinserttheneedlejustbelowthespuroftheupperlobecarina.Whenthepatientisapproached frombehind, therighthilarnode is locatedat therightside towardsthe2–3o’clockpositionintheanteriorspuroftherightupperlobecarina.Itisintheproximalportionofthebronchusintermedius.

Fig.7.9eBronchoscopic view of the station 10L lymph node which is in the 12 o’clock position about one intercartilage space below the carina in the left main bronchus.

Fig.7.9fBronchoscopic view of the needle inserted into a 10L lymph node.

Fig.7.10aCross-sectional CT scan of the thorax showing a station 11Rs (right upper hilar) lymph node.

Fig.7.10bCross-sectional CT scan with a superimposed clock face and a station 11Rs (right upper hilar) lymph node highlighted in yellow.

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Fig.7.10cCross-sectional CT scan of the thorax flipped on the vertical axis. The station 11Rs (right upper hilar) lymph node is in the 2–3 o’clock position.

Fig.7.10dCoronal section of CT scan showing the vertical position of the station 11Rs (right upper hilar) lymph node, which is usually located at the right upper lobe carina.

Fig.7.10eBronchoscopic view of the station 11Rs (right upper hilar) lymph node which is in the 2–3 o’clock position in the anterior spur of the right upper lobe carina.

Fig.7.10fRotation of the bronchoscope by 90° anticlockwise facilitates access to the station 11Rs (right upper hilar) lymph node.

Fig.7.10gBronchoscopic view of the needle inserted into a station 11Rs (right upper hilar) lymph node with the scope rotated 90° anticlockwise.

Fig.7.10hBronchoscopic view of the needle inserted into a station 11Rs (right upper hilar) lymph node in the 2–3 o’clock position with the scope in the neutral position.

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Station11R:Rightlowerhilarlymphnode(Fig.7.11)OntheCTscantheright lowerhilar lymphnodeis locatedlateraltothebronchusintermedius in the 9 o’clock position at the level of the right middle lobe. Atbronchoscopy theneedle shouldbe inserted in the3o’clockposition in thedistalaspectofthebronchusintermediusattheleveloftherightmiddlelobeorigin.

Fig.7.11a Cross-sectional CT scan of the thorax showing a station 11Ri (right lower hilar) lymph node.

Fig.7.11c Cross-sectional CT scan of the thorax flipped on the vertical axis. The station 11Ri (right lower hilar) lymph node is in the 3 o’clock position.

Fig.7.11d Coronal section of CT scan showing the vertical position of the station 11Ri (right lower hilar) lymph node, which is usually just higher than the right middle lobe origin.

Fig.7.11b Cross-sectional CT scan with a superimposed clock face and a station 11Ri (right lower hilar) lymph node highlighted in yellow.

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Station11L:Lefthilarlymphnode(Fig.7.12)Thestation11Lorlefthilarlymphnodeislocatedatthebifurcationoftheleftmainbronchus.Itisaccessedfromtheleftlowerlobetowardstheupperlobe.Theneedleisinsertedintothe11–12o’clockpositionfromtheleftlowertotheleftupperlobe.

Fig.7.11e Bronchoscopic view of the station 11Ri (right lower hilar) lymph node, which is in the 3 o’clock position in the bronchus intermedius just above the origin of the right middle lobe.

Fig.7.11f Rotation of the bronchoscope 90° anticlockwise facilitates access to the station 11Ri (right lower hilar) lymph node.

Fig.7.11g Bronchoscopic view of the needle inserted into a station 11Ri (right lower hilar) lymph node with the scope rotated 90° anticlockwise.

Fig.7.11h Bronchoscopic view of the needle inserted into a station 11Ri (right lower hilar) lymph node in the 3 o’clock position with the scope in the neutral position.

Fig.7.12a Cross-sectional CT scan of the thorax showing a station 11L lymph node.

Fig.7.12bCross-sectional CT scan with a superimposed clock face and a station 11L lymph node highlighted in yellow.

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Fig.7.12c Cross-sectional CT scan of the thorax flipped on the horizontal axis. The 11L lymph node is in the 11–12 o’clock position.

Fig.7.12e Bronchoscopic view of the station 11L lymph node which is in the 11–12 o’clock position about one intercartilage space above the carina.

Fig.7.12fBronchoscopic view of the needle inserted into an 11L lymph node in the 11–12 o’clock position.

Fig.7.12d Coronal section of CT scan showing the vertical position of the station 11L lymph node, which is usually at level of the carina between the left upper and lower lobe.

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CHAPTER

8Endobronchial ultrasound

bronchoscopyEndobronchial ultrasound is usually performed using the oral approach with thepatient lying supine and approached frombehind.The currentOlympus ultrasoundbronchoscopehasanoffsetviewingchip (Fig.8.1).Hence itdoesnothaveadirectend-onviewasinmostbronchoscopes,withimagesoffsetintheupwarddirectionof30°.Hencealittlepracticeisrequiredtolearnhowtomanipulatethebronchoscope,especiallyduringtheintubationphase.

Theultrasoundimageobtainedcanbeimprovedbyapplyingawater-filledballoontotheultrasoundtransducer.Thiscanbeattachedontothedistalendoftheendobronchialultrasoundbronchoscopewithaspecificapplicator.Thiswater-filledballoonimprovestheacousticcontactbutairbubbleswithinitmaycausesomeartefacts.

Fig.8.1bDistal tip of the endobronchial with offset video chip.

Fig.8.1aEndobronchial ultrasound bronchoscope.

Fig.8.1fArtefact on ultrasound image due to air bubbles within the water-filled balloon.

Fig.8.1eDistal view with air bubble visible within the water-filled balloon.

Fig.8.1dDistal view of the endobronchial ultrasound bronchoscope with water-filled balloon in place.

Fig.8.1cBalloon and applicator.

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IntubationDuringintubationtheidealviewobtainedofthecordsissuchthatonlythetopofthevocalcordsare inviewandthecuneiformandcorniculatetuberclesarenotvisible.Toobtain a full viewof the cords, the scopeneeds tobe angulateddown (thumbup)(Fig.8.2).However,thescopeshouldnotbeadvancedforwardinthisangulatedposition.Thescopewouldsimplymeetresistanceagainsttheepiglottisinthisposition.Thecordsareprepared for intubation in the standardmannerwith theapplicationoftwotothreealiquotsof1mLof2percentlidocaine.Furtheraliquotsoflidocaineare applied to the tracheaandmainbronchus after intubation.The imageobtainedwith theultrasoundbronchoscope is intended for intubationorientationwithin theairway. Although some diagnostic information is obtained, we would recommendusingaconventionalbronchoscopeforthesepurposesandthenusetheultrasoundbronchoscopeformediastinalsampling.

Fig.8.2aBronchoscopic image of the vocal cords: with the scope straight.

Fig.8.2bBronchoscopic image of the vocal cords: with the scope angled down.

Fig.8.2cBronchoscopic image: with endobronchial ultrasound bronchoscope.

Fig.8.2dBronchoscopic image: with video bronchoscope.

ExaminationapproachOurapproachistosystematicallyexamineallthelymphnodestations.Additionalareaswhichhavebeen identifiedonapositronemissiontomography(PET)orcomputedtomography(CT)scanshouldalsobecarefullyexamined.Wewouldrecommendfirstidentifyingtheaorticarchwhichislocatedatthemid-trachealevelontheleftlateralwallofthetrachea(Fig.8.3).

Abovetheaorticarcharestation2lymphnodes,andanyparatracheallymphnodesidentifiedbelow the aortic arch are station4 lymphnodes. So after identifying theaortic arch, the scope should be gently applied to the trachea wall and the moreproximal tracheaexaminedonbothsidesup to thesubglottic level tocheck if anystation2lymphnodesarevisible.Thebronchoscopeisthenrotatedbyabout150°–180°clockwiseand the rightparatrachealarea (station2R)examined.Thescope ismovedgentlydownuntilthebrachiocephalicveinisvisible.Thisdenotesthelowerlimitofstation2Randanynodesbelowthisareaarestation4lymphnodes.

Duringexaminationoftherightparatrachealarea(station4R),thesuperiorvenacavaandtheazygosveinshouldbeidentified.Thelowerlimitofstation4Risdenotedbytheazygosvein.Thescopeisthenmovedanteriorlyjustatthelevelofthecarinaandthepulmonarytrunkandtheanteriorcarinallymphnodes(station4R)areexamined.The scope is then further rotated anticlockwise towards the left lateralwallof thetracheaatthelevelofthecarina.Firsttheascendingaortaisvisualizedandsubsequentlytheleftparatracheallymphnodearea(station4L)andthenthepulmonaryartery.

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Thescopeisalsorunalongthelengthoftheposteriorwallofthetracheatolookforstation3plymphnodes.Thescopeisthenmanoeuvredontothemedialoftherightmainbronchustoexaminethesubcarinallymphnodes(station7).

Theendobronchialscopeisrotatedby90°clockwiseintherightmainbronchussothatitisfacingthe12o’clockpositiontoexaminetherighthilarlymphnodes(station10R).Followingthis,thescopeismovedtotheproximalaspectofthebronchusintermediusand the carina between the right upper lobe and the bronchus intermedius isexamined.Therightsuperiorhilarnodes(station11Rs)arelocatedinthisposition.Thebronchoscopeisthenrotatedanticlockwiseby150°toexaminethesubcarinallymphnodes(station7),extendingdowntothedistalmarginofthebronchusintermedius.Attheleveloftherightmiddlelobethescopeisagainrotated150°clockwiseontothelateralaspectofthebronchusintermedius,wheretherightinferiorhilar(station11Ri)islocated.

Thescopeisthenretractedbacktothecarinaandtheleftsideexamined.Clockwiserotationby90°andexaminationofthemedialaspectoftheleftmainbronchusallowstation7tobeexaminedfromtheleftside.Thescopecanthenberotatedback90°anticlockwisetoevaluatethelefthilarlymphnodes(station10L).Finally,thescopeisappliedtothecarinabetweentheleftlowerandupperlobedivisions.Theleftinterlobarlymphnodestation(11L)islocatedatthissite.

With endobronchial ultrasound, a key skill to acquire is navigation using ultrasoundimages.Theanatomicallandmarkshouldbeusedwhilelearningtheultrasoundanatomy.The combination of the endobronchial landmarks, location of blood vessels andultrasoundimagesshouldallowaccuratecharacterizationofthelymphnodelocationandassignmenttoaspecificlymphnodestation.Withthissystematicapproach,allthelymphnodelocationsadjacenttotheendobronchialtreecanbeevaluatedforaccuratestaging.Thesizeandlocationofallthelymphnodesshouldberecorded.Anylymphnodes>5mminsizeorwithabnormalfeatures(moreroundedappearance,lossoflargecentralbloodvessels)shouldbesampled.

Fig.8.3aUltrasound appearance of the aortic arch. Fig.8.3bBronchoscopic view of the trachea with the left lateral wall marked corresponding to the aortic arch.

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LymphnodestationsItispossibletosampleanyofthelymphnodesthatareadjacenttotheairwaysusingtransbronchialfineneedleaspiration(TBNA).ThelymphnodesstationsaredescribedaccordingtothenewInternationaIAssociationfortheStudyofLungCancerclassification.

●● Superior mediastinal lymph nodes: upper zoneStation2R:Higherrightparatracheallymphnode(Fig.8.4)Theuppermarginofstation2Risdifficulttodefineatendobronchialultrasoundbutisprimarilyattheleveloftheclavicle.Thelowerborderisdefinedbytheinferioraspectof the left brachiocephalic vein crossing the trachea.Anterolateral in this area, therightsubclavianarteryandrightcommoncarotidarteryarevisibleonendobronchialultrasound.More anterior to theseblood vessels are the right brachiocephalic veinandtherightexternaljugularvein.Theendobronchialpositionisdifficulttoestimateaccuratelybutisaboutone-thirdofthedistanceofthetracheafromthevocalcords.

Fig.8.4aCross-sectional CT scan of the thorax showing a station 2R lymph node.

Fig.8.4cCoronal 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.8.4bCross-sectional CT scan flipped left to right with the station 2R lymph node highlighted in blue.

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

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rt common carotid artery

rt subclavian artery

LN

external jugular vein

rt common carotid artery

rt subclavian artery

LN

jugular vein

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

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Station2L:Higherleftparatracheallymphnode(Fig.8.5)Theupperborderofstation2Lisdefinedagainbytheclavicleandhenceisdifficulttodefineatendobronchialultrasound.Thelowerborderisdeterminedbytheaorticarch.Ontheleftanterolateralaspectsthecommoncarotidandtheleftjugularveinarevisible.

rt common carotid artery

LN

jugular vein

Fig.8.5aCross-sectional CT scan of the thorax showing a station 2L lymph node.

Fig.8.5eUltrasound image of the station 2L lymph node.

Fig.8.5dBronchoscopic view of where the ultrasound probe should be placed to view the station 2L lymph nodes highlighted.

Fig.8.5cCoronal section of CT scan showing the 2L lymph node. Note the node is above the level of the aortic arch.

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

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Station3A:Anteriorprevascularlymphnode(Fig.8.6)Theupperborderisdemarcatedbytheclavicleandthelowerborderbythecarina,whichisvisibleontheendobronchialimage.Thesenodesareusuallylocatedanteriortothegreatvessels,i.e.theleftcommoncarotidandsubclavianartery,andhencecannotbesampledbyendobronchialultrasound.

lt common carotid artery

LN

jugular vein

Fig.8.6eUltrasound image of the station 3a lymph node.

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

Fig.8.6cCoronal section of CT scan showing the station 3a lymph node.

Fig.8.6bCross-sectional CT scan flipped left to right with the station 3a lymph node highlighted.

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

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Station3P:Posteriortracheallymphnode(Fig.8.7)Theupperborderisattheleveloftheclavicleandthelowerborderisatthecarina,whichcanbeconfirmedbythebronchoscopicimage.Thesenodesarelocatedontheposterioraspectofthetrachea.

LN

lung

Fig.8.7aCross-sectional CT scan of the thorax showing a station 3p lymph node.

Fig.8.7bCross-sectional CT scan flipped left to right with the station 3p lymph node highlighted.

Fig.8.7cCoronal section of CT scan showing the station 3p lymph node.

Fig.8.7dBronchoscopic view of where the ultrasound probe should be placed to view the station 3p lymph nodes highlighted.

Fig.8.7eUltrasound image of the station 3p lymph node.

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Station4R:Lowerrightparatracheallymphnode(Fig.8.8)The upper border is identified on endobronchial ultrasound as the inferior marginofthebrachiocephalicveincrossingthetrachea.Thelowerborderisdefinedbytheazygosvein,whichshouldbeidentifiedatultrasound.

brachio-cepahlicartery

superior vena cavaLN

brachio-cephalic vein

brachio-cephalic

superior vena cava

LN

Fig.8.8aCross-sectional PET-CT scan of the thorax showing an active station 4R lymph node.

Fig.8.8bCross-sectional PET-CT scan flipped left to right with the active station 4R lymph node.

Fig.8.8cCoronal section of PET-CT scan showing the 4R lymph node.

Fig.8.8dBronchoscopic view of where the ultrasound probe should be placed to view the station 4R lymph nodes highlighted.

Fig.8.8eUltrasound image of the station 4R lymph node with the brachiocephalic vein demarcating the border between stations 4R and 2R.

Fig.8.8fUltrasound image of the station 4R lymph node.

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LN

superior vena cava

azygos

azygos

superior vena cava

azygos vein LN

superior vena cava

azygos vein

superior vena cava

azygos

superior vena cava

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

Fig.8.8hUltrasound image of the station 4R lymph node with the azygos vein demarcating the border between station 4R and 10R lymph nodes.

Fig.8.8iUltrasound image of the azygos vein. Fig.8.8jUltrasound image of the azygos vein at a lower level with the superior vena cava visible distally.

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

Fig.8.8kUltrasound image of the azygos vein a few mm further distal.

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Fig.8.8oCoronal CT scan of the thorax showing an anterior carinal lymph node (station 4R lymph node).

Fig.8.8pBronchoscopic view of where the ultrasound probe should be placed to view the station 4R (anterior carinal node) lymph nodes highlighted.

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

Fig.8.8rUltrasound image of the station 4R (anterior carinal, acn) lymph node with the aorta visible just inferiorly.

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

Fig.8.8mFurther example of cross-sectional CT scan of the thorax showing a station 4R lymph node (anterior carinal lymph node).

acn LN

aorta

acn LN

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Station4L:Lowerleftparatracheallymphnode(Fig.8.9)Thelocationofthelymphnodeisbetweentheascendingaortaandthepulmonarytrunk.Theupperborder isdefinedbytheaorticarchandthe lowerborderby thepulmonaryartery.Theclassicalimagevisibleatultrasoundconsistsofthelymphnodeidentifiedinbetweentheaortawhichisontherightoftheimageandthepulmonaryarteryontheleftoftheimage.Thebronchoscopiclocationofthisstationistheleftlateralaspectofthetracheaatthelevelofthecarinaoronespaceabovethecarina.

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

Fig.8.9bCross-sectional PET-CT scan flipped left to right with the active station 4L lymph node.

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

aorta

acn LN

The4Rlymphnodeislocatedanterolateraltothetrachea,uptotheleftlateralborderof the trachea. In the classical right paratracheal position, the superior vena cava isvisibleperipheraltothelymphnode.Asyoumoveanteriorlytowardsthecarina,theascendingaortaalsobecomesvisible.

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LN

41 LN

aorta

4L LN

aorta

pulmonary trunk

4L LN

aortapulmonary trunk

aorta

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

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

Fig.8.9eUltrasound images of the station 4L lymph nodes.

Fig.8.9gUltrasound images of the station 4L lymph nodes with the aorta visible superior to, and the pulmonary trunk on the inferior aspect of, the nodes.

Fig.8.9fUltrasound images of the station 4L lymph nodes with the aorta visible superior and distal to the nodes.

Fig.8.9hUltrasound images of the station 4L lymph nodes with a greater portion of the pulmonary trunk visible.

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Station5:Aortopulmonarylymphnodes(Fig.8.10)Station 5 can be visualized on endobronchial ultrasound but cannot routinely besampled.Thenodesarelocatedbetweentheaortaandthepulmonaryarterylateraltotheligamentumarteriosum.Onendobronchialultrasound,thelymphnodeappearstobelyingmoreperipheraltothepulmonaryartery.

aorta

pulmonary artery

station 5 lymph node

Fig.8.10aCross-sectional CT scan of the thorax showing a station 5 lymph node.

Fig.8.10bCross-sectional CT scan flipped left to right with the active station 5 lymph node highlighted.

Fig.8.10cCoronal section of CT scan showing the station 5 lymph node highlighted.

Fig.8.10dBronchoscopic view of where the ultrasound probe should be placed to view the station 5 lymph nodes highlighted.

Fig.8.10eUltrasound image of the station 5 lymph node visible distal to the pulmonary artery. The aorta is partly visible superiorly.

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Station6:Para-aorticlymphnodes(Fig.8.11)Thepara-aorticlymphnodes,orstation6,maybevisibleonendobronchialultrasoundon the outer aspect of the ascending aorta and aortic arch, but again cannot beroutinelysampled.Thedepthofultrasoundmayneedtobeincreasedand,consequently,degradationoftheimagequalitymaymakeitdifficulttovisualizetheselymphnodes.

Fig.8.11aCross-sectional CT scan of the thorax showing a station 6 lymph node.

Fig.8.11bCross-sectional CT scan flipped left to right with the active station 6 lymph node highlighted.

Fig.8.11cCoronal section of PET-CT scan showing the station 6 lymph node.

Fig.8.11dBronchoscopic view of where the ultrasound probe should be placed to view the station 6 lymph nodes highlighted.

Fig.8.11eUltrasound image of the station 6 lymph node.

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●● Inferior mediastinal lymph nodesStation7:Subcarinallymphnode(Fig.8.12)The borders of station 7 are more clearly defined by the bronchoscopic view. Itrepresents the nodal area inferior to the carina and down to the level where therightmiddlelobebronchusoriginatesontherightsideandthesecondarycarinaontheleftside.Theultrasoundtransducermaybeappliedtothemedialaspectofeithertherightortheleftmainbronchus.Atthislevel,anteriormovementofthetransducerdemonstratesthepulmonaryarteryandpulmonarytrunk.

oesophagus

station 7 LN

station 7 LN

oesophagus

Fig.8.12aCross-sectional PET-CT scan of the thorax showing a station 7 lymph node.

Fig.8.12bCross-sectional PET-CT scan flipped left to right with the active station 7 lymph node.

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

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

Fig.8.12eUltrasound image of the station 7 lymph node with its characteristic bean shape.

Fig.8.12fUltrasound image of the station 7 lymph node with the oesophagus visible distally.

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azygos

pulmonaryartery

10R LN

SVC

pulmonaryartery

10R LN

SVC

pulmonary artery

10R LN

SVC

●● Hilar zone lymph nodesStation10R:Rightmainbronchiallymphnode(Fig.8.13)Theselymphnodesarelocatedattherightmainbronchus.Theupperborderisdefinedbythepositionoftheazygosvein,whichshouldbeidentifiedonultrasound,andthelowermarginistheoriginoftherightupperlobebronchus,whichisidentifiedonthebroncho-scopicimage.Thetransducerisappliedontheanterioraspectoftherightmainbron-chusandslowlyadvanced.Onultrasoundthestructurethatisvisibleontheanterioraspectincludestherightpulmonaryarteryand,moreperipheraltothat,thesuperiorvenacava.

Fig.8.13aCross-sectional CT scan of the thorax showing a station 10R lymph node.

Fig.8.13bCross-sectional CT scan flipped left to right with the station 10R lymph node highlighted.

Fig.8.13cCoronal section of CT scan showing the 10R lymph node.

Fig.8.13dBronchoscopic view of where the ultrasound probe should be placed to view the station 10R lymph nodes highlighted.

Fig.8.13eUltrasound images of the station 10R lymph node: with the azygos visible, which delineates the border between station 4R and 10R.

Fig.8.13fUltrasound images of the station 10R lymph node: in a more central position.

Fig.8.13gUltrasound images of the station 10R lymph node: with the right pulmonary artery inferior and distal to the node.

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Station10L:Leftmainbronchiallymphnode(Fig.8.14)Thesearelymphnodeslocatedontheleftmainbronchus.Theupperborderisagainjustbelowthecarinaontheleftsideandonultrasoundimageisdefinedbythesuperioraspectof thepulmonaryartery.The lowermargin is indicatedby thebifurcationoftheleftmainbronchusintothesuperiorlobarbronchusandtheleftlowerlobe.Thetransducershouldusuallybeappliedtotheanterioraspectoftheleftmainbronchusandadvancedslowlydowntowardsthesecondarycarina.Thestructurevisibleanteriortotheleftmainbronchusconsistsoftheleftpulmonaryarteryandtrunk,andmoreinferiorly the left atriummayalsobevisible.On themedial aspectof the leftmainbronchus,thedescendingaortamayalsobevisible.

pulmonary trunk

10L LN

Fig.8.14aCross-sectional CT scan of the thorax showing a station 10L lymph node.

Fig.8.14bCross-sectional CT scan flipped left to right with the station 10L lymph node highlighted.

Fig.8.14cCoronal section of CT scan showing the 10L lymph node.

Fig.8.14dBronchoscopic view with the location of station 10L lymph nodes highlighted.

Fig.8.14eUltrasound image of the station 10L lymph node with the pulmonary artery more superior and distal to the nodes. The pulmonary artery demarcates the 4L and 10L nodes.

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Station11Rs:Rightsuperiorhilarlymphnode(Fig.8.15)Thesearelocatedattheupperlobecarina.Theultrasoundtransducerisappliedjustbelowtheupperlobeorigininthebronchusintermedius.Superiortothe11Rlymphnode,therightupperlobebronchusandpulmonaryarterymaybevisible. Inferiorlythepulmonaryarterybranchand,moredistally,therightpulmonaryveinandsuperiorvenacavaarevisible.

superior vena cava

pulmonaryartery

11Rs LN

superior vena cava

rt pulmonary artery

11Rs LN

pulmonary vein

Fig.8.15aCross-sectional PET-CT scan of the thorax showing a station 11Rs (right upper hilar) lymph node.

Fig.8.15bCross-sectional PET-CT scan of the thorax flipped left to right showing the station 11Rs lymph node.

Fig.8.15cCoronal section of PET-CT scan showing the 11Rs lymph node.

Fig.8.15dBronchoscopic view of where the ultrasound probe should be placed to view the station 11Rs lymph nodes highlighted.

Fig.8.15eUltrasound images of the station 11Rs lymph node: with the superior vena cava visible superior and distal to the nodes.

Fig.8.15fUltrasound images of the station 11Rs lymph node: with the right pulmonary artery and vein visible inferior to the nodes.

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Station11Ri:Rightinferiorhilarlymphnode(Fig.8.16)Thesenodesare locatedat thedistalaspectof thebronchus intermedius.Theyarelateraltotherightmiddlelobe;anteriorlyatthisleveltheleftatriumandrightpulmonaryveinarevisibleontheultrasoundimages.

pulmonary vein

11r Inf LN

pulmonary veinleading to left atrium

descending branch ofpulmonary artery

11r Inf LN

Fig.8.16aCross-sectional PET-CT scan of the thorax showing a station 11Ri (right lower hilar) lymph node.

Fig.8.16bCross-sectional PET-CT scan of the thorax flipped left to right showing the station 11Ri lymph node.

Fig.8.16cCoronal section of PET-CT scan showing the 11Ri lymph node.

Fig.8.16dBronchoscopic view of where the ultrasound probe should be placed to view the station 11Ri lymph nodes highlighted.

Fig.8.16eUltrasound image of the station 11Ri lymph node.

Fig.8.16fStation 11Ri lymph node with the pulmonary vein which leads to the left atrium.

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Station11L:Lefthilarlymphnode(Fig.8.17)Thesenodesareatthesecondarycarinaontheleftsidebetweentheleftlowerlobeandtheleftupperlobebronchus.Theleftpulmonaryarteryandleftpulmonaryveinsareusuallyvisibleanteriorlyinthislocation.

Left pulmonaryartery

pulmonaryvein

11L LN

left pulmonaryartery

11L LN

Fig.8.17aCross-sectional PET-CT scan of the thorax showing a station 11L lymph node.

Fig.8.17bCross-sectional PET-CT scan of the thorax flipped left to right showing a station 11L lymph node.

Fig.8.17cCoronal section of PET-CT scan showing the 11L lymph node.

Fig.8.17dBronchoscopic view of where the ultrasound probe should be placed to view the station 11L lymph nodes highlighted.

Fig.8.17eUltrasound images of the station 11L lymph node: with left pulmonary artery and left upper lobe bronchus more superior.

Fig.8.17fUltrasound images of the station 11L lymph node: with the lingular bronchus visible inferior to the node.

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LymphnodesamplingAsinconventionalTBNA,thehighestlymphnodestationsshouldbesampled,i.e.anycontralateralhilarormediastinallymphnodes(N3stationlymphnodes)followedbyN2lymphnodesandfinallyanyhilarlymphnodes.AnyparatrachealtumourmassescanalsobesampledbutshouldbesampledonlyafteranyvisibleN3orN2lymphnodeshavebeensampled.Thisminimizestheriskoffalse-positiveresultstoalmostzeroandpreventsfalselyupstagingapatientwithlungcancer.Onlytherecommendedneedlesshouldbeusedwithultrasoundbronchoscope–theyarespeciallydesignedforthebronchoscopeandtheuseofalternativeneedlesmayleadtopunctureoftheworkingchannelofthisveryexpensiveinstrument.

●● TechniqueTheneedlelengthandpositioncanbesetpriortoinsertionofthebronchoscopeintothepatient.However,werecommendverifyingthattheneedlesheathisvisibleoutsidethe instrumentchannelbronchoscopeeachtimetheneedle is insertedthroughtheworkingchannelofthebronchoscopeandpriortoanyneedleaspiration.Theneedleshould be fixed in position so that a small crescent of the sheath is visible on theendotracheal image (Fig. 8.18).This will minimize instrument channel damage andsignificantlyprolongthelifeandserviceofyourultrasoundbronchoscope.

Fig.8.18aSpecific needle for the Olympus endobronchial bronchoscope.

Fig.8.18bClose-up of the handle of the needle showing the mechanism for the adjustment of the needle sheath.

Fig.8.18cBronchoscopic image showing the small crescent of the sheath which should be visible prior to attempted needle aspiration. This shows the ideal position.

Fig.8.18dBronchoscopic image showing the significant length of the visible sheath. This greater distance may impair acoustic contact and hence the ultrasound image.

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Theneedleshouldbeintroducedintothebronchoscopestraightintothetrachea.Theneedletipshouldbeadjustedsothataverysmallcrescentisvisibleintheendoscopicimageonthetopright-handcorner.Oncethelymphnodeormassisidentifiedintheultrasoundfield,anassistantisaskedtosecurethebronchoscopeandholditinposition.Thecentralstyletisthenwithdrawnabout3mmsothattheneedlepointissharp.Thesafetylockfortheneedleis loweredtotherequireddistanceandtheneedlegentlyinsertedthroughtheairwaywallwhilstmaintainingtheultrasoundimageatalltimes(Figs8.19and8.20).Oncetheneedleisthroughtheairwaywallintothelymphnode,thestyletisjiggledbackandforthinordertoremoveanycartilageorairwaywallplugfromtheneedle.Thestyletisthenremovedandtheaspirationsyringeconnected.Thesyringeispresetwithsuctionand,providingitiswithinthelymphnode,thethree-waytapisopenedandtheneedlemovedgentlybackandforththroughthelymphnode.Thisallowscellularmaterialfromthelymphnodetobeaspirated.Thebronchoscopecanbegentlymanipulatedsothatmaterialfromdifferentpartsofthelymphnodeisaspirated.Thethree-waytapisthenclosedandtheneedlewithdrawnbackintothesheathandtheneedleremoved.

Fig.8.19dEndobronchial ultrasound bronchoscope with the suction off on the attached syringe and the needle withdrawn back.

Fig.8.19aEndobronchial ultrasound bronchoscope with the needle fixed in position on the scope.

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

Fig.8.19cEndobronchial ultrasound bronchoscope with the needle protruding out, syringe attached distally and suction on. The needle is then gently pushed back and forth in the lymph node.

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The material that has been aspirated in the needle can be either smeared on toslidesorfixedorinjectedintosalineforliquidcytologymedia(Fig.8.21).Youshoulddiscussthepreparationwithyourpathologistssothatsamplesthataresuitedtothelocal practice are collected. Placing the cellular material in saline or liquid cytologymedia allows more professional slides to be prepared and furthermore allows thematerialtobespundownintoacellpelletwhichcanbefurtherevaluatedbyhistology.Immunohistochemistrycanalsobeperformedonthecellblockstooptimallyclassifyanymalignantcellsidentifiedandalsocharacterizethegenotypeinthebiopsymaterial.

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

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

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

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Fig.8.21aLymph node aspirate is injected on to a glass slide.

Fig.8.21bGlass slide with cellular material from lymph node aspiration.

Fig.8.21cThe glass slide with cellular material is gently apposed to another glass slide and then slid apart to create a thin smear on the slide.

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CHAPTER

9PathologyThis chapter consists mainly of bronchoscopic images of the various pathologicalconditionsencounteredduringbronchoscopy.Thesectionscoverpathologyseenonthevocalcordsthroughtothetrachea,lobarbronchiandbronchialsegments.

Fig.9.1aCandida plaques on vocal cords in a patient on inhaled steroids.

Fig.9.1dSquamous cell carcinoma involving the vocal cords.

Fig.9.1gSevere Kaposi’s sarcoma involving vocal cord.

Fig.9.1bParalysed left vocal cord. Note the left vocal cord is in the midline position.

Fig.9.1eVocal cords infiltrated by amyloid (primary tracheobronchial amyloid, AL type).

Fig.9.1cVocal cord polyp.

Fig.9.1fLimited Kaposi’s sarcoma involving vocal cord.

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Fig.9.2aDistorted trachea with deviation of the upper trachea towards the right with the tracheal web in the distal aspect.

Fig.9.2bTracheal web. Fig.9.2cAdenocarcinoma of the trachea.

Fig.9.2dAdenocystic carcinoma involving the trachea.

Fig.9.2ePoorly differentiated carcinoma infiltrating through the mid-trachea.

Fig.9.2fTracheo-oesophageal fistula in a patient with oesophageal carcinoma undergoing radiotherapy.

Fig.9.2gSome cartilage nodules on the trachea in the anterior aspect.

Fig.9.2hTracheobronchopathia osteochondroplastica: acute inflammatory stage.

Fig.9.2iTracheobronchopathia osteochondroplastica: chronic stage with thickening of the cartilaginous portions of the trachea.

Fig.9.2jSabre trachea. Fig.9.2kTracheobronchial amyloid with greater involvement of the anterior aspect of the trachea.

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Fig.9.3aTumour (renal cell carcinoma) involving the carina and almost completely occluding both main bronchi.

Fig.9.3bExtrinsic tumour circumferential involving the right main bronchus at the level of the carina.

Fig.9.3cWidening of the carina due to tumour involving the subcarinal lymph node. Note the infiltration of the mucosa in the medial aspect of the right main bronchus.

Fig.9.3dWidening of the carina and complete occlusion of the left main bronchus by tumour.

Fig.9.3eTracheobronchial amyloid involving the carina. Note the thickened nodular plaque-like aggregations.

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Fig.9.4aPolypoid non-small-cell carcinoma originating from the right upper lobe and occluding the right main bronchus.

Fig.9.4bInvasive squamous cell carcinoma originating from the posterior wall of the right main bronchus.

Fig.9.4cCircumferential tumour (adenocarcinoma) occluding the right lower lobe bronchus.

Fig.9.4dSegmental tumour (adenocarcinoma) occluding the anterior segment (RB3) of the right upper lobe.

Fig.9.4eConcentric segmental tumour (adenocarcinoma) involving the lateral segment of the left lower lobe (LB9).

Fig.9.4fPolypoid non-small cell carcinoma originating from the apical segment of the right upper lobe (RB1).

Fig.9.4gSmall cell carcinoma occluding the right upper lobe.

Fig.9.4hDiffuse infiltrative carcinoma involving the left main bronchus.

Fig.9.4iExtrinsic compression of the right upper lobe from extrabronchial tumour.

Fig.9.4jExtrinsic tumour bulging and partly occluding the apical segment of the right upper lobe (RB6).

Fig.9.4kComplete occlusion of the apical segment of the left lower lobe (LB6) from an extrinsic tumour.

Fig.9.4lKaposi’s sarcoma involving secondary carina of the left lower lobe (LC2).

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

Fig.9.5cSquamous cell carcinoma involving the apical segment of the left lower lobe following treatment with radiotherapy. Note the increased inflammatory changes and increased capillary loops.

Fig.9.6eRenal cell carcinoma involving the left main bronchus.

Fig.9.6fHurthle cell carcinoma involving the segmental bronchus in the right middle lobe.

Fig.9.6gLeiomyosarcoma involving the lateral segment of the left lower lobe (LB9).

Fig.9.6hSquamous cell carcinoma from a metastatic head and neck carcinoma involving the left main bronchus.

Fig.9.6aMetastatic colorectal carcinoma involving the right basal bronchus.

Fig.9.6bMetastatic colonic carcinoma occluding the left main bronchus.

Fig.9.6cInfiltrating oesophageal adenocarcinoma involving the right main bronchus.

Fig.9.6dMetastatic endometrial carcinoma involving the left lower lobe.

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Fig.9.7aNodules giving a cobblestone appearance in the right lower lobe from sarcoid.

Fig.9.7bNodularity around the lower trachea due to tuberculosis.

Fig.9.7cTuberculous granuloma occluding the anterior segment of the right upper lobe (RB3).

Fig.9.7dAnthracosis (darkened) area in the medial aspect, which is occasionally seen in patients with pulmonary tuberculosis.

Fig.9.7eMucus originating from the segmental bronchus.

Fig.9.7fMucus plugging due to allergic bronchopulmonary aspergillosis.

Fig.9.7gConcentric narrowing of upper lobe segments in a patient with allergic bronchopulmonary aspergillosis.

Fig.9.7hPith-like lesions in the bronchus intermedius due to bronchocentric granulomatosis.

Fig.9.7iUlceration of pith-filled lesions after steroid treatment in a patient with bronchocentric granulomatosis.

Fig.9.7jGranulation tissue which has developed secondary to a foreign body.

Fig.9.7kForeign body (tooth) in the right main bronchus.

Fig.9.7lA tooth visible in the right lower lobe of a patient presenting with recurrent lobar pneumonia.

Fig.9.7mInflammatory pseudo-tumour.

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CHAPTER

10Fluorescence-based imagingAutofluorescencebronchoscopyAllepithelialtissuehasaninnatefluorescencebutthisisnotdiscerniblewithoutsomeenhancement.Withautofluorescencebronchoscopytheairwaysareilluminatedwithabluelight(395–445nm).Theautofluorescencesignal(550nm)isincorporatedinthevideoprocessorwiththeotherreflectedlighttoformacompositeimagewherenormaltissueappearsasgreen(fluorescenttissue).Anyreductioninfluorescenceshowsupasapinkthroughtomagentacolour.Bloodappearsdarkgreen(Fig.10.1).Careshouldbetakenasanymucusorsecretionsoverlyingtheepithelialtissueconcealthenormalfluorescentepithelialandfalselyappearpink.Autofluorescencebronchoscopyrequiresa special bronchoscope andusually themode canbe switched fromwhite light tofluorescencebysimplypressingaremotebuttononthebronchoscopeorafootpedal.

Fig.10.1aVideo bronchoscopy and fluorescence bronchoscopy image of the left lower lobe.

Fig.10.1bMucus secretions in the right middle lobe which appear pink and can be easily mistaken for an abnormal area.

Fig.10.1cLoss of fluorescence in the inflammatory nodule in the lower trachea.

Fig.10.1dAbnormal fluorescence of the left main carina showing subtle abnormality not visible on video bronchoscopy.

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Fluorescencebronchoscopyisusedprimarilyasaresearchtool.Insomecases,whereapatienthashadmultiple cancers (headandneckor lung cancer)orwhere therearemultipleareasoffieldeffect (patchychange inairways frommetaplasia throughto carcinoma in situ), the patients undergo regular fluorescence bronchoscopy forclinicalsurveillance.Thesepatientsmayundergorepeatedbronchoscopyoverseveralyears and possibly by several operators. Hence, careful documentation is essentialand standard nomenclature is required to describe the location and extent of theabnormalities(Fig.10.2).WewouldrecommenduseofnomenclatureasinChapter2.

Fig.10.1eBlood appears dark green on fluorescence bronchoscopy.

Fig.10.1fCartilage nodule in the right lower lobe segment with normal fluorescence.

Fig.10.1gInflammatory web with normal fluorescence in the left lower lobe.

Fig.10.2aThickening 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.

Fig.10.2bThickening 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.

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Fig.10.2cNodularity with abnormal fluorescence in the inferior aspect of the right upper lobe carina due to severe dysplasia.

Fig.10.2eAbnormal fluorescence of polypoid tumour in the apical segment of the left lower lobe.

Fig.10.2gTumour with abnormal fluorescence around the anterior segment of the right upper lobe.

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

Fig.10.2fTumour around the apical segment of the right upper lobe and some narrowing of the anterior segment of the right upper lobe.

Fig.10.2hRight lower lobe sleeve resection with nodularity which appears suspicious on white light but has normal fluorescence. Patchy abnormal fluorescence due to secretions.

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ConfocalmicroscopyConfocalendomicroscopyisafluorescence-basedimagingtechniquewhichilluminatestheairwaysorlungparenchymawithablueargonlaserlightatawavelengthof488nm.Theprobe,whichconsistsofabundleofopticalfibres,isinsertedthroughtheinstrumentchannelof thebronchoscope(Fig.10.3).Theprobecanbeapplied to theproximalairways for evaluating the trachea,main bronchi and bronchial segments (Fig. 10.4).Theelastin,whichisfoundinthebasementmembrane,providesinformationonthebronchialtree.Theprobecanbeeasilypassedintoasubsegmentandslowlyadvancedfromthelobularbronchustotheterminalbronchiole,therespiratorybronchioleandthentothealveolaracinus.Elastinisastructuralconnectivetissuecomponentofthealveolarwalls and theconfocalprobedetects thefluorescentelastin scaffoldof thelobuleusedtoimagetheproximalairwaysanddowntothealveoli.

Fig.10.3aCellvizio confocal microscopy system. Fig.10.3bConfocal probe.

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Fig.10.4gNormal blood vessel in alveoli.

Fig.10.4dConfocal probe inserted into the bronchial segment and into lung parenchyma.

Fig.10.4eConfocal microscopy image of a bronchiole.

Fig.10.4fNormal alveoli with elastin scaffolding visible with confocal microscopy.

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

Fig.10.4aConfocal probe applied on the airway segment.

Fig.10.4bConfocal microscopy images of the bronchial segments showing the lattice network of elastin in the basement membrane.

Fig.10.4cConfocal microscopy of a bronchial segment with an area without fluorescence due to a bronchial gland.

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Fig.10.5aLoss of fluorescence and reticular pattern due to a bronchial tumour (squamous cell carcinoma).

Fig.10.5bEdge of endobronchial tumour with some distortion of fluorescence pattern in the upper aspect and loss of fluorescence in the inferior aspect.

Fig.10.5dLoss of fluorescence from the alveolar architecture due to non-small cell lung cancer.

Fig.10.5cLoss of fluorescence from the alveolar architecture in bronchioloalveolar cell carcinoma.

Fig.10.6aConfocal microscopy in a patient with moderate emphysema. Note the large cystic spaces.

Fig.10.6bDisruption of elastin alveolar structure with large cystic areas in emphysema.

Lightradiatingbackfromthefluorescingtissuebetween500and650nmiscollectedat12frames/second.Thiscreatesahigh-qualityreal-timeimagewithadiameterfieldofviewof600µmbutadepthofpenetrationofapproximately50µmandalateralresolutionof3.5µm.ThisisadevelopingfieldandtheimagesshowninFigs10.5–10.8arefromtheearlyresearch.

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Fig.10.6cLarge bulla in a patient with severe emphysema with some remaining alveolar structure in the superior aspect.

Fig.10.6dFluorescent macrophages in the alveoli in a smoker with chronic obstructive pulmonary disease.

Fig.10.7aThickened interstitium and increased elastin network in interstitial pneumonitis (pulmonary fibrosis).

Fig.10.7dAbnormal spiral loops of elastin in a granuloma in a patient with sarcoidosis.

Fig.10.7gDrug-related hypersensitivity pneumonitis with normal elastin alveolar architecture and increased cellularity.

Fig.10.7bMarked increase in the elastin network with thickening of the alveoli in interstitial pneumonitis (pulmonary fibrosis).

Fig.10.7eFurther example of abnormal spiral loops of elastin in a granuloma due to sarcoidosis.

Fig.10.7cIncreased fluorescent cells and some thickening of the elastin network in pulmonary sarcoidosis.

Fig.10.7fIncreased fluorescent cells within normal elastin alveolar architecture in drug-related hypersensitivity pneumonitis.

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Fig.10.8aReduced fluorescence of alveolar architecture due to consolidation from pneumonia.

Fig.10.8dIncreased fluorescent cells adjacent to a blood vessel in organizing pneumonia.

Fig.10.8bAlveolar architecture obscured by cells with low fluorescence in pneumonia.

Fig.10.8cIncreased fluorescent cells in organizing pneumonia.

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CHAPTER

11Electromagnetic navigationThe superDimension® system (iLogic) is a real-time navigation system using anelectromagneticfieldtoaidnavigationtoaparticulartargetarea(Fig.11.1;theindicationsforitsusearegiveninBox11.1).

BOX11.1Indications for superDimension® navigation

●● Samplingofperipheralnodule●● Guidancefortransbronchialfine-needleaspirationofmediastinallymphnodes

andperibronchialmasses●● Targetedtransbronchialcryobiopsy●● Insertionoffiducialmarkersforstereotacticradiotherapyorcyberknife●● Insertionofmarkersforvideo-assistedthoracicsurgical(VATS)biopsy

Fig.11.1SuperDimension® system.

PlanningstageThe initial planning stage requires amulti-sliceCT scan (2mmwith at least1mmoverlap).TheCTisthenuploadedontoaplanningmodule.Avirtualbronchoscopyisperformedontheplanningmoduleandimportantlandmarkssuchasthemaincarina,rightupperlobecarina,rightmiddlelobecarina,leftmaincarinaandcarinabetweentheleftbasalsegmentsandtheapicalsegmentoftheleftlowerlobe(LC,LB6–LB8)aremarked(Fig.11.2).

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Fig.11.2aSuperDimension® CT planning module. Virtual bronchoscopy mode showing: carina.

Fig.11.2bSuperDimension® CT planning module. Virtual bronchoscopy mode showing: close-up of carina.

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Fig.11.2cSuperDimension® CT planning module. Virtual bronchoscopy mode showing: right upper lobe. (RC1)

Fig.11.2dSuperDimension® CT planning module. Virtual bronchoscopy mode showing: right middle lobe (RC2).

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Fig.11.2cSuperDimension® CT planning module. Virtual bronchoscopy mode showing: right upper lobe. (RC1) Fig.11.2eSuperDimension® CT planning module. Virtual bronchoscopy mode showing: left main carina (LC2).

Fig.11.2fSuperDimension® CT planning module. Virtual bronchoscopy mode showing: carina of the left apical basal segment (LC LB6–LB8).

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Fig.11.2gSuperDimension® CT planning module. Virtual bronchoscopy mode showing: the target located.

Thetargetareasarealsomarkedontheplanningmodule intheCTmodewithorwithoutintermediatemarkers(Fig.11.3).TheinformationfortheplanningmoduleisexportedandloadedontothesuperDimensionnavigationmodule.

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Fig.11.3aMarking of landmarks during virtual bronchoscopy on the superDimension® CT planning module:main carina.

Fig.11.3bMarking of landmarks during virtual bronchoscopy on the superDimension® CT planning module:right upper lobe carina (RC1).

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Fig.11.3cMarking of landmarks during virtual bronchoscopy on the superDimension® CT planning module:right middle lobe carina (RC2).

Fig.11.3dMarking of landmarks during virtual bronchoscopy on the superDimension® CT planning module:carina of the right apical basal segment marked (RC RB6–RB8).

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Fig.11.3eMarking of landmarks during virtual bronchoscopy on the superDimension® CT planning module:left secondary carina (LC2).

Fig.11.3fMarking of landmarks during virtual bronchoscopy on the superDimension® CT planning module:carina between the left apical basal (LB6) and basal segments (LC LB6–LB8).

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RegistrationprocessThebronchoscopyisperformedwiththepatientlyingflatonanelectromagneticboard(Fig.11.4).Thiscreatesamagneticfield,andtheelectromagnetictrackerplacedthroughthe instrumentchannelof thebronchoscopecanbeusedtodetect thepositionofthetipinthiselectromagneticfield.Thenavigationphaseinvolvesregisteringthesamelandmarksmarkedonthenavigationmoduleinthepatient.Themagnetictrackingguideisinsertedthroughthebronchoscope,andattheprocedurethesamelandmarksaremarked,i.e.themaincarina,therightupperlobecarina,themiddlelobecarina,theleftmaincarinaandthecarinabetweentheleftbasalsegmentsandtheapicalsegmentoftheleftlowerlobe(Fig.11.5).Thisisachievedbyapplyingthemagneticlocatorguideatthecarinaandusingafootpedaltomarkthispoint.Thesystemthencorrelatesthetwopiecesofdataandco-registerstheinformation.

Fig.11.5aRegistration 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.11.4Electromagnetic board with the field depicted with white arrows and the locatable guide as a black arrow moving through the field.

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Fig.11.5bRegistration 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.11.5cRegistration 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).

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Fig.11.5dRegistration 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.11.5eRegistration 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).

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Fig.11.5fRegistration 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.

The system calculates the error between the two pieces of data, i.e. computedtomography(CT)andpatientdata,andthelowerthesystemerror,themoreaccuratethenavigation.ThelatestversionofiLogic’ssoftwareautomaticallyco-registerstheCTandpatientdata.Thelocatableguideisinsertedthroughtheinstrumentchannelofthebronchoscopewith the tipprotruding.Thebronchoscope is thennavigatedthroughtheairwaysandduringthisprocessthesystemco-registersnumerousdatapoints,thusimprovingaccuracy.Thesystemalsoallowsthemanualregistrationprocessifrequired.

The locatable guide is manoeuvred to the target area using a steerable catheter(Fig.11.6).Thiscathetermovesin12differentdirectionswithadialonitshandle(akinto a clock face) that can be adjusted to different positions.The handle also allowsvaryingamountsofpressuretochangethedegreeofbendinthecatheter.

Fig.11.6bMovement of the steerable catheter in directions akin to a clock face: 2 o’clock direction.

Fig.11.6aMovement of the steerable catheter in directions akin to a clock face: 12 o’clock direction (note the position of the red arrow on the catheter handle).

Fig.11.6cMovement of the steerable catheter in directions akin to a clock face: 4 o’clock direction.

Fig.11.6dMovement of the steerable catheter in directions akin to a clock face: 11 o’clock direction (note the position of the red arrow on the catheter handle).

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NavigationAfter inserting the catheter with the locatable guide to the appropriate bronchialsegment, the navigation system can be used to guide it to the target location.Thesystemshowsthelocationoftheguideoncoronal,axialandsagittalCTsections(Fig.11.7).Thereisalsoascreenwhichadvisestheoperatorinwhichdirection,i.e.1o’clockor2o’clocketc.,tomanipulatethesteerablecatheter.A‘bull’seye’appearswhenthelocatable guide iswithin10mmof the target location.Once the target is reached,thecatheterislockedintoposition.Thescopeisheldfirmlyinposition,thelocatableguideisremovedandinstrumentssuchascytologybrushes,transbronchialneedlesandbiopsyforcepscanbepassedthroughthesteerablecatheterinordertoobtainsamplesfromthetargetlocation.Wherefacilitiesexist,radialultrasoundprobesorfluoroscopycanbeusedtoverifythelocationofthecathetertiporlocatableguide.

Fig.11.7aNavigation 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:10 o’clock position.

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Fig.11.7bNavigation 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.11.7cNavigation 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.

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Fig.11.7dNavigation 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 to the steering guide (orange circle).

Fig.11.7eNavigation 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 11 mm of the target site as indicated by green dot being close to the steering guide.

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●● Recent advancesWiththelatestiLogic™software,thenavigationmodulenowhassixpossiblescreenmodes.Itcreatesabronchialtreediagramwitharoutemaptothetarget.Aftertheregistrationprocess,thevirtualbronchoscopyimagedisplaysthepathwaytothetarget(Fig.11.8).Thisfacilitatesnavigationofthebronchoscopetothewedgeposition.FromthatpointonwardstheimagescanbesettodisplaytheclockfacewithCTsectionstoguidethesteerablecathetertothetargetsite.Aclose-upimagecanbeselectedwhenthelocatableguideiswithin10mmofthetargetsitetoguidetheoptimalpositionforsampling.

Fig.11.8aiLogic™ software module with three-dimensional bronchial tree.

Fig.11.8biLogic™ software with three-dimensional bronchial tree and route to the target highlighted in pink.

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Fordiagnosticpurposesitmaybemoreappropriatetosetatargetpointwhereanairwayisleadingintothelesion.Bycontrast,atargetareawheretheairwayispassinglateral to the lesion may be closer but less likely to have a diagnostic yield.Wheninsertingfiducialmarkersforradiotherapyorguidesforvideo-assistedthoracoscopicbiopsy,accuratepositioningofthemarkerswithinthelesionisnotnecessary.Placementoffiducialmarkersinthreedifferentspatiallocationswithin10mmofthenoduleortargetareaisacceptable.ThesuperDimension®navigationsystemcanalsobeusedtoplaceacatheterinamoredistallocationforbrachytherapy.

Fig.11.8cLatest 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.11.8dLatest iLogic™ software showing the six-screen mode with close-up CT views when the locatable guide is close to the target.

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CHAPTER

12Intubation and management

of airway haemorrhageIntubationAirway control is a primary skill that should be acquired by the interventionalbronchoscopist.As a safety precaution and to facilitate rapid, repeated insertionand removal of the bronchoscope, patients should be intubated prior to anyinterventionalproceduressuchastumourablationorstentinsertion.Asize8.5or9.0uncuffedendotrachealtubeisrecommendedinmenandasize8.0–8.5tubeinwomen.Theendotrachealtubeiscuttotheappropriatelength–usuallytotheoralmarkingsontheendotrachealtube–andplacedoverthebronchoscope(Fig.12.1).

An endotracheal tube with a Murphy eye may be useful in some circumstances.Dependingon theposition itmay allowventilationof the contralateral lungduringinterventionalprocedures.Furthermore,anydebrisortumourfragmentswouldthentendtofallbackintothelungbeingtreatedandnotintothecontralaterallung.

Fig.12.1aUncuffed endotracheal tube (size 8.0, full length 32 cm).

Fig.12.1bEndotracheal tube cut to marker for oral intubation (25 cm).

Fig.12.1cUncuffed endotracheal tube with Murphy eye slid over the distal aspect of the bronchoscope.

Fig.12.1dUncuffed endotracheal tube slid over to the proximal aspect of the bronchoscope.

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Anoralapproachispreferredandthebronchoscopewithanoverlyingendotrachealtubeisinsertedthroughaprotectivemouthpiece.Twoorthree2mLaliquotsof2percentlidocaineareappliedtothevocalcordsandthesubglotticregion.Thebronchoscopeispassedthroughthevocalcordandintothetrachea.Thepatientisaskedtotakeadeepbreathandtheendotrachealtubeisthencarefullyslidoverthebronchoscopeand through the vocal cords. Small rotationalmovements are occasionally requiredwhileadvancingtheendotrachealtube.

TheimagesinFigure12.2showthesequenceofstepsinvolvedinintubationfromtopicalapplicationof lidocainetothevocalcords throughto insertionof theendotrachealtubethroughthevocalcordsandintothetrachea.

Fig.12.2aSequence 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.

Fig.12.2bSequence of images demonstrating intubation: uncuffed endotracheal tube inserted through the vocal cords and into the trachea.

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

In our experience, with adequate topical anaesthesia patients have toleratedan endotracheal tube for up to 1 hour with minimal conscious sedation (0–5 mgmidazolamintravenously).Themaincautionistoavoidforcingtheendotrachealtubeagainstresistance,whichisoftenduetotheendotrachealtubebeingcaughtaroundtheepiglottisorthevocalcords.Forcefulinsertionmayleadtosometraumaofthevocalcords(Fig.12.3).

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Oncetheendotrachealtubeisinserted,theassistantshouldholdtheproximalportioninfrontofthepatient’smouthpiece.

Thekeyadvantagesofusinganendotrachealtubeisthatitoffersrapidandeasyaccessintotheairways,allowingthebronchoscopetobeinsertedandremovedatwillwithoutcausing any further inconvenience to the patient.This is particularly important forremovingpiecesoftumourduringdebulkingandallowsinsertionofotheraccessoriessuch as balloon blockers, which may be required in case of complications such asbleeding.Itprimarilyallowssafeairwaymanagementofthepatientduringinterventionalprocedures.

A laryngeal mask is an alternative option to endotracheal intubation. Oxygenationduring interventional procedures needs to be carefully managed. Hypoxia triggerscardiac arrhythmias and can increase the risk of complications. However, in certainprocedures,suchaslasertreatment,theinspiredoxygen(Fio2)shouldnotbegreaterthan 0.4.During suchprocedures, patientsmay need cyclical oxygen administrationfollowedbyshortperiodswhenthetreatmentisappliedwithalowerFio2.Weuseamaskwitharebreatherbagandcutoutapieceonthesideofthemaskwhichallowsaccesstotheendotrachealtubeandforthebronchoscopetopassinandout.

Fig.12.3aSequence of images showing common problems with intubation:endotracheal tube caught on arytenoid cartilage.

Fig.12.3bSequence of images showing common problems with intubation:endotracheal tube caught on corniculate cartilage.

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BallooncathetersBalloon catheters are used for a number of purposes, including collapse of a lungduringsurgery.Forourpurpose,theprimaryaimistoenableairwaycontrolofmassivehaemorrhage.

●● Cohen endobronchial balloon blockerTheCohenendobronchialballoonblockerhasatipthatcanbedeflected(Fig.12.4).Itcanbeinsertedthroughanadaptorwhichattachestothedistalendoftheendotrachealtube.Theballooncatheterisinsertedthroughtheside-angledportofthisadaptorandthroughtheendotrachealtubeintotherightorleftmainbronchus.Itnaturallytendstogodowntherightmainbronchusbutcanbemanipulatedorsteeredbyasmalldegreeinordertoplacetheballoonintheleftside.Thereisagaugeontheproximalendwhich,whenturned,pullsonan in-builtthread-wireandcausesthedistaltipofthecathetertobend(Fig.12.5).Theproximalanddistalaspectsof thecatheteraremarkedwithanarrowinthedirectioninwhichthetiptendstodeflect.Thereforetheblockershouldbeinsertedthroughtheendotrachealtubesothatthearrowsdenotingdirectionofdeflectionareintheappropriateposition.

Fig.12.4aCohen tip deflecting balloon catheter.

Fig.12.4bEndotracheal tube mount adaptor for use with balloon catheters.

Fig.12.4cEndotracheal tube mount adaptor with balloon catheter and bronchoscope in position.

Fig.12.5aCohen tip deflecting balloon catheter shown in various positions:neutral position.

Fig.12.5bCohen tip deflecting balloon catheter shown in various positions:dial moved by 45° anticlockwise causing a small deflection in the balloon tip.

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Fig.12.5cCohen tip deflecting balloon catheter shown in various positions:dial moved by 90° anticlockwise causing a deflection in the balloon tip.

Fig.12.5eCohen tip deflecting balloon catheter shown in various positions:inserted into the left main bronchus with the balloon inflated.

Fig.12.5dCohen tip deflecting balloon catheter shown in various positions:dial moved by 180° anticlockwise causing further deflection in the balloon tip.

Careful manipulation of the catheter and position of the patient’s head allows thecathetertobeintroducedintotheleftmainbronchus.Thispositionisoftenthemainbronchusbuttheballoonblockermaybeadvancedfurtherintoalobarbronchus.Theballooncanbeinflatedwithabout4mLofair.Theexactamountshouldbecheckedineachpatientpriortoproceedingwiththeinterventionalaspectoftheprocedure.Thecathetercanbelockedintopositionbytighteningthescrewfittingontheportoftheendotrachealtubeadaptorthroughwhichtheblockerwasintroduced.

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InsertionintotheleftmainbronchusThesequenceofimagesinFigures12.6and12.7showsinsertionoftheballooncatheterintothe leftmainbronchus.Occasionallytheballooncathetertiphasatendencytorepeatedly go down the right side and then catch on the cartilage rings or carina,preventingcorrectplacement.Figure12.8demonstratesthisproblemandalsohowitcanbeovercomebymanipulationoftheballoontipandapplyinggentletorsiontotheballooncatheter.Inflationoftheballoonmayalsohelpwhenaballoonispartlyinsertedintothedesiredairwaybutstuckonacartilagering.

Fig.12.6aSequences showing the insertion of a Cohen tip deflecting balloon catheter into the left main bronchus:inserted into the right main bronchus.

Fig.12.6bSequences 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.12.6cSequences 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.12.6dSequences 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.

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Fig.12.7cCohen tip deflecting balloon catheter: in the left main bronchus with the balloon being inflated.

Fig.12.7aCohen tip deflecting balloon catheter:being inserted via the endotracheal tube and into the lower trachea – the tip is directed into left main bronchus.

Fig.12.7bCohen tip deflecting balloon catheter: in the left main bronchus.

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Fig.12.8aSequence 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.12.8bSequence 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.12.8cSequence 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.12.8dSequence 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.

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Intheeventofsignificanthaemorrhageorbleedingduringtheinterventionalprocedure,theballooncanbeinflatedtoisolatethatlobeorsideofthelung.Thisprotectsthecontralateral lung from overspill of blood (which would affect its ventilation).Thetamponadeeffectalsohelpstocontrolthebleeding.Theballoon iskept inflatedforabout2minutesandthencarefullydeflated.Iffreshbleedingisstilloccurring,theballooncathetershouldbeinflatedforafurther2-minutecycle.

TheseriesofimagesinFigure12.9showstheproblemsofoverinflationorincorrectfixationoftheballoon.Thisemphasizestheneedtocheckplacementbyinflationoftheballoonpriortocommencingtheinterventionalprocedure.

Fig.12.9aSequence 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.

Fig.12.9bThe problem is corrected by inserting the balloon further into the left main bronchus.

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●● Arndt endobronchial balloon blockerTheArndtendobronchialballoonblockerhasasmalladjustableloopattheend.Thisisdesignedtobeusedinconjunctionwithasmall-calibrebronchoscope.Thekitcontainsamulti-portadaptorwhichshouldbeattachedtotheendotrachealtube(Fig.12.10).Theballoon shouldbe fully deflated and theendobronchial blocker lubricated. It isinsertedthroughtheangledportwhichisdesignedfortheblocker.Thecaponthisportcanbescreweddowntotightenthegriparoundtheblockerandloosenedtoallowgreatermanipulation.Theendobronchialblockerisadvanceduntilitisvisibleinthemid-portionoftheadaptor.Thebronchoscopeisthenadvancedthroughthecentralportandadvancedthroughtheloopontheendobronchialblocker.Theloopiscoupledtothebronchoscopebypullingbackonthesnareandcanalsobeloosenedbyreducingthetensiononthesnare.Oncetheloopistightenedaroundthebronchoscope,theendobronchialblockercanbeguidedtoanylobarbronchus(Fig.12.11).Onceinthecorrectposition, the snare shouldbe loosenedand thebronchoscopecan thenbewithdrawnleavingtheballoonblockerinposition.

Fig.12.10aArndt balloon catheter (note the loop on the distal tip).

Fig.12.10bArndt balloon catheter inserted through a multi-port adaptor.

Fig.12.10cArndt balloon catheter inserted through a mutli-port adaptor: note the position of the loop.

Fig.12.10dBronchoscope and Arndt blocker inserted through the mutli-port adaptor.

Fig.12.10eArndt balloon catheter inserted through a mutli-port adaptor: bronchoscope passed through the loop at the distal end of the Arndt catheter.

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Fig.12.11aArndt balloon catheter and bronchoscope: in neutral position in the trachea.

Fig.12.11bArndt balloon catheter and bronchoscope: being directed into left main bronchus.

Fig.12.11cArndt balloon catheter and bronchoscope: being directed into left main bronchus.

Fig.12.11dArndt balloon catheter and bronchoscope: positioned in the left main bronchus.

Fig.12.11eArndt balloon catheter and bronchoscope: bronchoscope being withdrawn after positioning the Arndt balloon catheter in the left main bronchus and inflating it.

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ManagementofairwaybleedingIce-coldsaline,adrenaline(1mLaliquotsof1:100000)andballooncathetersshouldbeavailablepriortoanyinterventionalprocedure.Intheeventofbleeding,thefirstkeyprincipleistoremaincalmandnottoremovethebronchoscopefromtheairways.Thescopeshouldbemovedmoreproximallyfromthesourceofbleedingandcontinuedsuctionappliedinordertomaintaintheairwaysfreeofblood.Suctioningalittlewayaway from the sourceof bleeding alsoensures that clot formation is not impaired.If thebleedingpersists, injecta fewmLofaliquotsof ice-coldsaline.Continuewithregularsuctioninordertoensureoptimalclearanceofanybloodwhichwillotherwiseaffectventilation.Ifthisisunsuccessfulandbleedingcontinues,instil1–2mLaliquotsof1:100000adrenaline.Followthisbyeffectivesuctionofanybloodthatcouldclotandoccludeadjacentairways(seethebleedingprotocolinBox12.1).

BOX12.1Bleeding protocol

Step1●● Keepbronchoscopethere●● Donotremovebronchoscope

– Suction,suction,suction– Coldsaline,coldsaline– Suction– Adrenaline– Suction– Adrenaline– Callforhelp

Step2●● Balloonblocker●● IfCohenblockerisreadyinairway,deployandinflate●● Ifnotinplace,useArndtballoonblocker(couplewithbronchoscopepriorto

insertionintotheairways)●● Suctionanybloodintheairwaysespeciallyinthecontralaterallung●● Deflateballoonafter2minutesandcheckifstillbleeding●● Ifstillbleeding,re-inflateandcontinuewithproximalsuctioning●● Ensureadequateventilationofthepatient●● Considerturningpatientontothesideofbleeding

Keypoints●● A–suction,airwaycontrol●● B–ventilatethroughendotrachealtubewithL-shapedadaptor●● C–Intravenousaccess,fluid,urgentcross-matchblood,freshfrozenplasma●● D–Considerturningpatientontothesideofbleeding

If thepatient is intubatedwith an endotracheal tube, consider insertionof a ballooncatheter;oriftheballooncatheterisalreadyinplacepriortotheinterventionalprocedure,inflatetheballoonandoccludethelobeoraffectedlung(Fig.12.12).Theballoonshouldbeinflatedforatleast2minutes.Duringthisperiodanybloodthathasspilledintothecontralaterallungshouldbesuctionedawaytoensureoptimalventilation.After2minutestheballoonisdeflatedslowly.Suctionismaintainedtoclearanyresidualblood,butcaremustbetakennottodislodgeorclearanyclotthathasbeenformedaroundthesiteofbleeding.Ifthereisstillpersistentbleedingthentheballoonshouldbereinflatedforafurther2-minutecycle.Thepatientcanalsobeturnedontothesideofbleedingtoenhancethetamponadeeffectandallowmaximalactivityoftheunaffectedlung.

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In the situationwhere there is spontaneousmassive bleeding and no endotrachealtube is inplace, it is importanttoretainthebronchoscope inpositionandmaintainsuction.Whereskillsexist,anattemptshouldbemadetointubatethepatienteitherviastandardlaryngoscopeorbysleevingitoverthebronchoscopeandthenunderdirectvision.Analternativeistousethevideolaryngoscope.Thisshouldbedoneasquicklyandefficientlyaspossibleimmediatelyafterintubation;anybloodthathasspilledintothenormalsideshouldbesuctionedandclearedfirst.

The easiest balloon to use is theArndt balloon.The balloon catheter is insertedthroughtheendotrachealtube,andbiopsyorgraspingforcepsareintroducedthroughtheworking channelof thebronchoscope.The forceps are thenused to grasp theballoonandtheballooncanthenbedirectedtowardsthelobarbronchus,fromwherethebleeding is originating.Theballoon is then inserted to tamponade thebleedingforatleast2–3minutes.Withpracticethistechniquecanbeutilizedveryquicklyandeffectively.

Alternatively the multi-port adaptor can be set up with theArndt balloon blockerandbronchoscope.Oncetheloopiscoupledwiththebronchoscope,theunitcanbeattachedtotheendotrachealtubeandmanipulatedtothetargetlobeinthepatient.Intheemergencysituation,itisquickertosimplyoccludethelungwherethebleedingisoriginating.Mortalityandmorbidityfromairwayhaemorrhageareusuallyduetolossofgasexchangeasaresultofthebloodclottingofftheairwaysbeforeexsanguinationbecomesafactor.Hence,ifyoublockoffthelungwhichisthesourceofthehaemorrhagethenyouprotecttheotherlungfromoverspillofbloodandconsequentocclusionoftheairways.Suctioningofanybloodthathasspilledoverintothenormalsidehelpstomaximizeoxygenationofthepatient.

Fig.12.12aActive 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.12.12bCohen 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.

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CHAPTER

13Endobronchial tumour debulkingCentralairwaytumourscausesignificantmorbidityandmortality.Theeffects includeairflowobstructionwithdyspnoea,haemoptysis,impairedclearanceofsecretionswithrepeatedinfectionsandpneumonia.Inpatientswhoareinoperableduetoadvanceddisease or significant comorbidity, active palliation by debulking the endobronchialtumour is an important aspect of treatment. Although there are no definitiverandomizedcontroltrials,tumourablationbyavarietyoftechniqueshasbeenshownto improvedyspnoea, reduce frequencyof haemoptysis, improvequality of life andpotentiallyimprovesurvival.

Avarietyoftechniquesareavailablefortumourdebulkingandthechoiceisdependenton local availability andexpertise.All the available techniques areof similar efficacy.Electrocautery or diathermy tends to be available in most endoscopy units and isrelativelyinexpensive.Similarly,cryotherapyequipmentisinexpensivecomparedtotheneodymium-yttriumaluminiumgarnet (Nd-Yag) laserwhichhasmuchhighercapitalandmaintenancecosts.Wepredominantlyuseelectrocauteryandamodifiedversionofcryotherapytermedcryoextraction–thesearethemainfocusofthischapter.

ElectrocauteryElectrocauteryordiathermyisanalternativetechniquefortumourablation.Itutilizeshigh-frequencyalternatingcurrent(10-5to10-7Hz)togenerateheatlocallyandinducecoagulationandtissuenecrosis.Low-frequencycurrentstimulatesnervesandmusclefibres and is thereforenot used.The resistancewithin a tissuewhere theelectricalcurrentisappliedleadstothegenerationofheat.Diathermyorelectrocauteryrequirestheuseof special insulatedflexiblebronchoscopes.Thepatientplate is required togroundthepatientandhencecompletethecircuit.Thisshouldbealargesurfacesuchasthebackofthethighinordertoeasilyconductelectricityaway.Poorconductionaroundthepatientplatewouldalsoleadtoheatgenerationandlocalburns.

Electrocauteryisperformedwithanumberofaccessories,suchasacoagulationprobe,snares,biopsyforcepsandacuttingknife(Fig.13.1).

Fig.13.1aElectrocautery accessories: coagulation probe.

Fig.13.1bElectrocautery accessories: hot biopsy forceps.

Fig.13.1cElectrocautery accessories: snare.

Fig.13.1dElectrocautery accessories: electrosurgical knife.

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Low-voltage,high-amperagecurrentleadstocoagulation,whereascuttinginvolveshighvoltage and low amperage.A blend of these two modes is used to achieve tissuedestructionwithcoagulation.Electrocauteryallowsrapidablationofthetumourandrestorationofairwaypatency.Hence,electrocauterycanbeusedinanacutesettingwhererapidrestorationofairwaypatencyisrequired.Acoagulationprobeisabluntprobe and is usually thefirst tool used (Fig. 13.2).A test patchonnormalmucosaderivessomeinformationandallowsthepowersettingtobeadjustedsothatasmallwhiteblanchedarea isobtainedonapplicationof theelectrocauteryprobe(usually10–30 watts). Contact with the tumour with a 3–5 second activation should alsoprovidesomeinformationabouttumoursusceptibility,friabilityandpotentialbleedingrisk. Elongatedor plaque-like lesions are amenable to treatmentwith a coagulationprobe.Itmayalsobeusedtofreeuptumourfromedgesoftheairwaywall.

Fig.13.2aCoagulation 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.

Fig.13.2bThe 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.13.2cThe 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.

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Theelectrosurgicalsnareismoreeffectiveintreatingandremovingpolypoidlesions(Fig. 13.3).The snare is used to loop over the tissue and is then slowly tightened.Thediathermyisactivatedasthesnareisslowlytightenedtocutandcoagulatethetissueatthebase.Ifthesnareistightenedtooquicklywithinadequateelectrocauteryactivation,themechanicalcheese-wireeffectwillcutoffthetumourbutwithoutthecoagulationeffectandhencethereisagreaterriskofbleeding.Aftersnaringthetissue,the bronchoscope with suction is applied to the free piece and the whole unit isremovedviatheendotrachealtube.Regularsuctionofblooddebrisisrequired.Goodcontrolofbleedingisnecessaryasitalsoimpairstheeffectivenessofelectrocauteryastheelectricityisconductedoveramuchwiderareaandhencethelocalheatingeffectissignificantlyreduced.

Fig.13.3aElectrosurgical snare placed around polypoid tumour originating from the left main bronchus into the trachea.

Fig.13.3bOnce 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.13.3cSnare opened and looped over residual tumour.

Fig.13.3dResected tumour being withdrawn through the endotracheal tube with the bronchoscopic view from the trachea showing complete resection of tumour from the left main bronchus.

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Thehotbiopsyforcepscanalsobeusedtodebulktumours.Theforcepsareusedtobiteon the tumourandare thengentlypulledupprior toactivating thediathermyenergy.Electricalcurrentaccumulatesat thebaseoftheneck,heatingthatareaandallowingalargerbiopsiedpiecetobeobtainedwithminimalbleeding.

Theelectrosurgical knife is sparingly usedbut is invaluable for treating tracheal andendobronchialwebs.Acruciate incisioncanbeperformedon theweb.PrecautionswhenusingelectrocauteryanditspotentialcomplicationsareshowninBoxes13.1and13.2.

BOX13.1Precautions when performing electrocautery

●● Ensuregoodcontactofgroundingplateonthepatient●● Useinsulatedand(approved)bronchoscopesforelectrocautery●● Removeringsoranypiecesofmetalonthepatient●● Checkwiththecardiologistbeforetreatingpatientswithapacemakeror

implantabledefibrillator●● EnsureFio2<0.4andinpracticaltermslimitthegasflowto<4L/minvianasal

cannulae(thereisariskofairwayfirewithhighoxygenlevels)●● Alwaysensurethegreenbandontheelectrocauteryaccessory(probe,snare

etc.)isvisiblebeforeactivationofthediathermyunit

BOX13.2Complications of electrocautery

●● Bleeding/haemorrhage●● Respiratoryfailure●● Trachealorbronchialperforation●● Airwayfire●● Pneumothorax●● Arrhythmias●● Post-treatmentstenosis●● Pneumonia

●● Argon plasma coagulationArgonplasmacoagulation isanon-contact formofelectrocautery(Fig.13.4). Ionizedargongasiscreatedbyahigh-frequencygeneratorandflowsthroughaTefloncatheter.Awirewithinthecatheterconductsthehigh-frequencycurrentandatungstentipattheendconvertstheargontoanionizedplasma.Theelectricityisconductedthroughthegasplasma.Itisveryeffectiveatcoagulationandhasafixeddepthofpenetrationof3–5mm.Therapidcoagulatingeffectisveryusefulattreatingthesurfaceofexophytictumoursthatarebleeding.Theplasmaalsotendstobendtothepartofleastresistanceandcanbeusedtotreatareasthatarenotaccessibletoconventionalelectrocauterycoagulationprobes.Bothend-firingandside-firingtreatmentcathetersareavailable.Theargonflowistypicallysetbetween0.3and2.0L/minwiththewattageat30to40W.

Theprecautionswhenusingargonplasmacoagulationanditscomplicationsaresimilartothoseofelectrocautery.

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Fig.13.4aArgon 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.13.4bArgon plasma coagulation of the vascular right middle lobe tumour.

Fig.13.4cVascular right middle lobe tumour treated with spray coagulation to the surface. The whole surface of tumour in the right middle lobe is coagulated.

CryotherapyObstructingendobronchialtumourscanbeeasilyrelievedwithcryotherapyextractionofthetumours.Cryotherapycanbeusedinitstraditionalformatorbycryoextraction.

Traditionalcryotherapy involves theapplicationof thecryoprobedirectlyon to thetumour(Fig.13.5).Thecryoprobeitselfispassedthroughtheinstrumentchannel,untilthetipprotrudesbyabout2cmfromthedistalendofthebronchoscope.Theprobesaremarkedandhenceshouldbeadvanceduntilacleardistalblackbandisvisibleonthe probe.This is to prevent accidental freezing anddamageof the bronchoscope.Under direct vision, the probe is applied to the tumour and the freezing processis activated with a foot pedal and the tissue frozen for approximately 10 secondsdependingontheconstitutionofthetumour.Theextentoftissuethatisfrozencanbevisuallyidentifiedbytheice-front.Thetissueisthenallowedtothawandfurtherfreezecyclesareapplied.Multipleoverlappingapplicationsareperformedtoensurethatthewholeendobronchialtumourisadequatelytreated.

The freezing leads to vasoconstriction and microthrombi formation, which in turnreduce theblood supply to the tumour. Freezingalso leads toproteinandenzymedamageandtheneteffectiscellnecrosis.Mechanicaldamagefromtheformationoficecrystalsmayalsoexplainsomeofthenecrosis.Repeatedfreeze–thawcyclesleadtooverall tumour necrosis.This technique is easily and safely applied, but themaindisadvantageisitsdelayedeffect.Arepeatbronchoscopyisusuallyrequired72hoursto1weekaftertheinitialproceduretoremovethenecrotictumourdebris.Henceitisnotanappropriatetechniqueinthepresenceofacriticallesion.

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●● CryoextractionCryoextractionutilizesamodifiedcryoprobefromErbewherethecentralgaschannelhasbeenstabilizedandthejointbetweentheprobeandthecatheterisstrengthenedtowithstandforcesofupto50newtons.Thecryoprobeiscooleddowntotemperaturesofaround–90°Catthetipoftheprobeonactivationandfreezestissueincontactwiththeprobe(Fig.13.6).Theprobeisappliedtothetumourandactivatedforabout3–6seconds.Thedurationismodulatedaccordingtothesizeoftheice-frontandthetissuebeingtreated.Thebronchoscopeandprobearegentlytuggedtogetherasoneunitandapieceoftumouradheringtotheprobeisextracted.Thebronchoscopeandprobeareremovedviatheendotrachealtube,thetissueisallowedtothawandisthenremovedfromtheprobe.Thebronchoscopeandprobearethenre-insertedthroughtheendotrachealtubeandanotherpieceoftumourfrozenwiththecryoprobeandextracted.Withthistechnique,airwayobstructionfromtumourscanbequicklyandeffectivelydebulkedtoalleviateairwayobstruction.

Fig.13.5aCryoprobe activated while in contact with tumour and with an ice ball formed around the tip of the cryoprobe.

Fig.13.5bThe probe is allowed to thaw and then the cryoprobe is moved a few mm to the side and activated again.

Fig.13.5cNote 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.13.5dThe cryoprobe again moved a few mm and activated to create multiple overlapping areas of treatment.

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

Fig.13.6bThe 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.

Fig.13.6cIce-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.13.6dA further piece of tumour in contact with the cryoprobe is frozen and pulled off.

Fig.13.6eSignificant debulking of the tumour with cyclical freezing and breaking off adherent frozen tumour.

Fig.13.6fRestoration of patency in the right main bronchus with pus arising through the reopened airway.

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LasertreatmentNeodymium–yttriumaluminiumgarnetlaserisusuallyusedthrougharigidbronchoscopebutflexiblefibresarealsoavailablewhichcanbeusedthroughaflexiblebronchoscope.This laser tendstovaporizetissue.Thepowershouldbe limitedto40wattsas thedepthofpenetrationcanvaryaccordingtothetissuecompositionandclinical trialshaveshownanincreasedfrequencyofadverseeventsinpowersettingsabove40watts.Thecolourofthetissuemayalsoaffectthethermalenergyabsorbed.

The laser is delivered through flexible fibres, but the laser light itself is invisible(wavelength=1064nanometres)andhenceisusedinconjunctionwithredhelium-neonaimingbeamtoguidetreatmentapplication.TheprecautionstobetakenwhenusinglaserareshowninBox13.3.

BOX13.3Precautions when using laser

●● Inspiredoxygenconcentration(Fio2)<0.4●● Limitpowertolessthan40watts●● Protectthepatient’seyes●● Ensureallpersonnelwearprotectivegoggles●● Avoiditsuseinthepresenceofsiliconeorcoveredstents●● Ensurethedistaltipissufficientlybeyondthetipofthebronchoscope

PhotodynamictherapyPhotodynamic therapyutilizes aphotosensitizerwhich is activatedby a special lightsource.Photofrinisacommonlyusedagentthatisadministered48hoursbeforethetherapeuticbronchoscopy(dose2mg/kgintravenously).Thedrugisclearedfrommosttissueswithin3daysbutisretainedintumourtissue,skin,liverandspleenforupto6weeks.Atbronchoscopyanon-thermallaserlightsuchaspotassiumtitanylphosphate(KTP) or argon pumped laser is applied using a cylindrical diffuser.The laser light(wavelength630nanometres)penetrates the tissueandcauses tumourdestruction.Thecylindricaldiffusertipisavailableinavarietyoflengthsandischosenaccordingtothetumourextent.Thecylindricaldiffuserispositionedadjacenttothetumourandthelightisemittedina360°arcfromthediffuser.Approximately200joulesisappliedpercmtreatedandthistakesapproximately8minutes.Itiscrucialtoensurethatthetipisheldinastableposition.Ifanuntreatedsectionisleft,thediffusercanberepositionedandtheadditionalarearetreated.Arepeatbronchoscopyshouldbeperformedafter48hourstodebulkanynecrotictissueandsuctionoutanyinflammatorydebrisandmucus.

Thekeycomplicationsarehaemorrhage,hypoxiaduetopluggingoftheairways,infectionduetoretentionofsecretions,andnecroticdebris.Themainsideeffect limiting theutilityofphotodynamictherapyisskinsensitivity.Retentionofthephotosensitizerintheskinmeansthatexposuretolightleadstoburns.Patientsareaskedtocompletelycovertheirbodyandnotexposethemselvestolightforatleast6weeks.Latecomplicationsincludecircumferentialstricturesinthetreatedareas.

BrachytherapyBrachytherapyinvolvestheplacementofablind-endingcatheterclosetothetumour.Bronchoscopywith thenasal approach isperformedandapolyethylenecatheter isplacedthroughtheinstrumentchannelofthebronchoscopeandintothedesiredairway.

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Thecatheterpositioncanbeverifiedwithfluoroscopyifrequired.Thebronchoscopeisslowlywithdrawnwhilethecatheterisadvanced.Thecatheterissecuredinpositionatthenoseandthebronchoscope isreintroducedthroughtheoralroutetocheckcorrectplacementofthecatheter.

Thetreatmentareaisplannedusingavailableradiologyandthepost-procedurechestradiograph.The treatment is performed in a lead-shielded room. A remote after-loading device is connected to the proximal portion of the catheter.According tothetreatmentareaplanned,thecatheterisloadedwithacombinationofinactiveandradioactivebeads.High-dosebrachytherapyismorecommonlyperformedandusesaniridium-192source.

Thekeycomplicationsofhigh-dosebrachytherapyincludemassivehaemoptysis,fistulaformation, radiationbronchitisandstenosis.These risksare increasedbyconcurrentexternalbeamradiotherapy,previousendobronchial lasertreatment, increasingdoseintensityofbrachytherapyandacellsubtypeoflargecellcarcinoma.

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14Stents

Endobronchialorendotrachealstentsareusedwhereairwayobstructioniscausedbyextrinsiccompressionfromatumour.Theymayalsoberequiredafterendobronchialtumourdebulking if theairwayhas lost itssupportstructureandalso if thetumourisprolapsingthroughalobarbronchusandoccludingthemainbronchus.Avarietyofdifferentstentsexist,butthemaingrouparemetallicornon-metallicstents.Metallicstents themselves are subdivided into covered and uncovered stents. Non-metallicstentsusuallyrequireinsertionwitharigidbronchoscopeandarenotdiscussedfurtherhere.Metallicstentsareusuallymadefromnitinol(anickeltitaniumalloy)(Fig.14.1).

Fig.14.1aSelf-expanding uncovered nitinol stent.

Fig.14.1bNitinol stent, laser-cut from a single piece and covered with silicon.

Fig.14.1cNitinol stent, laser-cut from a single piece and covered with silicon.

Fig.14.1dDeployment handle for self-expanding stent.

Techniqueofstentinsertion

●● Direct visionThefirststepistointubatethepatientwithasize8or9uncuffedendotrachealtube.An ultra-fine bronchoscope with an external diameter of 2.8 mm is used and theareaofnarrowinginspectedunderdirectvision.Apulmonaryguidewire(jagwirewithasoftdistal tip) is insertedthroughthe instrumentchannelandpassedthroughthestenoticairwayintothedistalaspectsofthelung(Fig.14.2).Awireexchangetechniqueisemployed inorder toremovethebronchoscopewhilemaintaining the jagwire initscurrentposition.Thisisbestachievedbyfeedingthewireacoupleofcentimetresdeeperwhileremovingthebronchoscopebyasimilaramount.Thisisperformeduntilthebronchoscopeisremovedbutthewireismaintainedinposition.Thebronchoscopeis passed through the endotracheal tube to check that the guidewire is still in thecorrectposition.Theguidewireshouldbeheldtautbyanassistantandcaretakentomaintainitsposition,

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Thepatient is then re-bronchoscopedby inserting thebronchoscope through thevocal cords via the oral route adjacent to the endotracheal tube.This allows thestent tobepassed through theendotracheal tubeandmanipulated in the tracheaorbronchiwhilemaintaining visionwith thebronchoscope (Fig. 14.3).The stent isfedovertheguidewirethroughtheendotrachealtubeandintothedesiredlocationin the airways.The stents havemarkers highlighting the proximal endof the stentwithinthedeliverycatheter.Beforetheprocedure,aCTscanofthethoraxshouldbecarefullystudiedtoensurethatstentingisasuitabletreatmentoption.Forexample,it is importanttoascertainthatthereisagoodpatencyoftheairwaysbeyondthestenosis.ThesizeandlengthofthestentsrequiredcanalsobedeterminedbytheCTscan.Thisiscomplementedbycarefulexaminationoftheairwaysatbronchoscopy.

Fig.14.2aNarrowing in right main bronchus secondary to tumour.

Fig.14.2dStent inserted over the guidewire. The positioning of the stent is confirmed by bronchoscopy.

Fig.14.2gFull deployment of the stent under bronchoscopic control.

Fig.14.2bGuidewire inserted through a narrowed right main bronchial tumour.

Fig.14.2eInitial deployment of the stent under bronchoscopic control.

Fig.14.2cBronchoscope removed while retaining guidewire in position through the right main bronchial tumour. The bronchoscope is then reinserted into the airway to check the position.

Fig.14.2fGradual deployment of the stent under bronchoscopic control.

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Fig.14.3aCT scan showing narrowing of the right main bronchus.

Fig.14.3fStent placed in the constricted right main bronchus.

Fig.14.3gSilicon-coated nitinol stent with a suture in the proximal aspect.

Fig.14.3h, iCovered 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.14.3eDelivery 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.14.3dGuidewire 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.14.3cConcentric infiltration and narrowing of the right main bronchus. Guidewire inserted into the right main bronchus.

Fig.14.3bConcentric narrowing of the right main bronchus.

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Thestentiscarefullypositionedsothattheproximalmarkerisvisibleproximaltotheareaofnarrowingunderdirectvisionandthestentiscarefullydeployed.Avarietyofdeploymentmechanismsexistandinprincipleallusethetechniqueofwithdrawingtheoverlyingprotectivecatheter(Figs14.4and14.5).Pleasecheckandfamiliarizeyourselfwiththemanufacturer’sinstructions.Werecommendfixingthepositionofyourarm,forexample,holdingtheelbowfixedoveryourabdomenandthenpullingbacktheoverlying sheathover the stent.This is an important step for correct placement asthere isa tendency topush forwardduringdeploymentand this leads to thestentbeingdeployedfurtherintotheairwaysthandesired.Thestentshouldbedeployedinasteadymannerunderdirectvisionsothatanysmalladjustmentscanbemadetoensurethatthestentisoptimallypositionedpriortofulldeployment.

Fig.14.4cAn uncovered nitinol stent which has been fully deployed with an improvement in the calibre of the right main bronchus.

Fig.14.4bThe stent is inserted through the narrowed right main bronchus and gradually deployed by removing the silk thread around the stent.

Fig.14.4aFollowing intubation, the guidewire is inserted into the narrowed right main bronchus.

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Someofthestentscanbemanipulatedintoaproximalpositionbygraspingasilkstitchattheendoftheproximalportionofthestentwithforcepsandthengentlymovingthestentproximally(Fig.14.3h,i).However,manipulatingthestentbyapreciseamountisdifficultandthestentshouldneverbepusheddistally.

Fig.14.5cTracheo-oesophageal fistula visible in the posterior aspect of the upper trachea. Stent inserted over the guidewire under visual control with a thin hybrid bronchoscope.

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

Fig.14.5aCT scan at the level of a tracheo-oesophageal fistula.

Fig.14.5bCT scan showing some changes of basal pneumonia due to aspiration.

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●● Radiology-guided stent insertionEndotracheal and endobronchial stents can also be positioned and deployedunder fluoroscopic guidance (Figs. 14.6 and 14.7).The initial steps are similar todeploymentofthestentsunderdirectvision.Oncetheguidewire isplacedthroughthe appropriate narrowed lobar bronchus, the stent is fed over the guidewire andthroughtheendotrachealtube.Underfluoroscopicguidancethestentisadvancedandpositionedoverthedesiredarea.Thestentsusuallyhaveproximalanddistalradiologicalmarkers,whichallowtheaccuratepositioningofthestentunderfluoroscopiccontrol.Thedeploymentof the stent isagain thesameaswithdirectvisionexcepton thisoccasionthefluoroscopyprovidesthevisualguidance.Stentscanalsobeplacedwithacombinationofdirectvisualguidanceandfluoroscopy.Thismaybemoreappropriateincircumstanceswherethedistalaspectcannotbevisualizedatbronchoscopyevenwithanultra-finebronchoscope.

Fig.14.6aChest radiograph of a patient with left lower lobe and lingular collapse.

Fig.14.6bStent positioned and deployed under fluoroscopic control.

Fig.14.6cChest radiograph showing significant reinflation of the left lung after stent placement (visible in the left main bronchus).

Fig.14.7aThree silicon-coated stents inserted in a patient: one in the main carina with two other stents visible distally in the right and left main bronchi.

Fig.14.7bClose-up of the carina showing two stents from each main bronchus joining at the carina.

ComplicationsofstentsMalignant endobronchial tumour involvement is the most common indication fortracheal or bronchial stents. Hence the covered variety is more frequently utilized.However, thesestents impairnormalmucociliaryclearanceandhencearepronetocomplications such as mucus retention and bio-fouling of the stents.This is wherebacteriagrowmucoidbiofilmsontheinnersurfaceofthestent(Fig.14.8).Afurthercomplicationofthisphenomenaishalitosis.Thesestentsarealsopronetodisplacement.

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Fig.14.8aPseudomonas biofilm formation on a covered endobronchial stent with some mucus plugging.

Fig.14.8bEarly stage of biofilm formation on a covered endobronchial stent.

Fig.14.8cClose-up view of a covered nitinol stent with early biofilm formation.

Fig.14.8dDevelopment of biofilm with mucus stasis on a covered endobronchial stent.

Fig.14.8eProgressive development of biofilm with mucus stasis on a covered endobronchial stent.

Fig.14.8fGranulation tissue developing as a result of an uncovered nitinol stent.

Fig.14.8gGranulation tissue at the distal end of an uncovered nitinol stent.

Fig.14.8hGranulation tissue developing around an uncovered nitinol stent.

Fig.14.8iTumour growth through an uncovered nitinol stent.

Fig.14.8jTumour ingrowth through an uncovered stent with epithelialization of the stent visible on the other side.

Fig.14.8kTumour recurrence around an epithelialized uncovered stent.

Fig.14.8lDistal tumour recurrence in an uncovered stent.

Fig.14.8mCovered nitinol stent in the main bronchus, with mucus plugging visible on the inner surface of the stent due to impaired mucociliary clearance.

Fig.14.8nMucus collection on a covered stent.

Fig.14.8oStent fracture – a nitinol stent has warped in areas with stent fractures.

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BalloondilatorsInsomepatientswithextrinsicnarrowingandalsoinsomepatientswithcircumferentialsubmucosal disease causing airway obstruction, airway dilatation is first requiredprior to stent insertion.This can be achievedwith balloondilators. Several sizes ofballoondilatorsareavailable.OnceagainIwouldrecommendperformingtheflexiblebronchoscopyinapatientwhohasbeenintubatedwithanuncuffedendotrachealtube.

Theballoonsareinflatedwithapressurizedsaline-filledsyringe.Thissyringeincreasesthepressuretoaspecifiedamountdependingonthedegreeofdilatationrequired.Themajorityofendotrachealballoondilatations requirean interventionalbronchoscopewithatleasta2.8mminstrumentchannel.Theballoonispassedthroughtheinstrumentchannel of the bronchoscope and then manipulated through the narrowed airwayunder direct vision (Fig. 14.10). Once the balloon is appropriately positioned, it isinflatedtothesetpressure.Thisshouldnormallybeperformedinastepwisedilatation(forexample,from6to8to10mminthreeseparateinflations).

Othercomplicationsofstentsincludedevelopmentofgranulationtissueandovergrowthfromthetumouritselfattheproximalanddistalmargins.Thestentsareexposedtosignificant forces during coughing and also through the respiratory cycle (Fig. 14.9).Stentfracturesareapotentialcomplicationandadifficultproblemasthestentneedstoberemoved,usuallypiecemealbyremovingtheindividualwirescarefullywitharigidbronchoscope.

Fig.14.9aMigration of stent inserted into the right main bronchus. With coughing the stent moves up into the trachea.

Fig.14.9bThe stent has migrated to the trachea and is then removed by grasping with biopsy forceps.

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

Fig.14.10bCircumferential narrowing of the right main bronchus in a patient with left-sided pneumonectomy. Insertion of balloon dilator through the narrowed right main bronchus.

Fig.14.10cInflation 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.

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CHAPTER

15Bronchoscopic treatment for emphysema and asthma: bronchoscopic lung volume reductionInpatientswithsevereend-stageemphysema,hyperinflation–andparticularlydynamichyperinflationduringexertion–isthemaincauseofdyspnoeaandexerciselimitation.Patientswhoaresymptomaticdespitemaximalmedicaltherapywhohaveundergonepulmonaryrehabilitationmaybeconsideredforbronchoscopiclungvolumereduction.Bronchoscopic techniques and treatment adopted depend on the pattern ofemphysema.Themajorityofpatientswhohavesevereemphysemahavehomogenousdiseaseandabout25percentofpatientshaveheterogenousdisease.

HeterogenousdiseaseThisisdefinedasgreaterthan10percentvariationintheemphysematousdestructionbetweentheupperandlowerlobes.Amoreaccuratewayofassessingthisisbyapplyingadensitymasktolungwindowsandareaswithanattenuationvalueoflessthan910Houndsfieldunitson10mmcomputedtomography(CT)sections(Fig.15.1).

Fig.15.1aCT scan showing emphysematous destruction in the upper lobes.

Fig.15.1dDensity mask highlighting areas with emphysema (> 910 Houndsfield units): in the lower lobe.

Fig.15.1bCT scan from the same patient with emphysema showing relatively less destruction from emphysema.

Fig.15.1eCT scans showing a greater degree of emphysema in the upper lobes than in the lower lobes: coronal section.

Fig.15.1cDensity mask highlighting areas with emphysema (> 910 Houndsfield units): in the upper lobe.

Fig.15.1fCT scans showing a greater degree of emphysema in the upper lobes than in the lower lobes: sagittal section.

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●● Zephyr valveThe strategy of lobar atelectasis has been utilized with this valve. Hence therecommendationisthatthewholeofthelobeistreatedinaunilateralmanner.Thisisoneofthethird-generationvalvesthatcanbeeasilyinsertedthroughtheinstrumentchannelofabronchoscope.Itisavailableintwomainsizes:4–7mmand5.5–8.5mm.

Fig.15.2aZephyr valve. Fig.15.2bDelivery catheter handle with a blue button that needs to be pressed prior to pressing the blue lever to slowly deliver the valve. The tip has side blue flanges measuring 4 mm (small flanges) to 7 mm (larger side flanges) which allow you to determine if the valve is the correct size for the target airway segment.

Fig.15.2cValve loading device. The valve is moved into the narrow loading funnel by pulling at the two ends of the device.

Fig.15.2dThe retaining thread is cut.

Fig.15.2eThe funnel with the Zephyr valve in the channel is removed from the capsule.

Fig.15.2fThe Zephyr valve in funnel channel.

Fig.15.2gThe delivery catheter positioned in the loading device.

Fig.15.2hThe delivery catheter positioned in the loading device and pulled down into the narrow channel.

Fig.15.2iThe Zephyr valve inserted into the loading device.

Fig.15.2jPusher used to push the valve from the funnel-like capsule into the delivery catheter.

Fig.15.2kThe Zephyr valve loaded into the distal end of the delivery catheter.

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SizingisnotascriticalwithZephyrvalvesasitiswithintrabronchialvalves.Thedeliverycatheterhastwoflangeswhichprovideanestimateoftheairwaysizeandthereforethevalvethatisrequired.Thecatheterisplacedcentrallyintheappropriatesegmentandanestimatecanbemadeusingthesideflangestodeterminewhichvalveshouldbeused.

Once the valve is loaded into the delivery catheter, it is manoeuvred into theappropriateairwaysegment(Figs15.2and15.3).Werecommendusingthetechniqueofpartialdeployment.Thevalveisveryslightlydeployedsothatitprotrudesthroughthedistaltipofthedeliverycatheter.Thevalvecanthenbewedgedagainstthecarinawithinthesegmenttobetreatedanddeployed.Thisensuresthatthevalveiscorrectlypositionedsoastooccludethewholesegment.Fulldeploymentinasinglemanoeuvrecan sometimes force the valve into a particular subsegment leading to only partialclosureofthesegmentandthisinturnwillpreventfulllobaratelectasis.

Fig.15.3aDelivery 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.

Fig.15.3bSlow deployment of the Zephyr valve after wedging against a subsegmental carina.

Fig.15.3cThe Zephyr valve which is closed in inspiration and open in expiration, therefore allowing air out.

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●● Intrabronchial valveTheintrabronchialvalveisanumbrella-shapeddevice,whichisavailableinsizesof5,6and7mm(Fig.15.5).Themanufacturershavebeenpromotingthestrategyofairflowre-directionandhencerecommendthatonesubsegmentisleftpatentontherightsideandthelingularisuntreatedontheleftside.Thevalveshavealowermarginoferrorasoversizingcausesrufflingofthevalveandhenceincompetence.Undersizingdoesnotallowapropersealoftheairwayeither.Thevalvethereforerequiresaccuratesizingoftheairwaysusingaballoonsizingkit.

Thevalvescanbeeasilyremovedwithgraspingforceps.Theproximalduck-billedvalvecanbegraspedwith the forcepsand thevalvepulledoutasawholeunitwith thebronchoscope.

Themaincomplicationsobservedareacuteexacerbations.Otheracutecomplicationsincludeapneumothorax.Inthelongterm,developmentofgranulationtissuearoundthevalveshasbeenobserved. In somecases, theremaybe secondary colonizationofthevalveswithbacteriasuchasPseudomonasorfungalspeciessuchasAspergillus (Fig.15.4).

Fig.15.4aGranulation tissue around the valve in RB2 and the valve in RB1 has been colonized with Aspergillus.

Fig.15.4eAppearance of the right upper lobe after removal of Zephyr valves.

Fig.15.4fAppearance of the right upper lobe 6 weeks after removal of Zephyr valves. Note the significant regression of granulation tissue.

Fig.15.4gCombination of granulation tissue and biofilm formation around first-generation duck-billed valve.

Fig.15.4bClose-up of a Zephyr valve colonized with Aspergillus.

Fig.15.4cAnother example of granulation tissue developing around the valve.

Fig.15.4dZephyr valves covered with a biofilm of mucoid Pseudomonas.

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Fig.15.5aLoading device and delivery catheter.

Fig.15.5bIntrabronchial valves (5 mm valve in centre, 6 mm valve on left and 7 mm valve on the right side).

Fig.15.5cIntrabronchial valves with colour-coordinated housing: 5 mm valve (blue), 6 mm valve (yellow) and 7 mm valve (green).

Airwaysizing

Balloon preparation and calibrationAll the air has to be extracted from the balloon and replaced with normal saline.Athree-waytapisattachedtotheballooncatheterwitha10mLsyringe,whichisfilledwithapproximately5mLofnormalsaline.Strongsuctionisappliedsoastoremoveasmuchairaspossiblefromtheballoons.Theballoonisthenfilledwithnormalsaline(Fig.15.6).Anyairbubbles still present aregentlymanipulated to thecentreof theballoonandsuctionisappliedtothesyringeinanattempttoaspiratethegasbubbles.Thisprocessisthenrepeateduntiltherearenoairbubblespresentor,alternatively,thebubblepresentinthecatheterissmallerthantheinnerstemoftheballooncatheter.

Fig.15.6aBalloon catheter.

Fig.15.6bBalloon catheter inflated with saline but with a significant air bubble.

Fig.15.6cBalloon catheter with multiple small bubbles (air extracted by repeated suction).

Fig.15.6dGently flicking the balloon encourages the small bubbles to coalesce and form larger bubbles that may be removed by repeated suctioning and inflation of the saline-filled balloon.

Fig.15.6eA single bubble smaller than the diameter of the catheter is acceptable for calibration and sizing.

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Thesyringeisthenexchangedfora500µLglasssyringeandfilledwithexactly500µLofnormalsaline.Thesaline-filledballoonisthencalibratedusingasizingtemplate.Theballooniscarefullyinsertedandinflatedtofitdifferent-sizedtemplatesfrom3,5,7and9mmholesandthevolumeofsalineintheglasssyringeisrecordedforeachsize(Fig.15.7).Inthiswayacalibrationcurvefortheparticularballoonisproducedwhichcanthenbeusedtosizetheairwaysinapatient.

Fig.15.7aCalibration template and 500µL glass syringe.

Fig.15.7bThe balloon is slowly inflated at each template size. Here, partial inflation of the balloon at the 9 mm hole can be seen.

Fig.15.7cThe balloon optimally inflated to 9 mm size template (the volume required to inflate the balloon to this size read from glass syringe).

Patient preparationIntubationofallpatientsundergoingtheprocedureisrecommended.Thisprovidesasecureairwaybutalsofacilitatesremovalofvalvesifrequiredduringtheprocedure.ThetreatmentsitesareusuallyplannedaccordingtothefindingsofaspiralCTscanandaventilation–perfusionscan.Thelobeswiththegreatestdestructionaretargeted.Thecalibrationballoonisinsertedthroughtheinstrumentchannelandinflatedinthetargetsegmentsuntiltheballoonfitssnuglyinthesegment(Fig.15.8).Theballoonisthenmovedbackandforthinordertodeterminewhethertheballooniscorrectlyinflated.Overinflationleadstosomeindentationintheballoon.Wherethereisunderinflationagapmaybevisible.

Fig.15.8aBalloon catheter inserted into a bronchial segment. Balloon inflated in the bronchial segment and then moved back and forth in the segment. The balloon is optimally inflated to the size of the airway.

Fig.15.8bThe optimally inflated balloon moved back and forth in the bronchial segment.

Fig.15.8cNote a gap between the segment and the balloon, indicating under-inflation, and then note the slight dimpling in balloon indicating overinflation.

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ProcedureThe valve is loaded on to the delivery catheter (Fig. 15.9).This in turn is insertedthroughtheinstrumentchannelofthebronchoscope.Someadjustmentofthedeliveryrod in thetrachea is requiredunderdirectvision.Thecatheter is thenmanoeuvredinto thedesiredsegmentalairway.Thedeliverycatheterhasaproximalmarkerandismanipulated so that it is appropriately positioned.The valve is delivered and thecatheter removed (Fig. 15.10).The valve should be inspected to ensure that it hasbeencorrectlyplacedandthatitisfullyopenwithminimalrufflingoftheedgesoftheumbrella.Itdoestendtoretractbackbyabout1mmafterafewhours.Hence,itisimportanttocheckthatanysidebranchesorsubsegmentsarefullyoccludedwithanoverlapofmorethan2mm.Ifthevalve isoversizedthentheumbrellatendstoberuffledandnot fullyopenwhich leadsto incompetenceofthevalve.Similarly if thevalveisundersized,thevalvetendstoleak.

Fig.15.9aPlunger retracted in the loading device.

Fig.15.9bA 7 mm (green) valve inserted into the loading device.

Fig.15.9cDelivery catheter inserted into the loading device.

Fig.15.9dPlunger pushed into the loading device to transfer the valve into the delivery catheter.

Fig.15.9eDelivery catheter released from the loading device by pushing down the yellow button.

Fig.15.9fIntrabronchial valve loaded into the delivery catheter.

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Fig.15.10aDelivery 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 (LB1 + 2) of the upper lobe.

Fig.15.10bThe 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 (LB1 + 2) of the upper lobe.

Fig.15.10cCatheter tip inserted into the anterior segment of the left upper lobe (LB3).

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

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ValveremovalTheintrabronchialvalvecanbeeasilyremovedifithasbeenincorrectlypositionedorifthevalvesizeisincorrect(Fig.15.11).Itcanalsoberemovedifthepatientdoesnotimprovewithinterventionoriftheydevelopanycomplicationssuchaspost-obstructiveinfection.Thebiopsyforcepsareinsertedthroughtheinstrumentchannelandusedtograspthecentralrodlocatedonthevalve.Thevalveisthenpulledclosetowardsthebronchoscopeandtheunitisremovedinitsentirety.Donotattempttopullthevalvethroughtheinstrumentchannelasitwillnotbepossibleandthereisariskofdamagingthedistalportionofthebronchoscope.

Fig.15.11bBiopsy 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.

Fig.15.11aIncorrectly positioned intrabronchial valve. Removal of valve using biopsy forceps which are first positioned over the intrabronchial valve.

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●● Complications of endobronchial valve treatment (Fig.15.12)

The most common complication is exacerbation of chronic obstructive pulmonarydisease(COPD)whichoccursinupto10percentofpatientsfollowinginsertionofendobronchialvalves.Thepatientpresentswithincreasedbreathlessness,cough,wheezyspellsorevenmucoushypersecretion.Treatmentiswithsteroidsandantibiotics.Theotheracutecomplicationisthatofpneumothorax.Itusuallyresolveswithconservativemanagement, requiring intercostal drainage, but only in a small proportion is therea prolonged air leak of more than 7 days. Haemoptysis and haemorrhage are lesscommon and are usually related to incorrect placement of the valve where theprotruding sectionof thevalve is rubbingagainst theairwaymucosa.Similarly, valvedisplacementcanoccasionallyoccurbuttheincidencecanbereducedbycorrectvalvereplacement. Granulation tissue also develops in some patients with endobronchialvalves.Wehaveobserved chronic infection such asAspergillus infection around thevalve,whichusuallyresolveswithremovalofthevalves.

Fig.15.12aGranulation tissue enclosing the whole valve with the central rod just visible.

Fig.15.12bMucosal hypertrophy on the lateral aspect of the intrabronchial valve and mucus around the central rod.

Fig.15.12cAlmost complete occlusion of the valve by epithelial tissue.

Fig.15.12dMucosal hypertrophy encircling the valve, in particular around the inferior margin.

Fig.15.12eIntrabronchial valve encircled with tissue hypertrophy.

Fig.15.12fColonization of the valve with Aspergillus.

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●● PneumRx® RePneu® Lung Volume Reduction Coil (LURC®) System

Thesearememorycoilsmade fromnitinol,whichareavailable inavarietyof sizes.Insertion of PneumRx® coils is performed under fluoroscopic guidance during abronchoscopy(Figs.15.13and15.14).

Thecoilisaself-actuatingdevicewhichisdeliveredstraightintotheairway.Thecoilrecovers to a non-straight, pre-determined shape upon deployment. The deviceconsistsofsterilecoilsandasterile,disposable,single-patientdeliverysystemconsistingofacartridge,catheter,guidewireandforceps.

Fig.15.13aPneumRx® nitinol coil.

Fig.15.13bPneumRx® nitinol coils of differing lengths.

Fig.15.13cPneumRx® coil in sterile protective housing.

Fig.15.13dCatheter and guidewire.

Fig.15.13iPneumRx® coil grasped by the forceps. Note the blue screw lock is in the locked position.

Fig.15.13jPneumRx® coil released by the forceps. Note the blue screw lock is in the unlocked position.

Fig.15.13eGrasping forceps with screw (blue) locking mechanism.

Fig.15.13fPneumRx® coil with loading cartridge. Grasped with forceps and locked to prevent inadvertent opening and release of the coil.

Fig.15.13gCoil being loaded into the cartridge by first drawing the grasped coil into the loader.

Fig.15.13hCoil being loaded into the cartridge.

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Fig.15.14aCatheter inserted into the apicoposterior (LB1 + 2) segment of the left upper lobe. Note the radio-opaque tip of the catheter. PneumRx® coil being advanced through the catheter.

Fig.15.14eThe 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.15.14dThe guidewire and overlying catheter advanced into the bronchial subsegment.

Fig.15.14cGrasping forceps are opened releasing the PneumRx® coil. The forceps are then withdrawn. The catheter is repositioned in another airway subsegment and the guidewire is advanced into the bronchial segment.

Fig.15.14bOverlying catheter being steadily withdrawn with the PneumRx® coil reverting to its original shape. Grasping forceps are visible at the distal end of the bronchoscope.

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Theprocedurecanbeperformedunderconscioussedationandideallythepatientshouldbe intubated.The bronchoscope is then passed through the endotracheal tube andmanoeuvredtowardsthetargetbronchialsegment.Acatheterwithaguidewireisthenpassed through the instrument channel into the bronchial subsegment.The guidewireis advanced into thebronchial segmentunderfluoroscopic guidance.The guidewire isinserteduntilresistanceisfeltorupto3cmfromthepleuraedge.Thecatheteristhengentlyfedovertheguidewiretothedistaltipoftheguidewire.Thecatheterhasatipthatisvisibleatfluoroscopyandtheguidewirehasmarkingsevery25mmalongitslengththatareradiologicallyvisible.Theguidewireisthenwithdrawnbacktothetipofthecatheterand thedistancebetween the tipof the catheter and the tipof thebronchoscope iscalculatedfromthe25mminterspacedradiologicalmarkers.Thisallowsanestimateofthecoillengththatshouldbeinserted.Thecoilisusuallyoversizedbyapproximately50mm.

Adaptedbronchialforcepswithalockingmechanismareusedtograspthecoilandthen load it intoa specificdeliverymechanismand it is fed through thecatheter. Itis insertedup to thecatheter tipunderfluoroscopicguidance.Thecoil isadvanceduntilthedistalaspectofthecoilreachesthedistalpointofthecatheterandthentheoverlyingcatheter isgraduallyretractedandthisallowsthecoil toconformbacktoitsoriginalshapeandindoingsofallsandpullstheportionofthelungintowhichitisinserted.Oncethecatheteriswithdrawnsothattheproximalportionofthecoil isprotrudingoutofthecatheter,thelockingmechanismonthebiopsyforcepsisreleasedandthecoil isthenreleasedintoposition.Thebiopsyforcepscanthenberemovedandthecatheterrepositionedforthenexttreatmentarea.Thetargetlobeistreatedsystematicallywithanaverageof10coils.

Ifacoilismalpositionedthenitcanberemovedorrepositioned.Thebiopsyforcepsneedtobeinsertedthroughthecatheterandthenusedtograspthesmallball-liketipontheproximalaspectofthecoil.Oncethecoilisfirmlygraspedbyitsproximalaspect,thebiopsyforcepsarelockedandthecatheterisslowlyadvancedoverthecoilunderfluoroscopicguidance.There-sheathedcoiliseffectivelystraightenedandcanthenberemovedormanipulatedintoadifferentposition.

Ideallyacoilshouldbeinsertedintoeachofthesubsegments.Henceanupperlobemaybetreatedwithanaverageof10coils.

Fig.15.14fThe 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 PneumRx® coil is still grasped by forceps.

Fig.15.14gThe grasping forceps are opened to release the PneumRx® coil with the distal tip of PneumRx® coil visible in the airway.

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HomogenousemphysemaInpatientswithhomogenousdisease,thereissignificantdestructionofthelungthroughoutthelungfields.Henceimprovementsarenotbasedonsimplycollapsingdiseasedlungandallowingbetterlungtissuetofunction,butmoreonimprovementsofchestwalldynamics–inparticular,reducingdynamichyperinflationwhichisobservedonexercise.Thisgroupofpatientsaccountsforthemajorityofpatientswithsevereemphysema.

●● Airway bypassThistechniquereliesonthecreationofcollateralchannelswhichallowairwaysofdestroyedlung to emptymore effectively during expiration and hence reduce hyperinflation.Adetailed spiralCT scan is performed first.This allows identification of areaswith themostemphysematouslungdestruction.Otherparameterssuchastheproximityofbloodvessels,airwaycalibreandbronchoscopicaccesstothesegmentarealsoassessedandscored.Acumulativescoreisgeneratedtoidentifytheoptimalsitesofstentinsertion.

ProcedureTheprocessisusuallyperformedundergeneralanaesthesia.Airwayblockersshouldbepositionedatthestartoftheproceduretodealwithanypotentialairwayhaemorrhage.FirstaDopplerprobeisusedandpositivecontrolisidentifiedbylocatinganaudibleDopplersignalorabloodvessel(Figs.15.15and15.16).Thenthetargetareaisidentifiedcarefullytolookforanavasculararea(wherethereisnoaudibleDopplersignal).ThebronchoscopeisheldinpositionandtheDopplerproberemoved.Aneedlewithaballoondilatoristheninsertedthroughthebronchoscopechannelsandinsertedintotheavascularareaidentified.Thedilatorintheneedleisinflatedanda3mmholeiscreatedbetweentheairwaysegmentandthealveolarparenchyma.Theballoon isslowlydeflatedtoensurethatthere isnosignificantbleeding.Anyminorbleedingisdealtwithbygentlesuction.Ifnecessary,aliquotsofice-coldsalineanddilutedadrenalinecanbeusedtocontrolthebleeding.

Theareaaroundthenewlycreatedpassagebetweentheairwayandalveolarparenchymais carefully re-inspectedwith theDopplerprobe toensure that there arenobloodvessels incloseproximity to thepassage.This is importantas releaseof trappedgaswhentheholeismademightbringvesselscloserthanwouldbesafeforstentinsertion.

Fig.15.15gExhale® drug-eluting stent with the inflated balloon delivery catheter.

Fig.15.15fExhale® drug-eluting stent (white) and underlying balloon mounted on the delivery catheter.

Fig.15.15eExhale® drug-eluting stent.

Fig.15.15dExhale® transbronchial dilation needle with the needle withdrawn and the balloon inflated.

Fig.15.15cExhale® transbronchial dilation needle with the needle protruding and the balloon deflated.

Fig.15.15bExhale® transbronchial dilation needle with the needle withdrawn and the balloon deflated.

Fig.15.15aExhale® Doppler probe.

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Fig.15.16aExhale® 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.15.16bBalloon dilatation with the Exhale® transbronchial needle after insertion of the needle through the airway into the lung parenchyma.

Fig.15.16cHole 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.15.16dExhale® 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 in order to ensure correct inflation of the balloon.

Fig.15.16eThe 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.

Atlas_of_Flexo_Broncho.indb 234 10/10/2011 13:27

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Adrug-elutingstentonaballooncatheteristheninsertedthroughtheairwaypassage(Fig.15.16d).Thestentonthedeliverycatheteristhencarefullypositionedsothatthemid-portionofthestentisjustthroughthebronchialwall.Careshouldalsobetakentoensuretheballoondilatorisfullyextendedoutfromthedistaltipofthebronchoscopeandtheblackmarkerlineonthecatheterisvisible.Onceappropriatelypositioned,theballoonisinflatedtoaspecificpressureandheldinpositionforatleast10seconds.Thedilationoftheballoondeploysthestentandmaintainsthepassagecreated.Theballoonisthenslowlydeflatedandthecathetercarefullyremoved.

Thestentshouldbeinspectedtoensurethatitiscorrectlypositionedandthereisnooverlyinglipofmucosa.Theprocedureisrepeatedtocreatefurtherairwaypassagesandthreestentsareusuallyinsertedintoeachlung,withamaximumoftwoineachlobe.

Theprocedureislikelytoevolvesothatinfutureacombinationofaneedledilatorandultrasoundtransducerwillreduceitsduration.Itisalsopossiblethatonlytwooptimallyplacedstentsmayberequiredforclinicalbenefit.

Occasionallythebronchialtissuemaybeveryfriableandthiswillleadtoairwaytearingduringballoondilatation.Thisresultsinlargerholesthanaresuitablefortheairwaystent.Insuchcases, itmaybepossibletoomittheballoondilatationwiththeneedleandproceedstraighttostentdeployment.Insomecases,thestentmaybeangulatedornotproperlydeployedandrequireretrieval.Thiscanbeachievedeasilywithbiopsyforceps.Werecommendsimplypassingthebiopsyforcepsthroughthedisplacedchannelandthenopeningtheforcepssothatthestentisnowtrappedwithinthem,andremovingthebronchoscope,forcepsandstentasasingleunit.

The main limitation of the stents is that they become occluded over time (usuallywithin3months).Figure15.17showsepithelializationofthestentsinvariousstages.

Fig.15.17dMembrane completely covering and occluding the stent.

Fig.15.17eMembrane covering and occluding the inner surface of the stent.

Fig.15.17fCombination of epithelium growing over the stent and membrane covering the inner surface.

Fig.15.17aThe stent deployed so that lateral leaflets are embedded in the airway mucosa.

Fig.15.17bEpithelium growing over the majority of the stent but still patent.

Fig.15.17cThe stent almost completely embedded within the airway. It was originally deployed in a position where part of the stent was covered with epithelium.

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ComplicationsAirway haemorrhage is the most serious potential complication, hence care andattention are required throughout the procedure. It is essential that the Dopplerassessmentofbloodvesselsisperformedcarefully.Anybleedingshouldbehandledasdescribedinthebleedingprotocol(Box12.1,p.212).Inaddition,anybleedingnoticedduring theballoondeflationcanberapidlymanagedbyre-inflating theballoon.Thetamponadeeffectoftheballoonshouldmanageandcontaintheairwaybleeding.AftertheprocedurethemostcommoncomplicationobservedisexacerbationofCOPDoracutebronchitis.Pneumomediastinumisalsofrequentlyseenwiththisprocedure,butit isusuallyself-limitinganddoesnotrequireanyintervention.Pneumothoraxisalsoobservedandagainthisisself-limitingandisusuallymanagedwithintercostaldrainage.

BronchialthermoplastyforasthmaBronchialthermoplastyisatechniquethatreducesairwaysmoothmuscleinpatientswith asthma.Treatment reduces the frequency of hospitalization, exacerbations andhealthcareutilization.

ThetechniqueusestheAlairradiofrequencycontrollerandAlaircatheter,whichdeliverstheenergytotheairways(Fig.15.18).Theenergydeliveredheatsupthelocaltissuetoaround65°Candselectivelyreducestheairwaysmoothmusclebulk.Thereissomemucosaloedemawhichrecoversoverthenext7–14days.

Fig.15.18aAlair radiofrequency controller with Alair bronchial thermoplastic catheter.

Fig.15.18bDistal aspect of the Alair catheter. Note the small bare (not insulated) mid-section of the open catheter.

Fig.15.18cAlair radiofrequency controller with foot pedal, earthing plate and Alair bronchial thermoplastic catheter.

Thepatienthasanearthingplateattachedtothethighorlowerback.TheAlaircatheterisintroducedthroughtheinstrumentchannelofthebronchoscopeandinsertedintothemostdistalaccessibleairway.Successofthetreatmentdependsoncomprehensivetreatmentoftheairway,withcaretakennottoapplyrepeatedtreatmentstothesameairway.Thisreliesonasystematicapproach.Intheclinicaltrialsthetreatmentswereadministeredoverthreesessions,treatingtherightlowerlobe,theleftlowerlobeandthenthetwoupperlobesandlingulabybronchoscopyevery3weeks.Ourapproach,forexample,fortherightlowerlobeistotreatRB10(rightposteriorbasalbronchus)first,usingtheBF260bronchoscope(externaldiameter4.3mm)sothatthedistalsubsegmentscanbeassessed.

TheAlaircatheterispassedthroughtheinstrumentchannelandthenopenedinthedistalairway(Fig.15.19).Oncefullyincontactwiththeairway,thefootpedalisactivatedtodelivertheradiofrequencyenergyinaspecificalgorithm.Thetreatmenttakesabout10secondsandanaudiblesignalindicatesdurationandcompletionoftreatment.Thewirebasketisthenpartiallyclosedandthecathetermovedproximallybyabout4mmandthenreopened.Thismanoeuvreisrepeatedsothatalltheairwaysfromthedistalaspecttotheproximalportionaretreatedinastepwisemanner.Anysidebranchesthatarevisualizedshouldalsobetreatedatthesametime.

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The radiofrequency controller delivers the energy over a 10-second period and anylossofcontactofthecatheterfromtheairwaywall,duetocoughingetc.,willcausetheradiofrequencycontrollertocutoutwithincompletedeliveryoftheenergy.Afurthercyclecanbedeliveredatthesamesite,butiftherearetwoincompleteactivationsatoneindividualsitethenthecathetershouldbemovedmoreproximallybeforefurthertreatment.

Patientmanagementisanimportantstepduringthebronchoscopytoensureadequateapplication of lidocaine through the airways and appropriate sedation to minimizepatientmovementandcoughing.

Once the full segmenthasbeen treated, thebronchoscope is systematicallymovedtothenextsegment, inthiscaseRB9(lateralsegmentoftherightlowerlobe)thenRB8,RB7andRB6 in sequence.Themainadverseevents andcomplicationsareanexacerbationoftheasthma,increasedmucoussecretionsandsomemucosaloedema.Mucouspluggingandatelectasisareoccasionallyobserved.

Inversion of the wire basket portion of the catheter occasionally occurs and theradiofrequencygeneratorwouldpreventactivation(Fig.15.20).Thewirebasketshouldbevisualizedatalltimesandcaretakentoensurethatitiscorrectlyopenedandapposedtotheairwaywallbeforetheradiofrequencygeneratorisactivatedtodeploytheenergy.

Fig.15.19aAlair 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.15.19bAlair 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.

Fig.15.20aInversion of an Alair catheter in the apical segment of the right upper lobe.

Fig.15.20bClose-up of the inverted catheter. Note the green wire is in the superior position and partially insulated wires are inverted and inferior to the green wire.

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Aaccessorybronchus,47,72accessorysegment,rightlowerlobe,70accessorysubapicalsegment,rightlowerlobe,45,68,

70adenocarcinoma,161 oesophageal,rightmainbronchus,162 trachea,159adenocysticcarcinoma,trachea,159adrenaline,airwaybleedingmanagement,200,201airwaybypass,233–6 complications,235 drug-elutingstents,235 equipment,233 procedure,233,234–5airwaysizing,intrabronchialvalve,224–5Alaircatheter,236–7Alairradiofrequencycontroller,236–7allergicbronchopulmonaryaspergillosis,163alveoli,confocalmicroscopy,168amyloid tracheobronchial,159 vocalcords,158anteriorapproach,28–52 see alsospecific anatomical featuresanteriorbasalsegment,rightlowerlobe,68,69anteriorborder,rightlung,14anteriorbranchrightupperlobebronchus,CT,61anteriorprevascularlymphnode(Station3A),

endobronchialultrasoundbronchoscopy,139anteriorsegment leftlowerlobe,48,51,52,76 CT,73,77 leftupperlobe,48,49,73,74,75 CT,58,61,64,73 rightlowerlobe,45,68,70 CT,69 rightupperlobe,36,37,38,61,62,63anteriorsegmentalbronchus,rightupperlobe,CT,59anterobasalsegments,rightlowerlobe,43,44anthracosis,tuberculosis,163aorta,78,79 CT,31,55 endobronchialultrasoundbronchoscopy,143,145aorticarch CT,23,31,55 endobronchialultrasoundbronchoscopy,134,135

aorticlymphnodes(Station5),86aortopulmonarylymphnodes(Station5),endobronchial

ultrasoundbronchoscopy,146apicalbranch,rightupperlobebronchus,CT,61apicalsegment leftlowerlobe,46,47,49,51,72,73,76 leftupperlobe,48 CT,61 rightlowerlobe,64,66,68 rightupperlobe,15,36,37,38,61,62,63,64 CT,58,59apicoanteriorsegments,rightupperlobe,38apicobasalsegments,rightlowerlobe,43,68apicoposteriorsegments leftlowerlobe,48 CT,73 leftupperlobe,48,49,73,74,75 CT,58,61,64 rightupperlobe,62argonplasmacoagulation,205,206argonpumpedlaser,photodynamictherapy,209Arndtendobronchialballoonblocker,198–9,201aryepiglotticfold,30,55 CT,53 rightseerightaryepiglotticfoldarytenoidcartilage,28,53 intubationproblems,191ascendingaorta,CT,58Aspergillusinfection intrabronchialvalvecomplications,229 Zephyrvalvecomplications,223asthma,220–37 bronchialthermoplasty,236–7autofluorescencebronchoscopy,164–6azygosarch,CT,59azygosvein CT,39,59,64 endobronchialultrasoundbronchoscopy,134,142

Bbacterialcolonization,Zephyrvalvecomplications,223ballooncatheters,192–9 see alsoArndtendobronchialballoonblocker;

Cohenendobronchialballoonblockerballoondilators,218,219balloonpreparation/calibration,intrabronchialvalve,

224–5

IndexNotes

Asthesubjectofthisbookisbronchoscopy,entriesunderthistermhavebeenkepttoaminimum.Readersareadvisedtolookformoredefiniteterms.

Entriesforright-orleft-sidedanatomicalstructurescanbefoundunderrightorleft,notundertheanatomicalstructure.

Tosavespaceintheindex,thefollowingabbreviationshavebeenused:

CT–computedtomography;TBNA–transbronchialfine-needleaspiration

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basalsegments,64 electromagneticnavigation,179,182 leftlowerlobe,47,51,72,76 rightlowerlobe,43,44,64,66,68basementmembraneelastin,confocalmicroscopy,

168basolateralsegments,rightlowerlobe,43,44bio-fouling,stents,216,217biopsyforceps,8 sterilization,3–4bipartitedivision,upperlobe,37,38,56,62bleedingseehaemorrhagebleedingdiathesis,5blood,autofluorescencebronchoscopy,165bloodvessels confocalmicroscopy,168 see alsospecific vesselsbrachiocephalicveins,78 endobronchialultrasoundbronchoscopy,141brachytherapy,tumourdebulking,209–10bronchialbiopsies,8bronchialbrushings,9bronchialgland,confocalmicroscopy,168bronchialthermoplasty,asthma,236–7bronchialtree,CTcorrelation,23bronchialwashings,8bronchioalveolarcellcarcinoma,confocal

microscopy,169bronchioles,confocalmicroscopy,168bronchoalveolarlavage,9–10bronchocentricgranulomatosis,163bronchopulmonarysegments,11–27 nomenclature,11–13bronchoscopes,1–2 diameter,2,3 instrumentchannels,2 lineararrayultrasoundprobes,2,3bronchoscopiclungvolumereductionseelung

volumereductionbronchus leftmainseeleftmainbronchus lingularseelingularbronchus rightmainseerightmainbronchusbronchusintermedius,39,60,63–4 CT,24,39,42,61,64

Ccandidiasis,158carcinomainsitu,rightlowerlobe,

autofluorescencebronchoscopy,166carina,31,33–4,56,57–8 CT,33,58,59 dysplasia,autofluorescencebronchoscopy,

166 electromagneticnavigation,173 leftmainseeleftmaincarina mainseemaincarina nomenclature,12 renalcellcarcinoma,160 thickening,autofluorescencebronchoscopy,

165 tracheobronchialamyloid,160 tumours,160

cartilagenodules rightlowerlobe,autofluorescence

bronchoscopy,165 trachea,159cartilagerings,31cartilagesseespecific cartilagesCCDs(charge-coupleddevices),1cellularcomposition,bronchoalveolarlavage,10charge-coupleddevices(CCDs),1chronicobstructivepulmonarydisease

(COPD) confocalmicroscopy,170 intrabronchialvalvecomplications,229coagulationprobe,electrocautery,202,203Cohenendobronchialballoonblocker,192–3,

192–7 difficulties,196–7 leftmainbronchusinsertion,194–5,194–7colorectalcarcinoma,metastasesseemetastatic

colorectalcarcinomacomputedtomography(CT) anteriorTBNA,94,95,96 balloondilators,219 bronchopulmonarysegments,23–7 emphysema,220 patientpreparation,5 pre-electromagneticnavigation,172,173 pre-endobronchialultrasoundbronchoscopy,

134 pre-intrabronchialvalve,225 pre-TBNA,113,114–15 stentinsertion,212,213,215 see alsospecific anatomical featuresconcentricsegmentaltumour,161confocalmicroscopy,167–71 equipment,167conscioussedation,PneumRx®coils,232consent,5contraindications(forbronchoscopy),5COPDseechronicobstructivepulmonary

disease(COPD)corniculatecartilage,intubationproblems,191corniculatetubercle,30,55 CT,53 rightseerightcorniculatetuberclecoughtechnique anteriorTBNA,98 transbronchialfineneedleaspiration(TBNA),

posteriorapproach,117cricoidcartilage,CT,53cross-infection,3cryoextraction,207,208cryotherapy,202,206–8,207CTseecomputedtomography(CT)cuneiformcartilage,28,53cuneiformtubercle,30,55 CT,53 rightseerightcuneiformtuberclecytology anteriorTBNA,98 endobronchialultrasoundbronchoscopy,156,

157 TBNA,98

Ddensitymask,emphysema,220descendingaorta,CT,58,59diameter,bronchoscopes,2,3diathermyseeelectrocauterydiffuseinfiltrativecarcinoma,161diffuselungdisease,4(Box) bronchoalveolarlavage,9directvision,stentinsertion,211–15,212–15disinfection,3–4disposableinstruments,4distortion,trachea,159drug-elutingstents,airwaybypass,235drug-relatedhypersensitivitypneumonitis,

confocalmicroscopy,170dysplasia,carina,autofluorescencebronchoscopy,

166

Eelastinnetwork,confocalmicroscopy,168electrocautery,202–5 coagulationprobe,202,203 complications,205(Box) electrosurgicalknife,202 electrosurgicalsnare,202,204 equipment,202 hotbiopsyforceps,202,205 precautions,205(Box) see alsoargonplasmacoagulationelectromagneticnavigation,172–88 advances,187–8 equipment,172 navigation,184–6,184–8 planningstage,172–9 registrationprocess,180–3electrosurgicalknife,202electrosurgicalsnare,202,204emphysema,220–37 confocalmicroscopy,169,170 CT,220 densitymask,220 heterogenousdisease,220–32 homogenous,233–6 see alsoairwaybypassendobronchialtumourdebulkingseetumour

debulkingendobronchialtumours confocalmicroscopy,169 stents,216,217endobronchialultrasoundbronchoscopy,133–57 equipment,133 examinationapproach,134–5 hilarzonelymphnodes,149–53 lefthilarlymphnode(Station11L),153 leftmainbronchiallymphnode(Station

10R),150 rightinferiorhilarlymphnode(Station

11Ri),152 rightmainbronchiallymphnode(Station

10R),149 rightsuperiorhilarlymphnode(Station

11Rs),151 inferiormediastinallymphnodes,148

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endobronchialultrasoundbronchoscopy–contd intubation,134 lymphnodesampling,154–7,156 cytology,156,157 equipment,154–5 technique,154–6 lymphnodestations,136–53 see alsospecific lymph nodes subcarinallymphnode(Station7),148 superiormediastinallymphnodes,136–47 anteriorprevascularlymphnode(Station

3A),139 aortopulmonarylymphnodes(Station5),

146 higherleftparatracheallymphnode

(Station2L),138 higherrightparatracheallymphnode

(Station2R),136–7 lowerleftparatracheallymphnode

(Station4L),144–5 lowerrightparatracheallymphnode

(Station4R),141–4 para-aorticlymphnodes(Station6),147 posteriortracheallymphnode(Station

3P),140 see alsospecific anatomical featuresendometrialcarcinoma,leftlowerlobe,162endotrachealtube,stentinsertion,219epiglottis,28,29,30,54,55equipment,1–2 electromagneticnavigation,172extrabronchialtumour,rightupperlobe

compression,161

Ffiberopticbronchoscope,1fluorescence-basedimaging,164–71 see alsospecific methodsforeignbodies,granulationtissue,163fungalcolonization Zephyrvalvecomplications,223 see alsospecific fungal infections

Ggranulationtissue foreignbodies,163 intrabronchialvalvecomplications,229 stents,217,218

Hhaemoptysis,intrabronchialvalvecomplications,

229haemorrhage intrabronchialvalvecomplications,229 management,200–1,200(Box) transbronchiallungbiopsy,10higherleftparatracheallymphnode(Station2L),

endobronchialultrasoundbronchoscopy,138

higherrightparatracheallymphnode(Station2R),endobronchialultrasoundbronchoscopy,136–7

hilarzonelymphnodes anteriorTBNA,106–12 endobronchialultrasoundbronchoscopysee

endobronchialultrasoundbronchoscopy posteriorTBNA,125–32horizontalfissure,rightlung,14hotbiopsyforceps,202,205Hurthlecellcarcinoma,rightmiddlelobe,162hyoidbone,CT,53hypersensitivitypneumonitis confocalmicroscopy,170 drug-related,170hypoxia,5

Iindications(forbronchoscopy),4,4(Box)infection,4(Box)inferiormediastinallymphnodes,88 anteriorTBNA,105 endobronchialultrasoundbronchoscopy,148 posteriorTBNA,124inferiorpulmonaryvein CT,42,44,46,48,49,50,52,69,71,73,74,

76,77inferiorsegment,lingula,CT,77inflammatorypseudo-tumour,163inflammatoryweb,leftlowerlobe,

autofluorescencebronchoscopy,165informedconsent,5instrumentchannels,bronchoscopes,2interlobarlymphnodes(Station11),92–3interstitialpneumonitis,confocalmicroscopy,170intrabronchialvalves airwaysizing,224–5 balloonpreparation/calibration,224–5 complications,229 equipment,224,225 lungvolumereduction,223–8 patientpreparation,225 procedure,225,226–7 removal,228intubation,189–91 equipment,189 problems,191 techniques,190–1invasivesquamouscellcarcinoma,161

Jjabbingtechnique anteriorapproachTBNA,97–8 posteriorapproachTBNA,116–17

KKaposi’ssarcoma secondarycarina,161 vocalcords,158

Llaryngealmaskairway(LMA),191lasertreatment,tumourdebulking,209lateralsegment leftlowerlobe,48,51,52,76 CT,73,77

rightlowerlobe,45,66,68,69,70 CT,69,73 rightmiddlelobe,CT,65leftapicalbasalsegment(LB6),electromagnetic

navigation,179,183leftaryepiglotticfold,29,54leftatrium,CT,31,40,42,49,55,58,65,74leftbrachiocephalicvein,78leftbronchopulmonarytree,19,20 nomenclature,12lefthilarlymphnode(Station11L) endobronchialultrasoundbronchoscopy,153 posteriorTBNA,131–2leftinferiorpulmonaryvein,CT,31,40,55,58,65leftlowerlobe,20,22,46,47,50–2,72,75–7,76 anteriorsegment,48,51,52,76 CT,73,77 apicalsegment,46,47,49,51,72,73,76 apicoposteriorsegment,48 CT,73 autofluorescencebronchoscopy,164 basalsegments,47,51,72,76 CT,26,42,48,50,51,52,76,77 inflammatoryweb,autofluorescence

bronchoscopy,165 lateralsegment,48,51,52,76 CT,73,77 leftlung,20,22 leiomyosarcoma,162 metastaticendometrialcarcinoma,162 polypoidtumour,autofluorescence

bronchoscopy,166 posteriorsegment,51,52,76 CT,77 squamouscellcarcinoma,162leftlowerlobebronchus,73 CT,71,76leftlung,18–20,22 leftlowerlobeseeleftlowerlobe leftupperlobeseeleftupperlobeleftmainbronchiallymphnode(Station10L) anteriorTBNA,107,108 endobronchialultrasoundbronchoscopy,150 posteriorTBNA,127–8leftmainbronchiallymphnode(Station10R),

endobronchialultrasoundbronchoscopy,150

leftmainbronchus,34,46–7,56,58,71–2,73–2 Cohenendobronchialballoonblocker

insertion,194–5,194–7 CT,39,46,48,59,64,71,73,76 metastaticcolorectalcarcinoma,162 renalcellcarcinoma,162 secondarycarina,72 squamouscellcarcinoma,162leftmaincarina autofluorescencebronchoscopy,164 electromagneticnavigation,175leftpulmonaryartery,79 CT,31,42,46,48,50,55,58,59,71,73,76leftsecondarycarina(LC2),electromagnetic

navigation,179,182leftsuperiordivisionbronchus,73

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leftsuperiorpulmonaryvein,CT,39,46,64,71leftupperlobe,18–19,22,47–8,51,72,73–4,76 anteriorsegment,48,49,73,74,75 CT,58,61,64,73 apicalsegment,48 CT,61 apicoposteriorsegment,48,49,73,74,75 CT,58,61,64 CT,39,49,73,74 leftlung,19,22 posteriorsegment,74leftupperlobebronchus,72 CT,64leftvallecula,29,54leftventricle,CT,40,65leftventricularoutflowtract,CT,39,64leftvocalcord,29leiomyosarcoma,leftlowerlobe,162lidocaine,intubation,190lineararrayultrasoundprobes,bronchoscopes,

2,3lingula,48,49,73,74–5 CT,49,74 inferiorsegment,CT,77 superiorsegment,CT,76lingularbronchus,47,72,75 CT,74lowercervicallymphnodes,81lowerleftparatracheallymphnode(Station4L) anteriorTBNA,102–3 posteriorTBNA,121–2lowerlobe,basalsegments,64lowerparatracheallymphnodes(Station4),85lowerrightparatracheallymphnode(Station4R) anteriorTBNA,99–101 posteriorTBNA,118–20lowerzonelymphnodestations,89–90lungs,leftseeleftlunglungvolumereduction,220–37 intrabronchialvalve,223–8 Zephyrvalve,221–3lymphnodestations,81–93 hilar/intralobarzone(hilarnodes),91–2 inferiormediastinallymphnodes,88 interlobarlymphnodes(station11),92–3 lowerzone,89–90 mainbronchiallymphnodes(station10),91 para-oesophageallymphnodes(Station8),89 para-oesophageallymphnodes(Station9),89 peripheralzone(station12,13and14),93 pulmonaryligamentlymphnodes(Station9),

90 subcarinallymphnodes(Station7),88 superiormediastinalzone,82–7 aorticlymphnodes(Station5),86 lowerparatracheallymphnodes(Station

4),85 para-aorticlymphnodes(Station6),87 posteriorlymphnodes(Station3P),84 prevascularlymphnodes(Station3A),83 retrosternallymphnodes(Station3A),83 retrotracheallymphnodes(Station3P),

84

station3,83–4 upperparatracheallymphnodes(Station

2),82 supraclavicularzone(Station1),81 see alsospecific lymph nodes

Mmainbronchiallymphnodes(Station10),91mainbronchus leftseeleftmainbronchus rightseerightmainbronchusmaincarina electromagneticnavigation,177 leftseeleftmaincarinamanualcleaning,3medialsegment rightlowerlobe,45,66,68,70 rightlowerlobebronchus,CT,73metastaticcolorectalcarcinoma leftmainbronchus,162 rightbasalbronchus,162metastaticendometrialcarcinoma,leftlower

lobe,162microscopy,confocalseeconfocalmicroscopymicrothrombiformation,cryotherapy,206midazolam,6migration,stents,218mucosalhypertrophy,intrabronchialvalve

complications,229mucus segmentalbronchus,163 stents,216,217

Nneodymium–yttriumaluminiumgarnetlaser,209neoplasia,4(Box)nodules rightlowerlobe,163 trachea,163nomenclature,bronchopulmonarysegments,

11–13non-smallcelllungcancer,confocalmicroscopy,

169

Oobliquefissure CT,58 leftlung,18 rightlung,14occupationallungexposure,bronchoalveolar

lavage,9oesophagealadenocarcinoma,rightmain

bronchus,162oesophagus,CT,31,55organizingpneumonia,confocalmicroscopy,171

Ppara-aorticlymphnodes(Station6),87 endobronchialultrasoundbronchoscopy,147para-oesophageallymphnodes(Station8),89parenchymalinfiltrates,bronchoalveolarlavage,9partialdeployment,Zephyrvalve,222patientpreparation,5,5(Box)

intrabronchialvalve,225PET(positronemissiontomography),pre-

endobronchialultrasoundbronchoscopy,134,141,144–5,146,148,150,151,152,153

photodynamictherapy,tumourdebulking,209Photofrin,photodynamictherapy,209photosensitizers,photodynamictherapy,209piggybackmethod anteriorTBNA,98 transbronchialfineneedleaspiration(TBNA),

posteriorapproach,117planningstage,electromagneticnavigation,172–9pneumonectomy,balloondilators,219pneumonia,confocalmicroscopy,171pneumonitis,170pneumothorax transbronchiallungbiopsy,10 Zephyrvalvecomplications,223PneumRx®coils,230–2polypoidnecrotictumour,rightupperlobe,162polypoidtumours leftlowerlobe,autofluorescence

bronchoscopy,166 polypoidnon-smallcellcarcinoma,161polyps,vocalcords,158poorlydifferentiatedcarcinoma,trachea,159positronemissiontomography(PET),pre-

endobronchialultrasoundbronchoscopy,134,141,144–5,146,148,150,151,152,153

posteriorapproach,53–77 see alsospecific anatomical featuresposteriorbasalsegment,rightlowerlobe,68posteriorborder,rightlung,14posteriorlymphnodes(Station3P),84posteriormembranoustrachea,56posteriorpharyngealwall,29posteriorsegment leftlowerlobe,51,52,76 CT,77 leftupperlobe,74 rightlowerlobe,45,69,70 CT,69,73 rightupperlobe,15,36,37,38,61,62,63 CT,58posteriorsegmentalbronchus,rightupperlobe,

CT,59posteriortracheallymphnode(Station3P) anteriorTBNA,103–4 endobronchialultrasoundbronchoscopy,140 posteriorTBNA,122–3posterobasalsegments,rightlowerlobe,43,44potassiumtitanylphosphate(KTP),photodynamic

therapy,209prevascularlymphnodes(Station3A),83primarytracheobronchialamyloid,158Pseudomonasinfection,Zephyrvalve

complications,223pulmonaryarteries,79 CT,40,42,44,46,49,50,52,58,61,65,74,76 endobronchialultrasoundbronchoscopy,134,

146

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pulmonaryarteries–contd leftseeleftpulmonaryartery rightseerightpulmonaryarterypulmonaryarterytrunk,CT,61pulmonaryfibrosis,confocalmicroscopy,170pulmonaryhilum leftlung,18 rightlung,14pulmonaryligamentlymphnodes(Station9),90pulmonarysarcoidosis,confocalmicroscopy,170pulmonarytrunk,CT,39,64pulmonaryveins,79,80

Rradiology-guidedstentinsertion,216rapidon-sitecytologicalevaluation(ROSE),

anteriorTBNA,98RCCseerenalcellcarcinoma(RCC)registrationprocess,electromagneticnavigation,

180–3renalcellcarcinoma(RCC) carina,160 leftmainbronchus,162retrosternallymphnodes(Station3A),83retrotracheallymphnodes(Station3P),84rightapicalbasalsegment(RB6),electromagnetic

navigation,178,182rightaryepiglotticfold,29,54rightatrium,CT,40,42,65rightbasalbronchus,metastaticcolorectal

carcinoma,162rightbronchopulmonarytree,nomenclature,11rightcorniculatetubercle,29,54rightcuneiformtubercle,29,54righthilarlymphnodes,endobronchialultrasound

bronchoscopy,135rightinferiorhilarlymphnode(Station11Ri) anteriorTBNA,110–11 endobronchialultrasoundbronchoscopy,152 posteriorTBNA,130–1rightinferiorpulmonaryvein,CT,40,65rightlowerlobe,17,21,41,42–5,44,45,66,

67–70,68–70 accessorysegment,70 accessorysubapicalsegment,45,68,70 anteriorbasalsegment,68,69 anteriorsegment,45,68,70 CT,69 anterobasalsegments,43,44 apicalsegment,64,66,68 apicobasalsegments,43,68 basalsegments,43,64,66,68 basolateralsegments,43,44 carcinomainsitu,autofluorescence

bronchoscopy,166 cartilagenodule,autofluorescence

bronchoscopy,165 CT,26,40,42,43,44,65,67,69 lateralbasalsegment,68,69 lateralsegment,45,66,69,70 CT,69,73 medialbasalsegment,68 medialsegment,45,66,68,70

nodules,163 posteriorbasalsegment,68 posteriorsegment,45,69,70 CT,69,73 posterobasalsegments,43,44 rightlung,17,21 sleeveresection,autofluorescence

bronchoscopy,166 subapicalsegment,69rightlowerlobebronchus,medialsegment,CT,

73rightlung nomenclature,14–17 rightlowerlobeseerightlowerlobe rightmiddlelobeseerightmiddlelobe rightupperlobeseerightupperlobe segments,21–2rightmainbronchiallymphnode(Station10R) anteriorTBNA,106–7 endobronchialultrasoundbronchoscopy,149 posteriorTBNA,125–6rightmainbronchus,34–5,56,58,59–60,71 CT,35,59,61,64 oesophagealadenocarcinoma,162rightmiddlelobe,16,21,40–1,64,65–6 autofluorescencebronchoscopy,164 CT,25,40,65 electromagneticnavigation,174 Hurthlecellcarcinoma,162 lateralsegment,CT,65rightmiddlelobebronchus,64rightmiddlelobecarina,electromagnetic

navigation,178,181rightpulmonaryartery,79 CT,31,39,46,55,58,64,71rightsuperiorhilarlymphnode(Station11Rs),

endobronchialultrasoundbronchoscopy,151

rightsuperiorhilarnodes,endobronchialultrasoundbronchoscopy,135

rightsuperiorpulmonaryvein,CT,39,40,64,65rightupperhilarlymphnode(Station11Rs) anteriorTBNA,109–10 posteriorTBNA,128–9rightupperlobe,15,21,36–8,37,38,56,60–3,

61–3 anteriorsegment,61,62,63 anteriorsegmentalbronchus,CT,59 apicalsegment,61,62,63,64 CT,58 apicalsegmentalbronchus,CT,59 apicoposteriorsegment,62 bipartitedivision,37,62 CT,24,36,39,40,58,61,65 electromagneticnavigation,174 extrabronchialtumour,161 polypoidnecrotictumour,162 posteriorsegment,61,62,63 CT,58 posteriorsegmentalbronchus,CT,59 smallcellcarcinoma,162 tuberculosis,163 tumour,autofluorescencebronchoscopy,166

rightupperlobebronchus anteriorbranch,CT,61 apicalbranch,CT,61 CT,59,61,64rightupperlobecarina(RC1),electromagnetic

navigation,177,181rightvallecula,29,54roomergonomics,6–7ROSE(rapidon-sitecytologicalevaluation),

anteriorTBNA,98rotation,bronchoscopes,2

Ssabretrachea,159sampling,8–10sarcoidosis,pulmonary,170SCCseesquamouscellcarcinoma(SCC)secondarycarina,76 Kaposi’ssarcoma,161 leftmainbronchus,72sedation,6segmentalbronchus,mucus,163segmentaltumour,161sleeveresection,rightlowerlobe,

autofluorescencebronchoscopy,166smallcellcarcinoma,161 rightupperlobe,162squamouscellcarcinoma(SCC) confocalmicroscopy,169 invasive,161 leftlowerlobe,162 leftmainbronchus,162 vocalcords,158Station2L(higherleftparatracheallymphnode),

endobronchialultrasoundbronchoscopy,138

Station2R(higherrightparatracheallymphnode),endobronchialultrasoundbronchoscopy,136–7

Station3A(prevascularlymphnodes),83Station3A(retrosternallymphnodes),83Station3Pseeposteriortracheallymphnode

(Station3P)Station3P(retrotracheallymphnodes),84Station4(lowerparatracheallymphnodes),85Station4Lseelowerleftparatracheallymph

node(Station4L)Station4Rseelowerrightparatracheallymph

node(Station4R)Station6seepara-aorticlymphnodes(Station6)Station7seesubcarinallymphnodes(Station7)Station8(para-oesophageallymphnodes),89Station9(pulmonaryligamentlymphnodes),90Station10(mainbronchiallymphnodes),91Station10Lseeleftmainbronchiallymphnode

(Station10L)Station10Rseerightmainbronchiallymphnode

(Station10R)Station11(interlobarlymphnodes),92–3Station11Lseelefthilarlymphnode(Station

11L)Station11Riseerightinferiorhilarlymphnode

(Station11Ri)

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stents,211–19 complication,216–18 insertiontechniques,211–16 directvision,211–15,212–15 radiology-guided,216 migration,218sternalnotchlymphnodes,81subapicalsegment,rightlowerlobe,69subcarinallymphnodes(Station7),88 anteriorTBNA,105–6 endobronchialultrasoundbronchoscopy,135,

148 posteriorTBNA,124–5 tumour,160SuperDimension®systemseeelectromagnetic

navigationsuperiormediastinallymphnodes anteriorTBNA,99–104 endobronchialultrasoundbronchoscopysee

endobronchialultrasoundbronchoscopy posteriorTBNA,118–23superiorpericardialrecess,CT,58superiorpulmonaryvein CT,40,42,49,65,74superiorsegment,lingula,CT,76superiorvenacava,78 CT,31,55,58,59,61 endobronchialultrasoundbronchoscopy,134,

142supraclavicularlymphnodes(Station1),81symptominvestigation,4(Box)

TTBNAseetransbronchialfineneedleaspiration

(TBNA)techniques,8–10therapeuticindications,4(Box)tissuehypertrophy,intrabronchialvalve

complications,229trachea,29–32,31–2,55–7,56–7 adenocarcinoma,159 adenocysticcarcinoma,159 autofluorescencebronchoscopy,164

cartilagenodules,159 CT,31,55,57,59 distortion,159 nodules,163 poorlydifferentiatedcarcinoma,159trachealbronchus,29,32,56 CT,32,56trachealweb,159tracheobronchialamyloid,159 carina,160tracheobronchopathiaosteochondroplastica,159tracheo-oesophagealfistula,159transbronchialfineneedleaspiration(TBNA) anteriorapproachseebelow cytology,116–17 equipment,94,113 lymphnodestationsseespecific lymph nodes posteriorapproachseebelowtransbronchialfineneedleaspiration(TBNA),

anteriorapproach,94–112 coughtechnique,98 CT,94,95,96 cytology,98 jabbingtechnique,97–8 lymphnodestations,99–112 see alsospecific lymph nodes piggybackmethod,98 planning,94 siteselection,94 technique,97–8 virtualbronchoscopy,96transbronchialfineneedleaspiration(TBNA),

posteriorapproach,113–32 coughtechnique,117 jabbingtechnique,116–17 lymphnodestations,118–32 see alsospecific lymph nodes piggybackmethod,117 planning,113 siteselection,113 technique,116–17 virtualbronchoscopy,115transbronchiallungbiopsy,10

tuberculosis,163 anthracosis,163 rightupperlobe,163tumour(s) rightupperlobe autofluorescencebronchoscopy,166 see alsospecific tumourstumourdebulking,202–10 brachytherapy,209–10 lasertreatment,209 photodynamictherapy,209 see alsoargonplasmacoagulation;

electrocautery

Uulcers,bronchocentricgranulomatosis,163uncuffedendotrachealtube,189upperleftlobe,72upperparatracheallymphnodes(Station2),82

Vvascularrelationships,78–81 bronchoscopicviews,80 see alsospecific arteries;specific veinsvasoconstriction,cryotherapy,206ventilation–perfusionscan,pre-intrabronchial

valve,225videobronchoscope,1,2virtualbronchoscopy anteriorTBNA,96 pre-TBNA,115 see alsoelectromagneticnavigationvocalcords,28–9,30,53–5,54–5 amyloidinfiltration,158 CT,28,29,53–4 Kaposi’ssarcoma,158 left,29 paralysis,158 polyps,158 squamouscellcarcinoma(SCC),158

ZZephyrvalve,lungvolumereduction,221–3