Bronchial Anatomy and Procedures
Let me first show you the normal anatomy. You have to familiarize yourself with
the segmental anatomy and a three dimensional feel for the tracehobronchial tree. The
video segment lasts for four minutes and 20 seconds. You can abort the video by pressing
the [ENTER/RETURN] key.
- Let us start with the trachea. Observe the tracheal rings. The posterior
membranous portion will bulge normally during expiration and cough.
- Anesthesia of the tracheobronchial tree is important. Instill 2 cc's of 2%
xylocaine to each new area prior to advancing the scope. Use suction to remove any
secretions. Do not be trigger happy! Use suction sparingly and intermittently. Otherwise,
you will damage the mucous membrane and cause it to bleed. The subsegments will also
collapse with excessive suction.
- I always enter the side opposite to the known abnormal lung for the following
- My preoccupation with the abnormal lung may preclude me from spending sufficient
time for evaluation of the normal side.
- The anesthesia will stay current.
- Right bronchial tree: Let us to the right side first. The right main stem
bronchus is in line with the trachea and is short. The right upper lobe bronchus branches
immediately beyond the carina along the lateral wall. A gentle turn of the bronchoscope
tip towards the right side will bring the RUL orifice into view. Observe the posterior,
anterior and apical segments.
- Withdraw the scope and enter the right intermediate bronchus. Three orifices will
be noted. They are the RML anteriorly, RLL straight down and the superior segment
posteriorly across from the RML. The arrow will be pointing to the RLL.
- Withdraw the bronchoscope and enter posteriorly the superior segment of the RLL.
Withdraw the scope again and avance to the RLL. The medial basal segment will branch off
first along the medial side. At the end you will see the posterior, anterior and lateral
basal segments clustered together.
- Left bronchial tree: You will now inspect the left bronchial tree. Withdraw the
scope to the carina. Continue to instill the anesthetic as before into each new area.
Observe the angulation and length of the left main stem bronchus. Recognize the pulsation
along the inferomedial aspect.
- Note the secondary carina. At the orifice of the LLL, the superior segment
branches off posteriorly. Upon entering the LL, the three basal segments can be seen.
- Withdraw the scope and enter the left upper orifice. This divides into the LUL
and lingular. Inspect the superior and inferior segments of the lingula. Enter the LUL and
observe the apical, posterior and anterior segments.