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.

  1. Let us start with the trachea. Observe the tracheal rings. The posterior membranous portion will bulge normally during expiration and cough.
  2. 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.
  3. I always enter the side opposite to the known abnormal lung for the following reasons:
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.