The flexible bronchoscope does not replace the rigid instrument in diagnosis nor in management of airway lesions, but it is a very useful adjunctive tool. It should be used liberally by pulmonologists to rule out organic obstruction in patients thought to have "adult onset asthma," to clarify the origin of hemoptysis (however minor), and to investigate the possible causes of recurrent or unyielding volume loss, atelectasis, or pneu-monitis. Intubation, for any reason, is facilitated by using the flexible bronchoscope as a guide. Difficult intubations are made simple in this way. Traumatic tracheal separation may respond to this technique.
Rigid bronchoscopy is truly impossible in only very few patients. Examples included 2 patients with achondroplastic dwarfism with prognathous jaws, which produced a deep right angle between the oropharynx and the trachea. Another patient suffered severe fixed cervical deformity as a result of radical neck surgery and remote high-dose irradiation. In such patients, only flexible bronchoscopy is possible. If general anesthesia is elected, intubation may be avoided by passing the flexible bronchoscope through a laryn-geal mask airway (Figure 5-8A).5
The flexible instrument may be used with the sealing cap used for telescopes through a rigid bron-choscope, in order to expand examination to include segmental bronchi. It is also introduced via an adapter through an endotracheal tube to identify a precise point in the airway during surgery (Figure 5-8B). If necessary, the endotracheal tube is partly withdrawn and the bronchoscopic light transilluminates the trachea to the operative field (with operating table lights deflected). Thus, the extremities of a postintubation stenosis, not clearly defined visually from the outside of the trachea, can be identified precisely. The surgeon passes a no. 25 needle through the tracheal wall into the lumen, and the needle is adjusted precisely by bronchoscopic confirmation (see Figure 24-10 in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection").
The flexible bronchoscope is also invaluable in placing and replacing either double or single lumen tubes in the left or right main bronchus during bronchial or carinal resections. A pediatric flexible bron-choscope can be passed through one of the channels of a double lumen tube. Tracheobronchial anastomosis can be examined intraoperatively in this way. Correction of postpneumonectomy syndrome, of splinting procedures for tracheobronchomalacia, and assessment for malacia after excision of huge compressive goiters are established by repeated intraoperative flexible endoscopy. Transillumination may help to identify the location of a bronchial stump, in the event of a chronic bronchopleural fistula being buried in dense, irradiated mediastinal cicatrix. Flexible bronchoscopy has become our routine method for examination of an anastomosis, prior to discharge of a patient recovering from tracheal reconstruction. It is much more dependable than any other imaging technique for the early identification of anastomotic defects of any type.
figure 5-8 A, Laryngeal mask airway (LMA). A flexible bronchoscope is easily passed through the LMA. B, Adapter for bronchoscopy via endotracheal tube or LMA (Portex).
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If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.