Flexible bronchoscopy in many ways defines the procedural component of pulmonary medicine. Unfortunately, in many fellowship programs, little attention is directed toward a structured educational effort to attain the necessary skills to become a solid endoscopist. Often a “see one, do one, teach one” approach is taken, which does not lend itself to educating bronchoscopists in the best possible environment and frequently leaves little time to discuss components of the procedure at hand. Additionally, it is difficult to teach more advanced, less common procedures in this setting.

The specifics of particular procedures are rarely a matter of discussion, and neither is the maintenance of bronchoscopes. Even though pulmonologists are frequently in charge of or medically direct bronchoscopy units, the lack of this knowledge puts the new trainee in a difficult position.

It should also not come as a surprise that even basic minimally invasive procedures such as transbronchial needle aspiration are performed by only a minority of pulmonologists – reflecting the aforementioned significant shortcomings in procedural education.

In 2000, we introduced a standardized introduction to bronchoscopy for all pulmonary medicine trainees of the Harvard Medical School–associated teaching hospitals. It included a half-day of lectures, followed by hands-on training in basic techniques as well as simulation practice. It was enthusiastically embraced and quickly expanded to include Fellows from many training programs around New England.

Over the past decade a range of new diagnostic tools has become available to the bronchoscopist, and this range reflects technological advancements such as the development of miniaturized transducers as well as advanced image guidance. Many of these techniques have yet to find an established role in practice and remain research tools. Others, in particular endobronchial ultrasound (EBUS) guidance, have had an immediate clinical impact and are now considered state-of-the-art technologies. The tools discussed below can be broadly grouped together into two categories based on their utility. The first group is used to extend the diagnostic reach of the bronchoscope to direct biopsy of distal lesions or lesions outside the airway and includes EBUS, ultrathin, and electromagnetic navigational bronchoscopy (ENB). The second broad category includes tools such as autofluorescence bronchoscopy (AFB), narrow band imaging (NBI), and high-magnification videobronchoscopy, which primarily aim to improve detection rates for the preinvasive bronchial lesions of dysplasia and carcinoma in situ (CIS). Such lesions, which are only a few cell layers thick, are often missed on regular white light bronchoscopy.

ENDOBRONCHIAL ULTRASOUND

EBUS technology has probably been the greatest advance in diagnostic bronchoscopy since the widespread introduction of the flexible bronchoscope (FB) in the 1960s. It provides the enormous advantage of allowing the endoscopist to look within, as well as outside, the airway wall, is safe and noninvasive for patients, and is relatively straightforward to use.

INTRODUCTION

Bronchoscopy is a diagnostic and therapeutic procedure that permits direct visualization of normal and pathological alterations of the upper and lower airways. Expert knowledge of airway anatomy is a prerequisite for successful performance of the procedure. The major advantages of the flexible bronchoscope (FB) include the ability to insert it nasally, orally, or through a tracheostomy stoma to visualize apical segments of upper lobes as well as segmental and subsegmental bronchi in all lobes. This chapter focuses on identification of normal anatomy, landmarks, and pathologies seen during bronchoscopy of upper airways (from nares to glottis) and lower airways (trachea and conducting bronchi).

Bronchoscopists commonly refer to airway anatomy according to the Jackson–Huber classification with segmental airway anatomy named according to spatial orientation (i.e., anterior/posterior, superior/inferior, and medial/lateral) (Figure 4.1) Table 4.1 lists the nomenclature accordingly. Many thoracic surgeons prefer to use the Boyden surgical classification, which assigns numbers to the segmental airways (Table 4.1). It is advised that beginning bronchoscopists learn the Jackson–Huber classification first, emphasizing accurate and consistent usage.

The FB is introduced by the bronchoscopist standing either behind the head of the supine patient or facing the patient. The anatomic orientation of airways varies depending on the operator's position. For the purpose of consistency in this chapter, the anatomical orientation is presented with the operator standing behind the supine patient.