The Equipment

There are several commonalities of all video bronchoscopes, regardless of manufacturer, that you should be familiar with. Numbered descriptions of the parts of the bronchoscope below can be matched to numbers on images of the fiberoptic and video bronchoscope.

3. Control lever: Only controls the tip of the scope by allowing movement in the vertical plane. Pulling the lever down will flex the tip UP while pushing the lever up will retroflex the tip DOWN. Side to side (or left to right) movement is accomplished by rotation of the body of the bronchoscope with the operator's wrist (see below).

4. Working channel port: For biopsy, instillation of local anesthetic, suctioning or oxygen delivery through the internal working channel. Note that larger scopes have larger working channels.

5. Body: Incorporates control level, working channel and eye piece (when present).

6. Insertion cord: Contains fiberoptic bundle for light and image transmission, tip bending control wires and working channel. Average length 600mm (range 500 – 650mm).  Note that larger scopes also have larger fiber bundles (i.e. better imaging capabilities)

7. Light source: Can be a portable battery powered source or via a cable connected to the fiberoptic tower.

8. Suction valve and port: Communicates with the same internal channel utilized by the working channel port. Note that larger scopes have larger working channels (i.e. better suction capabilities).

Differences that matter (Most importantly size …)

1. Working channel 

   The size of the working channel becomes relevant when airway suctioning is a priority (i.e. smaller scopes have smaller working channels, making suction less effective 2/2 plugging)

   

2. Outside or external diameter – Given in millimeters (mm). As a general rule, use a scope with an external diameter only slightly less than the internal diameter of the ETT (A 0.7 – 1.0mm diameter differential is ideal, a 2.0 mm differential commonly works without issue. Larger differentials significantly increase the risk of tissue impingement during ETT railroading).

Most of our scopes come in these standard sizes:

“Adult Scope”, aka the "5-0" – outer diameter of 5.0 mm

• Used for most awake and asleep fiberoptic intubations, simply because it is the largest scope and allows for less complicated and more successful placement of larger ETTs (6.0 to 7.0 endotracheal tubes fit well)

• Also used in an endotracheal tube for LMA exchange utilizing the “blue stylet technique”

  
  

“Intermediate Scope”, aka the "4-0" – outer diameter of 4.0 mm

• Used in Aintree assisted intubations through the LMA. (The Aintree catheter has an internal diameter of 4.7 mm)

  
  

“Pediatric/Slim Scope”, aka the "3-0" – outer diameter of 3.0 mm

• Utilized for bronchial blocker and double lumen tube placement as its small size fits better in crowded spaces (i.e. An ETT lumen which is also accommodating a bronchial blocker cannot also accommodate a large scope)

• Note that attempting a fiberoptic intubation with the slimmer scopes can be difficult, if not impossible, when utilizing a standard adult size ETT due to scope/tube size discrepancy.

Driving the Scope – 3 Basic Moves

** It is important to note that one can only reliably drive the scope when the length of the scope is kept straight, without slack or bend.

** Furthermore, targets must stay centered on the screen. A centered target is one which is located immediately below the center of the scope. Trying to advance the scope towards and through a target which is not centered below the scope will be difficult. Any success you have in doing so can be attributed to the scope sliding off of adjacent tissue and eventually and haphazardly slipping into the target.

1. Flex/Retroflex

2. Rotate left / Rotate right

Rotating the scope body involves a simple move of the wrist. Keeping the scope straight (without bends) will translate to clean and predictable transitions (i.e. rotating the scope 90 degrees CW will rotate images on your screen 90 degrees CW and vice versa)

3. Advance / Withdraw

   1. Always advance slowly, keeping targets centered.

   2. Small movements require small corrections.

   3. When you lose your way (i.e. Video image shows nothing but pink mucosa) simply withdraw until structures once again become identifiable. Continuing to advance past pink mucosa turns a fiberoptic procedure into a BLIND procedure… with very expensive equipment.

Care of the bronchoscope

• Always lubricate the scope with silicone lubricant before use. Always.

• Unsure if THIS is gonna fit through THAT? A 0.7 mm diameter differential is usually adequate assuming good lubrication. But if unsure, test for appropriate fit ex vivo.

• Use a bite block in awake patients to prevent inadvertent biting of the scope. Not only is this a safety risk but teeth can easily damage the delicate coating of the scope.

Basic checklist prior to use

1. Bronchoscope sterilized?

2. Check tip movement

3. Suction valve attached and suction available

4. Light source attached and operational

5. Connect bronchoscope to monitor if using a screen and ensure correct orientation (i.e. Somewhere you can easily view the screen while performing the procedure. Craning your neck to view a screen located behind you is far from ideal)

6. Defog tip of scope. Have more defogger available and easily accessible should you need to reapply during the procedure.

7. White balance

8. Focus the eyepiece or monitor on some written words. Confirm integrity of image, i.e. no pixel drop-out

9. For a standard fiberoptic intubation through the intubating oral airway, lubricate the scope and load the ETT, securing it into place with a piece of tape.