Atlas of

Flexible
Bronchoscopy
I would like to dedicate this book to my family for all their support and encouragement
despite the endless evenings and weekends spent on this book. A special thanks to my
wife, Mala who created some of the initial anatomical drawing for this book.
 Atlas of
Flexible
Bronchoscopy
Pallav Shah md frcp
Consultant Physician and Honorary Senior Lecturer
Royal Brompton Hospital, Chelsea and Westminster
Hospital and Imperial College London, UK
First published in Great Britain in 2012 by
Hodder Arnold, an imprint of Hodder Education, an Hachette UK company,
338 Euston Road, London NW1 3BH

http://www.hodderarnold.com

© 2012 Pallav Shah

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administering any of the drugs recommended in this book.

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 Contents
Preface  vii
1 Introduction 1
2 Bronchopulmonary segments 11
3 Normal anatomy (anterior approach) 28
4 Normal anatomy (posterior approach) 53
5 Vascular relationships and lymph node stations 78
6 Transbronchial fine-needle aspiration (anterior approach) 94
7 Transbronchial fine-needle aspiration (posterior approach) 113
8 Endobronchial ultrasound bronchoscopy 133
9 Pathology 158
10 Fluorescence-based imaging 164
11 Electromagnetic navigation 172
12 Intubation and management of airway haemorrhage 189
13 Endobronchial tumour debulking 202
14 Stents 211
15 Bronchoscopic treatment for emphysema and asthma 220
Index 238

v
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 Preface
‘Striving for excellence in the care of our patients’.
My ambition for this book is to provide a simple step wise approach to flexible
bronchoscopy. I have linked gross anatomy with the radiology and correlated it to
the bronchoscopic findings and view. This approach should assist the bronchoscopist
with both diagnostic and therapeutic procedures. Safe practice is also of paramount
importance and is a key theme throughout this book.

vii
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 Introduction Chapter
Bronchoscopy has become an essential tool for the respiratory physician. The original
fibreoptic bronchoscopes were primarily utilized for visualizing the airways and also
for sampling. The modern video bronchoscopes provide high-definition images of the
airways so that even subtle lesions are recognized. The procedure has also expanded
1
from simple diagnostic procedures to therapeutic procedures. The development has
seen the therapeutic capabilities progress from palliative treatment of endobronchial
tumours to asthma and emphysema.

Equipment
The bronchoscope is essentially a flexible tube consisting of fibreoptic bundles, channels
for instruments and a number of wires for manipulating the distal end. The bundles
of optical fibres carry light to the distal end in order to illuminate the airways, and
further bundles transmit the image back to the eyepiece (Fig. 1.1). The modern video
bronchoscopes have a charge-coupled device (CCD) chip at the distal end which
captures the image and is subsequently transmitted to the monitor (Figs 1.2–1.4).
The resolution of the image is excellent and continues to improve, with some scopes
providing very high-definition images with digital magnification options. There are also
hybrid devices for special circumstances, which use the fibreoptic bundle to transmit
the image back towards the head of the bronchoscope. In this case, the CCD is located
at the head of the bronchoscope, which then transmits the image to the monitor.
The hybrid setup allows the space of the chip at the distal end to be utilized for

Fig. 1.1 Fibreoptic bronchoscope with Fig. 1.2 Video bronchoscope.

eyepiece. 1
 Fig. 1.3 Distal tip of a video bronchoscope showing the Fig. 1.4 Video bronchoscope with connections to image
instrument channel, fibreoptics and charge-coupled device processor and light source.
video chip.

other purposes, i.e. larger instrument channels, dual channels or simply to facilitate the
manufacture of slimmer bronchoscopes.
The distal end of the bronchoscope can be rotated through 160° by a lever at the
end of the scope. This, in combination with manual rotation of the scope, allows it to
be manipulated during examination of the airways. The new range of scopes being
developed also have a rotating function with the ability to lock the degree of rotation
in a specific position. This development increases the range of movement of the
bronchoscope and facilitates access to some of the areas in the lung.
A wide range variety of bronchoscopes are available with different external diameters
ranging from 2.2 to 6.3 mm (Fig. 1.5). The instrument channels and the quality of the
video chip and images also vary accordingly (Fig. 1.6). A standard bronchoscope should
be able to undertake the majority of tasks (good CCD, instrument channel of at least
2.2 mm and external diameter of about 4.6 mm). Slimmer bronchoscopes can allow for
smaller airways to be inspected and sampled. An ultra-fine bronchoscope can examine
much smaller airways but can also facilitate other procedures such as insertion of stents
etc. under direct vision. A larger bronchoscope with a large instrument channel would
be more appropriate for interventional procedures where a large channel for suction
and introduction of instruments is required. Bronchoscopes with a built-in linear array
ultrasound probe are also available which allow sampling of lymph nodes and lung
masses adjacent to the central airways (Fig. 1.7).

2
Fig. 1.5 Distal portion of a number of bronchoscopes
showing the variety of instruments available with differing
external diameters and functional characteristics.

Fig. 1.6 Two bronchoscopes with different sizes of the Fig. 1.7 Distal tip of the linear array ultrasound
charge-coupled device video chip, and instrument channel. bronchoscope.

Disinfection
Manual cleaning of the bronchoscope is an essential step, as any biological debris left
behind would not be adequately sterilized by any disinfectant liquid. The suction parts
and instrument channels are susceptible areas where debris may not be completely
removed and can then become colonized by bacteria. Manual cleaning with a brush
is the most important first step and this is usually followed by automatic disinfection.
Instruments are placed in specialized washers and cleaned with disinfection solution
such as 0.2 per cent para-acetic acid. The method of disinfecting instruments by hand
and placing them in a disinfection solution such as 2 per cent alkaline glutaraldehyde
is being phased out due to the risks to staff from occupational exposure to the fumes
from the cleaning liquids. Most modern systems can clean several scopes in one cycle
and a wash cycle usually lasts 40 minutes.
Cross-infection has been observed with organisms such as environmental Mycobacterium
and Pseudomonas species. Hence processes should be in place to ensure that records
of disinfection before use in a patient and the serial numbers of bronchoscopes used
in individual patients are maintained.This is essential for tracing patients in the event of
suspected cross-infection. Again, in the majority of cases, inadequate manual cleaning
of the bronchoscopes, particularly of the suction ports has been a key factor.
Biopsy forceps and needles are more invasive and hence need to be sterilized rather
than simply disinfected.The potential risk of infection with viruses and prions has driven 3
 the development of single-use disposable instruments. Hence, in most bronchoscopy
units, the biopsy forceps, transbronchial aspiration needles and so on are now disposable
single-use instruments. Bronchoscopes that can be sterilized rather than disinfected are
also in development, which would further reduce the risk from prions, but these would
require most bronchoscopy units to significantly increase the number of instruments
they have in order to manage a bronchoscopy list. Single-use bronchoscopes are also
in development which employ LED light sources and small distal chips within a simple
plastic tubing. However, thus far they have limited functionality.

Indications
The main indications for flexible bronchoscopy are listed in Box 1.1. Suspected lung
cancer is the major indication for bronchoscopy followed by the assessment of pulmonary
infiltrates for microbiological sampling. Traditionally bronchoscopy was conducted for
diagnostic purposes but the role of therapeutic bronchoscopy is increasing with the
development of new endoscopic treatments for respiratory diseases.

BOX 1.1 Indications for bronchoscopy

●● Investigations of symptoms
–– haemoptysis
–– persistent cough
–– recurrent infection
●● Suspected neoplasia
–– unexplained paralysis of vocal cords
–– stridor
–– localized monophonic wheeze
–– segmental or lobar collapse
–– assessment of nodules or masses identified on radiology
–– unexplained paralysis of hemi-diaphragm or raised right hemi-diaphragm
–– suspicious sputum cytology
–– unexplained pleural effusions
–– mediastinal tissue diagnosis and staging
–– assess suitability for surgery
–– staging of lung cancer
●● Infection
–– assessment of pulmonary infiltrates
–– identification of organisms
–– evaluate airways if recurrent or persistent infection
–– clinical or radiological features of environmental mycobacterial infection
●● Diffuse lung disease
–– differential cell counts and cytology
–– transbronchial lung biopsy
●● Therapeutic
–– clearance of airway secretions
–– recurrent mucous plugging causing lobar collapse and atelectasis in patients
on mechanical ventilators
–– foreign body removal
–– palliation of neoplasm
–– endobronchial ablation of tumour (cryotherapy, electrocautery, laser)
–– insertion of airway stents
–– insertion of brachytherapy catheters
–– insertion of fiducial markers for the gamma/cyberknife
–– bronchoscopic lung volume reduction
4
–– bronchial thermoplasty for asthma
–– treatment of bronchopleural fistula
Contraindications
Failure of the patient or their representative (in special circumstances) to provide
consent is a contraindication, and written consent is required before the procedure.
The main contraindications for bronchoscopy are hypoxia that cannot be adequately
corrected by oxygen supplementation and a bleeding diathesis. However, even in these
circumstances, firm cut-offs are not given as the risk–benefit should be evaluated
on an individual-patient basis. Full resuscitation equipment should be available in
the bronchoscopy suite and the staff should have the appropriate level of skill and
experience to deal with any potential complications. These include respiratory failure,
cardiac arrhythmias, haemorrhage and intercostal drain insertion.

Patient preparation
All patients need to provide informed consent prior to the procedure.They should be
provided with written information in advance of the procedure and the key aspects,
such as risks of the procedure and alternative approaches, should be discussed
before final consent. The procedure is usually performed on an outpatient basis with
conscious sedation. Patients should be advised not to eat for at least 6 hours before
the procedure but they may be allowed to drink water for up to 2 hours before the
procedure. Box 1.2 provides a simple checklist for patient preparation prior to the
procedure.

BOX 1.2 Preparation for bronchoscopy

●● Patient information – verbal and written
●● Full blood count and clotting prior to transbronchial lung biopsy and
interventional procedures such as tumour ablation
●● Informed consent
●● Spirometry if oxygen saturations < 95 per cent
●● Arterial blood gases if oxygen saturations < 92 per cent
●● Baseline electrocardiogram (ECG) if there is a history of cardiac disease
●● If patients are to have any sedation, ensure that someone is going to
accompany them home after the procedure
●● Remind patients that if they are sedated they will be unable to drive or
operate machinery for at least 24 hours
●● Intravenous access
●● Consider bronchodilators if there is evidence of bronchospasm
●● Consider prophylactic antibiotics if at very high risk of endocarditis: asplenia,
heart valve prosthesis or previous history of endocarditis

Computed tomography (CT) scan should be performed prior to bronchoscopy and there
is good evidence that reviewing CT scans of the thorax before flexible bronchoscopy
significantly improves the yield from the procedure. It allows the bronchoscopist to
select more accurately the segment of the lung that should be sampled and hence
improve the diagnostic accuracy of the investigation.The CT scan may also demonstrate
the presence of mediastinal lymph nodes and hence allow additional procedures such as
transbronchial fine-needle aspiration to be performed at the same time as the diagnostic
bronchoscopy.

5
 Sedation
Bronchoscopy can be easily performed without any sedation providing the patient
is relaxed and fully informed about the procedure and what to expect. Short-acting
sedatives that are commonly used include a short-acting intravenous (IV) benzodiazepine,
such as IV midazolam, or an opiate such as fentanyl or alfentanil. Midazolam has the
advantage of amnesic properties whereas fentanyl or alfentanil have good antitussive
properties. In some institutions, low-dose propofol infusion is used to induce and
maintain sedation.
Patients who have been given sedation should be advised not to drive or handle any
machinery for at least 24 hours after the procedure. Patients who are given sedatives
need to be collected and accompanied home after the procedure.

Room ergonomics and approach to the

procedure
The procedure can be performed with the patient sitting upright in a semi-recumbent
position being approached from the front (Fig. 1.8). This has the advantage of allowing
it to be carried out in sicker patients who desaturate upon lying flat. For this setup the
bronchoscope image obtained is such that the posterior aspect is visible at the top, the
anterior aspect is below, the right is on the left part of the image and the left is on the
right part of the image (Fig. 1.9).

Fig. 1.8 Room setup with the semi-recumbent patient Fig. 1.9 Bronchoscopic image obtained with the semi-
being approached from the front. recumbent patient approached from the front.

6
The posterior approach with the patient lying flat is also widely used (Fig. 1.10). This
approach is also required in a number of procedures such as endobronchial ultrasound
and also the superdimension procedure. With this approach the image obtained is such
that the anterior aspect is at the top, the posterior aspect is the inferior aspect of the
image and the left side of the patient is the left sided image and the right side of the
patient is the right side of the image (Fig .1.11).

Fig. 1.10 Room setup with patient being approached Fig. 1.11 Bronchoscopic image obtained with the supine
from the back in a supine position. patient approached from the back.

The different approaches have their own merits and limitations and we would
advocate that the bronchoscopist becomes familiar with both approaches and hence
becomes flexible and adaptive to the circumstances. In order to simplify the anatomy
for beginners, this is discussed separately in the following chapters, depending on the
approach. Chapter 3 demonstrates the anatomy according to the anterior approach
and Chapter 4 the anatomy according to the posterior approach.

7
 Basic techniques and sampling

●●Bronchial washings
Bronchial washings allow targeted sampling of proximal or segmental airways. The
bronchoscope is held proximal, but close, to the site of abnormality. About 10–20 mL
aliquots of saline are instilled and aspirated back. The sensitivity of bronchial washings is
very variable (average 50 per cent; range 21–76 per cent).

●●Bronchial biopsies
A variety of biopsy forceps, from cupped to serrated, are available for obtaining tissue
samples.The forceps are inserted through the instrument channel of the bronchoscope.
The forceps are just opened, apposed to the area of abnormality and then closed in
order to obtain biopsies under direct vision (Fig. 1.12). Several biopsies should be
obtained to ensure that adequate tissue has been obtained for diagnosis. Crush artefact
is the main limiting factor that affects the interpretation of the tissue obtained. A higher
yield is obtained from endobronchial biopsies, with an overall sensitivity of 74 (range
48–97) per cent. However, where an exophytic tumour is visible, the diagnostic yield
should be at least 90 per cent. The technique is generally very safe and the main
complication is that of bleeding, particularly when vascular lesions are sampled. The
bleeding is rarely significant and can usually be controlled with conservative measures.

Fig. 1.12a Distal view of the biopsy forceps in an open Fig. 1.12b Proximal view of the biopsy forceps showing
and closed position. the handle that is used to open and shut them.

8
●●Bronchial brushings
Bronchial brushings can be obtained by using the cytology brush to scrape some cells
from the surface of any abnormal areas. The brush consists of fine bristles similar to
a bottle brush with a protective plastic sheath. The instrument is passed through the
instrument channel of the bronchoscope towards the abnormal area.The brush portion
is then protruded out of the plastic sheath and brushed against the abnormal mucosa.
The brush is then withdrawn back into the plastic sheath (Fig. 1.13). The cells are then
either smeared on to a slide or rinsed into saline according to local preferences. In
some centres, the brushings are rinsed into cytolyte solution for processing. The yield
from bronchial brushings is 59 (range 23–93) per cent; the main complication is minor
bleeding but there is a risk of a pneumothorax where a brush is advanced blindly
beyond a subsegmental bronchus.

Fig. 1.13a Close-up of a bronchial brush (left) and handle Fig. 1.13b Close-up of a bronchial brush (left) and
(right): when the brush is protruding out of the sheath. handle (right): when the brush is retracted.

●●Bronchoalveolar lavage
Bronchoalveolar lavage enables sampling of the distal airways and alveolar spaces. It is
particularly useful in the assessment of:

●● diffuse interstitial lung disease

●● parenchymal infiltrates
●● pulmonary infiltrates in immunocompromised patients
●● assessment of occupational dust exposure.
The procedure is performed by wedging the bronchoscope in the desired subsegment.
In diffuse lung disease, the right middle lobe is the segment of choice as it drains well
and hence provides the best yield. Otherwise the optimal segment is selected on the
basis of radiological findings. Once the bronchoscope is wedged into the subsegment,
50–60 mL aliquots of normal saline are instilled and aspirated back either by gentle
hand suction or with low-pressure suction into a collecting bottle.The total fluid instilled
ranges from 100 to 250 mL depending on the exact indication and local circumstances.
The key aspect of the technique is to maintain the position of the bronchoscope in
the bronchial segment and also to maintain low suction pressure. Displacement of
the bronchoscope and higher suction pressure causing airway collapse are the main
factors that lead to lower yields from bronchoalveolar lavage. Patients with obstructive 9
 airways disease and emphysema also tend to have low yields. The main adverse events
in bronchoalveolar lavage are usually cough, dyspnoea, wheezing and transient fevers.
A significant proportion of the patients who are sampled are hypoxic due to underlying
disease, and instillation of significant volumes of saline can precipitate hypoxia and in
some patients with pulmonary oedema.
The sampling provides information on the cellular composition of the pulmonary
infiltrates, types of infective organisms, and presence of particulate and acellular
material in the alveolar spaces. Identification of specific bacteria, fungi and acid-fast
bacilli may be diagnostic. Malignant cells can be identified in the lavage in patients with
bronchioloalveolar cell carcinoma, lymphangitis carcinomatosis or diffuse metastatic
disease. Milky proteinaceous lavage which is laden with amorphous periodic acid-Schiff
(PAS)-positive staining to the debris is almost pathognomonic of pulmonary alveolar-
proteinosis.

●●Transbronchial lung biopsy

Transbronchial lung biopsy is utilized in the assessment of diffuse lung disease and in
patients where there is a localized parenchymal shadow (at least involving a pulmonary
segment). The yield is greater in bronchocentric conditions such as sarcoidosis. It
also has a useful role in the diagnosis of diffuse lung diseases, such as lymphangitis
carcinomatosis, disseminated malignancy, interstitial pneumonitis and extrinsic allergic
alveolitis.
The biopsy forceps are inserted through the instrument channel of the bronchoscope
into the desired segment. Ideally the bronchoscope should also be wedged into this
area, so that if there is any bleeding it can be contained within a small area of the lung.
The forceps should be advanced until there is resistance during inspiration. The forceps
are then withdrawn 1–2 cm and opened. The patient is then asked to breathe out
whilst the forceps are advanced during expiration. When resistance is felt, the forceps
are closed and gently tugged. This is usually repeated until four biopsies are obtained
for pathological analysis.
The two main adverse events from transbronchial lung biopsy are haemorrhage and
pneumothorax. The risk of a pneumothorax is between 5 and 10 per cent, but a
clinically significant pneumothorax requiring intervention occurs in about 1 per cent of
cases. The degree of bleeding is very variable but blood loss of more than 250 mL is
infrequent. Any significant bleeding is managed with suctioning of any blood, combined
with instillation of ice-cold saline and diluted adrenaline (1:100 000). As described
earlier, wedging of the bronchoscope in the segment where the biopsy is obtained also
contains the bleeding. For additional information regarding management, please see the
section on airway haemorrhage (Chapter 12).

10
 Bronchopulmonary Chapter
segments
The lungs are made up of the right and left lung, three lobes in the right lung, two
2
lobes in the left lung, 10 segments in the right lung and nine segments in the left lung.
The trachea divides into two main bronchi, which in turn divide into the lobar bronchi
and then the segmental bronchi. The segmental bronchi continue to divide into smaller
airways. The patency of these airways is maintained by the sections of cartilage within
the airway.The cartilaginous component of the airway decreases with more progressive
divisions of airways and the airways also become progressively narrow.

Nomenclature
The bronchopulmonary segments are numbered according to the relative position of
the origin of segmental bronchi. The bronchial segment that originates at the highest
position is labelled 1 (apical segment of the upper lobe); the next bronchial segment
that originates is labelled 2, and so on. The bronchial segments are named using Arabic
numerals and pulmonary segments with Roman numerals (Figs 2.1a and 2.2a). The
bronchial subsegments are subsequently labelled as a, b, c in sequence. In the left lung
the labelling is in a clockwise direction, whereas in the right lung the subsegments are
labelled in an anticlockwise direction (Figs 2.1b,c and 2.2b,c).

RB1
Fig. 2.1b Example
RB2 RB6a of labelling of
RB3 subsegments in the right
RB6b
bronchopulmonary tree:
segments of the apical
RB6 RB6c segment of the right lower
lobe, labelled a, b and c in
an anticlockwise direction.
RB4

RB5

RB7 RB10a
Fig. 2.1c Example
RB8 of labelling of
subsegments in the
right bronchopulmonary
RB9 RB10b RB10c tree: segments of the
posterior segment of
RB10 the right lower lobe,
labelled a, b and c in an
anticlockwise direction.

Fig. 2.1a Right bronchopulmonary tree with numbering

of segments. 11
 LB1+2
LB3

LB3a

LB6 LB3c
LB4

LB5 LB3b

Fig. 2.2b Example of labelling of subsegments in the left

bronchopulmonary tree: segments of the anterior segment of
the left upper lobe, denoted a, b and c in a clockwise direction.

LB10
LB8

LB6a

LB9 LB6b

Fig. 2.2a Left bronchopulmonary tree with numbering

of segments.
LB6c

Fig. 2.2c Example of labelling of subsegments in the left

bronchopulmonary tree: segments of the apical segment of
the left lower lobe, denoted a, b and c in a clockwise direction.

The carina are also denoted in a systematic manner. The main carina is labelled as
MC. On the right side, the first carina is at the junction of the right upper lobe and
the bronchus intermedius (labelled as RC1). The next carina is at the junction of the
right middle and the right lower lobe and is labelled as RC2. In the left lung, the main
secondary carina is the division between the left upper lobe and the left lower lobe
and is termed LC2. The carina between the left upper lobe and the lingula is in a more
superior position and is denoted by LC1. Other carina can be denoted according to
the segments that form the carina, e.g. the carina between the posterior and anterior
segments of the right upper lobe may be described as RC RB2–RB3 (Figs 2.2d–2.2j).

12
Fig. 2.2d Highlighted area would be Fig. 2.2e Highlighted area would be Fig. 2.2f Highlighted area would be
denoted as follows: RC RB1–RB3. denoted as follows: RC RB1–RB2. denoted as follows: RC RB2–RB3.

Fig. 2.2g Highlighted area would be Fig. 2.2h Highlighted area would be Fig. 2.2i Highlighted area would be
denoted as follows: RC RB1–RB2–RB3. denoted as follows: RB1 to RC RB1–RB3. denoted as follows: RB3.

Fig. 2.2j Highlighted area would be

denoted as follows: RB3 to RC RB2–RB3.

13
 Right lung
The right lung consists of three lobes separated by the oblique and horizontal fissures.
The oblique fissure separates the upper and middle lobes from the lower lobes. The
horizontal fissure separates the upper and the middle lobes (Fig. 2.3).

Horizontal
fissure Pulmonary
hilum

Posterior
Posterior Anterior Horizontal aspect
border border fissure

Anterior
aspect

Oblique fissure Oblique fissure

Fig. 2.3a Oblique and horizontal fissures in the right lung: Fig. 2.3b Oblique and horizontal fissures in the right lung:
lateral or costal view. medial or hilar view.

14
●●Right upper lobe (Fig. 2.4)
The apical segment (RB1) of the right upper lobe is the most superior bronchus from the
upper lobe branches. Its branches supply the apical portion of the lung (I). The posterior
segment of the right upper lobe is lower (RB2) and branches to form the posteroinferior
part of the upper lobe (II). The anterior segment of the right upper lobe is slightly lower
(RB3) and branches to form the anterior inferior portion of the upper lobe (III).

I
I

II

II
III

III

Fig. 2.4a Apical segments of the lung. I, apical; II, posterior; Fig. 2.4b Apical segments of the lung. I, apical; II, posterior;
III, anterior pulmonary segments of the right upper lobe: III, anterior pulmonary segments of the right upper lobe:
lateral or costal view. medial or hilar view.

RB1a
RB1b
RB1
RB2
RB2a RB3
RB2b
RB3a
RB3b

Fig. 2.4c Right bronchopulmonary tree showing the 15

apical segments of the lung. Right upper lobe: RB1, apical;
RB2, posterior; RB3, anterior bronchial segment.
 ●●Right middle lobe (Fig. 2.5)
The right middle lobe is a branch from the anterior portion of the right main bronchus.
It divides into a lateral segment (RB4) and a medial segment (RB5). These segments
form the lateral (IV) and medial portions (V) of the middle lobe.

IV
V

Fig. 2.5a Segments of the right middle lobe. IV, lateral; Fig. 2.5b Segments of the right middle lobe.V, medial
V, medial pulmonary segment. Lateral or costal view. pulmonary segment. Medial or hilar view.

RB4
RB4a
RB5
RB5a

RB4b

RB5b

16
Fig. 2.5c Right bronchopulmonary tree showing the right
middle lobe: RB4, lateral; RB5, medial bronchial segment.
●●Right lower lobe (Fig. 2.6)
The right lower lobe bronchus gives off a posterior branch (RB6) a short distance
from the right middle lobe origin. This supplies the apical portion to the lower lobe
(VI). The main airway continues posterolaterally from its anterior medial aspect to form
the origin of the medial segment (RB7), which supplies the inferior medial portion of
the lung (VII). It continues to give off the anterior segment (RB8) and supplies the anterior
portion of the lower lobe (VIII). The airway continues posterolaterally and also gives off a
lateral segment (RB9) and then forms the posterior basal segment (RB10).These form the
lateral (IX), and posterior inferior (X) pulmonary segments of the right lung, respectively.

VI

VI

VII
X

VIII
IX VIII IX

Fig. 2.6a Basal segments of the right lung.VI, superior; Fig. 2.6b Basal segments of the right lung.VI, superior;
VIII, anterior; IX, lateral; X, posterior pulmonary segments VII, medial;VIII, anterior; IX, lateral; X, posterior pulmonary
of the right lower lobe. Lateral or costal view. segments of the right lower lobe. Medial or hilar view.

RB6

RB6a

RB6b
Fig. 2.6c Right bronchopulmonary tree showing the basal
RB6c
segments.VI, superior;VII, medial;VIII, anterior; IX, lateral;
X posterior bronchial segments of the right lower lobe.
RB7

RB8a
RB8
RB10
RB8b
RB10a

RB9a
RB9
RB10b
RB9b
RB10c

17
 Left lung
The left lung consists of two lobes which are separated by the oblique fissure (Fig. 2.7).
The upper lobe comprises five segments and the lower lobe has four segments.

Oblique
Anterior Posterior fissure
aspect aspect
Pulmonary
hilum

Anterior
aspect
Posterior
aspect

Oblique fissure

Fig. 2.7a Oblique fissure of the left lung: lateral or Fig. 2.7b Oblique fissure of the left lung: medial or
costal view. hilar view.

●●Left upper lobe (Fig. 2.8)

The left upper lobe has a superior and an inferior division. From the superior division,
the highest branch is the apicoposterior segment (LB1 + 2), which in turn separates to
form the apical segmental bronchus (LB1) and the posterior segmental bronchus (LB2).
These form the apical segment (I) and the posterior segment (II) of the upper lobe.
Just below the origin of the apicoposterior branch is the anterior branch (LB3) and this
forms the anterior segment (III). The inferior division of the left upper lobe forms the
lingular segments, the superior branch LB4 forms the superior segment (IV) and the
subsequent slightly inferior division (LB5) forms the inferior segment of the lingula (V).

18
 I + II

I + II

III III

IV
IV

V
V

Fig. 2.8a Segments of the upper lobe of the left lung. I + II, Fig. 2.8b Segments of the upper lobe of the left lung.
apicoposterior; III, anterior ; IV, superior lingular;V, inferior I + II, apicoposterior; III, anterior ; IV, superior lingular;
lingular pulmonary segments. Lateral or costal view. V, inferior lingular pulmonary segments. Medial or hilar view.

LB1+2a
LB1+2b
LB3a
LB1+2
LB3

LB3c
LB1+2c
LB3b

LB4
LB4a
LB4b
LB5
LB5a

LB5b

Fig. 2.8c Left bronchopulmonary tree showing the

segments of the upper lobe. I + II, apicoposterior; III, anterior;
IV, superior lingular;V, inferior lingular bronchial segments. 19
 ●●Left lower lobe (Fig. 2.9)
The lower lobe bronchus descends in a posterolateral direction. The apical segmental
bronchus LB6 arises from the posterior aspect and forms the apical basal lobe (VI). It
then gives off an anterior segmental bronchus (LB7 + 8) from its anterior medial aspect
to form the anterior basal segment (VIII). The next is the lateral segmental bronchus
(LB9) and finally the airway forms the posterior segment of bronchus LB10. The latter
two form the lateral aspects of the inferior lobe (IX) and the posteroinferior part of
the lower lobe (X).

VI
VI

X
X

VIII
IX IX VIII

Fig. 2.9a Basal segments of the lower lobe of the left Fig. 2.9b Basal segments of the lower lobe of the left
lung.VI, superior;VIII, anterior; IX, lateral; X, posterior lung.VI, superior;VIII, anterior; IX, lateral; X, posterior
pulmonary segments. Lateral or costal view. pulmonary segments. Medial or hilar view.

LB6
LB6a

Fig. 2.9c Left bronchopulmonary tree showing the basal LB6b

segments of the left lower lobe.VI, superior;VIII, anterior;

IX, lateral; X, posterior bronchial segments. LB6c

LB10
LB8a
LB8 LB8b LB10a

LB9b LB10b

LB9
LB9a LB10c

20
Overall view of segments
The lateral and medial views of the right and left lung, as well as the bronchopulmonary
tree, demonstrating all the segments are shown in Figures 2.10 and 2.11.

I I

II

III
II

III
VI

VI

IV
V
X
V
VII
X

VIII
IX VIII IX

Fig. 2.10a Segments of the right lung. Right upper lobe: Fig. 2.10b Segments of the right lung. Right upper lobe:
I, apical; II, posterior; III, anterior pulmonary segments. I, apical; II, posterior; III, anterior pulmonary segments.
Right middle lobe: IV, lateral;V, medial pulmonary segment. Right middle lobe: IV, lateral; V, medial pulmonary
Right lower lobe:VI, superior;VIII, anterior; IX, lateral; segment. Right lower lobe: VI, superior; VII, medial;
X, posterior pulmonary segments. Lateral or costal view. VIII, anterior; IX, lateral; X, posterior pulmonary
segments. Medial or hilar view.

RB1a
RB1b

RB2a
RB2b

RB3a
RB3b

Fig. 2.10c Right bronchopulmonary tree showing all the RB6a

segments of the right lung. Right upper lobe: I, apical; RB6b RB4a
II, posterior; III anterior bronchial segments. Right middle RB6c
RB5a
lobe: IV, lateral; V, medial bronchial segment. Right lower RB4b
lobe: VI, superior; VII, medial; VIII, anterior; IX, lateral; RB7 RB5b
X, posterior bronchial segments.
RB8a

RB8b
RB10a

RB9a
RB10b
RB9b
RB10c

21
 I + II
I + II

III
III
VI
VI

IV IV

V
V
X
X

VIII
IX IX VIII

Fig. 2.11a Segments of the left lung. Left upper lobe: I + Fig. 2.11b Segments of the left lung. Left upper lobe: I +
II, apicoposterior; III, anterior ; IV, superior lingular;V, inferior II, apicoposterior; III, anterior; IV, superior lingular;V, inferior
lingular pulmonary segments. Left lower lobe:VI, superior; lingular pulmonary segments. Left lower lobe:VI, superior;
VIII, anterior; IX, lateral; X, posterior pulmonary segments. VIII, anterior; IX, lateral; X, posterior pulmonary segments.
Lateral or costal view. Medial or hilar view.

LB1+2a
LB1+2b
LB3a

LB3c
LB1+2c
LB3b

LB4a LB6a
Fig. 2.11c Left bronchopulmonary tree showing
LB4b LB6b
all segments of the left lung. Left upper lobe: I + II,
apicoposterior; III, anterior ; IV, superior lingular; V, inferior LB5a
lingular bronchial segments. Left lower lobe: VI, superior; LB6c
VIII, anterior; IX, lateral; X, posterior bronchial segments. LB5b

LB8a
LB8b LB10a

LB9a
LB9b LB10b

LB10c
22
 Correlation of CT scans and
bronchopulmonary segments
Correlation of the radiographic changes on a computed tomography (CT) scan to
a particular bronchopulmonary segment is important and improves the yield from
procedures such as bronchial lavage and transbronchial lung biopsy. The images in
Figures 2.12–2.17 are to guide the bronchoscopist as to which areas of a CT scan
relate to the various bronchopulmonary segments. I also recommend reviewing the
whole CT scan carefully and following the airways sequentially to determine the exact
segment involved in a particular patient.

apical segment anterior

right upper lobe (RB2) segment
anterior left upper
segment lobe (LB3)
right upper
lobe (RB3) apico-posterior
segment of the
left upper
lobe (LB1+2)

posterior
apical
segment
segment
right upper
Atlas of Flexible Bronchoscopy
left lower
lobe (RB2)
Shah lobe (LB6)
Fig. 2.12a
2_12c Cross-sectional CT scans of the Fig. 2.12b Cross-sectional CT scans of
thorax at the level of the aortic arch. the thorax at the level of the aortic arch;
FOR PROOFING ONLY – Jane Fallows
the overlay shows the margins of the
pulmonary segments.

LB1+2

RB2 RB1
LB3

RB3
RB6 LB6

Fig. 2.12c Bronchial tree showing the segments

correlating with the CT scan.

23
 anterior segment anterior segment
right upper lobe (RB3) left upper lobe (LB3)

apico-posterior
posterior segment
segment of the
right upper lobe
left upper lobe
(RB2)
(LB1&2)
Atlas of Flexible Bronchoscopy
Shah

2_13c
Fig. 2.13a Cross-sectional CT scans of the apical segment apical segment
FOR PROOFING ONLY – Jane Fallows
thorax at the level of the right upper lobe right lower lobe (RB8) left lower lobe (LB8)
origin.
Fig. 2.13b Cross-sectional CT scans of the thorax at the level of
the right upper lobe origin; the overlay shows the margins of the
pulmonary segments.

LB1+2

RB2
LB3

RB3
RB6 LB6

Atlas of Flexible Bronchoscopy

Shah

2_14c

FOR PROOFING ONLY – Jane Fallows

Fig. 2.13c Bronchial tree showing the Fig. 2.14a Cross-sectional CT scans of the
segments correlating with the CT scan. thorax at the level of the bronchus intermedius.

posterior
posterior
segment
segment
right upper
left upper
lobe (RB2)
lobe (LB2)
LB3

RB3
apical RB6 LB6
segment apical
right lower segment
lobe (RB6) left lower
lobe (LB6)

Fig. 2.14b Cross-sectional CT scans of the thorax at the level

of the bronchus intermedius; the overlay shows the margins of Fig. 2.14c Bronchial tree showing the
24 the pulmonary segments. segments correlating with the CT scan.
 medial segment superior
right middle lobe (RB5) segment
lateral of lingula (LB4)
segment
right middle
lobe (RB4) inferior
segment of
lingula (LB5)

apical apical
segment segment of
right lower left lower
lobe (RB6) lobe (LB6)
Fig. 2.15a Cross-sectional CT scans of the
thorax at the level of the origin of the right Fig. 2.15b Cross-sectional CT scans of the
middle lobe. thorax at the level of the origin of the right
middle lobe; the overlay shows the margins
of the pulmonary segments.

RB4 RB6 LB4

LB6
LB5
RB5

Fig. 2.15c Bronchial tree showing the segments

correlating with the CT scan.

25
 medial segment of inferior segment
right middle lobe (RB5) of lingula (LB5)

lateral anterior
segment of segment of
right middle left lower
lobe (RB4) lobe (LB8)

anterior lateral
segment of segment of
right lower left lower
lobe (RB8) lobe (LB9)

lateral posterior
Fig. 2.16a Cross-sectional CT scans of the segment of segment of
thorax at the level of the origin of the lower right lower left lower
lobe (RB9) lobe (LB10)
lobe bronchial segments.
Atlas of Flexible Bronchoscopy
posterior segment of
Shah
left lower lobe (RB10)
2_16c
Fig. 2.16b Cross-sectional CT scans of the
thorax
FOR at the
PROOFING level
ONLY of Fallows
– Jane the origin of the lower
lobe bronchial segments; the overlay shows
the margins of the pulmonary segments.

RB4
LB5
RB5
RB8 LB8

RB9 LB10
RB10
LB9

Fig. 2.16c Bronchial tree showing the segments

correlating with the CT scan.

26
 lateral segment of medial segment
right middle lobe (RB4) right middle lobe (RB5)

anterior inferior
segment of segment
right lower lingula (LB5)
lobe (RB8)

medial anterior
segment of segment of
right lower left lower
lobe (RB7) lobe (LB8)

lateral lateral
segment of segment of
Fig. 2.17a Cross-sectional CT scans of the right lower left lower
thorax at the level of the basal pulmonary lobe (RB9) lobe (LB9)
Atlas of Flexible Bronchoscopy
segments.
Shah posterior segment of posterior segment of
right lower lobe (RB10) left lower lobe (LB10)
2_17c

FOR PROOFING ONLY – Jane Fallows Fig. 2.17b Cross-sectional CT scans of the
thorax at the level of the basal pulmonary
segments; the overlay shows the margins of
the pulmonary segments.

RB4
LB5
RB5
RB8 RB7 LB8

RB9 LB10
RB10
LB9

Fig. 2.17c Bronchial tree showing the segments

correlating with the CT scan.

27
 Chapter Normal anatomy
3 (anterior approach)
In this chapter the endoscopic images are related to the computed tomography
(CT) images. The overall appearance, main characteristics and normal variations are
described. The anatomical images in this chapter are presented as they appear when
the procedure is performed with the patient in a semi-recumbent position being
approached from the front.
In order to minimize confusion, the normal anatomy is described again in the next
chapter but the bronchoscopic images are presented as they appear when the patient
is bronchoscoped in a supine position and approached from behind.

Vocal cords (Fig. 3.1)

The larynx is composed of a series of cartilages, ligaments and fibrous membranes.
At bronchoscopy the epiglottis is the more proximal structure. It is a broad leaf-
like structure. The sides are attached by the arytenoid cartilages. The cuneiform and
corniculate can be seen at the end of the arytenoid cartilage. The cuneiform cartilage
is more anterior and superior to the corniculate cartilage. The vocal folds consist of
the false cords or vestibular folds and the true vocal folds. They stretch back from the
thyroid angle to the vocal processes of the arytenoids. The vocal folds are involved in
the production of sound.

left vocal cord aryepiglottic fold

vocal fold hyoid bone cricoid cartilage

R L

cuneiform tubercle corniculate tubercle

Fig. 3.1a Cross-sectional CT scan at the superior aspect Fig. 3.1b Coronal section CT scan of the vocal cords,
of the thorax at the level of the vocal cords, which are which are apposed.
apposed.
28
 right cuneiform right corniculate posterior
right aryepiglottic fold posterior pharyngeal wall tubercle tubercle pharyngeal wall

right vallecula epiglottis left vallecula left vocal cord epiglottis left aryepiglottic fold
Fig. 3.1c Endoscopic view of the epiglottis and vocal cords. Fig. 3.1d Endoscopic view of the vocal cords.

vocal folds
hyoid bone open vocal folds

Fig. 3.1e Cross-sectional CT scan at the superior aspect of Fig. 3.1f Coronal section CT scan of the vocal cords,
the thorax at the level of the vocal cords, which are open. which are open.

29
 corniculate tubercle apposed vocal cords
open vocal cords

aryepiglottic fold epiglottis cuneiform tubercle

Fig. 3.1g Endoscopic view of the open vocal cords. Fig. 3.1h Endoscopic view of apposed vocal cords.

Trachea (Fig. 3.2)

The trachea is a horseshoe- or D-shaped structure which extends from the cricoid
cartilage to the carina. The anterior aspect is composed of 16–20 incomplete cartilage
rings with a flat fibromuscular posterior component.There is also a longitudinal band of
connective tissue which runs down the posterior end of the cartilage. At bronchoscopy
the cartilage bands on the anterior surface appear as ridges and the posterior wall
appears to bulge into the trachea. The posterior bulge is accentuated in expiration.
The trachea measures approximately 110 mm in length with an external diameter that
ranges from 15 mm in women to 20 mm in men. The internal diameter of the trachea
is about 12–14 mm.
The trachea divides into the right and left main bronchi at the level of the sternomanubrial
junction or the body of the fourth thoracic vertebrae.
A tracheal bronchus is a rare normal variant and originates from the lateral wall of the
trachea and into the upper lobe on the right side in about 0.1–2 per cent of individuals
and on the left side in 0.3–1 per cent of individuals. The term tracheal bronchus is also
used for other anomalous airways arising from the main bronchi and directed to the
upper lobes.

30
 superior vena cava fat aorta right pulmonary left pulmonary
artery trachea aortic arch artery

trachea oesophagus left atrium left inferior pulmonary vein

Fig. 3.2a Cross-sectional CT scan of the thorax at the Fig. 3.2b Coronal sectional CT scan of the thorax through
mid-tracheal level. the trachea.

posterior membranous trachea carina posterior tracheal wall

Rt Lt

cartilage rings anterior aspect cartilage rings anterior wall

Fig. 3.2c Endoscopic view of the trachea from the level of Fig. 3.2d Endoscopic view of the upper trachea.
the subglottis.

31
 right posterior
main tracheal
bronchus wall carina (mc) right membranous left tracheal posterior wall right upper tracheal
main posterior main bronchus of trachea lobe bronchus
bronchus wall bronchus

Rt Lt
Rt Lt

anterior left right anterior right right main posterior

anterior carina (mc)
tracheal main upper aspect main bronchus wall of
wall bronchus lobe of trachea bronchus trachea

Fig. 3.2e Endoscopic view Fig. 3.2f Endoscopic view Fig. 3.2g Endoscopic view Fig. 3.2h Endoscopic view
of the trachea from the of the distal portion of the of a tracheal bronchus as of a tracheal bronchus as
mid-tracheal level. trachea. viewed from above with seen at the distal trachea
the patient upright and just above the carina.
approached from the The right upper lobe and
front.The right upper lobe bronchus intermedius are
arises from the right main visible below.
bronchus.

anterior segment tracheal bronchus trachea

posterior segment
Fig. 3.2i Bipartite division of the upper lobe in the Fig. 3.2j Cross-sectional CT scan showing the tracheal
presence of a tracheal bronchus. bronchus arising at the distal trachea just above the carina.

32
Carina (Fig. 3.3)
The carina is a concave spur of cartilage located where the distal trachea divides into
the right and left main bronchi. The carina normally appears as a sharp structure and
forms the medial borders of the origin of the right and left main bronchi. The sharp
angle is maintained as it is primarily composed of cartilage (carinal) and ligaments
(interbronchial). Enlargement of the subcarinal structures, such as the subcarinal lymph
nodes or the left atrium, may lead to blunting or widening of the carina. It usually
measures about 12 mm in diameter and stretches in the midline in the anteroposterior
dimension. Very rarely there is an accessory bronchus opening from the lateral walls
directed towards the upper lobe.

anterior segment apicoposterior

superior ascending pulmonary of the left upper oblique right segment of the anterior segment
vena cava aorta artery lobe (LB3) fissure pulmonary aortic left upper lobe of the left upper
artery trachea arch (LB1+2) lobe (LB3)

right upper lobe left atrium left inferior left pulmonary

posterior apical segment superior carina descending apicoposterior pulmonary vein artery
segment of of right upper pericardial aorta segment of the
right upper lobe (RB1) recess left upper lobe
lobe (RB2) (LB1+2)
Fig. 3.3a Cross-sectional CT scan of the thorax at the level of Fig. 3.3b Coronal sectional CT scan of the thorax
the carina. through the trachea.

33
 posterior membranous posterior membranous
right main bronchus carina (mc) wall of trachea wall of trachea carina (mc)

left main bronchus right main bronchus left main bronchus

Fig. 3.3c Endoscopic view of the carina. Fig. 3.3d Close-up endoscopic view of the carina.

Right main bronchus (Fig. 3.4)

The right main bronchus extends from the carina to the origin of the right upper lobe.
It then forms the bronchus intermedius. The right main bronchus has a steeper decline
from the trachea and hence, in the upright position, foreign bodies tend to fall into
the right main bronchus. It is slightly larger in diameter than the left main bronchus,
measuring between 10 and 12 mm in external diameter. The inferior lip of the upper
lobe bronchus is easily visible at the distal end of the right main bronchus. A rare
variation is the origin of an airway leading to the upper lobe. This is classified as a pre-
eparterial tracheal bronchus. It may be either a supernumerary or a displaced airway.
Where the airway is displaced, there is also a missing upper lobe branch. An accessory
cardiac bronchus is a supernumerary bronchus arising from the medial aspect of the
right main bronchus and leading towards the pericardium.

34
anterior segmental apical segmental superior left right upper
bronchus of right bronchus of right vena pulmonary lobe spur azygos main carina left main
upper lobe (RB3) upper lobe (RB1) cava carina artery (RC1) arch trachea (mc) bronchus

right upper lobe bronchus right main bronchus

posterior segmental right azygos descending left
bronchus of right main vein aorta main
upper lobe (RB2) bronchus bronchus
oesophagus
Fig. 3.4a Cross-sectional CT scan of the thorax at the Fig. 3.4b Coronal sectional CT scan of the thorax showing
carina, showing the right main bronchus. the right main bronchus.

right upper lobe posterior wall of right main bronchus

posterior wall of
right upper lobe origin basal segments right main bronchus

right upper bronchus anterior wall medial wall of right upper lobe right middle anterior wall of medial wall of
lobe spur intermedius of right main right main spur (RC1) lobe right main right main
(RC1) bronchus bronchus bronchus bronchus

Fig. 3.4c Endoscopic view of the right main bronchus Fig. 3.4d Endoscopic view of the right main bronchus with 35
visible below the carina. more of the right upper lobe visible.
 Right upper lobe (Fig. 3.5)
The right upper lobe has three main segmental divisions: the apical, anterior and
posterior segments. The upper lobe segments divide into segments about 10 mm from
the origin. The upper lobe is subject to considerable normal variation:

●● In 40 per cent the segmental bronchi arise independently.

●● In 24 per cent there is a common apical and anterior trunk and an independent
posterior-segmental bronchus. (see Fig. 3.5g)
●● In 14 per cent there is a common apical and posterior trunk and an independent
anterior segment. (see Fig 3.5h)
●● In 10 per cent there is a common anterior and posterior trunk with an independent
apical segment.
●● In 10 per cent the posterior segmental bronchus is absent.
●● In 2 per cent the apical segment is absent.
●● In < 1 per cent of patients there is a tracheal bronchus which originates either
directly from the trachea or at the level of the carina. In some cases there is an
additional branch to the upper lobe, which originates from the right main bronchus.

superior branch of superior right main pulmonary anterior branch of apical branch of apical segment of
right pulmonary artery vena cava bronchus artery trunk right upper lobe right upper lobe right upper the left upper
bronchus (RB3) bronchus (RB1) lobe lobe (LB1)

right upper lobe anterior segment of the apico posterior

bronchus left upper lobe (LB3) segment of the
left upper lobe bronchus intermedius right main bronchus
(LB1+2)

Fig. 3.5a Cross-sectional CT scan of the thorax at the Fig. 3.5b Coronal sectional CT scan of the thorax showing
level of the right upper lobe origin. the right upper lobe.

36
 apical segment of the
apical segment of the right upper lobe (RB1)
right upper lobe (RB1) RB2b RB2a

anterior segment of the posterior segment of the anterior segment of the posterior segment of the
right upper lobe (RB3) right upper lobe (RB2) right upper lobe (RB3) right upper lobe (RB2)
Fig. 3.5c Endoscopic view of the right upper lobe from Fig. 3.5d Another example of the tripartite right upper
above with the patient upright being approached from the lobe arrangement.
front.

Fig. 3.5e Bipartite division of the right upper lobe with Fig. 3.5f Bipartite division of the right upper lobe with
division at the horizontal axis. division in the vertical axis.

37
 apicoposterior segment
apicoanterior segment of anterior segment of the of the right upper lobe apical segment
the right upper lobe (RB1+3) apical segment (RB1) right upper lobe (RB3) (RB1+2) (RB1)

anterior segment (RB3) posterior segment of the RB2b posterior RB2a

right upper lobe (RB2) segment (RB2)
Fig. 3.5g Bipartite division of the right upper lobe with Fig. 3.5h Bipartite division of the right upper lobe with
apical and anterior segments (RB1 + 3 arising together) apical and posterior segments arising together (RB1 + 2)
and a separate posterior segment (RB2). and a separate posterior segment (RB3).

Fig. 3.5i Four divisions of the right upper lobe.

38
Bronchus intermedius (Fig. 3.6)
The bronchus intermedius originates from the right main bronchus and extends from
the origin of the right upper lobe to the right middle lobe. It is approximately 20 mm
long and has a diameter of about 10 mm.The right middle lobe, the apical segment of the
lower lobe and the basal segments are visible at the distal end of bronchus intermedius.

right superior bronchus left ventricular pulmonary left main apicoposterior

pulmonary vein intermedius outflow tract trunk bronchus right upper segment of left anterior segment of
lobe bronchus upper lobe (LB1+2) the left bronchus (LB3)

right azygos left lower lobe left superior left upper right lower lobe bronchus right main left upper
pulmonary vein pulmonary pulmonary lobe pulmonary artery intermedius bronchus lobe bronchus
artery artery vein bronchus

Fig. 3.6a Cross-sectional CT scan of the thorax at the level of Fig. 3.6b Coronal sectional CT scan of the thorax through
the bronchus intermedius (distal to the right upper lobe origin). the bronchial tree showing the bronchus intermedius.

apical segment of right basal segments of

lower lobe (RB6) the right lower lobe

carina between right middle right middle lobe

lobe and lower lobe (RC2) bronchus (RB4+5)
39
Fig. 3.6d Endoscopic view of the distal aspect of the
Fig. 3.6c Endoscopic view of the bronchus intermedius. bronchus intermedius.
 Right middle lobe (Fig. 3.7)
The right middle lobe is a semi-lunar (D-shaped) bronchus at the anterior end of the
bronchus intermedius. In approximately 70 per cent of cases, there are two distinct
segments: lateral and medial. In 23 per cent of normal individuals the middle lobe
bifurcates in a superior-inferior fashion, similar to that of the lingula. In up to 20 per
cent of individuals there is a main lateral bronchus and a smaller medial bronchus which
arises from the lateral segment. Occasionally the reverse is seen, with a larger medial
segment and a smaller lateral segment arising from it.

right lower
lobe medial segment superior left inferior
pulmonary of right middle pulmonary right pulmonary
artery lobe (RB5) vein atrium vein
right upper lobe segment right superior pulmonary vein

lateral segment right right left left lower lobe right middle right right inferior left left
of right middle middle lower atrium pulmonary lobe pulmonary middle pulmonary atrium ventricle
lobe (RB4) lobe lobe artery artery lobe vein
Fig. 3.7a Cross-sectional CT scan of the thorax at the level Fig. 3.7b Coronal sectional CT scan of the thorax at the
of the right middle lobe. level of the right middle lobe.

40
 basal segments of the medial segment of the
right lower lobe right lower lobe (RB7)
right lower lobe segments

apical segment of the carina between right right middle lobe

right lower lobe (RB6) middle lobe and lower carina between right middle right middle lobe
lobe (RC2) lobe and right lower lobe (RC2) bronchus (RB4+5)

Fig. 3.7c Endoscopic view of the right middle and Fig. 3.7d Endoscopic view of right middle lobe.
lower lobes.

lateral segment of the lateral segment of the

RB4a right lower lobe (RB4) RB4b RB4a right middle lobe (RB4) RB4b

RB5a medial segment of the RB5b RB5a medial segment of the RB5b posterior wall
right lower lobe (RB5) right middle lobe (RB5)
Fig. 3.7e Endoscopic view of the right middle lobe Fig. 3.7f Close-up endoscopic view of the right middle
subsegments viewed from the origin of the right main lobe subsegments.
bronchus. 41
 Right lower lobe (Fig. 3.8)
The right lower lobe comprises five main segments: apical basal, medial basal, anterior
basal, lateral basal and posterior basal. In about 40–60 per cent of individuals there is
an additional subapical basal segment. The apical basal segment of the right lower lobe
is positioned posteriorly at the end of the bronchus intermedius. The apical segment
divides immediately into three subsegmental bronchi. The normal pattern observed
in the lower lobe bronchial segments are a large medial basal segment (RB7), which
is proximal to the other basal segments. The anterior basal segment is in the lateral
position, with the lower bronchus dividing further into lateral and posterior segments.
This pattern is seen in over 70 per cent of individuals. The other common variation
observed is where the anterior basal, lateral basal and posterior basal segments all
originate independently at the same level.
A bipartite division is occasionally observed where the anterior and lateral segments
arise together proximally to the posterior basal segment from a separate branch.
The position and size of the apical basal segment frequently influence the pattern of
branching of the basal segments. For example, in some individuals there is a larger apical
bronchus and, as a result, the medial through to posterior segment arises in a tripartite
from the same level.

superior pulmonary vein right atrium left lower lobe bronchus bronchus intermedius left pulmonary artery

right lower lobe right lower left inferior left lower anterior segment of right lower left atrium inferior
pulmonary lobe bronchus atrium pulmonary lobe right lower lobe (RB8) lobe bronchus pulmonary
artery vein pulmonary vein
artery
Fig. 3.8a Cross-sectional CT scan of the thorax at the level Fig. 3.8b Coronal sectional CT scan showing the right
of the basal segments of the right lower lobe. lower lobe.

42
 apical segment of the subsegments of the
right lower lobe (RB6) apical segment of the apical segments of the
right lower lobe (RB6) RB6b RB6a RB6b right lower lobe (RB6)

anterior segment medial segment basal segments of the RB6ci RB6cii RB6a
of the right of the right right lower lobe
lower lobe (RB8) lower lobe (RB7)
Fig. 3.8c Endoscopic view Fig. 3.8d Endoscopic view Fig. 3.8e Endoscopic view Fig. 3.8f Close-up
of the basal segments of the of the right apicobasal of the apicobasal segments endoscopic view of the right
right lower lobe. segment. of the right lower lobe. apicobasal subsegments.

lateral basal segment of posterior basal segment of lateral segment of the posterior segment of the
the right lower lobe (RB9) the right lower lobe (RB10) right lower lobe (RB9) right lower lobe (RB10)

RB8a
RB8a

anterior basal segment of RB8b medial basal segment of anterior segment of the RB8b medial segment of the
the right lower lobe (RB8) the right lower lobe (RB7) right lower lobe (RB8) right lower lobe (RB7)

Fig. 3.8g Endoscopic view of the basal segments of Fig. 3.8h Closer endoscopic view of the basal
the right lower lobe. segments of the right lower lobe.

accessory subapical bronchus posterior segment of the

lateral segment of the posterior segment of the of the right lower lobe RB10a right lower lobe (RB10)
right lower lobe (RB9) RB10a right lower lobe (RB10)

RB10c RB10c

RB8a

anterior segment of the RB8b lateral wall of medial segment RB10b lateral basal segment of
right lower lobe (RB8) of the right lower lobe the right lower lobe (RB9)
Fig. 3.8i Endoscopic view of the anterobasal, Fig. 3.8j Endoscopic view of the basolateral and
basolateral and posterobasal segments of the right posterobasal segments of the right lower lobe. In this
lower lobe. example a normal variant subapical segment is present. 43
 anterior segment right
lower lobe (RB8) inferior pulmonary vein

right lower lobe lateral segment right posterior segment right posterior segment of anterior segment of the
pulmonary artery lower lobe (RB9) lower lobe (RB10) the right lower lobe (RB10) right lower lobe (RB8)

Fig. 3.8k Cross-sectional CT scan at the level of the basal Fig. 3.8l Coronal CT scan showing the basal segments of
segments of the right lower lobe. the right lower lobe.

lateral segment of accessory subapical segment

the right lower lobe (RB9) of the right lower lobe

anterior segment of the posterior segment of the lateral segment of the posterior segment of the
right lower lobe (RB8) right lower lobe (RB10) right lower lobe (RB9) right lower lobe (RB10)
Fig. 3.8m Endoscopic view of the anterobasal, basolateral Fig. 3.8n Endoscopic view of the basolateral and
44 and posterobasal segments of the right lower lobe. posterobasal segments of the right lower lobe.
 accessory subapical posterior segment lateral segment of the posterior segment of the
lateral segment of the segment of the right of the right lower right lower lobe (RB9) right lower lobe (RB10)
right lower lobe (RB9) lower lobe lobe (RB10)

anterior segment of the accessory segment of medial segment of the

anterior segment of the RB7b medial segment of the RB7a right lower lobe (RB8) the right lower lobe right lower lobe (RB7)
right lower lobe (RB8) right lower lobe (RB7)
Fig. 3.8o Endoscopic view of the basal segments of the Fig. 3.8p Endoscopic view of the right lower lobe variant
right lower lobe showing a normal variant of a subapical with submedial segment.
segment.

lateral segment of the posterior segment of

right lower lobe (RB9) the right lower lobe (RB10)

anterior segment accessory segment medial segment of the

of the right lower of the right lower right lower lobe (RB7)
lobe (RB8) lobe
Fig. 3.8q Close-up of the right lower lobe variant with a 45
submedial segment.
 Left main bronchus (Fig. 3.9)
The left main bronchus is approximately 4 cm long and descends in a gentle lateral
curve. At its terminal portion it divides into two main branches: the left lower lobe
and the left upper lobe bronchus. There is an obliquely placed sharp carina separating
the two bronchi. The upper lobe is joined at a 60° angle to the left main bronchus.
Occasionally the upper lobe bronchus joins the left main bronchus at an acute angle.

left superior
left main bronchus left pulmonary artery
right pulmonary artery pulmonary artery pulmonary vein

inferior left lower lower lobe

left main bronchus left lower lobe pulmonary artery pulmonary vein lobe bronchus pulmonary artery
Fig. 3.9a Cross-sectional CT scan of the thorax at the Fig. 3.9b Coronal sectional CT scan of the thorax at the
level of the left main bronchus. level of the left main bronchus.

medial wall lateral curve secondary carina

anterior wall right main of left main of left main of left main left lower lobe
medial wall of left bronchus (LC2) segments
of trachea bronchus bronchus bronchus
main bronchus

left main carina posterior left main posterior wall left main posterior wall anterior left upper apical
bronchus wall of bronchus of left main bronchus of left main aspect of lobe segment of
trachea bronchus bronchus left main bronchus left lower
bronchus lobe (LB6)
Fig. 3.9c Endoscopic view Fig. 3.9d Endoscopic view Fig. 3.9e Endoscopic view of Fig. 3.9f Endoscopic view of
of the left main bronchus of the curve in the left main the left main bronchus viewed the left main bronchus viewed
from the carina. bronchus. from halfway down the left from two-thirds the way down
46 main bronchus with the left the left main bronchus, with the
lower lobe visible distally. left lower lobe visible distally.
 secondary carina basal segments left lower medial wall of left
of left main of left lower lobe main bronchus
bronchus (LC2) lobe

lingular LC1 left upper left apical segment left upper accessory posterior wall
bronchus division upper of left lower lobe bronchus of left main
(LB4+5) bronchus lobe lobe (LB6) bronchus
Fig. 3.9g Endoscopic view of the left secondary Fig. 3.9h Endoscopic view of the left lower and
carina with both the upper and lower lobes visible. upper lobes, with the apical segment of the left
upper lobe arising from the left main bronchus.
secondary
secondary
carina left lower lobe
carina left lower lobe

left upper lobe accessory left upper lobe accessory

bronchus bronchus bronchus

Fig. 3.9i Endoscopic view of the left lower Fig. 3.9j Endoscopic view of the left lower and
and upper lobes with a close view of the upper lobes with a view of the apical segment
apical segment of the left upper lobe of the left upper lobe arising from the left main
arising from the left main bronchus. bronchus, just from above its origin.

Left upper lobe (Fig. 3.10)

The upper lobe bronchus usually divides into the upper division orifice and the lingular
bronchus. The upper division divides into an apicoposterior and anterior bronchus. In
the majority of individuals, the apicoposterior bronchus divides into three segmental
branches: the apical, posterior and posterolateral branches. In about 15 per cent of
individuals the apicoposterior segment has a bipartite structure with the posterolateral
subsegment arising from the anterior segment. 47
 superior bronchus left upper lobe
inferior pulmonary vein pulmonary artery bronchus
left upper lobe bronchus
left pulmonary artery anterior segment (LB3)

anterior
segment
of the left
lower
lobe
(LB7+8)

lateral
segment
of the
left lower
lobe (LB9)

left main bronchus apicoposterior segment posterior segment of the lateral segment of the medial segment of the
of the left upper lobe (LB1+2) right lower lobe (RB10) right lower lobe (RB9) right lower lobe (RB7)

Fig. 3.10a Cross-sectional CT scan of the thorax at Fig. 3.10b Coronal sectional CT scan of the thorax at the level
the level of the left upper lobe bronchus. of the left upper lobe bronchus.
left lower lobe apical segment of left lower
bronchial segments lobe bronchus (LB6) lingula (LB4+5)

secondary
carina (LC2)

lingula
(LB4+5) left superior
division
bronchus

anterior segment of the apicoposterior segment anterior segment of the apicoposterior segment of
left upper lobe (LB3) of the left upper lobe (LB1+2) left upper lobe (LB3) the left upper lobe (LB1+2)
Fig. 3.10c Endoscopic view of the left superior Fig. 3.10d Close-up of the left superior bronchus
bronchus from above the left main bronchial carina. showing the lingula and left upper lobe segments.

anterior segment of the anterior segment of the

lingula LB3b left upper lobe (LB3) left upper lobe (LB3)

apicoposterior
segment of
the left upper
lobe (LB1+2)
LB3a apicoposterior segment of posterior segment of apical segment of the
the left upper lobe (LB1+2) the left upper lobe (LB2) left upper lobe (LB1)
48 Fig. 3.10e Left upper lobe segments showing anterior Fig. 3.10f Endoscopic view of the apicoposterior
and apicoposterior segments. segment of the left upper lobe.
Lingula (Fig. 3.11)
The lingular bronchus arises from the left upper division bronchus. It divides into superior
segmental and inferior segmental branches, which in turn divide into two subsegmental
branches. In 25 per cent of individuals, the lingula bifurcates in a lateral and medial fashion.
On rare occasions the orifice of the lingula is merged with a segment from the upper lobe.

superior segment inferior segment of

lingular bronchus of the lingula (LB4) the lingula (LB5) superior pulmonary vein left upper lobe

left lower apical segment of the lower lobe pulmonary left atrium inferior pulmonary lingular bronchus
lobe bronchus left lower lobe (LB6) pulmonary artery artery vein
Fig. 3.11a Cross-sectional CT scan of the thorax at the Fig. 3.11b Coronal sectional CT scan of the thorax at the
level of the lingular bronchus. level of the lingular bronchus.

inferior segment of the lingula (LB5)

lingular orifice

LB3a anterior segment of LB3b apicoposterior segment of

the left upper lobe (LB3) the left upper lobe (LB1+2) superior segment of the lingula (LB4)
Fig. 3.11c Bronchoscopic view of the lingula and anterior Fig. 3.11d Endoscopic view of the lingular segments. 49
segment of the left upper lobe.
 Left lower lobe (Fig. 3.12)
The left lower lobe bronchus descends posterolaterally and divides into four segments to
form the left lower lobe. The apical segment arises about 1 cm after the origin of the left
lower lobe bronchus. After a further 1–2 cm the inferior bronchus divides into an anterior
basal segmental bronchus and a posterolateral basal bronchus which further bifurcates
into lateral basal and posterior basal segments. Endoscopically a prominent secondary
carina appears to divide into the apical basal bronchus and the other inferior branches.
The most common pattern of division of the left lower lobe is into three branches
(tripartite) with separate anterior basal, lateral basal and posterior basal divisions.

superior segment of the lingula (LB4) left pulmonary artery

left main left lower left lower lobe

left inferior left lower lower lobe inferior segment bronchus lobe bronchus pulmonary artery
pulmonary lobe bronchus pulmonary of the lingula
vein artery (LB5)
Fig. 3.12a Cross-sectional CT scan of the thorax at the Fig. 3.12b Coronal sectional CT scan of the thorax at the
level of the left lower lobe bronchus. level of the left lower lobe bronchus.

50
 basal segments of the left lower lobe basal segments of the left lower lobe

left upper lobe secondary apical segment of the LB6a apical segment of the LB6b
carina (LC2) left lower lobe (LB6) left lower lobe (LB6)
Fig. 3.12c Bronchoscopic view of the left lower lobe Fig. 3.12d Endoscopic view of the left lower lobe.
viewed from just above the left secondary carina.

lateral segment of the posterior segment of the

left lower lobe (LB9) left lower lobe (LB1)

basal segments of the left lower lobe

LB6a apical segment of the LB6b LB7+8a anterior segment of the LB7+8b
left lower lobe (LB6) left lower lobe (LB7+8)
Fig. 3.12e Bronchoscopic view of the apical segment of Fig. 3.12f Bronchoscopic view of the basal segments of
the left lower lobe. the left lower lobe. 51
 left lower lobe lingular inferior
pulmonary artery segmental bronchus (LB5)

lateral segment of
left main bronchus left pulmonary left lower lobe (LB9)

inferior posterior lateral segment anterior segment

pulmonary segment of of the left of the left lower
vein the left lower lower lobe (LB9) lobe (LB8)
lobe (LB10) inferior pulmonary left lower lobe

Fig. 3.12g Cross-sectional CT scan of the thorax showing Fig. 3.12h Coronal sectional CT scan of the thorax
the left lower lobe segments. showing the left lower lobe segments.

52
 Normal anatomy Chapter
(posterior approach)
In this chapter the endoscopic images are related to the computed tomography (CT)
4
images.The overall appearance, main characteristics and normal variations are described.
Here, in contrast to Chapter 3, the endoscopic images are presented as they appear
when the patient is bronchoscoped in a supine position and approached from behind.

Vocal cords (Fig. 4.1)

The larynx is composed of a series of cartilages, ligaments and fibrous membranes.
At bronchoscopy the epiglottis is the more proximal structure. It is a broad leaf-
like structure. The sides are attached by the arytenoid cartilages. The cuneiform and
corniculate can be seen at the end of the arytenoid cartilage. The cuneiform cartilage
is more anterior and superior to the corniculate cartilage. The vocal folds consist of
the false cords or vestibular folds and the true vocal folds. They stretch back from the
thyroid angle to the vocal processes of the arytenoids. The vocal folds are involved in
the production of sound.

left vocal cord aryepiglottic fold

vocal fold hyoid bone cricoid cartilage

cuneiform tubercle corniculate tubercle

Fig. 4.1a Cross-sectional CT scan at the superior aspect Fig. 4.1b Coronal section CT scan of the vocal cords,
of the thorax at the level of the vocal cords, which are which are apposed.
apposed.

53
 left vallecula epiglottis right vallecula left vocal cord epiglottis

posterior pharyngeal wall right aryepiglottic fold left aryepiglottic posterior right right
fold pharyngeal corniculate cuneiform
wall tubercle tubercle

Fig. 4.1c Endoscopic view of the epiglottis and vocal cords. Fig. 4.1d Endoscopic view of the vocal cords.

hyoid bone open vocal folds vocal folds

Fig. 4.1e Cross-sectional CT scan at the superior aspect Fig. 4.1f Coronal section CT scan of the vocal cords,
of the thorax at the level of the vocal cords, which are open. which are open.

54
 apposed vocal cords corniculate tubercle cuneiform tubercle
epiglottis open vocal cords aryepiglottic fold

Fig. 4.1g Cross-sectional CT scan at the superior aspect Fig. 4.1h Coronal section CT of the vocal cords, which are
of the thorax at the level of the vocal cords. apposed.

Trachea (Fig. 4.2)

The trachea is a horseshoe- or D-shaped structure which extends from the cricoid
cartilage to the carina. The anterior aspect is composed of 16–20 incomplete cartilage
rings with a flat fibromuscular posterior component.There is also a longitudinal band of
connective tissue which runs down the posterior end of the cartilage. At bronchoscopy
the cartilage bands on the anterior surface appear as ridges and the posterior wall
appears to bulge into the trachea. The posterior bulge is accentuated in expiration.

superior vena cava fat aorta trachea aortic arch left pulmonary artery

trachea oesophagus right pulmonary artery left atrium left inferior pulmonary vein
Fig. 4.2a Cross-sectional CT scan of the thorax at the Fig. 4.2b Coronal sectional CT scan of the thorax through
mid-tracheal level. the trachea. 55
 cartilage rings anterior aspect carina anterior wall cartilage rings

posterior membranous trachea posterior tracheal wall

Fig. 4.2c Endoscopic view of the trachea from the level of Fig. 4.2d Endoscopic view of the upper trachea.
the subglottis.

anterior
tracheal left main right main anterior right right
wall bronchus bronchus aspect of upper tracheal right main upper tracheal
trachea lobe bronchus bronchus lobe bronchus
left main anterior right main
bronchus aspect bronchus

posterior carina (mc) membranous carina (mc) right main posterior wall posterior wall
tracheal wall posterior wall bronchus of trachea of trachea
Fig. 4.2e Endoscopic view Fig. 4.2f Endoscopic view Fig. 4.2g Endoscopic view Fig. 4.2h Endoscopic view
of the trachea from the of the distal portion of the of a tracheal bronchus as of a tracheal bronchus as
mid-tracheal level. trachea. viewed from above with seen at the distal trachea
the patient supine and just above the carina.
approached from behind. The right upper lobe and
The right upper lobe bronchus intermedius are
arises from the right main visible below.
bronchus.

56
 anterior segment of the right upper lobe tracheal bronchus trachea

posterior segment of the right upper lobe

Fig. 4.2i Bipartite division of the upper lobe in the Fig. 4.2j Cross-sectional CT scan showing the tracheal
presence of a tracheal bronchus. bronchus arising at the distal trachea just above the carina.

The trachea measures approximately 110 mm in length with an external diameter that
ranges from 15 mm in women to 20 mm in men. The internal diameter of the trachea
is about 12–14 mm.
The trachea divides into the right and left main bronchi at the level of the sternomanubrial
junction or the body of the fourth thoracic vertebrae.
A tracheal bronchus is a rare normal variant and originates from the lateral wall of the
trachea and into the upper lobe on the right side in about 0.1–2 per cent of individuals
and on the left side in 0.3–1 per cent of individuals. The term tracheal bronchus is also
used for other anomalous airways arising from the main bronchi and directed to the
upper lobes.

Carina (Fig. 4.3)

The carina is a concave spur of cartilage located where the distal trachea divides into
the right and left main bronchi. The carina normally appears as a sharp structure and
forms the medial borders of the origin of the right and left main bronchi. The sharp
angle is maintained as it is primarily composed of cartilage (carinal) and ligaments
(interbronchial). Enlargement of the subcarinal structures, such as the subcarinal lymph
nodes or the left atrium, may lead to blunting or widening of the carina. It usually
measures about 12 mm in diameter and stretches in the midline in the anteroposterior
dimension. Very rarely there is an accessory bronchus opening from the lateral walls
directed towards the upper lobe.

57
 apical segment
of the right anterior segment
upper lobe superior ascending pulmonary of the left upper oblique
(RB1) vena cava aorta artery lobe (LB3) fissure

right pulmonary right upper apicoposterior segment

artery lobe of the left upper lobe (LB1+2)

posterior segment superior carina descending apicoposterior

of the right upper pericardial aorta segment of the left atrium left pulmonary left inferior anterior segment of
lobe (RB2) recess left upper lobe artery pulmonary vein the left upper lobe
(LB1+2) (LB3)

Fig. 4.3a Cross-sectional CT scan of the thorax at the level Fig. 4.3b Coronal sectional CT scan of the thorax
of the carina. through the trachea.

left main bronchus carina (mc) right main bronchus

left main bronchus carina (mc) right main bronchus

posterior membranous wall of trachea posterior membranous wall of trachea

58 Fig. 4.3c Endoscopic view of the carina. Fig. 4.3d Close-up endoscopic view of the carina.
Right main bronchus (Fig. 4.4)
The right main bronchus extends from the carina to the origin of the right upper lobe.
It then forms the bronchus intermedius. The right main bronchus has a steeper decline
from the trachea and hence, in the upright position, foreign bodies tend to fall into
the right main bronchus. It is slightly larger in diameter than the left main bronchus,
measuring between 10 and 12 mm in external diameter. The inferior lip of the upper
lobe bronchus is easily visible at the distal end of the right main bronchus. A rare
variation is the origin of an airway leading to the upper lobe. This is classified as a pre-
eparterial tracheal bronchus. It may be either a supernumerary or a displaced airway.
Where the airway is displaced, there is also a missing upper lobe branch. An accessory
cardiac bronchus is a supernumerary bronchus arising from the medial aspect of the
right main bronchus and leading towards the pericardium.

anterior segmental apical segmental superior

bronchus of right bronchus of right vena carina
upper lobe (RB3) upper lobe (RB1) cava (mc) azygos arch trachea carina (mc) left main bronchus

posterior segmental azygos descending left main left right upper right upper lobe right main
bronchus of right vein aorta bronchus pulmonary lobe bronchus spur (RC1) bronchus
upper lobe (RB2) artery
Fig. 4.4a Cross-sectional CT scan of the thorax at the Fig. 4.4b Coronal sectional CT scan of the thorax
carina, showing the right main lobe. showing the right main bronchus.

59
 anterior wall of right upper lobe
right main bronchus spur (RC1) right upper lobe

posterior wall of bronchus intermedius

right main bronchus
Fig. 4.4c Endoscopic view of the right main bronchus Fig. 4.4d Endoscopic view of the right main bronchus
visible below the carina. which shows more of the right upper lobe origin.

Right upper lobe (Fig. 4.5)

The right upper lobe has three main segmental divisions: the apical, anterior and
posterior segments. The upper lobe segments divide into segments about 10 mm from
the origin. The upper lobe is subject to considerable normal variation:

●● In 40 per cent the segmental bronchi arise independently.

●● In 24 per cent there is a common apical and anterior trunk and an independent
post-segmental bronchus. (See Fig 4.5g)
●● In 14 per cent there is a common apical and posterior trunk and an independent
anterior segment. (See Fig 4.5h)
●● In 10 per cent there is a common anterior and posterior trunk with an independent
apical segment.
●● In 10 per cent the posterior segmental bronchus is absent.
●● In 2 per cent the apical segment is absent.
●● In < 1 per cent of patients there is a tracheal bronchus which originates either
directly from the trachea or at the level of the carina. In some cases there is an
additional branch to the upper lobe, which originates from the right main bronchus.

60
superior branch pulmonary anterior segment anterior branch of apical branch of right apical segment
of pulmonary superior right main artery of the left upper right upper lobe right upper lobe upper of left upper
artery vena cava bronchus trunk lobe (LB3) bronchus (RB3) bronchus (RB1) lobe lobe (LB1)

right upper lobe bronchus apicoposterior segment

of the left upper lobe (LB1+2) bronchus intermedius right main bronchus
Fig. 4.5a Cross-sectional CT scan of the thorax at the Fig. 4.5b Coronal sectional CT scan of the thorax
level of the right upper lobe origin. showing the right upper lobe.

apical segment of the

apical segment of the right upper lobe (RB1)
right upper lobe (RB1) RB2b RB2a

anterior segment of the posterior segment of the anterior segment of the posterior segment of the
right upper lobe (RB3) right upper lobe (RB2) right upper lobe (RB3) right upper lobe (RB2)
Fig. 4.5c Endoscopic view of the right upper lobe. Fig. 4.5d Another example of the tripartite right upper
lobe arrangement. 61
 apicoposterior segment of the apicoanterior segment of
right upper lobe (RB1+2) the right upper lobe (RB1+3)

apical segment of the posterior segment of the anterior segment apical segment posterior segment
right upper lobe (RB1) right upper lobe (RB2) of the right upper of the right upper of the right upper
lobe (RB3) lobe (RB1) lobe (RB2)

RB3b anterior segment of the RB3a

right upper lobe (RB3)
Fig. 4.5e Bipartite division of the right upper lobe with Fig. 4.5f Bipartite division of the right upper lobe with
division at the horizontal axis. division in the vertical axis.

apicoanterior segment of anterior segment apicoposterior

the right upper lobe (RB1+3) apical segment (RB1) of the right upper segment of the right
lobe (RB3) upper lobe (RB1+2) apical segment (RB1)

anterior segment (RB3) posterior segment of the

right upper lobe (RB2) RB2b posterior segment (RB2) RB2a
Fig. 4.5g Bipartite division of the right upper lobe with Fig. 4.5h Bipartite division of the right upper lobe with
apical and anterior segments (RB1 + 3 arising together) apical and posterior segments arising together (RB1 + 2)
62 and a separate posterior segment (RB2). and a separate posterior segment (RB3).
 anterior segment apical segment apicoposterior segment
of the right upper of the right upper of the right upper lobe
lobe (RB3) lobe (RB1) (RB1+2)

RB3a RB3b posterior segment of the

right upper lobe (RB2)

Fig. 4.5i Four divisions of the right upper lobe.

Bronchus intermedius (Fig. 4.6)

The bronchus intermedius originates from the right main bronchus and extends from
the origin of the right upper lobe to the right middle lobe. It is approximately 20 mm
long and has a diameter of about 10 mm. The right middle lobe, the apical segment
of the lower lobe and the basal segments are visible at the distal end of bronchus
intermedius.

63
 left superior anterior segment
bronchus left ventricular pulmonary left main pulmonary right upper apicoposterior segment of of the left upper
intermedius outflow tract trunk bronchus vein lobe bronchus the left upper lobe (LB1+2) lobe (LB3)

right superior right azygos left lobe left upper

pulmonary pulmonary vein pulmonary lobe bronchus right lower lobe bronchus right main left upper
vein artery artery pulmonary artery intermedius bronchus lobe bronchus
Fig. 4.6a Cross-sectional CT scan of the thorax at the Fig. 4.6b Coronal sectional CT scan of the thorax through
level of the bronchus intermedius (distal to the right upper the bronchial tree showing the bronchus intermedius.
lobe origin).

right middle lobe carina between right middle

right middle lobe (RB4+5) bronchus (RB4+5) lobe and lower lobe (RC2)

basal segments of the apical segment of the basal segments of lower lobe apical segment of right upper
right lower lobe right lower lobe (RB6) lobe (RB6)
Fig. 4.6c Endoscopic view of the bronchus intermedius. Fig. 4.6d Endoscopic view of the distal aspect of the
64 bronchus intermedius.
Right middle lobe (Fig. 4.7)
The right middle lobe is a semi-lunar (D-shaped) bronchus at the anterior end of the
bronchus intermedius. In approximately 70 per cent of cases, there are two distinct
segments: lateral and medial. In 23 per cent of normal individuals the middle lobe
bifurcates in a superior-inferior fashion, similar to that of the lingula. In up to 20 per
cent of individuals there is a main lateral bronchus and a smaller medial bronchus which
arises from the lateral segment. Occasionally the reverse is seen, with a larger medial
segment and a smaller lateral segment arising from it.

right lower lobe superior right left inferior

pulmonary artery pulmonary vein atrium pulmonary vein

right upper lobe segment right superior pulmonary vein

lateral segment right right left atrium left lower lobe right middle lobe right right inferior left left
of right middle middle lower pulmonary artery pulmonary artery middle pulmonary vein atrium ventricle
lobe (RB4) lobe lobe lobe
Fig. 4.7a Cross-sectional sectional CT scan of the thorax Fig. 4.7b Coronal sectional CT scan of the thorax at the
at the level of the right middle lobe. level of the right middle lobe.

65
 carina between right middle carina between right middle lobe
right middle lobe lobe and lower lobe (RC2) right middle lobe and right lower lobe (RC2)

medial segment basal segments apical segment of right lower lobe segments
of right lower of right lower the right lower
lobe (RB7) lobe lobe (RB6)
Fig. 4.7c Endoscopic view of the right middle and lower Fig. 4.7d Endoscopic view of the right middle lobe.
lobes.

medial segment of the medial segment of the

RB5b RB5a right lower lobe (RB5) RB5b right middle lobe (RB5) RB5a

RB4b lateral segment of RB4a RB4b lateral segment of the RB4a

right lower lobe (RB4) right middle lobe (RB4)
Fig. 4.7e Endoscopic view of right middle lobe subsegments Fig. 4.7f Close-up endoscopic view of the right middle
66 viewed from the origin of the right main bronchus. lobe subsegments.
Right lower lobe (Fig. 4.8)
The right lower lobe comprises five main segments: apical basal, medial basal, anterior
basal, lateral basal and posterior basal. In about 40–60 per cent of individuals there is
an additional subapical basal segment. The apical basal segment of the right lower lobe
is positioned posteriorly at the end of the bronchus intermedius. The apical segment
divides immediately into three subsegmental bronchi. The normal pattern observed
in the lower lobe bronchial segments are a large medial basal segment (RB7), which
is proximal to the other basal segments. The anterior basal segment is in the lateral
position, with the lower bronchus dividing further into lateral and posterior segments.
This pattern is seen in over 70 per cent of individuals. The other common variation
observed is where the anterior basal, lateral basal and posterior basal segments all
originate independently at the same level.
A bipartite division is occasionally observed where the anterior and lateral segments
arise together proximally to the posterior basal segment from a separate branch.
The position and size of the apical basal segment frequently influence the pattern of
branching of the basal segments. For example, in some individuals there is a larger apical
bronchus and, as a result, the medial through to posterior segment arises in a tripartite
from the same level.

right atrium left atrium left lower lobe bronchus

bronchus intermedius left pulmonary artery

right lower lobe right lower lobe left inferior left lower lobe anterior segment right lower left atrium left inferior
pulmonary artery bronchus pulmonary pulmonary of the right lower lobe bronchus pulmonary vein
vein artery lobe (RB8)
Fig. 4.8a Cross-sectional CT scan of the thorax at the Fig. 4.8b Coronal sectional CT scan showing the right
level of the right lower lobe. lower lobe.

67
 medial segment anterior segment
of right lower of the right lower Subsegments of the apical
lobe (RB7) lobe (RB8) Basal segment of segment of the right
right lower lobe RB6ci RB6cii lower lobe (RB6)

RB6a RB6b
apical segment of the apical segment of right RB6a RB6b
right lower lobe (RB6) lower lobe (RB6)
Fig. 4.8c Cross-sectional Fig. 4.8d Endoscopic view Fig. 4.8e Endoscopic view Fig. 4.8f Close-up
CT scan of the thorax at the of the right apicobasal of the apicobasal segments endoscopic view of the right
level of the basal segments of segment. of the right lower lobe. apicobasal subsegments.
the right lower lobe, showing
the right basal segments.

medial basal segment of anterior basal segment of medial basal segment of anterior basal segment of
the right lower lobe (RB7) RB8b the right lower lobe (RB8) the right lower lobe (RB7) RB8b the right lower lobe (RB8)

RB8a

RB8a

posterior basal segment of lateral basal segment of posterior basal segment of lateral basal segment of
the right lower lobe (RB10) the right lower lobe (RB9) the right lower lobe (RB10) the right lower lobe (RB9)

Fig. 4.8g Endoscopic view of the basal segments of the Fig. 4.8h Closer endoscopic view of the basal segments
right lower lobe. of the right lower lobe.

lateral basal segment of accessory subapical segment

lateral wall of the medial anterior basal segment of the right lower lobe (RB9) of the right lower lobe
segment of the right lower lobe RB8b the right lower lobe (RB8)

RB8a

RB10c

RB10c RB10a

posterior basal segment of RB10a lateral basal segment of posterior basal segment of RB10b
the right lower lobe (RB10) the right lower lobe (RB9) the right lower lobe (RB10)

Fig. 4.8i Endoscopic view of the anterobasal, basolateral Fig. 4.8j Endoscopic view of the basolateral and
and posterobasal segments of the right lower lobe. posterobasal segments of the right lower lobe. In this
68 example a normal variant subapical segment is present.
 anterior segment right lower lobe (RB8)

right lower lateral segment posterior segment inferior

lobe pulmonary of the right lower of right lower lobe pulmonary posterior segment of the anterior segment of the
artery lobe (RB9) (RB10) vein right lower lobe (RB10) right lower lobe (RB8)
Fig. 4.8k Endoscopic view of the anterobasal, basolateral Fig. 4.8l Endoscopic view of the basolateral and
and posterobasal segments of the right lower lobe. posterobasal segments of the right lower lobe.

posterior segment of the anterior basal segment lateral segment of the posterior segment of the
right lower lobe (RB10) of the right lower lobe (RB8) right lower lobe (RB9) right lower lobe (RB10)

lateral basal segment of the right lower lobe (RB9) subapical segment of the right lower lobe

Fig. 4.8m Endoscopic view of the anterobasal, basolateral Fig. 4.8n Endoscopic view of the basolateral and
and posterobasal segments of the right lower lobe. posterobasal segments of the right lower lobe. 69
 medial segment of accessory segment anterior segment
medial segment of anterior segment of the the right lower lobe of the right lower of the right lower
the right lower lobe RB7a right lower lobe (RB8) (RB7) lobe lobe (RB8)

RB7a posterior segment accessory subapical lateral segment of posterior segment of lateral segment of
of the right lower segment of the the right lower the right lower lobe the right lower lobe
lobe (RB10) right lower lobe lobe (RB9) (RB10) (RB9)
Fig. 4.8o Endoscopic view of the basal segments of the Fig. 4.8p Endoscopic view of the right lower lobe variant
right lower lobe showing a normal variant of a subapical with submedial segment.
segment.
medial segment of the accessory segment of
right lower lobe (RB7) the right lower lobe

posterior segment of lateral segment of anterior segment of

the right lower lobe the right lower lobe the right lower lobe
(RB10) (RB9) (RB8)
Fig. 4.8q Close-up of the right lower lobe variant with a
70 submedial segment.
Left main bronchus (Fig. 4.9)
The left main bronchus is approximately 4 cm long and descends in a gentle lateral
curve. At its terminal portion it divides into two main branches: the left lower lobe
and the left upper lobe bronchus. There is an obliquely placed sharp carina separating
the two bronchi. The upper lobe is joined at a 60o angle to the left main bronchus.
Occasionally the upper lobe bronchus joins the left main bronchus at an acute angle.

left superior
right pulmonary artery pulmonary artery pulmonary vein left main bronchus left pulmonary artery

inferior pulmonary vein left lower lobe left lower lobe

left main bronchus left lower lobe pulmonary artery bronchus pulmonary artery
Fig. 4.9a Cross-sectional CT scan of the thorax at the Fig. 4.9b Coronal sectional CT scan of the thorax at the
level of the left main bronchus. level of the left main bronchus.

left main anterior wall left main medial wall of left main medial wall of
bronchus of trachea bronchus left main bronchus bronchus left main bronchus

carina (mc) right main posterior wall of lateral curve of posterior wall of
bronchus left main bronchus left main bronchus left main bronchus
Fig. 4.9c Endoscopic view Fig. 4.9d Endoscopic view of the Fig. 4.9e Endoscopic view of the left
of the left main bronchus curve in the left main bronchus. main bronchus viewed from halfway
from the carina. down the left main bronchus with the left
lower lobe visible distally. 71
 left upper anterior aspect secondary carina upper secondary carina
lobe of left main of left main left lingular of left main
bronchus bronchus bronchus (LC2) lobe bronchus bronchus (LC2)
accessory left upper
bronchus lobe

posterior wall left lower

apical segment of left lower lobe apical segment left lower lobe of left main lobe
left lower lobe (LB6) segments of left lower basal segments bronchus
lobe (LB6)
Fig. 4.9f Endoscopic view of the left Fig. 4.9h Endoscopic view of the left
Fig. 4.9g Endoscopic view of the left
main bronchus viewed from two-thirds lower and upper lobes, with the apical
secondary carina with both the upper
the way down the left main bronchus, segment of the left upper lobe arising
and lower lobes visible.
with the left lower lobe visible distally. from the left main bronchus.

accessory left upper

accessory left upper
bronchus lobe bronchus
bronchus lobe bronchus

left lower secondary left lower lobe secondary

lobe carina (LC2) carina (LC2)

Fig. 4.9i Endoscopic view of the left Fig. 4.9j Endoscopic view of the left
lower and upper lobes with a close lower and upper lobes with a view
view of the apical segment of the left of the apical segment of the left
upper lobe arising from the left main upper lobe arising from the left main
bronchus. bronchus, from just above its origin.

72
Left upper lobe (Fig. 4.10)
The upper lobe bronchus usually divides into the upper division orifice and the lingual
bronchus. The upper division divides into an apicoposterior and anterior bronchus. In
the majority of individuals, the apicoposterior bronchus divides into three segmental
branches: the apical, posterior and posterolateral branches. In about 15 per cent of
individuals the apicoposterior segment has a bipartite structure with the posterolateral
subsegment arising from the anterior segment.

posterior lateral segment medial segment superior

segment of of the right of the right bronchus
the right lower lower lobe lower lobe pulmonary
left pulmonary anterior segment of lobe (RB10) (RB8) bronchus (RB7) artery
artery left upper lobe (LB3)

left main bronchus apicoposterior segment inferior anterior segment lateral segment
of the left lower lobe pulmonary vein of the left lower of the left lower
(LB1+2) lobe (LB7+8) lobe (LB9)
Fig. 4.10a Cross-sectional CT scan of the thorax at the Fig. 4.10b Coronal sectional CT scan of the thorax at
level of the left upper lobe bronchus. the level of the left upper lobe bronchus.

apicoposterior segment of anterior segment of

left upper lobe (LB1+2) left upper lobe (LB3) apicoposterior segment of anterior segment of
left upper lobe (LB1+2) the left upper lobe (LB3)
left superior
division lingula
bronchus (LB4+5)

apical segment of left left lower secondary

lower lobe (LB6) lobe bronchus carina (LC2) lingula (LB4+5)
Fig. 4.10c Endoscopic view of the left superior bronchus Fig. 4.10d Close-up of the left superior bronchus 73
from above the left main bronchial carina. showing the lingula and left upper lobe segments.
 apicoposterior segment anterior segment posterior segment
of the left upper lobe of the left upper of the left upper
(LB1+2) LB3a lobe (LB1) lobe (LB2)

LB3b anterior segment lingula apicoposterior anterior segment

of the upper lobe segment of the left of the left upper
(LB3) upper lobe (LB1+2) lobe (LB3)

Fig. 4.10e Left upper lobe segments Fig. 4.10f Endoscopic view of the
showing anterior and apicoposterior apicoposterior segment of the left upper
segments. lobe.

Lingula (Fig. 4.11)

The lingular bronchus arises from the left upper division bronchus. It divides into superior
segmental and inferior segmental branches, which in turn divide into two subsegmental
branches. In 25 per cent of individuals, the lingula bifurcates in a lateral and medial
fashion. On rare occasions the orifice of the lingula is merged with a segment from the
upper lobe.

superior segment of inferior segment

lingular bronchus the lingula (LB4) of the lingula (LB5)
superior pulmonary vein left upper lobe

pulmonary left atrium inferior pulmonary lingular bronchus

lower lobe pulmonary artery artery vein

Fig. 4.11a Cross-sectional CT scan of the thorax at the Fig. 4.11b Coronal sectional CT scan of the thorax at the
74 level of the lingular bronchus. level of the lingular bronchus.
apicoposterior anterior segment
segment of the left of left upper lobe superior segment of lingula (LB4)
upper lobe (LB1+2) LB3b (LB3) LB3a

lingular bronchus inferior segment of lingula (LB5)

Fig. 4.11c Bronchoscopic view of the lingula and anterior Fig. 4.11d Endoscopic view of the lingular segments.
segment of the left upper lobe.

Left lower lobe (Fig. 4.12)

The left lower lobe bronchus descends posterolaterally and divides into four segments
to form the left lower lobe. The apical segment arises about 1 cm after the origin of
the left lower lobe bronchus. After a further 1–2 cm the inferior bronchus divides
into an anterior basal segmental bronchus and a posterolateral basal bronchus which
further bifurcates into lateral basal and posterior basal segments. Endoscopically a
prominent secondary carina appears to divide into the apical basal bronchus and the
other inferior branches. The most common pattern of division of the left lower lobe is
into three branches (tripartite) with separate anterior basal, lateral basal and posterior
basal divisions.

75
 superior segment of the lingula (LB4) left lower lobe
left pulmonary artery pulmonary artery

left inferior left lower lower lobe inferior segment

pulmonary lobe bronchus pulmonary of the lingula
left main bronchus left lower lobe bronchus
vein artery (LB5)
Fig. 4.12a Cross-sectional CT scan of the thorax at the Fig. 4.12b Coronal sectional CT scan of the thorax at
level of the left lower lobe bronchus. the level of the left lower lobe bronchus.

anterior segment
apical segment apical segment of left lower
secondary of the left lower of the left lower LB8b lobe (LB7+8) LB8a
carina (LC2) left upper lobe LB6b lobe (LB6) LB6a LB6b lobe (LB6) LB6a

apical segment basal segments basal segments of basal segments of posterior segment lateral segment
of the left lower of the left the left lower lobe left lower lobe of left lower of left lower
lobe (LB6) lower lobe lobe (LB10) lobe (LB9)

Fig. 4.12c Bronchoscopic Fig. 4.12d Endoscopic Fig. 4.12e Bronchoscopic Fig. 4.12f Bronchoscopic view
view of the left lower lobe view of the left lower lobe. view of the apical segment of the basal segments of the
viewed from just above the of the left lower lobe. left lower lobe.
left secondary carina.

76
left lower lobe anterior segment of inferior segment
pulmonary artery the left lower lobe (LB8) of lingula (LB5)

lateral segment of
left main bronchus left pulmonary left lower lobe (LB9)

inferior posterior segment lateral segment

pulmonary vein of the left lower of the left lower
lobe (LB10) lobe (LB9) inferior pulmonary left lower lobe

Fig. 4.12g Cross-sectional CT scan of the thorax showing Fig. 4.12h Coronal sectional CT scan of the thorax
the left lower lobe segments. showing the left lower lobe segments.

77
 CHAPTER Vascular relationships and
5 lymph node stations
A good knowledge of the mediastinal anatomy, particularly the relationship between
the trachea, bronchial tree and the major vessels, is essential for procedures such
as transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guided
transbronchial needle aspiration (EBUS-TBNA). The thoracic lymph nodes also have
an important role in the staging, and hence treatment, of lung cancer. The anatomy is
described in relation to the new International Association for the Study of Lung Cancer
(IASLC) lymph node map.

Vascular relationships
The aorta is closely related to the anterior and left lateral aspect of the trachea. The
aortic root ascends below the carina and then arches over on the distal aspect of the
trachea on the left side and curves around the left hilum (Fig. 5.1).

Fig. 5.1a Relationship to the tracheobronchial tree of Fig. 5.1b Relationship to the tracheobronchial tree of
the aorta. the brachiocephalic veins, the superior vena cava and
the aorta.

The left brachiocephalic vein crosses the anterior aspect of the trachea, and its inferior
border on the right side of the trachea is at the same level as the aortic arch. It joins
with the right brachiocephalic vein and forms the superior vena cava. The superior
vena cava crosses the anterior aspect of the right main bronchus and drains into the
right atrium.

78
The pulmonary trunk divides at the level of the carina into the right and left pulmonary
arteries (Fig. 5.2). The pulmonary artery trunk is lateral to the aorta, and the right
pulmonary artery crosses the infracarinal region and is anterior to the trachea. It is
located posterior to the aorta. On the left, the pulmonary artery crosses the anterior
aspect of the left main bronchus and then advances behind the left upper lobe, where
it divides into superior and inferior branches.The superior branch of the left pulmonary
artery is located lateral and posterior to the left upper lobe bronchus. The inferior
branch follows the left lower lobe and is lateral and posterior to the left lower lobe.
The right pulmonary artery crosses anterior to the right main bronchus and divides
into superior and inferior branches lateral to the right main bronchus. The superior
Atlas of Flexible Bronchoscopy
Shah
branch of the right pulmonary artery is located anterolateral to the right upper lobe
bronchus. The inferior branch is sent posterior to the bronchus intermedius 5_2c and is
located posterior and lateral to the right middle lobe and lower lobe branches.
FOR PROOFING ONLY – Jane Fallows

Atlas of Flexible Bronchoscopy

Shah
Fig. 5.2a Relationship to the Fig. 5.2b Relationship to the Fig. 5.2c Relationship to the
tracheobronchial
5_2d tree of the tracheobronchial tree of the aorta and tracheobronchial tree of the left
pulmonary arteries. the pulmonary arteries. pulmonary artery.
FOR PROOFING ONLY – Jane Fallows

Fig. 5.2d Relationship Fig. 5.2e Relationship to the Fig. 5.2f Relationship Fig. 5.2g Relationship
to the tracheobronchial tracheobronchial tree of the aorta, to the tracheobronchial to the tracheobronchial
tree of the right pulmonary arteries and pulmonary tree of the left pulmonary tree of the right
pulmonary artery. veins. artery (blue) and pulmonary artery
pulmonary vein (red). (blue) and pulmonary
vein (red).

79
 The pulmonary veins are located anterior and inferior to the pulmonary artery. The
superior pulmonary vein is inferior and anterior to the pulmonary artery. On the left side,
the superior pulmonary vein is anterior to the left main bronchus, and the branches are
predominantly anterior to the bronchi.The inferior pulmonary vein arises in branches that
are predominantly posterior to the bronchus and pulmonary arteries, and forms the inferior
pulmonary vein medial to the left lower lobe. On the right side, the superior pulmonary
vein crosses over anterior to the right main bronchus and the branches arise from the
upper and middle lobes.The inferior pulmonary vein on the right side crosses the bronchus
intermedius and then travels posterior to the bronchus and pulmonary artery branches.

●●Bronchoscopic views
The cross-sectional drawings in Figure 5.3 are from the level of the third to the sixth
thoracic vertebral bodies.The drawings give the view that is obtained when looking from
above and hence the relationships are those found when performing a bronchoscopy
with the patient supine and approached from behind (posterior approach).

left brachiocephalic
vein

left phrenic
nerve brachiocephalic aortic arch
artery
left common
corotid artery right
superior
brachiocephalic
left recurrent vena cava
vein
laryngeal nerve
right vagnus
left subclavian azygos vein
nerve
artery
oesophagus

T3 T4
Fig. 5.3a Cross-sectional view at the level of the Fig. 5.3b Cross-sectional view at the
third vertebral body as viewed from above, showing upper level of the fourth vertebral body
the main vascular relationships to the trachea. as viewed from above, showing the main
vascular relationships to the trachea.

T4 T5 T6
Fig. 5.3c Cross-sectional view at the Fig. 5.3d Cross-sectional view at the Fig. 5.3e Cross-sectional view at the
lower level of the fourth vertebral body level of the fifth vertebral body as viewed level of the sixth vertebral body as viewed
as viewed from above, showing the main from above, showing the main vascular from above, showing the main vascular
80 vascular relationships to the trachea. relationships to the main bronchi. relationships to the main bronchi.
Lymph node stations
The mediastinal and hilar lymph nodes are described in this section according to the
new IASLC classification.

●●Superclavicular zone
Station 1 (Fig. 5.4)
These are the low cervical, supraclavicular and sternal notch lymph nodes. The upper
border is defined as the lower margin of the cricoid cartilage. The lower border is
defined by the clavicles and the upper border of the manubrium. Laterality (right or left
side) is determined by the midline of the trachea.

Fig. 5.4a Station 1 lymph nodes. Fig. 5.4b Coronal section of CT scan
depicting margins of the station 1
lymph node zone.

Fig. 5.4c Axial sections of CT scan Fig. 5.4d Axial sections of CT scan
depicting the margins of the station 1 depicting the margins of the station 1
lymph node zone: upper margins. lymph node zone: lower margin.

81
 ●●Superior mediastinal zone
Station 2: Upper paratracheal lymph nodes (Fig. 5.5)
The upper paratracheal lymph nodes are part of the superior mediastinal zone.The upper
border is defined by the apex of the lung to the superior border of the clavicles and
manubrium bilaterally. On the right side, the lower border is defined by where the inferior
aspect of the brachiocephalic vein crosses the trachea. On the left side, the lower border
is defined by the superior border of the aortic arch. The lateral margin is determined by
the left lateral border of the trachea so that nodes that are in the anterior aspect of the
trachea through to the left lateral margin of the trachea are defined as station 2R lymph
nodes, whereas nodes on the left lateral aspect of the trachea are defined as station 2L.

Fig. 5.5a Station 2R lymph nodes. Fig. 5.5b Station 2L lymph nodes.

Fig. 5.5c Axial sections of CT scan Fig. 5.5d Axial sections of CT scan Fig. 5.5e Coronal section of CT scan
depicting the margins of the station 2 depicting the margins of the station 2 depicting the margins of the station 2
lymph node zone: upper margins. lymph node zone: lower margin. lymph node zone.

Fig. 5.5f Sagittal views of CT scan Fig. 5.5g Sagittal views of CT scan
82 highlighting the station 2 lymph node highlighting the station 2 lymph node
area: left lateral. area: right lateral.
Station 3
Station 3A: Prevascular and retrosternal lymph nodes (Fig. 5.6)
The prevascular lymph nodes located on the right side anterior to the superior vena
cava up to the sternum. The upper border is defined by the apex of the chest and the
lower border at the level of the carina. On the left side, the lymph nodes are anterior
to the left carotid artery up to the sternal surface.The upper border is again defined as
the apex of the lung and the lower border by the level of the carina. Laterality is defined
according to the midline of the trachea.

Fig. 5.6a Station 3a lymph nodes: Fig. 5.6b Station 3a lymph nodes: Fig. 5.6c Sagittal views of CT scan
anterior view. coronal view. highlighting the station 3a lymph node
area: right lateral.

Fig. 5.6d Sagittal views of CT scan Fig. 5.6e Axial sections of CT scan Fig. 5.6f Axial sections of CT scan
highlighting the station 3a lymph node depicting the borders of the station 3a depicting the borders of the station 3a
area: left lateral. lymph node zone: upper border. lymph node zone: lower border.

83
Atlas of Flexible Bronchoscopy
Shah

5_7a Station 3P: Posterior or retrotracheal lymph nodes (Fig. 5.7)

These are the lymph nodes located posterior to the trachea. The upper margin is
FOR PROOFING ONLY – Jane Fallows
defined by the apex of the chest and the lower by the carina.

Fig. 5.7a Station 3p lymph nodes Fig. 5.7b Coronal view of CT scan Fig. 5.7c Sagittal view (right lateral)
(lateral view). depicting the area of the station 3p of CT scan highlighting the station 3p
lymph node. lymph node area.

Fig. 5.7d Sagittal view (left lateral) Fig. 5.7e Axial section of CT scan Fig. 5.7f Axial section of CT scan
of CT scan highlighting the station 3p depicting the upper border of the depicting the lower border of the
lymph node area. station 3p lymph node zone. station 3p lymph node zone.

84
Station 4: Lower paratracheal lymph nodes (Fig. 5.8)
The lower right paratracheal lymph nodes include the right paratracheal and anterior
carinal lymph nodes. Laterality is defined by the left lateral border of the trachea
(2 o’clock position if the midline is considered to be 12 o’clock through to 6 o’clock).
The upper border of the 4R lymph nodes is at the level where the lower border of
the brachiocephalic vein crosses the trachea.The lower border is defined by the azygos
vein. On the left side, the left paratracheal or 4L lymph node is on the left lateral aspect
of the trachea from the 2 o’clock position. Its upper border is the upper margin of the
aortic arch and the lower border is the upper rim of the left main pulmonary artery.

Fig. 5.8a Station 4R lymph nodes (azygos vein Fig. 5.8b Station 4L lymph nodes.
showing lower border).

Fig. 5.8c Axial section of CT scan Fig. 5.8d Axial section of CT scan Fig. 5.8e Coronal section of CT scan
depicting the upper margins of the depicting the lower margin of the depicting the margins of the station 2
station 4 lymph node zone. station 4 lymph node zone. lymph node zone.

Fig. 5.8f Sagittal views of CT scan Fig. 5.8g Sagittal views of CT scan
highlighting the margins of the station highlighting the margins of the station 85
4 lymph node zone: right lateral. 4 lymph node zone: left lateral.
 Station 5: Aortic lymph nodes (Fig. 5.9)
Atlas of Flexible Bronchoscopy
Shah These lymphnodes are located on the left side lateral to the ligamentum arteriosum.
The upper margin is defined by the lower border of the aortic arch and the lower
5_9a
margin by the upper border of the left main pulmonary artery.
FOR PROOFING ONLY – Jane Fallows

Fig. 5.9a Station 5 lymph notes: Fig. 5.9b coronal section of CT scan
anterior view (nodes in brown). depicting station 5 lymph nodes.

Fig. 5.9c Sagittal section of CT scan Fig. 5.9d Axial section of CT scan
demonstrating station 5 lymph node: demonstrating station 5 lymph node.
left.

86
Station 6: Para-aortic lymph nodes (Fig. 5.10)
The para-aortic lymph nodes are located on the left side and found anterolateral to
the ascending aorta and the aortic arch. The upper border is a horizontal line through
the upper border of the aortic arch and the lower border defined by the lower level
of the aortic arch.

Fig. 5.10a Station 6 lymph nodes: Fig. 5.10b Station 6 lymph nodes:
anterior view. coronal view.

Fig. 5.10c Sagittal view (left lateral) of CT Fig. 5.10d Axial view of CT scan depicting
scan depicting the station 6 lymph node. the station 6 lymph node.

87
 ●●Inferior mediastinal nodes
Station 7: Subcarinal lymph nodes (Fig. 5.11)
These are the lymph nodes located below the main carina of the trachea. The lower
border is defined by the lower border of the bronchus intermedius on the right side
and the lower border of the left main bronchus on the left side.

Fig. 5.11a Station 7 lymph nodes. Fig. 5.11b Coronal section of CT Fig. 5.11c Sagittal views of CT scan
scan depicting the margins of the depicting the station 7 lymph node:
station 7 lymph node zone. right lateral.

Fig. 5.11d Sagittal views of CT scan Fig. 5.11e Axial section of CT scan Fig. 5.11f Axial section of CT scan
depicting the station 7 lymph node: depicting the upper margins of the depicting the lower margins of the
left lateral. station 7 lymph node zone. station 7 lymph node zone.

88
●●Lower zone
Atlas of Flexible Bronchoscopy
Station
Shah 8: Para-oesophageal lymph nodes (Fig. 5.12)
These are lymph nodes lying adjacent to the wall of the oesophagus. They are the
5_12a
nodes located below the sub-carinal lymph nodes. Hence the upper border on the
right side is defi
FOR PROOFING ONLYned byFallows
– Jane the lower border of the bronchus intermedius and the left by
the lower border of the left main bronchus. The inferior extent of the lymph nodes is
the dome of the diaphragm.

Fig. 5.12a Station 8 lymph nodes. Fig. 5.12b Coronal section of CT Fig. 5.12c Axial section of CT scan
scan depicting the margins of the depicting the upper margins of the
station 8 lymph node zone. station 8 lymph node zone.

Fig. 5.12d Axial section of CT scan Fig. 5.12e Sagittal views of CT scan Fig. 5.12f Sagittal views of CT scan
depicting the lower margins of the depicting the station 8 lymph node: depicting the station 8 lymph node:
station 8 lymph node zone. left lateral. right lateral.

89
 Atlas of Flexible Bronchoscopy
Shah

5_13a Station 9: Pulmonary ligament lymph nodes (Fig. 5.13)

The pulmonary ligament lymph nodes are located along the pulmonary ligament. The
FOR PROOFING ONLY – Jane Fallows
upper border of station 9 is defined by the inferior pulmonary vein and the lower
border by the diaphragm.

Fig. 5.13a Station 9 lymph nodes. Fig. 5.13b Coronal section of CT Fig. 5.13c Axial section of CT scan
scan depicting the lower margins of depicting the upper margins of the
the station 9 lymph node zone. station 9 lymph node zone.

Fig. 5.13d Axial section of CT scan Fig. 5.13e Sagittal views of CT scan Fig. 5.13f Sagittal views of CT scan
depicting the lower margins of station depicting the station 9 lymph node: depicting the station 9 lymph node:
9 lymph node zone. left lateral. right lateral.

90
●●Hilar/interlobar zone (hilar nodes)
Station 10: Main bronchial lymph nodes (Fig. 5.14)
Station 10 or hilar lymph nodes are found adjacent to the right and left main bronchi
and the main pulmonary artery and pulmonary vein. On the right side, the upper
border is determined by the lower rim of the azygos vein down to the distal margin
of the right main bronchus. On the left side, the lymph nodes are located between the
upper rim of the pulmonary artery and the lower aspect of the left main bronchus.

Fig. 5.14a Station 10R lymph nodes (azygos vein Fig. 5.14b Station 10L lymph nodes.
depicting upper margin).

Fig. 5.14c Coronal view of CT scan Fig. 5.14d Axial sections of CT scan Fig. 5.14e Axial sections of CT scan
depicting the margins of the station depicting the margins of the station depicting the margins of the station
10 lymph node zone. 10 lymph node zone: upper margins. 10 lymph node zone: lower margins.

Fig. 5.14f Sagittal section of CT Fig. 5.14g Sagittal section of CT

scan depicting the station 10R (right) scan (left lateral) depicting the station 91
lymph node. 10L (left) lymph node zone.
 Station 11: Interlobar lymph nodes (Fig. 5.15)
These interlobar lymph nodes are located between the origin of the lobar bronchus.
On the right side are the superior station 11 lymph nodes (11Rs), which are located
between the right upper lobe and the bronchus intermedius. The inferior station 11
lymph nodes (11Ri) are located between the middle lobe bronchus and the lower lobe
bronchus. On the left side, the station 11 lymph nodes (11L) are located between the
left superior division bronchus and the left lower lobe bronchus.

Fig. 5.15a Station 11Rs lymph nodes. Fig. 5.15b Station 11Ri lymph nodes.

Fig. 5.15c Station 11L lymph nodes. Fig. 5.15d Coronal view of CT scan
depicting the station 11 lymph nodes.
92
Fig. 5.15e Axial section of CT scan Fig. 5.15f Axial sections of CT scan Fig. 5.15g Axial sections of CT scan
depicting Station 11Rs lymph node. depicting: station 11Ri lymph node. depicting: station 11L lymph node.

Fig. 5.15h Sagittal section of CT Fig. 5.15i Sagittal section of CT scan Fig. 5.15j Sagittal section of CT scan
scan (right lateral) depicting the (right lateral) depicting the station (left lateral) depicting the station 11L
station 11Rs (right) lymph node. 11R (right) lymph node. (left) lymph node.

●●Peripheral zone
Stations 12, 13 and 14
These are the lymph nodes located adjacent to the lobar bronchi (station 12) nodes,
adjacent to the upper lobes (12u), middle lobe (12m) and lower lobes (12l).The station
13 lymph nodes are segmental nodes and the station 14 nodes are located adjacent to
the subsegmental bronchi. These lymph nodes are not accessible at bronchoscopy and
are therefore not discussed further.

93
 Chapter Transbronchial fine-
6 needle aspiration
(anterior approach)
Transbronchial fine-needle aspiration (TBNA) is a simple, cheap technique for sampling
mediastinal nodes. Hilar lymph nodes, masses adjacent to the airways and submucosal
disease may also be sampled with this technique. A variety of needles are available but
the needle should be retractable with a length of between 13 and 15 mm and a gauge
of between 18 and 22 (Fig. 6.1).

Fig. 6.1a Bronchoscope with Fig. 6.1b Bronchoscope with

transbronchial fine-needle aspiration needle: transbronchial fine-needle aspiration needle:
withdrawn into the sheath. extended out of the sheath.

Planning/site selection
The computed tomography (CT) scan of the thorax should be examined prior to
TBNA and the site of aspiration should be predetermined (Fig. 6.2a). The simplest
approach is to relate the airway to a clock face and plan the position of target sites in
this manner (Fig. 6.2b). The CT scan is obtained by imaging from the feet upwards (Fig.
6.2c), whereas at bronchoscopy the patient is approached from the head downwards
(Fig. 6.2d). It is therefore important to account for these differences. For patients who
are being approached from the anterior side, the simple trick is to flip the image in
the horizontal axis (Fig. 6.2e). The vertical position also needs to be determined and
can be described in terms of cartilage spaces or rings above and below the carina
(Fig. 6.2f). In some cases it may be necessary to relate the vertical position to the
origin of the segmental bronchi. More detailed descriptions are given for the example
lymph node stations in this chapter, but it should be emphasized that this is merely
a guide and individual sites for aspiration are determined according to the patient’s
CT scan. Modern multi-planar reformatting of CTs and software modules with virtual
bronchoscopy (Fig. 6.2g) and lymph node highlighting (Fig. 6.2h) may help to determine
94 the site of needle aspiration.
Fig. 6.2a CT scan with right paratracheal lymph node Fig. 6.2b CT scan with the right paratracheal lymph node
present. highlighted in yellow and the clock face showing that the
lymph node is in 10–11 o’clock position.

Fig. 6.2c Cross-sectional CT scan of the thorax; note the Fig. 6.2d Bronchoscopic view; note the relative position of
relative position of the anterior and posterior aspects of the anterior and posterior aspects of the patient.
the patient.

95
 Fig. 6.2e Cross-sectional CT scan of the thorax flipped on Fig. 6.2f Coronal CT reformat to help determine the
the horizontal axis so as to align the anterior and posterior vertical position of the lymph node in relation to the carina.
aspects of the patient with the bronchoscopic view.

Fig. 6.2g Virtual bronchoscopy derived from CT scanning. Fig. 6.2h Virtual bronchoscopy derived from CT scanning
with lymph node highlighting.

96
Technique
Transbronchial fine-needle aspiration should be performed first during the bronchoscopy
and, in the case of mediastinal lymph node sampling, before inspection of the airways.
Minimal use of suction should be employed in order to minimize the risk of aspirating
cellular material from the distal airways, which may lead to false-positive results. These
simple precautions virtually prevent any false-positive results. This is important in the
staging of lung cancer where a false-positive result would upstage a patient and deny
him or her potentially curative surgery. It is also important to sample the highest-
stage lymph nodes first, e.g. N3 lymph nodes followed by N2 lymph nodes and finally
N1 lymph nodes. The needle should be inserted through the instrument channel of
the bronchoscope with the bronchoscope as straight as possible in the trachea. Any
flexion or extension of the distal portion of the scope should be avoided until the
hub of the needle is outside the bronchoscope. This is essential in order to minimize
bronchoscope damage.
A number of techniques can be used to sample the lymph node (Fig. 6.3):

●● jabbing
●● piggyback
●● cough.

●●Jabbing technique
This involves guiding the bronchoscope to the target area and then apposing the distal
hub of the needle to the airway wall.The distal portion of the scope should be angulated
to ensure that the needle penetrates through the airway as perpendicular as possible.
There should be an angle of at least 45° between the airway wall and the needle. The

Fig. 6.3a Transbronchial needle apposed on to the airway Fig. 6.3b Transbronchial needle penetrating through the
wall at an angle of at least 45° in the anterior carinal airway wall in the anterior carinal position.
position.

97
 Fig. 6.3c Cytology slides being prepared from aspirates.
The aspirate is first sprayed on to the slides and then thin
smears are made.

needle is then pushed through the airway wall and gently manipulated back and forth.
At the same time, an assistant should apply suction at the proximal end of the TBNA
needle with a 20 mL syringe. The samples collected are then smeared on to slides
and sprayed with a fixative, or alternatively injected into saline or cytolyte solution,
depending on the preference of the local site pathologist. Any tissue fragments or
slivers obtained are placed in formalin and sent for histological analysis. The availability
of rapid on-site cytological evaluation (ROSE) significantly reduces the time of the
procedure and improves diagnostic yield.
In the absence of a ROSE, at least four needle passes are made at each target site when
assessing patients with suspected lung cancer. The site with the highest possible lymph
node stage should be sampled first, then moving progressively down to the lower site.

●●Piggyback method
With this method the needle is advanced, and once the hub is protruding through the
distal end, the needle is fixed by pressing the insertion port of the bronchoscope with
an index finger. This does cause the catheter to bend at this point and the technique
is better reserved for single-use disposable needles. Once the needle is fixed into
position, the scope and the needle can be moved in unison and pushed forward at the
desired location until the needle penetrates the airway wall. The needle is moved back
and forth with an assistant applying suction as described for the jabbing technique.

●●Cough technique
This method employs either of the above approaches in conjunction with a controlled
cough to facilitate penetration of the needle through the airway wall. It relies on patient
cooperation and may not always be successful.

98
Lymph node stations
It is possible to sample any of the lymph nodes that are adjacent to the airways using
TBNA. The lymph node stations are described according to the new InternationaI
Association for the Study of Lung Cancer (IASLC) classification.

●●Superior mediastinal lymph nodes: upper zone

Station 4R: Lower right paratracheal lymph node (Fig. 6.4)
The station 4R or right paratracheal lymph node is classically located in the right
anterior aspect of the trachea. The exact position should be predetermined from the
CT scan. Usually on the CT scan the right paratracheal lymph node is located in the
10–11 o’clock position, if the anterior midline is considered to be 12 o’clock. However,
one should note that the CT scans are obtained by looking at the patient from the
feet upwards; but when patients undergo a bronchoscopy, the airways are viewed with
the head downwards. When the patient is approached from the front, with the patient
in a semi-recumbent position, the posterior wall is now at the 12 o’clock position and
the anterior wall at the 6 o’clock position. Hence, in this position the right paratracheal
lymph node is now positioned between the seven and 8 o’clock positions.The simplest
way is to flip the CT scan in the horizontal axis.The bronchoscopic position of the right
paratracheal lymph node is between seven and 8 o’clock. Bending the bronchoscope
posteriorly in this position is more difficult. Easier and more accurate access can be
achieved by rotating the bronchoscope by about 180°. The lymph node is now in the
one to 2 o’clock position. The vertical position of the right paratracheal lymph node is
about two to four intercartilage spaces above the carina.

Fig. 6.4a Cross-sectional CT scan of the thorax at the Fig. 6.4b Cross-sectional CT scan with a superimposed
level of the aortic arch showing a station 4R lymph node. clock face and a station 4R lymph node highlighted in yellow.

99
 Fig. 6.4c Cross-sectional CT scan of the thorax flipped Fig. 6.4d Coronal section of CT scan showing the vertical
on the horizontal axis.The 4R lymph node is in the 7–8 position of the lymph node, which is usually about two to
o’clock position. four rings above the carina.

Fig. 6.4e Bronchoscopic Fig. 6.4f Rotation of the Fig. 6.4g Bronchoscopic Fig. 6.4h Bronchoscopic
view of the station 4R bronchoscope by 180° view of the needle inserted view of the needle inserted
lymph node which is in the facilitates access of the into a 4R lymph node in the into a 4R lymph node in
7–8 o’clock position about station 4R lymph node 2 o’clock position with the the 8 o’clock position with
two to four intercartilage which is now in the 1–2 scope rotated anteriorly by the scope in the neutral
spaces above the carina. o’clock position. 180°. position.

100 Fig. 6.4i Cross-sectional CT scan of anterior carinal Fig. 6.4j Cross-sectional CT scan with a superimposed
lymph node (station 4R) anterior to the carina. clock face and anterior carinal lymph node (station 4R)
highlighted in yellow.
Fig. 6.4k Cross-sectional CT scan flipped on the Fig. 6.4l Coronal section of CT scan showing the vertical
horizontal axis.The anterior carinal lymph node (station position of the anterior carinal lymph node which is usually
4R) is in the 6–6.30 o’clock position. at the level of the carina.

Fig. 6.4m Bronchoscopic Fig. 6.4n Rotation of the Fig. 6.4o Bronchoscopic Fig. 6.4p Bronchoscopic
view of the station 4R bronchoscope by 180° view of needle inserted into view of the needle inserted
(anterior carinal) lymph facilitates access of the a 4R lymph node in the 12 into a 4R lymph node in
node which is in the 6 station 4R (anterior carinal) o’clock position with the the 6 o’clock position with
o’clock position at the level lymph node, which is now in scope rotated anteriorly by the scope in the neutral
of the carina. the 12 o’clock position. 180°. position.

As described in Chapter 5, station 4R can extend anterior to the trachea through to

the 2 o’clock position. Nodes located anterior to the trachea were previously described
as anterior carinal lymph nodes. They are usually located in the 11.30 to 12 o’clock
position on the CT scan. At bronchoscopy this relates to the 6–6.30 position when the
patient is being approached from the front. During TBNA when the patient is being
approached from the front, it is easier to sample the lymph nodes if the scope is rotated
by 180° so that the lymph node is now in an anterior direction of the bronchoscope.

101
 Station 4L: Lower left paratracheal lymph node (Fig. 6.5)
The station 4L or left paratracheal lymph node is located on the left lateral position
of the trachea at or above the level of the carina. On the CT scan the lymph node
is located in the 3 o’clock position. When the patient is being approached from the
front at bronchoscopy, the lymph node is located at the same 3 o’clock position. The
vertical position of the lymph node is at the level of the carina or one space above.
In practice this lymph node is more easily accessed by rotating the bronchoscope 90°
in an anticlockwise direction. Once the needle has penetrated the airway wall, the
torsion on the bronchoscope can be relaxed and the needle moved back while the
bronchoscope is in the neutral position (as in Fig. 6.5h).

Fig. 6.5a Cross-sectional CT scan of the thorax showing a Fig. 6.5b Cross-sectional CT scan with a superimposed
station 4L lymph node. clockface and a station 4L lymph node highlighted in yellow.

Fig. 6.5c Cross-sectional CT scan of the thorax flipped on Fig. 6.5d Coronal section of CT scan showing the vertical
the horizontal axis.The 4L lymph node is in the 3 o’clock position of the station 4L lymph node, which is usually at
102 position. one intercartilage space above the carina.
Fig. 6.5e Bronchoscopic Fig. 6.5f Rotation of the Fig. 6.5g Bronchoscopic Fig. 6.5h Bronchoscopic
view of the station 4L bronchoscope by 90° view of the needle inserted view of the needle inserted
lymph node which is in the anticlockwise facilitates into a 4L lymph node into a 4L lymph node in
3 o’clock position about one access of the station 4L with the scope rotated the 3 o’clock position with
intercartilage space above lymph node. anticlockwise by 90°. the scope in the neutral
the carina. position.

Station 3P: Posterior tracheal lymph node (Fig. 6.6)

The posterior carinal lymph node is usually located at the level of the carina on the
posterior aspect of the trachea. On CT terms it can be considered to be in the 5.30–6
o’clock position. At bronchoscopy it is located at the level of the carina in the 12–12.30
o’clock position when the patient is approached from the front.The forward angulation
of the bronchoscope is greater in the anterior direction and therefore access for TBNA
is improved by rotating the scope to 180° so that the lymph nodes are now anterior
in the 12–12.30 o’clock position. The seventh edition of the IASLC staging classification
regards all lymph nodes posterior to the trachea as station 3p, so the site of needle
sampling should be planned from the CT scan of the thorax.

Fig. 6.6a Cross-sectional CT scan of the thorax showing a Fig. 6.6b Cross-sectional CT scan with a superimposed
station 3p lymph node. clockface and a station 3p lymph node highlighted in yellow.

103
 Fig. 6.6c Cross-sectional CT scan of the thorax flipped on Fig. 6.6d Coronal section of CT scan showing the vertical
the horizontal axis.The 3p lymph node is in the 12–12.30 position of the station 3p lymph node, which is usually at
o’clock position. the level of the carina.

Fig. 6.6e Bronchoscopic view of the station 3p lymph Fig. 6.6f Bronchoscopic view of needle inserted into a 3p
node which is in the 12–12.30 o’clock position about one lymph node in the 12 o’clock position with the scope in
intercartilage space above the carina. the neutral position.

104
●●Inferior mediastinal lymph nodes
Station 7: Subcarinal lymph node (Fig. 6.7)
The station 7 or subcarinal lymph nodes are located just inferior to the carina.The carina
is composed of three bundles of cartilage and ligament and hence direct puncture
through the carina tends to be unsuccessful. The subcarinal lymph nodes should be
approached in the right main bronchus by one space below the carina. On the CT
scan this translates to the 3 o’clock position and is the same if the patient is being
approached from the front. Easier and more accurate access is facilitated by rotating
the bronchoscope by 90° anticlockwise.

Fig. 6.7a Cross-sectional CT scan of the thorax showing Fig. 6.7b Cross-sectional CT scan with a superimposed
a station 7 lymph node. clock face and a station 7 lymph node highlighted in yellow.

Fig. 6.7c Cross-sectional CT scan of the thorax flipped Fig. 6.7d Coronal section of CT scan showing the vertical
on the horizontal axis.The station 7 lymph node is in the position of the station 7 lymph node which is usually one
3 o’clock position. intercartilage space below the carina in the right main
bronchus. 105
 Fig. 6.7e Bronchoscopic Fig. 6.7f Rotation of the Fig. 6.7g Bronchoscopic Fig. 6.7h Bronchoscopic
view of the station 4L bronchoscope by 90° view of needle inserted into view of the needle inserted
lymph node which is in anticlockwise facilitates a station 7 lymph node into a station 7 lymph node
the 3 o’clock position one access of the station 7 with the scope rotated in the 3 o’clock position
intercartilage space below lymph node. anticlockwise by 90°. with the scope in the
the carina in the right main neutral position.
bronchus.

●●Hilar zone lymph nodes

Station 10R: Right main bronchial lymph node (Fig. 6.8)
The station 10R or right main bronchial lymph node is located anterior to the right
main bronchus about one intercartilage space below the carina in the 12 o’clock
position on the CT scan. Where the patient is being bronchoscoped from the front,
this is equivalent to the 6 o’clock position in the right main bronchus one space below
the carina. Again, for improved access when performing TBNA, the bronchoscope
should be rotated by 180° so that the lymph node is now positioned anteriorly at the
12 o’clock position.

Fig. 6.8a Cross-sectional CT scan of the thorax showing a Fig. 6.8b Cross-sectional CT scan with a superimposed clock
station 10R lymph node. face and a station 10R lymph node highlighted in yellow.

106
Fig. 6.8c Cross-sectional CT scan of the thorax flipped on Fig. 6.8d Coronal section of CT scan showing the vertical
the horizontal axis.The 10R lymph node is in the 6 o’clock position of the station 10R lymph node which is usually
position in the right main bronchus. one intercartilage space below the carina in the right main
bronchus.

Fig. 6.8e Bronchoscopic Fig. 6.8f Rotation of the Fig. 6.8g Bronchoscopic Fig. 6.8h Bronchoscopic
view of the station 10R bronchoscope by 180° view of the needle inserted view of the needle inserted
lymph node which is in the clockwise facilitates access into a 10R lymph node with into a station 10R lymph
6 o’clock position about one of the station 10R lymph the scope rotated clockwise node in the 6 o’clock
intercartilage space below node. by 180°. position with the scope in
the carina in the right main the neutral position.
bronchus.

Station 10L: Left main bronchial lymph node (Fig. 6.9)

The left main bronchial lymph node is located on the anterior aspect of the left main
bronchus approximately one interspace below the carina in the 12 o’clock position.
During bronchoscopy when the patient is being approached from the front, the lymph
node is in the 6 o’clock position and again access improved by rotating the scope
through 180° so that the approach is now in the 12 o’clock position.

107
 Fig. 6.9a Cross-sectional CT scan of the thorax showing a Fig. 6.9b Cross-sectional CT scan with a superimposed
station 10L lymph node. clock face and a station 10L lymph node highlighted in
yellow in the 6 o’clock position.

Fig. 6.9c Cross-sectional CT scan of the thorax flipped Fig. 6.9d Coronal section of CT scan showing the vertical
on the horizontal axis.The 10L lymph node is in the 12 position of the station 10L lymph node which is usually
o’clock position. one intercartilage space below the carina.

Fig. 6.9e Bronchoscopic Fig. 6.9f Rotation of the Fig. 6.9g Bronchoscopic Fig. 6.9h Bronchoscopic
view of the station 10L bronchoscope by 180° view of the needle inserted view of the needle inserted
lymph node which is in the clockwise facilitates access into a 10L lymph node with into a 10L lymph node in
6 o’clock position about one of the station 10L lymph the scope rotated clockwise the 6 o’clock position with
108
intercartilage space below node. by 180°. the scope in the neutral
the carina in the left main position.
bronchus.
Station 11Rs: Right upper hilar lymph node (Fig. 6.10)
The station 11R includes the right upper and right lower hilar nodes. The right upper
hilar node is located on the CT scan between the right upper lobe bronchus and the
bronchus intermedius. On the CT cross-section it relates to the 9 o’clock position just
below the origin of the bronchus intermedius. At bronchoscopy this relates to the
anterior spur of the right upper lobe carina and the optimal approach is to insert the
needle just below the spur of the upper lobe carina. When the patient is approached
from the front, this is just below the origin of the bronchus intermedius in the 9–10
o’clock position. It is in the proximal portion of the bronchus intermedius.

Fig. 6.10a Cross-sectional CT scan of the thorax showing Fig. 6.10b Cross-sectional CT scan with a superimposed
a station 11Rs (right upper hilar) lymph node. clock face and a station 11Rs (right upper hilar) lymph
node highlighted in yellow.

Fig. 6.10c Cross-sectional CT scan of the thorax flipped Fig. 6.10d Coronal section of CT scan showing the
on the horizontal axis.The station 11Rs (right upper hilar) vertical position of the station 11Rs (right upper hilar)
lymph node is in the 9 o’clock position. lymph node, which is usually located at the right upper
lobe carina.

109
 Fig. 6.10e Bronchoscopic Fig. 6.10f Rotation of Fig. 6.10g Bronchoscopic Fig. 6.10h Bronchoscopic
view of the station 11Rs the bronchoscope by 90° view of the needle inserted view of the needle inserted
(right upper hilar) lymph clockwise facilitates access into a station 11Rs (right into a station 11Rs (right
node which is in the 9 of the station 11Rs (right upper hilar) lymph node upper hilar) lymph node in
o’clock position in the upper hilar) lymph node. with the scope rotated the 9 o’clock position with
anterior spur of the right clockwise by 90°. the scope in the neutral
upper lobe carina. position.

Station 11Ri: Right lower hilar lymph node (Fig. 6.11)

On the CT scan, the right lower hilar lymph node is located lateral to the bronchus
intermedius in the 9 o’clock position at the level of the right middle lobe.At bronchoscopy
the needle should be inserted in the distal part of the bronchus intermedius in the
9 o’clock position at the level of the right middle lobe origin. Access into this lymph
node is also facilitated by rotation of the scope by 90°.

Fig. 6.11a Cross-sectional CT scan of the thorax showing Fig. 6.11b Cross-sectional CT scan with a superimposed
a station 11Ri (right lower hilar) lymph node. clock face and a station 11Ri (right lower hilar) lymph
node highlighted in yellow.

110
Fig. 6.11c Cross-sectional CT scan of the thorax flipped Fig. 6.11d Coronal section of CT scan showing the
on the horizontal axis.The station 11Ri (right lower hilar) vertical position of the station 11Ri (right lower hilar)
lymph node is in the 9 o’clock position. lymph node, which is usually just higher than the right
middle lobe origin.

Fig. 6.11e Bronchoscopic Fig. 6.11f Rotation of Fig. 6.11g Bronchoscopic Fig. 6.11h Bronchoscopic
view of the station 11Ri the bronchoscope by 90° view of the needle inserted view of the needle inserted
(right lower hilar) lymph clockwise facilitates access into a station 11Ri (right into a station 11Ri (right
node which is in the 9 of the station 11Ri (right lower hilar) lymph node lower hilar) lymph node in
o’clock position in the lower hilar) lymph node. with the scope rotated the 9 o’clock position with
bronchus intermedius just clockwise by 90°. the scope in the neutral
above the origin of the right position.
middle lobe.

Station 11L: Left hilar lymph node (Fig. 6.12)

The station 11L or left hilar lymph node is located at the bifurcation of the left main
bronchus. It is accessed from the left lower lobe towards the upper lobe in the 6–7
o’clock position. Needle insertion is easier if the bronchoscope is rotated by 180° and
the needle is inserted into the 12–1 o’clock position from the left lower lobe to the
left upper lobe.

111
 Fig. 6.12a Cross-sectional CT scan of the thorax showing Fig. 6.12b Cross-sectional CT scan with a superimposed
a station 11L lymph node. clock face and a station 11L lymph node highlighted in yellow.

Fig. 6.12c Cross-sectional CT scan of the thorax flipped Fig. 6.12d Coronal section of CT scan showing the vertical
on the horizontal axis.The 11L lymph node is in the 6–7 position of the station 11L lymph node which is usually at the
o’clock position when approached from the left lower lobe. level of the carina between the left upper and lower lobes.

Fig. 6.12e Bronchoscopic Fig. 6.12f Rotation of the Fig. 6.12g Bronchoscopic Fig. 6.12h Bronchoscopic
view of the station 11L bronchoscope by 180° view of the needle inserted view of the needle inserted
lymph node which is in the clockwise facilitates access of into an 11L lymph node into an 11L lymph node in
6–7 o’clock position when the station 11L lymph node with the scope rotated the 3 o’clock position with
approached from the left and the lymph node is in anticlockwise by 90°. the scope in the neutral
lower lobe and about one the 12 to 1 o’clock position position.
intercartilage space below when approached from the
the left main bronchial left lower lobe and about one
112 carina. intercartilage space below
the left main bronchial carina.
 Transbronchial fine- Chapter
needle aspiration 7
(posterior approach)
Transbronchial fine-needle aspiration (TBNA) is a simple, cheap technique for sampling
mediastinal nodes. Hilar lymph nodes, masses adjacent to the airways and submucosal
disease may also be sampled with this technique. A variety of needles are available but
the needle should be retractable with a length of between 13 and 15 mm and a gauge
of between 18 and 22 (Fig. 7.1).

Fig 7.1a Bronchoscope with transbronchial Fig 7.1b Bronchoscope with

fine-needle aspiration needle: withdrawn transbronchial fine-needle aspiration needle:
into the sheath. extended out of the sheath.

Planning/site selection
The computed tomography (CT) scan of the thorax should be examined prior to
TBNA and the site of aspiration should be predetermined (Fig. 7.2a). The simplest
approach is to relate the airway to a clock face and plan the position of target sites in
this manner (Fig. 7.2b). The CT scan is obtained by imaging from the feet upwards (Fig.
7.2c), whereas at bronchoscopy the patient is approached from the head downwards
(Fig. 7.2d). It is therefore important to account for these differences. For patients who
are being approached from the posterior side, the simple trick is to flip the image
in the vertical axis (Fig. 7.2e). The vertical position also needs to be determined and
can be described in terms of cartilage spaces or rings above and below the carina
(Fig. 7.2f). In some cases it may be necessary to relate the vertical position to the
origin of the segmental bronchi. More detailed descriptions are given for the example
lymph node stations in this chapter, but it should be emphasized that this is merely
a guide and individual sites for aspiration are determined according to the patient’s
CT scan. Modern multi-planar reformatting of CTs and software modules with virtual
bronchoscopy (Fig. 7.2g) and lymph node highlighting (Fig. 7.2h) may help to determine
the site of needle aspiration. 113
 Fig 7.2a CT scan with the right paratracheal lymph node Fig 7.2b CT scan with the right paratracheal lymph node
present. highlighted in yellow and the clock face showing that the
lymph node is in 10–11 o’clock position.

Fig 7.2c Cross-sectional CT scan of the thorax; note the Fig 7.2d Bronchoscopic view; note the relative position of
relative position of the anterior and posterior aspects of the anterior and posterior aspects of the patient.
the patient.

114
Fig 7.2e Cross-sectional CT scan of the thorax flipped on Fig 7.2f Coronal CT reformat to help determine the
the vertical axis so as to align the right and left aspects of vertical position of the lymph node in relation to the carina.
the patient with the bronchoscopic view.

Fig 7.2g Virtual bronchoscopy derived from CT scanning. Fig 7.2h Virtual bronchoscopy derived from CT scanning
with lymph node highlighting.

115
 Technique
Transbronchial fine-needle aspiration should be performed first during the bronchoscopy
and, in the case of mediastinal lymph node sampling, before inspection of the airways.
Minimal use of suction should be employed in order to minimize the risk of aspirating
cellular material from the distal airways, which may lead to false-positive results. These
simple precautions virtually prevent any false-positive results. This is important in the
staging of lung cancer where a false-positive result would upstage a patient and deny
him or her potentially curative surgery. It is also important to sample the highest-
stage lymph nodes first, e.g. N3 lymph nodes followed by N2 lymph nodes and finally
N1 lymph nodes. The needle should be inserted through the instrument channel of
the bronchoscope with the bronchoscope as straight as possible in the trachea. Any
flexion or extension of the distal portion of the scope should be avoided until the
hub of the needle is outside the bronchoscope. This is essential in order to minimize
bronchoscope damage.
A number of techniques can be used to sample the lymph node:

●● jabbing
●● piggyback
●● cough.

●●Jabbing technique
This involves guiding the bronchoscope to the target area and then apposing the
distal hub of the needle to the airway wall. The distal portion of the scope should be
angulated to ensure that the needle penetrates through the airway as perpendicular
as possible. There should be an angle of at least 45° between the airway wall and
the needle (Fig. 7.3). The needle is then pushed through the airway wall and gently
manipulated back and forth. At the same time, an assistant should apply suction at the

Fig. 7.3a Transbronchial needle apposed on to the airway Fig. 7.3b Transbronchial needle penetrating the airway
wall at an angle of a least 45° in the anterior carinal position. wall in the anterior carinal position.
116
Fig. 7.3c Cytology smears prepared by spraying aspirates
on to the slides.

proximal end of the TBNA needle with a 20 mL syringe.The samples collected are then
smeared on to slides and sprayed with a fixative, or alternatively injected into saline or
cytolyte solution, depending on the preference of the local site pathologist. Any tissue
fragments or slivers obtained are placed in formalin and sent for histological analysis.
The availability of rapid on-site cytological evaluation (ROSE) significantly reduces the
time of the procedure and improves diagnostic yield.
In the absence of a ROSE, at least four needle passes are made at each target site when
assessing patients with suspected lung cancer. The site with the highest possible lymph
node stage should be sampled first, then moving progressively down to the lower site.

●●Piggyback method
With this method the needle is advanced, and once the hub is protruding through the
distal end, the needle is fixed by pressing the insertion port of the bronchoscope with
an index finger. This does cause the catheter to bend at this point and the technique
is better reserved for single-use disposable needles. Once the needle is fixed into
position, the scope and the needle can be moved in unison and pushed forward at the
desired location until the needle penetrates the airway wall. The needle is moved back
and forth with an assistant applying suction as described for the jabbing technique.

●●Cough technique
This method employs either of the above approaches in conjunction with a controlled
cough to facilitate penetration of the needle through the airway wall. It relies on patient
cooperation and may not always be successful.

117
 Lymph node stations
It is possible to sample any of the lymph nodes that are adjacent to the airways using
TBNA. The lymph node stations are described according to the new InternationaI
Association for the Study of Lung Cancer (IASLC) classification.

●●Superior mediastinal lymph nodes: upper zone

Station 4R: Lower right paratracheal lymph node (Fig. 7.4)
The right paratracheal lymph node is classically located in the right anterior aspect of
the trachea. The exact position should be predetermined from the CT scan. Usually on
the CT scan the right paratracheal lymph node is located in the 10–11 o’clock position
if the anterior midline is considered to be 12 o’clock. However, one should note that
the CT scans are obtained by looking at the patient from the feet upwards; but when
patients undergo a bronchoscopy, the airways are viewed with the head downwards.
When the patient is approached from the back with the patient supine, their right side
is now at the 3 o’clock position and the left side at the 9 o’clock position. Hence, in this
position the right paratracheal lymph node is actually positioned between the 1 and 2
o’clock position.The simplest way is to flip the CT scan on the vertical axis. The vertical
position of the right paratracheal lymph node is about two to four intercartilage spaces
above the carina.

Fig. 7.4a Cross-sectional CT scan of the thorax at the Fig. 7.4b Cross-sectional CT scan with a superimposed
level of the aortic arch showing a station 4R lymph node. clock face and a station 4R lymph node highlighted in
yellow.

118
Fig. 7.4c Cross-sectional CT scan of the thorax flipped on Fig. 7.4d Coronal section of CT scan showing the vertical
the vertical axis.The 4R lymph node is in the 1–2 o’clock position of the lymph node, which is usually about two to
position. four rings above the carina.

Fig. 7.4e Bronchoscopic view of the Fig. 7.4f Bronchoscopic view of the Fig. 7.4g Further example of needle
station 4R lymph node which is in the needle inserted into a 4R lymph node inserted into the 4R lymph node.
1–2 o’clock position about two to four in the 2 o’clock position.
intercartilage spaces above the carina.

Fig. 7.4h Cross-sectional CT scan of the thorax at the Fig. 7.4i Cross-sectional CT scan of the thorax at the level of
level of the carina showing an anterior carinal lymph node the carina with a superimposed clock face and highlighting an 119
(station 4R lymph node). anterior carinal lymph node (station 4R lymph node).
 Fig. 7.4j Cross-sectional CT scan of the thorax flipped on Fig. 7.4k Coronal section of CT scan showing the vertical
the vertical axis.The anterior carinal lymph node is in the position of the lymph node, which is usually at the level of
12–12.30 o’clock position. the carina.

Fig. 7.4l Bronchoscopic view of the Fig. 7.4m Bronchoscopic view Fig. 7.4n Bronchoscopic view of
anterior carinal (station 4R) lymph of the needle inserted into the the needle inserted into the anterior
node which is in the 6 o’clock position anterior carinal lymph node in the carinal lymph node in the 12.30
at the level of the carina. 12 o’clock position. o’clock position.

As described in Chapter 5, the station 4R can extend anterior to the trachea through
to the 2 o’clock position. Nodes located anterior to the trachea were previously
described as anterior carinal lymph nodes. It is usually located in the 11.30–12 o’clock
position on the CT scan. In patients being bronchoscoped from behind, this is the
12–12.30 position.

120
Station 4L: Lower left paratracheal lymph node (Fig. 7.5)
The left paratracheal lymph node is located on the left lateral position of the trachea
at or above the level of the carina. On the CT scan the lymph node is located at the 3
o’clock position. When the patient is being approached from behind, at bronchoscopy
the lymph node is located at the 9 o’clock position. The vertical position of the lymph
node is at the level of the carina or one space above. In practice this lymph node is
more easily accessed by rotating the bronchoscope 90° in a clockwise direction. Once
the needle has penetrated the airway wall, the torsion on the bronchoscope can be
relaxed and the needle moved back while the bronchoscope is in the neutral position
(as in Fig. 7.5h).

Fig. 7.5a Cross-sectional CT scan of the thorax showing a Fig. 7.5b Cross-sectional CT scan with a superimposed
station 4L lymph node. clock face and a station 4L lymph node highlighted in yellow.

Fig. 7.5c Cross-sectional CT scan of the thorax flipped Fig. 7.5d Coronal section of CT scan showing the vertical
on the vertical axis.The 4L lymph node is in the 9 o’clock position of the station 4L lymph node which is usually at
position. one intercartilage space above the carina.
121
 Fig. 7.5e Bronchoscopic Fig. 7.5f Rotation of the Fig. 7.5g Bronchoscopic Fig. 7.5h Bronchoscopic
view of the station 4L bronchoscope by 90° view of the needle inserted view of the needle inserted
lymph node, which is in the clockwise facilitates access to into a 4L lymph node with into a 4L lymph node in
9 o’clock position about the station 4L lymph node. the scope rotated clockwise the 9 o’clock position with
one intercartilage space by 90°. the scope in the neutral
above the carina. position.

Station 3P: Posterior tracheal lymph node (Fig. 7.6)

The posterior carinal lymph node is located at the level of the carina on the posterior
aspect of the trachea. On CT terms it can be considered to be in the 5.30–6 position.
At bronchoscopy when the patient is approached from behind, the lymph nodes
are now located at the 6–6.30 o’clock position. The forward angulation of the
bronchoscope is greater in the anterior direction and therefore access for TBNA is
improved by rotating the scope to 180° so that the lymph nodes are now anterior in
the 11.30–12 o’clock position.

Fig. 7.6a Cross-sectional CT scan of the thorax showing a Fig. 7.6b Cross-sectional CT scan with a superimposed
station 3p lymph node. clock face and a station 3p lymph node highlighted in yellow.

122
Fig. 7.6c Cross-sectional CT scan of the thorax flipped Fig. 7.6d Coronal section of CT scan showing the vertical
on the vertical axis.The 3p lymph node is in the 6–6.30 position of the station 3p lymph node which is usually at
o’clock position. the level of the carina.

Fig. 7.6e Bronchoscopic Fig. 7.6f Rotation of the Fig. 7.6g Bronchoscopic Fig. 7.6h Bronchoscopic
view of the station 3p bronchoscope by 180° view of the needle inserted view of the needle inserted
lymph node which is in the facilitates access to the into a 3p lymph node with into a 3p lymph node in
6–6.30 o’clock position station 3p lymph node. the scope rotated clockwise the 6 o’clock position with
about one intercartilage by 180°. the scope in the neutral
space above the carina. position.

123
 ●●Inferior mediastinal lymph nodes
Station 7: Subcarinal lymph node (Fig. 7.7)
The subcarinal lymph nodes are located just inferior to the carina. The carina is
composed of three bundles of cartilage and ligament, and hence direct puncture
through the carina tends to be unsuccessful. The subcarinal lymph nodes should be
approached in the right main bronchus at one space below the carina. On the CT
scan this translates to the 3 o’clock position and it is at the 9 o’clock position (medially
in the right main bronchus one space below the carina) when the patient is being
bronchoscoped from behind.

Fig. 7.7a Cross-sectional CT scan of the thorax showing a Fig. 7.7b Cross-sectional CT scan with a superimposed
station 7 lymph node. clock face and a station 7 lymph node highlighted in yellow.

Fig. 7.7c Cross-sectional CT scan of the thorax flipped Fig. 7.7d Coronal section of CT scan showing the vertical
on the vertical axis.The station 7 lymph node is in the 9 position of the station 4L lymph node, which is usually at
124 o’clock position. one intercartilage space above the carina.
Fig. 7.7e Bronchoscopic Fig. 7.7f Rotation of Fig. 7.7g Bronchoscopic Fig. 7.7h Bronchoscopic
view of the station 7 the bronchoscope 90° view of the needle inserted view of the needle inserted
lymph node which is in clockwise facilitates access into a station 7 lymph node into a station 7 lymph node
the 9 o’clock position one to the station 7 lymph node. with the scope rotated 90° in the 9 o’clock position
intercartilage space below clockwise. with the scope in the
the carina in the right main neutral position.
bronchus.

●●Hilar zone lymph nodes

Station 10R: Right main bronchial lymph node (Fig. 7.8)
The right main bronchial node is located anterior to the right main bronchus about
one intercartilage space below the carina at the 12 o’clock position on the CT scan.
When the patient is being approached from behind, the lymph node is also located in
the 12 o’clock position in the right main bronchus one space below the carina.

Fig. 7.8a Cross-sectional CT scan of the thorax showing a Fig. 7.8b Cross-sectional CT scan with a superimposed clock
station 10R lymph node. face and a station 10R lymph node highlighted in yellow.

125
 Fig. 7.8c Cross-sectional CT scan of the thorax flipped on Fig. 7.8d Coronal section of CT scan showing the vertical
the vertical axis.The 10R lymph node is in the 12 o’clock position of the station 10R lymph node which is usually
position in the right main bronchus. one intercartilage space below the carina in the right main
bronchus.

Fig. 7.8e Bronchoscopic view of the station 10R lymph node Fig. 7.8f Bronchoscopic view of the needle inserted into a
which is in the 12 o’clock position about one intercartilage 10R lymph node.
space below the carina in the right main bronchus.

126
Station 10L: Left main bronchial lymph node (Fig. 7.9)
The left main bronchial lymph node is located on the anterior aspect of the left main
bronchus approximately one interspace below the carina in the 12 o’clock position.
This is naturally the position in which the lymph node is located when the patient is
being bronchoscoped from behind.

Fig. 7.9a Cross-sectional CT scan of the thorax showing a Fig. 7.9b Cross-sectional CT scan with a superimposed
station 10L lymph node. clock face and a station 10L lymph node highlighted in
yellow in the 6 o’clock position.

Fig. 7.9c Cross-sectional CT scan of the thorax flipped on Fig. 7.9d Coronal section of CT scan showing the vertical
the vertical axis.The 10L lymph node is in the 12 o’clock position of the station 10L lymph node which is usually
position. one intercartilage space below the carina.

127
 Fig. 7.9e Bronchoscopic view of the station 10L lymph node Fig. 7.9f Bronchoscopic view of the needle inserted into a
which is in the 12 o’clock position about one intercartilage 10L lymph node.
space below the carina in the left main bronchus.

Station 11Rs: Right upper hilar lymph node (Fig. 7.10)

The right upper hilar node is located on the CT scan between the right upper lobe
bronchus and the bronchus intermedius. On the CT cross-section it relates to the 9
o’clock position just below the origin of the bronchus intermedius. At bronchoscopy
this relates to the anterior spur of the right upper lobe carina and the optimal approach
is to insert the needle just below the spur of the upper lobe carina. When the patient
is approached from behind, the right hilar node is located at the right side towards
the 2–3 o’clock position in the anterior spur of the right upper lobe carina. It is in the
proximal portion of the bronchus intermedius.

Fig. 7.10a Cross-sectional CT scan of the thorax showing Fig. 7.10b Cross-sectional CT scan with a superimposed
128 a station 11Rs (right upper hilar) lymph node. clock face and a station 11Rs (right upper hilar) lymph
node highlighted in yellow.
Fig. 7.10c Cross-sectional CT scan of the thorax flipped Fig. 7.10d Coronal section of CT scan showing the vertical
on the vertical axis.The station 11Rs (right upper hilar) position of the station 11Rs (right upper hilar) lymph node,
lymph node is in the 2–3 o’clock position. which is usually located at the right upper lobe carina.

Fig. 7.10e Bronchoscopic Fig. 7.10f Rotation of Fig. 7.10g Bronchoscopic Fig. 7.10h Bronchoscopic
view of the station 11Rs the bronchoscope by 90° view of the needle inserted view of the needle inserted
(right upper hilar) lymph anticlockwise facilitates into a station 11Rs (right into a station 11Rs (right
node which is in the 2–3 access to the station 11Rs upper hilar) lymph node upper hilar) lymph node
o’clock position in the (right upper hilar) lymph with the scope rotated 90° in the 2–3 o’clock position
anterior spur of the right node. anticlockwise. with the scope in the
upper lobe carina. neutral position.

129
 Station 11R: Right lower hilar lymph node (Fig. 7.11)
On the CT scan the right lower hilar lymph node is located lateral to the bronchus
intermedius in the 9 o’clock position at the level of the right middle lobe. At
bronchoscopy the needle should be inserted in the 3 o’clock position in the distal
aspect of the bronchus intermedius at the level of the right middle lobe origin.

Fig. 7.11a Cross-sectional CT scan of the thorax showing Fig. 7.11b Cross-sectional CT scan with a superimposed
a station 11Ri (right lower hilar) lymph node. clock face and a station 11Ri (right lower hilar) lymph
node highlighted in yellow.

Fig. 7.11c Cross-sectional CT scan of the thorax flipped Fig. 7.11d Coronal section of CT scan showing the
on the vertical axis.The station 11Ri (right lower hilar) vertical position of the station 11Ri (right lower hilar)
lymph node is in the 3 o’clock position. lymph node, which is usually just higher than the right
middle lobe origin.

130
Fig. 7.11e Bronchoscopic Fig. 7.11f Rotation of Fig. 7.11g Bronchoscopic Fig. 7.11h Bronchoscopic
view of the station 11Ri the bronchoscope 90° view of the needle inserted view of the needle inserted
(right lower hilar) lymph anticlockwise facilitates into a station 11Ri (right into a station 11Ri (right
node, which is in the 3 access to the station 11Ri lower hilar) lymph node lower hilar) lymph node in
o’clock position in the (right lower hilar) lymph with the scope rotated 90° the 3 o’clock position with
bronchus intermedius just node. anticlockwise. the scope in the neutral
above the origin of the right position.
middle lobe.

Station 11L: Left hilar lymph node (Fig. 7.12)

The station 11L or left hilar lymph node is located at the bifurcation of the left main
bronchus. It is accessed from the left lower lobe towards the upper lobe. The needle
is inserted into the 11–12 o’clock position from the left lower to the left upper lobe.

Fig. 7.12a Cross-sectional CT scan of the thorax showing Fig. 7.12b Cross-sectional CT scan with a superimposed
a station 11L lymph node. clock face and a station 11L lymph node highlighted in yellow.

131
 Fig. 7.12c Cross-sectional CT scan of the thorax flipped Fig. 7.12d Coronal section of CT scan showing the vertical
on the horizontal axis.The 11L lymph node is in the position of the station 11L lymph node, which is usually at
11–12 o’clock position. level of the carina between the left upper and lower lobe.

Fig. 7.12e Bronchoscopic view of the station 11L lymph Fig. 7.12f Bronchoscopic view of the needle inserted into
node which is in the 11–12 o’clock position about one an 11L lymph node in the 11–12 o’clock position.
intercartilage space above the carina.

132
 Endobronchial ultrasound Chapter
bronchoscopy
Endobronchial ultrasound is usually performed using the oral approach with the
8
patient lying supine and approached from behind. The current Olympus ultrasound
bronchoscope has an offset viewing chip (Fig. 8.1). Hence it does not have a direct
end-on view as in most bronchoscopes, with images offset in the upward direction of
30°. Hence a little practice is required to learn how to manipulate the bronchoscope,
especially during the intubation phase.
The ultrasound image obtained can be improved by applying a water-filled balloon to
the ultrasound transducer.This can be attached onto the distal end of the endobronchial
ultrasound bronchoscope with a specific applicator. This water-filled balloon improves
the acoustic contact but air bubbles within it may cause some artefacts.

Fig. 8.1a Endobronchial Fig. 8.1b Distal tip of the Fig. 8.1c Balloon and applicator.
ultrasound bronchoscope. endobronchial with offset
video chip.

Fig. 8.1d Distal view of the Fig. 8.1e Distal view with Fig. 8.1f Artefact on ultrasound image due to air
endobronchial ultrasound air bubble visible within the bubbles within the water-filled balloon.
bronchoscope with water- water-filled balloon.
filled balloon in place.

133
 Intubation
During intubation the ideal view obtained of the cords is such that only the top of the
vocal cords are in view and the cuneiform and corniculate tubercles are not visible.
To obtain a full view of the cords, the scope needs to be angulated down (thumb
up) (Fig. 8.2). However, the scope should not be advanced forward in this angulated
position. The scope would simply meet resistance against the epiglottis in this position.
The cords are prepared for intubation in the standard manner with the application
of two to three aliquots of 1 mL of 2 per cent lidocaine. Further aliquots of lidocaine
are applied to the trachea and main bronchus after intubation. The image obtained
with the ultrasound bronchoscope is intended for intubation orientation within the
airway. Although some diagnostic information is obtained, we would recommend
using a conventional bronchoscope for these purposes and then use the ultrasound
bronchoscope for mediastinal sampling.

Fig. 8.2a Bronchoscopic Fig. 8.2b Bronchoscopic Fig. 8.2c Bronchoscopic Fig. 8.2d Bronchoscopic
image of the vocal cords: image of the vocal cords: image: with endobronchial image: with video
with the scope straight. with the scope angled down. ultrasound bronchoscope. bronchoscope.

Examination approach
Our approach is to systematically examine all the lymph node stations. Additional areas
which have been identified on a positron emission tomography (PET) or computed
tomography (CT) scan should also be carefully examined. We would recommend first
identifying the aortic arch which is located at the mid-trachea level on the left lateral
wall of the trachea (Fig. 8.3).
Above the aortic arch are station 2 lymph nodes, and any paratracheal lymph nodes
identified below the aortic arch are station 4 lymph nodes. So after identifying the
aortic arch, the scope should be gently applied to the trachea wall and the more
proximal trachea examined on both sides up to the subglottic level to check if any
station 2 lymph nodes are visible. The bronchoscope is then rotated by about 150°–
180° clockwise and the right paratracheal area (station 2R) examined. The scope is
moved gently down until the brachiocephalic vein is visible.This denotes the lower limit
of station 2R and any nodes below this area are station 4 lymph nodes.
During examination of the right paratracheal area (station 4R), the superior vena cava
and the azygos vein should be identified. The lower limit of station 4R is denoted by
the azygos vein. The scope is then moved anteriorly just at the level of the carina and
the pulmonary trunk and the anterior carinal lymph nodes (station 4R) are examined.
The scope is then further rotated anticlockwise towards the left lateral wall of the
trachea at the level of the carina. First the ascending aorta is visualized and subsequently
the left paratracheal lymph node area (station 4L) and then the pulmonary artery.
134
Fig. 8.3a Ultrasound appearance of the aortic arch. Fig. 8.3b Bronchoscopic view of the trachea with the left
lateral wall marked corresponding to the aortic arch.

The scope is also run along the length of the posterior wall of the trachea to look for
station 3p lymph nodes. The scope is then manoeuvred on to the medial of the right
main bronchus to examine the subcarinal lymph nodes (station 7).
The endobronchial scope is rotated by 90° clockwise in the right main bronchus so that
it is facing the 12 o’clock position to examine the right hilar lymph nodes (station 10R).
Following this, the scope is moved to the proximal aspect of the bronchus intermedius
and the carina between the right upper lobe and the bronchus intermedius is
examined. The right superior hilar nodes (station 11Rs) are located in this position. The
bronchoscope is then rotated anticlockwise by 150° to examine the subcarinal lymph
nodes (station 7), extending down to the distal margin of the bronchus intermedius. At
the level of the right middle lobe the scope is again rotated 150° clockwise on to the
lateral aspect of the bronchus intermedius, where the right inferior hilar (station 11Ri)
is located.
The scope is then retracted back to the carina and the left side examined. Clockwise
rotation by 90° and examination of the medial aspect of the left main bronchus allow
station 7 to be examined from the left side. The scope can then be rotated back 90°
anticlockwise to evaluate the left hilar lymph nodes (station 10L). Finally, the scope is
applied to the carina between the left lower and upper lobe divisions.The left interlobar
lymph node station (11L) is located at this site.
With endobronchial ultrasound, a key skill to acquire is navigation using ultrasound
images.The anatomical landmark should be used while learning the ultrasound anatomy.
The combination of the endobronchial landmarks, location of blood vessels and
ultrasound images should allow accurate characterization of the lymph node location
and assignment to a specific lymph node station. With this systematic approach, all the
lymph node locations adjacent to the endobronchial tree can be evaluated for accurate
staging. The size and location of all the lymph nodes should be recorded. Any lymph
nodes > 5 mm in size or with abnormal features (more rounded appearance, loss of
large central blood vessels) should be sampled.

135
 Lymph node stations
It is possible to sample any of the lymph nodes that are adjacent to the airways using
transbronchial fine needle aspiration(TBNA). The lymph nodes stations are described
according to the new InternationaI Association for the Study of Lung Cancer classification.

●●Superior mediastinal lymph nodes: upper zone

Station 2R: Higher right paratracheal lymph node (Fig. 8.4)
The upper margin of station 2R is difficult to define at endobronchial ultrasound but is
primarily at the level of the clavicle. The lower border is defined by the inferior aspect
of the left brachiocephalic vein crossing the trachea. Anterolateral in this area, the
right subclavian artery and right common carotid artery are visible on endobronchial
ultrasound. More anterior to these blood vessels are the right brachiocephalic vein
and the right external jugular vein. The endobronchial position is difficult to estimate
accurately but is about one-third of the distance of the trachea from the vocal cords.

Fig. 8.4a Cross-sectional CT scan of the thorax showing Fig. 8.4b Cross-sectional CT scan flipped left to right
a station 2R lymph node. with the station 2R lymph node highlighted in blue.

Fig. 8.4c Coronal section of CT scan showing the 2R Fig. 8.4d Bronchoscopic view of where the ultrasound
lymph node. Note that the node is above the level of the probe should be placed to view the station 2R lymph
brachiocephalic vein crossing the trachea. nodes highlighted.
136
 LN
LN
rt common rt subclavian artery
rt common
carotid artery
rt subclavian artery carotid artery

jugular vein
external jugular vein

Fig. 8.4e Ultrasound image of the station 2R lymph Fig. 8.4f Ultrasound image of the station 2R lymph node
node in a central position with the right common carotid and the right common carotid artery more superior.
artery superior to the node and the right subclavian artery
inferior.

137
 Station 2L: Higher left paratracheal lymph node (Fig. 8.5)
The upper border of station 2L is defined again by the clavicle and hence is difficult to
define at endobronchial ultrasound. The lower border is determined by the aortic arch.
On the left anterolateral aspects the common carotid and the left jugular vein are visible.

Fig. 8.5a Cross-sectional CT scan of the thorax showing a Fig. 8.5b Cross-sectional CT scan flipped left to right with
station 2L lymph node. the station 2L lymph node highlighted in blue.

Fig. 8.5c Coronal section of CT scan showing the 2L lymph Fig. 8.5d Bronchoscopic view of where the ultrasound probe
node. Note the node is above the level of the aortic arch. should be placed to view the station 2L lymph nodes highlighted.

LN

rt common carotid artery

jugular vein

138

Fig. 8.5e Ultrasound image of the station 2L lymph node.

Station 3A: Anterior prevascular lymph node (Fig. 8.6)
The upper border is demarcated by the clavicle and the lower border by the carina,
which is visible on the endobronchial image.These nodes are usually located anterior to
the great vessels, i.e. the left common carotid and subclavian artery, and hence cannot
be sampled by endobronchial ultrasound.

Fig. 8.6a Cross-sectional CT scan of the thorax showing a Fig. 8.6b Cross-sectional CT scan flipped left to right with
station 3a lymph node. the station 3a lymph node highlighted.

Fig. 8.6c Coronal section of CT scan showing the station Fig. 8.6d Bronchoscopic view of where the ultrasound
3a lymph node. probe should be placed to view the station 3a lymph
nodes highlighted.

lt common carotid artery

LN

jugular vein

139

Fig. 8.6e Ultrasound image of the station 3a lymph node.

 Station 3P: Posterior tracheal lymph node (Fig. 8.7)
The upper border is at the level of the clavicle and the lower border is at the carina,
which can be confirmed by the bronchoscopic image. These nodes are located on the
posterior aspect of the trachea.

Fig. 8.7a Cross-sectional CT scan of the thorax showing a Fig. 8.7b Cross-sectional CT scan flipped left to right with
station 3p lymph node. the station 3p lymph node highlighted.

Fig. 8.7c Coronal section of CT scan showing the station Fig. 8.7d Bronchoscopic view of where the ultrasound
3p lymph node. probe should be placed to view the station 3p lymph
nodes highlighted.

LN

lung

Fig. 8.7e Ultrasound image of the station 3p lymph node.

140
Station 4R: Lower right paratracheal lymph node (Fig. 8.8)
The upper border is identified on endobronchial ultrasound as the inferior margin
of the brachiocephalic vein crossing the trachea. The lower border is defined by the
azygos vein, which should be identified at ultrasound.

Fig. 8.8a Cross-sectional PET-CT scan of the thorax Fig. 8.8b Cross-sectional PET-CT scan flipped left to right
showing an active station 4R lymph node. with the active station 4R lymph node.

Fig. 8.8c Coronal section of PET-CT scan showing the 4R Fig. 8.8d Bronchoscopic view of where the ultrasound
lymph node. probe should be placed to view the station 4R lymph
nodes highlighted.

LN LN
superior vena cava brachio-cepahlic
artery
brachio-cephalic
brachio-cephalic vein
superior vena cava

Fig. 8.8e Ultrasound image of the station 4R lymph node Fig. 8.8f Ultrasound image of the station 4R lymph node.
with the brachiocephalic vein demarcating the border
between stations 4R and 2R.
141
 LN azygos vein LN

superior vena cava superior vena cava

Fig. 8.8g Ultrasound image of the station 4R lymph node Fig. 8.8h Ultrasound image of the station 4R lymph node
with the superior vena cava more distal to the lymph node. with the azygos vein demarcating the border between
station 4R and 10R lymph nodes.

azygos
azygos vein

superior vena cava

Fig. 8.8i Ultrasound image of the azygos vein. Fig. 8.8j Ultrasound image of the azygos vein at a lower
level with the superior vena cava visible distally.

azygos azygos

superior vena cava

superior vena cava

Fig. 8.8k Ultrasound image of the azygos vein a few mm Fig. 8.8l Ultrasound image of the azygos vein at a lower
further distal. level draining into the superior vena cava.
142
Fig. 8.8m Further example of cross-sectional CT scan Fig. 8.8n Cross-sectional CT scan flipped left to right with
of the thorax showing a station 4R lymph node (anterior the station 4R (anterior carinal) lymph node highlighted.
carinal lymph node).

Fig. 8.8o Coronal CT scan of the thorax showing an Fig. 8.8p Bronchoscopic view of where the ultrasound
anterior carinal lymph node (station 4R lymph node). probe should be placed to view the station 4R (anterior
carinal node) lymph nodes highlighted.

acn LN acn LN

aorta

Fig. 8.8q Ultrasound image of the station 4R (anterior Fig. 8.8r Ultrasound image of the station 4R (anterior
carinal, acn) lymph node. carinal, acn) lymph node with the aorta visible just inferiorly.
143
 acn LN

aorta

Fig. 8.8s Ultrasound image of the station 4R (anterior carinal,

acn) lymph node with a greater aspect of the aorta visible.

The 4R lymph node is located anterolateral to the trachea, up to the left lateral border
of the trachea. In the classical right paratracheal position, the superior vena cava is
visible peripheral to the lymph node. As you move anteriorly towards the carina, the
ascending aorta also becomes visible.

Station 4L: Lower left paratracheal lymph node (Fig. 8.9)

The location of the lymph node is between the ascending aorta and the pulmonary
trunk. The upper border is defined by the aortic arch and the lower border by the
pulmonary artery. The classical image visible at ultrasound consists of the lymph node
identified in between the aorta which is on the right of the image and the pulmonary
artery on the left of the image. The bronchoscopic location of this station is the left
lateral aspect of the trachea at the level of the carina or one space above the carina.

Fig. 8.9a Cross-sectional PET-CT scan of the thorax Fig. 8.9b Cross-sectional PET-CT scan flipped left to right
showing an active station 4L lymph node. with the active station 4L lymph node.
144
Fig. 8.9c Coronal section of PET-CT scan showing the 4L Fig. 8.9d Bronchoscopic view of where the ultrasound
lymph node. probe should be placed to view the station 4L lymph nodes
highlighted.

41 LN 4L LN

LN

aorta
aorta

Fig. 8.9e Ultrasound images of the station 4L lymph Fig. 8.9f Ultrasound images of the station 4L lymph nodes
nodes. with the aorta visible superior and distal to the nodes.

4L LN

pulmonary trunk

pulmonary trunk
aorta

aorta

Fig. 8.9g Ultrasound images of the station 4L lymph Fig. 8.9h Ultrasound images of the station 4L lymph
nodes with the aorta visible superior to, and the pulmonary nodes with a greater portion of the pulmonary trunk visible.
trunk on the inferior aspect of, the nodes. 145
 Station 5: Aortopulmonary lymph nodes (Fig. 8.10)
Station 5 can be visualized on endobronchial ultrasound but cannot routinely be
sampled. The nodes are located between the aorta and the pulmonary artery lateral
to the ligamentum arteriosum. On endobronchial ultrasound, the lymph node appears
to be lying more peripheral to the pulmonary artery.

Fig. 8.10a Cross-sectional CT scan of the thorax showing Fig. 8.10b Cross-sectional CT scan flipped left to right
a station 5 lymph node. with the active station 5 lymph node highlighted.

Fig. 8.10c Coronal section of CT scan showing the station Fig. 8.10d Bronchoscopic view of where the ultrasound probe
5 lymph node highlighted. should be placed to view the station 5 lymph nodes highlighted.

pulmonary artery

station 5 lymph node

aorta

146
Fig. 8.10e Ultrasound image of the station 5 lymph node
visible distal to the pulmonary artery.The aorta is partly
visible superiorly.
Station 6: Para-aortic lymph nodes (Fig. 8.11)
The para-aortic lymph nodes, or station 6, may be visible on endobronchial ultrasound
on the outer aspect of the ascending aorta and aortic arch, but again cannot be
routinely sampled.The depth of ultrasound may need to be increased and, consequently,
degradation of the image quality may make it difficult to visualize these lymph nodes.

Fig. 8.11a Cross-sectional CT scan of the thorax showing Fig. 8.11b Cross-sectional CT scan flipped left to right
a station 6 lymph node. with the active station 6 lymph node highlighted.

Fig. 8.11c Coronal section of PET-CT scan showing the Fig. 8.11d Bronchoscopic view of where the ultrasound
station 6 lymph node. probe should be placed to view the station 6 lymph nodes
highlighted.

147
Fig. 8.11e Ultrasound image of the station 6 lymph node.
 ●●Inferior mediastinal lymph nodes
Station 7: Subcarinal lymph node (Fig. 8.12)
The borders of station 7 are more clearly defined by the bronchoscopic view. It
represents the nodal area inferior to the carina and down to the level where the
right middle lobe bronchus originates on the right side and the secondary carina on
the left side. The ultrasound transducer may be applied to the medial aspect of either
the right or the left main bronchus. At this level, anterior movement of the transducer
demonstrates the pulmonary artery and pulmonary trunk.

Fig. 8.12a Cross-sectional PET-CT scan of the thorax Fig. 8.12b Cross-sectional PET-CT scan flipped left to
showing a station 7 lymph node. right with the active station 7 lymph node.

Fig. 8.12c Coronal section of PET-CT scan showing the Fig. 8.12d Bronchoscopic view of where the ultrasound
station 7 lymph node. probe should be placed to view the station 7 lymph
nodes highlighted.

station 7 LN
station 7 LN
Fig. 8.12e Ultrasound Fig. 8.12f Ultrasound
image of the station image of the station
7 lymph node with its 7 lymph node with
characteristic bean the oesophagus visible
shape. distally. oesophagus
oesophagus
148
●●Hilar zone lymph nodes
Station 10R: Right main bronchial lymph node (Fig. 8.13)
These lymph nodes are located at the right main bronchus. The upper border is defined
by the position of the azygos vein, which should be identified on ultrasound, and the lower
margin is the origin of the right upper lobe bronchus, which is identified on the broncho-
scopic image. The transducer is applied on the anterior aspect of the right main bron-
chus and slowly advanced. On ultrasound the structure that is visible on the anterior aspect
includes the right pulmonary artery and, more peripheral to that, the superior vena cava.

Fig. 8.13a Cross-sectional CT scan of the thorax showing Fig. 8.13b Cross-sectional CT scan flipped left to right
a station 10R lymph node. with the station 10R lymph node highlighted.

Fig. 8.13c Coronal section of CT scan showing the 10R Fig. 8.13d Bronchoscopic view of where the ultrasound
lymph node. probe should be placed to view the station 10R lymph
nodes highlighted.

10R LN 10R LN 10R LN

azygos

pulmonary pulmonary artery

artery
pulmonary
artery

SVC

SVC SVC

Fig. 8.13e Ultrasound images of Fig. 8.13f Ultrasound images of the Fig. 8.13g Ultrasound images of the
the station 10R lymph node: with the station 10R lymph node: in a more station 10R lymph node: with the right
149
azygos visible, which delineates the central position. pulmonary artery inferior and distal to
border between station 4R and 10R. the node.
 Station 10L: Left main bronchial lymph node (Fig. 8.14)
These are lymph nodes located on the left main bronchus. The upper border is again
just below the carina on the left side and on ultrasound image is defined by the superior
aspect of the pulmonary artery. The lower margin is indicated by the bifurcation of
the left main bronchus into the superior lobar bronchus and the left lower lobe. The
transducer should usually be applied to the anterior aspect of the left main bronchus
and advanced slowly down towards the secondary carina.The structure visible anterior
to the left main bronchus consists of the left pulmonary artery and trunk, and more
inferiorly the left atrium may also be visible. On the medial aspect of the left main
bronchus, the descending aorta may also be visible.

Fig. 8.14a Cross-sectional CT scan of the thorax showing Fig. 8.14b Cross-sectional CT scan flipped left to right
a station 10L lymph node. with the station 10L lymph node highlighted.

Fig. 8.14c Coronal section of CT scan showing the 10L Fig. 8.14d Bronchoscopic view with the location of station
lymph node. 10L lymph nodes highlighted.

10L LN

Fig. 8.14e Ultrasound image of the station 10L

lymph node with the pulmonary artery more superior pulmonary trunk

and distal to the nodes.The pulmonary artery

demarcates the 4L and 10L nodes.
150
Station 11Rs: Right superior hilar lymph node (Fig. 8.15)
These are located at the upper lobe carina. The ultrasound transducer is applied just
below the upper lobe origin in the bronchus intermedius. Superior to the 11R lymph
node, the right upper lobe bronchus and pulmonary artery may be visible. Inferiorly
the pulmonary artery branch and, more distally, the right pulmonary vein and superior
vena cava are visible.

Fig. 8.15a Cross-sectional PET-CT scan of the thorax Fig. 8.15b Cross-sectional PET-CT scan of the thorax
showing a station 11Rs (right upper hilar) lymph node. flipped left to right showing the station 11Rs lymph node.

Fig. 8.15c Coronal section of PET-CT scan showing the Fig. 8.15d Bronchoscopic view of where the ultrasound
11Rs lymph node. probe should be placed to view the station 11Rs lymph
nodes highlighted.

11Rs LN

pulmonary 11Rs LN
artery rt pulmonary
superior vena cava artery

superior vena cava

pulmonary
vein

Fig. 8.15e Ultrasound images of the station 11Rs lymph Fig. 8.15f Ultrasound images of the station 11Rs lymph
151
node: with the superior vena cava visible superior and distal node: with the right pulmonary artery and vein visible
to the nodes. inferior to the nodes.
 Station 11Ri: Right inferior hilar lymph node (Fig. 8.16)
These nodes are located at the distal aspect of the bronchus intermedius. They are
lateral to the right middle lobe; anteriorly at this level the left atrium and right pulmonary
vein are visible on the ultrasound images.

Fig. 8.16a Cross-sectional PET-CT scan of the thorax Fig. 8.16b Cross-sectional PET-CT scan of the thorax
showing a station 11Ri (right lower hilar) lymph node. flipped left to right showing the station 11Ri lymph node.

Fig. 8.16c Coronal section of PET-CT scan showing the Fig. 8.16d Bronchoscopic view of where the ultrasound
11Ri lymph node. probe should be placed to view the station 11Ri lymph
nodes highlighted.

11r Inf LN
11r Inf LN
descending branch of
pulmonary artery
pulmonary vein
pulmonary vein leading to left atrium

152
Fig. 8.16e Ultrasound image of the station 11Ri lymph Fig. 8.16f Station 11Ri lymph node with the pulmonary
node. vein which leads to the left atrium.
Station 11L: Left hilar lymph node (Fig. 8.17)
These nodes are at the secondary carina on the left side between the left lower lobe
and the left upper lobe bronchus. The left pulmonary artery and left pulmonary veins
are usually visible anteriorly in this location.

Fig. 8.17a Cross-sectional PET-CT scan of the thorax Fig. 8.17b Cross-sectional PET-CT scan of the thorax
showing a station 11L lymph node. flipped left to right showing a station 11L lymph node.

Fig. 8.17c Coronal section of PET-CT scan showing the Fig. 8.17d Bronchoscopic view of where the ultrasound
11L lymph node. probe should be placed to view the station 11L lymph
nodes highlighted.

11L LN 11L LN

pulmonary
vein Left pulmonary left pulmonary
artery artery

Fig. 8.17e Ultrasound images of the station 11L lymph Fig. 8.17f Ultrasound images of the station 11L lymph 153
node: with left pulmonary artery and left upper lobe node: with the lingular bronchus visible inferior to the node.
bronchus more superior.
 Lymph node sampling
As in conventional TBNA, the highest lymph node stations should be sampled, i.e. any
contralateral hilar or mediastinal lymph nodes (N3 station lymph nodes) followed by
N2 lymph nodes and finally any hilar lymph nodes. Any paratracheal tumour masses can
also be sampled but should be sampled only after any visible N3 or N2 lymph nodes
have been sampled. This minimizes the risk of false-positive results to almost zero and
prevents falsely upstaging a patient with lung cancer. Only the recommended needles
should be used with ultrasound bronchoscope – they are specially designed for the
bronchoscope and the use of alternative needles may lead to puncture of the working
channel of this very expensive instrument.

●●Technique
The needle length and position can be set prior to insertion of the bronchoscope into
the patient. However, we recommend verifying that the needle sheath is visible outside
the instrument channel bronchoscope each time the needle is inserted through the
working channel of the bronchoscope and prior to any needle aspiration. The needle
should be fixed in position so that a small crescent of the sheath is visible on the
endotracheal image (Fig. 8.18). This will minimize instrument channel damage and
significantly prolong the life and service of your ultrasound bronchoscope.

Fig. 8.18a Specific needle for the Olympus endobronchial Fig. 8.18b Close-up of the handle of the needle showing
bronchoscope. the mechanism for the adjustment of the needle sheath.

Fig. 8.18c Bronchoscopic image showing the small Fig. 8.18d Bronchoscopic image showing the significant
crescent of the sheath which should be visible prior to length of the visible sheath.This greater distance may
154
attempted needle aspiration.This shows the ideal position. impair acoustic contact and hence the ultrasound image.
The needle should be introduced into the bronchoscope straight into the trachea. The
needle tip should be adjusted so that a very small crescent is visible in the endoscopic
image on the top right-hand corner. Once the lymph node or mass is identified in the
ultrasound field, an assistant is asked to secure the bronchoscope and hold it in position.
The central stylet is then withdrawn about 3 mm so that the needle point is sharp. The
safety lock for the needle is lowered to the required distance and the needle gently
inserted through the airway wall whilst maintaining the ultrasound image at all times
(Figs 8.19 and 8.20). Once the needle is through the airway wall into the lymph node,
the stylet is jiggled back and forth in order to remove any cartilage or airway wall plug
from the needle. The stylet is then removed and the aspiration syringe connected. The
syringe is preset with suction and, providing it is within the lymph node, the three-way
tap is opened and the needle moved gently back and forth through the lymph node.
This allows cellular material from the lymph node to be aspirated. The bronchoscope
can be gently manipulated so that material from different parts of the lymph node is
aspirated. The three-way tap is then closed and the needle withdrawn back into the
sheath and the needle removed.

Fig. 8.19a Endobronchial ultrasound bronchoscope with Fig. 8.19b Endobronchial ultrasound bronchoscope
the needle fixed in position on the scope. with the needle protruding out at the distal tip of the
bronchoscope.

Fig. 8.19c Endobronchial ultrasound bronchoscope with Fig. 8.19d Endobronchial ultrasound bronchoscope with
the needle protruding out, syringe attached distally and the suction off on the attached syringe and the needle
suction on.The needle is then gently pushed back and withdrawn back.
forth in the lymph node.

155
 Fig. 8.20a Bronchoscopic view of the needle sheath and ultrasound image of the
lymph node.

Fig. 8.20b Bronchoscopic view of the needle tip and ultrasound image of the lymph
node showing initial penetration of the needle.

Fig. 8.20c Bronchoscopic view of the needle tip and sheath with the corresponding
ultrasound image of the lymph node showing needle aspiration of the lymph node.

The material that has been aspirated in the needle can be either smeared on to
slides or fixed or injected into saline for liquid cytology media (Fig. 8.21). You should
discuss the preparation with your pathologists so that samples that are suited to the
local practice are collected. Placing the cellular material in saline or liquid cytology
media allows more professional slides to be prepared and furthermore allows the
material to be spun down into a cell pellet which can be further evaluated by histology.
Immunohistochemistry can also be performed on the cell blocks to optimally classify
any malignant cells identified and also characterize the genotype in the biopsy material.

156
Fig. 8.21a Lymph node aspirate is injected on to a glass Fig. 8.21b Glass slide with cellular material from lymph
slide. node aspiration.

Fig. 8.21c The glass slide with cellular material is gently

apposed to another glass slide and then slid apart to
create a thin smear on the slide.

157
 Chapter Pathology
9 This chapter consists mainly of bronchoscopic images of the various pathological
conditions encountered during bronchoscopy. The sections cover pathology seen on
the vocal cords through to the trachea, lobar bronchi and bronchial segments.

Fig. 9.1a Candida plaques on vocal Fig. 9.1b Paralysed left vocal cord. Fig. 9.1c Vocal cord polyp.
cords in a patient on inhaled steroids. Note the left vocal cord is in the
midline position.

Fig. 9.1d Squamous cell carcinoma Fig. 9.1e Vocal cords infiltrated by Fig. 9.1f Limited Kaposi’s sarcoma
involving the vocal cords. amyloid (primary tracheobronchial involving vocal cord.
amyloid, AL type).

Fig. 9.1g Severe Kaposi’s

sarcoma involving vocal cord.
158
Fig. 9.2a Distorted Fig. 9.2b Tracheal web. Fig. 9.2c Adenocarcinoma Fig. 9.2d Adenocystic
trachea with deviation of of the trachea. carcinoma involving the
the upper trachea towards trachea.
the right with the tracheal
web in the distal aspect.

Fig. 9.2e Poorly Fig. 9.2f Tracheo- Fig. 9.2g Some cartilage Fig. 9.2h
differentiated carcinoma oesophageal fistula in a nodules on the trachea in Tracheobronchopathia
infiltrating through the mid- patient with oesophageal the anterior aspect. osteochondroplastica: acute
trachea. carcinoma undergoing inflammatory stage.
radiotherapy.

Fig. 9.2i Fig. 9.2j Sabre trachea. Fig. 9.2k Tracheobronchial

Tracheobronchopathia amyloid with greater
osteochondroplastica: involvement of the anterior
chronic stage with thickening aspect of the trachea.
of the cartilaginous portions
of the trachea.

159
 Fig. 9.3a Tumour (renal Fig. 9.3b Extrinsic tumour Fig. 9.3c Widening of
cell carcinoma) involving circumferential involving the the carina due to tumour
the carina and almost right main bronchus at the involving the subcarinal
completely occluding both level of the carina. lymph node. Note the
main bronchi. infiltration of the mucosa
in the medial aspect of the
right main bronchus.

Fig. 9.3d Widening of Fig. 9.3e Tracheobronchial

the carina and complete amyloid involving the carina.
occlusion of the left main Note the thickened nodular
bronchus by tumour. plaque-like aggregations.

160
Fig. 9.4a Polypoid non- Fig. 9.4b Invasive Fig. 9.4c Circumferential Fig. 9.4d Segmental
small-cell carcinoma squamous cell carcinoma tumour (adenocarcinoma) tumour (adenocarcinoma)
originating from the right originating from the occluding the right lower occluding the anterior
upper lobe and occluding posterior wall of the right lobe bronchus. segment (RB3) of the right
the right main bronchus. main bronchus. upper lobe.

Fig. 9.4e Concentric Fig. 9.4f Polypoid non- Fig. 9.4g Small cell Fig. 9.4h Diffuse
segmental tumour small cell carcinoma carcinoma occluding the infiltrative carcinoma
(adenocarcinoma) involving originating from the apical right upper lobe. involving the left main
the lateral segment of the segment of the right upper bronchus.
left lower lobe (LB9). lobe (RB1).

Fig. 9.4i Extrinsic Fig. 9.4j Extrinsic tumour Fig. 9.4k Complete Fig. 9.4l Kaposi’s sarcoma
compression of the bulging and partly occluding occlusion of the apical involving secondary carina
right upper lobe from the apical segment of the segment of the left lower of the left lower lobe (LC2).
extrabronchial tumour. right upper lobe (RB6). lobe (LB6) from an extrinsic
tumour.

161
 Fig. 9.5a Polypoid necrotic tumour originating from the Fig. 9.5b Small cell carcinoma involving the right upper
posterior segment of the right upper lobe (RB2) and extrinsic lobe with increased tortuosity of blood vessels and blind-
compression of the anterior segment of the right upper lobe ending punctate vessels.
(RB3). Left: video bronchoscopy image; right: narrow-band
imaging. Increased vascularity is evident in the extrinsic lesion
and lack of blood vessels in the necrotic tumour.

Fig. 9.5c Squamous cell carcinoma involving the apical

segment of the left lower lobe following treatment with
radiotherapy. Note the increased inflammatory changes
and increased capillary loops.

Fig. 9.6a Metastatic Fig. 9.6b Metastatic Fig. 9.6c Infiltrating Fig. 9.6d Metastatic
colorectal carcinoma colonic carcinoma occluding oesophageal endometrial carcinoma
involving the right basal the left main bronchus. adenocarcinoma involving involving the left lower lobe.
bronchus. the right main bronchus.

Fig. 9.6e Renal cell Fig. 9.6f Hurthle cell Fig. 9.6g Leiomyosarcoma Fig. 9.6h Squamous
carcinoma involving the left carcinoma involving the involving the lateral cell carcinoma from a
main bronchus. segmental bronchus in the segment of the left lower metastatic head and neck
162 right middle lobe. lobe (LB9). carcinoma involving the left
main bronchus.
Fig. 9.7a Nodules giving Fig. 9.7b Nodularity Fig. 9.7c Tuberculous Fig. 9.7d Anthracosis
a cobblestone appearance around the lower trachea granuloma occluding the (darkened) area in the
in the right lower lobe from due to tuberculosis. anterior segment of the medial aspect, which is
sarcoid. right upper lobe (RB3). occasionally seen in patients
with pulmonary tuberculosis.

Fig. 9.7e Mucus Fig. 9.7f Mucus Fig. 9.7g Concentric Fig. 9.7h Pith-like lesions
originating from the plugging due to allergic narrowing of upper lobe in the bronchus intermedius
segmental bronchus. bronchopulmonary segments in a patient with due to bronchocentric
aspergillosis. allergic bronchopulmonary granulomatosis.
aspergillosis.

Fig. 9.7i Ulceration of Fig. 9.7j Granulation Fig. 9.7k Foreign body Fig. 9.7l A tooth visible
pith-filled lesions after tissue which has developed (tooth) in the right main in the right lower lobe of
steroid treatment in a secondary to a foreign body. bronchus. a patient presenting with
patient with bronchocentric recurrent lobar pneumonia.
granulomatosis.

Fig. 9.7m Inflammatory 163

pseudo-tumour.
 Chapter Fluorescence-based
10 imaging
Autofluorescence bronchoscopy
All epithelial tissue has an innate fluorescence but this is not discernible without some
enhancement. With autofluorescence bronchoscopy the airways are illuminated with a
blue light (395–445 nm). The autofluorescence signal (550 nm) is incorporated in the
video processor with the other reflected light to form a composite image where normal
tissue appears as green (fluorescent tissue). Any reduction in fluorescence shows up
as a pink through to magenta colour. Blood appears dark green (Fig. 10.1). Care should
be taken as any mucus or secretions overlying the epithelial tissue conceal the normal
fluorescent epithelial and falsely appear pink. Autofluorescence bronchoscopy requires
a special bronchoscope and usually the mode can be switched from white light to
fluorescence by simply pressing a remote button on the bronchoscope or a foot pedal.

Fig. 10.1a Video bronchoscopy and fluorescence Fig. 10.1b Mucus secretions in the right middle lobe which
bronchoscopy image of the left lower lobe. appear pink and can be easily mistaken for an abnormal area.

Fig. 10.1c Loss of fluorescence in the inflammatory Fig. 10.1d Abnormal fluorescence of the left main carina
nodule in the lower trachea. showing subtle abnormality not visible on video bronchoscopy.

164
 Fig. 10.1e Blood appears Fig. 10.1f Cartilage nodule in the right lower lobe
dark green on fluorescence segment with normal fluorescence.
bronchoscopy.

Fig. 10.1g Inflammatory web with normal fluorescence in

the left lower lobe.

Fluorescence bronchoscopy is used primarily as a research tool. In some cases, where

a patient has had multiple cancers (head and neck or lung cancer) or where there
are multiple areas of field effect (patchy change in airways from metaplasia through
to carcinoma in situ), the patients undergo regular fluorescence bronchoscopy for
clinical surveillance. These patients may undergo repeated bronchoscopy over several
years and possibly by several operators. Hence, careful documentation is essential
and standard nomenclature is required to describe the location and extent of the
abnormalities (Fig. 10.2). We would recommend use of nomenclature as in Chapter 2.

Fig. 10.2a Thickening of the carina with abnormal Fig. 10.2b Thickening of the carina with abnormal
fluorescence between the lateral segment of the left lower fluorescence between the anterior segment of the right
lobe (LB9) and the posterior segment of the left lower lobe lower lobe (RB8) and the lateral segment of the right
(LB10) due to mild dysplasia. lower lobe (RB9) due to moderate dysplasia.

165
 Fig. 10.2c Nodularity with abnormal fluorescence in the Fig. 10.2d Thickening of the segmental carina with
inferior aspect of the right upper lobe carina due to severe abnormal fluorescence in the right lower lobe due to
dysplasia. carcinoma in situ.

Fig. 10.2e Abnormal fluorescence of polypoid tumour in Fig. 10.2f Tumour around the apical segment of the right
the apical segment of the left lower lobe. upper lobe and some narrowing of the anterior segment of
the right upper lobe.

Fig. 10.2g Tumour with abnormal fluorescence around Fig. 10.2h Right lower lobe sleeve resection with nodularity
the anterior segment of the right upper lobe. which appears suspicious on white light but has normal
fluorescence. Patchy abnormal fluorescence due to secretions.

166
Confocal microscopy
Confocal endomicroscopy is a fluorescence-based imaging technique which illuminates
the airways or lung parenchyma with a blue argon laser light at a wavelength of 488 nm.
The probe, which consists of a bundle of optical fibres, is inserted through the instrument
channel of the bronchoscope (Fig. 10.3). The probe can be applied to the proximal
airways for evaluating the trachea, main bronchi and bronchial segments (Fig. 10.4).
The elastin, which is found in the basement membrane, provides information on the
bronchial tree. The probe can be easily passed into a subsegment and slowly advanced
from the lobular bronchus to the terminal bronchiole, the respiratory bronchiole and
then to the alveolar acinus. Elastin is a structural connective tissue component of the
alveolar walls and the confocal probe detects the fluorescent elastin scaffold of the
lobule used to image the proximal airways and down to the alveoli.

Fig. 10.3a Cellvizio confocal microscopy system. Fig. 10.3b Confocal probe.

167
 Fig. 10.4a Confocal probe applied on Fig. 10.4b Confocal microscopy Fig. 10.4c Confocal microscopy
the airway segment. images of the bronchial segments of a bronchial segment with an
showing the lattice network of elastin area without fluorescence due to a
in the basement membrane. bronchial gland.

Fig. 10.4d Confocal probe inserted Fig. 10.4e Confocal microscopy Fig. 10.4f Normal alveoli with
into the bronchial segment and into image of a bronchiole. elastin scaffolding visible with confocal
lung parenchyma. microscopy.

Fig. 10.4g Normal blood vessel in Fig. 10.4h Normal pleura with
alveoli. longitudinal elastin network and fewer
cross-linking fibres.
168
Light radiating back from the fluorescing tissue between 500 and 650 nm is collected
at 12 frames/second. This creates a high-quality real-time image with a diameter field
of view of 600 µm but a depth of penetration of approximately 50 μm and a lateral
resolution of 3.5 μm. This is a developing field and the images shown in Figs 10.5–10.8
are from the early research.

Fig. 10.5a Loss of fluorescence and Fig. 10.5b Edge of endobronchial Fig. 10.5c Loss of fluorescence
reticular pattern due to a bronchial tumour with some distortion of from the alveolar architecture in
tumour (squamous cell carcinoma). fluorescence pattern in the upper bronchioloalveolar cell carcinoma.
aspect and loss of fluorescence in the
inferior aspect.

Fig. 10.5d Loss of fluorescence from Fig. 10.6a Confocal microscopy in a Fig. 10.6b Disruption of elastin
the alveolar architecture due to non- patient with moderate emphysema. alveolar structure with large cystic
small cell lung cancer. Note the large cystic spaces. areas in emphysema.

169
 Fig. 10.6c Large bulla in a patient Fig. 10.6d Fluorescent macrophages Fig. 10.7a Thickened interstitium
with severe emphysema with some in the alveoli in a smoker with chronic and increased elastin network in
remaining alveolar structure in the obstructive pulmonary disease. interstitial pneumonitis (pulmonary
superior aspect. fibrosis).

Fig. 10.7b Marked increase in the Fig. 10.7c Increased fluorescent cells Fig. 10.7d Abnormal spiral loops of
elastin network with thickening of and some thickening of the elastin elastin in a granuloma in a patient
the alveoli in interstitial pneumonitis network in pulmonary sarcoidosis. with sarcoidosis.
(pulmonary fibrosis).

Fig. 10.7e Further example of Fig. 10.7f Increased fluorescent Fig. 10.7g Drug-related
abnormal spiral loops of elastin in a cells within normal elastin alveolar hypersensitivity pneumonitis with
granuloma due to sarcoidosis. architecture in drug-related normal elastin alveolar architecture
170 hypersensitivity pneumonitis. and increased cellularity.
Fig. 10.8a Reduced fluorescence of Fig. 10.8b Alveolar architecture
alveolar architecture due to consolidation obscured by cells with low fluorescence in
from pneumonia. pneumonia.

Fig. 10.8c Increased fluorescent cells in Fig. 10.8d Increased fluorescent cells
organizing pneumonia. adjacent to a blood vessel in organizing
pneumonia.

171
 Chapter Electromagnetic navigation
11 The superDimension® system (iLogic) is a real-time navigation system using an
electromagnetic field to aid navigation to a particular target area (Fig. 11.1; the indications
for its use are given in Box 11.1).

BOX 11.1 Indications for superDimension® navigation

●● Sampling of peripheral nodule
●● Guidance for transbronchial fine-needle aspiration of mediastinal lymph nodes
and peribronchial masses
●● Targeted transbronchial cryobiopsy
●● Insertion of fiducial markers for stereotactic radiotherapy or cyberknife
●● Insertion of markers for video-assisted thoracic surgical (VATS) biopsy

Fig. 11.1 SuperDimension® system.

Planning stage
The initial planning stage requires a multi-slice CT scan (2 mm with at least 1 mm
overlap). The CT is then uploaded onto a planning module. A virtual bronchoscopy is
performed on the planning module and important landmarks such as the main carina,
right upper lobe carina, right middle lobe carina, left main carina and carina between
the left basal segments and the apical segment of the left lower lobe (LC, LB6–LB8)
are marked (Fig. 11.2).

172
Fig. 11.2a SuperDimension® CT planning module.Virtual bronchoscopy mode showing: carina.

Fig. 11.2b SuperDimension® CT planning module.Virtual bronchoscopy mode showing: close-up of carina. 173
 Fig. 11.2c SuperDimension® CT planning module.Virtual bronchoscopy mode showing: right upper lobe. (RC1)

174 Fig. 11.2d SuperDimension® CT planning module.Virtual bronchoscopy mode showing: right middle lobe (RC2).
Fig. 11.2e SuperDimension® CT planning module.Virtual bronchoscopy mode showing: left main
carina (LC2).

Fig. 11.2f SuperDimension® CT planning module.Virtual bronchoscopy mode showing: carina of the
left apical basal segment (LC LB6–LB8). 175
 Fig. 11.2g SuperDimension® CT planning module.Virtual bronchoscopy mode showing: the target
located.

The target areas are also marked on the planning module in the CT mode with or
without intermediate markers (Fig. 11.3). The information for the planning module is
exported and loaded onto the superDimension navigation module.

176
Fig. 11.3a Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning
module: main carina.

Fig. 11.3b Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning
177
module: right upper lobe carina (RC1).
 Fig. 11.3c Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning
module: right middle lobe carina (RC2).

Fig. 11.3d Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning
178
module: carina of the right apical basal segment marked (RC RB6–RB8).
Fig. 11.3e Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning
module: left secondary carina (LC2).

Fig. 11.3f Marking of landmarks during virtual bronchoscopy on the superDimension® CT planning 179
module: carina between the left apical basal (LB6) and basal segments (LC LB6–LB8).
 Registration process
The bronchoscopy is performed with the patient lying flat on an electromagnetic board
(Fig. 11.4).This creates a magnetic field, and the electromagnetic tracker placed through
the instrument channel of the bronchoscope can be used to detect the position of
the tip in this electromagnetic field. The navigation phase involves registering the same
landmarks marked on the navigation module in the patient.The magnetic tracking guide
is inserted through the bronchoscope, and at the procedure the same landmarks are
marked, i.e. the main carina, the right upper lobe carina, the middle lobe carina, the left
main carina and the carina between the left basal segments and the apical segment of
the left lower lobe (Fig. 11.5). This is achieved by applying the magnetic locator guide
at the carina and using a foot pedal to mark this point. The system then correlates the
two pieces of data and co-registers the information.

Fig. 11.4 Electromagnetic board with the field depicted with white arrows and the locatable guide as a black arrow
moving through the field.

Fig. 11.5a Registration process with the module showing virtual bronchoscopy and
locatable guide on a real-time bronchoscopic image co-registering the following: the main
180
carina (MC).
Fig. 11.5b Registration process with the module showing virtual bronchoscopy and
locatable guide on a real-time bronchoscopic image co-registering the following: the right
upper lobe carina.

Fig. 11.5c Registration process with the module showing virtual bronchoscopy and
locatable guide on a real-time bronchoscopic image co-registering the following: the right
middle lobe carina (RC2).

181
 Fig. 11.5d Registration process with the module showing virtual bronchoscopy and
locatable guide on a real-time bronchoscopic image co-registering the following: the carina
between the apical basal segment (RB6) and basal segments.

Fig. 11.5e Registration process with the module showing virtual bronchoscopy and
locatable guide on a real-time bronchoscopic image co-registering the following: the left
secondary carina (LC1).

182
Fig. 11.5f Registration process with the module showing virtual bronchoscopy and
locatable guide on a real-time bronchoscopic image co-registering the following: the carina
between the apical basal segment (LB6) and basal segments.

The system calculates the error between the two pieces of data, i.e. computed
tomography (CT) and patient data, and the lower the system error, the more accurate
the navigation. The latest version of iLogic’s software automatically co-registers the CT
and patient data. The locatable guide is inserted through the instrument channel of the
bronchoscope with the tip protruding. The bronchoscope is then navigated through
the airways and during this process the system co-registers numerous data points, thus
improving accuracy. The system also allows the manual registration process if required.
The locatable guide is manoeuvred to the target area using a steerable catheter
(Fig. 11.6). This catheter moves in 12 different directions with a dial on its handle (akin
to a clock face) that can be adjusted to different positions. The handle also allows
varying amounts of pressure to change the degree of bend in the catheter.

Fig. 11.6a Movement of Fig. 11.6b Movement of Fig. 11.6c Movement of Fig. 11.6d Movement of
the steerable catheter in the steerable catheter in the steerable catheter in the steerable catheter in
directions akin to a clock directions akin to a clock directions akin to a clock directions akin to a clock
face: 12 o’clock direction face: 2 o’clock direction. face: 4 o’clock direction. face: 11 o’clock direction
(note the position of the (note the position of the
red arrow on the catheter red arrow on the catheter
handle). handle). 183
 Navigation
After inserting the catheter with the locatable guide to the appropriate bronchial
segment, the navigation system can be used to guide it to the target location. The
system shows the location of the guide on coronal, axial and sagittal CT sections (Fig.
11.7). There is also a screen which advises the operator in which direction, i.e. 1 o’clock
or 2 o’clock etc., to manipulate the steerable catheter. A ‘bull’s eye’ appears when the
locatable guide is within 10 mm of the target location. Once the target is reached,
the catheter is locked into position. The scope is held firmly in position, the locatable
guide is removed and instruments such as cytology brushes, transbronchial needles and
biopsy forceps can be passed through the steerable catheter in order to obtain samples
from the target location. Where facilities exist, radial ultrasound probes or fluoroscopy
can be used to verify the location of the catheter tip or locatable guide.

Fig. 11.7a Navigation module showing the positions of the locatable guide on the CT
sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the
steerable catheter: 10 o’clock position.

184
Fig. 11.7b Navigation module showing the positions of the locatable guide on the CT
sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the
steerable catheter: 8 o’clock position, guiding the catheter towards the right upper lobe.

Fig. 11.7c Navigation module showing the positions of the locatable guide on the CT
sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the
steerable catheter: 5 o’clock position guiding the catheter towards the right upper lobe. 185
 Fig. 11.7d Navigation module showing the positions of the locatable guide on the CT
sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the
steerable catheter: locatable guide close to the target site – the green dot appears close
to the steering guide (orange circle).

Fig. 11.7e Navigation module showing the positions of the locatable guide on the CT
sections (axial, sagittal and coronal) with a clock face guiding the manipulation of the
steerable catheter: locatable guide within 11 mm of the target site as indicated by green
186 dot being close to the steering guide.
●●Recent advances
With the latest iLogic™ software, the navigation module now has six possible screen modes.
It creates a bronchial tree diagram with a route map to the target. After the registration
process, the virtual bronchoscopy image displays the pathway to the target (Fig. 11.8). This
facilitates navigation of the bronchoscope to the wedge position. From that point onwards
the images can be set to display the clock face with CT sections to guide the steerable
catheter to the target site. A close-up image can be selected when the locatable guide is
within 10 mm of the target site to guide the optimal position for sampling.

Fig. 11.8a iLogic™

software module with three-
dimensional bronchial tree.

Fig. 11.8b iLogic™

software with three-
dimensional bronchial tree
and route to the target
highlighted in pink. 187
 Fig. 11.8c Latest iLogic™ software showing the six-screen mode with axial, coronal and
sagittal CT views, with the position of the locatable guide and the virtual bronchoscopy
with the route to the target.

Fig. 11.8d Latest iLogic™ software showing the six-screen mode with close-up CT views
when the locatable guide is close to the target.

For diagnostic purposes it may be more appropriate to set a target point where an
airway is leading into the lesion. By contrast, a target area where the airway is passing
lateral to the lesion may be closer but less likely to have a diagnostic yield. When
inserting fiducial markers for radiotherapy or guides for video-assisted thoracoscopic
biopsy, accurate positioning of the markers within the lesion is not necessary. Placement
of fiducial markers in three different spatial locations within 10 mm of the nodule or
target area is acceptable. The superDimension® navigation system can also be used to
188 place a catheter in a more distal location for brachytherapy.
Intubation and management Chapter
of airway haemorrhage 12
Intubation
Airway control is a primary skill that should be acquired by the interventional
bronchoscopist. As a safety precaution and to facilitate rapid, repeated insertion
and removal of the bronchoscope, patients should be intubated prior to any
interventional procedures such as tumour ablation or stent insertion. A size 8.5 or
9.0 uncuffed endotracheal tube is recommended in men and a size 8.0–8.5 tube in
women. The endotracheal tube is cut to the appropriate length – usually to the oral
markings on the endotracheal tube – and placed over the bronchoscope (Fig. 12.1).
An endotracheal tube with a Murphy eye may be useful in some circumstances.
Depending on the position it may allow ventilation of the contralateral lung during
interventional procedures. Furthermore, any debris or tumour fragments would then
tend to fall back into the lung being treated and not into the contralateral lung.

Fig. 12.1a Uncuffed endotracheal tube (size 8.0, full Fig. 12.1b Endotracheal tube cut to marker for oral
length 32 cm). intubation (25 cm).

Fig. 12.1c Uncuffed endotracheal tube with Murphy eye Fig. 12.1d Uncuffed endotracheal tube slid over to the
slid over the distal aspect of the bronchoscope. proximal aspect of the bronchoscope.

189
 An oral approach is preferred and the bronchoscope with an overlying endotracheal
tube is inserted through a protective mouthpiece. Two or three 2 mL aliquots of 2 per
cent lidocaine are applied to the vocal cords and the subglottic region.The bronchoscope
is passed through the vocal cord and into the trachea. The patient is asked to take a
deep breath and the endotracheal tube is then carefully slid over the bronchoscope
and through the vocal cords. Small rotational movements are occasionally required
while advancing the endotracheal tube.
The images in Figure 12.2 show the sequence of steps involved in intubation from topical
application of lidocaine to the vocal cords through to insertion of the endotracheal
tube through the vocal cords and into the trachea.

Fig. 12.2a Sequence of images demonstrating intubation: topical lidocaine 2 per cent applied to
the vocal cords.The endotracheal tube is moved to the distal aspect of the bronchoscope and over the
vocal cords.

Fig. 12.2b Sequence of images demonstrating intubation: uncuffed endotracheal tube inserted
through the vocal cords and into the trachea.

Fig. 12.2c Sequence of images demonstrating intubation: endotracheal tube inserted into the trachea.

In our experience, with adequate topical anaesthesia patients have tolerated

an endotracheal tube for up to 1 hour with minimal conscious sedation (0–5 mg
midazolam intravenously). The main caution is to avoid forcing the endotracheal tube
against resistance, which is often due to the endotracheal tube being caught around the
epiglottis or the vocal cords. Forceful insertion may lead to some trauma of the vocal
cords (Fig. 12.3).
190
Fig. 12.3a Sequence of images showing common problems with intubation: endotracheal tube caught
on arytenoid cartilage.

Fig. 12.3b Sequence of images showing common problems with intubation: endotracheal tube caught
on corniculate cartilage.

Once the endotracheal tube is inserted, the assistant should hold the proximal portion
in front of the patient’s mouthpiece.
The key advantages of using an endotracheal tube is that it offers rapid and easy access
into the airways, allowing the bronchoscope to be inserted and removed at will without
causing any further inconvenience to the patient. This is particularly important for
removing pieces of tumour during debulking and allows insertion of other accessories
such as balloon blockers, which may be required in case of complications such as
bleeding. It primarily allows safe airway management of the patient during interventional
procedures.
A laryngeal mask is an alternative option to endotracheal intubation. Oxygenation
during interventional procedures needs to be carefully managed. Hypoxia triggers
cardiac arrhythmias and can increase the risk of complications. However, in certain
procedures, such as laser treatment, the inspired oxygen (Fio2) should not be greater
than 0.4. During such procedures, patients may need cyclical oxygen administration
followed by short periods when the treatment is applied with a lower Fio2. We use a
mask with a rebreather bag and cut out a piece on the side of the mask which allows
access to the endotracheal tube and for the bronchoscope to pass in and out.

191
 Balloon catheters
Balloon catheters are used for a number of purposes, including collapse of a lung
during surgery. For our purpose, the primary aim is to enable airway control of massive
haemorrhage.

●●Cohen endobronchial balloon blocker

The Cohen endobronchial balloon blocker has a tip that can be deflected (Fig. 12.4). It
can be inserted through an adaptor which attaches to the distal end of the endotracheal
tube. The balloon catheter is inserted through the side-angled port of this adaptor and
through the endotracheal tube into the right or left main bronchus. It naturally tends
to go down the right main bronchus but can be manipulated or steered by a small
degree in order to place the balloon in the left side. There is a gauge on the proximal
end which, when turned, pulls on an in-built thread-wire and causes the distal tip of
the catheter to bend (Fig. 12.5). The proximal and distal aspects of the catheter are
marked with an arrow in the direction in which the tip tends to deflect. Therefore the
blocker should be inserted through the endotracheal tube so that the arrows denoting
direction of deflection are in the appropriate position.

Fig. 12.4a Cohen tip Fig. 12.4b Endotracheal Fig. 12.4c Endotracheal
deflecting balloon catheter. tube mount adaptor for use tube mount adaptor with
with balloon catheters. balloon catheter and
bronchoscope in position.

Fig. 12.5a Cohen tip deflecting balloon catheter shown in Fig. 12.5b Cohen tip deflecting balloon catheter shown in
192 various positions: neutral position. various positions: dial moved by 45° anticlockwise causing
a small deflection in the balloon tip.
Fig. 12.5c Cohen tip deflecting balloon catheter shown in Fig. 12.5d Cohen tip deflecting balloon catheter shown
various positions: dial moved by 90° anticlockwise causing in various positions: dial moved by 180° anticlockwise
a deflection in the balloon tip. causing further deflection in the balloon tip.

Fig. 12.5e Cohen tip deflecting balloon catheter shown in

various positions: inserted into the left main bronchus with
the balloon inflated.

Careful manipulation of the catheter and position of the patient’s head allows the
catheter to be introduced into the left main bronchus. This position is often the main
bronchus but the balloon blocker may be advanced further into a lobar bronchus. The
balloon can be inflated with about 4 mL of air. The exact amount should be checked in
each patient prior to proceeding with the interventional aspect of the procedure. The
catheter can be locked into position by tightening the screw fitting on the port of the
endotracheal tube adaptor through which the blocker was introduced.

193
 Insertion into the left main bronchus
The sequence of images in Figures 12.6 and 12.7 shows insertion of the balloon catheter
into the left main bronchus. Occasionally the balloon catheter tip has a tendency to
repeatedly go down the right side and then catch on the cartilage rings or carina,
preventing correct placement. Figure 12.8 demonstrates this problem and also how it
can be overcome by manipulation of the balloon tip and applying gentle torsion to the
balloon catheter. Inflation of the balloon may also help when a balloon is partly inserted
into the desired airway but stuck on a cartilage ring.

Fig. 12.6a Sequences showing the insertion of a Cohen tip deflecting balloon catheter into the left
main bronchus: inserted into the right main bronchus.

Fig. 12.6b Sequences showing the insertion of a Cohen tip deflecting balloon catheter into the
left main bronchus: being withdrawn from the right main bronchus to the carina and then being
manipulated into the left main bronchus.

Fig. 12.6c Sequences showing the insertion of a Cohen tip deflecting balloon catheter into the
left main bronchus: being manipulated into the left main bronchus. Note the arrow at the tip of the
catheter, which indicates the direction of deflection.

Fig. 12.6d Sequences showing the insertion of a Cohen tip deflecting balloon catheter into the left
194 main bronchus: positioned in the left main bronchus with balloon being inflated.
Fig. 12.7a Cohen tip deflecting balloon catheter: being inserted via the endotracheal tube and into
the lower trachea – the tip is directed into left main bronchus.

Fig. 12.7b Cohen tip deflecting balloon catheter: in the left main bronchus.

Fig. 12.7c Cohen tip deflecting balloon catheter: in the left main bronchus with the balloon being inflated.

195
 Fig. 12.8a Sequence showing difficult insertion of the Cohen tip deflecting balloon catheter into the
left main bronchus: the balloon catheter first enters the right main bronchus.

Fig. 12.8b Sequence showing difficult insertion of the Cohen tip deflecting balloon catheter into the
left main bronchus: the balloon catheter is withdrawn from the right main bronchus.

Fig. 12.8c Sequence showing difficult insertion of the Cohen tip deflecting balloon catheter into the
left main bronchus: the catheter tip is caught on the cartilage ring above the carina.

Fig. 12.8d Sequence showing difficult insertion of the Cohen tip deflecting balloon catheter into the
left main bronchus: the balloon catheter inserted in an inverted position into the left main bronchus.
Balloon inflation is being attempted to try to push the tip down into the left main bronchus.The balloon
is finally inserted down into the left main bronchus.The balloon is then inflated to check position.

196
The series of images in Figure 12.9 shows the problems of overinflation or incorrect
fixation of the balloon.This emphasizes the need to check placement by inflation of the
balloon prior to commencing the interventional procedure.

Fig. 12.9a Sequence of images showing effects of inflating a balloon that is too proximal,
with the tendency for the balloon to pop out of the left main bronchus.

Fig. 12.9b The problem is corrected by inserting the balloon further into the left main
bronchus.

In the event of significant haemorrhage or bleeding during the interventional procedure,

the balloon can be inflated to isolate that lobe or side of the lung. This protects the
contralateral lung from overspill of blood (which would affect its ventilation). The
tamponade effect also helps to control the bleeding. The balloon is kept inflated for
about 2 minutes and then carefully deflated. If fresh bleeding is still occurring, the balloon
catheter should be inflated for a further 2-minute cycle.

197
 ●●Arndt endobronchial balloon blocker
The Arndt endobronchial balloon blocker has a small adjustable loop at the end. This is
designed to be used in conjunction with a small-calibre bronchoscope. The kit contains
a multi-port adaptor which should be attached to the endotracheal tube (Fig. 12.10).
The balloon should be fully deflated and the endobronchial blocker lubricated. It is
inserted through the angled port which is designed for the blocker.The cap on this port
can be screwed down to tighten the grip around the blocker and loosened to allow
greater manipulation.The endobronchial blocker is advanced until it is visible in the mid-
portion of the adaptor. The bronchoscope is then advanced through the central port
and advanced through the loop on the endobronchial blocker. The loop is coupled to
the bronchoscope by pulling back on the snare and can also be loosened by reducing
the tension on the snare. Once the loop is tightened around the bronchoscope, the
endobronchial blocker can be guided to any lobar bronchus (Fig. 12.11). Once in the
correct position, the snare should be loosened and the bronchoscope can then be
withdrawn leaving the balloon blocker in position.

Fig. 12.10a Arndt balloon Fig. 12.10b Arndt balloon Fig. 12.10c Arndt balloon
catheter (note the loop on catheter inserted through a catheter inserted through a
the distal tip). multi-port adaptor. mutli-port adaptor: note the
position of the loop.

Fig. 12.10d Bronchoscope Fig. 12.10e Arndt balloon

and Arndt blocker inserted catheter inserted through
through the mutli-port a mutli-port adaptor:
adaptor. bronchoscope passed
through the loop at the distal
end of the Arndt catheter.

198
Fig. 12.11a Arndt balloon catheter and bronchoscope: in Fig. 12.11b Arndt balloon catheter and bronchoscope:
neutral position in the trachea. being directed into left main bronchus.

Fig. 12.11c Arndt balloon catheter and bronchoscope: Fig. 12.11d Arndt balloon catheter and bronchoscope:
being directed into left main bronchus. positioned in the left main bronchus.

Fig. 12.11e Arndt balloon catheter and bronchoscope:

bronchoscope being withdrawn after positioning the Arndt
balloon catheter in the left main bronchus and inflating it.

199
 Management of airway bleeding
Ice-cold saline, adrenaline (1 mL aliquots of 1:100 000) and balloon catheters should
be available prior to any interventional procedure. In the event of bleeding, the first key
principle is to remain calm and not to remove the bronchoscope from the airways.The
scope should be moved more proximally from the source of bleeding and continued
suction applied in order to maintain the airways free of blood. Suctioning a little way
away from the source of bleeding also ensures that clot formation is not impaired.
If the bleeding persists, inject a few mL of aliquots of ice-cold saline. Continue with
regular suction in order to ensure optimal clearance of any blood which will otherwise
affect ventilation. If this is unsuccessful and bleeding continues, instil 1–2 mL aliquots of
1:100 000 adrenaline. Follow this by effective suction of any blood that could clot and
occlude adjacent airways (see the bleeding protocol in Box 12.1).

BOX 12.1 Bleeding protocol

Step 1
●● Keep bronchoscope there
●● Do not remove bronchoscope
–– Suction, suction, suction
–– Cold saline, cold saline
–– Suction
–– Adrenaline
–– Suction
–– Adrenaline
–– Call for help
Step 2
●● Balloon blocker
●● If Cohen blocker is ready in airway, deploy and inflate
●● If not in place, use Arndt balloon blocker (couple with bronchoscope prior to
insertion into the airways)
●● Suction any blood in the airways especially in the contralateral lung
●● Deflate balloon after 2 minutes and check if still bleeding
●● If still bleeding, re-inflate and continue with proximal suctioning
●● Ensure adequate ventilation of the patient
●● Consider turning patient on to the side of bleeding

Key points
●● A – suction, airway control
●● B – ventilate through endotracheal tube with L-shaped adaptor
●● C – Intravenous access, fluid, urgent cross-match blood, fresh frozen plasma
●● D – Consider turning patient on to the side of bleeding

If the patient is intubated with an endotracheal tube, consider insertion of a balloon

catheter; or if the balloon catheter is already in place prior to the interventional procedure,
inflate the balloon and occlude the lobe or affected lung (Fig. 12.12). The balloon should
be inflated for at least 2 minutes. During this period any blood that has spilled into the
contralateral lung should be suctioned away to ensure optimal ventilation. After 2 minutes
the balloon is deflated slowly. Suction is maintained to clear any residual blood, but care
must be taken not to dislodge or clear any clot that has been formed around the site
of bleeding. If there is still persistent bleeding then the balloon should be reinflated for
a further 2-minute cycle. The patient can also be turned on to the side of bleeding to
200 enhance the tamponade effect and allow maximal activity of the unaffected lung.
Fig. 12.12a Active brisk bleeding from right lower lobe managed with a cycle of suction, ice-cold
saline and dilute adrenaline.The Cohen balloon blocker is inflated to isolate the right lung.

Fig. 12.12b Cohen balloon blocker inflated to isolate right lung with suction of blood from the
remaining airways.The balloon is deflated after 2 minutes. Saline is instilled and gentle suction is
applied proximally in the right lower lobe after deflation and removal of the Cohen balloon.

In the situation where there is spontaneous massive bleeding and no endotracheal

tube is in place, it is important to retain the bronchoscope in position and maintain
suction. Where skills exist, an attempt should be made to intubate the patient either via
standard laryngoscope or by sleeving it over the bronchoscope and then under direct
vision. An alternative is to use the video laryngoscope. This should be done as quickly
and efficiently as possible immediately after intubation; any blood that has spilled into
the normal side should be suctioned and cleared first.
The easiest balloon to use is the Arndt balloon. The balloon catheter is inserted
through the endotracheal tube, and biopsy or grasping forceps are introduced through
the working channel of the bronchoscope. The forceps are then used to grasp the
balloon and the balloon can then be directed towards the lobar bronchus, from where
the bleeding is originating. The balloon is then inserted to tamponade the bleeding
for at least 2–3 minutes. With practice this technique can be utilized very quickly and
effectively.
Alternatively the multi-port adaptor can be set up with the Arndt balloon blocker
and bronchoscope. Once the loop is coupled with the bronchoscope, the unit can be
attached to the endotracheal tube and manipulated to the target lobe in the patient.
In the emergency situation, it is quicker to simply occlude the lung where the bleeding
is originating. Mortality and morbidity from airway haemorrhage are usually due to loss
of gas exchange as a result of the blood clotting off the airways before exsanguination
becomes a factor. Hence, if you block off the lung which is the source of the haemorrhage
then you protect the other lung from overspill of blood and consequent occlusion of
the airways. Suctioning of any blood that has spilled over into the normal side helps to
maximize oxygenation of the patient.

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 Chapter Endobronchial tumour
13 debulking
Central airway tumours cause significant morbidity and mortality. The effects include
airflow obstruction with dyspnoea, haemoptysis, impaired clearance of secretions with
repeated infections and pneumonia. In patients who are inoperable due to advanced
disease or significant comorbidity, active palliation by debulking the endobronchial
tumour is an important aspect of treatment. Although there are no definitive
randomized control trials, tumour ablation by a variety of techniques has been shown
to improve dyspnoea, reduce frequency of haemoptysis, improve quality of life and
potentially improve survival.
A variety of techniques are available for tumour debulking and the choice is dependent
on local availability and expertise. All the available techniques are of similar efficacy.
Electrocautery or diathermy tends to be available in most endoscopy units and is
relatively inexpensive. Similarly, cryotherapy equipment is inexpensive compared to the
neodymium-yttrium aluminium garnet (Nd-Yag) laser which has much higher capital
and maintenance costs. We predominantly use electrocautery and a modified version
of cryotherapy termed cryoextraction – these are the main focus of this chapter.

Electrocautery
Electrocautery or diathermy is an alternative technique for tumour ablation. It utilizes
high-frequency alternating current (10-5 to 10-7 Hz) to generate heat locally and induce
coagulation and tissue necrosis. Low-frequency current stimulates nerves and muscle
fibres and is therefore not used. The resistance within a tissue where the electrical
current is applied leads to the generation of heat. Diathermy or electrocautery requires
the use of special insulated flexible bronchoscopes. The patient plate is required to
ground the patient and hence complete the circuit. This should be a large surface such
as the back of the thigh in order to easily conduct electricity away. Poor conduction
around the patient plate would also lead to heat generation and local burns.
Electrocautery is performed with a number of accessories, such as a coagulation probe,
snares, biopsy forceps and a cutting knife (Fig. 13.1).

Fig. 13.1a Electrocautery Fig. 13.1b Electrocautery Fig. 13.1c Electrocautery Fig. 13.1d Electrocautery
accessories: coagulation accessories: hot biopsy accessories: snare. accessories: electrosurgical
probe. forceps. knife.
202
Low-voltage, high-amperage current leads to coagulation, whereas cutting involves high
voltage and low amperage. A blend of these two modes is used to achieve tissue
destruction with coagulation. Electrocautery allows rapid ablation of the tumour and
restoration of airway patency. Hence, electrocautery can be used in an acute setting
where rapid restoration of airway patency is required. A coagulation probe is a blunt
probe and is usually the first tool used (Fig. 13.2). A test patch on normal mucosa
derives some information and allows the power setting to be adjusted so that a small
white blanched area is obtained on application of the electrocautery probe (usually
10–30 watts). Contact with the tumour with a 3–5 second activation should also
provide some information about tumour susceptibility, friability and potential bleeding
risk. Elongated or plaque-like lesions are amenable to treatment with a coagulation
probe. It may also be used to free up tumour from edges of the airway wall.

Fig. 13.2a Coagulation probe and tumour visible in the left main bronchus. Note the green band
protruding from the bronchoscope.The coagulation probe is inserted into the centre of the tumour.

Fig. 13.2b The edge of the tumour being treated with the coagulation probe in order to free the
tumour from the airway.The coagulation probe is being used to free the lateral edge of the tumour
and then the superior margin.

Fig. 13.2c The coagulation probe is activated in a blend mode (combination of coagulation and
cut) and moved from side to side to free the tumour from the airway wall.There is some debulking of
tumour with the distal airway visible in the superolateral aspect.

203
 The electrosurgical snare is more effective in treating and removing polypoid lesions
(Fig. 13.3). The snare is used to loop over the tissue and is then slowly tightened.
The diathermy is activated as the snare is slowly tightened to cut and coagulate the
tissue at the base. If the snare is tightened too quickly with inadequate electrocautery
activation, the mechanical cheese-wire effect will cut off the tumour but without the
coagulation effect and hence there is a greater risk of bleeding. After snaring the tissue,
the bronchoscope with suction is applied to the free piece and the whole unit is
removed via the endotracheal tube. Regular suction of blood debris is required. Good
control of bleeding is necessary as it also impairs the effectiveness of electrocautery as
the electricity is conducted over a much wider area and hence the local heating effect
is significantly reduced.

Fig. 13.3a Electrosurgical snare placed around polypoid tumour originating from the left main
bronchus into the trachea.

Fig. 13.3b Once the snare is around tumour, the electrocautery is activated in 2-second bursts while
the snare is slowly tightened around the tumour.The snare cuts through the tumour and is removed.

Fig. 13.3c Snare opened and looped over residual tumour.

Fig. 13.3d Resected tumour being withdrawn through the endotracheal tube with the bronchoscopic
view from the trachea showing complete resection of tumour from the left main bronchus.

204
The hot biopsy forceps can also be used to debulk tumours. The forceps are used to
bite on the tumour and are then gently pulled up prior to activating the diathermy
energy. Electrical current accumulates at the base of the neck, heating that area and
allowing a larger biopsied piece to be obtained with minimal bleeding.
The electrosurgical knife is sparingly used but is invaluable for treating tracheal and
endobronchial webs. A cruciate incision can be performed on the web. Precautions
when using electrocautery and its potential complications are shown in Boxes 13.1 and
13.2.

BOX 13.1 Precautions when performing electrocautery

●● Ensure good contact of grounding plate on the patient
●● Use insulated and (approved) bronchoscopes for electrocautery
●● Remove rings or any pieces of metal on the patient
●● Check with the cardiologist before treating patients with a pacemaker or
implantable defibrillator
●● Ensure Fio2 < 0.4 and in practical terms limit the gas flow to < 4 L/min via nasal
cannulae (there is a risk of airway fire with high oxygen levels)
●● Always ensure the green band on the electrocautery accessory (probe, snare
etc.) is visible before activation of the diathermy unit

BOX 13.2 Complications of electrocautery

●● Bleeding/haemorrhage
●● Respiratory failure
●● Tracheal or bronchial perforation
●● Airway fire
●● Pneumothorax
●● Arrhythmias
●● Post-treatment stenosis
●● Pneumonia

●●Argon plasma coagulation

Argon plasma coagulation is a non-contact form of electrocautery (Fig. 13.4). Ionized
argon gas is created by a high-frequency generator and flows through a Teflon catheter.
A wire within the catheter conducts the high-frequency current and a tungsten tip at
the end converts the argon to an ionized plasma. The electricity is conducted through
the gas plasma. It is very effective at coagulation and has a fixed depth of penetration of
3–5 mm. The rapid coagulating effect is very useful at treating the surface of exophytic
tumours that are bleeding. The plasma also tends to bend to the part of least resistance
and can be used to treat areas that are not accessible to conventional electrocautery
coagulation probes. Both end-firing and side-firing treatment catheters are available.The
argon flow is typically set between 0.3 and 2.0 L/min with the wattage at 30 to 40 W.
The precautions when using argon plasma coagulation and its complications are similar
to those of electrocautery.

205
 Fig. 13.4a Argon plasma coagulation activated in the airway. Note that the first black marking band
is visible, indicating that the catheter is a safe distance from the tip of the bronchoscope. A test area of
coagulation is performed in the airway to check the energy level selected.

Fig. 13.4b Argon plasma coagulation of the vascular right middle lobe tumour.

Fig. 13.4c Vascular right middle lobe tumour treated with spray coagulation to the surface.The whole
surface of tumour in the right middle lobe is coagulated.

Cryotherapy
Obstructing endobronchial tumours can be easily relieved with cryotherapy extraction
of the tumours. Cryotherapy can be used in its traditional format or by cryoextraction.
Traditional cryotherapy involves the application of the cryoprobe directly on to the
tumour (Fig. 13.5). The cryoprobe itself is passed through the instrument channel, until
the tip protrudes by about 2 cm from the distal end of the bronchoscope. The probes
are marked and hence should be advanced until a clear distal black band is visible on
the probe. This is to prevent accidental freezing and damage of the bronchoscope.
Under direct vision, the probe is applied to the tumour and the freezing process
is activated with a foot pedal and the tissue frozen for approximately 10 seconds
depending on the constitution of the tumour. The extent of tissue that is frozen can be
visually identified by the ice-front. The tissue is then allowed to thaw and further freeze
cycles are applied. Multiple overlapping applications are performed to ensure that the
whole endobronchial tumour is adequately treated.
The freezing leads to vasoconstriction and microthrombi formation, which in turn
reduce the blood supply to the tumour. Freezing also leads to protein and enzyme
damage and the net effect is cell necrosis. Mechanical damage from the formation of
ice crystals may also explain some of the necrosis. Repeated freeze–thaw cycles lead
to overall tumour necrosis. This technique is easily and safely applied, but the main
disadvantage is its delayed effect. A repeat bronchoscopy is usually required 72 hours
206 to 1 week after the initial procedure to remove the necrotic tumour debris. Hence it is
not an appropriate technique in the presence of a critical lesion.
Fig. 13.5a Cryoprobe activated while in contact with tumour and with an ice ball formed around the
tip of the cryoprobe.

Fig. 13.5b The probe is allowed to thaw and then the cryoprobe is moved a few mm to the side and
activated again.

Fig. 13.5c Note the formation of the ice-front around the tip of the probe.The ice-front enlarges with
continued application of the cryoprobe. Regression of the ice-front is observed after switching off the
probe.

Fig. 13.5d The cryoprobe again moved a few mm and activated to create multiple overlapping areas
of treatment.

●●Cryoextraction
Cryoextraction utilizes a modified cryoprobe from Erbe where the central gas channel
has been stabilized and the joint between the probe and the catheter is strengthened to
withstand forces of up to 50 newtons. The cryoprobe is cooled down to temperatures
of around – 90°C at the tip of the probe on activation and freezes tissue in contact
with the probe (Fig. 13.6). The probe is applied to the tumour and activated for about
3–6 seconds. The duration is modulated according to the size of the ice-front and the
tissue being treated. The bronchoscope and probe are gently tugged together as one
unit and a piece of tumour adhering to the probe is extracted. The bronchoscope and
probe are removed via the endotracheal tube, the tissue is allowed to thaw and is then
removed from the probe. The bronchoscope and probe are then re-inserted through
the endotracheal tube and another piece of tumour frozen with the cryoprobe and
extracted. With this technique, airway obstruction from tumours can be quickly and
effectively debulked to alleviate airway obstruction. 207
 Fig. 13.6a Necrotic tumour almost completely occluding the right main bronchus.The cryoprobe is
activated after contact with the tumour.

Fig. 13.6b The tumour adheres to the tip of the cryoprobe and the adherent tumour is broken off.The
cryoprobe with adherent tumour and bronchoscope are removed as one unit via the endotracheal tube.

Fig. 13.6c Ice-front formed in the tumour in the area of contact with the cryoprobe.The adherent
tumour is being gently pulled to detach another piece of tumour.

Fig. 13.6d A further piece of tumour in contact with the cryoprobe is frozen and pulled off.

Fig. 13.6e Significant debulking of the tumour with cyclical freezing and breaking off adherent
frozen tumour.

208
Fig. 13.6f Restoration of patency in the right main bronchus with pus arising through the reopened airway.
Laser treatment
Neodymium–yttrium aluminium garnet laser is usually used through a rigid bronchoscope
but flexible fibres are also available which can be used through a flexible bronchoscope.
This laser tends to vaporize tissue. The power should be limited to 40 watts as the
depth of penetration can vary according to the tissue composition and clinical trials
have shown an increased frequency of adverse events in power settings above 40 watts.
The colour of the tissue may also affect the thermal energy absorbed.
The laser is delivered through flexible fibres, but the laser light itself is invisible
(wavelength = 1064 nanometres) and hence is used in conjunction with red helium-
neon aiming beam to guide treatment application. The precautions to be taken when
using laser are shown in Box 13.3.

BOX 13.3 Precautions when using laser

●● Inspired oxygen concentration (Fio2) < 0.4
●● Limit power to less than 40 watts
●● Protect the patient’s eyes
●● Ensure all personnel wear protective goggles
●● Avoid its use in the presence of silicone or covered stents
●● Ensure the distal tip is sufficiently beyond the tip of the bronchoscope

Photodynamic therapy
Photodynamic therapy utilizes a photosensitizer which is activated by a special light
source. Photofrin is a commonly used agent that is administered 48 hours before the
therapeutic bronchoscopy (dose 2 mg/kg intravenously).The drug is cleared from most
tissues within 3 days but is retained in tumour tissue, skin, liver and spleen for up to 6
weeks. At bronchoscopy a non-thermal laser light such as potassium titanyl phosphate
(KTP) or argon pumped laser is applied using a cylindrical diffuser. The laser light
(wavelength 630 nanometres) penetrates the tissue and causes tumour destruction.
The cylindrical diffuser tip is available in a variety of lengths and is chosen according to
the tumour extent.The cylindrical diffuser is positioned adjacent to the tumour and the
light is emitted in a 360° arc from the diffuser. Approximately 200 joules is applied per
cm treated and this takes approximately 8 minutes. It is crucial to ensure that the tip is
held in a stable position. If an untreated section is left, the diffuser can be repositioned
and the additional area retreated. A repeat bronchoscopy should be performed after
48 hours to debulk any necrotic tissue and suction out any inflammatory debris and
mucus.
The key complications are haemorrhage, hypoxia due to plugging of the airways, infection
due to retention of secretions, and necrotic debris. The main side effect limiting the
utility of photodynamic therapy is skin sensitivity. Retention of the photosensitizer in the
skin means that exposure to light leads to burns. Patients are asked to completely cover
their body and not expose themselves to light for at least 6 weeks. Late complications
include circumferential strictures in the treated areas.

Brachytherapy
Brachytherapy involves the placement of a blind-ending catheter close to the tumour.
Bronchoscopy with the nasal approach is performed and a polyethylene catheter is
placed through the instrument channel of the bronchoscope and into the desired airway. 209
 The catheter position can be verified with fluoroscopy if required. The bronchoscope
is slowly withdrawn while the catheter is advanced. The catheter is secured in position
at the nose and the bronchoscope is reintroduced through the oral route to check
correct placement of the catheter.
The treatment area is planned using available radiology and the post-procedure chest
radiograph. The treatment is performed in a lead-shielded room. A remote after-
loading device is connected to the proximal portion of the catheter. According to
the treatment area planned, the catheter is loaded with a combination of inactive and
radioactive beads. High-dose brachytherapy is more commonly performed and uses an
iridium-192 source.
The key complications of high-dose brachytherapy include massive haemoptysis, fistula
formation, radiation bronchitis and stenosis. These risks are increased by concurrent
external beam radiotherapy, previous endobronchial laser treatment, increasing dose
intensity of brachytherapy and a cell subtype of large cell carcinoma.

210
 Stents Chapter
Endobronchial or endotracheal stents are used where airway obstruction is caused by
extrinsic compression from a tumour. They may also be required after endobronchial
tumour debulking if the airway has lost its support structure and also if the tumour
is prolapsing through a lobar bronchus and occluding the main bronchus. A variety of
14
different stents exist, but the main group are metallic or non-metallic stents. Metallic
stents themselves are subdivided into covered and uncovered stents. Non-metallic
stents usually require insertion with a rigid bronchoscope and are not discussed further
here. Metallic stents are usually made from nitinol (a nickel titanium alloy) (Fig. 14.1).

Fig. 14.1a Self-expanding Fig. 14.1b Nitinol stent, Fig. 14.1c Nitinol stent, Fig. 14.1d Deployment
uncovered nitinol stent. laser-cut from a single piece laser-cut from a single piece handle for self-expanding
and covered with silicon. and covered with silicon. stent.

Technique of stent insertion

●●Direct vision
The first step is to intubate the patient with a size 8 or 9 uncuffed endotracheal tube.
An ultra-fine bronchoscope with an external diameter of 2.8 mm is used and the
area of narrowing inspected under direct vision. A pulmonary guidewire (jagwire with
a soft distal tip) is inserted through the instrument channel and passed through the
stenotic airway into the distal aspects of the lung (Fig. 14.2). A wire exchange technique
is employed in order to remove the bronchoscope while maintaining the jagwire in
its current position. This is best achieved by feeding the wire a couple of centimetres
deeper while removing the bronchoscope by a similar amount. This is performed until
the bronchoscope is removed but the wire is maintained in position.The bronchoscope
is passed through the endotracheal tube to check that the guidewire is still in the
correct position. The guidewire should be held taut by an assistant and care taken to
maintain its position,

211
 Fig. 14.2a Narrowing in right main Fig. 14.2b Guidewire inserted Fig. 14.2c Bronchoscope removed
bronchus secondary to tumour. through a narrowed right main while retaining guidewire in position
bronchial tumour. through the right main bronchial
tumour.The bronchoscope is then
reinserted into the airway to check
the position.

Fig. 14.2d Stent inserted over the Fig. 14.2e Initial deployment of the Fig. 14.2f Gradual deployment of the
guidewire.The positioning of the stent stent under bronchoscopic control. stent under bronchoscopic control.
is confirmed by bronchoscopy.

Fig. 14.2g Full deployment of the

stent under bronchoscopic control.

The patient is then re-bronchoscoped by inserting the bronchoscope through the

vocal cords via the oral route adjacent to the endotracheal tube. This allows the
stent to be passed through the endotracheal tube and manipulated in the trachea
or bronchi while maintaining vision with the bronchoscope (Fig. 14.3). The stent is
fed over the guidewire through the endotracheal tube and into the desired location
in the airways. The stents have markers highlighting the proximal end of the stent
within the delivery catheter. Before the procedure, a CT scan of the thorax should be
carefully studied to ensure that stenting is a suitable treatment option. For example,
it is important to ascertain that there is a good patency of the airways beyond the
stenosis. The size and length of the stents required can also be determined by the CT
scan. This is complemented by careful examination of the airways at bronchoscopy.

212
Fig. 14.3a CT scan showing Fig. 14.3b Concentric narrowing of
narrowing of the right main bronchus. the right main bronchus.

Fig. 14.3c Concentric infiltration and narrowing of the right main bronchus. Guidewire inserted into
the right main bronchus.

Fig. 14.3d Guidewire advanced distally into the right main bronchus while sequentially withdrawing
the bronchoscope. Delivery catheter with the stent advanced over the guidewire under bronchoscopic
vision with 2.8 mm hybrid fibrescope (round images).

Fig. 14.3e Delivery catheter with the stent positioned so that the yellow markers for the proximal limits
of the stent are above the area of stenosis. Distal and proximal aspects of the stent are inspected.

Fig. 14.3f Stent placed in Fig. 14.3g Silicon-coated Fig. 14.3h, i Covered nitinol stent in the airway with a
the constricted right main nitinol stent with a suture in proximal silk thread which can be used to grab the stent 213
bronchus. the proximal aspect. and manipulate it into a more proximal position (the stent
should not be pushed distally).
 The stent is carefully positioned so that the proximal marker is visible proximal to the
area of narrowing under direct vision and the stent is carefully deployed. A variety of
deployment mechanisms exist and in principle all use the technique of withdrawing the
overlying protective catheter (Figs 14.4 and 14.5). Please check and familiarize yourself
with the manufacturer’s instructions. We recommend fixing the position of your arm,
for example, holding the elbow fixed over your abdomen and then pulling back the
overlying sheath over the stent. This is an important step for correct placement as
there is a tendency to push forward during deployment and this leads to the stent
being deployed further into the airways than desired.The stent should be deployed in a
steady manner under direct vision so that any small adjustments can be made to ensure
that the stent is optimally positioned prior to full deployment.

Fig. 14.4a Following intubation, the guidewire is inserted into the narrowed right main bronchus.

Fig. 14.4b The stent is inserted through the narrowed right main bronchus and gradually deployed by
removing the silk thread around the stent.

Fig. 14.4c An uncovered nitinol stent which has been fully deployed with an improvement in the
calibre of the right main bronchus.

214
Fig. 14.5a CT scan at
the level of a tracheo- Fig. 14.5b CT scan
oesophageal fistula. showing some changes of
basal pneumonia due to
aspiration.

Fig. 14.5c Tracheo-oesophageal fistula visible in the posterior aspect of the upper trachea. Stent
inserted over the guidewire under visual control with a thin hybrid bronchoscope.

Fig. 14.5d Covered nitinol stent being positioned in the trachea.The yellow marker defines the
proximal limit of the stent and the stent is carefully positioned in the trachea to fully seal the tracheo-
oesophageal fistula.

Fig. 14.5e Steady deployment of stent in the trachea with repositioning of the stent in order to
ensure an adequate seal of the tracheo-oesophageal fistula.

Some of the stents can be manipulated into a proximal position by grasping a silk stitch
at the end of the proximal portion of the stent with forceps and then gently moving
the stent proximally (Fig. 14.3h,i). However, manipulating the stent by a precise amount
is difficult and the stent should never be pushed distally.

215
 ●●Radiology-guided stent insertion
Endotracheal and endobronchial stents can also be positioned and deployed
under fluoroscopic guidance (Figs. 14.6 and 14.7). The initial steps are similar to
deployment of the stents under direct vision. Once the guidewire is placed through
the appropriate narrowed lobar bronchus, the stent is fed over the guidewire and
through the endotracheal tube. Under fluoroscopic guidance the stent is advanced and
positioned over the desired area.The stents usually have proximal and distal radiological
markers, which allow the accurate positioning of the stent under fluoroscopic control.
The deployment of the stent is again the same as with direct vision except on this
occasion the fluoroscopy provides the visual guidance. Stents can also be placed with a
combination of direct visual guidance and fluoroscopy.This may be more appropriate in
circumstances where the distal aspect cannot be visualized at bronchoscopy even with
an ultra-fine bronchoscope.

Fig. 14.6a Chest Fig. 14.6b Stent positioned Fig. 14.6c Chest
radiograph of a patient with and deployed under radiograph showing
left lower lobe and lingular fluoroscopic control. significant reinflation of
collapse. the left lung after stent
placement (visible in the left
main bronchus).

Fig. 14.7a Three silicon-

coated stents inserted in Fig. 14.7b Close-up of the
a patient: one in the main carina showing two stents
carina with two other stents from each main bronchus
visible distally in the right joining at the carina.
and left main bronchi.

Complications of stents
Malignant endobronchial tumour involvement is the most common indication for
tracheal or bronchial stents. Hence the covered variety is more frequently utilized.
However, these stents impair normal mucociliary clearance and hence are prone to
complications such as mucus retention and bio-fouling of the stents. This is where
bacteria grow mucoid biofilms on the inner surface of the stent (Fig. 14.8). A further
216 complication of this phenomena is halitosis.These stents are also prone to displacement.
Fig. 14.8a Pseudomonas Fig. 14.8b Early stage Fig. 14.8c Close-up view Fig. 14.8d Development
biofilm formation on a of biofilm formation on a of a covered nitinol stent of biofilm with mucus stasis
covered endobronchial stent covered endobronchial stent. with early biofilm formation. on a covered endobronchial
with some mucus plugging. stent.

Fig. 14.8e Progressive Fig. 14.8f Granulation Fig. 14.8g Granulation Fig. 14.8h Granulation
development of biofilm with tissue developing as a result tissue at the distal end of tissue developing around an
mucus stasis on a covered of an uncovered nitinol an uncovered nitinol stent. uncovered nitinol stent.
endobronchial stent. stent.

Fig. 14.8i Tumour growth Fig. 14.8j Tumour Fig. 14.8k Tumour Fig. 14.8l Distal tumour
through an uncovered ingrowth through an recurrence around an recurrence in an uncovered
nitinol stent. uncovered stent with epithelialized uncovered stent.
epithelialization of the stent stent.
visible on the other side.

Fig. 14.8m Covered nitinol Fig. 14.8n Mucus Fig. 14.8o Stent fracture
stent in the main bronchus, collection on a covered stent. – a nitinol stent has warped
with mucus plugging visible in areas with stent fractures.
on the inner surface of
the stent due to impaired 217
mucociliary clearance.
 Other complications of stents include development of granulation tissue and overgrowth
from the tumour itself at the proximal and distal margins. The stents are exposed to
significant forces during coughing and also through the respiratory cycle (Fig. 14.9).
Stent fractures are a potential complication and a difficult problem as the stent needs
to be removed, usually piecemeal by removing the individual wires carefully with a rigid
bronchoscope.

Fig. 14.9a Migration of stent inserted into the right main bronchus.With coughing the stent moves
up into the trachea.

Fig. 14.9b The stent has migrated to the trachea and is then removed by grasping with biopsy forceps.

Balloon dilators
In some patients with extrinsic narrowing and also in some patients with circumferential
submucosal disease causing airway obstruction, airway dilatation is first required
prior to stent insertion. This can be achieved with balloon dilators. Several sizes of
balloon dilators are available. Once again I would recommend performing the flexible
bronchoscopy in a patient who has been intubated with an uncuffed endotracheal tube.
The balloons are inflated with a pressurized saline-filled syringe. This syringe increases
the pressure to a specified amount depending on the degree of dilatation required.The
majority of endotracheal balloon dilatations require an interventional bronchoscope
with at least a 2.8 mm instrument channel.The balloon is passed through the instrument
channel of the bronchoscope and then manipulated through the narrowed airway
under direct vision (Fig. 14.10). Once the balloon is appropriately positioned, it is
inflated to the set pressure. This should normally be performed in a stepwise dilatation
(for example, from 6 to 8 to 10 mm in three separate inflations).

218
Fig. 14.10a CT scan in a patient with left
pneumonectomy and narrowed right main bronchus.

Fig. 14.10b Circumferential narrowing of the right main bronchus in a patient with left-sided
pneumonectomy. Insertion of balloon dilator through the narrowed right main bronchus.

Fig. 14.10c Inflation of a balloon dilator which has been inserted through the narrowed right main
bronchus.There is partial improvement in calibre in the right main bronchus.

219
 Chapter Bronchoscopic treatment for
15 emphysema and asthma:
bronchoscopic lung volume
reduction
In patients with severe end-stage emphysema, hyperinflation – and particularly dynamic
hyperinflation during exertion – is the main cause of dyspnoea and exercise limitation.
Patients who are symptomatic despite maximal medical therapy who have undergone
pulmonary rehabilitation may be considered for bronchoscopic lung volume reduction.
Bronchoscopic techniques and treatment adopted depend on the pattern of
emphysema. The majority of patients who have severe emphysema have homogenous
disease and about 25 per cent of patients have heterogenous disease.

Heterogenous disease
This is defined as greater than 10 per cent variation in the emphysematous destruction
between the upper and lower lobes. A more accurate way of assessing this is by applying
a density mask to lung windows and areas with an attenuation value of less than 910
Houndsfield units on 10 mm computed tomography (CT) sections (Fig. 15.1).

Fig. 15.1a CT scan showing Fig. 15.1b CT scan from the same Fig. 15.1c Density mask highlighting
emphysematous destruction in the patient with emphysema showing areas with emphysema (> 910
upper lobes. relatively less destruction from Houndsfield units): in the upper lobe.
emphysema.

Fig. 15.1d Density mask highlighting Fig. 15.1e CT scans showing a Fig. 15.1f CT scans showing a
areas with emphysema (> 910 greater degree of emphysema in the greater degree of emphysema in the
Houndsfield units): in the lower lobe. upper lobes than in the lower lobes: upper lobes than in the lower lobes:
220 coronal section. sagittal section.
●●Zephyr valve
The strategy of lobar atelectasis has been utilized with this valve. Hence the
recommendation is that the whole of the lobe is treated in a unilateral manner. This is
one of the third-generation valves that can be easily inserted through the instrument
channel of a bronchoscope. It is available in two main sizes: 4–7 mm and 5.5–8.5 mm.

Fig. 15.2a Zephyr valve. Fig. 15.2b Delivery catheter Fig. 15.2c Valve loading Fig. 15.2d The retaining
handle with a blue button that device.The valve is moved thread is cut.
needs to be pressed prior to into the narrow loading
pressing the blue lever to slowly funnel by pulling at the two
deliver the valve.The tip has ends of the device.
side blue flanges measuring
4 mm (small flanges) to 7 mm
(larger side flanges) which
allow you to determine if the
valve is the correct size for the
target airway segment.

Fig. 15.2e The funnel with Fig. 15.2f The Zephyr Fig. 15.2g The delivery Fig. 15.2h The delivery
the Zephyr valve in the valve in funnel channel. catheter positioned in the catheter positioned in the
channel is removed from loading device. loading device and pulled
the capsule. down into the narrow
channel.

Fig. 15.2i The Zephyr Fig. 15.2j Pusher used to Fig. 15.2k The Zephyr
valve inserted into the push the valve from the valve loaded into the distal 221
loading device. funnel-like capsule into the end of the delivery catheter.
delivery catheter.
 Sizing is not as critical with Zephyr valves as it is with intrabronchial valves. The delivery
catheter has two flanges which provide an estimate of the airway size and therefore the
valve that is required.The catheter is placed centrally in the appropriate segment and an
estimate can be made using the side flanges to determine which valve should be used.
Once the valve is loaded into the delivery catheter, it is manoeuvred into the
appropriate airway segment (Figs 15.2 and 15.3). We recommend using the technique
of partial deployment. The valve is very slightly deployed so that it protrudes through
the distal tip of the delivery catheter. The valve can then be wedged against the carina
within the segment to be treated and deployed. This ensures that the valve is correctly
positioned so as to occlude the whole segment. Full deployment in a single manoeuvre
can sometimes force the valve into a particular subsegment leading to only partial
closure of the segment and this in turn will prevent full lobar atelectasis.

Fig. 15.3a Delivery catheter for the Zephyr valve with blue side flanges measuring 4 mm (smallest
flange) and 7 mm (largest flange). Measurement of the airway segment with a 4 mm catheter
demonstrates that the segment diameter is larger than the small flange (4 mm) and smaller than the
larger (7 mm) flange and hence suitable for a 4 mm valve, which has a range of 4–7mm.The delivery
catheter with a blue margin demarcating the proximal limit of the valve.

Fig. 15.3b Slow deployment of the Zephyr valve after wedging against a subsegmental carina.

Fig. 15.3c The Zephyr valve which is closed in inspiration and open in expiration, therefore allowing
air out.

222
The valves can be easily removed with grasping forceps. The proximal duck-billed valve
can be grasped with the forceps and the valve pulled out as a whole unit with the
bronchoscope.
The main complications observed are acute exacerbations. Other acute complications
include a pneumothorax. In the long term, development of granulation tissue around
the valves has been observed. In some cases, there may be secondary colonization
of the valves with bacteria such as Pseudomonas or fungal species such as Aspergillus
(Fig. 15.4).

Fig. 15.4a Granulation Fig. 15.4b Close-up of a Fig. 15.4c Another Fig. 15.4d Zephyr valves
tissue around the valve in Zephyr valve colonized with example of granulation covered with a biofilm of
RB2 and the valve in RB1 Aspergillus. tissue developing around mucoid Pseudomonas.
has been colonized with the valve.
Aspergillus.

Fig. 15.4e Appearance of Fig. 15.4f Appearance Fig. 15.4g Combination

the right upper lobe after of the right upper lobe 6 of granulation tissue and
removal of Zephyr valves. weeks after removal of biofilm formation around
Zephyr valves. Note the first-generation duck-billed
significant regression of valve.
granulation tissue.

●●Intrabronchial valve
The intrabronchial valve is an umbrella-shaped device, which is available in sizes of 5, 6
and 7 mm (Fig. 15.5). The manufacturers have been promoting the strategy of airflow
re-direction and hence recommend that one subsegment is left patent on the right side
and the lingular is untreated on the left side. The valves have a lower margin of error as
oversizing causes ruffling of the valve and hence incompetence. Undersizing does not
allow a proper seal of the airway either. The valve therefore requires accurate sizing of
the airways using a balloon sizing kit. 223
 Fig. 15.5a Loading device Fig. 15.5b Intrabronchial Fig. 15.5c Intrabronchial
and delivery catheter. valves (5 mm valve in valves with colour-coordinated
centre, 6 mm valve on left housing: 5 mm valve (blue),
and 7 mm valve on the 6 mm valve (yellow) and
right side). 7 mm valve (green).

Airway sizing
Balloon preparation and calibration
All the air has to be extracted from the balloon and replaced with normal saline.
A three-way tap is attached to the balloon catheter with a 10 mL syringe, which is filled
with approximately 5 mL of normal saline. Strong suction is applied so as to remove
as much air as possible from the balloons. The balloon is then filled with normal saline
(Fig. 15.6). Any air bubbles still present are gently manipulated to the centre of the
balloon and suction is applied to the syringe in an attempt to aspirate the gas bubbles.
This process is then repeated until there are no air bubbles present or, alternatively, the
bubble present in the catheter is smaller than the inner stem of the balloon catheter.

Fig. 15.6a Balloon Fig. 15.6b Balloon Fig. 15.6c Balloon

catheter. catheter inflated with saline catheter with multiple small
but with a significant air bubbles (air extracted by
bubble. repeated suction).

Fig. 15.6d Gently flicking Fig. 15.6e A single

the balloon encourages the bubble smaller than the
small bubbles to coalesce diameter of the catheter is
and form larger bubbles that acceptable for calibration
may be removed by repeated and sizing.
suctioning and inflation of
the saline-filled balloon.
224
The syringe is then exchanged for a 500 µL glass syringe and filled with exactly 500 µL
of normal saline. The saline-filled balloon is then calibrated using a sizing template. The
balloon is carefully inserted and inflated to fit different-sized templates from 3, 5, 7 and
9 mm holes and the volume of saline in the glass syringe is recorded for each size (Fig.
15.7). In this way a calibration curve for the particular balloon is produced which can
then be used to size the airways in a patient.

Fig. 15.7a Calibration Fig. 15.7b The balloon Fig. 15.7c The balloon
template and 500µL glass is slowly inflated at each optimally inflated to 9 mm
syringe. template size. Here, partial size template (the volume
inflation of the balloon at required to inflate the
the 9 mm hole can be seen. balloon to this size read
from glass syringe).

Patient preparation
Intubation of all patients undergoing the procedure is recommended.This provides a secure
airway but also facilitates removal of valves if required during the procedure.The treatment
sites are usually planned according to the findings of a spiral CT scan and a ventilation–
perfusion scan.The lobes with the greatest destruction are targeted.The calibration balloon
is inserted through the instrument channel and inflated in the target segments until the
balloon fits snugly in the segment (Fig. 15.8). The balloon is then moved back and forth in
order to determine whether the balloon is correctly inflated. Overinflation leads to some
indentation in the balloon. Where there is underinflation a gap may be visible.

Fig. 15.8a Balloon catheter

inserted into a bronchial
segment. Balloon inflated in
the bronchial segment and
then moved back and forth
in the segment.The balloon
is optimally inflated to the
size of the airway.

Fig. 15.8b The optimally

inflated balloon moved
back and forth in the
bronchial segment.

Fig. 15.8c Note a gap

between the segment and
the balloon, indicating under-
inflation, and then note the
slight dimpling in balloon 225
indicating overinflation.
 Procedure
The valve is loaded on to the delivery catheter (Fig. 15.9). This in turn is inserted
through the instrument channel of the bronchoscope. Some adjustment of the delivery
rod in the trachea is required under direct vision. The catheter is then manoeuvred
into the desired segmental airway. The delivery catheter has a proximal marker and
is manipulated so that it is appropriately positioned. The valve is delivered and the
catheter removed (Fig. 15.10). The valve should be inspected to ensure that it has
been correctly placed and that it is fully open with minimal ruffling of the edges of the
umbrella. It does tend to retract back by about 1 mm after a few hours. Hence, it is
important to check that any side branches or subsegments are fully occluded with an
overlap of more than 2 mm. If the valve is oversized then the umbrella tends to be
ruffled and not fully open which leads to incompetence of the valve. Similarly if the
valve is undersized, the valve tends to leak.

Fig. 15.9a Plunger Fig. 15.9b A 7 mm Fig. 15.9c Delivery

retracted in the loading (green) valve inserted into catheter inserted into the
device. the loading device. loading device.

Fig. 15.9d Plunger pushed Fig. 15.9e Delivery Fig. 15.9f Intrabronchial
into the loading device to catheter released from the valve loaded into the
transfer the valve into the loading device by pushing delivery catheter.
delivery catheter. down the yellow button.

226
Fig. 15.10a Delivery catheter inserted into the left main bronchus.There is a small gap between the
delivery rod and the valve that is closed in the delivery catheter.The catheter is advanced into the left
apicoposterior segment (LB1 + 2) of the upper lobe.

Fig. 15.10b The delivery catheter is slowly withdrawn back and the yellow line (proximal marker
for valve leaflet) is positioned at the origin of the bronchial segment.The valve deployed in left
apicoposterior segment (LB1 + 2) of the upper lobe.

Fig. 15.10c Catheter tip inserted into the anterior segment of the left upper lobe (LB3).

Fig. 15.10d Valve in the subsegment of the left anterior upper lobe (LB3).

227
 Valve removal
The intrabronchial valve can be easily removed if it has been incorrectly positioned or
if the valve size is incorrect (Fig. 15.11). It can also be removed if the patient does not
improve with intervention or if they develop any complications such as post-obstructive
infection. The biopsy forceps are inserted through the instrument channel and used to
grasp the central rod located on the valve. The valve is then pulled close towards the
bronchoscope and the unit is removed in its entirety. Do not attempt to pull the valve
through the instrument channel as it will not be possible and there is a risk of damaging
the distal portion of the bronchoscope.

Fig. 15.11a Incorrectly positioned intrabronchial valve. Removal of valve using biopsy forceps which
are first positioned over the intrabronchial valve.

Fig. 15.11b Biopsy forceps grasp the central rod on the intrabronchial valve.The intrabronchial valve
is pulled closer to the bronchoscope and removed through the endotracheal tube as one unit.

228
●●Complications of endobronchial valve
treatment (Fig. 15.12)
The most common complication is exacerbation of chronic obstructive pulmonary
disease (COPD) which occurs in up to 10 per cent of patients following insertion of
endobronchial valves.The patient presents with increased breathlessness, cough, wheezy
spells or even mucous hypersecretion. Treatment is with steroids and antibiotics. The
other acute complication is that of pneumothorax. It usually resolves with conservative
management, requiring intercostal drainage, but only in a small proportion is there
a prolonged air leak of more than 7 days. Haemoptysis and haemorrhage are less
common and are usually related to incorrect placement of the valve where the
protruding section of the valve is rubbing against the airway mucosa. Similarly, valve
displacement can occasionally occur but the incidence can be reduced by correct valve
replacement. Granulation tissue also develops in some patients with endobronchial
valves. We have observed chronic infection such as Aspergillus infection around the
valve, which usually resolves with removal of the valves.

Fig. 15.12a Granulation Fig. 15.12b Mucosal Fig. 15.12c Almost

tissue enclosing the whole hypertrophy on the lateral complete occlusion of the
valve with the central rod aspect of the intrabronchial valve by epithelial tissue.
just visible. valve and mucus around the
central rod.

Fig. 15.12d Mucosal Fig. 15.12e Intrabronchial Fig. 15.12f Colonization of

hypertrophy encircling the valve encircled with tissue the valve with Aspergillus.
valve, in particular around hypertrophy.
the inferior margin.

229
 ●●PneumRx® RePneu® Lung Volume Reduction
Coil (LURC®) System
These are memory coils made from nitinol, which are available in a variety of sizes.
Insertion of PneumRx® coils is performed under fluoroscopic guidance during a
bronchoscopy (Figs. 15.13 and 15.14).
The coil is a self-actuating device which is delivered straight into the airway. The coil
recovers to a non-straight, pre-determined shape upon deployment. The device
consists of sterile coils and a sterile, disposable, single-patient delivery system consisting
of a cartridge, catheter, guidewire and forceps.

Fig. 15.13a PneumRx® Fig. 15.13b PneumRx® Fig. 15.13c PneumRx® coil Fig. 15.13d Catheter and
nitinol coil. nitinol coils of differing in sterile protective housing. guidewire.
lengths.

Fig. 15.13e Grasping Fig. 15.13f PneumRx® Fig. 15.13g Coil being Fig. 15.13h Coil being
forceps with screw (blue) coil with loading cartridge. loaded into the cartridge by loaded into the cartridge.
locking mechanism. Grasped with forceps first drawing the grasped
and locked to prevent coil into the loader.
inadvertent opening and
release of the coil.

Fig. 15.13i PneumRx® Fig. 15.13j PneumRx®

coil grasped by the forceps. coil released by the forceps.
Note the blue screw lock is Note the blue screw lock is
230 in the locked position. in the unlocked position.
Fig. 15.14a Catheter inserted into the apicoposterior (LB1 + 2) segment of the left upper lobe. Note
the radio-opaque tip of the catheter. PneumRx® coil being advanced through the catheter.

Fig. 15.14b Overlying catheter being steadily withdrawn with the PneumRx® coil reverting to its original
shape. Grasping forceps are visible at the distal end of the bronchoscope.

Fig. 15.14c Grasping forceps are opened releasing the PneumRx® coil.The forceps are then
withdrawn.The catheter is repositioned in another airway subsegment and the guidewire is advanced
into the bronchial segment.

Fig. 15.14d The guidewire and overlying catheter advanced into the bronchial subsegment.

Fig. 15.14e The catheter being advanced over the guidewire until resistance is felt or the catheter
tip is about 3 cm from the pleural edge.The guidewire is withdrawn to the tip of the catheter and the
length is estimated with the guidewire which has radio-opaque markers every 25 mm.The guidewire is
completely withdrawn leaving the catheter in place. 231
 Fig. 15.14f The PneumRx® coil being advanced through the catheter.The overlying catheter is fully withdrawn
with the PneumRx® coil being fully deployed.The distal aspect of the PneumRx® coil is still grasped by forceps.

Fig. 15.14g The grasping forceps are opened to release the PneumRx® coil
with the distal tip of PneumRx® coil visible in the airway.

The procedure can be performed under conscious sedation and ideally the patient should
be intubated. The bronchoscope is then passed through the endotracheal tube and
manoeuvred towards the target bronchial segment. A catheter with a guidewire is then
passed through the instrument channel into the bronchial subsegment. The guidewire
is advanced into the bronchial segment under fluoroscopic guidance. The guidewire is
inserted until resistance is felt or up to 3 cm from the pleura edge. The catheter is then
gently fed over the guidewire to the distal tip of the guidewire. The catheter has a tip that
is visible at fluoroscopy and the guidewire has markings every 25 mm along its length that
are radiologically visible. The guidewire is then withdrawn back to the tip of the catheter
and the distance between the tip of the catheter and the tip of the bronchoscope is
calculated from the 25 mm interspaced radiological markers.This allows an estimate of the
coil length that should be inserted. The coil is usually oversized by approximately 50 mm.
Adapted bronchial forceps with a locking mechanism are used to grasp the coil and
then load it into a specific delivery mechanism and it is fed through the catheter. It
is inserted up to the catheter tip under fluoroscopic guidance. The coil is advanced
until the distal aspect of the coil reaches the distal point of the catheter and then the
overlying catheter is gradually retracted and this allows the coil to conform back to
its original shape and in doing so falls and pulls the portion of the lung into which it is
inserted. Once the catheter is withdrawn so that the proximal portion of the coil is
protruding out of the catheter, the locking mechanism on the biopsy forceps is released
and the coil is then released into position. The biopsy forceps can then be removed
and the catheter repositioned for the next treatment area. The target lobe is treated
systematically with an average of 10 coils.
If a coil is malpositioned then it can be removed or repositioned. The biopsy forceps
need to be inserted through the catheter and then used to grasp the small ball-like tip
on the proximal aspect of the coil. Once the coil is firmly grasped by its proximal aspect,
the biopsy forceps are locked and the catheter is slowly advanced over the coil under
fluoroscopic guidance. The re-sheathed coil is effectively straightened and can then be
removed or manipulated into a different position.
232 Ideally a coil should be inserted into each of the subsegments. Hence an upper lobe
may be treated with an average of 10 coils.
Homogenous emphysema
In patients with homogenous disease, there is significant destruction of the lung throughout
the lung fields. Hence improvements are not based on simply collapsing diseased lung and
allowing better lung tissue to function, but more on improvements of chest wall dynamics
– in particular, reducing dynamic hyperinflation which is observed on exercise.This group
of patients accounts for the majority of patients with severe emphysema.

●●Airway bypass
This technique relies on the creation of collateral channels which allow airways of destroyed
lung to empty more effectively during expiration and hence reduce hyperinflation. A
detailed spiral CT scan is performed first. This allows identification of areas with the
most emphysematous lung destruction. Other parameters such as the proximity of blood
vessels, airway calibre and bronchoscopic access to the segment are also assessed and
scored. A cumulative score is generated to identify the optimal sites of stent insertion.

Procedure
The process is usually performed under general anaesthesia. Airway blockers should be
positioned at the start of the procedure to deal with any potential airway haemorrhage. First
a Doppler probe is used and positive control is identified by locating an audible Doppler
signal or a blood vessel (Figs. 15.15 and 15.16).Then the target area is identified carefully to
look for an avascular area (where there is no audible Doppler signal).The bronchoscope is
held in position and the Doppler probe removed. A needle with a balloon dilator is then
inserted through the bronchoscope channels and inserted into the avascular area identified.
The dilator in the needle is inflated and a 3 mm hole is created between the airway segment
and the alveolar parenchyma. The balloon is slowly deflated to ensure that there is no
significant bleeding. Any minor bleeding is dealt with by gentle suction. If necessary, aliquots
of ice-cold saline and diluted adrenaline can be used to control the bleeding.
The area around the newly created passage between the airway and alveolar parenchyma
is carefully re-inspected with the Doppler probe to ensure that there are no blood
vessels in close proximity to the passage. This is important as release of trapped gas
when the hole is made might bring vessels closer than would be safe for stent insertion.

Fig. 15.15a Exhale® Fig. 15.15b Exhale® Fig. 15.15c Exhale® Fig. 15.15d Exhale®
Doppler probe. transbronchial dilation needle transbronchial dilation needle transbronchial dilation needle
with the needle withdrawn with the needle protruding with the needle withdrawn
and the balloon deflated. and the balloon deflated. and the balloon inflated.

Fig. 15.15f Exhale® drug- Fig. 15.15g Exhale®

eluting stent (white) and drug-eluting stent with the
Fig. 15.15e Exhale® drug- underlying balloon mounted inflated balloon delivery 233
eluting stent. on the delivery catheter. catheter.
 Fig. 15.16a Exhale® Doppler catheter first identifies a blood vessel (positive control signal to ensure
the Doppler probe is functioning).The Exhale® transbronchial dilation needle is inserted through the
avascular area identified by the Doppler probe.

Fig. 15.16b Balloon dilatation with the Exhale® transbronchial needle after insertion of the needle
through the airway into the lung parenchyma.

Fig. 15.16c Hole created by the Exhale® transbronchial needle.The Exhale® Doppler probe checking
around the hole created to ensure that it is still free of blood vessels.

Fig. 15.16d Exhale® drug-eluting stent on the delivery catheter inserted through the hole created
and positioned midway through the stent before balloon inflation. Deployment of the stent by inflation
of the balloon catheter. It is important to ensure that black marker on the balloon catheter is visible in
order to ensure correct inflation of the balloon.

Fig. 15.16e The stent visible through the dilated balloon.The balloon is deflated after deployment of
the stent followed by removal of the delivery catheter.The Exhale® drug-eluting stent supporting the
234 hole that was created. Emphysematous lung is visible through the stent.

Atlas_of_Flexo_Broncho.indb 234 10/10/2011 13:27

A drug-eluting stent on a balloon catheter is then inserted through the airway passage
(Fig. 15.16d). The stent on the delivery catheter is then carefully positioned so that the
mid-portion of the stent is just through the bronchial wall. Care should also be taken to
ensure the balloon dilator is fully extended out from the distal tip of the bronchoscope
and the black marker line on the catheter is visible. Once appropriately positioned, the
balloon is inflated to a specific pressure and held in position for at least 10 seconds.The
dilation of the balloon deploys the stent and maintains the passage created.The balloon
is then slowly deflated and the catheter carefully removed.
The stent should be inspected to ensure that it is correctly positioned and there is no
overlying lip of mucosa.The procedure is repeated to create further airway passages and
three stents are usually inserted into each lung, with a maximum of two in each lobe.
The procedure is likely to evolve so that in future a combination of a needle dilator and
ultrasound transducer will reduce its duration. It is also possible that only two optimally
placed stents may be required for clinical benefit.
Occasionally the bronchial tissue may be very friable and this will lead to airway tearing
during balloon dilatation.This results in larger holes than are suitable for the airway stent.
In such cases, it may be possible to omit the balloon dilatation with the needle and
proceed straight to stent deployment. In some cases, the stent may be angulated or not
properly deployed and require retrieval.This can be achieved easily with biopsy forceps.
We recommend simply passing the biopsy forceps through the displaced channel and
then opening the forceps so that the stent is now trapped within them, and removing
the bronchoscope, forceps and stent as a single unit.
The main limitation of the stents is that they become occluded over time (usually
within 3 months). Figure 15.17 shows epithelialization of the stents in various stages.

Fig. 15.17a The stent Fig. 15.17b Epithelium Fig. 15.17c The stent almost
deployed so that lateral growing over the majority of completely embedded within the
leaflets are embedded in the stent but still patent. airway. It was originally deployed
the airway mucosa. in a position where part of the
stent was covered with epithelium.

Fig. 15.17d Membrane Fig. 15.17e Membrane Fig. 15.17f Combination

completely covering and covering and occluding the of epithelium growing over
235
occluding the stent. inner surface of the stent. the stent and membrane
covering the inner surface.
 Complications
Airway haemorrhage is the most serious potential complication, hence care and
attention are required throughout the procedure. It is essential that the Doppler
assessment of blood vessels is performed carefully. Any bleeding should be handled as
described in the bleeding protocol (Box 12.1, p. 212). In addition, any bleeding noticed
during the balloon deflation can be rapidly managed by re-inflating the balloon. The
tamponade effect of the balloon should manage and contain the airway bleeding. After
the procedure the most common complication observed is exacerbation of COPD or
acute bronchitis. Pneumomediastinum is also frequently seen with this procedure, but
it is usually self-limiting and does not require any intervention. Pneumothorax is also
observed and again this is self-limiting and is usually managed with intercostal drainage.

Bronchial thermoplasty for asthma

Bronchial thermoplasty is a technique that reduces airway smooth muscle in patients
with asthma. Treatment reduces the frequency of hospitalization, exacerbations and
health care utilization.
The technique uses the Alair radiofrequency controller and Alair catheter, which delivers
the energy to the airways (Fig. 15.18). The energy delivered heats up the local tissue
to around 65°C and selectively reduces the airway smooth muscle bulk. There is some
mucosal oedema which recovers over the next 7–14 days.

Fig. 15.18a Alair Fig. 15.18b Distal aspect Fig. 15.18c Alair
radiofrequency controller of the Alair catheter. radiofrequency controller
with Alair bronchial Note the small bare (not with foot pedal, earthing
thermoplastic catheter. insulated) mid-section of the plate and Alair bronchial
open catheter. thermoplastic catheter.

The patient has an earthing plate attached to the thigh or lower back.The Alair catheter is
introduced through the instrument channel of the bronchoscope and inserted into the most
distal accessible airway. Success of the treatment depends on comprehensive treatment of
the airway, with care taken not to apply repeated treatments to the same airway.This relies
on a systematic approach. In the clinical trials the treatments were administered over three
sessions, treating the right lower lobe, the left lower lobe and then the two upper lobes and
lingula by bronchoscopy every 3 weeks. Our approach, for example, for the right lower
lobe is to treat RB10 (right posterior basal bronchus) first, using the BF260 bronchoscope
(external diameter 4.3 mm) so that the distal subsegments can be assessed.
The Alair catheter is passed through the instrument channel and then opened in the
distal airway (Fig. 15.19). Once fully in contact with the airway, the foot pedal is activated
to deliver the radiofrequency energy in a specific algorithm. The treatment takes about
10 seconds and an audible signal indicates duration and completion of treatment. The
wire basket is then partially closed and the catheter moved proximally by about 4 mm
and then reopened. This manoeuvre is repeated so that all the airways from the distal
aspect to the proximal portion are treated in a stepwise manner. Any side branches
236 that are visualized should also be treated at the same time.
Fig. 15.19a Alair catheter opened in the distal aspect of the airway.The energy is
delivered when the catheter is expanded and in full contact with the airways.The catheter
is partially closed and moved proximally by about 4 mm.The catheter is then re-expanded
and a further cycle of energy is delivered. In this stepwise manner, the whole length of the
airway and any side branches are treated.

Fig. 15.19b Alair catheter in contact with the airways.The bare section through which
the energy is delivered can be seen.The catheter is fully expanded against the airways.
Note the central green wire and four equally spaced, partially insulated wires.

The radiofrequency controller delivers the energy over a 10-second period and any
loss of contact of the catheter from the airway wall, due to coughing etc., will cause the
radiofrequency controller to cut out with incomplete delivery of the energy. A further cycle
can be delivered at the same site, but if there are two incomplete activations at one individual
site then the catheter should be moved more proximally before further treatment.
Patient management is an important step during the bronchoscopy to ensure adequate
application of lidocaine through the airways and appropriate sedation to minimize
patient movement and coughing.
Once the full segment has been treated, the bronchoscope is systematically moved
to the next segment, in this case RB9 (lateral segment of the right lower lobe) then
RB8, RB7 and RB6 in sequence. The main adverse events and complications are an
exacerbation of the asthma, increased mucous secretions and some mucosal oedema.
Mucous plugging and atelectasis are occasionally observed.
Inversion of the wire basket portion of the catheter occasionally occurs and the
radiofrequency generator would prevent activation (Fig. 15.20). The wire basket should
be visualized at all times and care taken to ensure that it is correctly opened and apposed
to the airway wall before the radiofrequency generator is activated to deploy the energy.

Fig. 15.20b Close-up

of the inverted catheter.
Fig. 15.20a Inversion of
Note the green wire is in
an Alair catheter in the
the superior position and
apical segment of the right
partially insulated wires are
upper lobe.
inverted and inferior to the
green wire.
237
 Index
Notes
As the subject of this book is bronchoscopy, entries under this term have been kept to
a minimum. Readers are advised to look for more definite terms.
Entries for right- or left-sided anatomical structures can be found under right or left, not
under the anatomical structure.
To save space in the index, the following abbreviations have been used:
CT – computed tomography; TBNA – transbronchial fine-needle aspiration

A aortic lymph nodes (Station 5), 86

accessory bronchus, 47, 72 aortopulmonary lymph nodes (Station 5), endobronchial
accessory segment, right lower lobe, 70 ultrasound bronchoscopy, 146
accessory subapical segment, right lower lobe, 45, 68, apical branch, right upper lobe bronchus, CT, 61
70 apical segment
adenocarcinoma, 161 left lower lobe, 46, 47, 49, 51, 72, 73, 76
oesophageal, right main bronchus, 162 left upper lobe, 48
trachea, 159 CT, 61
adenocystic carcinoma, trachea, 159 right lower lobe, 64, 66, 68
adrenaline, airway bleeding management, 200, 201 right upper lobe, 15, 36, 37, 38, 61, 62, 63, 64
airway bypass, 233–6 CT, 58, 59
complications, 235 apicoanterior segments, right upper lobe, 38
drug-eluting stents, 235 apicobasal segments, right lower lobe, 43, 68
equipment, 233 apicoposterior segments
procedure, 233, 234–5 left lower lobe, 48
airway sizing, intrabronchial valve, 224–5 CT, 73
Alair catheter, 236–7 left upper lobe, 48, 49, 73, 74, 75
Alair radiofrequency controller, 236–7 CT, 58, 61, 64
allergic bronchopulmonary aspergillosis, 163 right upper lobe, 62
alveoli, confocal microscopy, 168 argon plasma coagulation, 205, 206
amyloid argon pumped laser, photodynamic therapy, 209
tracheobronchial, 159 Arndt endobronchial balloon blocker, 198–9, 201
vocal cords, 158 aryepiglottic fold, 30, 55
anterior approach, 28–52 CT, 53
see also specific anatomical features right see right aryepiglottic fold
anterior basal segment, right lower lobe, 68, 69 arytenoid cartilage, 28, 53
anterior border, right lung, 14 intubation problems, 191
anterior branch right upper lobe bronchus, CT, 61 ascending aorta, CT, 58
anterior prevascular lymph node (Station 3A), Aspergillus infection
endobronchial ultrasound bronchoscopy, 139 intrabronchial valve complications, 229
anterior segment Zephyr valve complications, 223
left lower lobe, 48, 51, 52, 76 asthma, 220–37
CT, 73, 77 bronchial thermoplasty, 236–7
left upper lobe, 48, 49, 73, 74, 75 autofluorescence bronchoscopy, 164–6
CT, 58, 61, 64, 73 azygos arch, CT, 59
right lower lobe, 45, 68, 70 azygos vein
CT, 69 CT, 39, 59, 64
right upper lobe, 36, 37, 38, 61, 62, 63 endobronchial ultrasound bronchoscopy, 134, 142
anterior segmental bronchus, right upper lobe, CT, 59
anterobasal segments, right lower lobe, 43, 44 B
anthracosis, tuberculosis, 163 bacterial colonization, Zephyr valve complications, 223
aorta, 78, 79 balloon catheters, 192–9
CT, 31, 55 see also Arndt endobronchial balloon blocker;
endobronchial ultrasound bronchoscopy, 143, 145 Cohen endobronchial balloon blocker
aortic arch balloon dilators, 218, 219
CT, 23, 31, 55 balloon preparation/calibration, intrabronchial valve,
238 endobronchial ultrasound bronchoscopy, 134, 135 224–5
basal segments, 64 cartilage nodules D
electromagnetic navigation, 179, 182 right lower lobe, autofluorescence density mask, emphysema, 220
left lower lobe, 47, 51, 72, 76 bronchoscopy, 165 descending aorta, CT, 58, 59
right lower lobe, 43, 44, 64, 66, 68 trachea, 159 diameter, bronchoscopes, 2, 3
basement membrane elastin, confocal microscopy, cartilage rings, 31 diathermy see electrocautery
168 cartilages see specific cartilages diffuse infiltrative carcinoma, 161
basolateral segments, right lower lobe, 43, 44 CCDs (charge-coupled devices), 1 diffuse lung disease, 4(Box)
bio-fouling, stents, 216, 217 cellular composition, bronchoalveolar lavage, 10 bronchoalveolar lavage, 9
biopsy forceps, 8 charge-coupled devices (CCDs), 1 direct vision, stent insertion, 211–15, 212–15
sterilization, 3–4 chronic obstructive pulmonary disease disinfection, 3–4
bipartite division, upper lobe, 37, 38, 56, 62 (COPD) disposable instruments, 4
bleeding see haemorrhage confocal microscopy, 170 distortion, trachea, 159
bleeding diathesis, 5 intrabronchial valve complications, 229 drug-eluting stents, airway bypass, 235
blood, autofluorescence bronchoscopy, 165 coagulation probe, electrocautery, 202, 203 drug-related hypersensitivity pneumonitis,
blood vessels Cohen endobronchial balloon blocker, 192–3, confocal microscopy, 170
confocal microscopy, 168 192–7 dysplasia, carina, autofluorescence bronchoscopy,
see also specific vessels difficulties, 196–7 166
brachiocephalic veins, 78 left main bronchus insertion, 194–5, 194–7
endobronchial ultrasound bronchoscopy, 141 colorectal carcinoma, metastases see metastatic E
brachytherapy, tumour debulking, 209–10 colorectal carcinoma elastin network, confocal microscopy, 168
bronchial biopsies, 8 computed tomography (CT) electrocautery, 202–5
bronchial brushings, 9 anterior TBNA, 94, 95, 96 coagulation probe, 202, 203
bronchial gland, confocal microscopy, 168 balloon dilators, 219 complications, 205(Box)
bronchial thermoplasty, asthma, 236–7 bronchopulmonary segments, 23–7 electrosurgical knife, 202
bronchial tree, CT correlation, 23 emphysema, 220 electrosurgical snare, 202, 204
bronchial washings, 8 patient preparation, 5 equipment, 202
bronchioalveolar cell carcinoma, confocal pre-electromagnetic navigation, 172, 173 hot biopsy forceps, 202, 205
microscopy, 169 pre-endobronchial ultrasound bronchoscopy, precautions, 205(Box)
bronchioles, confocal microscopy, 168 134 see also argon plasma coagulation
bronchoalveolar lavage, 9–10 pre-intrabronchial valve, 225 electromagnetic navigation, 172–88
bronchocentric granulomatosis, 163 pre-TBNA, 113, 114–15 advances, 187–8
bronchopulmonary segments, 11–27 stent insertion, 212, 213, 215 equipment, 172
nomenclature, 11–13 see also specific anatomical features navigation, 184–6, 184–8
bronchoscopes, 1–2 concentric segmental tumour, 161 planning stage, 172–9
diameter, 2, 3 confocal microscopy, 167–71 registration process, 180–3
instrument channels, 2 equipment, 167 electrosurgical knife, 202
linear array ultrasound probes, 2, 3 conscious sedation, PneumRx® coils, 232 electrosurgical snare, 202, 204
bronchoscopic lung volume reduction see lung consent, 5 emphysema, 220–37
volume reduction contraindications (for bronchoscopy), 5 confocal microscopy, 169, 170
bronchus COPD see chronic obstructive pulmonary CT, 220
left main see left main bronchus disease (COPD) density mask, 220
lingular see lingular bronchus corniculate cartilage, intubation problems, 191 heterogenous disease, 220–32
right main see right main bronchus corniculate tubercle, 30, 55 homogenous, 233–6
bronchus intermedius, 39, 60, 63–4 CT, 53 see also airway bypass
CT, 24, 39, 42, 61, 64 right see right corniculate tubercle endobronchial tumour debulking see tumour
cough technique debulking
C anterior TBNA, 98 endobronchial tumours
candidiasis, 158 transbronchial fine needle aspiration (TBNA), confocal microscopy, 169
carcinoma in situ, right lower lobe, posterior approach, 117 stents, 216, 217
autofluorescence bronchoscopy, 166 cricoid cartilage, CT, 53 endobronchial ultrasound bronchoscopy, 133–57
carina, 31, 33–4, 56, 57–8 cross-infection, 3 equipment, 133
CT, 33, 58, 59 cryoextraction, 207, 208 examination approach, 134–5
dysplasia, autofluorescence bronchoscopy, cryotherapy, 202, 206–8, 207 hilar zone lymph nodes, 149–53
166 CT see computed tomography (CT) left hilar lymph node (Station 11L), 153
electromagnetic navigation, 173 cuneiform cartilage, 28, 53 left main bronchial lymph node (Station
left main see left main carina cuneiform tubercle, 30, 55 10R), 150
main see main carina CT, 53 right inferior hilar lymph node (Station
nomenclature, 12 right see right cuneiform tubercle 11Ri), 152
renal cell carcinoma, 160 cytology right main bronchial lymph node (Station
thickening, autofluorescence bronchoscopy, anterior TBNA, 98 10R), 149
165 endobronchial ultrasound bronchoscopy, 156, right superior hilar lymph node (Station
tracheobronchial amyloid, 160 157 11Rs), 151
tumours, 160 TBNA, 98 inferior mediastinal lymph nodes, 148
239
 endobronchial ultrasound bronchoscopy – contd hilar zone lymph nodes right lower lobe, 45, 66, 68, 69, 70
intubation, 134 anterior TBNA, 106–12 CT, 69, 73
lymph node sampling, 154–7, 156 endobronchial ultrasound bronchoscopy see right middle lobe, CT, 65
cytology, 156, 157 endobronchial ultrasound bronchoscopy left apical basal segment (LB6), electromagnetic
equipment, 154–5 posterior TBNA, 125–32 navigation, 179, 183
technique, 154–6 horizontal fissure, right lung, 14 left aryepiglottic fold, 29, 54
lymph node stations, 136–53 hot biopsy forceps, 202, 205 left atrium, CT, 31, 40, 42, 49, 55, 58, 65, 74
see also specific lymph nodes Hurthle cell carcinoma, right middle lobe, 162 left brachiocephalic vein, 78
subcarinal lymph node (Station 7), 148 hyoid bone, CT, 53 left bronchopulmonary tree, 19, 20
superior mediastinal lymph nodes, 136–47 hypersensitivity pneumonitis nomenclature, 12
anterior prevascular lymph node (Station confocal microscopy, 170 left hilar lymph node (Station 11L)
3A), 139 drug-related, 170 endobronchial ultrasound bronchoscopy, 153
aortopulmonary lymph nodes (Station 5), hypoxia, 5 posterior TBNA, 131–2
146 left inferior pulmonary vein, CT, 31, 40, 55, 58, 65
higher left paratracheal lymph node I left lower lobe, 20, 22, 46, 47, 50–2, 72, 75–7, 76
(Station 2L), 138 indications (for bronchoscopy), 4, 4(Box) anterior segment, 48, 51, 52, 76
higher right paratracheal lymph node infection, 4(Box) CT, 73, 77
(Station 2R), 136–7 inferior mediastinal lymph nodes, 88 apical segment, 46, 47, 49, 51, 72, 73, 76
lower left paratracheal lymph node anterior TBNA, 105 apicoposterior segment, 48
(Station 4L), 144–5 endobronchial ultrasound bronchoscopy, 148 CT, 73
lower right paratracheal lymph node posterior TBNA, 124 autofluorescence bronchoscopy, 164
(Station 4R), 141–4 inferior pulmonary vein basal segments, 47, 51, 72, 76
para-aortic lymph nodes (Station 6), 147 CT, 42, 44, 46, 48, 49, 50, 52, 69, 71, 73, 74, CT, 26, 42, 48, 50, 51, 52, 76, 77
posterior tracheal lymph node (Station 76, 77 inflammatory web, autofluorescence
3P), 140 inferior segment, lingula, CT, 77 bronchoscopy, 165
see also specific anatomical features inflammatory pseudo-tumour, 163 lateral segment, 48, 51, 52, 76
endometrial carcinoma, left lower lobe, 162 inflammatory web, left lower lobe, CT, 73, 77
endotracheal tube, stent insertion, 219 autofluorescence bronchoscopy, 165 left lung, 20, 22
epiglottis, 28, 29, 30, 54, 55 informed consent, 5 leiomyosarcoma, 162
equipment, 1–2 instrument channels, bronchoscopes, 2 metastatic endometrial carcinoma, 162
electromagnetic navigation, 172 interlobar lymph nodes (Station 11), 92–3 polypoid tumour, autofluorescence
extrabronchial tumour, right upper lobe interstitial pneumonitis, confocal microscopy, 170 bronchoscopy, 166
compression, 161 intrabronchial valves posterior segment, 51, 52, 76
airway sizing, 224–5 CT, 77
F balloon preparation/calibration, 224–5 squamous cell carcinoma, 162
fiberoptic bronchoscope, 1 complications, 229 left lower lobe bronchus, 73
fluorescence-based imaging, 164–71 equipment, 224, 225 CT, 71, 76
see also specific methods lung volume reduction, 223–8 left lung, 18–20, 22
foreign bodies, granulation tissue, 163 patient preparation, 225 left lower lobe see left lower lobe
fungal colonization procedure, 225, 226–7 left upper lobe see left upper lobe
Zephyr valve complications, 223 removal, 228 left main bronchial lymph node (Station 10L)
see also specific fungal infections intubation, 189–91 anterior TBNA, 107, 108
equipment, 189 endobronchial ultrasound bronchoscopy, 150
problems, 191 posterior TBNA, 127–8
G techniques, 190–1 left main bronchial lymph node (Station 10R),
granulation tissue invasive squamous cell carcinoma, 161 endobronchial ultrasound bronchoscopy,
foreign bodies, 163 150
intrabronchial valve complications, 229 J left main bronchus, 34, 46–7, 56, 58, 71–2, 73–2
stents, 217, 218 jabbing technique Cohen endobronchial balloon blocker
anterior approach TBNA, 97–8 insertion, 194–5, 194–7
H posterior approach TBNA, 116–17 CT, 39, 46, 48, 59, 64, 71, 73, 76
haemoptysis, intrabronchial valve complications, metastatic colorectal carcinoma, 162
229 K renal cell carcinoma, 162
haemorrhage Kaposi’s sarcoma secondary carina, 72
intrabronchial valve complications, 229 secondary carina, 161 squamous cell carcinoma, 162
management, 200–1, 200(Box) vocal cords, 158 left main carina
transbronchial lung biopsy, 10 autofluorescence bronchoscopy, 164
higher left paratracheal lymph node (Station 2L), L electromagnetic navigation, 175
endobronchial ultrasound bronchoscopy, laryngeal mask airway (LMA), 191 left pulmonary artery, 79
138 laser treatment, tumour debulking, 209 CT, 31, 42, 46, 48, 50, 55, 58, 59, 71, 73, 76
higher right paratracheal lymph node (Station lateral segment left secondary carina (LC2), electromagnetic
2R), endobronchial ultrasound left lower lobe, 48, 51, 52, 76 navigation, 179, 182
bronchoscopy, 136–7 CT, 73, 77 left superior division bronchus, 73
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left superior pulmonary vein, CT, 39, 46, 64, 71 station 3, 83–4 intrabronchial valve, 225
left upper lobe, 18–19, 22, 47–8, 51, 72, 73–4, 76 upper paratracheal lymph nodes (Station PET (positron emission tomography), pre-
anterior segment, 48, 49, 73, 74, 75 2), 82 endobronchial ultrasound bronchoscopy,
CT, 58, 61, 64, 73 supraclavicular zone (Station 1), 81 134, 141, 144–5, 146, 148, 150, 151, 152,
apical segment, 48 see also specific lymph nodes 153
CT, 61 photodynamic therapy, tumour debulking, 209
apicoposterior segment, 48, 49, 73, 74, 75 M Photofrin, photodynamic therapy, 209
CT, 58, 61, 64 main bronchial lymph nodes (Station 10), 91 photosensitizers, photodynamic therapy, 209
CT, 39, 49, 73, 74 main bronchus piggyback method
left lung, 19, 22 left see left main bronchus anterior TBNA, 98
posterior segment, 74 right see right main bronchus transbronchial fine needle aspiration (TBNA),
left upper lobe bronchus, 72 main carina posterior approach, 117
CT, 64 electromagnetic navigation, 177 planning stage, electromagnetic navigation, 172–9
left vallecula, 29, 54 left see left main carina pneumonectomy, balloon dilators, 219
left ventricle, CT, 40, 65 manual cleaning, 3 pneumonia, confocal microscopy, 171
left ventricular outflow tract, CT, 39, 64 medial segment pneumonitis, 170
left vocal cord, 29 right lower lobe, 45, 66, 68, 70 pneumothorax
leiomyosarcoma, left lower lobe, 162 right lower lobe bronchus, CT, 73 transbronchial lung biopsy, 10
lidocaine, intubation, 190 metastatic colorectal carcinoma Zephyr valve complications, 223
linear array ultrasound probes, bronchoscopes, left main bronchus, 162 PneumRx® coils, 230–2
2, 3 right basal bronchus, 162 polypoid necrotic tumour, right upper lobe, 162
lingula, 48, 49, 73, 74–5 metastatic endometrial carcinoma, left lower polypoid tumours
CT, 49, 74 lobe, 162 left lower lobe, autofluorescence
inferior segment, CT, 77 microscopy, confocal see confocal microscopy bronchoscopy, 166
superior segment, CT, 76 microthrombi formation, cryotherapy, 206 polypoid non-small cell carcinoma, 161
lingular bronchus, 47, 72, 75 midazolam, 6 polyps, vocal cords, 158
CT, 74 migration, stents, 218 poorly differentiated carcinoma, trachea, 159
lower cervical lymph nodes, 81 mucosal hypertrophy, intrabronchial valve positron emission tomography (PET), pre-
lower left paratracheal lymph node (Station 4L) complications, 229 endobronchial ultrasound bronchoscopy,
anterior TBNA, 102–3 mucus 134, 141, 144–5, 146, 148, 150, 151, 152,
posterior TBNA, 121–2 segmental bronchus, 163 153
lower lobe, basal segments, 64 stents, 216, 217 posterior approach, 53–77
lower paratracheal lymph nodes (Station 4), 85 see also specific anatomical features
lower right paratracheal lymph node (Station 4R) N posterior basal segment, right lower lobe, 68
anterior TBNA, 99–101 neodymium–yttrium aluminium garnet laser, 209 posterior border, right lung, 14
posterior TBNA, 118–20 neoplasia, 4(Box) posterior lymph nodes (Station 3P), 84
lower zone lymph node stations, 89–90 nodules posterior membranous trachea, 56
lungs, left see left lung right lower lobe, 163 posterior pharyngeal wall, 29
lung volume reduction, 220–37 trachea, 163 posterior segment
intrabronchial valve, 223–8 nomenclature, bronchopulmonary segments, left lower lobe, 51, 52, 76
Zephyr valve, 221–3 11–13 CT, 77
lymph node stations, 81–93 non-small cell lung cancer, confocal microscopy, left upper lobe, 74
hilar/intralobar zone (hilar nodes), 91–2 169 right lower lobe, 45, 69, 70
inferior mediastinal lymph nodes, 88 CT, 69, 73
interlobar lymph nodes (station 11), 92–3 O right upper lobe, 15, 36, 37, 38, 61, 62, 63
lower zone, 89–90 oblique fissure CT, 58
main bronchial lymph nodes (station 10), 91 CT, 58 posterior segmental bronchus, right upper lobe,
para-oesophageal lymph nodes (Station 8), 89 left lung, 18 CT, 59
para-oesophageal lymph nodes (Station 9), 89 right lung, 14 posterior tracheal lymph node (Station 3P)
peripheral zone (station 12, 13 and 14), 93 occupational lung exposure, bronchoalveolar anterior TBNA, 103–4
pulmonary ligament lymph nodes (Station 9), lavage, 9 endobronchial ultrasound bronchoscopy, 140
90 oesophageal adenocarcinoma, right main posterior TBNA, 122–3
subcarinal lymph nodes (Station 7), 88 bronchus, 162 posterobasal segments, right lower lobe, 43, 44
superior mediastinal zone, 82–7 oesophagus, CT, 31, 55 potassium titanyl phosphate (KTP), photodynamic
aortic lymph nodes (Station 5), 86 organizing pneumonia, confocal microscopy, 171 therapy, 209
lower paratracheal lymph nodes (Station prevascular lymph nodes (Station 3A), 83
4), 85 P primary tracheobronchial amyloid, 158
para-aortic lymph nodes (Station 6), 87 para-aortic lymph nodes (Station 6), 87 Pseudomonas infection, Zephyr valve
posterior lymph nodes (Station 3P), 84 endobronchial ultrasound bronchoscopy, 147 complications, 223
prevascular lymph nodes (Station 3A), 83 para-oesophageal lymph nodes (Station 8), 89 pulmonary arteries, 79
retrosternal lymph nodes (Station 3A), 83 parenchymal infiltrates, bronchoalveolar lavage, 9 CT, 40, 42, 44, 46, 49, 50, 52, 58, 61, 65, 74, 76
retrotracheal lymph nodes (Station 3P), partial deployment, Zephyr valve, 222 endobronchial ultrasound bronchoscopy, 134,
84 patient preparation, 5, 5(Box) 146
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 pulmonary arteries – contd nodules, 163 right upper lobe bronchus
left see left pulmonary artery posterior basal segment, 68 anterior branch, CT, 61
right see right pulmonary artery posterior segment, 45, 69, 70 apical branch, CT, 61
pulmonary artery trunk, CT, 61 CT, 69, 73 CT, 59, 61, 64
pulmonary fibrosis, confocal microscopy, 170 posterobasal segments, 43, 44 right upper lobe carina (RC1), electromagnetic
pulmonary hilum right lung, 17, 21 navigation, 177, 181
left lung, 18 sleeve resection, autofluorescence right vallecula, 29, 54
right lung, 14 bronchoscopy, 166 room ergonomics, 6–7
pulmonary ligament lymph nodes (Station 9), 90 subapical segment, 69 ROSE (rapid on-site cytological evaluation),
pulmonary sarcoidosis, confocal microscopy, 170 right lower lobe bronchus, medial segment, CT, anterior TBNA, 98
pulmonary trunk, CT, 39, 64 73 rotation, bronchoscopes, 2
pulmonary veins, 79, 80 right lung
nomenclature, 14–17 S
R right lower lobe see right lower lobe sabre trachea, 159
radiology-guided stent insertion, 216 right middle lobe see right middle lobe sampling, 8–10
rapid on-site cytological evaluation (ROSE), right upper lobe see right upper lobe sarcoidosis, pulmonary, 170
anterior TBNA, 98 segments, 21–2 SCC see squamous cell carcinoma (SCC)
RCC see renal cell carcinoma (RCC) right main bronchial lymph node (Station 10R) secondary carina, 76
registration process, electromagnetic navigation, anterior TBNA, 106–7 Kaposi’s sarcoma, 161
180–3 endobronchial ultrasound bronchoscopy, 149 left main bronchus, 72
renal cell carcinoma (RCC) posterior TBNA, 125–6 sedation, 6
carina, 160 right main bronchus, 34–5, 56, 58, 59–60, 71 segmental bronchus, mucus, 163
left main bronchus, 162 CT, 35, 59, 61, 64 segmental tumour, 161
retrosternal lymph nodes (Station 3A), 83 oesophageal adenocarcinoma, 162 sleeve resection, right lower lobe,
retrotracheal lymph nodes (Station 3P), 84 right middle lobe, 16, 21, 40–1, 64, 65–6 autofluorescence bronchoscopy, 166
right apical basal segment (RB6), electromagnetic autofluorescence bronchoscopy, 164 small cell carcinoma, 161
navigation, 178, 182 CT, 25, 40, 65 right upper lobe, 162
right aryepiglottic fold, 29, 54 electromagnetic navigation, 174 squamous cell carcinoma (SCC)
right atrium, CT, 40, 42, 65 Hurthle cell carcinoma, 162 confocal microscopy, 169
right basal bronchus, metastatic colorectal lateral segment, CT, 65 invasive, 161
carcinoma, 162 right middle lobe bronchus, 64 left lower lobe, 162
right bronchopulmonary tree, nomenclature, 11 right middle lobe carina, electromagnetic left main bronchus, 162
right corniculate tubercle, 29, 54 navigation, 178, 181 vocal cords, 158
right cuneiform tubercle, 29, 54 right pulmonary artery, 79 Station 2L (higher left paratracheal lymph node),
right hilar lymph nodes, endobronchial ultrasound CT, 31, 39, 46, 55, 58, 64, 71 endobronchial ultrasound bronchoscopy,
bronchoscopy, 135 right superior hilar lymph node (Station 11Rs), 138
right inferior hilar lymph node (Station 11Ri) endobronchial ultrasound bronchoscopy, Station 2R (higher right paratracheal lymph
anterior TBNA, 110–11 151 node), endobronchial ultrasound
endobronchial ultrasound bronchoscopy, 152 right superior hilar nodes, endobronchial bronchoscopy, 136–7
posterior TBNA, 130–1 ultrasound bronchoscopy, 135 Station 3A (prevascular lymph nodes), 83
right inferior pulmonary vein, CT, 40, 65 right superior pulmonary vein, CT, 39, 40, 64, 65 Station 3A (retrosternal lymph nodes), 83
right lower lobe, 17, 21, 41, 42–5, 44, 45, 66, right upper hilar lymph node (Station 11Rs) Station 3P see posterior tracheal lymph node
67–70, 68–70 anterior TBNA, 109–10 (Station 3P)
accessory segment, 70 posterior TBNA, 128–9 Station 3P (retrotracheal lymph nodes), 84
accessory subapical segment, 45, 68, 70 right upper lobe, 15, 21, 36–8, 37, 38, 56, 60–3, Station 4 (lower paratracheal lymph nodes), 85
anterior basal segment, 68, 69 61–3 Station 4L see lower left paratracheal lymph
anterior segment, 45, 68, 70 anterior segment, 61, 62, 63 node (Station 4L)
CT, 69 anterior segmental bronchus, CT, 59 Station 4R see lower right paratracheal lymph
anterobasal segments, 43, 44 apical segment, 61, 62, 63, 64 node (Station 4R)
apical segment, 64, 66, 68 CT, 58 Station 6 see para-aortic lymph nodes (Station 6)
apicobasal segments, 43, 68 apical segmental bronchus, CT, 59 Station 7 see subcarinal lymph nodes (Station 7)
basal segments, 43, 64, 66, 68 apicoposterior segment, 62 Station 8 (para-oesophageal lymph nodes), 89
basolateral segments, 43, 44 bipartite division, 37, 62 Station 9 (pulmonary ligament lymph nodes), 90
carcinoma in situ, autofluorescence CT, 24, 36, 39, 40, 58, 61, 65 Station 10 (main bronchial lymph nodes), 91
bronchoscopy, 166 electromagnetic navigation, 174 Station 10L see left main bronchial lymph node
cartilage nodule, autofluorescence extrabronchial tumour, 161 (Station 10L)
bronchoscopy, 165 polypoid necrotic tumour, 162 Station 10R see right main bronchial lymph node
CT, 26, 40, 42, 43, 44, 65, 67, 69 posterior segment, 61, 62, 63 (Station 10R)
lateral basal segment, 68, 69 CT, 58 Station 11 (interlobar lymph nodes), 92–3
lateral segment, 45, 66, 69, 70 posterior segmental bronchus, CT, 59 Station 11L see left hilar lymph node (Station
CT, 69, 73 small cell carcinoma, 162 11L)
medial basal segment, 68 tuberculosis, 163 Station 11Ri see right inferior hilar lymph node
medial segment, 45, 66, 68, 70 tumour, autofluorescence bronchoscopy, 166 (Station 11Ri)
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stents, 211–19 cartilage nodules, 159 tuberculosis, 163
complication, 216–18 CT, 31, 55, 57, 59 anthracosis, 163
insertion techniques, 211–16 distortion, 159 right upper lobe, 163
direct vision, 211–15, 212–15 nodules, 163 tumour(s)
radiology-guided, 216 poorly differentiated carcinoma, 159 right upper lobe
migration, 218 tracheal bronchus, 29, 32, 56 autofluorescence bronchoscopy, 166
sternal notch lymph nodes, 81 CT, 32, 56 see also specific tumours
subapical segment, right lower lobe, 69 tracheal web, 159 tumour debulking, 202–10
subcarinal lymph nodes (Station 7), 88 tracheobronchial amyloid, 159 brachytherapy, 209–10
anterior TBNA, 105–6 carina, 160 laser treatment, 209
endobronchial ultrasound bronchoscopy, 135, tracheobronchopathia osteochondroplastica, 159 photodynamic therapy, 209
148 tracheo-oesophageal fistula, 159 see also argon plasma coagulation;
posterior TBNA, 124–5 transbronchial fine needle aspiration (TBNA) electrocautery
tumour, 160 anterior approach see below
SuperDimension® system see electromagnetic cytology, 116–17 U
navigation equipment, 94, 113 ulcers, bronchocentric granulomatosis, 163
superior mediastinal lymph nodes lymph node stations see specific lymph nodes uncuffed endotracheal tube, 189
anterior TBNA, 99–104 posterior approach see below upper left lobe, 72
endobronchial ultrasound bronchoscopy see transbronchial fine needle aspiration (TBNA), upper paratracheal lymph nodes (Station 2), 82
endobronchial ultrasound bronchoscopy anterior approach, 94–112
posterior TBNA, 118–23 cough technique, 98 V
superior pericardial recess, CT, 58 CT, 94, 95, 96 vascular relationships, 78–81
superior pulmonary vein cytology, 98 bronchoscopic views, 80
CT, 40, 42, 49, 65, 74 jabbing technique, 97–8 see also specific arteries; specific veins
superior segment, lingula, CT, 76 lymph node stations, 99–112 vasoconstriction, cryotherapy, 206
superior vena cava, 78 see also specific lymph nodes ventilation–perfusion scan, pre-intrabronchial
CT, 31, 55, 58, 59, 61 piggyback method, 98 valve, 225
endobronchial ultrasound bronchoscopy, 134, planning, 94 video bronchoscope, 1, 2
142 site selection, 94 virtual bronchoscopy
supraclavicular lymph nodes (Station 1), 81 technique, 97–8 anterior TBNA, 96
symptom investigation, 4(Box) virtual bronchoscopy, 96 pre-TBNA, 115
transbronchial fine needle aspiration (TBNA), see also electromagnetic navigation
T posterior approach, 113–32 vocal cords, 28–9, 30, 53–5, 54–5
TBNA see transbronchial fine needle aspiration cough technique, 117 amyloid infiltration, 158
(TBNA) jabbing technique, 116–17 CT, 28, 29, 53–4
techniques, 8–10 lymph node stations, 118–32 Kaposi’s sarcoma, 158
therapeutic indications, 4(Box) see also specific lymph nodes left, 29
tissue hypertrophy, intrabronchial valve piggyback method, 117 paralysis, 158
complications, 229 planning, 113 polyps, 158
trachea, 29–32, 31–2, 55–7, 56–7 site selection, 113 squamous cell carcinoma (SCC), 158
adenocarcinoma, 159 technique, 116–17
adenocystic carcinoma, 159 virtual bronchoscopy, 115 Z
autofluorescence bronchoscopy, 164 transbronchial lung biopsy, 10 Zephyr valve, lung volume reduction, 221–3

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