In 1897, Gustav Killian published his success in removing a pork bone from the right mainstem bronchus using a rigid esophagoscope and an external light source. Killian went on to lecture throughout the world, ushering in the era of modern bronchoscopy. Chevalier Jackson perfected the technique of rigid bronchoscopy as we now know it. Much of today’s expertise in endoscopy is based on his original methods or modiﬁcations of them.
Although the use of the ﬂexible bronchoscope largely replaced the rigid bronchoscope for diagnostic purposes, rigid bronchoscopy remains an indispensable therapeutic tool. The rigid bronchoscope lacks the maneuverability of the ﬂexible bronchoscope, but it is able to provide an airway for oxygenation and ventilation and allows the passage of large-bore suction catheters as well as multiple other tools such as large forceps and lasers. Silicone airway stents can only be placed via a rigid bronchoscope, and the bronchoscope itself can be used to “core out” tumors invading the airway. Because the ﬂexible bronchoscope can be easily passed through the rigid barrel, the two methods of airway visualization should be regarded as complementary.
The bronchoscope is basically an open steel tube. Some rigid bronchoscopes have a proximal or distal lighting source, but others use an optical telescope. The external diameter of the adult rigid bronchoscope ranges from 9 to 14 mm and is usually 40 cm long. There is a distal beveled end to allow for lifting of the epiglottis and safer insertion through the vocal cords. The diameter of the bronchoscope used depends on the patient’s size and degree of airway obstruction. Fenestrations are present at the distal third of the bronchoscope to allow for contralateral lung ventilation when the bronchoscope is inserted into a mainstem bronchus. A variety of instruments such as suction catheters and biopsy forceps should be available for use.
Rigid bronchoscopy is generally performed in the operating suite under general anesthesia, which can be delivered via inhalational or total intravenous techniques.
Correct positioning of the head is important to bring the mouth, larynx, and trachea in line with each other. The head is typically extended and sometimes dropped posteriorly to facilitate this alignment. As such, patients with cervical spine instability or ankylosing spondylitis may not be able to be intubated with the rigid bronchoscope. Dentures should be removed, and the upper teeth should be protected, with particular attention to avoid leverage against them.
The bronchoscope is introduced gently with one hand while the other hand keeps the mouth open and maintains head position. The bronchoscope is passed over the base of the tongue, and its tip used to lift the epiglottis anteriorly. The arytenoepiglottic folds, arytenoids, and vocal cords are then visualized. At this point, the bronchoscope is rotated 90 degrees clockwise. The left vocal cord becomes centered in the visual ﬁeld, and the tip of the bronchoscope is brought between the two cords. With gentle progression and continued clock-wise rotation, the bronchoscope will pass into the trachea. At no time should its passage be forced; if there is difﬁculty, a smaller sized bronchoscope may be needed. Ventilation is then initiated, and inspection of the tracheobronchial tree is continued under direct vision.
To examine the left-sided airways, the head is turned toward the right, and to examine the right-sided airways, the head is turned left. The use of oblique or lateral viewing telescopes is helpful for full visualization of the upper lobes, although this technique has largely been replaced by passing the ﬂexible bronchoscope through the rigid bronchoscope.
Withdrawal of the bronchoscope requires similar care to that used during insertion. If the patient remains anesthetized, an endotracheal tube or laryngeal mask airway ca be placed until the effects of anesthesia are reversed.