1	Flexible Bronchoscopy Basic Techniques Part 1A: Introduction Prepared By Bronchoscopy International Contact us at BI@bronchoscopy.org
2	Bronchoscopy Haiku
3	Normal Inspection
4	Fiberoptic Equipment
5	Instrumentation
6	Nasal Approach Check with patient for most patent nostril Deviated Septum? History of Broken Nose? Lubricate nostril liberally with 2% Lidocaine Jelly
7	Oral Approach A bite-block is necessary to protect the bronchoscope whenever the oral approach is chosen. It is best that the bite-block surround an endotracheal tube during bronchoscopy.
8	Expensive repairs are necessary!!!!!!
9	In case of problems
10	These small black dots signify that
11	Technique: control section
12	Manipulating the control section
13	Flexion-extension
14	Right hand lever positions
15	Manipulating the insertion tube
16	Technique: insertion tube
17	Avoid bending the insertion tube
18	Correct hand positions
19	Curious hand positions
20	Weight and balance Posture Position Poise
21	Each of the following is considered poor technique when handling a flexible bronchoscope except Twisting the insertion tube rather than rotating the entire instrument along its longitudinal axis. Advancing the bronchoscope by pushing down from the handle. Exerting excessive pressure with one’s fingers on the patient’s nostril or cheek. Attempting to pass an instrument through a fully flexed distal extremity of the bronchoscope Keeping the bronchoscope in the midline of the airway lumen throughout the procedure.
22	Procedure Begins Oxygen administered at 15 l/m via mask with hole cut to accommodate bronchoscope. Towel placed on patient’s chest for protection. Bronchoscope lubricated with 2% Lidocaine Jelly. Physician advances bronchoscope through nose and pharynx until epiglottis and vocal cords are visualized. 1% Lidocaine is sprayed on the epiglottis and cords with a 5 cc slip-tip syringe (2 cc with a 2 cc air back).
23	Anatomic Exam The bronchoscope is advanced through the vocal cords and into the trachea. 1% Lidocaine again is administered through the bronchoscope biopsy channel. The trachea, main bronchi, lower, middle and upper lobes of the lungs are visualized and examined by bronchoscopist as he/she carefully advances and skillfully guides the flexible bronchoscope while observing the video images.
24	Washings and Bronchial Alveolar Lavage Bronchial Washings and lavage are obtained by injecting normal saline through the working channel of the bronchoscope in 30 -50 cc increments up to 150cc of solution. Suction traps are connected by the technician at the bronchoscopist’s direction, “Traps on.” After each washing, suction is applied by the bronchoscopist and collected in the suction traps. When the process is completed the bronchoscopist instructs the technician to disconnect the suction with the direction, “Traps off.” For BAL, the scope is wedged into a targeted segmental bronchus administering saline. Aspirate may have a sudsy appearance signifying presence of surfactant.
25	Bronchial Brushings The sheathed brush is advanced by the technician or bronchoscopist through the working channel until visualized. The brush is advanced and unsheathed by the technician at the bronchoscopist’s instruction, “Brush out.” The sample is obtained by the bronchoscopist moving the brush in and out along the targeted area vigorously but also gently to prevent bleeding. “Brush in,” resheaths the brush before it is removed. Brush samples are applied by the technician to glass slides. Microbiology slides are air dried. Cytology slides are immediately fixed by immersing in alcohol.
26	Endobronchial and Transbronchial Biopsies The biopsy forceps is advanced by the technician or bronchoscopist through the working channel until visualized seen on a fluoroscopy monitor. Biopsies are obtained at the bronchoscopist’s instruction, “ Open” and then “Close.” Biopsy samples are placed in formalin by the technician. The forceps are then rinsed in saline.
27	Transbronchial Needle Biopsies (TBNA) To obtain transcarinal or transbronchial needle biopsies the sheathed needle is advanced by the technician or bronchoscopist through the working channel until visualized. The needle is unsheathed by the technician at the bronchoscopist’s instruction, “Needle out.” The sample is obtained by the bronchoscopist by inserting the needle into the targeted area and then applying suction at the instruction, “Suction.” “Needle in,” resheaths the needle before it is removed. Samples are applied by the technician to glass slides and immediately fixed by immersing in alcohol. Onsite Cytology can make an immediate diagnosis.
28	This presentation is part of a comprehensive curriculum for Flexible Bronchoscopy. Our goals are to help health care workers become better at what they do, and to decrease the burden of procedure-related training on patients.
29	A new curriculum Web-based Self-learning study guide. Computer-based simulations, didactic lectures, and image encyclopedia. Bronchoscopy step-by-step^©: Practical exercises, skills and tasks, competency testing. Guided apprenticeship. Learning the art of Bronchoscopy.
30	All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as: Bronchoscopy International: Art of Bronchoscopy, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. Published 2005 (Please add “Date Accessed”).