1	Flexible Bronchoscopy Step by Step^© Video exercises to learn bronchoscopy skills Prepared By Bronchoscopy International Contact us at BI@bronchoscopy.org
2	Main Objectives To learn bronchoscopic techniques using an approach similar to learning to dance, play tennis or play a musical instrument. To develop “muscle memory” To develop a “systematic approach” to bronchoscopic inspection. To learn how to handle the flexible bronchoscope and to accurately identify and enter lobar and segmental bronchial segments with ease.
3	Art of Bronchoscopy
4	Bronchoscopy Exercises
5	8 steps
6	Bronchoscopy exercises
7	Background A: Flexion-Extension
8	Background B: Down-Neutral-Up positions
9	Group 1 Exercises
10	Step 1: nose to larynx The scope is advanced from the nose to the larynx . This step includes local anesthesia.
11	Step 2: larynx to subglottis From the larynx the trachea is entered to the subglottic area. If from the head: once the vocal cords are passed the scope is slightly flexed downwards. If from the front: once the vocal cords are passed the scope is slightly flexed upwards.
12	Step 3: Follow the curve to the carina The Trachea is not a “straight pipe”; It deviates posteriorly and slightly to the right when approaching the main carina.
13	Step 4a: Carina to left main bronchus From the neutral position the LMB is entered just by twisting the wrist to the left and advancing for 1 -2 cm.
14	Step 4b: Carina to right main bronchus From the neutral position the RMB is entered just by twisting the wrist to the right and advancing the scope for 1 -2 cm.
15	Step 4c: Left-right-neutral From the neutral position the left and right main bronchi are entered alternatively just by twisting the wrist and advancing the scope for few cm.
16	Step 5a: Down-up-left main bronchus The scope is slowly advanced the pulled back up the LMB while always keeping it in the middle of the airway lumen.
17	Step 5b: Down-up right main bronchus The scope is slowly advanced down the RMB to RLL and pulled back upwards while always keeping it in the middle of the airway lumen.
18	Group 2 Exercises
19	Step 6a: Left main to left upper lobe bronchus From the LMB the scope is advanced to the entrance of the LUL bronchus.
20	Step 6b: Left main to left lower lobe bronchus The scope is advanced down the LMB to the entrance of the LLL bronchus.
21	Step 6c: Right main to right upper lobe bronchus The scope is advanced down the RMB then with the wrist twisted 60 degrees from midline the scope is flexed up to the entrance of RUL.
22	Step 6d: Right main to bronchus intermedius From the carina advance the scope down the RMB to the distal bronchus intermedius and visualize the entrance to RB456 and the basal pyramid.
23	Step 6e: Right main to right lower lobe bronchus Advance the scope from the carina to the entrance of the RLL while always keeping it in the midline.
24	Group 3 Exercises
25	Step 7a: Left upper lobe uno dos From the carina, the scope is advanced to LUL entrance; there, just by thumb movement, the lingula and upper division bronchus are visualized.
26	Step 7b: Left before five six (LB 456) From the LMB, the lingula is entered, then the scope is pulled back into the distal LMB and the scope is advanced into the superior segment of the LLL. ! Wrist movements are “in the mirror”
27	Step 7c: Left B6-8,9,10 With the scope at the LLL bronchus entrance, the superior segment is entered, then alternately, the antero, lateral and postero-basal segments of the LLL are entered.
28	Step 7d: Right upper lobe uno-dos-tres From the RMB the scope is advanced and flexed up into the RUL bronchus where just by wrist and thumb movements the three segments are visualized; then the scope is withdrawn to the main carina.
29	Step 7e: Right before five six (RB 4,5,6) From the distal bronchus intermedius, the RML and superior segment are entered alternatively; ! Wrist movements are “in the mirror”.
30	Step 7f: Right medial basal (RB7) (d”Artagnan) From the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered.
31	Step 8a: Left lower lobe basal pyramid From the entrance of the LLL bronchus go in and out of the 3 basal segments, then withdraw the scope to the carina.
32	Step 8b: Right lower lobe basal pyramid (D’Artagnan and the three musketeers) From the carina advance the scope to the RLL bronchus entrance and then enter the medial-basal segment, pull back and then examine the other three segments of the basal pyramid.
33	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.
34	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.
35	Thank you