Flexible Bronchoscopy Step-by-Step© Exercises to master inspection bronchoscopy 5/6/17 BI, All Rights Reserved, 2017

Advantages of step-by-step training Short exercises are used to master inspection bronchoscopy similar to the way we learn to dance or play a musical instrument. “Muscle memory” is acquired quickly. Airway anatomy is rapidly learned through repeated perfect practice. 5/6/17 BI, All Rights Reserved, 2017

Instructions Perfect posture and position Economy of Movement Always know exactly where you are Practice positive reinforcement 5/6/17 BI, All Rights Reserved, 2017

Bronchoscopy Step-by-Step Step 1 Nose / Mouth to Larynx Step 2 Larynx to subglottis Step 3 Follow the Curve to the Carina Step 4 Carina to Left Carina to right Left-right neutral Step 5 Down Up Left Down Up Right Step 6 LMB to LUL LMB to LLL RMB to RUL RMB to BI RMB to RLL Step 7 LUL LB456 LLL RUL RB456 RB7 uno-dos B6-8910 uno- dos- tres d’ Artagnan Step 8 LLL pan-pan–pan RLL & 3 musketeers 5/6/17 BI, All Rights Reserved, 2017

Group 1 Group 2 Group 3 Grouped exercises Nose/mouth to larynx Larynx-subglottis Follow curve to carina Carina to left Carina to right Left right neutral Down-up right Down-up left Group 2 LMB to LLL LMB to LUL RMB to BI RMB to RLL RMB to RUL Subglottis to RLL Subglottis to LLL Group 3 LLL pan pan pan LLL B6-8910 LUL uno dos LUL456 RB 456 RLL medio-basal (D’Artagnan) RLL D’Artagnan & 3 musketeers RUL uno dos tres 5/6/17 BI, All Rights Reserved, 2017

Flexion-Extension Extension Flexion 5/6/17 BI, All Rights Reserved, 2017

Down-Neutral-Up positions Lever straight (Neutral) Lever down 5/6/17 BI, All Rights Reserved, 2017 Lever up

Group 1 Exercises Perfect posture and position 5/6/17 BI, All Rights Reserved, 2017

Step 1: nose to larynx Advance scope from nose to larynx . This step includes local anesthesia. Click HERE to view video From the head 5/6/17 BI, All Rights Reserved, 2017

Step 2: larynx to subglottis From larynx the trachea is entered to the sub glottis. From the head: After passing vocal cords, the scope is slightly flexed downwards. From the front: After vocal cords are passed, the scope is slightly flexed upwards. Click HERE to view video From the front 5/6/17 BI, All Rights Reserved, 2017

Step 3: Follow the curve to the carina The Trachea is not straight. It deviates posteriorly and slightly to the right near the carina. Click HERE to view video From the head 5/6/17 BI, All Rights Reserved, 2017

Step 4a: Carina to left main bronchus From the neutral position, the LMB is entered by twisting the wrist to the left and advancing 1 -2 cm. From head Click HERE to view video 5/6/17 BI, All Rights Reserved, 2017

Step 4b: Carina to right main bronchus From neutral position the RMB is entered by twisting the wrist to the right and advancing the scope 1 -2 cm. From head Click HERE to view video 5/6/17 BI, All Rights Reserved, 2017

Step 4c: Left-right-neutral From the neutral position, the left and right main bronchi are entered alternatively by twisting the wrist and advancing the scope a few centimeters. From head Click HERE to view video 5/6/17 BI, All Rights Reserved, 2005

Step 5a: Down-up-left main bronchus The scope is slowly advanced then pulled back up the LMB while keeping it in the middle of the airway lumen. From the front Click HERE to view video 5/6/17 BI, All Rights Reserved, 2017

Step 5b: Down-up right main bronchus The scope is slowly advanced to the RMB and RLL then pulled back while keeping it in the middle of the airway lumen. Click HERE to view video From the front 5/6/17 BI, All Rights Reserved, 2017

Group 2 Exercises Always know exactly where you are 5/6/17 BI, All Rights Reserved, 2017

Step 6a: Left main to left upper lobe bronchus From the LMB, the scope is advanced to the entrance of the LUL bronchus. Click HERE to view video From the front 5/6/17 BI, All Rights Reserved, 2017

Step 6b: Left main to left lower lobe bronchus The scope is advanced down the LMB to the entrance of the LLL bronchus. Click HERE to view video From the front 5/6/17 BI, All Rights Reserved, 2017

Step 6c: Right main to right upper lobe bronchus The scope is advanced down the RMB. The wrist is twisted slightly. The scope is flexed up to the entrance of RUL. Click HERE to view video From the front 5/6/17 BI, All Rights Reserved, 2017

Step 6d: Right main to bronchus intermedius From the carina advance the scope down the RMB to the distal Bronchus Intermedius. Identify the entrance to RB456 and the basal pyramid (RB8910). Click HERE to view video From the front 5/6/17 BI, All Rights Reserved, 2017

Step 6e: Right main to right lower lobe bronchus Advance the scope from the carina to the entrance of the RLL while keeping it in the midline. Click HERE to view video From the front 5/6/17 BI, All Rights Reserved, 2017

Group 3 Exercises Economy of Movement 5/6/17 BI, All Rights Reserved, 2017

Step 7a: Left upper lobe uno dos From the carina, the scope is advanced to LUL entrance; Using your thumb, the lingula and upper division bronchus are visualized. Click HERE to view video From the head 5/6/17 BI, All Rights Reserved, 2017

Step 7b: Left before five six (LB 456) From the LMB, the lingula is entered. The scope is pulled back into the distal LMB, then advanced into the superior segment of the LLL. Click HERE to view video From the head 5/6/17 BI, All Rights Reserved, 2017

Step 7c: Left B6-8,9,10 With the scope at the LLL bronchus entrance, the superior segment is entered. Alternately, the anterior, lateral and posterior-basal segments of the LLL are entered. Click HERE to view video From the head 5/6/17 BI, All Rights Reserved, 2017

Step 7d: Right upper lobe uno-dos-tres From the RMB the scope is advanced and flexed into the RUL bronchus. Using wrist and thumb movements, all three segments of RUL are visualized. The scope is withdrawn to the carina. From the head Click HERE to view video 5/6/17 BI, All Rights Reserved, 2017

Step 7e: Right before five six (RB 4,5,6) From the distal Bronchus Intermedius, the RML and superior segment RLL are entered sequentially. This exercise masters micro movements. Click HERE to view video From the head 5/6/17 BI, All Rights Reserved, 2017

Step 7f: Right medial basal (RB7) (d”Artagnan) From the distal bronchus Intermedius, the scope is advanced and the medial- basal segment of the RLL is entered. Click HERE to view video From the front 5/6/17 BI, All Rights Reserved, 2017

Step 8a: Left lower lobe basal pyramid From the entrance of the LLL bronchus, enter each of the 3 basal segments sequentlially, then withdraw the scope to the carina. Pan - Pan - Pan Click HERE to view video From the head 5/6/17 BI, All Rights Reserved, 2017

Step 8b: Right lower lobe basal pyramid (D’Artagnan and the three musketeers) From the carina, advance scope to the RLL bronchus entrance. Enter the medial-basal segment (RB7), examine the three segments of the basal pyramid (RB 8910). Click HERE to view video From the front STAY IN THE MIDLINE 5/6/17 BI, All Rights Reserved, 2017

Perfect practice makes perfect