1. Flexible Bronchoscopy Step-by-Step© Exercises to master inspection bronchoscopy
5/6/17
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2. 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.
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3. Instructions Perfect posture and position Economy of Movement
Always know exactly where you are
Practice positive reinforcement
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4. Bronchoscopy Step-by-Step
Step Nose / Mouth to Larynx
Step Larynx to subglottis
Step Follow the Curve to the Carina
Step Carina to Left Carina to right Left-right neutral
Step Down Up Left Down Up Right
Step 6 LMB to LUL LMB to LLL RMB to RUL RMB to BI RMB to RLL
Step LUL LB LLL RUL RB RB7
uno-dos B uno- dos- tres d’ Artagnan
Step LLL pan-pan–pan RLL
& 3 musketeers
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5. 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
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6. Flexion-Extension Extension Flexion 5/6/17
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7. Down-Neutral-Up positions
Lever straight (Neutral)
Lever down
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Lever up

8. Group 1 Exercises Perfect posture and position 5/6/17
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9. Step 1: nose to larynx Advance scope from nose to larynx .
This step includes local anesthesia.
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From the head
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10. 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.
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From the front
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11. Step 3: Follow the curve to the carina
The Trachea is not straight.
It deviates posteriorly and slightly to the right near the carina.
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From the head
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12. 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
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13. 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
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14. 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
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15. 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
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16. 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.
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From the front
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17. Group 2 Exercises Always know exactly where you are 5/6/17
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18. Step 6a: Left main to left upper lobe bronchus
From the LMB, the scope is advanced to the entrance of the LUL bronchus.
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From the front
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19. Step 6b: Left main to left lower lobe bronchus
The scope is advanced down the LMB to the entrance of the LLL bronchus.
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From the front
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20. 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.
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From the front
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21. 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).
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From the front
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22. 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.
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From the front
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23. Group 3 Exercises Economy of Movement 5/6/17
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24. 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.
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From the head
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25. 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.
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From the head
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26. 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.
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From the head
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27. 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
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28. 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.
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From the head
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29. 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.
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From the front
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30. 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
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From the head
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31. 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).
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From the front
STAY IN THE MIDLINE
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32. Perfect practice makes perfect