1. Rigid Bronchoscopy: Indications and Techniques
Daniel G. Nicastri, MD, Todd S. Weiser, MD 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 17, Issue 1, Pages (March 2012)
DOI: /j.optechstcvs
Copyright © 2012 Elsevier Inc. Terms and Conditions

2. Figure 1
The 9-millimeter rigid bronchoscope (Bryan Corporation). (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

3. Figure 2
Various lengths of the tubes for lesions in the trachea and lesions in the bronchi. There are also various diameter pictures here. The longer bronchial tubes (for more distal lesions) have distal side holes (Bryan Corporation). (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

4. Figure 3
This close-up demonstrates the side holes along the distal aspect of the bronchoscope that allows cross-ventilation to the contralateral lung when working on an obstructing lesion in 1 main bronchus. (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

5. Figure 4
This is a close-up of the proximal attachments of the rigid scope. To the right is the wider port for connecting to ventilation. This attachment can be modified to allow for Jet ventilation, intermittent ventilation, or continuous insufflations. To the left is a smaller attachment that allows passage of instrumentation, including a flexible bronchoscope. (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

6. Figure 5
The viewing telescope with its light source is inserted into rigid bronchoscope. (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

7. Figure 6
On top is a grasping forceps, which would be inserted into the main channel. This can be used for grasping foreign bodies or taking biopsies. On the bottom is an optical biopsy forceps (Bryan Corporation). The advantage of this particular instrument is the ability to watch on a monitor when biopsying a lesion or extracting a foreign body. (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

8. Figure 7
Intubation of the trachea with the rigid bronchoscope. Before the procedure begins, it is imperative that the surgeon be familiar with the necessary equipment and that the operating room trays be properly organized. The patient should be positioned in the supine position with the head in the “sniffing/intubation” position with the patient's head at the edge of the bed. The “sniffing” position optimally aligns the pharynx, larynx, and trachea (A and B). A right-handed surgeon protects the teeth with the left thumb in the mouth and inserts the scope into the right side of the mouth (when inserting the ventilator sidepiece is oriented upward), advancing to the base of the tongue at the posterior median groove. This is achieved by directing the scope directly down. The proximal end is then slowly brought downward into a more horizontal fashion while carefully protecting the patient's teeth. Elevating the tongue and advancing slowly will bring the epiglottis into view (C and D). If the epiglottis is not visualized, the scope should be brought back and advanced slowly again. Proper observation of the epiglottis is the crucial step in proceeding to intubate the cords. The scope is then advanced posteriorly and is used to lift the epiglottis gently, exposing the glottis (E-H). As the cords are approached, the bronchoscope should be rotated 90 degrees so that it traverses the cords with the minimum diameter (J, K, and L). In the picture shown, the scope is rotated 90 degrees clockwise so the left cord is visualized and the distal tip of the scope traverses the glottis and enters the trachea first (I and L). Once the airway is entered, the scope is rotated back to the original orientation. In general, when choosing the size of the scope, the largest scope that is anticipated to traverse the stenosis (if one is present) should be used, without damaging the cords
(Adapted with permission from Pierre AF.5) (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

9. Figure 7
Intubation of the trachea with the rigid bronchoscope. Before the procedure begins, it is imperative that the surgeon be familiar with the necessary equipment and that the operating room trays be properly organized. The patient should be positioned in the supine position with the head in the “sniffing/intubation” position with the patient's head at the edge of the bed. The “sniffing” position optimally aligns the pharynx, larynx, and trachea (A and B). A right-handed surgeon protects the teeth with the left thumb in the mouth and inserts the scope into the right side of the mouth (when inserting the ventilator sidepiece is oriented upward), advancing to the base of the tongue at the posterior median groove. This is achieved by directing the scope directly down. The proximal end is then slowly brought downward into a more horizontal fashion while carefully protecting the patient's teeth. Elevating the tongue and advancing slowly will bring the epiglottis into view (C and D). If the epiglottis is not visualized, the scope should be brought back and advanced slowly again. Proper observation of the epiglottis is the crucial step in proceeding to intubate the cords. The scope is then advanced posteriorly and is used to lift the epiglottis gently, exposing the glottis (E-H). As the cords are approached, the bronchoscope should be rotated 90 degrees so that it traverses the cords with the minimum diameter (J, K, and L). In the picture shown, the scope is rotated 90 degrees clockwise so the left cord is visualized and the distal tip of the scope traverses the glottis and enters the trachea first (I and L). Once the airway is entered, the scope is rotated back to the original orientation. In general, when choosing the size of the scope, the largest scope that is anticipated to traverse the stenosis (if one is present) should be used, without damaging the cords
(Adapted with permission from Pierre AF.5) (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

10. Figure 8
Shown is Dr. Grillo's technique of measuring the location and length of airway pathology. The rigid bronchoscope with telescope inserted almost to the end is used to measure the distance from the carina to the inferior margin, superior margin, and inferior border of the cricoids (A). This is done by starting distally and moving proximally. A ruler measures a proximal fixed point from the bronchoscope to the incisors. This allows the surgeon to draw a schematic with relative distances between the carina and the distal margin of the lesion, the length of the lesion, and between the proximal margin of the lesion and the cricoid cartilage (B). Thus, a tracheal resection can be planned when appropriate.
(Adapted with permission from Grillo HC.6)
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions

11. Figure 9
Typical circumferential postintubation stenosis. This lesion was initially dilated with an esophageal bougie to accommodate an adult rigid bronchoscope. The measurements listed in Figure 8 can then be used to plan a resection. (Color version of figure is available online at
Operative Techniques in Thoracic and Cardiovascular Surgery  , 44-51DOI: ( /j.optechstcvs )
Copyright © 2012 Elsevier Inc. Terms and Conditions