Introduction

Rigid bronchoscopy involves insertion of a rigid bronchoscope into the tracheobronchial tree to visualise the airway, diagnose diseases, and perform lifesaving therapeutic interventions. The rigid bronchoscope is a straight, hollow, stainless-steel tube, primarily used for therapeutic procedures; however, it also offers excellent diagnostic capabilities.

The key advantage lies in its wide lumen, which allows simultaneous ventilation, suction, and the passage of various large instruments. Although flexible bronchoscopy is popular, rigid bronchoscopy remains irreplaceable when securing the airway, controlling bleeding, removing large foreign bodies, or performing endobronchial surgery.

Parts of a Rigid Bronchoscope

It has two main ends: distal (inside the patient) and proximal (outside the patient).

Distal End

The distal tip has a bevelled tip that helps it to pass smoothly behind the epiglottis and between the vocal cords. It contains side holes (ventilating pores) that allow oxygenation of the contralateral bronchus even when one side is blocked by the bronchoscope.

Proximal End

This end houses multiple ports for crucial connections:

• Central Lumen: The main opening for visualisation, passing telescopes (Hopkins Rods telescopes for magnification), and introducing various rigid instruments (forceps, suction tubes).
• Side Ports (Typically Three):
  • Port for the Light Source and Fibreoptic Cable.
  • Port for the Anaesthesia Ventilator circuit.
  • A small port for Jet Ventilation (for oxygen supply) or passing fine suction catheters.

Key Equipment Required for Rigid Bronchoscopy

• Ventilating Bronchoscope: It provides a clear view of the airway and allows ventilation during the procedure. Standard Adult Size: 6-9 mm external diameter, 40 cm length.
• Telescopes (0°, 30°, 70°): They provide magnified and angled views, especially of segmental bronchi.
• Special Forceps: They is used for biopsy, foreign body removal (FBR), and tumour resection.
• High-Flow Suction: It removes blood, mucus, or secretions during the procedure to provide clean and visible airway.
• Light source and cable.
• Camera and monitor: Allows the entire team to view the procedure and aids in recording and teaching.

Airway Management During Rigid Bronchoscopy

It is important to maintain good oxygenation and ventilation during bronchoscopy. The anaesthetist chooses the method depending on the patient’s condition and type of procedure.

• Ventilating Bronchoscope: It is the most common method used. The anaesthesia machine is directly connected to the proximal end of bronchoscope to provide oxygen and ventilation.
• Intermittent Apnoea: The patient is briefly paralysed and oxygenated. The surgeon gets short time windows to perform the procedure before re-oxygenating again.
• High-Frequency Jet Ventilation (HFJV): In this, a thin catheter delivers rapid, high-pressure oxygen pulses, which maintains oxygen and carbon dioxide exchange without major chest movement.
• Spontaneous Breathing with Total Intravenous Anaesthesia (TIVA): Allows the patient to breathe spontaneously while deeply sedated.
• THRIVE (Transnasal Humidified Rapid Insufflation Ventilatory Exchange): In this, a continuous warm and humidified oxygen is given through the nose. It is particularly useful in difficult airway cases.

Rigid Bronchoscopy Technique: Steps

Position (Sniffing, Barking-Dog, Sword Swallowing Position)

The patient lies supine. A 10–15 cm head ring is placed under the head to flex the neck on the chest. The head is then extended at the atlanto-occipital joint. This alignment straightens the oral, pharyngeal, and laryngeal axis.

Preparation

Select the appropriate bronchoscope size (Refer to Table 1), apply a dental guard for teeth protection, and lubricate the scope’s distal tip (often with liquid paraffin or jelly).

Introduction (Oral Cavity)

Introduce the lubricated scope into the oral cavity. Hold the scope like a pen in your right hand. Use the fingers of your left hand to retract the upper lip and guide the scope, protecting the teeth and lips and guide the scope. Repeated removal and introduction of bronchoscope should be avoided.

Laryngoscopy & Epiglottis Lift

Now looking through the scope, advance the scope until the posterior pharyngeal wall is seen. Tilt the scope anteriorly to identify the tip of the epiglottis. Pass the scope behind the epiglottis, with the bevelled tip facing downwards and lift the epiglottis forward, exposing the glottis.

Glottis Entry (The 90° Rotation)

At the level of the vocal cords, rotate the scope 90° clockwise (making the bevel parallel to the cords’ axis) to facilitate entry without trauma.

Tracheal Entry

Advance the scope slowly past the vocal cords. Once in the trachea, rotate the scope back 90° (bevel facing downwards) to the original position. Do not force bronchoscope through closed glottis.

Examination & Cannulation

Advance the scope gradually. Visualize the entire trachea down to the carina (the point of bifurcation).

• Right Bronchus: To enter the more vertical Right Main Bronchus, turn the patient’s head to the Left (This straightens the angle of approach).
• Left Bronchus: To enter the more oblique Left Main Bronchus, turn the patient’s head to the Right.

Distal Examination

Use angled telescopes (30°, 70°) for a detailed examination of the segmental and subsegmental bronchi, which are difficult to visualize directly.

Time of Procedure

In infants and children, do not prolong the procedure beyond 20 minutes to prevent life-threatening subglottic oedema.

Postoperative Care

Keep the patient in a humidified atmosphere to soothe the airways.

Closely watch for respiratory distress. Inspiratory stridor and suprasternal retraction indicate laryngeal oedema, which may require urgent intervention, including tracheostomy.

Table 1: Size of tracheostomy tube and bronchoscope according to age

Age Group	Inner Diameter of Tracheostomy Tube (mm)	Size of Rigid Bronchoscope Tube (External Diameter in mm)
Preterm–1 month	2.5–3.0	2.5
1–6 months	3.5	3.0
6–18 months	4.0	3.5
18 months to 3 years	4.5	4.0
3–6 years	5.0	4.5
6–9 years	5.5	5.0
9–12 years	6.0	6.0
12–14 years	7.0	6.0
14+ years (Adults)	7.5–8.5	7.5–8.5 (up to 9.0 mm)

Indications for Bronchoscopy (Diagnostic & Therapeutic)

The indications for bronchoscopy are broad, encompassing both diagnostic confirmation and direct therapeutic intervention.

Diagnostic Indications (The 4 ‘H’s and X-ray Findings)

• Haemoptysis: To identify the source of bleeding. Always the top indication.
• Hoarseness/Vocal Cord Palsy: To rule out a lower tracheobronchial or lung mass causing recurrent laryngeal nerve involvement.
• Hard Cough (Unexplained/Persistent): Cough lasting more than 4 weeks, unresponsive to standard treatment.
• Hardening/Mass:
  • Radiological Opacities on chest X-ray or CT (e.g., atelectasis of a segment/lobe, localized opacity, hilar or mediastinal shadows). Moreover, to evaluate for underlying malignancy or obstruction.
  • Obstructive Emphysema: To exclude a foreign body acting as a one-way valve.
• Collection of Secretions/Washes: For microbiology (culture, AFB, fungus) and cytology (malignant cells).

Therapeutic Indications

• Acute airway obstruction.
• Removal of Foreign Bodies (FBR): The gold standard, especially in children, is Rigid Bronchoscopy.
• As a part of panendoscopy
• Removal of Secretions/Mucus Plugs: Especially in critically ill, comatose, or post-operative patients (e.g., after chest trauma or surgery).
• Endobronchial Stenting: To relieve central airway obstruction caused by tumours or strictures.
• Tracheal/Bronchial Dilation: For benign or malignant strictures.
• Tumour Debulking/Palliative Procedures: Using laser or cryotherapy.
• Balloon tracheobronchoplasty

Contraindications

Absolute Contraindications

• Inability to Adequately Oxygenate/Ventilate the Patient.
• Untreatable Life-Threatening Arrhythmias.
• Severe Tracheal Obstruction.

Relative Contraindications

• Acute Respiratory Failure with Hypercapnia.
• Recent Myocardial Infarction (MI) or Unstable Angina.
• Coagulopathy/Bleeding Disorders.
• Cervical Spine Instability.

Complications and Precautions

• Airway/Vocal Cord Trauma: Injury to teeth, lips, soft palate, or posterior pharyngeal wall, Vocal cord trauma and subsequent oedema, Arytenoid trauma and dislocation (from excessive force/poor technique), Laryngeal/Subglottic Oedema (often due to prolonged procedure, especially in children).
• Respiratory: Laryngospasm and Bronchospasm (can lead to acute distress). Hypoxia and hypercapnia (due to inadequate ventilation). Pneumothorax (due to bronchial perforation or aggressive distal manipulation).
• Cardiovascular: Cardiac Arrhythmias (hypoxia-induced), Cardiac Arrest.
• Haemorrhage: From the biopsy site. Therefore, coagulation status must be checked pre-procedure.
• Infection/Aspiration: Bleeding or secretions can be aspirated.