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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2702_Библиотеки_им_академика_М_И_Перельмана
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To Trace theBronchial Branch
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Accurately
1
Abbreviations
EBUS Endobronchial ultrasonography
EBUS-GS Endobronchial ultrasonography using a guide
sheath
GGN
Ground-glass nodule
GS Guide sheath
STC Sensitivity time control
1.1 Nomenclature oftheBronchial
Branch
The nomenclature of bronchi is based on the direction in
which the lungs with the bronchi are located [1–8].
The three principles of the bronchi nomenclature are as
follows:
1. Cranial side → caudal side
2. Dorsal (posterior) → ventral (anterior)
3. Lateral side → medial side
Considering these principles, the segmental bronchi (II:
second-generation bronchus) are named as 1, 2, 3, …; the
subsegmental bronchi (III: third-generation bronchus) are
named as a, b, c, … …; the sub-subsegmental bronchi (IV:
fourth-generation bronchus) are named as i to i, ii, iii, ……;
the sub-sub-subsegmental bronchi (V: fth-generation bronchus) are named as α, β, γ, … …; and the sub-sub-subsubsegmental bronchi (VI: sixth-generation bronchus) are
named as x, y.
These three principles consider the cranial side as the top
priority. When nominating the bronchi, caudal and dorsal
side or the cranial and ventral side in these conicting principles, the bronchi to the cranial side are considered as the
top priority (Figs.1.1 and 1.2).
When branching further from the subsegmental bronchus,
the recognition of the positional relation of the cranial side/
caudal side, dorsal/ventral side, and lateral side/medial side
becomes challenging.
The bronchus is named referring to the direction of the
proximal bronchial branch. However, considering the complicated branch naming at the time of bronchoscopic examination, a more correct nomenclature is possible using the
thin-slice CT images after bronchoscopy.
In the actual bronchoscopic examination, expressing the
direction of the next-generation bronchial opening, such as
up, down, left, right, upper right, lower right, upper left,
lower left, etc., is useful without mentioning the name of the
bronchus.
This book describes the naming method as follows: the
direction from which the next bronchial lumen on the CT
images can be indicated, is followed by the name based on
the nomenclature in parentheses, for example, “from B
superior (B1aiα), inferior (B1aiβ) ….”
The nomenclature of the segmental bronchus/subsegmental bronchus was made considering the route and distribution
of the bronchus. For example, when the bronchus heading
toward the region of S1b branches off from the cranial side in
B3, it is considered to be B1b branched from B3a and, thus,
named B1b.
Opportunities to identify the lateral branch (daughter
branch) heading to the lungs of the inner layer closer to the
hilar and the middle layer, which branches from the bronchial tract from the segmental bronchus to the sub-subsubsegmental bronchus, are increasing.
As the bronchoscope has become smaller in diameter, we
have also experienced observing the entrance of the lateral
branch with the bronchoscope. When the bronchus branched
off from the parent branch is as thin as about half the inner
diameter of the counterpart branch (main shaft branch), and
the branch angle is also steep, it can be considered to be a
lateral branch [9–11].
1
ai to
© Springer Nature Singapore Pte Ltd. 2020
N. Kurimoto, K. Morita, Bronchial Branch Tracing, https://doi.org/10.1007/978-981-13-9905-3_1
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Fig. 1.1 Bronchial
nomenclature. [Quoted from
the Japan Lung Cancer
Society (ed.): General Rule
for Clinical and Pathological
Record of Lung Cancer, 7th
edition, p151, Kanehara
Publishing, 2010]
1 To Trace theBronchial Branch Accurately
In the symposium [12] of “Over the daughter branch,” by
the 11th Japanese Society for Bronchology in 1988, It was
recommended to attach an asterisk on the right shoulder of
the name of the parent branch, although, seemingly, no prescription of the daughter branch exists at present.
From this proposal, the lateral branch attaches an asterisk
(∗) to the right shoulder of the name of the parent branch and
does not add it in the generation of the branch. For example,
the lateral branch branched from left B3a is described as left
B3a∗.
After the completion of bronchoscopy, the nomenclature
is given from the bronchial lumen while following the actual
bronchial lumen observation. The nomenclature of the
peripheral bronchus is an essential arrangement for the
advancement and dissemination of bronchoscopy for peripheral bronchi in the future.
Bronchial nomenclature
Main bronchus: 0 generation
Intermediate trunk: 0 to I generation
Upper lobe bronchus, middle lobe bronchus, lower lobe
bronchus: I generation
Superior segmental bronchus, lingular segmental bronchus,
basal bronchus: I–II generation
Segmental bronchus: II generation
Subsegmental bronchus (e.g., B1a, B1b): III generation
Sub-subsegmental bronchus (e.g., B1ai B1aii): IV
generation
Sub-sub-subsegmental bronchus (e.g., B1aiα, B1aiβ): V
generation
Regarding the nomenclature of IV and V generation, it is
named i, ii, and α, β based on the branch of a and b of the
subsegmental bronchus.
The bronchi of the cranial, dorsal, or lateral side as viewed
from the distribution region are dened as i or α, and the
bronchi of the caudal, ventral, or medial side are dened
as ii or β
1.2 CT Imaging Condition
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Fig. 1.2 Standard branching of the subsegmental bronchi
1.2 CT Imaging Condition
Assumedly, the condition with a slice as thin as possible
is good for reading CT images. Owing to a difference in
the CT apparatus at each facility, we should keep it to the
reference level. However, the CT conditions used for the
reading branch at St. Marianna Medical University are as
follows:
CT protocol collimation of 64 rows:
0.5mm to tube voltage: 120kV
Tube current: automatic tube current modulation (Z-axis
modulation with Real E.C. technique; Toshiba Medical)
Used gantry rotation speed: 0.5s
Beam pitch: 0.83 (bed movement distance; 53, collimation
width; 64)
Reconstruction protocol ∗: FC 14, slice thickness: 0.5mm,
slice interval: 0.4mm
Pixel size (voxel size): 0.625mm × 0.625mm × 0.5mm
∗Reconstruction protocol is a mediastinal window.
4
Cranial
Caudal
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1.3 Method oftheReading Branch Using
CT Images
I. Observe the lung eld from the lung apex to the dia-
phragm (with a CT image looking through the entire lung
eld), and determine the subsegmental bronchus in which
the lesion is located.
II. In the CT images, follow the bifurcation:
Follow the bronchi that branch from the lobar bronchus to
the periphery. As shown in the gure, determine the position where the spur of the bronchial bifurcation is rst
located. Then, grasp the position of the spur of the nextgeneration branch, and draw a bronchial branch diagram
while considering the direction of the bronchial orice of
the next generation. Repeat this procedure.
The rst branches of the right middle lobe bronchus are the
right B4 and B5 (Fig.1.3, →), and the angle of the spur
between B4 and B5 exists from the upper right to the lower
left (① of Fig.
(Fig.1.3, →), and the spur between B5a and B5b is from
10 o’clock to 4 o’clock (② of Fig.1.4). Follow right B5b
(Fig.1.3, →).
Right B5b enters into the lesion. The lesion locates on both
S5b and S5a and primarily occupies S5b.
1.4). Right B5 branches into B5a and B5b
5
We select one branch of right B
b closer to B5a (Fig. 1.3,
proceed in the direction of × inside the right B5b).
III. Reverse or rotate the CT image.
1. In the lesions of the left and right lower lobe, right
middle lobe, or left lingual segment, reverse the CT
images left to right or right to left (Fig.1.5).
Then, the bronchi on the CT images are followed
from the cranial side to the lesion. The usual CT
images are tomographic images of the direction from
the caudal side to the cranial side; by reversing the
left and right, CT images can be viewed from the cranial side.
2. In the right upper lobe, rotate the CT image counterclockwise by 90°, and follow the bronchus from the
upper lobe entrance to the lung apex. The direction of
the bronchoscope looking at the apical portion of the
lung from the right upper lobe bronchus is the same
direction as CT observed from the caudal side. When
the bronchoscope advances to the right main bronchus, it is rotated by 90° in the clockwise direction
and enters the right upper bronchus; thus, when you
rotate the CT image 90° counterclockwise, it coin-
Fig. 1.3 Branching of right middle lobe bronchus
Fig. 1.4 Bronchial branch diagram
1.3 Method oftheReading Branch Using CT Images
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Fig. 1.5 To reverse
CT images
Fig. 1.6 To rotate CT images
5
rotate counter
clockwise 90º
Fig. 1.7 Rotation of the bronchoscope
cides with the bronchoscopic nding of the bronchus
from the upper lobe bronchus to the lung apex
(Fig.1.6).
3. In the left superior segment, rotate the CT image
clockwise 90°, and follow the bronchus from the
entrance of the left superior segment bronchus toward
the lung apex. The direction of the bronchoscope for
viewing the apical portion of the lung from the left
superior segment bronchus is the same direction as CT
observed from the caudal side. When a bronchoscope
advances to the left main bronchus, it is turned counterclockwise 90° and enters it; thus, when you rotate
the CT image clockwise 90°, it coincides with the
bronchoscopic ndings of the bronchus from the left
superior segment bronchus to the lung apex (Fig.1.6).
Reason to Rotate the CT Images Counterclockwise 90°
on the Right Upper Lobe
When advancing the right main bronchus, rotate the bronchoscope clockwise 90° (Fig.1.7).
Left gure: the bronchoscopist looks into the right upper
lobe bronchus from the right main bronchus in the supine
position with bronchoscopy (Fig.1.8).
Right gure: the right upper lobe bronchus is branching of
the bronchi on the CT image, while the bronchoscopist
looks into the right upper lobe bronchus from the right
main bronchus (Fig.1.8).
While the CT images are rotated counterclockwise 90°, we
observe the peripheral bronchial ndings from the
entrance of the right upper lobe bronchus (Fig.1.9).
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Fig. 1.8 Reason to rotate the
CT images counterclockwise
90° on the right upper lobe (1)
1 To Trace theBronchial Branch Accurately
Fig. 1.9 Reason to rotate the
CT images counterclockwise
90° on the right upper lobe (2)
1.3 Method oftheReading Branch Using CT Images
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Reason for Rotating the CT Images Clockwise 90° in the
Left Superior Segment
Fig.1.10: the bronchoscopist looks into the left superior seg-
ment bronchus from the left main bronchus in the supine
position with bronchoscopy.
Fig.1.11: the left superior segment bronchus is branching of
the bronchi on the CT images, while the bronchoscopist
looks into the left superior segment bronchus from the
caudal side.
While the CT images are rotated clockwise 90°, we observe
the peripheral bronchial nding from the entrance of the
left superior segment bronchus.
IV. Tracing the bronchus.
Four patterns of tracing the bronchus, based on the direction
of the bronchial branch in the axial CT images, and branch
reading is performed while considering which of these
patterns is applicable.
Vertical pattern: the direction of the bronchi advancing the
periphery is close to orthogonal to the CT section.
There are three patterns for the bronchial route from the
proximal bronchus where the bronchial route is nearly
parallel to the axial CT images. In these three patterns,
we will image how the bronchial branch can be viewed
from the proximal orice of this bronchus running
horizontally.
Horizontal–horizontal pattern: the bronchi advance nearly
parallel to the axial CT images and branches in the nextgeneration bronchus horizontally.
Horizontal–vertical pattern: the bronchi advance nearly
parallel to the axial CT images and branches in the nextgeneration bronchus vertically.
Horizontal–oblique pattern: the bronchi advance nearly
parallel to the axial CT images and branches in the nextgeneration bronchus obliquely.
Each pattern will be explained as follows.
Vertical pattern (Figs. 1.12 and 1.13): the bronchus
advances nearly orthogonal to the axial CT images
When the direction of the bronchi is close to orthogonal to
the axial CT images, the direction of the bronchial branching in the axial CT images can be drawn on the bronchial
branch diagram as it is (e.g., right B
1
, B2a, B8b, B9b, B10b,
and B10c).
Horizontal–horizontal pattern: the bronchus advances
nearly parallel to the axial CT images and further branches
horizontally.
The direction of the bronchial bifurcation in the CT image
cannot be drawn on the bronchial branch diagram as it is.
When the bronchus branches further horizontally from a
branch close to parallel to the axial CT images, the bifur-
Fig. 1.10 Reason for rotating
the CT images clockwise 90°
in the left superior segment
(1)
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Fig. 1.11 Reason for rotating
the CT images clockwise 90°
in the left superior segment
(2)
1 To Trace theBronchial Branch Accurately
Fig. 1.12 CT images rotated counterclockwise 90° because of the right upper lobe
cation is explained as branching to the left and right as
observed in the long axis of the bronchus running horizontally on the bronchial branch diagram. The bronchoscope itself is in the branch nearly parallel to the axial CT
images, and the horizontal–horizontal branch divides into
the right and left branch in the view from the bronchoscope (e.g., right B3a, B3b, B6, and B4a). When the bronchoscope itself is in a branch close to the axial CT images
1.3 Method oftheReading Branch Using CT Images
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Fig. 1.13 CT images
reversed right to left because
of the right lower lobe
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Fig. 1.14 Horizontal–horizontal pattern at the spur of right B3a and B3b
(right B3 in Fig.1.14), we watch B3a on the right side and
B3b on the left side in the eld of view from the
bronchoscope.
[Representative case 1: spur of right B3a and B3b]. The
branch of B3a and B3b from right B3 is often advancing in
a direction parallel to the axial CT images. In the direction of B3b and B3a, if the spur between B3b and B3a is
drawn in the bronchial branch diagram as it is on the CT
image, it is wrong. I think that the branch of B3a and B3b
is in the same direction as the branch of B
right and left in the bronchial branch diagram.
Furthermore, the direction of the spur between right B2
and B3 and the direction of spur of B3a and B3b on the
2
and B3 to the
bronchoscopic screen are the same and are considered to
be as shown in the right gure (Fig.1.14).
[Representative case 2: spur of right B3aiiα and B3aiiβ].
When the distal bronchus advances further horizontally
from a proximal branch nearly parallel to the axial CT
images, on the bronchial branch diagram, the proximal
bronchus is divided into the distal bronchi as observed
right and left from the axis of the proximal bronchus.
Assumedly, the right B3a branches into B3ai in the cranial
3
direction and into the B
aii in the caudal direction. The
next generation of B3aii divides into right–left direction as
the division of B3a and B3b similarly; B3aii branches into
B3aiiα in the right direction close to B2b and B3aiiβ in the
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Fig. 1.15 Horizontal–horizontal pattern at the spur of right B3aiiα and B3aiiβ
1 To Trace theBronchial Branch Accurately
Fig. 1.16 Horizontal–horizontal pattern at the spur of right B3biα, B3biβ, and B3biγ
left direction close to B3b, as shown in the bottom gure
(Fig.1.15).
direction. B
farthest from B3a.
Bronchial branch diagram: B3b branches into B3bi in the
cranial direction. B3bi branches into three branches in
[Representative case 3 (Fig. 1.16): spur of right B3biα,
B3biβ, and B3biγ] When the distal bronchus advances
further in a horizontal direction from the proximal branch
to parallel to the axial CT images, on the bronchial branch
diagram, the proximal bronchus branches into the distal
bronchi as observed right and left from the axis of the
proximal bronchus.
The CT image rotated counterclockwise 90°:
B3bi branched from the right B3b in the cranial direction
is divided into three branches in the horizontal direction. Among the three branches branched from B3bi in
the horizontal direction, the branch closest to B3a is
3
biα, while the branch farthest is B3biγ.
B
Multiplanner reconstruction (MPR) coronal CT image:
B3b branches into B3bi in the cranial direction, and
the horizontal direction. Among these three branches,
the branch closest to B3a was drawn as B3biα (red) and
the branch farthest to B3a as B3biγ.
Horizontal–vertical pattern (Fig. 1.17): the bronchus
advances nearly parallel to the axial CT images and further branches vertically.
When the distal bronchus advances further in the vertical
direction from the proximal branch to parallel to the axial
CT images, on the bronchial branch diagram, the proximal bronchus branches into the distal bronchi as observed
up and down from the axis of the proximal bronchus (e.g.,
right B3a, B3b, B6, and B4a).
When drawing a bronchus branching from the right B
toward the cranial side, the right B3a (yellow) branches
into B3ai (red) in the cranial direction, close to B1.
B3bi branches into three branches in the horizontal
3
biα is the closest to B3a, and B3biγ is the
3
a
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