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caudal

cranial

2 Actual Identication ofBronchial Branch

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cranial

ventral

dorsal

caudal

B1a

Fig. 2.19 CT, bronchial branch diagram and bronchoscopic ndings

diagram is drawn in the same direction based on the spur direction of the bronchus on the CT images (Figs.2.18,

2.19, 2.20 and 2.21).

The position of the transducer of the ultrasonic probe (→)

is remembered on the X-ray uoroscopic screen (Fig.

2.22).

The probe (→) was located within the lesion. The internal

echo is heterogeneous, and no hyperechoic points or lines are found, I diagnosed type IIIb (Fig. 2.23).

Furthermore, the biopsy forceps are opened (→) and closed

at the position just beyond the tip of the guide sheath (Fig.2.24).

Step-by-step procedure of the reading CT anatomy of right

and B3 on the axial CT images:

1. For the right upper lobe, rotate the CT images counterclockwise 90° (as the side of the chest wall comes downward).

2. Follow the bronchi to nd in which subsegment the lesion is approximately located.

3. From the slice at the entrance of the right upper lobe bronchus to the slice where the lesion is located, follow the bronchus gradually.

4. As the right B2 and B3 often branch in the similar direction (horizontal and lateral direction) as axial CT

caudal

cranial

2 Actual Identication ofBronchial Branch

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B1bi

B1biia

biiay

bii

B1biiax

B1bii

B1biia

biib

B1biiax

bii

B1biia

biib

B1biiax

B1biiay

biiay

B1biiax

Fig. 2.20 CT, bronchial branch diagram and bronchoscopic ndings

B1biiax

caudal

cranial

2 Actual Identication ofBronchial Branch

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Fig. 2.21 CT, bronchial branch diagram and bronchoscopic ndings

B1bii ax

Fig. 2.22 Fluoroscopy (1)

Fig. 2.23 EBUS

Fig. 2.24 Fluoroscopy (2)

images, MPR images in the direction orthogonal to the right B2a, B2b and B3a, B3b are also useful.

5. The bronchi orthogonal to the CT axial section are

drawn at the same angle of the spur at the bifurcation on CT images.

6. While the bronchi run parallelly to the CT axial sec-

tion, we draw the bronchial branch diagram, considering which direction the bronchus branches in the upward, downward, left, and right directions and which bronchus is approaching/leaving the other bronchi.

Right B2a

Rotate the CT images counterclockwise 90°, and follow the

CT images from the caudal side to the cranial side (Figs.2.25 and 2.26).

Right

2 Actual Identication ofBronchial Branch

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B2a

cranial

ventral

caudal

dorsal

B2a

B2b

B2a

B2ai

aii

B2ai

B2aii

B2a

Fig. 2.25 CT, bronchial branch diagram and bronchoscopic ndings

The ultrasonic probe is inserted into B2aiiαy and reaches

inside the lesion (within). The internal echo of the lesion within a radius approximately 1cm from the probe is relatively bright and heterogeneous. The internal echo far about ≥1 cm in radius from the probe is relatively hypoechoic, and, perhaps, the ultrasonic waves are attenuated by reection because of the irregular structures of the lesion. Hyperechoic lines are observed in the lesion and diagnosed as type IIIa (Fig.2.27).

The site to be biopsied in the lesion is where viable tissue

exists. When the probe is scanning the area to be biopsied (in the case of malignancy, avoid areas such as brosis and necrosis), the position of the transducer (e.g., the bottom edge of the rib: →) is memorized under the X-ray uoroscopic monitor (Fig. 2.28).

After reinserting the biopsy forceps into the guide sheath, the

cups of the biopsy forceps are opened and closed at the memorized position (e.g., the lower edge of the rib: →), and the tissue could be biopsied from the correct position (Fig.2.29).

Right B2b

For the right upper lobe lesion, rotate the CT images counter-

clockwise 90°, and follow from the caudal side to the cranial side. The right upper lobe bronchus has three standard segmental bronchi—B1, B2, and B3—and the classication with the pulmonary vein on the CT images is the central vein type (Fig.2.30).

caudal

cranial

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2 Actual Identication ofBronchial Branch

B2aiia

aiib

B2aiiax

aiiay

B2aiiax

aiiay

B2aiia

B2aiib

B2aiia

B2aiib

B2aiiax

B2aiiay

B2ai

aii

aiia

B2aiib

aiiax

B2aiiay

Fig. 2.26 CT, bronchial branch diagram and bronchoscopic ndings

B2aiiay

2 Actual Identication ofBronchial Branch

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Fig. 2.27 EBUS

Fig. 2.29 Fluoroscopy (2)

Fig. 2.28 Fluoroscopy (1)

B2 comprises two standard subsegmental bronchi. B2b

branches into B2bi in the cranial direction and B2bii in the caudal direction (horizontal–vertical pattern), and B2bi branches into B2biα in the cranial direction and B2biβ in the caudal direction (horizontal–vertical pattern). Furthermore, B2biβ branches into B2biβx in the cranial direction and B2biβy in the caudal direction (horizontal– vertical pattern), and a probe is inserted into B2biβx (Fig.2.30).

In EBUS, the entire circumference of the ultrasound probe is

surrounded by the lesion. The internal echo within a

radius approximately 1 cm from the probe is relatively hyperechoic and heterogeneous. In addition, hyperechoic lines (→) are observed in the lesion and are classied as type IIIa (Fig.2.31).

It is imperative to memorize the position of the transducer

(e.g., the center between the upper edge and the lower edge of the rib: →) under uoroscopy while scanning the site to be biopsied in the lesion with the probe. The biopsy forceps are inserted into the GS, and the opened cups of the biopsy forceps are closed at the memorized position (the center between the upper edge and the lower edge of the rib: →), and the tissue of the lesion is collected from the correct position (Fig.2.32).

Column

Basics of bronchoscopic procedures. The seven fundamental principles for bronchoscopists and

assistants performing bronchoscopy are as follows:

1. Close axilla (to move the bronchoscope precisely).

2. Hold the bronchoscope with your fourth and fth ngers, and create a space between the palm of your hand and the bronchoscope (do not grasp the bronchoscope deeply with the palm).

3. Place the insertion part of the bronchoscope straight; do not bend (to convey rotation to the bronchoscope).

4. Focus on the position of the foot (for easier rotation of the bronchoscope, e.g., while advancing from the trachea to the right main bronchus, move the bronchoscopist’s standing position slightly to the left, and turn the body clockwise).

caudal

cranial

2 Actual Identication ofBronchial Branch

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Right B2b

B2bib

B2bibx

cranial

ventral

B2b

caudal

dorsal

B2a

B2b

B2biby

B2bibx

B2bii (candal)

B2bii (cranial)

B2bib

B2a

B2bia

B2bib x

B2bii

B2bi

bii

180°rotation

biby

bibx

bia

bib

bibx

Fig. 2.30 CT, bronchial branch diagram and bronchoscopic ndings

2 Actual Identication ofBronchial Branch

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Fig. 2.31 EBUS

7. The assistant helps the bronchoscopist with words (expressing what is going on well in words, calming the mind of the bronchoscopist).

Right B3a (1)

For lesions in the right upper lobe, rotate the CT images

counterclockwise 90°, and follow from the caudal side to the cranial side. Three segmental bronchi are B1, B2, and B3 of the right upper lobe bronchus. B3a branches into B3ai in the cranial direction and B3aii in the caudal direction (horizontal–vertical pattern and branches are drawn on the up and down position). Furthermore, B3ai branches into B3aiα in the cranial direction and B3aiβ in the caudal direction (horizontal–vertical pattern and branches are drawn on the up and down position) (Fig.2.33).

B3aiβ branches into B3aiβx in the dorsal direction and

B3aiβy in the ventral direction (horizontal–horizontal pattern and branches are drawn on the right and left position). B3aiβx branches into B3aiβxx in the cranial direction and B3aiβxy in the caudal direction (horizontal–vertical pattern and branches are drawn on the up and down position). B3aiβxy enters in the center of the lesion (Fig. 2.33).

Fig. 2.32 Fluoroscopy

5. Rotation of the bronchoscope is performed in the order of (1) rotation of the operator’s body, (2) exion of the wrist, and (3) exion of the elbow.

6. The assistant assists the bronchoscopist in performing the next procedure (to prepare the next step ahead instead of being told by the bronchoscopist).

Right B3a (2)

Follow the sagittal MPR images, produced from the axial CT

images from the medial side to the lateral side. Right B3 has two branches of B3a and B3b as usual. B3a branches into B3ai in the cranial direction and B3aii in the caudal direction. B3ai branches into B3aiα in the cranial direction and B3aiβ in the caudal direction (Fig. 2.34).

B3aiβ branches into B3aiβx in the dorsal direction and B3aiβy

in the ventral direction. B3aiβx branches into B3aiβxx in the cranial direction and B3aiβxy in the caudal direction. B3aiβxy enters in the center of the lesion (Fig. 2.34).

caudal

cranial

Right

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B3a

B3aiib

2 Actual Identication ofBronchial Branch

cranial

aia

Rt. upper

B3aib

B3aib y

B3aia

B3aiia

B3aib

B3aib x

B3aibx

aib

ventral

aib y

aiib

B3aib xx

caudal

aib x

dorsal

B3b

B3aii

Fig. 2.33 CT, bronchial branch diagram and bronchoscopic ndings

B3aibxx

B3aibxy

B3aibxx

B3aibxy

aib xy

B3aib

aia

medial

lateral

2 Actual Identication ofBronchial Branch

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B3b

cranial

aib

ventral

B3aia

dorsal

B3a

aiia

aiib

caudal

Rt. upper

B3ai

B3aii

B3b

B3aia

B3aib

aii

B3b

B3aib xx

aib y

B3aib x

B3aib xx

aib xy

B3aib xx

aib xy

Fig. 2.34 CT, bronchial branch diagram and bronchoscopic ndings

aib xy

B3aib

B3aii

B3aia

B3aib

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