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2 Actual Identication ofBronchial Branch

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Fig. 2.38 Fluoroscopy (3)

Fig. 2.35 EBUS

Fig. 2.36 Fluoroscopy (1)

Fig. 2.37 Fluoroscopy (2)

rib

In the EBUS image, hyperechoic points are observed from 4

o’clock to 11 o’clock around the ultrasonic probe (adjacent to). In addition, hyperechoic points are observed in the lesion, but the blood vessels are not visible; hence, the condition is diagnosed as type IIa (Fig.

2.35).

The uoroscopic image is rotated 180°. It is essential to

memorize the position of the transducer (e.g., located at the lower edge from the center of the rib: →) under X-ray uoroscopy while scanning the site to be biopsied in the lesion with the probe (Fig. 2.36).

After pulling out the probe from the guide sheath, the brush

is inserted into the guide sheath, and cells are collected by brushing at the previously memorized position (e.g., between the center of the rib and the lower edge of the rib: →) (Fig. 2.37).

Furthermore, the biopsy forceps are inserted into the guide

sheath, and the opened cups of the biopsy forceps are closed, and the tissue is biopsied from the correct position at the memorized position previously (e.g., between the center of the rib and the lower edge: →) (Fig. 2.38).

Right B

b (the representative case in which we can make

complete use of the horizontal pattern) (Figs. 2.39, 2.40,

2.41 and 2.42).

Owing to the lesion in the right upper lobe, rotate the CT

images counterclockwise 90°, and follow from the caudal side to the cranial side. The orice of the right B1 is close to the ofce of B2. The vessel pattern of this case is the central vein type.

B3b branches into B3bi in the cranial direction and B3bii in

the caudal direction (horizontal–vertical pattern and branches are drawn on the up and down position). B3bi branches into B3biα in the lateral direction, B3biβ in the

caudal

crania

Right

2 Actual Identication ofBronchial Branch

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B3b

cranial

B3bii

ventral

dorsal

B3bi

bii

caudal

B3b

B3bi

big

bib

bia

big

bib

B3bia

B3bi

bii

B3bib

biby

B3bib

B3bibx

bibxy

B3bibxx

Fig. 2.39 CT, bronchial branch diagram and bronchoscopic ndings

B3biby

B3bibx

bii

B3a

B3bibxx

B3a

B3biby

B3bibx

biby

B3bibx

bibx

2 Actual Identication ofBronchial Branch

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Fig. 2.41 Fluoroscopy (1)

Fig. 2.40 EBUS

Fig. 2.43 Bronchial anatomy

in the right middle lobe

ventral and center direction, and B3biγ in the medial direction (three branches with the horizontal–horizontal pattern and branches are drawn on the right, center, and left position).

Fig. 2.42 Fluoroscopy (2)

B3biβ branches into B3biβx in the cranial direction (approach-

ing B1) and the lateral direction (approaching B3a) and B3biβy in the caudal direction (far from B1) and the medial side (away from B3a; horizontal–oblique pattern). B3biβx branches into B3biβxx in the lateral direction and B3biβxy

front view lateral view

2 Actual Identication ofBronchial Branch

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B4a

Fig. 2.44 Typical branching of the right middle lobe bronchus

B5b

B5a

medial lateral

Fig. 2.45 Schema of bronchial branching of the right middle lobe on

the CT images

ventral

dorsal

in the medial direction (horizontal–horizontal pattern and branches are drawn on the right and left position). B3biβxx passes through the center of the lesion (Fig. 2.39).

cranial

medial lateral

caudal

Fig. 2.46 Bronchoscopic image of the right middle lobe bronchus.

Notably, 12 o’clock direction from the bronchial lumen is the cranial side, 6 o’clock is the caudal side, 3 o’clock the lateral side, and 9 o’clock the medial side

B4b

The position where the lesion could be visualized with the

transducer is memorized on the uoroscopic screen, and biopsy is performed at the memorized position on the uoroscopic screen (Fig. 2.42).

The ultrasound probe is inserted into B3biβx leading to the

lesion, and hyperechoic points (→) surrounded the probe (within). Vessels are not recognized in the lesion, and it is classied as type IIa (Fig. 2.40).

A bronchoscope (BF-P260F; Olympus) with an external

diameter of 4mm is inserted up to B3biβ. The probe was inserted into B3biβx, and hyperechoic points are observed around the probe (Fig. 2.41).

Right middle lobe (Figs. 2.43 and 2.44)

The typical branching of the right middle lobe bronchus. Anatomical points of the right middle lobe bronchus are as

follows:

1. The right middle lobe bronchus branches into B4 in the lateral direction and B5 in the ventral and caudal directions.

dorsal ventral

2 Actual Identication ofBronchial Branch

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Fig. 2.47 CT and schema of the right middle lobe bronchus

B4a

B4b

B4a

B5a

B5b

cranial

B4a

B5a

medial lateral

B4b

caudal

B4a

Fig. 2.48 MPR (coronal) images and typical branching of the right middle lobe

2. The right B4 branches into B4a in the lateral and the

2. Follow the bronchi to nd in which subsegment the

dorsal direction and B4b in the lateral, ventral, and caudal directions.

3. From the slice at the entrance of the middle lobe bron-

3. Right B5 branches into B5a in the ventral and horizontal directions and B5b in the ventral and caudal directions.

4. In the right B4a, B4b, and B5a, many bronchi branch

4. Of note, B5a usually advances in the horizontal direction on the ventral side.

The CT images and bronchoscopic ndings of the right mid-

dle lobe bronchus. The right middle lobe bronchus in the reversed CT images. Normal bifurcation of the middle lobe bronchus observed

using the bronchoscope. Notably, 12 o’clock direction from the bronchial lumen is the

cranial side, 6 o’clock is the caudal side, 3 o’clock the

lateral side, and 9 o’clock the medial side.

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

5. In the right B

right middle lobe bronchus from the CT images (Fig.

2.47):

1. In the right middle lobe, reverse CT images left to right.

Regarding the direction of spurs of the right middle lobe

bronchus (Fig.2.48).

lesion is approximately located.

chus to the slice where the lesion is located, follow the bronchus gradually.

from the bronchi running in parallel to the CT axial images. While the bronchi run parallelly to the CT axial section, we draw the bronchial branch diagram, considering the direction in which the bronchus branches in the upward, downward, left, and right directions and in which the bronchus is approaching or leaving the other bronchi. In the bronchi running parallel to the axial CT images, the MPR images orthogonal to the bronchus heading to the lesion are highly useful. Tracking in the cross section orthogonal to the bronchus of the lesion facilitates drawing the bronchial branch more accurately.

b, while branching typically advances in the direction orthogonal to the axial CT images, we draw angles of spurs on the reversed CT images.

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Fig. 2.49 Typical patterns of

the subsegmental bronchus in the right middle lobe

medial lateral

cranial

caudal

MPR (coronal) images of the middle lobe bronchus from the

dorsal side to the ventral side.

On the coronal MPR images of the right middle lobe bron-

chus, following the bifurcation of bronchial branching is easy.

Right B

branches into B4a in the lateral, dorsal, and cranial

directions and B4b in the lateral and caudal directions.

Right B5 branches into B5a in the horizontal directions and

B5b in the caudal direction.

Bifurcation of the right middle lobe bronchus (B4 and B5)

(Fig.2.49) Image the tip of the bronchoscope (our eyes) comes to the

bifurcation between B4 and B5 in the right middle lobe bronchus. From the right middle lobe bronchus, the top of the bronchoscopic image is the cranial side of the body, the bottom is the caudal side, the right is the lateral side, and the left is the medial side. The representative pattern of the subsegment bronchus of the middle lobe is the “N” shape (bottom left gure). Right B4 branches into B4a in the lateral and cranial directions and B4b in the lateral and caudal directions. Right B5 branches into B5a in the medial and horizontal directions and B5b in the medial and caudal directions.

Besides, right B4 and B5 are sometimes arranged from the

lateral to the medial side, and a branched conguration is aligned with B4a, B4b, B5a, and B5b from the lateral to the medial side (Fig.2.49).

Procedure for the reading CT anatomy of right B4 on the

axial CT images:

1. For lesions on right B4, reverse the CT images left to right.

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

cranial

medial

B5b

B5a

caudal

3. From the slice at the entrance of the middle lobe bronchus to the slice where the lesion is present, follow the bronchus gradually.

4. Identify the bifurcations between the B4 with B5 and

a with B4b.

5. B4a and B4b almost run in parallel to the CT horizontal section direction. We draw the bronchial branching diagram while considering (1) which direction the bronchus branches on the CT images in the dorsal, ventral, lateral, or medial direction and (2) which other bronchi are approaching or leaving.

Right B4a (Figs. 2.50, 2.51 and 2.52)

For the bronchus of the right middle lobe, the axial CT

images are reversed left and right, which are traced from the cranial side to the caudal side. Understanding the direction from the bronchial lumen is essential when the bronchoscope tip is located at the entrance of the middle lobe bronchus. From the right middle lobe bronchus, the branches of B4 and B5 are running in the horizontal direction; thus, the upper side of the bronchoscopic view is the cranial side, while the lower side is the caudal side. B4 distributes in the lateral side, and B5 distributes in the ventral and medial sides. B4a distributes in the lateral and cranial sides, and B4b distributes in the medial and caudal sides (horizontal–oblique pattern) (Fig.2.50).

B4a branches into B4aii in the caudal and ventral directions

and B4ai in the cranial, lateral, and dorsal directions. The branching direction of B4aii and B4ai closely resembles the direction of B5 and B4 and draws the direction of the spur between B4aii and B4ai in the same direction as that between B5 and B4 (blue dotted line) (Fig.2.50).

A bronchoscope entered the B

lesion on the CT images. In the bronchoscopic nding,

ai nearest to the center of the

lateral

caudal

cranial

Right

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B4a

2 Actual Identication ofBronchial Branch

cranial

B4a

medial

B4a

cranial

caudal

B4b

aii

lateral

B4ai

B4aii

medial lateral

caudal

Fig. 2.50 CT and bronchial branch diagram

B4ai

B4b

caudal

cranial

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2 Actual Identication ofBronchial Branch

B4a

medial

cranial

B4a

lateral

B4aii

B4ai

B4a

medial

caudal

B4a

cranial

aii

B4ai

aii

lateral

aia

aib

Fig. 2.51 CT, bronchial branch diagram and bronchoscopic ndings

aia

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Fig. 2.52 EBUS

B4aiα, which branches in the cranial direction, could be observed, and a probe is inserted into B4aiα (Fig.2.51).

When entering the middle lobe bronchus from the intermedi-

ate trunk, the axis of the bronchoscope is rotated considerably in the counterclockwise direction, and in the middle lobe bronchus, it is rotated marginally in the clockwise direction; however, the rotation of the bronchoscope itself is still turned counterclockwise. Hence, the bronchial branch diagram of the reading CT anatomy is rotated clockwise, resembling bronchoscopic ndings closely (Fig.

2.51).

The tip of the bronchoscope is inserted up to B4ai and pushed

until the snug t. At that situation, approximately 7mL of physiological saline is injected into the bronchial lumen from the working channel of the bronchoscope. While moving the sputum in the bronchial lumen and observing the bronchial lumen cleanly, the ultrasonic probe could be inserted into B4aiα, which could be observed during bronchoscopy (Fig.2.51).

The probe was inserted into B4aiα, which branches in the

cranial direction from B4ai. The probe was reached within the lesion. Analyzing the EBUS image, the internal echo of the lesion is heterogeneous, and hyperechoic lines corresponding to air in the lesion are observed; this EBUS image is classied as type IIIa. As the attenuation of the ultrasonic waves is conspicuous at the site distant from the probe, it is judged that the internal echo is heterogeneous (Fig.2.52).

2 Actual Identication ofBronchial Branch

Column

What can we do with bronchoscopy? What do we want for bronchoscopic examination? I think that it is possible to summarize two things:

1. Seeing invisible objects

2. Collecting cells and tissues from the site of the lesion

Seeing invisible objects.

New bronchoscopic technologies are:

1. Further high-quality bronchoscopic images with white light

2. Narrow band imaging (NBI)

3. Ultra-magnifying bronchoscope, enabling the observation of cells/nucleus, and endoscopic confocal microscopy, which can observe ne structure/alveolar structure We would like to be sensitive to the future development of new technologies.

Collecting cells and tissues from the site of the lesion:

1. Collection of cells and tissues from the peribronchial lesions by EBUS-TBNA

2. Development of techniques to collect cells/tissues of peripheral lesions while observing peripheral lesions in real time

3. Enhancement of techniques for collecting cells and tissues from lesions with the bronchus sign

4. Establishment of new technologies for collecting cells and tissues from lesions without the bronchus sign

I would like to pursue further technical enhancements of

bronchoscopy.

Right B4b (Figs. 2.53, 2.54, 2.55 and 2.56) For the lesion in the middle lobe, the CT images are reversed

left to right, and the CT images are traced from the cranial side to the caudal side. From the right middle lobe bronchus, the branches of B4 and B5 are running in the horizontal direction; thus, the upper side of the bronchoscopic image is the cranial side, while the lower side is the caudal side. Right middle lobe bronchus branches in B4 in the lateral direction and B5 in the medial direction. B4 branches into B4a in the cranial and lateral directions and B4b in the caudal and medial directions (horizontal– oblique pattern).

caudal

cranial

Right

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2 Actual Identication ofBronchial Branch

B4b

medial

cranial

caudal

B4a

lateral

B4bibx

B4bib y

bib

B4b

B4a

B4bi

bii

B4bi

B4bia

B4a

B4bi

bii

B4bib

B4a

bia

B4bibx

Fig. 2.53 CT, bronchial branch diagram and bronchoscopic ndings

bib

bia

B4bibx

biby

B4bibx

bibx

B4a

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