Tips to diagnose Pneumothorax

The Bronchial Tree

While passing the bronchoscope through the oral cavity, follow up the uvula, at the tip of the uvula you will see the epiglottis, elevate the epiglottis with the tip of the bronchoscope. You will see the vocal cords; wait until the patient takes his breath. So the vocal cords will open, rotate the bronchoscope on its axis 90o and pass it between into the trachea. Make sure you are in the trachea and not in the oesophagus by seeing the tracheal rings. Pass the bronchoscope till you reach the carina.

 

Notice the mucosa for any abnormalities. See the carina, it has to be sharp. If it has widened and swollen, this indicates a sub carinal lesion. At the level of the carina. On the Rt. side and at 3 o'clock the upper lobe orifice arises with its 3 broncho-pulmonary segments:

You can see them with the Rt. angle telescope.

 

At the carina Rt. and Lt. main bronchi arise. The Rt. is wider than the Lt. one and is in continuation with the trachea.

 

Q: if there is a F.B. where will it go?

A: it can go to the Rt. or to the Lt. but; it is more likely to go to the Rt. since it is wider and is in continuation with the trachea.

 

During C.P.R:

The patient is intubated and connected to the ventilator but still his is cyanosed and his A.B.G result is poor.

** the endo-tracheal tube has slipped into the Rt. main bronchus and since the Rt. upper lobe is arising at the level of the carina, so it's orifice will be blocked by the tip of the tube, and since the endo-tracheal tube is in the Rt. main bronchus, so the Lt. lung and Rt. upper lobe are not getting any ventilation. Only the middle and the lower lobes of the Rt. lung are ventilated


 

** Management:-

Pull the endotracheal tube slightly out and ausculate equal air entries on both sides. After the site of the upper lobe is about 4cm tell the site of the orifice of the middle lobe, that this area of the Rt. main bronchus is called the bronchus inter medius.

Clinical importance, if tumor occurs in the area, resect and re-anastmose.

 

Sleeve resection and anastmosis.

 

After the bronchus inter medius area, at 12 o'clock you can see the orifice of the middle lobe, by the Rt. angle telescope, with its 2 segments:

Don’t move the telescope, just turn it on its axis 180o till 6 o'clock, you will see the orifice of the apecal segment of the lower lobe. After a small distance see the basal segments of the lower love with the straight telescope:

Notice any abnormalities, pus, bleeding, discharge or any other change in the mucosa.

 

Come out till the carina, and enter the Lt. main bronchus. Its orifice relatively narrower than the Rt. one and with slight angulations. You will see after a distance the orifice of the upper lobe with its compartments:

 

-         The upper lobe proper with its segments:

o       Apecoposterior and anterior.

-         The lingual with its segments:

o       Superior and inferior.

 

Then you see the lower lobe with its segments:

Like on the Rt. side – Apical

3 basal – anterior, posterior and lateral.

 

N.B. no medial basal on the Lt. side; it is taken by the apex of the heart.

 

The oblique fissures of the lungs arise at the level of T3 transverse process and run obliquely to the cardio-phrenic angle. On the Rt. side a horizontal fissure extends from the level of the 6th costal cartilage to meet the oblique one. Now on the Rt. side we have 3 lobes:

-         Upper

-         Middle

-         Lower

On the Lt. side there is no oblique fissure but there is an imaginary line instead. Now we have 2 lobes in the Lt. lung:

-         Upper

-         Lower

The upper lobe is subdivided into –

-         The upper lobe proper

-         Lingual

 

Rt. Lat. CXR

Take a line from the sternophrenic angle to the hilum and extend it upwards. Take another horizontal line from the hilum and extend it to the anterior chest wall. Now we have 3 lobes of the Rt. lung.


Lt. lateral CXR same as on the Rt. side, but there is no horizontal fissure. There is an imaginary line instead. The upper lobe is subdivided into:

-         The upper lobe proper

-         Lingual                  

 

 

In which lobe is this lesion located?

In P.A. view, we can't say in which lobe but we can say in which zone:

Upper, middle or lower zone of the lung field.

 

Take Rt. lateral view and see the lesion is in which lobe now?

It is in the apex of the lower lobe.

 

End of document.