Controlled Suction during Flexible Fiberoptic Bronchoscopy

Abstract

To the Editor: The performance of flexible fiberoptic bronchoscopy requires multiple stimultaneous manipulations to be carried out by the endoscopist. The instrument is rotated by bending the wrist of the same hand which moves the knob to alter flexion of the tip. The other hand moves the bronchoscope at the nose in and out of the tracheobronchial tree. Other maneuvers performed are instillation of local anesthetic and lavage solutions, manipulation of brush and biopsy forceps, and suctioning to effect the removal of secretions. An assistant is necessary to accomplish many of these tasks; however, aspiration of secretions requires accurate timing in the initiation and discontinuance of the negative pressure. Attempts at suctioning when the tip of the bronchoscope is more than 1 or 2 mm away from secretions result in failure to aspirate them. Excessive application of suction results in apposition of the mucosa against the end of the bronchoscope and further obscuration of visualization. This is especially critical when the bronchoscope tip lies within the smaller airways of the segmental and subsegmental levels. Here, suctioning must be very rapidly terminated to prevent complete collapse of the airway distal to the tip of the instrument. For these reasons the endoscopist must not delegate this task to his assistant; however, as stated, both hands are already occupied. A new model of one flexible bronchoscope *BF-B2 Bronchofibersoope, Olympus Inc., New Hyde Park, NY. has recently been marketed to allow application and release of aspirating pressure by the endoscopist without sacrificing control of the instrument. It is not necessary, however, to discard all the previously available instruments. A simple attachment* **Marketed by Rodel Medical, Inc., Somerville, NJ.* has been devised (Fig 1) that can be incorporated onto any flexible bronchoscope. A three-way stopcock which fits into the aspirating channel of the bronchoscope is at one end. A short length of tubing connects the stopcock to a plastic valve that has an opening in the path of flow. Occlusion of this opening results in application of suction through the bronchoscope. This is then connected by way of a 6foot length of tubing to a trap which is interposed in the suction line. This trap collects the specimen aspirated. The plastic valve containing the opening may be easily connected to the bronchoscope head opposite the control knob by pressing the Velcro material on the valve bottom to matching Velcro placed on the bronchoscope. Use of this attachment allows the endoscopist to rapidly apply and release occlusion, thus initiating and discontinuing suction with one finger without sacrificing control of the bronchoscope. Suction is applied only when the tip of the instrument is close enough to the secretions for their removal; suction is released immediately thereafter. Use of a three-way stopcock at the aspiration channel of the bronchoscope permits instillation of local anesthetic and lavaging solutions without removal of the suction connection from the instrument. Normal saline solution may be instilled by the assistant, who immediately returns the stopcock mode to aspiration. The lavage solution is removed and caught in the suction trap without interrupting endoscopic visualization. Use of this adapter obviates mucosal damage and airway collapse resulting from excessive application of suction to the aspiration channel of the bronchoscope. Lavaging solutions and bronchial secretions are thus more effectively removed. The complete adapter is discarded after each use, retaining the trap filled with bronchial washings for cytologic and bacteriologic examination. Modification of present flexible bronchoscopic techniques by incorporation of this disposable adapter will prevent instruments presently in use from being outmoded.