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possible to perform a bronchoscopy without an endotracheal tube, with a
small-bore tube or with a ventilating bronchoscope.

OPERATION. The position of the patient and the general preparations are the
same as those for direct laryngoscopy. The commonly used size for adults is
the 7 mm x 40 cm bronchoscope, but frequently a smaller tube, e.g. 5 mm x
30 cm bronchoscope is required.

In the case of children, bronchoscopes vary from the infant 4 mm x 30 cm
to the 5 mm and 6 mm bronchoscopes for older children and adolescents.

The bronchoscope (Fig. 104,4) may be passed through a laryngoscope, or
directly through the vocal cords into the trachea. As it passes through the
glottis it is rotated so that the bevelled tip lies in the long axis of the glottis.
The first point to be identified is the carina, a sharp, vertical spur at the distal
end of the trachea and situated between the openings into the main bronchi on

Fig. 106. Segmental bronchi. 1, Apical; 2,
Apicpposterior; 3, Anterior; 4, Lateral; 5,
Medial; 6, Posterior; 7, Superior, 8, Anterior
basal; 9, Lateral basal; 10, Medial basal; 11,
Posterior basal; 12, Inferior lingular; 13,
Superior lingular; 14, Left principal bronchus;
15, Right principal bronchus.

either side. The right bronchus, virtually a direct extension of the trachea, is
entered first and the lower tube segmental bronchi identified and examined.
All the carinae should be sharp and white. As the bronchoscope is withdrawn,
the middle and upper lobe bronchi are seen and the segmental bronchi
examined with a right-angled telescope. The bronchoscope is withdrawn to the
main carina, the patient's head flexed and turned to the right and the broncho-
scope inserted into the left main bronchus. A similar examination is
done using the right-angled telescope for the lingular and upper lobe

Any obvious mass is biopsied, but in the absence of a visible mass 5 ml of
saline should be instilled into each main bronchus and the washings sucked
back into a sterile container and sent for cytology. If the carina is not sharp
and narrow it, too, should be biopsied.

Fibreoptic Bronchoscopy. This is always done under local anaesthesia and a
minute examination is made of the whole bronchial tree right out to the
periphery. The fourth generation of bronchi can be entered. First reports