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Year : 2021  |  Volume : 38  |  Issue : 1  |  Page : 99-101  

Scope-in-scope versus conventional rigid bronchoscope design: Clinical efficacy and safety

1 Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India

Date of Web Publication31-Dec-2020

Correspondence Address:
Rakesh Garg
Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/lungindia.lungindia_493_20

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How to cite this article:
Kumar A, Madan K, Hadda V, Mohan A, Garg R. Scope-in-scope versus conventional rigid bronchoscope design: Clinical efficacy and safety. Lung India 2021;38:99-101

How to cite this URL:
Kumar A, Madan K, Hadda V, Mohan A, Garg R. Scope-in-scope versus conventional rigid bronchoscope design: Clinical efficacy and safety. Lung India [serial online] 2021 [cited 2021 Jan 26];38:99-101. Available from: https://www.lungindia.com/text.asp?2021/38/1/99/306021

Modern rigid bronchoscopes are popular among pulmonologists and thoracic surgeons for the diagnosis and therapeutic interventions of various benign and malignant airway and lung pathologies. Multiple indications of use include, but are not limited to foreign body retrieval, removal of blood clots and control of hemoptysis, multimodality removal of airway tumor causing central airway obstruction, tracheal dilatation for stenosis, and stent placement.[1]

A typical and conventional rigid bronchoscope consists of a long metallic cylindrical tube. The tubes are available in various length and diameters with the distal end beveled and blunted to prevent injury when intubating and scope manipulation. The longer tracheobronchial tubes also have side ventilation ports. Optical endoscopes for internal visualization are inserted through the proximal portion. The proximal end also has a port for assisted ventilation, connecting jet ventilation and one end plugged with a prismatic light deflector (rarely used). Pulmonologists select the sizes and lengths of bronchoscope depending on the patient physical habitus and operating site of tracheobronchial tree. Proximal lesions in trachea require short-length bronchoscopes (also called as tracheal tubes or tracheoscope). Longer bronchoscopes with side ventilation ports are required for interventions in the major proximal bronchi and distal regions of bronchus.

One disadvantage of the conventional rigid bronchoscopes is the need for repetitive scope removal and reintubation when performing a serial dilatation procedure or navigating through various areas of the tracheobronchial tree. The repeated extubation and intubation with a rigid bronchoscope during complex and longer interventional procedures subjects the patients at risk of airway edema, hypoxia, hemodynamic changes, increased operating time, and longer duration of anesthesia exposure.

The availability of a newer and alternative scope-in-scope rigid bronchoscope design may address these possible limitations. It consists of a graduated cylindrical; color-coded metallic tracheal and bronchial tubes with smooth round inner surface and are available in various sizes.[2] The smooth inner surface of the tracheal tubes allows passage of a thinner diameter bronchial tube through it coaxially in smooth fashion. Patients are first intubated with a size tracheal tube (shorter tube) [Figure 1]. The proximal part (universal base) is detachable and connects universally to all sizes of tracheal and bronchial tubes by Medlock connection. After intubation with a tracheal tube, the universal base is detached from it and the same is connected to a narrower bronchial tube. The narrow bronchial tube (with ventilation side ports) is subsequently introduced through the tracheal tube to negotiate to the distal airway. Side ports of the inner bronchoscope can ventilate both the lungs during tracheal lesion interventions. Another advantage of the design is minimization of ventilatory leak that would occur with a single longer bronchial tube. Scope-in-scope allows better air seal.
Figure 1: The patient is intubated by rigid short tracheal tube. A longer and narrower rigid bronchoscope (pulmonologist holding in right hand) is introduced through the rigid tracheal tube (scope-in-scope)

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Contralateral lung ventilation can also be achieved during manipulation of bronchial lesions. The universal base has unique characteristics. The proximal part of the base is allowed to rotate freely, whereas the distal part is fixed to the tracheal tube [Figure 2]. Lateral port silicone caps with one or two holes allow insertion of laser fiber, suction catheters, or argon-plasma coagulation fibers. These obturators are detachable to remove larger foreign bodies without extubating the patients. The proximal portion of universal base has attachments for breathing circuit and jet ventilators. The silicone caps allow smooth passage of various rigid and flexible instruments. They also prevent ventilatory leak during positive pressure ventilation, which is a common trouble faced by anesthesiologists during rigid bronchoscopic procedures. Corresponding color-coded tracheal stent introducers are also available. One of the safety features of these tracheal stent introducers is their inability to pass through the distal end of the tracheal tube to prevent injury to the bronchial tree.
Figure 2: Universal base is attached to the proximal portion of the rigid tracheal tube and is detachable. The red-colored silicone cap is attached to the proximal end. The lateral port with silicone caps (blue) allows introduction of instruments

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The above-mentioned modifications can have overall clinical benefits by decreasing the operating time, increasing the operating ease of surgeon, and less adverse effect of airway edema and respiratory complications. The scope-in-scope rigid bronchoscope design may be particularly advantageous in situations wherein a repetitive scope removal and reintubation is anticipated during the procedure. This may be especially advantageous in serial dilatation of a benign tracheal stenosis and performance of transbronchial lung cryobiopsy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Nicastri DG, Weiser TS. Rigid bronchoscopy: Indications and techniques. Oper Tech Thorac Cardiovasc Surg 2012;17:44-51.  Back to cited text no. 1
Pathak V, Welsby I, Mahmood K, Wahidi M, MacIntyre N, Shofer S. Ventilation and anesthetic approaches for rigid bronchoscopy. Ann Am Thorac Soc 2014;11:628-34.  Back to cited text no. 2


  [Figure 1], [Figure 2]


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