The application of endoscopic methods to evaluate and treat disorders of the airways is an essential skill for the clinician who practices anesthesiology, thoracic surgery, pulmonary medicine, or otolaryngology. As with most facets of practice, endoscopic technology is constantly changing. The clinician must, therefore, be aware not only of the historical development of techniques, but also of currently available methods and instrumentation, so that he may properly select the appropriate equipment and use it effectively.

Although ancient physicians from Greece and the Middle East clearly made efforts to peer into body orifices using specula, Bozzini seems to have been the first to create a device specifically designed to direct light into a cavity. He described his lichleiter in 1806. This used a wax candle as a light source and a mirror directing the light into the various parts of the body so that he could examine through a lens. He is reported to have performed vaginal, rectal, and pharyngeal examinations with this instrument.¹,²,³ The first clear use of an endoscopic technique to examine the airway was by Gustav Killian in 1897. For his initial efforts, he hired a paid volunteer but later successfully removed a foreign body from the airway.⁴ The use of various tubes, light sources, and lens systems flourished in the early half of the 20th century. A major contributor in the United States to the development of the techniques and devices was Chevalier Jackson who practiced bronchoesophagology in Pittsburgh and Philadelphia. He is widely considered to be the father of American otolaryngology.⁵ In 1968, Ikeda⁶ first reported on the use of the flexible fiberoptic bronchoscope. The ease of use and patient comfort with this device allowed it to quickly overshadow the rigid bronchoscope for the purpose of examination of the airways.

The rigid bronchoscope is a hollow tube, with a fiberoptic light source usually conveyed to the distal end. The distal end is beveled to facilitate insertion and maneuvering in the airway. There are side openings in the distal end to permit ventilation of the contralateral bronchus, when the scope is introduced into a distal bronchus. The tubes come in various diameters and lengths. Proximally there is an opening for viewing and working. Viewing is enhanced by inserting a telescope and camera through the tube. The proximal opening may be occluded with a window plug if a closed system is desired, or to prevent backflow of contaminated material. There is a side port for attaching a ventilation circuit and a smaller port for connecting a jet ventilator (Fig. 43-1).

There are several indications for considering rigid bronchoscopy. This method is clearly more effective than flexible bronchoscopy in clearing thick inspissated secretions or blood. When confronted with significant bronchial bleeding, clearing the blood, packing off the offending bronchus (with hemostatic gauze), and ventilating the contralateral lung requires rigid bronchoscopy. Many foreign bodies can be removed by flexible bronchoscopy, but the more troublesome ones that are elusive, large, or impacted can be best dealt with by rigid bronchoscopy. Obstructing tumors in the trachea and mainstem can be debrided more expeditiously with a rigid bronchoscope, and flexible laser bronchoscopy can be performed through a rigid bronchoscope to combine the advantages of each technique. The indications for rigid bronchoscopy are listed in Table 43-1.

Insertion of a rigid bronchoscope should be accompanied by an initial examination of the facial anatomy and the upper airway, as one would perform for standard endotracheal intubation. The ideal patient for rigid bronchoscopy is thin and edentulous, with a long supple neck and a generous mouth opening. Such a patient is rare. Features such as prominent teeth, small mouth with a receding chin, and cervical fixation or kyphotic posture, all contribute to making the procedure more difficult and thus more hazardous. Although none of these features will be an absolute contraindication to performing rigid bronchoscopy, the endoscopist must carefully weigh the risks presented by patient anatomy before proceeding.