Guide helps to Know about diagnostic bronchoscopy
No physician specializing in respiratory medicine today is considered adequately trained unless competent with the bronchoscope:
the problem is learning the art. While nothing can replace personal clinical practice and experience, access to a representative collection of illustrations helps to solve the problem. Normal anatomy and a variety of pathological conditions can be studied in a few hours to give preparatory knowledge, albeit superficial, which would take months to obtain in any other way. Rescrutiny of illustrations, after lesions have been seen in reality, further helps to consolidate knowledge and experience. The colour photographs reproduced in this book, forming a representative collection of normal and common abnormal findings, were all taken during routine bronchoscopy sessions and have been selected with the learner’s needs in view.
It should be stressed that the aim of the work is strictly limited. Technique is dis-cussed only in outline on the assumption that a practical apprenticeship will be . served. No attempt is made to produce an exhaustive atlas, to review literature, to deal with the special problems of bronchoscopy in children, to discuss the complicated subject of foreign body removal, or to advise on available apparatus. Such matters are either dealt with in other publications, or will depend on the personal preference of the operator and his teacher.
This book is produced to help the student of bronchoscopy appreciate the true value of the investigation and learn his way about the normal and abnormal bronchial tree; it is not an advanced textbook. Today, most respiratory physicians are competent with the fibrescope but very few young bronchoscopists have experience with the rigid bronchoscope. This is considered less than ideal, for the instruments have complementary advantages and limitations which require competence with both. Thus a chapter on rigid tube bronchoscopy is retained diagnostic bronchoscopy.
However, variations in bronchoscopic technique do not affect the value of this pictorial monograph: the findings are the same, however viewed. In this connection, the learner is advised constantly to think of the bronchial tree as a three dimensional entity; not in terms of two-dimensional pictures. Not only will this assist in handling the instruments, but will greatly reduce problems of orientation if changing the technique of operating, or viewing photographs taken with patients postured differently from that to which he is accustomed. No photographs taken through the bronchofibrescope have been included because the limitations imposed by fibre bundle image transmission make them markedly inferior to those obtained by the best rigid optics diagnostic bronchoscopy. Furthermore, pathological states occurring in small bronchi, only visible through the fibrescope, are no different, except in size, from those illustrated here. Photographs of the more peripheral normal anatomy are also considered unnecessary. The details are so varied and yet the general plan so comparable, whichever segment is studied, that the large number of similar photographs needed would be confusing and of little clinical value.
The text has been kept short and dogmatic to serve as an introduction to each group of photographs,diagnostic bronchoscopy which are then individually and briefly discussed. Although taken through a rigid bronchoscope with the patient supine, they have, for this edition, been inverted because it is appreciated that the majority of bronchoscopies are now performed with the operator facing his patient. An exception is made in Chapter 4 when discussing the introduction of the rigid bronchoscope. Annotated drawings are provided which serve to locate the items of major interest in each photograph. To help in appreciating the anatomy, perspective and spatial relationships, small conventional plans of the bronchial tree have been added. An arrow indicates the position of the telescope objective lens, and the direction in which it was pointing, when the photograph was taken. No attempt has been made to draw intraluminal lesions on these plans, but when the anatomy differs from the prevailing pattern, or has been distorted, this has been indicated where possible: distortions in the sagittal plane, however, cannot be expressed in this way (for example Plates 97, 98 & 102).
Approximately a fifth of the photographic plates are deliberately devoted to normality because this has a wide range and is very often as difficult for the beginner to appreciate as are the varieties of pathology. furthermore, patients with healthy mucosa are rarely bronchoscoped and thus the opportunity to see the normal occurs infrequently. Among the pathological conditions, pride of place is given to those arising most commonly; inflammatory changes, bronchial distortions and the manifestations of bronchial carcinoma. It is more important that the learner should thoroughly understand normality, and the common pathological conditions, than become confused by rarities. A few unusual conditions are included to whet the appetite.