06/03/2026
**SMALL STEPS, GIANT IMPACT**
A case that reminded us that bronchoscopy is sometimes more about problem solving than simply following the airway map.
We received a referral from our outstanding respiratory colleague in Terengganu. The patient was a 67-year-old gentleman, an ex-smoker, who had been experiencing pleuritic chest pain for about two months. Imaging revealed a mass in the right middle lobe.
Before the procedure, we carefully mapped the airway. Everything looked straightforward. The target bronchus was RB4a, a third-generation bronchus, and the expectation was that the radial EBUS would show a concentric lesion. With this in mind, we proceeded with bronchoscopy under conscious sedation. The patient tolerated the procedure well.
However, once inside the airway, the procedure did not go as smoothly as expected.
Despite multiple attempts, we were unable to cannulate the targeted RB4a bronchus. Rotating the body of the bronchoscope did not translate well to the tip. Several factors seemed to be working against us — the relatively small bronchial lumen compared to the scope size, the angulation of the airway, and the characteristics of the disposable bronchoscope we were using. To make things more complicated, the working channel exited on the left side while the target bronchus was on the right, making alignment of the radial EBUS probe and sheath particularly difficult.
After a brief pause, we decided to try something different. Something simple and crucial, but was missed in our initial plan!
Instead of continuing with the usual orientation, we rotated the bronchoscope 180 degrees using the rotation ring before entering the middle lobe bronchus. In essence, we approached the middle lobe using a reverse technique. This maneuver brought the working channel to the right side, aligning it much better with the target bronchus.
The difference was immediate. The radial EBUS probe and sheath could now be inserted smoothly into the RB4a bronchus. Radial EBUS showed a concentric lesion, and fluoroscopy confirmed the position. We proceeded with forceps biopsy, obtaining generous samples. Rapid on-site evaluation showed malignant cells.
Subsequent histopathology and FNAC confirmed the diagnosis of non-small cell lung carcinoma.
This case was a good reminder that even when airway mapping suggests an easy target, real procedures can still present unexpected mechanical challenges. The orientation of the bronchoscope and the direction of the working channel can make a significant difference, especially when dealing with angled bronchi and disposable scopes.
Sometimes the solution is not pushing further down the same path, but simply changing the angle from which we approach the problem.
Happy to learn from each of our little steps!!! :)
