Systematic Bronchoscopy: the Four Landmarks Approach

This protocol provides novice bronchoscopists with a memorable way to learn how to navigate the bronchial tree using the Four Landmarks Approach. For the unexperienced operator, it's quite difficult to find the way in the bronchial tree when performing a bronchoscopy. We have developed a Four Landmark Approach, meaning that you should find four landmarks, and you can always go back to the four landmarks when you lose your way, and then you can proceed.

And we use the four landmarks in connection with the angles. This is the distal end of the endoscope. This is the handle, so when I turn my wrist, I can turn the distal end of the endoscope in different angles, and these angles, we connect with the four landmarks.

With the development of artificial intelligence, we hope to develop an automatic bronchial identification system that can help novice bronchoscopists to identify the individual segments and ensure a full inspection of the bronchial tree. Bronchoscopy has historically been taught with a see one, do one, teach one approach. But with this protocol, we present a standardized way of teaching bronchoscopy.

To begin, enter the airways through the mouth or nostrils, then pass the vocal cords, and enter the trachea. Locate the four landmarks systematically from Landmarks 1 to 4, and note the correct angle of the endoscope in each position. Next, according to the four landmarks, find the segments chronologically from 1 to 10, from the right side first and then from the left side.

At Landmark 1, locate the bronchoscope in the distal part of the trachea at a zero-degree angle, maintaining a neutral position. Then at Landmark 2, turn the endoscope 90 degrees to the right, while simultaneously flexing the distal end of the bronchoscope upward by pushing the left thumb down to investigate the upper lobe. While visualizing the Mercedes star, defer from the 90 degree angle to inspect Segments 1, 2, and 3.

Next, at Landmark 3, move on to the bronchus intermedius by placing the distal end of the endoscope at a 45-degree angle to the right to view Segments 4 and 5. Temporarily defer from the 45-degree angle to examine Segments 4 and 5. Then return to the 45-degree angle, and extend the tip of the endoscope by pushing the stewing lever up with the left thumb to inspect Segment 6.

Turn the scope to a zero-degree angle and proceed to the lower lobe to locate Segments 7, 8, 9, and 10. Then defer from the zero-degree angle to inspect Segments 7 to 10. At Landmark 4, move the bronchoscope to the left main bronchus at a 90-degree angle, upward to view the upper lobe and downward to view the lower lobe.

Retain the scope at a 90-degree angle, and inspect the left upper lobe with the lingula. Then defer from the 90-degree angle to examine Segments 1 plus 2, and 3 from the left upper lobe, and Segments 4 and 5 from the lingula. Then return to the left main bronchus.

Turn the scope to a 45-degree angle, and extend the end of the bronchoscope to inspect Segment 6, which is opposite Segments 4 and 5. Finally, turn the scope to a zero-degree angle to visualize the lower lobe. Then defer from the zero-degree angle to inspect Segments 8, 9, and 10.

The most important factors for the completion of a simulation-based course in flexible bronchoscopy are shown here. The total of responses is greater than 100%as some participants mentioned more than one factor. Of those who completed the course, 57%found it clinically relevant, and 47%found the course valuable.