History

“The Glottiscope” (1807)

The honor of being the Father of “Endoscopy” belongs to Philipp Bozzini [1, 2], who revealed the precursor of all endoscopes in 1807. He managed to deliver candle light into the bodily cavities through his invention of “light conductor” [Lichtleiter]. Speculums of various sizes and designs were created based on the cavities to be examined, embarking in the era of endoscopy. The “glottiscope,” invented in 1828 by Benjamin Guy Babington, for the rst time allowed inspection and ability to visualize the laryngeal areas that were earlier not amenable to direct examination [2]. He carried this out by attaching a mirror to a tube to allow the refection of light and images.

T. S. Panchabhai

Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA

e-mail: Tanmay.panchabhai@dignityhealth.org

M. Ghobrial · A. C. Mehta (*)

Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA e-mail: mehtaa1@ccf.org

“The Esophagoscope” (1895)

A Spanish music teacher and singer, Manuel Garcia, took it upon himself to try to look at the “voice box” of his students in an attempt to see how voice is produced. This indeed was the rst known attempt to visualize the larynx, which he accomplished by using a dental mirror [3]. However, Alfred Kirstein (1895, Germany) was the rst to report direct visualization of the vocal cords and proximal large airways, using an esophagoscope. He called this process autoscopy (i.e., examining the airways without a mirror) [4, 5].

“Rigid Bronkoscopie”: From the Era

of Gustav Killian (1876–)

and Chevalier Jackson (1904–)

Gustav Killian is regarded as the Father of Modern Day Bronchoscopy (Fig. 42.1). He was born in Freiberg, Germany, and was an otolaryngologist. He examined the trachea and the main bronchi of a volunteer, using a laryngoscope, and was later able to remove a pork bone and three other foreign bodies from the main bronchi (Fig. 42.2). This incident was described later by his assistant O. Kollofrath as follows: “On March 30th of this year I had the honor to assist my admired principal, Prof. Killian, in extraction of a piece of bone from the right bronchus. This case is of such peculiarity with respect to its diagnos-

Fig. 42.1  Gustav Killian—the Father of Bronchoscopy

Fig. 42.2  Gustav Killian performing bronchoscopy

tic and therapeutic importance that a more extensive description seems justi ed.” [5, 6] This memorable experience led Killian to coin the term “directe bronkoscopie.”

A direct ocular mechanism consisting of an illumination and suction tubing attached to a rigid bronchoscope was developed by a Philadelphiabased otolaryngologist, Chevalier Jackson (1904) (Figs. 42.3, 42.4, and 42.5). This is considered to be the precursor of the modern day rigid bronchoscopes. Dr. Jackson became renowned in his time for extracting aspirated or swallowed foreign bodies from children and adults. He kept meticulous records of every object he removed to help other doctors learn his techniques. The Mütter Museum in Philadelphia displays 2374 objects recovered by Dr. Jackson during his 75-year- long career. He conducted numerous handson training courses that were instrumental in increasing the acceptance of bronchoscopy. The Pan-American Association of Otolaryngology and the International Bronchoesophagology Society were founded by Dr. Jackson. In 1907, he published the rst systematic textbook on bronchoesophagology and dedicated it to Killian, the “Father of Bronchoscopy.” [7] Notable men-

Fig. 42.3  Chevalier Jackson—the Father of American

Bronchoesophagology

Fig. 42.4  The rst illuminated rigid bronchoscope introduced by Chevalier Jackson

tion for other contributors who provided their valuable service in developing the eld of bronchoscopy were: Edwin Broyles who developed an optical telescope with forward viewing, Paul H. Holinger for bronchoscopic photography, Neel and Sanderson for endobronchial cryotherapy, Laforet for the use of a CO2 laser on

Fig. 42.5  Chevalier Jackson working in a watermill to construct rigid bronchoscope

the trachea in 1976, and Hooper and Jackson for endobronchial electrosurgery in 1985 [8].

The Rigid Bronchoscope (1897–)

Killian’s descriptions regarding bronchoscopic examination of the proximal airways were critical in providing inspiration to his coworkers Von Eiken, Brunings, Seiffert, and Albrecht, who worked on further development of the rigid bronchoscope. Storz and Wolf became the two pivotal companies that introduced newer technologies and newer versions of the rigid bronchoscope. On the other hand, the development of rigid bronchoscopy in the United States was brought about by Chevalier Jackson with his instrument maker, George Pilling. The next task at hand was the development of telescopic optics for bronchoscopy. This was accomplished by E. Broyles, who had trained under the mentorship of Dr. Jackson (1940). He then also went on to introduce the optical forceps in 1948 followed by ber illumination techniques in 1962. The use of rigid bronchoscopy had declined since creation of the fexible bronchoscope until special tools for stent placement and neodym- ium-doped yttrium aluminum garnet (Nd:YAG) laser application were invented by J.-F. Dumon. The use of rigid bronchoscopy has since

regained prominence, particularly for advanced therapeutic bronchoscopy [8].

The Flexible Bronchoscope (1968–)

The potential of beroptic imaging in bronchoscopy was rst recognized by Shigeto Ikeda (1962), a thoracic surgeon at the National Cancer Center in Japan (Fig. 42.6). He approached the Machida Corporation to develop a fexible bronchoscope with a diameter of less than 6 mm. In 1964, the prototype device was developed, which since then has undergone numerous revisions. In 1966, the rst useful device was presented at Copenhagen in 1966. This device, comprised of over 15,000 glass bers, was the rst modern dayberoptic bronchoscope [9].

After the optical technology was incorporated, the next round of modi cations involved the

Fig. 42.6  Shigeto Ikeda with fexible bronchoscope

adoption of a working channel. This Machida fexible bronchoscope became available in 1968, which is known as the year of the “second revolution” in bronchoscopy. Researchers further revised the bronchoscope to make it more maneuverable at the tip that allows U-turn angulation for entry into the upper lobes. Olympus rst came out with its model in 1970 with better imaging capabilities as well as ease of handling [9].

The rst videobronchoscope developed by Asahi Pentax Corporation (1967) also involved signi cant contributions from Shigeto Ikeda [9]. Today, video bronchoscopy is an integral part of the practice of chest medicine as most ailments of the airways can be diagnosed, palliated, or sometimes cured by use of the fexible bronchoscope. Although removal of foreign bodies from the endobronchial tree was the initial application for the rigid bronchoscope, currently the majority of foreign bodies, even in the pediatric age group, are successfully removed with the fexible bronchoscope in a relatively noninvasive fashion [10].

Transbronchial Lung Biopsy (1972) (Fig. 42.7)

Howard Anderson recognized the potential of accessing and sampling the lung parenchyma through the bronchoscope for histological analysis. After gaining some animal data with initial experiments, they reported their experience in obtaining bronchoscopic biopsies using a fexible forceps in 13 patients [11]. A subsequent larger series was published by Anderson and Fontana reporting data on 450 patients [12]. All biopsies performed by Anderson and colleagues were done using a fexible forceps passed through a rigid bronchoscope. These forceps were 60 cm in length and 7F in circumference. They also explained how they would engage a tiny peripheral bronchial carina with moderate pressure to obtain a small biopsy of the lung without causing a pneumothorax from pleural rupture. The rate of pneumothorax was 19% in the rst 150 patients