Which of the following statements regarding rigid bronchoscopy is true? 

A. General anesthesia is required for rigid bronchoscopy.
B. Muscle relaxants must be used for satisfactory ventilation.
C. Proper introduction involves insertion of the tip of the bronchoscope one cm beyond the tip 
of the epiglottis. 
D. It provides the best airway in a patient with critical post-intubation tracheal stenosis.
E. The sniff position is the best head position for introduction and examination. 

Answer D

Rigid bronchoscopy is commonly used to remove foreign bodies, to evaluate hemoptysis, to 
examine pediatric patients, to obtain deep biopsies, and to do therapeutic procedures (dilate 
strictures, core out tumors, place stents, or for laser resections). In a cooperative patient 
with a reasonable body habitus (edentulous, long flexible neck) rigid bronchoscopy can be 
performed with careful local anesthesia. However, most rigid bronchoscopies are done under 
general anesthesia. Muscle relaxants are usually used to facilitate quick induction and 
emergence from anesthesia for this procedure, but these drugs are not required. Patients with 
airway obstruction (i.e., from a tracheal tumor or postintubation stenosis) should not be 
paralyzed until the airway is secured by passing the bronchoscope beyond the obstruction. In 
this case, anesthesia is usually by a deep inhalational technique that allows for spontaneous 
ventilation. 

Proper introduction of the bronchoscope requires good anesthesia, patience, and 
experience because some airways are more difficult to intubate than others. The common mistake 
that beginners make is introducing the bronchoscope too far beyond the tip of the epiglottis 
(i.e., more than one centimeter) before lifting up to visualize the glottis. Similar to 
intubating a patient with an orotracheal tube utilizing a laryngoscope, the best position for 
introduction (not examination) of the bronchoscope is the "sniffing" position. After 
introduction of the bronchoscope into the larynx, the head is extended to facilitate the 
subsequent airway examination.

Rigid bronchoscopy is indicated for the presence of significant bleeding, a foreign body, 
or in pediatric patients. A thorough knowledge of endobronchial anatomy and expertise with rigid 
bronchoscopy is a necessity for the practicing general thoracic surgeon.