BRONCHOSCOPY

BRONCHOSCOPY

Background
A Otolaryngologist gets Germany nationality, Gustav Killian, doing bronkoskopi the first on year 1897, by use of bronkoskopi stiff to issue ham bone from bronkus right main (mainsterm bronkus). Killian successfuling to issue that intern object and preventing be done trakheostomi. Until at the early methods 19th century this accepted medically as tool to issue intern object. This tech continually been developed Killian so bronkoskopi's indications gets to extend. As a result of innovates and bronkoskopi's development worldwide, Killian in common known as Father Bronkoskopi.
At the early 19th century, Chevalier Jackson, a laryngologist at Philadelphia, developing yen on bronkhoskopi, and beginning develops “ tube ” bronkhoskopi. On year 1904, Jackson revamps bronkoskopi stiff, with adds direct ocular, suction's tube and distal's tip to lighting or illumination. Jackson continually designs and make bronkhoskopi new and affix tool to perfect new teches for evacuation or strange object expenditure. It also develops and emphasizing the importance for procedure for safety protocol up to action which is done and this tech still is utilized hitherto. On year 1907 Jackson publishes to bind books monumentalnya who gets title “ Tracheobronchoscopy, Esophagology and Bronchoscopy ”. Jackson understands the importance for training program endoskopi, and teaches instruksional bronchoesophagology's course. She is looked on as Bronchoesophagology's Father America (Raoof, 2001).
On year 1966 Shigeto Ikeda introduces bronkoskopi flexible (FB) with pencitraan's technology optic fiber. It constitutes area deep revolution bronkoskopi. Ability for flexi distal bronkoskopi's tip enables bronchoscopist (bronkoskopi's operator) to reach to as almost all part of smaller breath channel of treed tracheobronchial (bronkus's segment or smaller air-piping). Since introduced by its purpose on year 1960 an by Shigeto Ikeda, bronkoskopi is optic fiber have increased its utility, with more or less 500.000 procedure were done at USA each year it. FOB have become constant procedure by pro paru and also as tool of diagnostics for thorax surgeon, anaesthesia and also intensivist (Ovassapian, 2001).
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Hasegawa (1998), 27% bronkhoskopi emergensi is worked for atelektasis and sekret's retention respiratory tract, 17% for ARDS and edem paru, 13% for stenosis respiratory tract, 13% for pneumonia and empiema, 8% for about blood respiratory tract and strange object aspiration and 2% for bronkhiale's asthma. Of 198 FOB that is worked at ICU, 47% are done in consideration therapy, 44% for diagnostics reason and 9% for reason both (Raoof, 2001).
    One of utility from FOB is issue mucous plug one that constitute its happening cause respiratory tract retention and atelektasis. On patient with atelektasis lobar sinister soul or kolaps paru, bronkhoskopi may not be delayed if chest physical therapy fails. Gain terapiutiknya is remedial appreciable aeration with auskultasi, interchange gases radiografik's the better and prove of paru's volume expansion on 40% 80% procedures (Baughman, 2001)
    On patient with hemoptisis, bronkhoskopi can give amenity to access to lobus top-ranking and orificium one that more distal. If place about blood active can't be identified for sure, bronkhoskopi can be utilized to flush paru's segment and looking for arises it about blood. After hemoptisis's source is found, done by direct instilasi saline is chilled or saline combine with efineprin. This action gets to discontinue about blood and gives chance for preparation torakotomi (Raoof, 2001).
    On one research of 60 patients with corpus alienum  paru, about 60% successful being issued by FOB, and 98% by RB. Useful flexible equipment especially if that intern object is over distal to RB's action.
FOB'S action often been utilized to get specimen of under-side breath channel. Method that is utilized is bronchoalveolar lavage (BAL), protected is brush's side (PSB), and bronchoscopy lung is biopsy (BLB) one that often been worked ala all together to identify patogen that potential (Baughman, 2000).
Steven dkk (1991) in 92 bronkhoskopi's actions its diagnostics, finding bad ET place on 15% patients. In this case, bronkhoskopi can detect paska's complication tube's place, including damage trakea, subtracted tube assembly correct, trakea's oedema and erosion. It often barmanfaat in penatalaksanaan patient that experiences stridor ekstubasi's afters (Raoof, 2001).

A.    Bronkhoskopi
1.    Bronkhoskopi's savvy
Say bronkoskopi comes from greek; broncho that meaning windpipe and scopos what do mean to see or watching. So, bronkoskopi is probing visual clears a root paru's breath or respiratory tract bronkus the so called. More special again, bronkoskopi constitutes medical procedure, one that did by doctor that have interest at its area with checks bronkus or lung ramification for the purpose diagnostics and terapeutik (cure). To procedure it doctor utilizes bronkoskop, a sort endoskop, one that constitute instrument for probing organ in body. Cling to medical reason or clinical indication for bronkoskopi, doctor can utilize bronkoskopi stiff (rigid) or Fiber Optic Bronchoscopy (FOB). 














Image 2.3.  Broskhoskopi
2.    Bronkhoskopi's type
Base form and bronkoskopi's tool character, now recognised two bronkoskopi's kinds, which is Rigid Bronkoskopi( Rigorous pipe) and Fiber Is Bronkhoskopi's Optic( Optic fiber)
a.    Rigid Bronkoskopi( Rigorous pipe)
    Bronkoskopi rigid constitutes tube-shaped tool straight made from material stainless steel. Long and wide varies, but bronkoskopi for mature usually gets footage 40 cm and ranging diameters 9 13,5 mm, bronkoskop's wall thick ranging 2 3 mm. Bronkoskopi rigid usually being done by patient under general anesthesia. This action has to be done by bronchoscopist is experienced at room hads out. Bronkoskopi rigid is betokened on patient with obstruksi breath channel outgrows where with FOB can't be done. Another common indication is: 
1)    Control and blood cough handle massif
2)    Issuing strange object of trakeobronkial's channel
3)    stenosis's handle breath channel
4)    obstruksi's handle effect breath channel neoplasma
5)    sten bronkus's assembly
6)    bronkoskopi's laser











Image 2.4.  Rigid Bronchoscope
b.    Fiber Optic Bronkhoskopi( Optic fiber)
    Fiber Optic Bronkhoskopi really helps deep uphold diagnosis on abnormality that is met at lung, and amends as an invasif paru's diagnostic procedure. 
FOB as tubed as elongated flimsy with diameter 5 6 mm, constituting channel for additional instrumental insertion place one is utilized to get phlegm sample or network even. Usually 55 cm of full scale FOB'S tube length contain optic fiber that emits light. distal FOB's tip have light source who can enlarge 120o of 100o field sees that projected to video or camera display. Its tube so flexible so enables operator to see corner of 160o 180o onto and 100o 130o downwards. It enables bronchoscopist FOB to see to smaller segment and branch sub segment bronkus onto and downwards from bronkus main, and also back forwards (anterior and head and shoulders above). 











            Image 2.5.  Fiber Optic Bronchoscope

3.    Bronkhoskopi's indication
         Indication from bronkoskopi is subject to be help deep uphold diagnosis, as terapeutik and pre operatif / post's evaluation hads out. 
a.    Diagnostic indication
One that included bronkoskopi's diagnostic indication for example: 
1)    Cough
2)    Cough unknown blood its cause
3)    Wheezing is local and stridor
4)    Picture takes photograph abnormal thorax
5)    Obstruksi and atelektasis
6)    Mark sense strange object in breath channel
7)    Bronchoalveolar Lavage's check (BAL)  
8)    Lymphadenopathy or intrabronkial's mass on intra thorax
9)    Karsinoma bronkhus
10)    There is prove sitologi or still suspect
11)    karsinoma bronkus's degree determination
12)    Follow up karsinoma bronkus
b.    Indication is damped down
1)    One that included terapeutik bronkoskopi's indication for example: 
2)    Issuing sekret / bate mukus hank cause of atelektasis, paru's pneumonia and abscess
3)    Issuing strange object on trakeobronkial
4)    stent's assembly on trakeobronkial
5)    bronkus's dilatation by use of balloon
6)    Cyst on mediastinum
7)    Cyst on bronkus
8)    Issuing something with bronkoskopi
9)    Brachytherapy
10)    therapy's laser
11)    paru's abscess
12)    Chest trauma
13)    Therapeutic lavage (pulmonary alveolar proteinosis)


4.    Bronkhoskopi's position
a.    Supine sleep
b.    Sit in chair
5.    Bronkhoskopi's tech
There is 3 bronkhoskopi's tech kinds, which is:
a.    Trans nasal
b.    Trans oral (one that often been done)
c.    Via rigid or endotrakeal
6.    Bronkhoskopi's Indication con
Action indication con bronkoskopi consisting of absolute indication con and relative.
a.    Absolute indication con for example:
1)    kooperatif's subtracted patient
2)    Operator skill less
3)    Subtracted facility is equal to
4)    Unstable tonsillitis
5)    Aritmia that doesn't be controlled
6)    Hipoksia that doesn't respond with oxygen application
b.    Relative indication con for example:
1)    Heavy asthma
2)    Hiperkarbia is weight
3)    Koagulopati that serious
4)    Bulla emfisema is weight
5)    Obstruksi trakea
6)    High Positive end expiratory pressure

7.    Bronkhoskopi's complication
In a general way FOB have tall security bounds with mortaliti's number 0 0,4 % by major complications (about blood at the time done by biopsy, exhalation depression, henti is heart, aritmia, and pneumotoraks) < 1 % at the time action bronkoskopi. 
a.    premedikasi's effect complication
1)    Respiratory depression
2)    Hypotensi
3)    Sinkope
4)    Henti is breath
b.    Local anesthesia effect complication
1)    Spasme is larynx
2)    Methemoglobinemia
c.    Action effect complication bronkhoskopi
1)    Spasme is larynx
2)    Breath baffled
3)    Pneumonia
4)    Pneumothorax
5)    About blood
6)    Henti is heart (cardiac arrest)
7)    Takikardi
8.    Premedikasi Bronkhoskopi
premedikasi's action so encouraged for all patient which will do bronkhoskopi, but on stoned patient or patient already being assembled by endotrakeal tube.
a.    To the effect premedikasi
1)    To the effect common
a)    To prevent doctor effect simpatolitik of anaesthesia doctors
b)    To reduce has cold feet or ache and actively will give calm on patient. This doctor is working sentral's ala and amnestik (that amnesia patient).
2)    To the effect special
a)    Remove to have cold feet and alarm
b)    Increasing collaboration among patient and doctor
c)    Reducing reflek cough and reflek devours that gets to trouble action fluency, because if reflek extant cough can evoke disaritmia and bronkhospasme.
d)    Can reduce possible arise keracunan on nervus sentral's system because anaesthesia doctors.
b.    premedikasi's doctors
1)    Sulfas Atropin
Sulfas Atropin gave by dose 0.5 mg, dose can be increased according to need, given 30 minutes before done by bronkhoskopi with intent for:
a)    Constraining vasovagal reflek
b)    Reduce one diarrhoea
c)    Neutralizing local's anaesthesia doctor
d)    Reducing because of excitement bronkhoskopi
2)    dipenhydramin
a)    Given by dose 1 cc( 10 mg)
b)    Dose can be given until 20 mg or accords requirements
c)    Given in company with sulfas atropin IM's ala with intent to prevent marks sense allergy of body to anaesthesia doctors.
c.    Things that needs to be noticed by nurse
1)    Before done by premedikasi patient shall measure blood pressure, artery (cardinal's phenomena)
2)    Make ready emergency's doctors as adrenalin, kalmetason, petidin, midazolam, infuse, etc..
9.    Bronkhoskopi's anaesthesia
Anaesthesia application is meant that up to done by bronkhoskopi patient not perceives pain, rileks and cool headed so operator gets to work maximal ala. On bronkhoskopi's action, anaesthesia gave by two kind make the point, which is:

a.    Local anesthesia
1)    Routinely all action bronkhoskopi utilizes local anesthesia
2)    Local anesthesia is given 30 premedikasi's afters minute, with menyemprotkan xylocain spray 10% on tongued jetty, pharynx and larynx. Spraying may not be more than 20 spray times.
3)    Hereafter been done instilasi lidocain 2% 4 6 cc and was expected by this lidocain can scatter merata at bronkhus second main and its branch.
4)    Pemakain entirely may not be more than 400 mg.
b.    General anesthesia
    In a general way action bronkhoskopi not require general anesthesia but on situation as follows:
1)    If sensitif's patient or susceptible to local anesthesia doctors
2)    If pemakain bronkhoskopi requires so long time.
10.    Bronkhoskopi's Action preparation
bronkhoskopi's action preparation there is two kinds which is patient preparation and tool and doctor preparation.
a.    Patient preparation
1)    Information that gets bearing with previous diseased history, present disease, condition of physical and patient mental and allergic reaction history to doctor who will be utilized for bronkoskopi's action.
2)    Giving information to patient about step which will do beginning of bronkoskopi's preparation until pasca bronkoskopi, explanation about anaesthesia action that is done and anaesthesia effect that felt by patient
3)    Menandatangani is letter droves a hard bargain action (informed consent) 
4)    Physical preparation for example:
a)    Minimal fasting 6 hours before done by actions
b)    lidocain's test 2% 0.1 cc given by intracutan and read by afters 15 minutes
5)    Supporter preparation
a)    AP thorax photograph Lateral
b)    paru's action
(1)    VC> 1000 cc
(2)    FEV1> 800 cc
c)    PAO PAO> 65 mmHg
d)    hemostatis's action
(1)    Hb> 10 gr%
e)    EKG
b.    Tool and doctor preparation
1)    Anaesthesia table and premedikasi
a)    Headlamp (head lamp)
b)    Gullet glass (keel spiegel)
c)    Xylocain spray 10%
d)    Spirit lamp
e)    Disp spuit 5 cc
f)    spatel's barrel
g)    Spuit instilasi
h)    Cucing contains lidocain 2%
i)    Wire-netting and tissue at sufficiently
j)    sulfas atropine's doctors and dipenhydramin
2)    instrument's table
a)    Disp Spuit 50 cc
b)    Disp Spuit 10 cc
c)    Disp Spuit 5 cc
d)    Cucing contains PZ
e)    Cucing contains lidocain 2%
f)    Hand schoon
g)    penampung washing's bottle
h)    Tool for biopsy aspiration
i)    Tool for forcep biopsy
j)    Tool for brushing
k)    bronkhoskopi's tool (fiber optic)
l)    Alcohol 90%
m)    Alcohol 70%
n)    Formal moltens 10%
o)    Wire-netting and tissue at sufficiently
p)    glass's object
q)    Dental peacemaker (mouth piece)
3)    emergency's doctors
a)    Pethidin
b)    Adrenalin
c)    Kalmetason
d)    Midazolam
e)    Aminophylin
f)    Valium
g)    Transamin
h)    Epidrin
i)    Alupent
j)    set's transfusion
k)    Surflo
l)    Liquid infuses
4)    Other supporter tools
a)    Oxymeter
b)    Oxygen
c)    Suction
d)    2 mugs contains tepol's solutions and aquades (to wash bronkhoskopi's tool)


11.    Bronkhoskopi's performing
a.    I. phase
1)    Given by motivation about aim and effect that maybe evoked of bronkhoskopi's action, expected by that kooperatif's patient this action is successful maximal ala
2)    Menandatangani is letter droves a hard bargain action, well by patient and also its family
3)    cardinal's phenomena fathom( blood pressure, artery)
b.    Phase II.
1)    lidocain's test 2% 0.1 cc intracutan and read by afters 15 minutes
2)    Given by dipenhydramin 1 cc (10 mg) and sulfas atropine 2 amp (0. 5 mg) intramuscular and is waited up to 30 minutes
3)    Denture escape if there is (in order not to most devours while patient cough, up to done by bronkhoskopi's action)
4)    After 30 minute were done by local anaesthesias with xylocain spray's application 10% on tongued jetty with dosed may not be more than 20 spray times
5)    Instilasi lidocain 2% as much 4 6 cc on plika vokalis and trakea. Using up lidocain may not be more than 400 mg
6)    Patient is slept at table hads out with supine position and eye closed by mitella
7)    Assembled by oxymeter to monitor artery and saturasi is oxygen
8)    Given by oxygen 2 lpm passes through nasal kanul
9)    Mouth piece (dental peacemaker) assembled, hereafter operator inserts bronkhoskop's tip already diolesu jelly (lubricating is gel) into mouth via mouth piece
10)    Nurse position stands up at patient and doctor left to make easy help that action performing
11)    Skop comes in malalui plika vokalis, trakea, karina is main, bronkhus and its branch
12)    On preconceived bronkhus branch available abnormality was done by take specimen by:
a)    Biopsy aspiration
    specimen's take by inserts minute hand at predisposed place available ferocity, sucked by disp spuit 50 cc and specimen disemprotkan up the stairs ojek glass












                Image 2.6.  Biopsy aspiration

b)    Forcep's biopsy
Networks taking trick by use forcep. Forcep was presented at by place that predisposed marks sense ferocity, forcep dinuka's mouth and is driven in to that network and is closed (accord operator command). It is done 2 3 times until gotten by networks for material probing












Image 2.7.   Forcep is Biopsy
c)    Bronkhial Brushing
    Done by abuse at predisposed place marks sense ferocity or heat to get check material. Of abuse result is dabbed on glass's object already been provided. After is finished bronkhoskopi's action patient was carried over by room special for further observation, what available complication of that action












                Image 2.8.  Bronkhial Brushing

d)    Bronkhial Washing
    Done by wash at predisposed place marks sense ferocity and done by sesuadah biopsy. Wash on wound ex biopsy is expected there is following network oddment deep liquid flushes that.
12.    Post Bronkhoskopi's care
a.    Patient care
1)    cardinal's phenomena observation
Blood pressure / artery, what available auspices:
a)    Aritmia
b)    Bradikardi
c)    Takikardi
Bear evidence of other:
Giddiness, bellyful, puke, cold sweat and marks sense bronkhospasme, note all that sign on observation sheet. Observation is done at paru's action room and further is performed at patient room is nursed. For patient what does nurse to clear a root if has no aforesaid abnormalities, therefore patient is let goes home by note: if arises patient expected complaints be taken in back to or direct are taken in to IRD
2)    Respiratory observation and about blood
a)    If asphyxia happening, given by oxygen 3 lpm or with oxygen oxygen mask 6 lpm, application can be added appropriate doctor road map.
b)    About blood can happen after been done biopsy, and if happening about blood: note color and its amount. Need to be worded on that patient about blood that is oddment of bronkhoskopi's action and patient not necessarily fears, later will own stop since was given doctor. Better if patient perceives to want cough doesn't be bated, that oddment about blood outward all, and patient sleep with positioning trendelenberg.
3)    Minimal fasting patient 2 hours after action bronkhoskopi. 
With aim: that salving effect oddment anaesthesia gets lost and function devour is back normal.
b.    Tool care
    After is finished bronkhoskopi's action, constant contrived tool clear by:
1)    Caress / bronkhoskopi's exterior mop with tepol's solution (antiseptic) several times and does tool interior purge bronkhoskopi by sucks tepol's solution passes through channel. If in advance channel used by biopsy, therefore sanitized with use beforehand special brush
2)    Caress / mop with fresh water (aquadest) several times, then sucks aquadest to clear bronkhoskop's interior
3)    Soaking in solution cidex  up to 15 20 minutes, then flushes by aquadest
4)    Dry by regular link bronkhoskopi's tool with inhalator tool (suction) a few minutes until liquid in channel is sucked the lot
5)    Keeping by hangs bronkhoskopi's tool at special cabinet with ultraviolet light up to ½ until 1 hour.
Attention
1)    Tool bronkhoskopi may not be bent, since optic fiber can hang up that cause image is not brightness
2)    Soaking at deep solution cidex may not too long, since bronkhoskopi is exterior wills be crude and can cause iritasi mukosa breath channel.
13.    Pemerikasaan is Laboratory
On bronkhoskopi's action usually there is specimen specimen which is checked at laboratory, which is:
a.    Material one oil lamp direct
1)    Culture
a)    Aerob
b)    An aerob
c)    Micobacterium TB
2)    Smear
a)    BTA
b)    Gram
b.    sitologi's material and its fixation
1)    Fixation biopsy aspiration alcohol 90%
2)    Bronkhial washing is alcohol fixation 70%
3)    Bronkhial brushing is alcohol fixation 70%

c.    histologi's material and its fixation
    forcep's biopsy with formal fixation 6 10%, that situation according to laboratory requisition that checks.

14.    Picture Performance criterion Bronkhoskopi
Upon does bronkoskopi, there are several situation who can be met, as:
a.    Normal
Where upon done by bronkoskopi is not met by abnormality on mukosa or branch even bronkus.
b.    Inflammation
Inflammation picture can comprehensive (e.g. chronic bronchitis) or local even (effect intern object). Inflammation can happen acute ala (e.g. inflammation paru who is engaged segmental) and also chronic (e.g. tuberkulosis).
Changing about ambush covers: 
1)    Hiperemis and vaskularisasi's step-up from mukosa (dark chromatic or pink or even red). Mukosa bronkus is normal as palepink or red colored yellow. 
2)    Swelling (swelling)
On about ambush demulcent, appear few periphery from karina dull and opaque or forfeit bronkial's contour so cartilage stands out. On about ambush which acute happening mukosa's narrowing. 
3)    sekresi
Mukosa that normal scanty result beneficent mucus for purge. At the time about ambush, sekresi becomes a lot of and highly varied character, e.g. mukoid, thick and mukus is viscous (chronic bronchitis), Mukus as plague (asthma), pus / is pus (heavy infection). 

4)    Changing localised (localized changes) 
Local reaction can be met on abnormality as pneumonia, paru's abscess, TBC, strange object aspiration, bronkiektasis, karsinoma, etc..
5)    Ascociated changes
Particularly appears on Paru Obstruksi's Diseased patient Chronic (PPOK), where met by submukosa atrofi, hipertrofi on bronkiol's membrane wall
6)    Tuberkulosis
Met about ambush on endobronkial, distortion on reverential trakea / bronkus lumen limfadenofati ekstrabronkial.
c.    Tumor
    bronkoskopi's picture on tumor, lymph gland amplification or metastasis can be met three changing mains, which is: 
1)    Anatomy distortion because of marks sense external pressure on trakeo bronkial, usually because of limfadenopati secondary as enlargement of karina's angle, swelling on trakea / bronkus's wall main
2)    Involvement of bronkial's wall with local distortion or ulserasi from mukosa on plays favorites or all lumina
3)    Growth intraluminer may constitute early from intralumen it own, met by enlargement or ruptur of limfe's gland secondary via bronkial's wall. Growth intralumen can close lumen totally or partial.
Tumor     Bronkhoskopi's characteristic
Karsinoma     berlobus / nekrotik, white chromatic / krem, mukusa's surface appears vein protrusion (engorged)
Karsinoid     cherry is red colored, bloody easy round
Kondromata     Ground, pale surface, crude consistency

               Table 2.1.   Bronkhoskopi's Picture characteristic Tumor
d.    Miscellaneous
1)    About blood bronkial
In a few blood cough case (hemoptisis), bronkoskopi's check give normal picture. On about blood which massif is done cleansing of from trakeobronkial with normal saline to help find source about blood
2)    Strange object
Frequent strange object causes about ambush local, even cause extensive infection and damage on bronkial and paru distal's network and gets to result sekresi purulen. 
3)    Sarcoidosis
Appear two main pictures, which is: 
a)    Lymph gland amplification, karina and subkarina melebar and trakeobronkial's distortion
b)    mukosa trakeobronkial's transformation,  hiperemis and sekresi what does increase. 
4)    Changing radiation
Changing follow common pattern: shortly,  reaction about ambush acute, hereafter depreciation or a loss tumor with its dwindling about ambush, mukosa wans and kontraktif is network rasps afters a few months and fibrosis's happening on region that strikes. 
5)    trakea's trauma
Met by fraktur on trakea's wall or bronkus. 
6)    Fistula Bronkopleura
Constituting secondary from empiema, paru's abscess, its break is paru's cyst, pneumotoraks, trauma or pasca hads out. On bronkoskopi's picture appears air bubble, sekresi's time appears exhalation movement. 
7)    Amiloidosis
Rarely happens, bronkial's wall rust colored / grey one takes after carsinomatous infiltratif's picture.


REFERENCE LIST


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Swidarmoko b, Susanto A.D. 2010.  Pulmonologi is Intervention and Dangerous Breath Emergency.  Pulmonologi's department and Respirasi's Medical Science kedokteran's Faculty Indonesia University. Jakarta

Prasenohadi. 2010.  Respiratory Tract management . kedokteran's faculty Indonesia University. Jakarta

Muttaqin, A. 2008.  Book Teaches Upbringing to Invasive Client care Respiratory System , Jakarta. Salemba Medika. Thing 4 31

Supartin & Sudiyasa k, 2003.  Upbringing to Tumor Patient care Paru who done by Bronkhoskopi's Action

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Moch is Amen, Hood Alsagaff, Righteous WBM Taib, 1993.  Paru's Pathology introduction

Righteous WBM taib, 1990.  Determining Bronkologi's diagnosis with Fiber Bronkhoskopi's Optic