Anchoring The Foreign Body Against The Tube Mouth


Categories: MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY EXTRACTION
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

If withdrawal be

made a bimanual procedure it is almost certain that the foreign body

will trail a centimeter or more beyond the tube mouth, and that the

closure of the glottic chink as soon as the distal end of the

bronchoscope emerges will strip the foreign body from the forceps

grasp, when the foreign body reaches the cords. This is avoided by

anchoring the foreign body against the tube mouth as soon as the

foreign body is grasped, as shown in Fig. 79. The left index finger

and thumb grasp the shaft of the forceps close to the ocular end of

the tube, while the other fingers encircle the tube; closure of the

forceps is maintained by the fingers of the right hand, while all

traction for withdrawal is made with the left hand, which firmly

clamps forceps and bronchoscope as one piece. Thus the three units are

brought out as one; the bronchoscope keeping the cords apart until the

foreign body has entered the glottis.



[FIG. 79--Method of anchoring the foreign body against the tube mouth

After the object has been drawn firmly against the lip of the

endoscopic tube the left finger and thumb grasp the forceps cannula

and lock it against the ocular end of the tube, the other fingers of

the left hand encircle the tube. Withdrawal is then done with the left

hand; the fingers of the right hand maintaining closure of the

forceps.]



[164] Bringing the Foreign Body Through the Glottis.--Stripping of

the foreign body from the forceps at the glottis may be due to:

1. Not keeping the object against the tube mouth as just mentioned.

2. Not bringing the greatest diameter of the foreign body into the

sagittal plane of the glottic chink.

3. Faulty application of the forceps on the foreign body.

4. Mechanically imperfect forceps.



Should the foreign body be lost at the glottis it may, if large become

impacted and threaten asphyxia. Prompt insertion of the laryngoscope

will usually allow removal of the object by means of the laryngeal

grasping forceps. The object may be dropped or expelled into the

pharynx and be swallowed. It may even be coughed into the naso-pharynx

or it may be re-aspirated. In the latter event the bronchoscope is to

be re-inserted and the trachea carefully searched. Care must be used

not to override the object. If much inflammatory reaction has occurred

in the first invaded bronchus, temporarily suspending the aerating

function of the corresponding lung, reaspiration of a dislodged

foreign body is liable to carry it into the opposite main bronchus, by

reason of the greater inspiratory volume of air entering that side.

This may produce sudden death by blocking the only aerating organ.



Extraction of Pins, Needles and Similar Long Pointed Objects.--When

searching for such objects especial care must be taken not to override

them. Pins are almost always found point upward, and the dictum can

therefore be made, Search not for the pin, but for the point of the

pin. If the point be found free, it should be worked into the lumen

of the bronchoscope by manipulation with the lip of the tube. It may

then be seized with the forceps and withdrawn. Should the pin be

grasped by the shaft, it is almost certain to turn crosswise of the

tube mouth, where one pull may cause the point to perforate,

enormously increasing the difficulties by transfixation, and perhaps

resulting fatally (Fig. 80).



[FIG. 80.--Schematic illustration of a serious phase of the error of

hastily seizing a transfixed pin near its middle, when first seen as

at M. Traction with the forceps in the direction of the dart in Schema

B will rip open the esophagus or bronchus inflicting fatal trauma, and

probably the pin will be stripped off at the glottic or the

cricopharyngeal level, respectively. The point of the pin must be

disembedded and gotten into the tube mouth as at A, to make forceps

traction safe.]



[FIG. 81.--Schema illustrating the mechanical problem of extracting a

pin, a large part of whose shaft is buried in the bronchial wall, B.

The pin must be pushed downward and if the orifice of the branches, C,

D, are too small to admit the head of the pin some other orifice (as

at A) must be found by palpation (not by violent pushing) to admit the

head, so that the pin can be pushed downward permitting the point to

emerge (E). The point is then manipulated into the bronchoscopic

tube-mouth by means of co-ordinated movements of the bronchoscopic lip

and the side-curved forceps, as shown at F.]





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