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Category: POSITION OF THE PATIENT FOR PERORAL ENDOSCOPY
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery
Bronchoscopic oxygen insufflation is a life-saving measure equalled by
no other method known to the science of medicine, in all cases of
asphyxia, or apnea, present or impending. Its especial sphere of
usefulness is in severe cases of electric shock, hanging, smoke
asphyxia, strangulation, suffocation, thoracic or abdominal pressure,
apnea, acute traumatic pneumothorax, respiratory arrest from absence
of sufficient oxygen, or apnea from the presence of quantities of
irrespirable or irritant gases. Combined with bronchoscopic aspiration
of secretions it is the best method of treatment for poisoning by
chlorine gas, asphyxiating, and other war gases.
Bronchoscopic oxygen insufflation should be taught to every interne in
every hospital. The emergency or accident ward of every hospital
should have the necessary equipment and an interne familiar with its
use. The method is simple, once the knack is acquired. The patient
being limp and recumbent on a table, the larynx is exposed with the
laryngoscope, and the bronchoscope is inserted as hereinafter
described. The oxygen is turned on at the tank and the flow regulated
before the rubber tube from the wash-bottle of tank is attached to the
side-outlet of the bronchoscope. It is necessary to be certain that
the flow is gentle, so that, with a free return flow the introduced
pressure does not exceed the capillary pressure; otherwise the blood
will be forced out of the capillaries and the ischemia of the lungs
will be fatal. Another danger is that overdistension causes inhibition
of inspiration resulting in apnea continuing as long as the distension
is maintained, if not longer. The return flow from the bronchoscope
should be interrupted for 2 or 3 seconds several times a minute to
inflate the lungs, but the flow must not be occluded longer than 3
seconds, because the intrapulmonary pressure would rise. A pearl of
amyl nitrite may be broken in the wash bottle. Slow rhythmic
artificial respiratory movements are a useful adjunct, and unless the
operator is very skillful in gauging the alternate pressures and
releases with the thumb according to the oxygen pressure, it is
vitally necessary to fill and deflate the lungs rhythmically by one of
the well known methods of artificial respiration. Anyone skilled in
the introduction of the bronchoscope can do bronchoscopy in a few
seconds, and it is especially easy in cases of respiratory arrest,
because of the limp condition of the patient.
The foregoing applies to cases in which a pulmotor would be used, such
as apnea from electric shocks, etc. For obstructive dyspnea and
asphyxia, tracheotomy is the procedure of choice, and the skillful
tracheotomist would be justified in preferring tracheotomy for the
other class of cases, insufflating the oxygen and amyl nitrite through
the tracheotomic wound. The pulmotor and similar mechanisms are,
perhaps, the best things the use of which can be taught to laymen; but
as compared to bronchoscopic oxygen insufflation they are woefully
inefficient, because the intraoral pressure forces the tongue back
over the laryngeal orifice, obstructing the airway in this death
zone. By the introduction of the bronchoscope this death zone is
entirely eliminated, and a free airway established for piping the
oxygen directly into the lungs.
TITLE POSITION OF THE PATIENT FOR PERORAL ENDOSCOPY
It is the author's invariable practice to place the patient in the
dorsally recumbent position. The sitting position is less favorable.
While lying on a well-padded, flat table the patient is readily
controlled, the head is freely movable, secretions can be easily
removed, the view obtained by the endoscopist is truly direct (without
reversal of sides), and, most important, the employment of one
position only favors smoother and more efficient team work, and a
better endoscopic technic.
Next: General Principles Of Position
Previous: Rules For Insertion Of The Catheter For Insufflation Anesthesia