Complications And After-effects Of Bronchoscopy

Categories: REMOVAL OF FOREIGN BODIES FROM THE LARYNX
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

All foreign body cases should be watched day and night by special

nurses until all danger of complications is passed. Complications are

rare after careful work, but if they do occur, they may require

immediate attention. This applies especially to the subglottic edema

associated with arachidic bronchitis in children under 2 years of age.



General Reaction.--There is usually no elevation in temperature

foll wing a short bronchoscopy for the removal of a recently lodged

metallic foreign body. If, however, an inflammatory condition of the

bronchi existed previous to the bronchoscopy, as for instance the

intense diffuse, purulent laryngotracheobronchitis associated with

the aspiration of nut kernels, or in the presence of pulmonary abscess

from long retained foreign bodies, a moderate temporary rise of

temperature may be expected. These cases almost always have had

irregular fever before bronchoscopy. Disturbance of the epithelium in

the presence of pus without abscess usually permits enough absorption

to elevate the temperature slightly for a few days.



Surgical shock in its true form has never followed a carefully

performed and time-limited bronchoscopy. Severe fatigue resulting in

deep sleep may be seen in children after prolonged work.



Local reaction is ordinarily noted by slight laryngeal congestion

causing some hoarseness and disappearing in a few days. If dyspnea

occur it is usually due to (1) Drowning of the patient in his own

secretions. (2) Subglottic edema. (3) Laryngeal edema.



Drowning of the Patient in His Own Secretions.--The accumulation of

secretions in the bronchi due to faulty bechic powers and seen most

frequently in children, is quickly relievable by bronchoscopic

sponge-pumping or aspiration through the tracheotomic wound, in cases

in which the tracheotomy may be deemed necessary. In other cases, the

aspirating bronchoscope with side drainage canal (Fig. 1, E) may be

used through the larynx. Frequent peroral passage of the bronchoscope

for this purpose is contraindicated only in case of children under 3

years of age, because of the likelihood of provoking subglottic edema.

In such cases instead of inserting a bronchoscope the aspirating tube

(Fig. 9) should be inserted through the direct laryngoscope, or a low

tracheotomy should be done.



Supraglottic edema is rarely responsible for dyspnea except when

associated with advanced nephritis.



Subglottic edema is a complication rarely seen except in children

under 3 years of age. They have a peculiar histologic structure in

this region, as is shown by Logan Turner. Even at the predisposing age

subglottic edema is a very unusual sequence to bronchoscopy if this

region was previously normal. The passage of a bronchoscope through an

already inflamed subglottic area is liable to be followed by a

temporary increase in the swelling. If the foreign body be associated

with but slight amount of secretion, the child can usually obtain

sufficient air through the temporarily narrowed lumen. If, however, as

in cases of arachidic bronchitis, large amounts of purulent secretion

must be expelled, it will be found in certain cases that the decreased

glottic lumen and impaired laryngeal motility will render tracheotomy

necessary to drain the lungs and prevent drowning in the retained

secretions. Subglottic edema occurring in a previously normal larynx

may result from: 1. The use of over-sized tubes. 2. Prolonged

bronchoscopy. 3. Faulty position of the patient, the axis of the tube

not being in that of the trachea. 4. Trauma from undue force or

improper direction in the insertion of the bronchoscope. 5. The

manipulation of instruments. 6. Trauma inflicted in the extraction of

the foreign body.



Diagnosis must be made without waiting for cyanosis which may never

appear. Pallor, restlessness, startled awakening after a few minutes

sleep, occurring in a child with croupy cough, indrawing around the

clavicles, in the intercostal spaces, at the suprasternal notch and at

the epigastrium, call for tracheotomy which should always be low. Such

a case should not be left unwatched. The child will become exhausted

in its fight for air and will give up and die. The respiratory rate

naturally increases because of air hunger, accumulating secretions

that cannot be expelled because of impaired glottic motility give

signs wrongly interpreted as pneumonia. Many children whose lives

could have been saved by tracheotomy have died under this erroneous

diagnosis.



Treatment.--Intubation is not so safe because the secretions cannot

easily be expelled through the tube and postintubational stenosis may

be produced. Low tracheotomy, the tracheal incision always below the

second ring, is the safest and best method of treatment.