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Complications And After-effects Of BronchoscopyCategory: REMOVAL OF FOREIGN BODIES FROM THE LARYNX Source: 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 following 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. Next: Removal Of Foreign Bodies From The Larynx Previous: Choice Of Time To Do Bronchoscopy For Foreign Body
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