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Mechanical Problems Of Bronchoscopic Foreign Body Extraction*

Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

* For more extensive consideration of mechanical problems than is here
possible the reader is referred to the Bibliography, page 311,
especially reference numbers 1, 11, 37 and 56.

The endoscopic extraction of a foreign body is a mechanical problem
pure and simple, and must be studied from this viewpoint. Hasty,
ill-equipped, ill-planned, or violent endoscopy on the erroneous
principle that if not immediately removed the foreign body will be
fatal, is never justifiable. While the lodgement of an organic foreign
body (such as a nut kernel) in the bronchus calls for prompt removal
and might be included under the list of emergency operations, time is
always available for complete preparation, for thorough study of the
patient, and localization of the intruder. The patient is better off
with the foreign body in the lung than if in its removal a
mediastinitis, rupture into the pleura, or tearing of a thoracic blood
vessel has resulted. The motto of the endoscopist should be I will do
no harm. If no harm be inflicted, any number of bronchoscopies can be
done at suitable intervals, and eventually success will be achieved,
whereas if mortality results, all opportunity ceases.

The first step in the solution of the mechanical problem is the study
of the roentgenograms made in at least three planes; (1)
anteroposterior, (2) lateral, and (3) the plane corresponding to the
greatest plane of the foreign body. The next step is to put a
duplicate of the foreign body into the rubber-tube manikin previously
referred to, and try to simulate the probable position shown by the
ray, so as to get an idea of the bronchoscopic appearance of the
probable presentation. Then the duplicate foreign body is turned into
as many different positions as possible, so as to educate the eye to
assist in the comprehension of the largest possible number of
presentations that may be encountered at the bronchoscopy on the
patient. For each of these presentations a method of disimpaction,
disengagement, disentanglement or version and seizure is worked out,
according to the kind of foreign body. Prepared by this practice and
the radiographic study, the bronchoscope is introduced into the
patient. The location of the foreign body is approached slowly and
carefully to avoid overriding or displacement. A study of the
presentation is as necessary for the bronchoscopist as for the
obstetrician. It should be made with a view to determining the
following points:
1. The relation of the presenting part to the surrounding tissues.
2. The probable position of the unseen portion, as determined by the
appearance of the presenting part taken in connection with the
knowledge obtained by the previous ray study, and by inspection of the
ray plate upside down on view in front of the bronchoscopist.
3. The version or other manipulation necessary to convert an
unfavorable into a favorable presentation for grasping and
4. The best instruments to use, and which to use first, as, hook,
pincloser, forceps, etc.
5. The presence and position of the forceps spaces of which there
must be two for all ordinary forceps, one for each jaw, or the
insertion space for any other instrument.

Until all of these points are determined it is a grave error to insert
any kind of instrument. If possible even swabbing of the foreign body
should be avoided by swabbing out the bronchus, when necessary, before
the region of the intruder is reached. When the operator has
determined the instrument to be used, and the method of using it, the
instrument is cautiously inserted, under guidance of the eye.

[160] The lip of the bronchoscope is one of the most valuable aids
in the solution of foreign-body problems. With it partial or complete
version of an object can be accomplished so as to convert an
unfavorable presentation into one favorable for grasping with the
forceps; edematous mucosa may be displaced, angles straightened and
space made at the side of the foreign body for the forceps' jaw. It
forms a shield or protector that can be slipped under the point of a
sharp foreign body and can make counterpressure on the tissues while
the forceps are disembedding the point of the foreign body. With the
bronchoscopic lip and the forceps or other instrument inserted through
the tube, the bronchoscopist has bimanual, eye-guided control, which
if it has been sufficiently practiced to afford the facility in
coordinate use common to everyone with knife and fork, will accomplish
maneuvers that seem marvelous to anyone who has not developed facility
in this coordinate use of the bronchoscopic instruments.

The relation of the tube mouth and foreign body is of vital
importance. Generally considered, the tube mouth should be as near the
foreign body as possible, and the object must be placed in the center
of the bronchoscopic field, so that the ends of the open jaws of the
forceps will pass sufficiently far over the object. But little lateral
control is had of the long instruments inserted through the tube;
sidewise motion is obtained by a shifting of the end of the
bronchoscope. When the foreign body has been centered in the
bronchoscopic field and placed in a position favorable for grasping,
it is important that this position be maintained by anchoring the tube
to the upper teeth with the left, third, and fourth fingers hooked
over the patient's upper alveolus (Fig. 63)

Next: The Light Reflex On The Forceps

Previous: Removal Of Foreign Bodies From The Larynx

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