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Rules For Endoscopic Foreign Body Extraction
Category: FOREIGN BODIES IN THE BRONCHI FOR PROLONGED PERIODS
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery
1. Never endoscope a foreign body case unprepared, with the idea of
taking a preliminary look.
2. Approach carefully the suspected location of a foreign body, so
as not to override any portion of it.
 3. Avoid grasping a foreign body hastily as soon as seen.
4. The shape, size and position of a foreign body, and its relations
to surrounding structures, should be studied before attempting to
apply the forceps. (Exception cited in Rule 10.)
5. Preliminary study of a foreign body should be from a distance.
6. As the first grasp of the forceps is the best, it should be well
planned beforehand so as to seize the proper part of the intruder.
7. With all long foreign bodies the motto should be Search, not for
the foreign body, but for its nearer end. With pins, needles, and the
like, with point upward, search always for the point. Try to see it
8. Remember that a long foreign body grasped near the middle
becomes, mechanically speaking, a toggle and ring.
9. Remember that the mortality to follow failure to remove a foreign
body does not justify probably fatal violence during its removal.
10. Laryngeally lodged foreign bodies, because of the likelihood
of dislodgment and loss, may be seized by any part first presented,
and plan of withdrawal can be determined afterward.
11. For similar reasons, laryngeal cases should be dealt with only
in the author's position (Fig. 53).
12. An esophagoscopy may be needed in a bronchoscopic case, or a
bronchoscopy in an esophageal case. In every case both kinds of tubes
should be sterile and ready before starting. It is the unexpected that
happens in foreign body endoscopy.
13. Do not pull on a foreign body unless it is properly grasped to
come away readily without trauma. Then do not pull hard.
14. Do no harm, if you cannot remove the foreign body.
15. Full-curved hooks are to be used in the bronchi with greatest
caution, if used at all, lest they catch inextricably in branch
 16. Don't force a foreign body downward. Coax it back. The
deeper it gets the greater your difficulties.
17. The watchword of the bronchoscopist should be, If I can do no
good, I will at least do no harm.
Fluoroscopic bronchoscopy is so deceptively easy from a superficial,
theoretical, point of view that it has been used unsuccessfully in
cases easily handled in the regular endoscopic way with the eye at the
proximal tube-mouth. In a collected series of cases by various
operators the object was removed in 66.7 per cent with a mortality of
41.6 per cent. In the problem of a pin located out of the field of
bronchoscopic vision, the fluoroscopist will yield invaluable aid. An
extremely delicate forceps is to be inserted closed into the invaded
bronchus, the grasp on the object being confirmed by the
fluoroscopist. It is to be kept in mind that while the object itself
may be in the grasp of the forceps, the fluoroscope will not show
whether there may not be included in the forceps' grasp a bronchial
spur or other tissue, the tearing of which may be fatal. Therefore
traction must not be sufficient to lacerate tissue. If the foreign
body does not come readily it must be released, and a new grasp may
then be taken. All of the cautions in faulty seizure already
mentioned, apply with particular force to fluoroscopic bronchoscopy.
The fluoroscope is of aid in finding foreign bodies held in abscess
cavities. The fluoroscope should show both the lateral and
anteroposterior planes. To accomplish this quickly, two Coolidge tubes
and two screens are necessary. Fluoroscopic bronchoscopy, because of
its high mortality and low percentage of successes, should be tried
only after regular, ocularly guided, peroral bronchoscopy has failed,
and only by those who have had experience in ocularly guided
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