Unsuccessful Bronchoscopy For Foreign Bodies


Categories: FOREIGN BODIES IN THE ESOPHAGUS
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The limitations of bronchoscopic removal of foreign bodies are usually

manifested in the failure to find a small foreign body which has

entered a minute bronchus far down and out toward the periphery. When

localization by means of transparent films, fluoroscopy, and

endobronchial bismuth insufflation has failed, the question arises as

to the advisability of endoscopic excision of the tissue intervening

between the foreign body and bronchoscope with the aid of two

fluoroscopes, one for the lateral and the other the vertical plane.

With foreign bodies in the larger bronchi near the root of the lung

such a procedure is unnecessary, and injury to a large vessel would be

almost certain. At the extreme periphery of the lung the danger is

less, for the vessels are smaller and serious hemorrhage less

probable, through the retention and decomposition of blood in small

bronchi with later abscess formation is a contingency. The nature of

the bridge of tissue is to be considered; should it be cicatricial,

the result of prolonged inflammatory processes, it may be carefully

excised without very great risk of serious complications. The blood

vessels are diminished in size and number by the chronic productive

inflammation, which more than offsets their lessened contractility.



The possibility of the foreign body being coughed out after

suppurative processes have loosened its impaction is too remote; and

the lesions established may result fatally even after the expulsion of

the object. Pulmonary abscess formation and rupture into the pleura

should not be awaited, for the foreign body does not often follow the

pus into the pleural cavity. It remains in the lung, held in a bed of

granulation tissue. Furthermore, to await the development is to

subject the patient to a prolonged and perhaps fatal sepsis, or a

fatal pulmonary hemorrhage from the erosion of a vessel by the

suppurative process. The recent developments in thoracic surgery have

greatly decreased the operative mortality of thoracotomy, so that this

operation is to be considered when bronchoscopy has failed.

Bronchoscopy can be considered as having failed, for the time being,

when two or more expert bronchoscopists on repeated search have been

unable to find the foreign body or to disentangle it; but the art of

bronchoscopy is developing so rapidly that the failures of a few years

ago would be easy successes today. Before considering thoracotomy

months of study of the mechanical problem are advisable. It is

probable that any foreign body of appreciable size that has gone down

the natural passages can be brought back the same way.



In the event of a foreign body reaching the pleura, either with or

without pus, it should be removed immediately by pleuroscopy or by

thoracotomy, without waiting for adhesive pleuritis.



The problem may be summarized thus:

1. Large foreign bodies in the trachea or large bronchi can always

be removed by bronchoscopy.

2. The development of bronchoscopy having subsequently solved the

problems presented by previous failures, it seems probable that by

patient developmental endeavor, any foreign body of appreciable size

that has gone down through the natural passages, can be

bronchoscopically removed the same way, provided fatal trauma is

avoided.



At the author's Bronchoscopic Clinics 98.7 per cent of foreign bodies

have been removed.





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