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Difficulties In The Introduction Of The Bronchoscope

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The beginner

may enter the esophagus instead of the trachea: this might be

a dangerous accident in a dyspneic case, for the tube could, by

pressure on the trachea, cause respiratory arrest. A bronchoscope thus

misplaced should be resterilized before introducing it into the air

passages, for while the lower air passages are usually free from

bacteria, the esophagus is a septic canal. If the given technic is

carefully carried out the bronchoscope will not be contaminated with

mouth secretions. The trachea is recognized as an open tube, with

whitish rings, and the expiratory blast can be felt and tubular

breathing heard; while if by mistake the bronchoscope has entered the

gullet it will be observed that the cervical esophagus has collapsed

walls. A puff of air may be felt and a fluttering sound heard when the

tube is in the esophagus, but these lack the intensity of the tracheal

blast. Usually a free flow of secretion is met with in the esophagus.

In diseased states the tracheal rings may not be visible because of

swollen mucosa, or the trachea itself may be in partial collapse from

external pressure. The true expiratory blast will, however, always be

recognized when the tube is in the trachea. Wide gagging of the mouth

renders exposure of the larynx difficult.

[FIG. 62.--Insertion of the bronchoscope. Note direction of the

trachea as indicated by the bronchoscope. Note that the patient's head

is held above the level of the table. The assistant's left hand should

be at the patient's mouth holding the bite-block. This is removed and

the assistant is on the wrong side of the table in the illustration in

order not to hide the position of the operator's hands. Note the

handle of the bronchoscope is to the right.]

[FIG. 63.--The heavy laryngoscope has been removed leaving the light

bronchoscope in position. The operator is inserting forceps. Note how

the left hand of the operator holds the tube lightly between the thumb

and first two fingers of the left hand, while the last two fingers are

hooked over the upper teeth of the patient anchoring the tube to

prevent it moving in or out or otherwise changing the relation of the

distal tube-mouth to a foreign body or a growth while forceps are

being used. Thus, also, any desired location of the tube can be

maintained in systematic exploration. The assistant's left hand is

dropped out of the way to show the operator's method. The assistant

during bronchoscopy holds the bite-block like a thimble on the index

finger of the left hand, and the assistant should be on the right side

of the patient. He is here put wrongly on the left side so as not to

hide the instruments and the manner of holding them.]