Mechanical Problems Of Bronchoscopic Foreign Body Extraction*

Categories: MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY EXTRACTION
Sources: 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 immedia ely 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

disengagement.

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)