_Spontaneous Expulsion of Foreign Bodies from the Air Pa.s.sages_. A large, light, foreign body in the larynx or trachea may occasionally be coughed out, but the frequent newspaper accounts of the sudden death of children known to have aspirated objects should teach us never to wait for this occurrence. The cause of death in these cases is usually the impaction of a large foreign body in the glottis producing sudden asphyxiation, and in a certain proportion of these cases the impaction has occurred on the reverse journey, when cough forced the intruder upward from below. The danger of subglottic impaction renders it imperative that attempts to aid spontaneous expulsion by inverting the patient should be discouraged. Sharp objects, such as pins, are rarely coughed out. The tendency of all foreign bodies is to migrate down and out to the periphery as their size and shape will allow. Most of the reported cases of bechic expulsion of bronchially lodged foreign bodies have occurred after a prolonged sojourn of the object, a.s.sociated which much lung pathology; and in some cases the object has been carried out along with an acc.u.mulation of pus suddenly liberated from an abscess cavity, and expelled by cough. This is a rare sequence compared to the usual formation of fibrous stricture above the foreign body that prevents the possibility of bechic expulsion. To delay bronchoscopy with the hope of such a solution of the problem is comparable to the former dependence on nature for the cure of appendiceal abscess.

We do our full duty when we tell the patient or parents that while the foreign body may be coughed up, it is very dangerous to wait; and, further, that the difficulty of removal usually increases with the time the foreign body is allowed to remain in the air pa.s.sages.

_Mortality and morbidity of bronchoscopy_ vary directly with the degree of skill and experience of the operator, and the conditions for which the endoscopies are performed. The simple insertion of the bronchoscope is devoid of harm if carefully done. The danger lies in misdirected efforts at removal of the intruder and in repeating bronchoscopies in children at too frequent intervals, or in prolonging the procedure unduly. In children under one year endoscopy should be limited to twenty minutes, and should not be repeated sooner than one week after, unless urgently indicated. A child of 5 years will bear 40 to 60 minutes work, while the adult offers no unvarying time limit.

More can be ultimately accomplished, and less reaction will follow short endoscopies repeated at proper intervals than in one long procedure.

_Indications for bronchoscopy for suspected foreign body_ may be thus summarized: 1. The appearance of a suspicious shadow in the radiograph, in the line of a bronchus.

2. In any case in which lung symptoms followed a clear history of the patient having choked on a foreign body.

3. In any case showing signs of obstruction in the trachea or of a bronchus.

4. In suspected bronchiectasis.

5. Symptoms of pulmonary tuberculosis with sputum constantly negative for tubercle bacilli. If the physical signs are at the base, particularly the right base, the indication becomes very strong even in the absence of any foreign body circ.u.mstance in the history.

6. In all cases of doubt, bronchoscopy should be done anyway.

There is no absolute _contraindication to bronchoscopy for foreign bodies_. Extreme exhaustion or reaction from previous efforts at removal may call for delay for recuperation, but pulmonary abscess and even the rarer complications, bronchopneumonia and gangrene of the lung, are improved by the early removal of the foreign body.

_Choice of Time to do Bronchoscopy for Foreign Body_.--The difficulties of removal usually increase from the time of aspiration of the object. It tends to work downward and outward, while the mucosa becomes edematous, partly closing over the foreign body, and even completely obliterating the lumen of smaller bronchi. Later, granulation tissue and the formation of stricture further hide the object. The patient's health deteriorates with the onset of pulmonary pathology, and renders him a less favorable subject for bronchoscopy.

Organic foreign bodies, which produce early and intense inflammatory reaction and are liable to swell, call for prompt bronchoscopy. When a bronchus is completely obstructed by the bulk of the foreign body itself immediate removal is urgently demanded to prevent serious lung changes, resulting from atelectasis and want of drainage. In short, removal of the foreign body should be accomplished as soon as possible after its entrance. This, however, does not justify hasty, ill-planned, and poorly equipped bronchoscopy, which in most cases is doomed to failure in removal of the object. The bronchoscopist should not permit himself to be stampeded into a bronchoscopy late at night, when he is fatigued after a hard day's work.

_Bronchoscopic finding of a foreign body_ is not especially difficult if the aspiration has been recent. If secondary processes have developed, or the object be small and in a bronchus too small to admit the tube-mouth, considerable experience may be necessary to discover it. There is usually inflammatory reaction around the orifice of the invaded bronchus, which in a measure serves to localize the intruder.

We must not forget, however, that objects may have moved to another location, and also that the irritation may have been the result of previous efforts at removal. Care must be exercised not to mistake the sharp, shining, interbronchial spurs for bright thin objects like new pins just aspirated; after a few days pins become blackened. If these spurs be torn pneumothorax may ensue. If a number of small bronchi are to be searched, the bronchoscope must be brought into the line of the axis of the bronchus to be examined, and any intervening tissue gently pushed aside with the lip of the bronchoscope. Blind probing for exploration is very dangerous unless carefully done. The straight forceps, introduced closed, form the best probe and are ready for grasping if the object is felt. Once the bronchoscope has been introduced, it should not be withdrawn until the procedure is completed. The light carrier alone may be removed from its ca.n.a.l if the illumination be faulty.

COMPLICATIONS AND AFTER-EFFECTS OF BRONCHOSCOPY

All foreign body cases should be watched day and night by special nurses until all danger of complications is pa.s.sed. Complications are rare after careful work, but if they do occur, they may require immediate attention. This applies especially to the subglottic edema a.s.sociated with arachidic bronchitis in children under 2 years of age.

_General Reaction_.--There is usually no elevation in temperature following a short bronchoscopy for the removal of a recently lodged metallic foreign body. If, however, an inflammatory condition of the bronchi existed previous to the bronchoscopy, as for instance the intense diffuse, purulent laryngotracheobronchitis a.s.sociated with the aspiration of nut kernels, or in the presence of pulmonary abscess from long retained foreign bodies, a moderate temporary rise of temperature may be expected. These cases almost always have had irregular fever before bronchoscopy. Disturbance of the epithelium in the presence of pus without abscess usually permits enough absorption to elevate the temperature slightly for a few days.

_Surgical shock_ in its true form has never followed a carefully performed and time-limited bronchoscopy. Severe fatigue resulting in deep sleep may be seen in children after prolonged work.

_Local reaction_ is ordinarily noted by slight laryngeal congestion causing some hoa.r.s.eness and disappearing in a few days. If dyspnea occur it is usually due to (1) Drowning of the patient in his own secretions. (2) Subglottic edema. (3) Laryngeal edema.

_Drowning of the Patient in His Own Secretions_.--The acc.u.mulation of secretions in the bronchi due to faulty bechic powers and seen most frequently in children, is quickly relievable by bronchoscopic sponge-pumping or aspiration through the tracheotomic wound, in cases in which the tracheotomy may be deemed necessary. In other cases, the aspirating bronchoscope with side drainage ca.n.a.l (Fig. 1, E) may be used through the larynx. Frequent peroral pa.s.sage of the bronchoscope for this purpose is contraindicated only in case of children under 3 years of age, because of the likelihood of provoking subglottic edema.

In such cases instead of inserting a bronchoscope the aspirating tube (Fig. 9) should be inserted through the direct laryngoscope, or a low tracheotomy should be done.

_Supraglottic edema_ is rarely responsible for dyspnea except when a.s.sociated with advanced nephritis.

_Subglottic edema_ is a complication rarely seen except in children under 3 years of age. They have a peculiar histologic structure in this region, as is shown by Logan Turner. Even at the predisposing age subglottic edema is a very unusual sequence to bronchoscopy if this region was previously normal. The pa.s.sage of a bronchoscope through an already inflamed subglottic area is liable to be followed by a temporary increase in the swelling. If the foreign body be a.s.sociated with but slight amount of secretion, the child can usually obtain sufficient air through the temporarily narrowed lumen. If, however, as in cases of arachidic bronchitis, large amounts of purulent secretion must be expelled, it will be found in certain cases that the decreased glottic lumen and impaired laryngeal motility will render tracheotomy necessary to drain the lungs and prevent drowning in the retained secretions. Subglottic edema occurring in a previously normal larynx may result from: 1. The use of over-sized tubes. 2. Prolonged bronchoscopy. 3. Faulty position of the patient, the axis of the tube not being in that of the trachea. 4. Trauma from undue force or improper direction in the insertion of the bronchoscope. 5. The manipulation of instruments. 6. Trauma inflicted in the extraction of the foreign body.

_Diagnosis_ must be made without waiting for cyanosis which may never appear. Pallor, restlessness, startled awakening after a few minutes sleep, occurring in a child with croupy cough, indrawing around the clavicles, in the intercostal s.p.a.ces, at the suprasternal notch and at the epigastrium, call for tracheotomy which should always be low. Such a case should not be left unwatched. The child will become exhausted in its fight for air and will give up and die. The respiratory rate naturally increases because of air hunger, acc.u.mulating secretions that cannot be expelled because of impaired glottic motility give signs wrongly interpreted as pneumonia. Many children whose lives could have been saved by tracheotomy have died under this erroneous diagnosis.

_Treatment_.--Intubation is not so safe because the secretions cannot easily be expelled through the tube and postintubational stenosis may be produced. Low tracheotomy, the tracheal incision always below the second ring, is the safest and best method of treatment.

[156] CHAPTER XIV--REMOVAL OF FOREIGN BODIES FROM THE LARYNX

_Symptoms and Diagnosis_.--The history of a sudden choking attack followed by impairment of voice, wheezing, and more or less dyspnea can be usually elicited. Laryngeal diphtheria is the condition most frequently thought of when these symptoms are present, and ant.i.toxin is rightly given while waiting for a positive diagnosis. Extreme dyspnea may render tracheotomy urgently demanded before any attempts at diagnosis are made. Further consideration of the symptomatology and diagnosis of laryngeal foreign body will be found on pages 128, 133 and 143.

_Preliminary Examination_.--In the adult, mirror examination of the larynx should be done, the patient being placed in the rec.u.mbent position. Whenever time permits roentgenograms, lateral and anteroposterior, should be made, the lateral one as low in the neck as possible. One might think this an unnecessary procedure because of the visibility of the larynx in the mirror; but a child's larynx cannot usually be indirectly examined, and even in the adult a pin may be so situated that neither head nor point is visible, only a portion of the shaft being seen. The roentgenogram will give accurate information as to the position, and will thus allow a planning of the best method for removal of the foreign body. A bone in the larynx usually is visible in a good roentgenogram. Accurate diagnosis in children is made by direct laryngoscopy without anesthesia, but direct laryngoscopy should not be done until one is prepared to remove a foreign body if found, to follow it into the bronchus and remove it if it should be dislodged and aspirated, and to do tracheotomy if sudden respiratory arrest occur.

[157] _Technic of Removal of Foreign Bodies from the Larynx_.--The patient is to be placed in the author's position, shown in Fig. 53. No general anesthesia should be given, and the application of local anesthesia is usually unnecessary and further, is liable to dislodge and push down the foreign body.* Because of the risk of loss downward it is best to seize the foreign body as soon as seen; then to determine how best to disimpact it. The fundamental principles are that a pointed object must either have its point protected by the forceps grasp or be brought out point trailing, and that a flat object must be so rotated that its plane corresponds to the sagittal plane of the glottic c.h.i.n.k. The laryngeal grasping forceps (Fig. 53) will be found the most useful, although the alligator rotation forceps (Fig.

31) may occasionally be required.

* In adolescents or adults a few drops of a 4 per cent solution of cocain applied to the laryngopharynx with an atomizer or a dropper will afford the minimum risk of dislodgement; but the author's personal preference is for no anesthesia, general or local.

[158] CHAPTER XV--MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY EXTRACTION*

* 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 a.s.sist 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 s.p.a.ces" of which there must be two for all ordinary forceps, one for each jaw, or the "insertion s.p.a.ce" 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 s.p.a.ce 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 pa.s.s 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)

_The Light Reflex on the Forceps_.--It is often difficult for the beginner to judge to what depth an instrument has been inserted through the tube. On slowly inserting a forceps through the tube, as the blades come opposite the distal light they will appear brightly illuminated; or should the blades lie close to the light bulb, a shadow will be seen in the previously brilliantly lighted opposite wall. It is then known that the forceps are at the tube mouth, and the endoscopist has but to gauge the distance from this to the foreign body. This a.s.sistance in gauging depth is one of the great advances in foreign body bronchoscopy obtained by the development of distal illumination.

_Hooks_ are useful in the solution of various mechanical problems, and may be turned by the operator himself into various shapes by heating small probe-pointed steel rods in a spirit lamp, the proximal end being turned over at a right angle for a controlling handle. Hooks with a greater curve than a right angle are p.r.o.ne to engage in small orifices from which they are with difficulty removed. A right angle curve of the distal end is usually sufficient, and a corkscrew spiral is often advantageous, rendering removal easy by a reversal of the twisting motion (Bib. 11, p. 311).

_The Use of Forceps in Endoscopic Foreign Body Extraction_.--Two different strengths of forceps are supplied, as will be seen in the list in Chapter 1. The regular forceps have a powerful grasp and are used on dense foreign bodies which require considerable pressure on the object to prevent the forceps from slipping off. For more delicate manipulation, and particularly for friable foreign bodies, the lighter forceps are used. Spring-opposed forceps render any delicacy of touch impossible. Forceps are to be held in the right hand, the thumb in one ring, and the third, or ring finger, in the other ring. These fingers are used to open and close the forceps, while all traction is to be made by the right index finger, which has its position on the forceps handle near the stylet, as shown in Fig. 78. It is absolutely essential for accurate work, that the forceps jaws be seen to close upon the foreign body. The impulse to seize the object as soon as it is discovered must be strongly resisted. A careful study of its size, shape, and position and relation to surrounding structures must be made before any attempt at extraction. The most favorable point and position for grasping having been obtained, the closed forceps are inserted through the bronchoscope, the light reflex obtained, the forceps blades now opened are turned in such a position that, on advancing, the foreign body will enter the open V, a sufficient distance to afford a good grasp. The blades are then closed and the foreign body is drawn against the tube mouth. Few foreign bodies are sufficiently small to allow withdrawal through the tube, so that tube, forceps and foreign body are usually withdrawn together.

[FIG. 78.--Proper hold of forceps. The right thumb and third fingers are inserted into the rings while the right index finger has its place high on the handle. All traction is made with the index finger, the ring fingers being used only to open and close the forceps. If any pushing is deemed safe it may be done by placing the index finger back of the thumb-nut on the stylet.]

_Anchoring the Foreign Body Against the Tube Mouth_.--If withdrawal be made a bimanual procedure it is almost certain that the foreign body will trail a centimeter or more beyond the tube mouth, and that the closure of the glottic c.h.i.n.k as soon as the distal end of the bronchoscope emerges will strip the foreign body from the forceps grasp, when the foreign body reaches the cords. This is avoided by anchoring the foreign body against the tube mouth as soon as the foreign body is grasped, as shown in Fig. 79. The left index finger and thumb grasp the shaft of the forceps close to the ocular end of the tube, while the other fingers encircle the tube; closure of the forceps is maintained by the fingers of the right hand, while all traction for withdrawal is made with the left hand, which firmly clamps forceps and bronchoscope as one piece. Thus the three units are brought out as one; the bronchoscope keeping the cords apart until the foreign body has entered the glottis.

[FIG. 79--Method of anchoring the foreign body against the tube mouth After the object has been drawn firmly against the lip of the endoscopic tube the left finger and thumb grasp the forceps cannula and lock it against the ocular end of the tube, the other fingers of the left hand encircle the tube. Withdrawal is then done with the left hand; the fingers of the right hand maintaining closure of the forceps.]

[164] _Bringing the Foreign Body Through the Glottis_.--Stripping of the foreign body from the forceps at the glottis may be due to: 1. Not keeping the object against the tube mouth as just mentioned.

2. Not bringing the greatest diameter of the foreign body into the sagittal plane of the glottic c.h.i.n.k.

3. Faulty application of the forceps on the foreign body.

4. Mechanically imperfect forceps.

Should the foreign body be lost at the glottis it may, if large become impacted and threaten asphyxia. Prompt insertion of the laryngoscope will usually allow removal of the object by means of the laryngeal grasping forceps. The object may be dropped or expelled into the pharynx and be swallowed. It may even be coughed into the naso-pharynx or it may be re-aspirated. In the latter event the bronchoscope is to be re-inserted and the trachea carefully searched. Care must be used not to override the object. If much inflammatory reaction has occurred in the first invaded bronchus, temporarily suspending the aerating function of the corresponding lung, reaspiration of a dislodged foreign body is liable to carry it into the opposite main bronchus, by reason of the greater inspiratory volume of air entering that side.

This may produce sudden death by blocking the only aerating organ.

_Extraction of Pins, Needles and Similar Long Pointed Objects_.--When searching for such objects especial care must be taken not to override them. Pins are almost always found point upward, and the dictum can therefore be made, "Search not for the pin, but for the point of the pin." If the point be found free, it should be worked into the lumen of the bronchoscope by manipulation with the lip of the tube. It may then be seized with the forceps and withdrawn. Should the pin be grasped by the shaft, it is almost certain to turn crosswise of the tube mouth, where one pull may cause the point to perforate, enormously increasing the difficulties by transfixation, and perhaps resulting fatally (Fig. 80).

[FIG. 80.--Schematic ill.u.s.tration of a serious phase of the error of hastily seizing a transfixed pin near its middle, when first seen as at M. Traction with the forceps in the direction of the dart in Schema B will rip open the esophagus or bronchus inflicting fatal trauma, and probably the pin will be stripped off at the glottic or the cricopharyngeal level, respectively. The point of the pin must be disembedded and gotten into the tube mouth as at A, to make forceps traction safe.]