Bronchoscopy and Esophagoscopy Part 11

[FIG. 81.--Schema ill.u.s.trating the mechanical problem of extracting a pin, a large part of whose shaft is buried in the bronchial wall, B.

The pin must be pushed downward and if the orifice of the branches, C, D, are too small to admit the head of the pin some other orifice (as at A) must be found by palpation (not by violent pushing) to admit the head, so that the pin can be pushed downward permitting the point to emerge (E). The point is then manipulated into the bronchoscopic tube-mouth by means of co-ordinated movements of the bronchoscopic lip and the side-curved forceps, as shown at F.]

_Inward Rotation Method_.--When the point is found to be buried in the mucosa, the best and usually successful method is to grasp the pin as near the point as possible with the side-grasping forceps, then with a spiral motion to push the pin downward while rotating the forceps about ninety degrees. The point is thus disengaged, and the shaft of the pin is brought parallel with that of the forceps, after which the point may be drawn into the tube mouth. The lips added to the side-curved forceps by my a.s.sistant Dr. Gabriel Tucker I now use exclusively for this inward rotation method. They are invaluable in preventing the escape of the pin during the manipulation. A hook is sometimes useful in disengaging a buried point. The method of its use is ill.u.s.trated in Fig. 82.

[FIG. 82.--Mechanical problem of pin, needle, tack or nail with embedded point. If the forceps are pulled upon the pin point will be buried still deeper. The side curved forceps grasp the pin as near the point as possible then with a corkscrew motion the pin is pushed downward and rotated to the right when the pin will be found to be parallel with the shaft of the forceps and can be drawn into the tube.

If the pin is prevented by its head from being pushed downward the point may be extracted by the hook as shown above The side curved forceps may be used instead of the hook for freeing the point, the author's "inward rotation" method. The very best instrument for the purpose is the forceps devised by my a.s.sistant, Dr. Gabriel Tucker (Fig. 21). The lips prevent all risk of losing the pin from the grasp, and at the same time bring the long axis of the pin parallel to that of the bronchoscope.]

Pins are very p.r.o.ne to drop into the smaller bronchi and disappear completely from the ordinary field of endoscopic exploration. At other times, pins not dropping so deeply may show the point only during expiration or cough, at which times the bronchi are shortened. In such instances the invaded bronchial orifice should be clearly exposed as near the axis of its lumen as possible; the forceps are now inserted, opened, and the next emergence watched for, the point being grasped as soon as seen.

_Extraction of Tacks, Nails and Large Headed Foreign Bodies from the Tracheobronchial Tree_.--In cases of this sort the point presents the same difficulty and requires solution in the same manner as mentioned in the preceding paragraphs on the extraction of pins. The author's inward-rotation method when executed with the Tucker forceps is ideal.

The large head, however, presents a special problem because of its tendency to act as a mushroom anchor when buried in swollen mucosa or in a fibrous stenosis (Fig. 83). The extraction problems of tacks are ill.u.s.trated in Figs. 84, 85, and 86. Nails, stick pins, and various tacks are dealt with in the same manner by the author's "inward rotation" method.

_Hollow metallic bodies_ presenting an opening toward the observer may be removed with a grooved expansile forceps as shown in Figs 23 and 25, or its edge may be grasped by the regular side-grasping forceps.

The latter hold is apt to be very dangerous because of the trauma inflicted by the catching of the free edge opposite the forceps; but with care it is the best method. Should the closed end be uppermost, however, it may be necessary to insert a hook beyond the object, and to coax it upward to a point where it may be turned for grasping and removal with forceps.

[FIG. 83.--"Mushroom anchor" problem of the upholstery tack. If the tack has not been _in situ_ more than a few weeks the stenosis at the level of the darts is simply edematous mucosa and the tack can be pulled through with no more than slight mucosal trauma, _provided_ axis-traction only be used. If the tack has been in situ a year or more the fibrous stricture may need dilatation with the divulsor.

Otherwise traction may rupture the bronchial wall. The stenotic tissue in cases of a few months' sojourn maybe composed of granulations, in which case axis-traction will safely withdraw it. The point of a tack rarely projects freely into the lumen as here shown. More often it is buried in the wall.]

[168] [FIG. 84.-Schema ill.u.s.trating the "mushroom anchor" problem of the bra.s.s headed upholstery tack. At A the tack is shown with the head bedded in swollen mucosa. The bronchoscopist, looking through the bronchoscope, E, considering himself lucky to have found the point of the tack, seizes it and starts to withdraw it, making traction as shown by the dart in drawing B. The head of the tack catches below a chondrial ring and rips in, tearing its way through the bronchial wall (D) causing death by mediastinal emphysema. This accident is still more likely to occur if, as often happens, the tack-head is lodged in the orifice of the upper lobe bronchus, F. But if the bronchoscopist swings the patient's head far to the opposite side and makes axis-traction, as shown at C, the head of the tack can be drawn through the swollen mucosa without anchoring itself in a cartilage. If necessary, in addition, the lip of the bronchoscope can be used to repress the angle, h, and the swollen mucosa, H. If the swollen mucosa, H, has been replaced by fibrous tissue from many months'

sojourn of the tack, the stenosis may require dilatation with the divulsor.]

[FIG. 85.--Problem of the upholstery tack with buried point. If pulled upon, the imminent perforation of the mediastinum, as shown at A will be completed, the bronchus will be torn and death will follow even if the tack be removed, which is of doubtful possibility. The proper method is gently to close the side curved forceps on the shank of the tack near the head, push downward as shown by the dart, in B, until the point emerges. Then the forceps are rotated to bring the point of the tack away from the bronchial wall.]

[169] _Removal of Open Safety Pins from the Trachea and Bronchi_.-- Removal of a closed safety pin presents no difficulty if it is grasped at one or the other end. A grasp in the middle produces a "toggle and ring" action which would prevent extraction. When the safety pin is _open with the point downward_ care must be exercised not to override it with the bronchoscope or to push the point through the wall. The spring or near end is to be grasped with the side-curved or the rotation forceps (Figs. 19, 20 and 31) and pulled into the bronchoscope, thus closing the pin. An open safety pin lodged point up presents an entirely different and a very difficult problem. If traction is made without closing the pin or protecting the point severe and probably fatal trauma will be produced. The pin may be closed with the pin-closer as ill.u.s.trated in Fig. 37, and then removed with forceps. Arrowsmith's pin-closer is excellent. Another method (Fig. 87) consists in bringing the point of the safety pin into the bronchoscope, after disengaging the point with the side curved forceps, by the author's "inward rotation" method. The forceps-jaws (Fig. 21) devised recently by my a.s.sistant, Dr. Gabriel Tucker, are ideal for this maneuver. As the point is now protected, the spring, seen just off the tube mouth, is best grasped with the rotation forceps, which afford the securest hold. The keeper and its shaft are outside the bronchoscope, but its rounded portion is uppermost and will glide over the tissues without trauma upon careful withdrawal of the tube and safety pin. Care must be taken to rotate the pin so that it lies in the sagittal plane of the glottis with the keeper placed posteriorly, for the reason that the base of the glottic triangle is posterior, and that the posterior wall of the larynx is membranous above the cricoid cartilage, and will yield. A small safety-pin may be removed by version, the point being turned into a branch bronchial orifice. No one should think of attempting the extraction of a safety pin lodged point upward without having practiced for at least a hundred hours on the rubber tube manikin. This practice should be carried out by anyone expecting to do endoscopy, because it affords excellent education of the eye and the fingers in the endoscopic manipulation of any kind of foreign body. Then, when a safety pin case is encountered, the bronchoscopist will be prepared to cope with its difficulties, and he will be able to determine which of the methods will be best suited to his personal equation in the particular case.

[FIG. 86.--Schema ill.u.s.trating the "upper-lobe-bronchus problem,"

combined with the "mushroom-anchor" problem and the author's method for their solution. The patient being rec.u.mbent, the bronchoscopist looking down the right main bronchus, M, sees the point of the tack projecting from the right upper-lobe-bronchus, A. He seizes the point with the side-curved forceps; then slides down the bronchoscope to the position shown dotted at B. Next he pushes the bronchoscopic tube-mouth downward and medianward, simultaneously moving the patient's head to the right, thus swinging the bronchoscopic level on its fulcrum, and dragging the tack downward and inward out of its bed, to the position, 1). Traction, as shown at C, will then safely and easily withdraw the tack. A very small bronchoscope is essential. The lip of the bronchoscopic tube-mouth must be used to pry the forceps down and over, and the lip must be brought close to the tack just before the prying-pushing movement. S, right stem-bronchus.]

[FIG. 87.--One method of dealing with an open safety pin without closing it.]

_Removal of Double Pointed Tacks_.--If the tack or staple be small, and lodged in a relatively large trachea a version may be done. That is, the staple may be turned over with the hook or rotation forceps and brought out with the points trailing. With a long staple in a child's trachea the best method is to "coax" the intruder along gently under ocular guidance, never making traction enough to bury the point deeply, and lifting the point with the hook whenever it shows any inclination to enter the wall. Great care and dexterity are required to get the intruder through the glottis. In certain locations, one or both points may be turned into branch bronchi as ill.u.s.trated in Fig.

88, or over the carina into the opposite main bronchus. Another method is to get both points into the tube-mouth. This may be favored, as demonstrated by my a.s.sistant, Dr. Gabriel Tucker, by tilting the staple so as to get both points into the longest diameter of the tube-mouth. In some cases I have squeezed the bronchoscope in a vise to create an oval tube-mouth. In other cases I have used expanding forceps with grooved blades.

[FIG. 88.-Schema ill.u.s.trating podalic version of bronchially-lodged staples or double-pointed tacks. H, bronchoscope. A, swollen mucosa covering points of staple. At E the staple has been manipulated upward with bronchoscopic lip and hooks until the points are opposite the branch bronchial orifices, B, C. Traction being made in the direction of the dart (F), by means of the rotation forceps, and counterpressure being made with the bronchoscopic lip on the points of the staple, the points enter the branch bronchi and permit the staple to be turned over and removed with points trailing harmlessly behind (K).]

_The Extraction of Tightly Fitting Foreign Bodies from the Bronchi.

Annular Edema_.--Such objects as marbles, pebbles, corks, etc., are drawn deeply and with force by the inspiratory blast into the smallest bronchus they can enter. The air distal to the impacted foreign body is soon absorbed, and the negative pressure thus produced increases the impaction. A ring of edematous mucosa quickly forms and covers the presenting part of the object, leaving visible only a small surface in the center of an acute edematous stenosis. A forceps with narrow, stiff, expansive-spring jaws may press back a portion of the edema and may allow a grasp on the sides of the foreign body; but usually the attempt to apply forceps when there are no s.p.a.ces between the presenting part of the foreign body and the bronchial wall, will result only in pushing the foreign body deeper.* A better method is to use the lip of the bronchoscope to press back the swollen mucosa at one point, so that a hook may be introduced below the foreign body, which then can be worked up to a wider place where forceps may be applied (Fig. 89). Sometimes the object may even be held firmly against the tube mouth with the hook and thus extracted. For this the unslanted tube-mouth is used.

* The author's new ball forceps are very successful with ball-bearing b.a.l.l.s and marbles.

[FIG. 89.--Schema ill.u.s.trating the use of the lip of the bronchoscope in disimpaction of foreign bodies. A and B show an annular edema above the foreign body, F. At C the edematous mucosa is being repressed by the lip of the tube mouth, permitting insinuation of the hook, H, past one side of the foreign body, which is then withdrawn to a convenient place for application of the forceps. This repression by the lip is often used for purposes other than the insertion of hooks. The lip of the esophagoscope can be used in the same way.]

_Extraction of Soft Friable Foreign Bodies from the Tracheobronchial Tree_.--The difficulties here consist in the liability of crushing or fragmenting the object, and scattering portions into minute bronchi, as well as the problem of disimpaction from a ring of annular edema, with little or no forceps s.p.a.ce. There is usually in these cases an abundance of purulent secretion which further hinders the work. The great danger of pushing the foreign body downward so that the swollen mucosa hides it completely from view, must always be kept in mind.

Extremely delicate forceps with rather broad blades are required for this work. The fenestrated "peanut" forceps are best for large pieces in the large bronchi. The operator should develop his tactile sense with forceps by repeated practice in order to acquire the skill to grasp peanut kernels sufficiently firmly to hold them during withdrawal, yet not so firmly as to crush them. Nipping off an edge by not inserting the forceps far enough is also to be avoided. Small fragments under 2 mm. in diameter may be expelled with the secretions and fragments may be found on the sponges and in the secretions aspirated or removed by sponge pumping. It is, however, never justifiable deliberately to break a friable foreign body with the hope that the fragments will be expelled, for these may be aspirated into small bronchi, and cause multiple abscesses. A hook may be found useful in dealing with round, friable, foreign bodies; and in some cases the mechanical spoon or safety-pin closer may be used to advantage. The foreign body is then brought close to, but not crushed against the tube mouth.

[174] _Removal of animal objects from the tracheobronchial tree_ is readily accomplished with the side-curved forceps. Leeches are not uncommon intruders in European countries. Small insects are usually coughed out. Worms and larvae may be found. Cocaine or salt solution will cause a leech to loosen its hold.

_Foreign bodies in the upper-lobe bronchi_ are fortunately not common.

If the object is not too far out to the periphery it may be grasped by the upper-lobe-bronchus forceps (Fig. 90), guided by the collaboration of the fluoroscopist. These forceps are made so as to reach high into the ascending branches of the upper-lobe bronchus. Full-curved coil-spring hooks will reach high, but must be used with the utmost caution, and the method of their disengagement must be practiced beforehand.

_Penetrating Projectiles_.--Foreign bodies that have penetrated the chest wall and lodged in the lung may be removed by oral bronchoscopy if the intruder is not larger than the lumen of the corresponding main bronchus (see Bibliography, 43)

[FIG. 90.--Schematic ill.u.s.tration of the author's upper-lobe-bronchus forceps in position grasping a pin in an anteriorly ascending branch of the upper-lobe bronchus. T, Trachea; UL, upper-lobe bronchus; LB, left bronchus; SB, stem bronchus. These forceps are made to extend around 180 degrees.]

RULES FOR ENDOSCOPIC FOREIGN BODY EXTRACTION

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.

[175] 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 first.

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 bronchi.

[176] 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 bronchoscopy.

[177] CHAPTER XVI--FOREIGN BODIES IN THE BRONCHI FOR PROLONGED PERIODS

The sojourn of an inorganic foreign body in the bronchus for a year or more is followed by the development of bronchiectasis, pulmonary abscess, and fibrous changes. The symptoms of tuberculosis may all be presented, but tubercle bacilli have never been found a.s.sociated with any of the many cases that have come to the Bronchoscopic Clinic.* The history of repeated attacks of malaise, fever, chills, and sweats lasting for a few days and terminated by the expulsion of an amount of foul pus, suggests the intermittent drainage of an abscess cavity, and special study should be made to eliminate foreign body as the cause of the condition, in all such cases, whether there is any history of a foreign body accident or not. Bronchoscopy for diagnosis is to be done unless the etiology can be definitely proven by other means. In all cases of chronic chest disease foreign body should be eliminated as a matter of routine.

* One exception has recently come to the Clinic. 12

_The time of aspiration of a foreign body_ may be unknown, having possibly occurred in infancy, during narcosis, or the object may even enter the lower air pa.s.sages without the patient being aware of the accident, as happened with a particularly intelligent business man who unknowingly aspirated the tip of an atomizer while spraying his throat. In many other cases the accident had been forgotten. In still others, in spite of the patient's statement of a conviction that the trouble was due to a foreign body he had aspirated, the physician did not consider it worthy of sufficient consideration to warrant a roentgenray examination. It is curious to note the various opinions held in regard to the gravity of the presence of a bronchial foreign body. One patient was told by his physician that the presence of a staple in his bronchus was an impossibility, for he would not have lived five minutes after the accident. Others consider the presence of a foreign body in the bronchus as comparatively harmless, in spite of the repeated reports of invalidism and fatality in the medical literature of centuries. The older authorities state that all cases of prolonged bronchial foreign body sojourn died from phthisis pulmonalis, and it is still the opinion of some pract.i.tioners that the presence of a foreign body in the lung predisposes to the development of true tuberculosis. With the dissemination of knowledge regarding the possibility of bronchial foreign body, and the marvellous success in their removal by bronchoscopy, the cases of prolonged foreign body sojourn should decrease in number. It should be the recognized rule, and not the exception, that all chest conditions, acute or chronic, should have the benefit of roentgenographic study, even apart from the possibility of foreign body.

Often even with the clear history of foreign-body aspiration, both patient and physician are deluded by a relatively long period of quiescence in which no symptoms are apparent. This symptomless interval is followed sooner or later by ever increasing cough and expectoration of sputum, finally by bronchiectasis and pulmonary abscess, chronic sepsis, and invalidism.

_Pathology_.--If the foreign body completely obstructs a main bronchus, preventing both aeration and drainage, such rapid destruction of lung tissue follows that extensive pathologic changes may result in a few months, or even in a few weeks, in the case of irritating foreign bodies such as peanut kernels and soft rubber. Very minute, inorganic foreign bodies may become encysted as in anthracosis. Large objects, however, do not become encysted. The object is drawn down by gravity and aspirated into the smallest bronchus it can enter. Later the negative pressure below from absorption of air impacts it still further. Swelling of the bronchial mucosa from irritation plus infection completes the occlusion of the bronchus. Retention of secretions and bacterial decomposition thereof produces first a "drowned lung" (natural pa.s.sages full of pus); then sloughing or ulceration in the tissues plus the pressure of the pus, causes bronchiectasis; further destruction of the cartilaginous rings results in true abscess formation below the foreign body. The productive inflammation at the site of lodgement of the foreign body results in cicatricial contraction and the formation of a stricture at the top of the cavity, in which the foreign body is usually held. The abscess may extend to the periphery and rupture into the pleural cavity. It may drain intermittently into a bronchus. Certain irritating foreign bodies, such as soft rubber, may produce gangrenous bronchitis and multiple abscesses. For observations on pathology (see Bibliography, 38).

_Prognosis_.--If the foreign body be not removed, the resulting chronic sepsis or pulmonary hemorrhage will prove fatal. Removal of the foreign body usually results in complete recovery without further local treatment. Occasionally, secondary dilatation of a bronchial stricture may be required. All cases will need, besides removal of the foreign body, an ant.i.tuberculous regimen, and offer a good prognosis if this be followed.

_Treatment_.--Bronchoscopy should be done in all cases of chronic pulmonary abscess and bronchiectasis even though radiographic study reveals no shadow of foreign body. The patient by a.s.suming a posture with the head lowered is urged to expel spontaneously all the pus possible, before the bronchoscopy. The aspirating bronchoscope (Fig.

2, E) is often useful in cases where large amounts of secretion may be antic.i.p.ated. Granulations may require removal with forceps and sponging. Disturbed granulations result in bleeding which further hampers the operation; therefore, they should not be touched until ready to apply the forceps, unless it is impossible to study the presentation without disturbing them. For this reason secretions hiding a foreign body should be removed with the aspirating tube (Fig.

9) rather than by swabbing or sponge-pumping, when the bronchoscopic tube-mouth is close to the foreign body. It is inadvisable, however, to insert a forceps into a ma.s.s of granulations to grope blindly for a foreign body, with no knowledge of the presentation, the forceps s.p.a.ces, or the location of branch-bronchial orifices into which one blade of the forceps may go. Dilatation of a stricture may be necessary, and may be accomplished by the forms of bronchial dilators shown in Fig. 25. The hollow type of dilator is to be used in cases in which the foreign body is held in the stricture (Fig. 83). This dilator may be pushed down over the stem of such an object as a tack, and the stricture dilated without the risk of pushing the object downward. It is only rarely, however, that the point of a tack is free. Dense cicatricial tissue may require incision or excision.

_Internal bronchotomy_ is doubtless, a very dangerous procedure, though no fatalities have occurred in any of the three cases in the Bronchoscopic Clinic. It is advisable only as a last resort.