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 canal 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 passed. Complications are rare after careful work, but if they do occur, they may require immediate attention. This applies especially to the subglottic edema associated 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 associated 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 hoarseness 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 accumulation 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 canal (Fig. 1, E) may be used through the larynx. Frequent peroral passage 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 associated with advanced nephritis.