[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 associated 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 passages 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 practitioners 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 passages 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 antituberculous 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 assuming 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 anticipated. 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 mass of granulations to grope blindly for a foreign body, with no knowledge of the presentation, the forceps spaces, 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.
[181] CHAPTER XVII—UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES
The limitations of bronchoscopic removal of foreign bodies are usually manifested in the failure to find a small foreign body which has entered a minute bronchus far down and out toward the periphery. When localization by means of transparent films, fluoroscopy, and endobronchial bismuth insufflation has failed, the question arises as to the advisability of endoscopic excision of the tissue intervening between the foreign body and bronchoscope with the aid of two fluoroscopes, one for the lateral and the other the vertical plane. With foreign bodies in the larger bronchi near the root of the lung such a procedure is unnecessary, and injury to a large vessel would be almost certain. At the extreme periphery of the lung the danger is less, for the vessels are smaller and serious hemorrhage less probable, through the retention and decomposition of blood in small bronchi with later abscess formation is a contingency. The nature of the bridge of tissue is to be considered; should it be cicatricial, the result of prolonged inflammatory processes, it may be carefully excised without very great risk of serious complications. The blood vessels are diminished in size and number by the chronic productive inflammation, which more than offsets their lessened contractility.