It is the duty of the anæsthetist or some competent assistant to note that normal respiration is maintained, and the necessity for tracheotomy or artificial respiration must always be borne in mind.
If the operator be experienced, bronchoscopy can be performed without endangering the patient’s life even in the case of a young child. A baby of eight months has been successfully treated by this method.
Lower bronchoscopy. Preliminary tracheotomy (median or low) having been performed, a wide tube is introduced into the bronchus through the wound in the trachea. This method has the following advantages: It is easier to perform, and the surgeon requires less experience of technique; the tube, being wider, is more readily illuminated; there is little danger of asphyxia; in passing the tube no organisms are introduced from the mouth, and there is less danger of pneumonia. If these advantages are weighed, it becomes apparent that the lower operation is preferable for surgeons without experience. In all cases with urgent dyspnœa preliminary tracheotomy is practically essential.
By a combination of the above methods the diagnosis of foreign bodies can be positively determined in the majority of cases. As Killian said in 1902: ‘We have now reached a position in which, in many cases at least, one can not only obtain a positive result but with confidence can assert that the foreign body is not present.’ In support of this statement numerous cases have been reported, especially in Germany and America. Von Eicken, in 1904, collected 42 cases of bronchoscopy, in 35 of which a definite diagnosis of a foreign body was made; in 4 it was shown that none was present; and in 3 only were negative results obtained. Since that time the results have been equally good, for in 1907 Killian increased this number to 164 reported cases in which a foreign body had been actually discovered.
As soon as the foreign body is clearly seen, a pair of forceps is selected and introduced through the tube. The object is grasped and drawn through the tube, if this be possible, or the tube and forceps may be withdrawn together from the trachea. If the foreign substance be broken the operation can be repeated until all of it has been removed. If the patient becomes collapsed it may be necessary to postpone the continuation of the treatment until the following day. A second attempt is often successful when the first has proved a failure.
Bronchoscopy is comparatively easy to perform (a) when the foreign body lies in the trachea or main bronchus; (b) when the foreign body has been accurately located; or (c) when the operation can be performed early, before inflammation has supervened. In the rare instances where the body lies in one of the secondary or tertiary bronchi, or has penetrated the substance of the lung, the difficulties are much increased, and in such conditions the question of the advisability of lower bronchoscopy should be considered.
Complications seldom occur after removal of foreign bodies by these methods if the surgeon is careful to avoid injury when passing the tubes. There may be temporary hoarseness owing to congestion of the mucous membrane. Ingals has reported two cases in which death occurred soon after the operation, with symptoms like those of delayed poisoning from an anæsthetic, and has raised the question whether it is advisable to use cocaine or atropin[e] in these operations. Delavan, on the other hand, suggests that injury to the pneumogastrics may account for such collapse. As stated above, the combination of chloroform and cocaine does not appear to be dangerous if used with discretion.
Fig. 279. Upper Bronchoscopy with the Patient in the Dorsal Position.