If a patient flexes his neck, and extends his head sufficiently, he can align his mouth with his trachea or oesophagus, so that a rigid tube can be passed down them. This is the ''sword-swallowing position', and is the basis of rigid bronchoscopy and ]]oesophagoscopy. In theory, these are simple procedures[md]the traditional type of bronchoscope is merely a long tube with a light at one end. In practice, however, removing a foreign body with one requires such skill, that it is one of the most difficult procedures we describe, and is at the very limits of ''Primary Surgery'. Anaesthesia is difficult, and the skill of your anaesthetist is the main determinant of success. You need a range of intruments to cover all sizes of patient, and also a variety of forceps. There are many opportunities for disaster, particularly tearing the patient's lower trachea and bronchi if he struggles, so causing mediastinal emphysema and mediastinitis. Many hospitals don't have bronchoscopes; this is for those that do. If you have other instruments with fibre-optic illumination, make sure that your bronchoscope is compatible with that system. You will need good suction.
You will find bronchoscopy useful for: (1) Sucking out a patient's stomach contents from his trachea, if he has been unfortunate enough to aspirate them during a general anaesthetic (A 16.3). Make this your first priority, especially if you are new to bronchoscopy. (2) Sucking out the secretions which have gathered in the bronchi of a desperately sick patient postoperatively (9.11). (3) Removing foreign bodies, especially peanuts inhaled by children. This is more difficult than the other two indications, so don't start with it, if you can avoid doing so. (4) Diagnosing carcinoma, and other diseases of the larger airways.
Inhaled foreign bodies in the larynx and tracheobronchial tree, particularly peanuts or watermelon pips, are common. If a child is lucky, his first immediate bout of coughing expels the nut. If he is not so lucky, wheezing and coughing stop without expelling it. This may be followed by a latent interval, during which there are no signs, especially if the nut has gone far down his bronchial tree. This latent interval is then followed by fever, a cough, and the symptoms of chest infection. Antibiotics may relieve his symptoms temporarily, but they always return when treatment stops. He is often misdiagnosed as having tuberculosis.
If coughing, or the ''upside down thump' described below, fail to remove a foreign body, it has to be removed through a bronchoscope. Even if you can successfully pass one, removing a foreign body is difficult, and sometimes impossible. Yet if you cannot refer him, and leave it inside him, suppuration and chronic disability, or death, are certain.
BRONCHOSCOPE, rigid, Negus, conventional lighting, distal illumination, complete with cords, Wappler fitting, battery box, two lamp carriers and 2.5 v lamps with 10 BA thread, (a) infant lumen 5.4[mu]4.1 mm, (b) child 7[mu]5.7 mm, (c) adolescent small 8[mu]6.7 mm, one only of each size, (optional). ALSO, 25 spare bulbs. If you are going to remove foreign bodies from the lower respiratory tract, you will need these. This is not the complete range, which includes the adolescent large, the small adult, the adult, and several for the lower bronchus. Darken the theatre so that you do not have to use the bulbs at voltages which shorten their lives.
FORCEPS, for bronchoscope, (a) Chevalier Jackson, 2/2 teeth on 50 cm shaft, one only, (b) Haslinger tubular shaft or sliding shaft type for small bronchoscopes (both optional). If you have bronchoscopes, you will need forceps for them. Mark the shaft of the forceps with tape, so that you know when the tip is beyond the bronchoscope.
BRONCHOSCOPY INDICATIONS. See above.
CAUTION ! This is not an easy procedure, so refer the patient to an expert, or call one in, if you can. Usually, this is impossible, so that, if you don't bronchoscope a patient, nobody else will. You will need a good anaesthetist and a good nurse.
BRONCHOSCOPY UNDER LOCAL ANAESTHESIA. Premedicate him. Give an adult chlorpromazine 50 mg, and atropine 0.6 mg. Sit him up and inject 5 ml of 4% lignocaine into his trachea with a short stiff fine-bore needle; aim to produce a fine spray. Go through his cricothyroid membrane (A 13.5). Check that you are in his trachea, by aspirating before you inject. Before you pass the instrument, spray his cords with more lignocaine and wait 2 minutes.
CAUTION ! Don't exceed the dose of lignocaine, particularly in a small child (A 5-1). 10 ml of 4% lignocaine is the absolute maximum for an adult.
BRONCHOSCOPY UNDER GENERAL ANAESTHESIA. Give him a general anaesthetic and a short-acting relaxant.
BRONCHOSCOPY [s7]FOR THE ASPIRATION OF STOMACH CONTENTS He will probably be in the theatre, and be partly or completely anaesthetized already, so there is no need for anaesthesia. He will not resist for long. Insert the bronchoscope, as rapidly as you can, and aspirate with a long sterile catheter.
BRONCHOSCOPY [s7]FOR THE RETENTION OF SECRETIONS INDICATIONS. He is likely to be a very sick adult, who has been unable to cough his airway clear of secretions postoperatively (see Section 9.11). His breathing is bubbly, and parts of his lungs may have collapsed. He is so ill that he will die, unless his lower respiratory tract is cleared.
METHOD. If you cannot call in anyone who is more expert, take him into a side ward, or better, the theatre. Have an anaesthetist and a competent nurse to help you. Sit him up in bed with pillows behind his back. Use local anaesthesia as above. Blindfold him, and wear spectacles to protect yourself from showers of sputum. Stand behind him on a firm chair, with the bronchoscope and sucker ready. Ask him to look upwards.
Now pass the bronchoscope gently behind his tongue. Look for his uvula and his epiglottis. This will lead you in the midline to his vocal cords, as when intubating. As soon as you see them, aim the bronchoscope in the same direction as his trachea. Slip its beak between his cords and advance it downwards, sucking out the secretions as you do so. Clear his airway and remove the instrument. This will produce a paroxysm of coughing[md]which will benefit him greatly.
CAUTION ! (1) Make sure you are not going down his oesophagus (you must recognize his cords on entry). (2) Very little movement should be possible between the bronchoscope and the patient. So hold its handle in your right hand. Hold its shaft between the index and middle fingers of your left hand. Rest your left thumb on his upper front teeth, and keep his lower lip out of the way with a gauze swab, held in your ring finger. If you hold the bronchoscope against his teeth like this, it and his head will turn as one and less damage is likely.
Alternatively, demonstrate his cords with a laryngoscope, before you pass the bronchoscope.
FOREIGN BODIES [s7]IN THE BRONCHI IMMEDIATE TREATMENT[md]THE ''UPSIDE DOWN THUMP'. If you are present when a child inhales a foreign body, turn him upside down and bang the back of his chest[md]he may cough it out. This is a very valuable procedure (and once saved the editor's life!).
HISTORY AND EXAMINATION. If he presents later, take a careful history, look for impaired movement on one side of his chest, and listen for localized wheezing.
X-RAYS. Look for a radio-opaque object, localized collapse, pneumonitis, consolidation of a segment or an entire lobe; and mediastinal shift. There will be obstructive emphysema if a foreign body allows air into a bronchus, but not out of it.
CAUTION ! (1) If a mother comes to you saying that her child has inhaled a peanut, believe her, she is almost certainly right. (2) Most plastics are radiolucent, so you will not see them on an X-ray film. (3) Negative X-rays never exclude a foreign body, unless everyone is sure it is radio-opaque.
Fig. 25-9 ARRANGEMENTS FOR BRONCHOSCOSCOPY. After induction the anaesthetist moves to the patient's left.
1, a syringe in a vein. 2, the anaesthetist. 3, the oxygen line. 4, the surgeon. 5, the sucker. 6, the trolley nurse. 7, the trolley with sucker tubes. 8, the nurse who controls the patient's head.
BRONCHOSCOPY [s7]FOR THE REMOVAL OF A FOREIGN BODY EQUIPMENT. A suitable size of bronchoscope. A long piece of bent wire with a hook on it (see below). Switch on the light, insert the grasping forceps, and practise picking up peanuts from an assistant's hand before you start.
ANAESTHESIA must abolish the child's cough reflex; local anaesthesia alone will not do this adequately: (1) Ketamine or thiopentone followed by intermittent suxamethonium (A 14.2), with oxygen intermittently introduced into the bronchoscope through an uncuffed tube. Be sure you have a drip up. (2) Suxamethonium followed by a long-acting relaxant, if the anaesthetist is skilled.
CAUTION ! Be sure to spray the child's larynx with lignocaine, because this will prevent laryngeal spasm as you pass the bronchoscope, and minimize difficult airway problems as he recovers.
You will need two tracheal tubes, one for ''normal' intubation between attempts at bronchoscopy, and a larger one which fits snugly into the end of the bronchoscope, so that you can ventilate him while the bronchoscope is in place, if his pulse rate falls, or if he becomes cyanosed. There is usually some leakage, so you will need a good flow of oxygen. Blow oxygen into him intermittently, watching his pulse rate meanwhile. A falling pulse is a sign of anoxia. Only proceed to remove the foreign body, if his pulse is satisfactory. Oxygen through the side tube will not by itself ventilate him adequately, if he is paralysed. The anaesthetist and the surgeon share the patient. The anaesthetist is in charge, and decides when he must give oxygen.
CAUTION ! (1) His chest must expand during ventilation. If it does not, remove the bronchoscope, intubate him, and then try to bronchoscope him again.
METHOD. Lay him flat on his back, with his head raised on the flap of the table (if it will raise), or on a cushion. Ask a nurse to stand on his right, to hold his head with the palms of her hands over his ears, and to move his head from left to right as required.
Spray his larynx (see above), anaesthetize him, and intubate him. When he is intubated, ask the anaesthetist to show you his cords with the laryngoscope. Holding the bronchoscope as described above, put your left thumb on his upper incisor teeth, guide it forwards over the dorsum of his tongue, obliquely across his mouth from the right. His palate is a useful guide to the midline. Lift it so as to draw his lower pharynx forwards, as if you were passing a laryngoscope, taking care not to injure his teeth.
Slowly flex his neck into the ''sword-swallowing position' as you pass the bronchoscope (the position is the same as for oesophagoscopy in B, and C, Fig. 25-10). As the bronchoscope goes down, you will need more extension of his head, then flexion of his neck. You should see his uvula first, then his epiglottis, and then his larynx with its cords. Pass the bronchoscope through them (they will remain open under general anaesthesia). Turn it through 90[de] as you do this, so that its bevel is in the long axis of his glottis. When you are through his glottis, turn it back again. Aim it in the line of his trachea.
Look for the foreign body in his bronchi: the common site is just distal to his carina in his right main bronchus. The right main bronchus is shorter, more vertical and wider than the left. Most foreign bodies enter the right one.
If his carina is normal, pass the bronchoscope down one or other bronchus, preferably the normal one first. When you withdraw from the right main bronchus and enter the left one, you will have to move his head to the right as you do so.
With luck you will see the foreign body, and perhaps the bronchi to particular lobes. If it is up a side bronchus (unusual) there is no way you can get it out. Try to bring it out on the end of the sucker. If this fails, grasp it with the forceps. If it will come up the bronchoscope, good. If it will not, gently withdraw the bronchoscope and the foreign body together. If there is much pus, suck that out too.
CAUTION ! (1) Hold the bronchoscope lightly in your fingers, so that if he moves, it will move with him, instead of injuring his respiratory tract. (2) Take care not to damage his teeth. (3) Remove it promptly if he struggles. (4) If you fail, and the anaesthetist says ''That's enough'', obey him, he is master of the team!
If you want to identify his bronchi, on the right, look for his right upper lobe bronchus in the 2 or 3 o'clock position, his apical lower lobe bronchus at 6 o'clock, and his right middle lobe bronchus at 12 o'clock. Then look into the bronchi of his lateral, anterior, posterior, and medial basal lobes.
On the left, look for his left upper lobe bronchus in the 10 o'clock position, his apical lower lobe bronchus at 6 o'clock, and then into the bronchi for his lateral, anterior, and posterior basal lobes.
DIFFICULTIES [s7]WITH BRONCHOSCOPY If he is SUFFOCATING AND BLUE from the procedure, wait and try again next day. If he is suffocating because of the foreign body, you will have to persist.
If a FOREIGN BODY BREAKS INTO PIECES, bring it up bit by bit. If it slips off while you are withdrawing it through his cords, try again. If necessary, squirt a little saline down the bronchoscope with a syringe.
If you are looking for a CARCINOMA, look for abnormalities of the wall, and biopsy any growth. It will be easier to remove a piece from the carina.
If the FOREIGN BODY ROLLS UP AND DOWN HIS TRACHEA, but you cannot get it past his cords, tip the table steeply head down, and manipulate it past them with the piece of hooked wire that you have prepared for this eventuality.