Airway Foreign Bodies
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The history of bronchoscopy is largely defined by pioneering spirit, innovative design and surgeons who were not risk averse. Advancements in the field paralleled strides in the realm of anesthetic management. Once developed, the design of the scopes and their associated instruments steadily improved and adapted according to the changing needs of patients.
Prior to the advent of bronchoscopy, the management of airway foreign bodies was crude at best. Most were treated with no intervention, assuming the patient survived the initial aspiration event, and consisted of waiting for them to be coughed out. The alternative was removal by tracheotomy, sweeping the airway blindly with forceps absent the use of an endoscope or anesthetic . Foreign bodies in the distal airways were managed by transthoracic bronchotomy .
Direct laryngoscopy was not possible until the development of appropriate lighting. Initially, light was obtained in a manner used by shoemakers by focusing through a glass bowl. Later, this consisted of a light source (e.g. kerosene lamp and later incandescent bulbs) held near the external opening of the scope . Eventually, illumination evolved into a lamp that passed down the working channel of the scope. This allowed the lights in the room to remain on and improved the safety for the anesthesized patient .
Gustav Killian is credited with the first successful extraction of a distal airway foreign body in 1897 - a pork bone from a 63 year old farmer that was lodged in the right mainstem bronchus. Extraction prior to this was limited to the larynx or trachea proximal to the bifurcation. In the years leading up to this first success, he prepared by using a laryngoscope on a servant in the comfort of his own home. Later, a retired janitor of the hospital served as a willing subject receiving a small amount of money in return for allowing Killian to practice bronchoscopy on him . Anesthestic management in this time period consisted of either local anesthetic with cocaine or general anesthetic with ether .
Further descriptions of the nuances involved in extraction are provided by Ingals throughout the early 1900s. His case histories stress the importance of an accurate history and physical including clear descriptions of “vocal fremitus” and chest resonance. Since many of these foreign bodies were chronic in nature a common theme is granulation tissue surrounding the foreign body and the release of pus that follows the uncorking effect. Ingals’ manuscripts provide important details on pre- and postoperative care. Though some of it is obsolete (dosing medications in quantities of grains and drams) many of the lessons still hold true - having adequate suction, assistants in the room for positioning, use of a croup tent with humidified air and positioning the patient with head down to aid in pulmonary toilet. These descriptions highlight the importance of instrumentation - early reports describe him repeatedly dropping the foreign body because the graspers slipped off of the usually metallic foreign body. In 1914, he described the addition of fluoroscopy during bronchoscopy to aid in locating a foreign body distal to a stricture that could not be passed visually. That same manuscript describes the design of new instrumentation built expressly for this purpose and describes the creation of jaws that grip metallic objects to avoid slippage .
Chevalier Jackson, an American surgeon and innovator, improved the design of the bronchoscope in 1904 adding a suction channel and distal illumination . The rigid bronchoscope with glass fiber for illumination was developed in 1962 but its utility for visualization, diagnosis and biopsy were limited because of rigidity that only allowed passage to branch points of primary bronchi. Development of flexible bronchoscopy required multiple iterations that addressed the need for increased flexibility in bending angle, a range in scope diameter and a working channel . Shigeto Ikeda successfully managed this feat in 1963 . The advent of fiberoptic illumination revolutionized the field by adding yet another important tool for the surgeon instrumenting the airway . This, in turn, has allowed an expanded approach to airway problems moving beyond the realm of foreign body retrieval into the current domain of advanced airway intervention.
see also Gastrointestinal Foreign Bodies