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Wire Basket Removal of a Large Endobronchial Foreign Body
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Wire Basket Removal of a Large Endobronchial foreign Body To the Editor:
Different extraction tools (forceps. claw. balloon catheter and wire basket) used with 6beroptic bronchoscopy for the removal of aspirated foreign bodies have been evaluated in arti6cial and animal (dog) lung models. as well as in human cases in the past.... In the followingcase report. the successful removal of a large foreign body is described using a wire stone basket passed through the biopsy channel of a 6beroptic bronchoscope . CASE REPORT
A 69·year-old man with a permanent tracheostomy presented to the emergency room after accidentally dropping a pair of forceps through his tracheal stoma. Eleven years previously he underwent a total laryngectomy and left radical neck dissection for squamous cell carcinoma of the larynx. He was without dyspnea. cough. or chest pain. On physical examination. breath sounds were symmetric-a! and no wheezes were heard . A chest x-ray film (Fig 1) revealed a pair of tweezer forceps, approximately 9 cm in length located in the distal trachea. right main and right lower lobe bronchus . It was felt after otolaryngologic evaluation that the patient's prior surgery precluded use of the rigid bronchoscope . Flexible 6beroptic bronchoscopic
FIGURE 2. Dormia wire basket and the retrieved forceps (9 cm in length). examination revealed the forceps tips in the proximal right main bronchus . Attempts to remove the tweezers with alligator forceps (Olympus) were unsuccessful. They were then easily captured and removed with a Dormia stone basket (Fig 2). DISCUSSION
Reports describing the use of the basket forceps with bronchoscopy in the removal of aspirated foreign bodies from the tracheobronchial tree have been few.""In experimental lung models. Zavala and Rhodes' concluded that wire baskets were most effective in recovering bulky and organic objects (peanuts. beans. chicken
FIGURE 1. Chest 61m(PAand lateral) showing a pair of tweezer forceps in the right tracheobronchial tree .
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Convnunlcallonllo the EdIIor
bones) and less helpful in retrieving thin metallic materials (paper clip or straight pin). The easy removal of the large pair of tweezers from the patient supports this observation. Avoidance of fragmentation of large organic objects, (eg, peanuts, tablets), a potential hazard when biopsy or alligator forceps are used and which can make complete removal difficult, is also felt to be an advantage of the basket techmque.'? In infants and young children, basket forceps used with the rigid (open tube) bronchoscope do not appear to Significantly compromise small airway diameters. 3 Although various retrieval instruments are available, the advantages of one over another depend on the size, location and type of material aspirated. In this case, wire basket forceps used under bronchoscopic guidance allowed the safe and quick removal of a large, bulky foreign body from the tracheobronchial tree and allowed the patient to be discharged from the emergency room.
Paul McCullough, M.D. Dioiaion ofPulmonary Medicine, CollegeofPhf/6icians and Surgeons, Columbia Univeraity, New York, N.1':
REFERENCES 1 Zavala DC, Rhodes ML. Experimental removal offoreign bodies in 6beroptic bronchoscopy. Am Rev Respir Dis 1974; 110:357-60 2 Zavala DC, Rhodes ML. Foreign body removal: a new role for the fiberoptic bronchoscope. Ann Otol Rhinol Laryngol 1975; 84:650-56 3 Tsueda K, Sjogren S, Debrand M, Pulito R. Wire basket extraction of foreign bodies from the tracheobronchial tree of small children. J Ky Med Assoc 1981; 79:13-5 4 Lee M, Fernandez N, Berger H, Givre H. Wire basket removal of a tack via flexible fiberoptic bronchoscopy. Chest 1982, 82:515 5 Arango LF, Chaudhary BA, Speir WA. Endobronchial foreign body removed by flexible bronchoscopy. J Med Assoc Ga 1982, 71:859-61
Contralateral Chylothorax: One More Complication of Subclavian Venous
Puncture
To the Editor: In June 1983, Ciment et al reported two cases of contralateral effusions secondary to subclavian venous catheters (Cheat 1983; 83:926-27). We recently observed right chylothorax in a 75-year-old man 15 days after problematic insertion of a definitive endovenous pacemaker into the left: subclavian vein. Other potential causes of chylothorax, especially neoplasm, were excluded. The chylothorax resolved spontaneously and did not recur. To our knowledge, this is the 6rst report of a chylothorax secondary to endovenous pacemaker insertion (Acta Clin Belgica, in press). However, subclavian vein puncture has already been mentioned by Marsac as a possible cause of chylothorax. 1 The mechanism is similar to that described by Ciment et al. Mediastinal leakage of chyle occurs first, and the pleural effusion (homolateral or contralateral) may appear as lateas two weeks after the puncture, as in our case. As central venous catheters are used more and more, it is important to be aware of potential complications, either classic or rare. Late-appearing contralateral effusion or chylothorax may represent a diagnostic challenge. As Ciment et al point out, the more frequent use of right internal jugular vein for central catheters may Significantly reduce complications, and subclavian venous catheters should be reserved for emergencies or profOundly hypovolemic patients. I Pneumothoraces and hydrothoraces are less frequent with the internal jugular vein approach and chylothorax has not been reported using this insertion route. 3
Barbara Polla, M.D. Heapiratory Diseases, Hopital Cantonal, Univeraitaire de Geneve, Geneva, Switzerland Reprint requests:Dr: Polla, Respiratory Diseases, H opital Cantonal, Univeraity of Geneva, Geneva, Switzerland
REFERENCES 1 Marsac J, Frija G, Bismuth ~ Chylothorax et pathologie lymphstique de la plevre. Rev fr Mal Resp 1982; 10:227-41 2 Stevens JC, Hamit HF: A simple method for percutaneous cannulation of the internal jugular vein. Am J Surg 1978; 135:722-23 3 Bernard RW, Stahl WM. Subclavian vein catheterization: a prospective study. Ann Surg 1971; 173:184-200
Early Diastolic Sound To the Editor: Humen and colleagues (Chelt 1984 1; 86:90-4) have identi6ed a potentially valuable association between a proposed septal heart sound and abrupt leftward motion of the interventricular septum during ventricular relaxation in patients with diastolic volume overload of the right ventricle, particularly after RV disconnection for arrhythmogenic dysplasia. In three of four cases the "septal sound" might equally be an early S3and in the fourth (patient 4) it does appear to be an extra sound between S2and S3' In conditions like constrictive pericarditis, for example, the abnormal early diastolic sound (an S3variant) occurs quite early, often at 0.11 to 0.12 second and, in fact, was reported by Hancock at 0.06 second after S2 in one case. It is easy to see why the authors had some difficulty in aligning the new sound with the apexcardiogram, if the sound is generated primarily by right ventricular events; the apexcardiogram is, after all, a left heart curve. Its registration in the reported patients shows some influence from right ventricular events; indeed, the inverted systolic phase is typical of constrictive pericarditis. I wonder if the authors would care to comment on the fact that with a nearly nonfunctional dilated right ventricle in three patients, we could be dealing with a situation analogous to pericardial constriction. Similarly, in RV infarction, the hemodynamics resemble those of constrictive pericarditis-mainly ascribable to the influence of the normal pericardium on ventricular interaction. Thus, a dilated right ventricle-at least in the short-run after disconnection-within a non-yielding pericardium, will act to tighten the pericardium and therefore relatively constrict the heart. Of course, the"septal sound" does coincide with leftward septal motion, not seen in constriction. Would the authors comment on whether this sound could be a RVS3, earlier than any LVS3?
David H. Spodick, M.D., F.C.C.P. Professor ofMedicine, Univerlity ofMtU,achusett, Medical School; Director, Division ofCardiologf/, St. Vincent Hoapital, Worceater To the Editor: Dr. Spodick suggests two alternate explanations for the early diastolic sound described in our article. Of these two, our discussion did not include his suggestion that "functional" pericardia! constriction might be responsible for the sound. Although its timing in early diastole was indeed compatible with a pericardia! sound, we discounted that possibility on several points. Only two of the patients underwent surgery and, in each case, the surgeon left the pericardium widely open making constriction unlikely. Also, the two CHEST I 87 I 2 I FEBRUARY, 1985
271
Wire Basket Removal of a Large Endobronchial foreign Body To the Editor:
Different extraction tools (forceps. claw. balloon catheter and wire basket) used with 6beroptic bronchoscopy for the removal of aspirated foreign bodies have been evaluated in arti6cial and animal (dog) lung models. as well as in human cases in the past.... In the followingcase report. the successful removal of a large foreign body is described using a wire stone basket passed through the biopsy channel of a 6beroptic bronchoscope . CASE REPORT
A 69·year-old man with a permanent tracheostomy presented to the emergency room after accidentally dropping a pair of forceps through his tracheal stoma. Eleven years previously he underwent a total laryngectomy and left radical neck dissection for squamous cell carcinoma of the larynx. He was without dyspnea. cough. or chest pain. On physical examination. breath sounds were symmetric-a! and no wheezes were heard . A chest x-ray film (Fig 1) revealed a pair of tweezer forceps, approximately 9 cm in length located in the distal trachea. right main and right lower lobe bronchus . It was felt after otolaryngologic evaluation that the patient's prior surgery precluded use of the rigid bronchoscope . Flexible 6beroptic bronchoscopic
FIGURE 2. Dormia wire basket and the retrieved forceps (9 cm in length). examination revealed the forceps tips in the proximal right main bronchus . Attempts to remove the tweezers with alligator forceps (Olympus) were unsuccessful. They were then easily captured and removed with a Dormia stone basket (Fig 2). DISCUSSION
Reports describing the use of the basket forceps with bronchoscopy in the removal of aspirated foreign bodies from the tracheobronchial tree have been few.""In experimental lung models. Zavala and Rhodes' concluded that wire baskets were most effective in recovering bulky and organic objects (peanuts. beans. chicken
FIGURE 1. Chest 61m(PAand lateral) showing a pair of tweezer forceps in the right tracheobronchial tree .
270
Convnunlcallonllo the EdIIor
bones) and less helpful in retrieving thin metallic materials (paper clip or straight pin). The easy removal of the large pair of tweezers from the patient supports this observation. Avoidance of fragmentation of large organic objects, (eg, peanuts, tablets), a potential hazard when biopsy or alligator forceps are used and which can make complete removal difficult, is also felt to be an advantage of the basket techmque.'? In infants and young children, basket forceps used with the rigid (open tube) bronchoscope do not appear to Significantly compromise small airway diameters. 3 Although various retrieval instruments are available, the advantages of one over another depend on the size, location and type of material aspirated. In this case, wire basket forceps used under bronchoscopic guidance allowed the safe and quick removal of a large, bulky foreign body from the tracheobronchial tree and allowed the patient to be discharged from the emergency room.
Paul McCullough, M.D. Dioiaion ofPulmonary Medicine, CollegeofPhf/6icians and Surgeons, Columbia Univeraity, New York, N.1':
REFERENCES 1 Zavala DC, Rhodes ML. Experimental removal offoreign bodies in 6beroptic bronchoscopy. Am Rev Respir Dis 1974; 110:357-60 2 Zavala DC, Rhodes ML. Foreign body removal: a new role for the fiberoptic bronchoscope. Ann Otol Rhinol Laryngol 1975; 84:650-56 3 Tsueda K, Sjogren S, Debrand M, Pulito R. Wire basket extraction of foreign bodies from the tracheobronchial tree of small children. J Ky Med Assoc 1981; 79:13-5 4 Lee M, Fernandez N, Berger H, Givre H. Wire basket removal of a tack via flexible fiberoptic bronchoscopy. Chest 1982, 82:515 5 Arango LF, Chaudhary BA, Speir WA. Endobronchial foreign body removed by flexible bronchoscopy. J Med Assoc Ga 1982, 71:859-61
Contralateral Chylothorax: One More Complication of Subclavian Venous
Puncture
To the Editor: In June 1983, Ciment et al reported two cases of contralateral effusions secondary to subclavian venous catheters (Cheat 1983; 83:926-27). We recently observed right chylothorax in a 75-year-old man 15 days after problematic insertion of a definitive endovenous pacemaker into the left: subclavian vein. Other potential causes of chylothorax, especially neoplasm, were excluded. The chylothorax resolved spontaneously and did not recur. To our knowledge, this is the 6rst report of a chylothorax secondary to endovenous pacemaker insertion (Acta Clin Belgica, in press). However, subclavian vein puncture has already been mentioned by Marsac as a possible cause of chylothorax. 1 The mechanism is similar to that described by Ciment et al. Mediastinal leakage of chyle occurs first, and the pleural effusion (homolateral or contralateral) may appear as lateas two weeks after the puncture, as in our case. As central venous catheters are used more and more, it is important to be aware of potential complications, either classic or rare. Late-appearing contralateral effusion or chylothorax may represent a diagnostic challenge. As Ciment et al point out, the more frequent use of right internal jugular vein for central catheters may Significantly reduce complications, and subclavian venous catheters should be reserved for emergencies or profOundly hypovolemic patients. I Pneumothoraces and hydrothoraces are less frequent with the internal jugular vein approach and chylothorax has not been reported using this insertion route. 3
Barbara Polla, M.D. Heapiratory Diseases, Hopital Cantonal, Univeraitaire de Geneve, Geneva, Switzerland Reprint requests:Dr: Polla, Respiratory Diseases, H opital Cantonal, Univeraity of Geneva, Geneva, Switzerland
REFERENCES 1 Marsac J, Frija G, Bismuth ~ Chylothorax et pathologie lymphstique de la plevre. Rev fr Mal Resp 1982; 10:227-41 2 Stevens JC, Hamit HF: A simple method for percutaneous cannulation of the internal jugular vein. Am J Surg 1978; 135:722-23 3 Bernard RW, Stahl WM. Subclavian vein catheterization: a prospective study. Ann Surg 1971; 173:184-200
Early Diastolic Sound To the Editor: Humen and colleagues (Chelt 1984 1; 86:90-4) have identi6ed a potentially valuable association between a proposed septal heart sound and abrupt leftward motion of the interventricular septum during ventricular relaxation in patients with diastolic volume overload of the right ventricle, particularly after RV disconnection for arrhythmogenic dysplasia. In three of four cases the "septal sound" might equally be an early S3and in the fourth (patient 4) it does appear to be an extra sound between S2and S3' In conditions like constrictive pericarditis, for example, the abnormal early diastolic sound (an S3variant) occurs quite early, often at 0.11 to 0.12 second and, in fact, was reported by Hancock at 0.06 second after S2 in one case. It is easy to see why the authors had some difficulty in aligning the new sound with the apexcardiogram, if the sound is generated primarily by right ventricular events; the apexcardiogram is, after all, a left heart curve. Its registration in the reported patients shows some influence from right ventricular events; indeed, the inverted systolic phase is typical of constrictive pericarditis. I wonder if the authors would care to comment on the fact that with a nearly nonfunctional dilated right ventricle in three patients, we could be dealing with a situation analogous to pericardial constriction. Similarly, in RV infarction, the hemodynamics resemble those of constrictive pericarditis-mainly ascribable to the influence of the normal pericardium on ventricular interaction. Thus, a dilated right ventricle-at least in the short-run after disconnection-within a non-yielding pericardium, will act to tighten the pericardium and therefore relatively constrict the heart. Of course, the"septal sound" does coincide with leftward septal motion, not seen in constriction. Would the authors comment on whether this sound could be a RVS3, earlier than any LVS3?
David H. Spodick, M.D., F.C.C.P. Professor ofMedicine, Univerlity ofMtU,achusett, Medical School; Director, Division ofCardiologf/, St. Vincent Hoapital, Worceater To the Editor: Dr. Spodick suggests two alternate explanations for the early diastolic sound described in our article. Of these two, our discussion did not include his suggestion that "functional" pericardia! constriction might be responsible for the sound. Although its timing in early diastole was indeed compatible with a pericardia! sound, we discounted that possibility on several points. Only two of the patients underwent surgery and, in each case, the surgeon left the pericardium widely open making constriction unlikely. Also, the two CHEST I 87 I 2 I FEBRUARY, 1985
271