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LETTER TO THE EDITOR

The Nephroscope Used for Emergency Therapeutic Bronchoscopy

Murali Chakravarthy, MD, Venkatesh Krishnamoorthy, MCh, Dilip Rangarajan, DM, Subramanyam Rajeev, MD, Srinivas Belur, MS

Wockardt Hospitals, Bannerghatta Road, Bangalore, India, Nephro Urology Trust Hospital, Bangalore, India

To the Editor:

The primary aim of the physician is to manage patients safely and many times only with the available instruments, particularly during emergencies. We describe a case of acute ‘white-out’ of left lung in the postoperative patient where we successfully employed a nephroscope (working length 37cm) for bronchoscopy.

A 60-year old male with a history of hypertension, diabetes, asthma and smoking underwent left radical nephrectomy under general anesthesia. At the end of surgery, following reversal of neuromuscular blockers, he developed severe bronchospasm. Partial pressure of arterial carbon dioxide was elevated and oxygen level decreased. Unresponsiveness to nebulizers warranted postoperative ventilation. Postoperative chest X ray revealed white-out of the left lung. Postural drainage or application of suction was not helpful with PaCO2 persistently above 65mmHg and PaO2 below 50mmHg. Peak airway pressure increased from 24 to 43cmH2O. A mucous plug obstructing the left main bronchus was suspected. Fiberoptic bronchoscope was not immediately available in the institute where the surgery was performed. Due to the rapidly deteriorating clinical condition, a nephroscope (ACMI Corporation, Southborough, MA, USA) (Figure 1Go), with outer diameter at distal tip 14.6-F, active deflection 180° up and 170° down was assembled. The extra oral portion of the endotracheal tube was cut short to enhance the working length with the scope. It was ascertained that the endoscope was sterile and a diagnostic bronchoscopy was performed without technical difficulty. The left main bronchus obstructed by a mucous plug was cleared by gentle suction and normal saline lavage. Examination of secondary bronchi could be carried out whereas entry beyond was not possible. Patient was extubated without event.


Figure 1
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  		Figure 1. Nephroscope with a scale showing the working length.

 
Various authors have used novel ways to retrieve foreign body lodged in the airway. Bunno and co-workers have recently reported the successful removal of a foreign body (artificial tooth) from the bronchial tree using a customized cap of nasogastric tube, based on the concept of attaching an endoscopic cap to the end of a bronchoscope.1

The requirement of bronchoscopies in the postoperative period either for diagnostic or therapeutic modality is not uncommon. Use of nephroscope highlights the possibility of utilizing available endoscopes to bail out patients during emergencies. Nephroscope is generally easily available in nephrology centers. Although cystoscope2 and cystoscope lens3 have been used to retrieve foreign bodies in the airway it is important to remember the shortcomings of using other instruments for bronchsocopy. The characteristics of nephroscope were comparable to a 6 mm bronchoscope however the shorter working length precludes examination of the distal bronchi. Possibility of bringing pathogens which are alien to the respiratory tract from urinary tract is yet another issue while nephroscope is used in airway examination. Performance of bronchoscopy may be challenging to the endoscopist, but the possible benefits of attending to a potential life threatening problem without delay, albeit with an available endoscope is noteworthy.

REFERENCES

  1. Bunno M, Kawaguchi M, Yamahara K, et al. Removal of a foreign body (artificial tooth) from the bronchial tree: a new method. Intern Med. 2008;47:1695–8.[Medline]

  2. Sembiring D, Sibarani H, Geary W, et al. The cystoscope used as a bronchoscope for the removal of a foreign body in the left stem bronchus. Trop Doct. 1995;25:134.[Medline]

  3. Hodges AM, Hodges S. Bronchoscopic foreign body removal using a cystoscope rod lens. Trop Doct. 1997;27:113.[Medline]

Asian Cardiovasc Thorac Ann 2009; 17:113-114
© 2009 by SAGE Publications
DOI: 10.1177/0218492309102610



This Article
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Murali Chakravarthy
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