tracheobronchial tree. especially those difficult to reach with the RB." \Ve present a case of removal of a cleuning brush from the tracheobronchial tree with use of an FFB . A 27-year-old man was diagnosed as having stage IV non-Hodgkins lymphoma. on the basis of a cervical lymph node hiopsy at a local hospital in July 1989. During the initial course of chemotherapy; he had a productive eough and a low-grade fever. An FFB study was done to mil.' out infection after increased gallium uptake was noticed in the left lower lobe . Bronchoalveolar lavage was performed . and transhronchtal biopsy specimens were obtained from that area; according to the patient . the procedures went uneventfully, The study material was nondiagnostic. The patient was admitted to the Cleveland Clinic Foundation in November 1990 for bone marrow transplantation after failure of multiple chemotherapy trials . A routine che st roentgenogram re vealed a 1.5-cm-lonl(. thin metallic foreign object in the medial portion of the right lower lung . with minimal surrounding fibrotic or inllammatory change-s (Fig 1). \\~ suspected that the object was the broken-off end of a cytolOh'y brush . Because the patient was to he subjected to an immunocornpromised state. it was decided to remove the foreign body, An FFB was introduced through a mouthpiece; the endobronchial examination was unremarkable except for the presence of a metal brush in tht, distal portion of the anterior hasal segment of the right lower lobe . Due to the cough induced hy the FFB. the object moved more distally to become out of visual range . Under Ruoroscopy, a basket forceps was introduced to the site of the object. The basket ".n·t'ps was then dosed. and the object within the closed forceps and the FFB were withdrawn I(radually up to the mouth. Clost, examination of the foretgn object revealed it to he the brokenoff distal end of an FFB cleaning brush (Fil( 2). Apparently the physician who performed the initial bronchoscopy was not aware of the incident. The distal end of the cleaning brush possibly broke off in the channel while the instrument was heing cleaned prior to the procedure and was then dropped into the patients endobronchial tree during bronchoscopic maneuvers. This case illnstrates several points. First . nondisposahle instruments used durinl( bronchoscopy should he exam ined periodically for their durability, Damaged instruments should he replaced or repaired . Second, the channel of the FFB should he inspected before it is stored for the next procedure. Broken cleaning instruments. mucus plugs. blood dots. dried-up radiographic contrast material used for hronchograms, metal tips from a laser fiber, and broken sapphire probes used for laser procedures are some of the ohjt'cts that can he inadvertently left in the channel. h.' Third. this

FIl:UIU: 2. Bronchoscopy cleaning hrush after heinl( extracted from the tracheobronchial tree. case supports the I(nm;ng notion that the FFB can he safely used to remove foreign objects from the endobronchial tree. \Ve also believe that the capahility of using fancy flexible accessories. such as baskets, snares. and FOl(arty catheters. puts till' FFB at an advantage over the RB in removing distally placed foreil(n objects. Hany l : Khalil. M.D ,. and Atul C. Mehta . .\1.0.• EC .C .P., Deptlrtmnlt of Pu/mtmary Disease, Cleoeland Clinic Foundation, Cleveland

Rqlrint requests : Dr Mehta , fu/rrnmary Department, Cleveland Clinic Foundation, Cleveland OH #106

REFERENCES

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Ikeda S. Atlas of lIexihle bronchofiberoseopy Baltimore: Universitv Park Press. 1974; 220 I...;n R. Lee C. Chiang Y. Wanl( WJ. Use offiberoptic bronchoscopy to retrieve hronchlal foreign bodies in adults. Am Rev Respir Dis 1989; 140:1734-37 Zevala DC , Rhodes ML. Experimental removal o[foreign bodies hy fiheroptic bronchoscopy, Am Rev Respir Dis 1974; 110:357-60 Sackner MA. State of the art : hronchofiberscopy Am Rev Respir Dis 1975; Ill :62-8Il Zevala DC, Rhodes ML. Foreign I>CKly removal : a new role lill the fiberoptic bronchoscope, Ann Otol Rhino) Laryngol 1975; 84:650-56 Mehta At,'. Grimm M. Breakal(eofNd-YAG laser sapphire contact probe inside the endobronchial tree [letter]. Chest 1988; 93:1119 Mehta AC. Golish JA, Livingston DR . Loss of the fiberoptic laser tip [letter] . Chest 1985; 85 :798

Use of pH Paper to Reflect Gastric pH 711 the Editor :

FI(;l'RE 1. Posteroanterior chest radiograph shows metallic "lreil(n hody (arllJlt'! in right lower lung,

\Ve read with I(reat interest the studv of I...ryon et al, I which appeared in the March 1991 issue of Chest. While the results are intril(uiTlI(. we question their use of pll paper as described in the Methods section. In our study of its utility, we found pll paper to he inaccurate iu its alnlity to reflect I(astri