Journal of Bronchology & Interventional Pulmonology:
Karpman, Craig MD; Midthun, David E. MD; Mullon, John J. MD
Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
This report has been previously presented during the 2012 American Thoracic Society meeting.
Disclosure: There is no conflict of interest or other disclosures.
Reprints: Craig Karpman, MD, Gonda Building, 100 Third Avenue SW, Rochester, MN 55905 (e-mail: email@example.com).
Received May 14, 2013
Accepted January 30, 2014
Distal airway foreign bodies can be challenging to remove with a flexible bronchoscope because of angulation or deep impaction. Thoracic surgery may be required if bronchoscopy is not successful. The use of electromagnetic navigation for pulmonary nodule localization and characterization is well established; however, its use to localize and remove distal foreign bodies has not been described. We report the initial case of electromagnetic navigation-assisted foreign body removal.
Foreign body aspiration is rare in adults but can occur, especially, in patients with trauma, altered mental status, and in the setting of neurologic disease.1 Flexible and rigid bronchoscopy has been used with relative effectiveness for foreign body removal.2 Flexible bronchoscopy, snares, or baskets can be used for visualized objects, and fluoroscopy can assist with localization of radiopaque distal foreign bodies.3,4 The use of Fogarty catheter has also been successful, placing the balloon distal to the object and after inflation mobilizing the object into the proximal airway, pushing it in a retrograde manner.4 If bronchoscopic techniques are unsuccessful, then surgical removal is required and appears more likely to be needed for objects impacted in the distal basilar segments.5 Electromagnetic navigation (EMN) is primarily being used for localization and characterization of peripheral lung lesions6,7; however, its use in the removal of the foreign bodies has not been reported. We present a case of effective use of EMN bronchoscopy to remove a distal foreign body that previously could not be retrieved by more conventional methods.
A 46-year-old male landscaper, never-smoker, presented to the pulmonary clinic for evaluation of a chronic cough. His medical history was significant for neck trauma sustained 5 years before the presentation when he ran over a length of copper wire while clearing land with a tractor mower. A piece of the wire broke free and was propelled into his neck, penetrating the trachea. He acutely developed hemoptysis and a respiratory failure. An emergency tracheostomy was performed in the field to establish an airway. Subsequent chest radiography showed a central metallic foreign body. Flexible bronchoscopy identified a piece of wire in the central airway but attempts to remove the wire proved unsuccessful. At repeat bronchoscopy the wire was no longer visible and chest radiograph showed distal migration; observation was recommended. Patient was symptom-free until 4 years later when he developed a chronic nonproductive cough. After the cough persisted for a year, he presented to our institution for further assessment and treatment. No history of acid reflux or postnasal drip could be elicited. He denied wheezing or any further hemoptysis after the initial event.
Evaluation included a normal examination, spirometry, methacholine challenge, and nitric oxide testing. Chest radiograph demonstrated a linear metallic density in the right lower lung field. Computed tomography (CT) scan of the chest (Fig. 1) further localized the object to the lateral segment of the right lower lobe nearly abutting the pleura without significant surrounding edema, hemorrhage, or bronchiectasis.
THE TECHNIQUE OF REMOVING THE WIRE
Flexible bronchoscopy was performed under conscious sedation after fiberoptic intubation. Thin secretions were present in the right lower lobe on inspection, but the object could not be visualized using a standard adult bronchoscope (Olympus P160, 4.8 mm external diameter), pediatric bronchoscope (Olympus 3C160, external diameter 3.8 mm), or an ultrathin bronchoscope (Olympus BF-XP160F, external diameter 2.7 mm). Multiple attempts to localize and remove the object using bronchoscopic forceps with fluoroscopic guidance also proved unsuccessful.
We then proceeded to use EMN bronchoscopy (superDimension Inc., Minneapolis, MN), which was successful in locating the object in the lateral basal segment of the right lower lobe (Fig. 2). Using flexible forceps through the catheter sheath, a 2.3 cm length (approximately 14 G) piece of copper wire (Fig. 3) was removed. Postprocedure chest radiograph was negative for pneumothorax or retained foreign object. After wire removal, the cough immediately improved and had completely resolved at 3-month follow-up.
Distal airway foreign body can be difficult to manage and may require thoracic surgery if bronchoscopy is not successful.5 The foreign body in this case was too distal to visualize and unlike a prior case,3 numerous attempts using fluoroscopic guidance failed to remove the wire. The Fogarty balloon technique4 was not utilized because of the very distal location (abutting the pleura), the cylindrical form of the wire, and the fear of pushing the wire distally.
EMN is primarily used for small parenchymal lesion biopsy. The success rate in studies using EMN to biopsy peripheral solitary nodules has been 60% to 70%6,7; the smallest nodules biopsied were 8 to 10 mm. The wire removed during this case was <2 mm in diameter, demonstrating the ability to localize and facilitate removal of very small objects. Besides parenchymal lesion biopsy, the numerous possible applications for EMN include: deployment of fiducial markers, pleural dye marking, and brachytherapy catheter insertion.8,9 Our case illustrates another possible use for EMN, as a method to locate and remove distal foreign objects. It was particularly helpful in our case for an object that could not be visualized or removed with fluoroscopy and conventional bronchoscopy. With the use of this technique, we were able to preclude the need for surgery.
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