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Retrieval of Aspirated Foreign Bodies in Children Using a Flexible Bronchoscope and a Laryngeal Mask Airway

Avital, Avraham M.D.*; Gozal, David M.D.; Uwyyed, Kamal M.D.*; Springer, Chaim M.D.*

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The gold standard for removal of foreign bodies from airways is rigid bronchoscopy in the operating room with the patient under general anesthesia. Flexible bronchoscopy is performed frequently in young children with recurrent or persistent pneumonia, and a foreign body may be found in the airway during the procedure. Pediatric flexible bronchoscopes have a narrow inner suction channel that does not allow the use of appropriate forceps to remove the foreign body. We describe five cases of foreign bodies found during routine flexible bronchoscopy (using a pediatric bronchoscope; Pentax FB10X) in children. The foreign bodies were extracted during the same anesthetic period using a laryngeal mask airway introduced through the mouth and a large flexible bronchoscope (Pentax FB15X) through which forceps were passed. This method allows the pediatric bronchoscopist to remove a foreign body during the same procedure and during the same anesthetic period.

*Institute of Pulmonology and †Anesthesiology Department, Hadassah University Hospital and Hadassah-Hebrew University Medical School, Jerusalem, Israel

Address reprint requests to Dr. Avraham Avital, Institute of Pulmonology, Hadassah University Hospital, PO Box 12000, Jerusalem 91120, Israel.

LMA, laryngeal mask airway.

Removal of aspirated foreign bodies in children is generally performed using a rigid bronchoscope 1–3 with the patient under general anesthesia. This procedure requires the skill of a trained bronchoscopist and an anesthesiologist, both with considerable expertise in the young pediatric age group. In most institutions, foreign bodies are extracted in the operating room by general surgeons or ear-nose-and-throat surgeons. Technical problems such as ankylosis of the jaw or neck 4,5 may interfere with tracheal intubation. The risk of trauma to the oropharynx and large airways is greater with a rigid bronchoscope than with a flexible bronchoscope. 6 There is also limited access of the rigid bronchoscope to the distal airways and to the upper lobes.

The use of a flexible bronchoscope passed through a laryngeal mask airway (LMA) for the extraction of foreign bodies has been described in adults 7 and in two pediatric patients 8 using a Fogarty catheter. With our method, an adult flexible bronchoscope (Pentax FB15X, Asahi Optical, Tokyo, Japan) with a broader inner channel was introduced through the LMA, and foreign bodies were extracted from the airways by the pediatric bronchoscopist using forceps.

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METHODS

Regular pediatric flexible bronchoscopy using the Pentax FB10X was performed in children for persistent pneumonia/cough or suspected foreign body aspiration, and a foreign body was seen within the bronchial tree. Patients were sedated with 0.5 to 1.0 mg/kg intravenous propofol, followed by a maintenance dose of 3.0 to 6.0 mg/kg/hour. No other drug was administered for anesthesia, such as muscle relaxants or narcotics. Topical anesthetics were placed on the LMA before its insertion (lidocaine jelly, 2% HCl) and through the bronchoscope (1% lidocaine for a total dose of 5 mg/kg) for the larynx and large airways. An LMA was inserted orally until it was seated behind the larynx, and the glottic opening was sealed by inflation of the cuff. When inserted properly, the opening of the laryngeal mask is located just in front of the vocal cords. Patients breathed spontaneously or were ventilated gently through an Ambu bag (Laerdal Company, Stavanger, Norway) or a modified Ayres-T-piece (Jackson–Rees Anatec Company, Belleville, Ontario, Canada) with an open-ended reservoir bag. An adult-size flexible bronchoscope (Pentax FB15X) was inserted through an aid adapter into the LMA (The Laryngeal Mask Company, Ltd., Oxon, UK) (Fig. 1), and forceps (FB15C-1; Olympus Optical Co., Ltd., Tokyo, Japan) were introduced through the bronchoscope. The foreign body was grasped firmly by the forceps, removed until the tip of the LMA was outside the larynx, then the LMA and the bronchoscope were removed. Rigid bronchoscopy was available in the bronchoscopy suite in case of failure of the procedure.

FIG. 1.

FIG. 1.

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CASE PRESENTATIONS

Case 1

A 2.5-year-old boy was hospitalized for persistent cough after a choking episode while eating watermelon seeds 3 weeks previously. There was no previous history of allergy or asthma. Physical examination revealed decreased air entry on the left hemithorax with local inspiratory and expiratory wheeze. Chest radiography was normal. He underwent rigid bronchoscopy by ear-nose-and-throat surgeons, and a watermelon seed was extracted from the left main bronchus. Cough persisted, and flexible bronchoscopy was performed 2 weeks later using a Pentax FB10X. A foreign body was seen in a distal segment of the left lower lobe. The segmental bronchus was edematous and bled easily. The child was administered systemic steroids and antibiotic treatment, and underwent rigid bronchoscopy a week later (3.5 mm, model 10338CD; Storz, Tuttlingen, Germany). The foreign body was too distal in the left lower lobe and could not be extracted with the usual pediatric forceps (Storz 10338u and 10378k). An LMA (no. 2; The Laryngeal Mask Company, Ltd., Oxon, UK) was introduced through the mouth (see Fig. 1) and a flexible bronchoscope with an outer diameter of 4.9 mm (Pentax FB15X) was passed through the LMA using an aid adapter. Forceps (Olympus FB15C-1) were inserted through the flexible bronchoscope channel and the foreign body (part of a watermelon seed) was extracted. The bronchoscope with forceps was pulled out until they passed the larynx; then the LMA and bronchoscope were removed together. There was no complication after the procedure.

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Case 2

A 5.5-year-old boy was examined 2 months earlier in another hospital with a clear history of choking while eating watermelon seeds. He had a normal physical examination and chest radiograph, and was discharged. He was referred to our clinic because of persistent cough without fever. There was no previous or family history of asthma or allergy. On examination, he had decreased air entry to the right chest, and mild hyperinflation of the right lung was seen on chest radiography. He underwent flexible bronchoscopy (Pentax FB10X), and a foreign body was seen beyond abundant granulation tissue in the right main bronchus. An LMA (no. 2) was inserted, and flexible bronchoscopy (Pentax FB15X) was performed. The foreign body (watermelon seed) was extracted using forceps (Olympus FB15C-1) through the bronchoscope channel. The granulation tissue disappeared after 2 weeks of oral steroids and antibiotics.

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Case 3

A 14.5-year-old girl was examined for persistent right lower lobe pneumonia lasting 4 weeks and for recent hemoptysis. She was treated with antibiotics but did not improve. There was no previous history of allergy or asthma and no history of choking while eating. On physical examination, there was decreased air entry over the right lower lung zone. Flexible bronchoscopy (Pentax FB15X) was performed, and a foreign body was seen beyond abundant granulation tissue in the right intermedius bronchus. An LMA (no. 3) was inserted, and the foreign body (watermelon seed) was extracted using forceps (Olympus FB15C-1) through the bronchoscope. Repeat bronchoscopy was performed after 2 weeks of antibiotics and oral steroids, and no granulation tissue was seen.

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Case 4

A 5-year-old boy was hospitalized with a persistent cough of 4 weeks' duration. There was no previous history of asthma or allergy and no report of choking while eating during the last month. He had no fever and was not treated with antibiotics. Physical examination revealed prolonged expiration and bilateral wheeze and rhonchi, partially reversible to bronchodilators. The child was treated with 2 mg/kg oral prednisone and bronchodilators for 5 days with no clinical improvement. He underwent flexible bronchoscopy (Pentax FB10X), and a foreign body was seen stuck in the middle of the left main bronchus. An LMA (no. 2) was inserted, and a flexible bronchoscope (Pentax FB15X) was introduced through the LMA. Forceps (Olympus FB15C-1) were inserted through the flexible bronchoscope channel and the foreign body (part of a watermelon seed) was extracted.

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Case 5

A 1.8-year-old boy was hospitalized for chronic barking cough since his perinatal period. During the last month before presentation the cough became more persistent. There was no personal or familial history of allergy or asthma. There was no history of choking with food. He was afebrile. Physical examination revealed decreased air entry over the left lung. Chest radiography revealed bilateral hyperinflation, more pronounced on the left. Fluoroscopy showed asymmetric movement of the diaphragm. He underwent flexible bronchoscopy (Pentax FB10X). Laryngomalacia and mild tracheomalacia were found. Intense granulation tissue and a foreign body were seen in the left main bronchus. An LMA (no. 2) was inserted through the mouth, and a flexible bronchoscope (Pentax FB15X) was introduced through the LMA. Forceps (Olympus FB15C-1) were inserted through the flexible bronchoscope channel and the foreign body (part of a watermelon seed) was extracted. Oxygen saturation was stable during the entire procedure. The child was treated with antibiotics and steroids for 10 days, and repeat flexible bronchoscopy was normal.

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DISCUSSION

Rigid bronchoscopy has been well established and is the procedure of choice for the extraction of foreign bodies from the tracheobronchial tree. This procedure is associated with rare complications. Cardiac arrhythmias, cardiac arrest, pneumothorax, bacteremia, and tracheal rupture have been documented after rigid bronchoscopy. 2,3,6,9 In the pediatric population, flexible bronchoscopy has been used for diagnostic and therapeutic purposes such as bronchial toilet to relieve atelectasis 10–12 resulting from mucous plugs or bronchial secretions with minimal minor complications.

Flexible bronchoscopy has been used in adults for the extraction of foreign bodies, and was found to be practical and safe. 13 Its use has also been described in children 14 using a regular flexible bronchoscope (Olympus 3C10) passed through an endotracheal tube. In those cases, the foreign bodies have been extracted using forceps and baskets generally used for the extraction of urethral stones.

LMAs were developed in 1983 and have been approved by the Food and Drug Administration since 1991 for use in the United States. The LMA has been used for difficult intubation, bronchoscopy/bronchoalveolar lavage in hypoxemic and immunosuppressive patients, in infants with abnormal upper airway anatomy, and for laryngotracheal surgery. 15–22 The use of the LMA impaired mucociliary clearance less than the use of cuffed endotracheal tube in humans. 23 We use the LMA to ventilate the child during the procedure and to bypass the narrow nasal passages with an adult flexible bronchoscope through which larger forceps could be passed that could grab properly the foreign body. In every case, we had rigid bronchoscopy immediately available in our bronchoscopy suite in case of failure or emergency.

Two of our five patients were 2.5 years old or younger, showing that this method can be used in very young children with efficient ventilation during the procedure.

This technique has several advantages: The foreign body can be removed during the same anesthetic period by the pediatric bronchoscopist, and there is no need to transfer the child to ear-nose-and-throat or general surgeons. Narrow nasal passages are bypassed by the LMA introduced through the mouth, and a larger flexible bronchoscope can be used. The child can be ventilated efficiently through the LMA during the procedure. Foreign bodies stuck in distal airways may not be reached by rigid bronchoscopy and can be removed using the LMA and a flexible bronchoscope, as in patient no. 1.

So far, we have used this method only to extract watermelon seeds. This method seems to be appropriate for solid, flat foreign bodies, but may not be suitable for large foreign bodies, round foreign bodies (like pearls), or crumbly foreign bodies that may break into pieces. This method of using the LMA to remove foreign bodies in the tracheobronchial tree is a complementary technique to the “gold standard” rigid bronchoscopy.

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Keywords:

Pediatric; Aspiration; Laryngeal masks; Fiberoptics; Instrumentation

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