The Mean Green Popsicle

Using Cryotherapy to Remove Aspirated Foreign Bodies

Abstract

Foreign body (FB) aspiration can be a life-threatening event. Although more common in children, FB aspiration can occur at any age. Symptoms related to FB aspiration range from coughing and shortness of breath to asphyxiation. Chest imaging can be nonspecific and infrequently identifies an FB. Herein, we describe a case of a 54-year-old male patient who aspirated an FB and experienced respiratory arrest. He failed to improve with conservative measures and required emergent bronchoscopy. He was found to have an FB in his proximal left mainstem bronchus that could not be removed using standard bronchoscopy and he was referred to our center for definitive care. We used a cryotherapy probe to remove the FB. We propose that cryotherapy is a useful tool to remove FBs that are soft and amenable to freezing.

Foreign body (FB) aspiration is a rare event in adults. Aspirated FBs are usually diagnosed by imaging modalities or with flexible bronchoscopy. FB removal is generally achieved with flexible or rigid bronchoscopy using a series of tools that include forceps, snares, or baskets. Some practitioners use unique and innovative advanced skills when faced with difficult-to-remove FBs.

CASE REPORT

A 54-year-old man was at a long-term acute care facility receiving rehabilitation after a subarachnoid hemorrhage and right middle cerebral artery stroke 3 months earlier. He developed respiratory arrest, which was manifested by distress and profound hypoxemia. He was aggressively suctioned without improvement. Chest x-ray showed complete collapse of the left hemithorax (Fig. 1). A bronchoscopy showed an FB in the proximal left bronchus. On the basis of the visual appearance of the FB, it was believed to be an oral care sponge. Several attempts were made to remove the FB without success. The patient was sent urgently to our facility for further care.

FIGURE 1.: Anteroposterior chest x-ray showing complete collapse of the left hemithorax.

At our institution, a therapeutic scope was inserted through the patient's existing tracheostomy tube. The FB was firmly wedged in the patient's proximal left mainstem bronchus (Fig. 2). A series of devices (large alligator forceps, 2 sizes of snares, bronchoscopy basket, urology snare, and a urology kidney stone retractor) were used in an attempt to remove the FB. The FB was easily deformable and was resistant to removal by mechanical means as small pieces of the FB would break off or the forceps and snares would easily slip off the FB. We buried the cryotherapy probe into the center of the FB and froze the cryotherapy probe directly to the FB (cryoadhesion; Fig. 3). We then removed the scope and cryotherapy probe/FB complex en bloc before thawing the cryoprobe. The patient improved immediately on the removal of the FB. Repeat bronchoscopic evaluation showed an edematous and inflamed left main stem bronchus with patent distal airways. Repeat chest imaging showed resolution of his left lung collapse. The FB was identified to be a mouth care sponge (Fig. 4).

FIGURE 2.: Foreign body in the proximal left mainstem bronchus.

FIGURE 3.: Cryotherapy probe adhered to the foreign body.

FIGURE 4.: A, Foreign body removed from the patient was identified as a mouth care sponge. B, Intact mouth care sponge.

DISCUSSION

Foreign body aspiration (FBA) can be a life-threatening event.^1–3 Risk factors for the aspiration of an FB in adults include stroke, neurologic or neuromuscular disease, alcohol or drug abuse, psychiatric illness, dementia, tracheostomy, recent dental manipulation or loose dentition, and head trauma.^4,5 Symptoms related to FBA are variable and nonspecific.^2,3 Although most patients present immediately after the aspiration event, some may wait days or even months before seeking medical attention.^2–6 The most common symptoms are the presence of a penetration syndrome (sudden onset of choking and cough related to an FBA event), cough, fever, breathlessness, and wheezing.^2,3 Chest radiography may be normal in 10% to 60% of patients.^2,3 Other common chest radiography findings include air trapping in 17% to 49%, atelectasis in 6% to 50%, pneumonia in 3% to 27%, and a radio-opaque FB in 4% to 25%.^2,3 In adults, of all bronchoscopies performed, less than 0.5% are performed to remove foreign bodies.^5,6 As expected, the majority of FBs are found in the right lung airways.^2,4–6 FBs vary and form an almost endless list of possible objects. Food particles (animal bones, nuts, and other soft foods) are by far the most common objects removed.^2,4–6

Adult patients suspected of having aspirated an FB should have a flexible bronchoscopy performed.^2–6 Flexible bronchoscopy can be both diagnostic and therapeutic in the majority of cases, with success rates as high as 90%.^5,6 Large or difficult FBs, or unstable patients, require rigid bronchoscopy or surgery.^2,5,6 The tools commonly used to remove FBs include forceps, snares, and baskets.^2–6 Tools that are used less commonly include balloons, magnetic extractors, and cryotherapy probes.⁷

After an extensive literature search of English-language journals, we found no case descriptions of using cryotherapy to remove aspirated FBs, even though this has been described at national meetings. We did find 2 review articles that referred to using cryotherapy to remove aspirated FBs.^7,8 We also found reference to using cryotherapy to remove aspirated FBs in several pulmonary medicine textbooks.^9,10 Cryotherapy has a unique utility in removing soft, deformable objects that have a high water content and are amenable to freezing. We have successfully used cryotherapy to remove large blood clots, large mucus plugs, and soft, deformable, partially digested food particles.

CONCLUSIONS

FBA represents a potentially life-threatening event. Although bronchoscopy with forceps, snares, or baskets may remove the majority of FBs, we describe a case that used cryotherapy to remove an FB that was not amenable to removal with standard techniques. We propose that cryotherapy is a useful alternative to standard techniques to remove FBs that are soft or amenable to being frozen. In this case, the deformable nature of the FB (sponge) created significant difficulty in its removal with conventional instruments. In our opinion, the soft, deformable nature of the FB and its high water content made cryoadhesion an ideal tool to remove the FB.