Accidental tracheobronchial foreign bodies (TBFBs) inhalation into the tracheobronchial tree is not uncommon and sometimes can present as a life-threatening emergency.1 Extraction of these TBFBs is normally carried out with the help of either rigid bronchoscopy (RB) or flexible bronchoscopy (FB) under general anesthesia or conscious sedation. It is a procedure that requires a high degree of skill, experience, and coordinated team work. We present in this article our experience of extraction of such TBFBs in children and adults since the year 2001 in 214 patients. There has been a debate among bronchoscopists as to the choice of the bronchoscope (RB vs. FB) for extraction of TBFBs.2 In this retrospective analysis, we present the clinical profile of these patients and a comparison of the results of extraction with the rigid and the flexible instrument. We hope to answer the question of choice of instrument for extraction of TBFBs.
PATIENTS AND METHODS
A retrospective analysis of medical records of patients admitted with suspected TBFBs, from the year 2001 to 2010, was performed. The clinical profile of these patients was studied, including age, sex, duration since aspiration, type of TBFB, symptoms at presentation, signs, and findings on chest radiography. Bronchoscopy was performed in all cases. For some patients with asphyxiating TBFBs (with severe respiratory distress) who were unstable and required immediate control of the airway and ventilation, RB under general anesthesia was undertaken as a first choice. In these patients, an initial evaluation of the oropharynx and throat was always performed to rule out asphyxiation due to a foreign body above or impacted in the larynx. For patients with nonasphyxiating TBFBs, FB under conscious sedation was undertaken first. For patients below 3 years, and all unstable patients, the extraction procedure was performed in the operating room with an anesthesiologist in attendance, and for older patients who were stable, it was performed in the bronchoscopy suite. For RB, a ventilating bronchoscope with varying sizes of insertion tubes was used. The patients were usually sedated with intravenous midazolam and then followed with ketamine or propofol infusion. Brief muscle relaxation was achieved with intravenous succinyl choline to facilitate insertion of the RB. During the procedure, the patient was ventilated with a manual jet venturi device or a close circuit for the administration of oxygen and anesthesia gases if required. For FB in patients more than 12 years of age, an adult 4.9-mm outer diameter flexible bronchoscope was used, and for younger patients, a pediatric instrument with an outer diameter of 3.2 mm was used. Normally, only local anesthesia with 2% lignocaine solution and intravenous midazolam for conscious sedation were used during FB. In very small children and infants, intravenous ketamine was used during FB. FB was always performed by the oral route to facilitate extraction of the TBFB. If a TBFB was identified, an attempt was made to extract it with the help of rat tooth forceps, a Dormia basket, or tripronged forceps passed through the suction channel of the bronchoscope. If this attempt failed, the procedure was converted to RB. In a few cases, an electrocautery probe was used to burn away granulation tissue around the TBFB or a balloon was used to dilate the strictured segment proximal to the TBFB. The number of successful extractions or failures with each type of instrument was noted. The complications encountered during these procedures were noted. The patients were normally kept in the hospital for 12 to 24 hours after the procedure for observation and a chest radiograph was performed before discharge.
Of 266 patients who underwent bronchoscopy for suspected TBFBs, the diagnosis was confirmed in 214 patients. In 207 patients, the TBFB was extracted successfully. The clinical profile of these patients was as follows:
Sex and Age Profile
Of the 214 patients who had TBFBs, 126 were males (59%) and 88 were females (41%). There were only 13 patients in the age group above 12 years. The agewise distribution of these patients is depicted in Table 1.
Duration Since Aspiration of TBFB
After aspiration, the majority of the patients reported to the hospital quite promptly. The pattern of reporting from time of aspiration is shown in Table 2.
Choking episodes were reported in 175 patients (82%). Cough and dyspnea were the most common symptoms in 199 (93%) and 139 (65%) patients, respectively. Twenty-eight patients were brought because of noisy breathing (13%). Seventeen patients had fever due to infection (8%). Eighteen patients presented in an asphyxiated state with severe distress (8%).
Decreased breath sounds on the side where the TBFB was stuck was the most common sign in 141 patients (66%).Thirty-eight patients had fixed rhonchi over the obstructed lung (18%). Five children were brought in a cyanosed state to the emergency room and had to be intubated before definitive treatment (2%). Twenty-eight patients with TBFBs had stridor and noisy breathing (13%).
Obstructive hyperinflation due to a check valve mechanism of the TBFB in the bronchus was a common finding. Collapse or consolidation of the distal lung beyond the site of TBFB impaction was the most frequent. A radio-opaque FB was seen in only a few cases. The x-ray picture was normal in a significant percentage. The distribution of these findings is depicted in Table 3.
As mentioned earlier, of 214 cases of foreign bodies confirmed by bronchoscopy, 207 were successfully extracted (96.7%). Of these 214 cases, 105 TBFBs (49%) were found on the right side, 81 TBFBs (38%) on the left side, and 28 TBFBs (13%) in the trachea. Of 214 confirmed cases of TBFBs, 18 patients (8%) had signs and symptoms of asphyxiation. These patients were too unstable and distressed, and so to maintain the airway and ventilation, extraction was attempted directly with RB under general anesthesia without undergoing diagnostic FB. The RB was successful in all the 18 cases. In the remaining 196 cases, extraction was attempted first with FB under conscious sedation, and RB was resorted to if required. In 79 cases, TBFB could be extracted with FB (40%), and RB was not required. Of these 196 patients, 13 patients were in the more than 12 years category, where an adult size FB was used, and it was successful in 12/13 patients (92%). In the rest who were in the below 12 years’ age group, where the pediatric FB was used, it was successful in 67/183 patients (37%). In the rest, the procedure was converted to RB with appropriate anesthesia and extraction completed in 110 of 117 cases (94%). There were only 7 failures with RB (6%). The comparison of the success of the RB against the FB is given in Table 4.
All the 7 failures were in children (<12 y old), and the time since aspiration was more than a month in all the cases. In 1 case, the TBFB had remained impacted inside for more than 2 years. Five of these cases were referred to the thoracic surgeon for surgical removal as the TBFBs were impacted and covered with granulation. In 1 case, a child had aspirated a metal pin, which on attempting extraction moved further down the left lower lobe into a basal subsegment out of sight for FB. The child was subsequently lost to follow-up. In another child, the TBFB, a peanut, broke into smaller pieces and one of the fragments got lodged into the left upper lobe and could not be removed. However, the child did well subsequently and the follow-up x-rays remained normal.
Type of Foreign Body
Of the 207 TBFBs extracted, 141 were organic: for example, peanuts, chickpeas, redbean seeds, betel nuts, and even a pod of garlic in an adult patient. The other 76 were inorganic such as pieces of whistles, rubber, metal, and plastic pen caps. Peanuts were the most common TBFBs to be extracted. Some of the TBFBs extracted are shown (Figs. 1–6).
There were very few complications related to the extraction procedure. Laryngeal edema occurred in a few patients and responded to steroids and oxygen. Subcutaneous emphysema and pneumothorax were seen but did not require a tube thoracostomy and resolved with conservative treatment. All the patients who had complications were in the less than 12 years age group, and in all cases, both FB and RB had to be performed due to difficulty in extraction. There was no mortality in this series related to the TBFB or due to the procedure. The frequency of these complications is listed in Table 5.
A retrospective analysis of our experience over the last 10 years in patients with TBFBs has brought out some facts, which are as follows.
Age and Sex
It was found that although TBFB aspiration was seen in all age groups, it was predominantly seen in children in the 1 to 2 year age group. This is probably due to the increased mobility at this age and the tendency of infants to put objects into their mouths coupled with poor reflexes and crying or trying to speak while eating. It also indicates poor parental supervision and carelessness regarding allowing such objects within reach of these children. Large families with many children to look after and lack of awareness could also be the reasons. Other series have also found this increased incidence in children <2 years.2–4 There were more males (59%) in our series than females (41%). This has also been reported by other investigators2–4 although there is no clear reason for this. There were very few patients above the age of 12 years. This is expected as they have adequate reflexes and coordination and therefore do not easily aspirate TBFBs.
Duration Since Aspiration
Most of the patients were brought to the hospital within the first 24 hours after aspiration of the TBFB; however, a significant number were brought quite late. In fact, 7% patients came to the hospital after more than a month and 15% reported 1 week to a month after aspiration. Another large Indian study in children reported a similar delay in 15% of cases.4 This is a matter of concern because almost 83% patients or parents reported choking episodes and yet many of them failed to come to the hospital promptly. This indicates poor health awareness among parents. Some of the case records showed that the patients reported the choking episode to the family physician but even then a TBFB was not suspected. TBFBs cause immediate respiratory distress with noisy breathing whenever they are stuck in the trachea but this distress usually subsides once the TBFB goes down into one of the main bronchi. It seems that this relief in distress after an initial choking episode misleads parents and sometimes even physicians into believing that there is no significant aspiration or that the TBFB may have been swallowed or expectorated, ultimately leading to delay in diagnosis.
Symptoms and Signs
The symptoms of TBFBs were on expected lines. Most patients or parents reported a choking episode (83%). Cough with or without dyspnea was the most common symptom. Patients who were brought late usually had only persistent cough and some of them had fever. The sign most often elicited was decreased breath sounds on the side where the TBFB was lodged. Patients who had tracheal TBFBs were found to have stridor or noisy breathing. Eighteen patients had asphyxiation, and of these, 5 children were brought in extreme distress with cyanosis and had to be intubated in the emergency room before being taken up for extraction. The endotracheal tube (ETT) in these patients helped in oxygenation and also to push down the TBFB from the trachea to one of the main bronchi, thus facilitating ventilation. All patients who had asphyxiating TBFBs were taken straight for RB under general anesthesia. It is important to recognize this subgroup of unstable patients who require airway control and therefore RB is an automatic first choice.
The TBFB could not be seen in the large majority of cases (84%) and the chest radiograph was normal in a significant percentage (21%). In such cases, a high index of suspicion is required to proceed with bronchoscopy, and thus due importance must be given to the history of choking and other symptoms and signs. Silva et al,5 after analyzing the utility of conventional radiography in the diagnosis and management of TBFBs, also concluded that the decision to go ahead with a bronchoscopy should be made despite a negative radiograph if clinical suspicion is strong. Indirect signs indicating the presence of a TBFB, such as collapse/consolidation, and obstructive hyperinflation due to a check valve mechanism, also merit a diagnostic bronchoscopy.
Mode of Extraction
Of the 214 confirmed cases of TBFBs, the extraction was successful in all but 7 cases (97%). The TBFBs were found more often on the right side (49%) and sometimes in the trachea (13%). This is probably due to the straighter right main bronchus allowing the TBFB to slip in more easily than into the angulated left main bronchus. The larger TBFBs were retained in the trachea. Of the 2 types of bronchoscopes, FB was used with success in only 40%, whereas RB was successful in extraction of the TBFBs in 94% of the remaining cases of nonasphyxiating TBFBs and in 100% of the asphyxiating TBFBs.
Nonasphyxiating TBFBs, Age More Than 12 Years
As mentioned earlier in patients with nonasphyxiating TBFBs, FB was always performed first. It is noteworthy that in 12 of 13 patients in the age group of more than 12 years, the TBFB was extracted successfully with FB (92%). In these patients, an instrument of outer diameter 4.9 mm with an inner channel of 2.2 mm was used. The larger diameter of the adult FB allowed instruments such as rat tooth forceps and larger Dormia baskets through the wide inner channel. In 3 cases where granulations had formed, electrocautery could be used to burn away the fibrotic tissue to loosen the embedded TBFB to help extraction. In 1 case, a balloon could be passed to dilate a stricture that had formed proximal to the impacted TBFB before its extraction. Also, the wider diameter of the tracheobronchial tree in these older patients allowed them to breathe adequately despite the TBFB, thus giving the bronchoscopist more time for extraction with FB using different accessories and using electrocautery or a balloon where necessary. During the procedure, the oxygenation could be maintained easily with oxygen supplementation through a mask or nasal cannula. Similar high success rates with FB for nonasphyxiating TBFBs in adults have been reported by several other workers,6–9 thus making it an excellent first choice for TBFBs in this group. It is worth mentioning here that although extraction of TBFBs in this age group with the rat tooth forceps and the Dormia basket is relatively easy, more advanced interventions such as electrocautery require a high degree of skill and should be attempted only by experienced bronchoscopists.
Nonasphyxiating TBFBs, Age Below 12 Years
Unlike the older group, in children less than 12 years of age, FB could be used successfully for extraction of the TBFB in only 67 of 183 cases (37%). The instrument for FB that was used for these children had an outer diameter of 3.2 mm and an inner channel of 1.2 mm. The ancillary instruments that could be used for extraction through this narrow channel were only a small urology Dormia basket or tripronged forceps, thus limiting the options. Moreover, these children, mostly in the 1 to 2 years age group, tended to become hypoxic more easily with a TBFB in the large airways, thereby limiting the time for the procedure. Therefore, if success was not achieved after a few attempts with FB, the procedure was then converted to RB under anesthesia to complete the extraction. The RB was successful in 110 of 117 cases (94%) where FB was unsuccessful.
Several authors have published their experience in the extraction of TBFBs in the pediatric age group.2–4,10–24 The large majority have exclusively used RB for this purpose with high rates of success.3,4,10–18 Only a few have reported their experience with FB in this subset of patients.2,19–24 In a series from the Mayo clinic, Swanson et al2 have reported their experience in 39 children where FB was successfully used in 26 cases. They performed the procedure under general anesthesia in all the cases, passing the bronchoscope through an ETT or a laryngeal mask airway. Where the ETT was too narrow, they used an ultrathin bronchoscope (which does not have a channel for suction) for visualization and had to pass the accessories for removal of the TBFB alongside the bronchoscope. Although they had a high success rate with FB, we consider that if general anesthesia and an ETT are to be used, then one may as well resort to RB straight away and take out the TBFB. In small children, because of the narrow ETT, the ultrathin bronchoscope was used by these authors. However, this instrument is not widely available in most institutions. Also, extracting the TBFB by manipulating an accessory that is lying alongside the ultrathin bronchoscope within a narrow ETT through which one is also administering anesthesia could not be an easy task. This recommendation therefore does not seem very practical. Finally, despite their recommendation for the use of FB for the extraction of all TBFBs, Swanson and colleagues themselves concluded that RB should be available in case FB fails.
Martinot et al19 and Wood et al20 have reported their experience with FB for TBFBs in pediatric patients, but used it only for diagnostic purposes in suspected cases and chose to use RB for extraction if a TBFB was found.
Monden et al21 in a series of 27 patients with airway TBFBs, have reported high success rates of 81%with FB. However, it is not clear from their series whether they excluded patients who were asphyxiated or unstable. Also, in this series, there were 19 children out of a total of 27 patients, and of these, only 9 were below 2 years of age. Hence, the age was quite varied and may explain the better extraction results with FB.
In a series reported by Ramirez-Figueroa et al22 of a total of 56 patients with TBFBs, FB was successful in extraction in 21 of 23 children where it was first attempted (91%). The mean age was 5 years, ranging from 9 months to 16 years. One is not sure from the article why FB was chosen in some, whereas RB was opted for in 33 of the total of 56 patients.
In a large series of 1027 children with TBFBs, Tang and colleagues reported a success rate of 91.3% with FB.24 The mean age of these patients was only 17 months. This study also, however, does not mention how many of their patients were asphyxiated and unstable. Moreover, the study states that the accessories used for extraction were disposable grasping forceps and biopsy forceps. In our experience, we found the pediatric grasping forceps too small for many of the TBFBs and the biopsy forceps useless for getting a firm grip for extraction.
It is difficult to draw firm conclusions from the literature regarding the efficacy of FB for extraction of TBFBs in children given the limited number of studies. It is in this light that we feel that our report assumes significance, as it makes a head to head comparison of the efficacy of FB against RB in a significant number of patients.
Asphyxiating TBFBs, all Ages
As an exception to the above where FB was tried first, 18 of the 214 patients were so unstable because of asphyxiating TBFBs that RB had to be resorted to as a primary tool. This allowed the bronchoscopist to assume control of the airway and maintain adequate ventilation and oxygenation. In 5 of these cases who presented with cyanosis and extreme respiratory distress, an ETT had to be placed to oxygenate them before the RB could be inserted for extraction of the TBFB. All five were children, and it should be pointed out that the inner diameter of the ETT used was 3.5 to 4.5 mm and this was too narrow to admit a pediatric FB with an outer diameter of 3.2 mm. Hence, the ETT was taken out once the patient was sufficiently stabilized and replaced by a rigid ventilating bronchoscope to maintain control of ventilation and to complete the extraction procedure. As mentioned earlier, RB was successful in all the 18 cases with asphyxiating TBFBs and appears to be a safe and effective method of dealing with this life-threatening emergency.
To sum it up, therefore, with good ancillary equipment and the requisite skills, FB appears to be highly successful for the extraction of nonasphyxiating TBFBs in adult patients and should be used as the instrument of first choice in this group. In children with nonasphyxiating TBFBs, FB is excellent as a diagnostic tool and should always be used first to confirm the presence of a TBFB. With tools such as Dormia baskets and tripronged forceps, extraction of many TBFBs is possible even in this age group with the advantage of avoiding general anesthesia; however, it cannot be relied upon alone for extraction and RB should be available lest it fails. In contrast, in unstable patients with asphyxiating TBFBs, RB is a clear choice as it offers the dual advantages of airway control and faster extraction albeit under general anesthesia.
Of a total of 214 cases where the TBFB was confirmed by bronchoscopy, in 7 cases, it could not be extracted by either FOB or RB. All 7 cases were below 12 years of age and all of them had presented late for treatment. Five of these cases had thick granulation formation around the impacted TBFB, rendering attempts at bronchoscopic removal impossible. As mentioned earlier, in selected older patients where granulations had formed, we had successfully used electrocautery through the bronchoscope to burn away the fibrotic tissue and disengage the TBFB to enable extraction; however, in these 5 cases, the granulations were too thick and the TBFBs embedded too deeply to allow safe extraction. One patient who had a metallic pin that could not be extracted did not report to the surgeon after being referred. Another patient who had a fragment of a peanut lodged in the upper lobe, which could not be removed, did not appear to have any problem during follow-up and may have coughed up small fragments unnoticed. It must be said that despite a skilled bronchoscopy team and adequate equipment, there will still be failures, and a competent thoracic surgeon should be accessible for surgical removal of the TBFB if both FB and RB fail.
Only a few patients suffered from any complications related to the extraction procedures. All the patients who had complications had difficult extractions as evidenced by the fact that both FB and RB had to be used to remove the TBFBs. The complications were minor and included laryngeal edema evidenced by swelling of the glottic apparatus seen on bronchoscopy and noisy breathing after the procedure. The edema probably occurred because of multiple passages of bronchoscopes through the larynx. However, it was mild in all the cases and responded to symptomatic treatment. A few cases developed surgical emphysema and pneumothorax. We feel this was a result of the patient straining excessively in trying to cough out the TBFB and thus raising the transpulmonary pressure and causing rupture of the lung into the medisatinum or into the pleural space and not due to the bronchoscopic procedure. Similar complications have been reported by Ciftci et al in their series of 663 children.25 The complications that occurred in our patients improved with conservative treatment. As mentioned before, there was no mortality associated with the procedure or otherwise in our series.
From our experience of extraction of TBFBs over more than a decade, we have drawn the following conclusions:
- TBFBs present most frequently in the age group of 1 to 2 years, with cough and/or breathlessness commonly following a choking episode.
- A high index of suspicion is essential and a diagnostic FB should be performed in all such cases even though the chest radiograph is normal.
- TBFBs can be life threatening and may require to be treated as an emergency.
- FB may be used first for diagnosis and extraction under conscious sedation for nonasphyxiating TBFBs. It is usually more successful in adults and less so in children.
- In these patients, if FB is unsuccessful, then RB may be used to extract the TBFB.
- For asphyxiating TBFBs, RB is the procedure of choice.
- Pulmonologists who wish to practice extraction of TBFBs ought to be trained in both FB and RB and must possess adequate equipment and a skilled team to assist them.
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