Airway Foreign Bodies: What s New?

Airway Foreign Bodies: What s New? Karen L. Swanson, D.O. 1 ABSTRACT Tracheobronchial foreign body (FB) aspiration is a common problem in children and adults. The medical history is the single most predictive factor in the clinical suspicion of FB aspiration. The penetration syndrome defined by the sudden onset of choking and coughing with or without vomiting should prompt concerns for FB aspiration. Findings on radiographic imaging include visualization of a radiopaque FB, atelectasis, postobstructive changes, mediastinal shift, and pneumomediastinum. In the presence of a high clinical suspicion even with normal imaging studies, bronchoscopy should be performed for a thorough evaluation of the airways. Bronchoscopic extraction of airway FBs can be safely accomplished with both the rigid as well as the flexible bronchoscope in adults and children. Rigid bronchoscopy allows for control of the airway and provides excellent visualization with a variety of ancillary instruments available. Increasingly, both the adult and pediatric flexible bronchoscopes have been used successfully in the extraction of airway FBs utilizing urologic or bronchoscopic instruments. Airway control can be achieved with an endotracheal tube or a laryngeal mask airway. A delay in diagnosis increases morbidity including cough, wheeze, edema, and granulation tissue formation. Bronchoscopic evaluation and removal should be performed as soon as the diagnosis is suspected. KEYWORDS: Airway, foreign body, bronchoscopy, flexible bronchoscope, rigid bronchoscope Objectives: Upon completion of this article, the reader should: (1) recognize historical clues, examination findings, and radiographic abnormalities suggesting the presence of a foreign body in the airway; and (2) understand the role of bronchoscopy (rigid and flexible) in foreign body extraction. Accreditation: The University of Michigan is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. Credits: The University of Michigan designates this educational activity for a maximum of 1 category 1 credit toward the AMA Physician s Recognition Award. Accidental aspiration of a foreign body (FB) into the tracheobronchial tree in both adults and children can result in significant morbidity and mortality. 1,2 In the year 2000, in the United States, 160 children died due to complications from airway FBs, and in 2001, an estimated 17,537 children were treated in emergency departments for choking-related instances. 3 A missed diagnosis can lead to life-threatening airway obstruction, chronic wheezing, protracted cough, and recurrent pneumonia. A delay in diagnosis can also result in Interventional Pulmonology; Editor in Chief, Joseph P. Lynch, III, M.D.; Guest Editors, Praveen N. Mathur, M.B., B.S., Atul C. Mehta, M.B., B.S. Seminars in Respiratory and Critical Care Medicine, volume 25, number 4, 2004. Address for correspondence and reprint requests: Karen L. Swanson, D.O., Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Mayo Medical Center and Mayo Clinic, 200 First Street, SW, Rochester, MN 55905. E-mail: Swanson.karen@mayo.edu. 1 Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Mayo Medical Center and Mayo Clinic, Rochester, Minnesota. Copyright # 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212 ) 584-4662. 1069-3424,p;2004,25,04,405,411,ftx,en;srm00312x. 405

406 SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 25, NUMBER 4 2004 significant airway compromise including edema, granulation tissue, bronchiectasis, and obstructive pneumonia. Management of airway FBs consists of clinical examination, appropriate tests to diagnose the presence of an airway FB, and quick removal of the FB from the airway. CLINICAL PRESENTATION A high index of clinical suspicion for FB aspiration into the tracheobronchial tree is an essential part of the diagnosis. Sudden paroxysms of coughing in a child, for example, should lead one to consider FB aspiration that may not have been witnessed. Similarly, in adults with impaired reflexes such as neurological abnormalities or drug/alcohol-induced diminution of oropharyngeal and glottic protective reflexes, it is important to consider FB aspiration as an etiology for radiographic abnormalities or relatively new respiratory symptoms. Tracheobronchial FB aspiration is much more common in children than in adults. Typically, children who aspirate FBs into their airways are in the age range of 2 to 3 years. Presenting symptoms are similar in children and adults. These include sudden onset of choking, intractable cough, dyspnea, and unresolved pulmonary infection. The penetration syndrome is commonly seen regardless of age group and consists of the sudden onset of choking and intractable cough with or without vomiting. 4,5 The odds ratio for the presence of airway FB in a witnessed event has been reported to be 7.1 while the odds ratio for choking was 7.3. 5 This further substantiates the importance of the medical history and the required high index of suspicion for the presence of a FB in patients (child or adult) with these symptoms. The physical examination in patients with a suspected tracheobronchial FB may elicit highly variable findings. If an airway FB causes significant obstruction of the trachea or both main bronchi, the patient may present with severe respiratory distress marked by stridor, cyanosis, and respiratory muscle retractions. If the FB is located more distally (in one of the main stem, lobar, or subsegmental bronchi) there may be minimal or no symptoms. Few studies have reported significant diagnostic yield from the physical examination in patients suspected to have tracheobronchial FBs. Adults present with FB aspiration more commonly in the right bronchial tree (> 50% of patients) likely due to the more direct pathway of the right main stem bronchus whereas in children there appears to be an equal distribution between right and left bronchial trees. 6,7 Table 1 lists the most common symptoms and physical examination findings in FB aspiration. IMAGING STUDIES The standard posteroanterior chest roentgenogram is commonly performed in patients with suspected airway Table 1 Symptoms and Physical Examination Findings in Patients with Airway Foreign Body Aspiration Symptoms Choking Intractable cough Dyspnea Fever Asymptomatic Nasal flaring Physical Examination Findings Stridor Wheeze Diminished breath sounds Tachypnea Muscle retractions Grunting FB aspiration. Radiopaque FBs such as the spring seen in the bronchus intermedius in Figure 1 may be visualized by chest radiography. Inspiratory and expiratory views as well as lateral neck radiographs may also help. Radiographic abnormalities may include atelectasis, infiltrates, hyperinflation, mediastinal shift, obstructive emphysema, and, less commonly, pneumomediastinum. In up to 40% of patients with suspected airway FBs, the chest radiograph is normal. Normal imaging studies should not obviate bronchoscopic evaluation in a clinical setting where the suspicion for airway FB aspiration is high. Clinically unsuspected FBs are found in 1 to 9% of routine bronchoscopies. A prospective study in suspected FB aspiration in children found the positive predictive value to be 94% if a child had unilaterally decreased breath sounds on examination and obstructive emphysema on chest imaging. 8 The sensitivity and specificity of conventional radiographic studies in the diagnosis of airway FB range from 68 to 73% and 45 to 67%. 9,10 These findings emphasize the importance of the entire clinical scenario including the medical history, physical examination findings, and imaging results. Common radiographic manifestations are listed in Table 2. REMOVAL OF TRACHEOBRONCHIAL FOREIGN BODIES Many airway FBs are expectorated before the patient seeks medical attention. Frequently, smaller FBs are expectorated into the pharyngeal region where they are swallowed. Nonbronchoscopic techniques have included the use of systemic steroids to decrease edema of the airway mucosa so that expectoration of the FB is facilitated. There are reports of a small number of cases in which fluoroscopically guided balloon extraction of airway FBs has been performed. This therapeutic approach is not recommended. The extraction of tracheobronchial FBs has traditionally been performed with rigid bronchoscopy, particularly in pediatric patients. This approach is still widely practiced in children. However, the versatility of the flexible bronchoscope has led to increasing use of this instrument to successfully remove aspirated FBs from the airways of adults as well as

AIRWAY FOREIGN BODIES/SWANSON 407 Figure 1 (A, B) Posteroanterior and lateral chest roentgenogram showing a radiopaque foreign body (metal spring) in the bronchus intermedius. (C) Visualization endobronchially of the foreign body in the bronchus intermedius in a stentlike position. Removed with flexible bronchoscopy and ureteral grasping forceps. children. The following paragraphs address these two techniques. Rigid Bronchoscopy Rigid bronchoscopy has been the traditional procedure of choice for the removal of tracheobronchial FBs, and Table 2 Common Radiographic Findings in Airway Foreign Body Aspiration Normal Atelectasis Consolidation Infiltrates Radiographic Findings Radiopaque foreign body Pneumomediastinum Obstructive emphysema Mediastinal shift extraction success rates have been high. Rigid bronchoscopy is performed under deep intravenous sedation or general anesthesia and is ideal for airway control as well as for the removal of FBs. Small airway FBs can be removed through the rigid bronchoscope. With larger FBs that will not pass through the bronchoscope, the FB is grasped and brought up to the end of the rigid bronchoscope and the entire unit is removed en masse. Figure 2 illustrates a large FB (dental prosthesis) aspirated into the midtrachea that was removed en masse with the rigid bronchoscope and rigid forceps. Care must be taken to avoid shearing the FB off as it is withdrawn through the glottis. The rigid bronchoscope provides ideal visualization with excellent optics as shown in Figure 3. This, in conjunction with a variety of instruments available to

408 SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 25, NUMBER 4 2004 Figure 2 (A) Lateral radiograph revealing a foreign body (dental prosthesis) in the midtrachea. (B) Foreign body was a dental prosthesis 3 cmin length that was removed with rigid bronchoscopy and rigid alligator forceps. pass through the large channel of the rigid bronchoscope, allows successful extraction of the majority of airway FBs. If the FB is distally impacted and cannot be seen with rigid bronchoscopy telescopes, a flexible bronchoscope can be easily passed through the hollow channel of the rigid bronchoscope to enable visualization and extraction. A disadvantage of the rigid bronchoscope is that it requires a significant degree of training and skill for the operator to become proficient, and it may not be available at all medical centers. Potential complications of rigid bronchoscopy include laryngeal edema, laryngotracheal lacerations, bronchial rupture, and bleeding. Complications of rigid bronchoscopy occurred in 42 of 504 patients with FB aspiration and included respiratory distress due to laryngeal edema in 12 patients necessitating a tracheotomy in nine and intubation in three patients. 11 This reiterates the fact that these patients Figure 3 Visualization through the rigid bronchoscope using the rigid alligator forceps to remove a penny in the distal trachea. can be complex in their management, and that rigid bronchoscopy should not be considered a benign procedure. Flexible Bronchoscopy Over the last several years, the vast majority of bronchoscopies have been successfully accomplished with the flexible bronchoscope. As a result, the use of rigid bronchoscopy has decreased. This observation applies also to the extraction of FBs in both adults and children. Success rates for extraction of a variety of airway FBs using the flexible bronchoscope have been high in reports from several institutions whereas the complication rates have been very low. Reports from the Mayo Clinic have demonstrated that the flexible bronchoscope was successful in extraction of 100% of airway FBs in 26 children, and 89% (n ¼ 54) of FBs in 61 adults. 12 14 Since 1993, all tracheobronchial FB extractions (n ¼ 23) in children performed by the Mayo Clinic Section of Bronchoscopy have been performed with the flexible bronchoscope with the exception of one patient where anesthesia personnel requested the procedure be done with the rigid bronchoscope. As experience accumulates with flexible bronchoscopic extraction of airway FBs, increasing numbers of bronchoscopists are likely to resort to this technique. The standard adult flexible bronchoscope has a working channel of 2.2 mm with an external diameter of 5.0 to 6.0 mm. The adult flexible bronchoscope can be used through the nasal passage, oral passage, and tracheostomy stoma, with or without an endotracheal tube. In children, however, oral insertion is ideal.

AIRWAY FOREIGN BODIES/SWANSON 409 A large-diameter endotracheal tube or a laryngeal mask airway will allow an adequate channel for oral insertion of the broncoscope. The advantage of the adult bronchoscope is its larger working/suction channel. Pediatric flexible bronchoscopes have also been used in FB extraction. The standard pediatric flexible bronchoscope has a working channel of 1.2 mm with an external diameter of 3.6 mm. This requires an endotracheal tube with an internal diameter of at least 4.5 mm. If a small-diameter, flexible bronchoscope with a working channel is used, a different set of ancillary instruments to extract the FB will be required because the standard flexible bronchoscopy instruments cannot pass through the smaller working channel of the pediatric flexible bronchoscope. The ultrathin flexible bronchoscope can be used to visualize a distally impacted FB, but removal will usually not be possible because it has no working channel. When considering extraction of a FB with the flexible bronchoscope, an important initial step is to determine how the airway is secured. If a patient is in significant respiratory distress because of major airway obstruction caused by the FB, rigid bronchoscopy is the procedure of choice. If the patient is stable, then the decision is whether or not to use an endotracheal tube. If an endotracheal tube is used, FBs that are too large to be removed through the endotracheal tube are grasped and pulled up to the endotracheal tube. The entire unit is then removed together with a firm grip on the FB. If the FB is sheared off and occludes the airway, the flexible bronchoscope can be reinserted to push the FB into one of the main stem bronchi so that the tracheal lumen is not compromised. In children, airway control and adequate ventilation can be accomplished with the use of a laryngeal mask airway (LMA). The LMA is inserted blindly into the oropharynx and is designed to sit just above the glottic opening. The flexible bronchoscope can be inserted through the LMA, through the vocal cords, and into the trachea. A study reported the use of the LMA in 10 children undergoing flexible bronchoscopy (ages 1.2 5 years). 15 In six of these children, the airway FBs were successfully extracted through the LMA. An advantage of the LMA is its larger diameter compared with an endotracheal tube. This allows the use of the adult flexible bronchoscope without compromising ventilation. A similar experience with the LMA has been reported from the Mayo Clinic in five pediatric patients with successful FB extraction. 12 One complication by this type of approach is that of acute laryngospasm. Anesthesia of the vocal cords can help to diminish this risk. The type of sedation and/ or anesthesia required to safely accomplish the procedure is an important aspect of management of airway FBs. In the majority of children, general anesthesia is preferred. Propofol intravenous infusion is an excellent alternative because of its rapid onset of action and short half-life. In adults, conscious sedation with narcotics and anxiolytics often suffices if the procedure is performed with the flexible bronchoscope. It is important to perform a complete visual inspection of the entire tracheobronchial tree in these patients once the FB is removed. If a known FB is in the right main stem bronchus and removed without visualizing the remainder of the tracheobronchial tree, other FBs might be missed. Ancillary Instruments A wide variety of instruments are available for use with the rigid bronchoscope for FB extraction. These include rigid cupped forceps, alligator forceps, a rigid suction catheter, and the flexible bronchoscope through the rigid bronchoscope. These instruments are sturdy in nature and have the ability to firmly grasp an FB. The primary ancillary instruments used for extraction of FBs using the flexible bronchoscope have largely been derived from those used in gastroenterologic and urologic procedures. These include the ureteral stone baskets and stone forceps used for the removal of ureteral stones. Figure 4 shows a FB removed with the ureteral stone basket. These pass easily through the working channel of a pediatric flexible bronchoscope with a working channel diameter of > 1.0 mm. For the standard adult, an adult flexible bronchoscope with a working channel (typically 2.2 mm diameter) can be used with other types of ancillary equipment such as a variety of bronchoscopic biopsy and grasping forceps, a Fogarty balloon catheter, a neodymium:yttrium-aluminumgarnet (Nd:YAG) laser contact tip, pronged snares, and suction. When the Fogarty balloon catheter is utilized, it is passed beyond the FB and the balloon is inflated and then slowly withdrawn. This is often successful in bringing an FB from a distal position in the bronchial tree to a more proximal one where it can be more easily grasped. The cryotherapy probe has also been used to extract airway FBs. 16,17 In this situation, the cryotherapy probe is placed against the FB, which adheres to it and is then removed. A case report has been published on the use of an intravascular wire loop snare passed through a flexible bronchoscope under fluoroscopic guidance in the successful removal of an FB. 18 The fishnet basket is a meshlike variation of a polypectomy snare that has been used successfully in extraction of FBs using the flexible bronchoscope. 16 A caveat in the use of flexible bronchoscopic removal of FBs in pediatric patients is that rigid bronchoscopy should be readily available if the flexible bronchoscope fails to extract the airway FB. This may necessitate coordination with other physicians or tertiary referral centers if both flexible and rigid bronchoscopies are not available within one institution.

410 SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 25, NUMBER 4 2004 the extraction of airway FBs. One report states that the flexible fiberoptic instruments are not indicated because they may cause dangerous consequences such as displacement of the foreign body to a difficult to access position, fragmentation of the foreign body or provocation of poor ventilation and heart attack. 20 Another declares that rigid bronchoscopy is the only procedure that allows diagnosis and removal of the foreign body. 21 As already discussed here, accumulated evidence suggests that flexible bronchoscopy is a safe procedure with good success rates for airway FB removal in both adults and children. 12 14,22 Flexible bronchoscopy has the advantages of being widely available, relatively easy and safe in experienced hands, and possible to perform with local anesthetic and conscious sedation. 14 Figure 4 The ureteral stone basket being used through the flexible bronchoscope to remove a foreign body. Complications Complications of FB extraction include laryngeal edema, stridor, fever, or airway obstruction if the FB is dropped inadvertently in the trachea. The critical thing to remember is if a FB is dropped and significant tracheal obstruction occurs, the bronchoscope should be used to immediately push the FB back into one of the mainstem bronchi. This will allow adequate ventilation of at least one lung while alternative plans are formulated. Rarely, an open surgical procedure is required to remove the FB. Organic FBs such as nuts or vegetable material have the propensity to cause significant mucosal reaction with edema and formation of granulation tissue. A delay in the diagnosis of an FB in this context could lead to significant long-term problems with cough, wheeze, and, occasionally, postobstructive pneumonia. Bugmann et al have described a severe bronchial synechia following the removal of a long-standing sharp FB (pistachio shell). 19 Controversy There is some controversy regarding the use of the flexible bronchoscope versus the rigid bronchoscope for CONCLUSIONS The medical history and a high index of clinical suspicion of FB are more useful than physical examination findings or radiographic studies (unless a radiopaque FB is visualized) in the determination of FB. Bronchoscopy is indicated in all cases to inspect the tracheobronchial tree and assess for FB. A planned approach to removal with special consideration to type of anesthesia, airway, stability of the patient, and procedure is crucial for successful FB removal. Flexible bronchoscopy is emerging as a useful tool in extraction of FBs in both adults and children. Rigid bronchoscopy should be available should attempts with the flexible bronchoscope fail. REFERENCES 1. Vane DW, Pritchard J, Colville CW, et al. Bronchoscopy for aspirated foreign bodies in children. Arch Surg 1988;123: 885 888 2. Blumhagen JD, Wesenberg RL, Brooks JG, et al. Endotracheal foreign bodies. Clin Pediatr (Phila) 1980;19:430 434 3. Nonfatal choking-related episodes among children United States, 2001. MMWR Morb Mortal Wkly Rep 2002;51:945 948 4. Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest 1999;115: 1357 1362 5. Swanson KL, Prakash UBS, Midthun DE, et al. Clinical characteristics in suspected tracheobronchial foreign body aspiration in children. J Bronchol 2002;9:276 280 6. Oguzkaya F, Akcali Y, Kahraman C, Bilgin M, Sahin A. Tracheobronchial foreign body aspirations in childhood: a 10-year experience. Eur J Cardiothorac Surg 1998;14:388 392 7. Brkic F, Delibegovic-Dedic S, Hajdarovic D. Bronchoscopic removal of foreign bodies from children in Bosnia and Herzegovina: experience with 230 patients. Int J Pediatr Otorhinolaryngol 2001;60:193 196

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