D24-14 The Claw: Removal of a Distal Foreign Body via Robotic Navigational Bronchoscopy

Introduction Bronchoscopic removal of distal foreign objects in the airway can pose a significant challenge. We present a case in which robotic navigational bronchoscopy was used to retrieve a distal foreign body and avoid the need for thoracic surgery. Case Description A 22-year old previously healthy male suffered a severe traumatic brain injury as the result of a high-speed motor vehicle accident. His trauma evaluation revealed a small metallic foreign body in the right lower lobe (RLL) bronchus versus parenchyma. A MRI brain was requested by neurology for prognostication, prompting pulmonary consultation for removal of the object. Flexible bronchoscopy confirmed the foreign body was endoluminal and positioned in the posterior subsegment of the RLL. However, removal at this time was deferred due to clinical instability. The patient was re-evaluated one month later after a tracheostomy had been placed and he was no longer requiring mechanical ventilation. A 6-mm metallic foreign body was successfully removed from the airway using a disposable bronchoscope with forceps and a Roth net. Subsequent airway inspection was without a remaining foreign body. However, a follow-up chest x-ray demonstrated a small retained object. Repeat bronchoscopy performed two days later was unsuccessful at visualizing the object despite examination to the 5th generation airway with escalating levels of positive end expiratory pressure and tidal volume. Repeat CT chest with thin-sections demonstrated a punctate metallic density in the posterior division of the RLL, measuring 1-mm (Figure 1). The patient then underwent robotic navigational bronchoscopy with the Ion robotic bronchoscopy system. A cryoprobe and forceps were used and the forceps were ultimately successful in removing the object (Figure 1). Repeat chest imaging confirmed complete removal of the foreign body. Discussion Robotic bronchoscopy has revolutionized the landscape of lung cancer diagnosis by making smaller targets accessible to bronchoscopic sampling, however this system has rarely been use for foreign body removal. To our knowledge, this is only the second reported case of this application. Robotic bronchoscopy is a safe and effective strategy for removing distal foreign bodies and obviates the need for surgical resection. Figure 1: 1-mm metallic object in the distal RLL. This abstract is funded by: none