Extraction of Airway Foreign Body in Adults

Nonasphyxiating airway foreign bodies (FBs) occur more commonly in children. Approximately 75% occur in children younger than 3 years old because small children have a tendency to explore their surroundings by putting objects into their mouth. 1–3 In adults, FB aspiration is seen most commonly after the sixth decade of life and is usually the result of the failure of airway protective mechanisms. 1,4,5 Airway FB clinical presentation is dependent on the site of object impaction. With large asphyxiating FBs at the larynx, severe coughing, choking, hoarseness, cyanosis, and gagging is frequently seen. In 1998, suffocation by an FB accounted for 3,200 deaths (1.2 per 100,00) in the United States. 6 If the FB is aspirated below the cords into the subglottic or tracheal region, inspiratory stridor with bouts of coughing can occur. If the FB passes into the bronchi, then there may be minimal symptoms, other than a unilateral or localized wheeze. The classic triad of cough, wheezing, and choking is present in only a small percentage of patients. 7,8 In adults, the clinical presentation of a nonasphyxiating tracheobronchial FB can be innocuous because most FBs will be wedged distally and rarely do patients report a history of choking, aspiration, or a precipitating event. 9 The most common site of impaction is the right lower lobe bronchus because it is larger and more vertically continuous with the trachea. 1,4,10 The FB, however, can be impacted at any subsegment. 4 Most commonly, FB aspiration presents with cough, hemoptysis, fever, or dyspnea. 4,5 Because of the absence or nonspecificity of symptoms, adult airway FB is often misdiagnosed. 5 Diagnosis can be delayed for months to years. 1,10,11 FB aspiration as late as 13 to 25 years after the initial event have been reported. 4,11 Because history and physical signs are often variable and nonspecific, a high index of suspicion for a possible airway FB is needed to avoid the potential morbidity from a delayed diagnosis. FB aspiration complications are shown in Table 1. 11,12TABLE 1: Sequelae of foreign body aspiration 11,57In the 1980s, aspiration of FB was associated with high morbidity and mortality. With the development of the bronchoscope, this decreased substantially. In 1897, Gustav Killan 13 removed the first airway FB using a rigid bronchoscope. In 1936, Chevalier Jackson 14 reported successful removal of FBs in 98% of patients and a decrease in mortality from 24% to 2% with his new bronchoscopic system. With technique refinement and better optical and grasping equipment, the success rate of FB removal by the rigid bronchoscope continues to improve. 15,16 In 2000, Hsu et al. 2 reported successful removal in 99% of 459 patients with a complication rate of only 0.2% and a mortality rate of less than 0.1%. In 1968, Shigeto Ikeda developed the flexible bronchoscope, which advanced the care of patients. The flexible fiberoptic system allowed bronchoscopy to be performed under local anesthesia and with better visualization of the distal airways. Initial hesitation about its safety and use were understandably raised 17; however, with development of expertise and experience, the flexible bronchoscope has supplanted almost completely the rigid bronchoscope. 18 Now, 99% of all bronchoscopic procedures in the United States are performed with the flexible bronchoscope. 18 In the evaluation of an FB, a radiograph is helpful, but flexible bronchoscopy is the gold standard for the identification and localization of an airway FB. When an FB is identified, removal of the visualized FB can be attempted. This will spare the patient the added cost, risk, and inconvenience of having to undergo a second procedure (i.e., rigid bronchoscopy with general anesthesia. Initial reports on the use of the flexible bronchoscope to remove airway FBs appeared in the 1970s. 19–23 In animal studies, Zavala and Rhodes 24,25 showed that various endobronchial FBs (e.g., screw, safety pin, paper clip, coins, chicken vertebra, peanut, etc.) can be removed easily with the use of newly designed grasping forceps and wire baskets for the flexible bronchoscope. Since then, several case reports have described successful removal of FBs by flexible bronchoscopy. A wide range of airway FBs removed by the flexible bronchoscope has been reported. This includes teeth, windscreen glass, ear plugs, pins, nails, fish bones, peanuts, and coins. 26–31 Increased experience and development of better accessories has advanced the acceptance of the flexible bronchoscope as the preferred initial instrument for both the diagnosis and removal of airway FBs in adults. 5,32,33 Table 24,5,10,34–37 provides a list of all major series of FB removal with a flexible bronchoscope. The flexible bronchoscope removed successfully 86% of 426 airway FBs. We have removed FBs with a flexible bronchoscope, with a success rate of 100% (30 of 30; unpublished data). Despite these reported successes, objections regarding the use of the flexible bronchoscope have not ceased. 38 In our opinion, these concerns are trivial and can be surmounted easily by a skilled operator.TABLE 2: Case series of airway foreign bodies managed by flexible bronchoscopyOur discussion on the removal of airway FBs is divided into four parts: (1) general bronchoscopic guidelines, (2) accessories for the flexible bronchoscope, (3) airway control and anesthesia, and (4) removal techniques. GENERAL BRONCHOSCOPIC GUIDELINES To be successful in the removal of airway FBs, we suggest that one follow the seven cardinal rules of bronchoscopy. These are general guidelines to which we adhere in all our bronchoscopic procedures: Rule 1. Complications occur when a bronchoscopy is performed for unclear reasons or for the wrong indications. Rule 2. Preparation ensures 50% success. Rule 3. Bronchoscopy is a three-handed procedure. Rule 4. A good bronchoscopist has excellent skills, but to be an excellent bronchoscopist one needs an excellent support staff. Rule 5. Time commitment to patient care is essential. Rule 6. Know your limitations. Rule 7. Each case should be viewed as a teaching or training opportunity. Rule 1 Complications occur when a bronchoscopy is performed for unclear reasons or for the wrong indications. Mistakes beget mistakes. Removal of an FB in children by flexible bronchoscopy under local anesthesia should probably not be performed. 39,40 Under general anesthesia, the flexible bronchoscope has been used to remove FBs in children. 41 However, in these instances, ability to convert to rigid bronchoscopy was possible at a moment's notice. The flexible bronchoscope may be useful as an adjunct and as a supplement to rigid bronchoscopy in the pediatric age group. 42 Rule 2 Preparation ensures 50% success. Adequate preparation cannot be stressed enough. If radiologic films identify an FB (e.g., a coin), a duplicate object can be placed in a lung model at the same site of impaction. Multiple practice sessions with the bronchoscopic team can be performed before the actual removal. This allows one to determine the most appropriate instrument to use. Nevertheless, all bronchoscopic accessories should be ready and tested before the procedure. Rule 3 Bronchoscopy is a three-handed procedure. For the best results, an extra pair of hands (i.e., a trained assistant) is needed. The bronchoscopist's only and primary concern is to maneuver the scope to the desired position while directing the assistant on the use of the grasping instrument. It is the assistant's responsibility to insert and to manipulate the grasping instruments. Rule 4 A good bronchoscopist has excellent skills, but an excellent bronchoscopist is surrounded by excellent support and backup. Superior, trained personnel are necessary for a smooth and uneventful procedure. The bronchoscopic team members must have well-defined roles. A nurse may be assigned to take care of sedation and to monitor vital signs, whereas the bronchoscope assistant, trained in the use of all the removal instruments, helps the physician with the procedure. Baharloo et al. 1 reported less time and stress for the participants when the FB removal was performed by the usual team of experienced physicians and nurses. In addition, thoracic surgery and anesthesiology need to be immediately accessible to help with unplanned complications. Rule 5 Time commitment to patient care is essential for a successful bronchoscopic procedure. The physician must be committed to take whatever time is necessary and must not rush in removing the FB. When the FB is visualized, he must study its shape and structure carefully in relation to the surrounding areas before an attempt to extract the FB is made. Review of radiologic films may be necessary during the procedure to determine the position of the unseen portion of the FB. In the event that an FB is enclosed within vigorous, bleeding granulation tissue, extraction may be difficult. Some authors suggest the use of a short course of steroids before attempted removal. 7,43 In most cases, a nonasphyxiating FB in an adult is rarely an emergency. However, the likelihood and extent of normal tissue reaction increases the longer an FB remains in the airway. 8,44,45 Wiseman 8 noted the presence of erythema, edema, granulation tissue, and purulent secretions in 36% of 85 patients presenting more than 24 hours after the aspiration, whereas there was absent or minimal inflammation in 96% of 72 patients who presented less than 24 hours after the aspiration. In the absence of acute respiratory distress, a delay of several hours to ensure an organized coordinated approach to removal is appropriate. Rule 6 Know your limitations. Adult airway FB is rare, and opportunities for acquiring the necessary skill to treat it can be infrequent. Removal of FBs is probably the most challenging flexible bronchoscopic procedure, and this task may need to be delegated to a member of a group or to another institution with the most experience and skill. Complications with FB removal have been shown to be higher in the hands of less experienced physicians. 1 In the same way, the success rate of FB removal via either bronchoscope (rigid vs. flexible) depends largely on the experience and skill of the operator rather than the instrument per se. Rule 7 Each case should be viewed as a teaching opportunity. More experienced and skilled operators need to pass on their skills to their students. By being actively involved in teaching and training other physicians, we are not only engaged in the care of our patients, but we are also ensuring the refinement of the art of bronchoscopy. ACCESSORIES FOR THE FLEXIBLE BRONCHCOSCOPE Because the type of FB aspirated is extremely diverse, one must have several accessories on hand to be successful. Multiple instruments have been made available for use with the flexible bronchoscope. The instrument of choice is dependent on the type of FB. Grasping Forceps Several forceps types are available for retrieval of an FB. Available grasping forceps include the w-shaped, alligator jaws, rat-tooth, shark-tooth, and covered-tips forceps (Fig. 1). The forceps selected should be able to expand sufficiently to enclose the full diameter of the FB. In cases in which a firm grip is needed to prevent a hard FB from slipping, then the alligator jaws, rat-tooth, or shark-tooth forceps are recommended. For more delicate manipulations, w-shaped or covered-tips forceps may be used. In general, grasping forceps are used only for the removal of flat or thin inorganic FBs (e.g., coins, pins, screw, clips, etc.) or hard organic FBs (e.g., bone), because attempted removal of friable organic FBs will cause the FB to fracture.FIG. 1.: (A–F) A variety of flexible forceps for foreign body removal.Figure 1: ContinuedFigure 1: ContinuedFigure 1: ContinuedFigure 1: ContinuedFigure 1: ContinuedBalloon Catheters Fogarty balloon catheters are the most useful tool in the removal of FBs. A size 4 to 7 catheter can be passed easily through the working channel of the bronchoscope. Inflation of the balloon to the desired size is achieved with the injection of 1 to 3 mL of air. Use of the balloon catheter is discussed later. Basket Modified versions of the Dormia basket of air, used by gastroenterologists and urologists to retrieve calculi from the common bile duct and bladder, are also available for the bronchoscope. The wings of the basket are normally retracted within a 1.6-mm-diameter Teflon catheter. By maneuvering the proximal ends, these wings can be made to surround the FB and to ensnare the object. Fish-net Basket The Fish-net is a meshlike basket variation of a polypectomy snare. The thin net can be retracted easily within the catheter. The Fish-net basket is released to surround the FB. By slowly retracting the snare, the FB is enclosed within the Fish-net. The basket, bronchoscope, and the captured FB are then removed as a unit. This basket is especially helpful in removing large and bulky objects (Fig. 2).FIG. 2.: (A) Fish-net basket. (B) A large foreign body in the trachea. (C) Fish-net securing the object.Figure 2: ContinuedFigure 2: ContinuedThree-, Four-, or Five-Prong Snares These snares are useful in the removal of large-airway FBs. When the handle of the snare is squeezed, the prongs of the distal end come together to capture the FB. Once secured, the FB, snare, and flexible bronchoscope are withdrawn carefully as a single unit (Fig. 3).FIG. 3.: (A, B) Three and five-pronged snares.Figure 3: ContinuedMagnet Extractor A magnetic cylinder forms the tip of a flexible probe that can be passed through the working channel of the flexible bronchoscope (Fig. 4). This is useful for retrieving small metallic foreign bodies such as broken forceps or cytology brushes. 46,47FIG. 4.: Magnetic extractor.Cryotherapy A liquid cryogen or coolant (usually nitrous oxide, nitrogen, or carbon dioxide) is delivered under pressure to a specially designed cryoprobe that can be passed through the working channel of the bronchoscope. The cryoprobe is applied in direct contact with the FB, and freezing is performed until the point of contact is frozen, causing adherence of the FB to the probe. This technique is particularly useful in the removal of blood clots, mucous balls, friable organic material, and small inorganic FBs (Fig. 5).FIG. 5.: Foreign body removal by cryoadhesion. CP, cryoprobe; FB, foreign body. (Reprinted with permission. Source: Vergnon J, Mathur P. Cryotherapy for endobronchial disorders. In: Bolliger C, Mathur P, eds. Interventional bronchoscopy—progress in respiratory research. Basel: Karger, 2000:133–145.)Nd:YAG Laser The most widely used laser for the treatment of endobronchial tumors is the Nd:YAG laser because it affords deeper penetration, allows better coagulation, and produces better hemostasis of blood vessels. 48,49 Laser photoresection can be performed through a rigid or a flexible bronchoscope. In certain instances, the laser can assist in removing FBs by breaking large FBs (e.g., chicken bones) 50,51 or by vaporizing surrounding granulation tissue. 52 The laser can also be used to dislodge the sharp ends of an FB (e.g., pins, needles, tacks, etc.) embedded in the bronchial mucosa, as well as to blunt the edges to prevent fixation of the FB during removal. AIRWAY CONTROL AND ANESTHESIA The major advantage of the flexible system over the rigid bronchoscope is that it can be performed under local anesthesia, thus avoiding the risks and cost of general anesthesia. With conscious sedation, the airway may not be as secure as it is in general anesthesia. This has been a cause of major concern for physicians who prefer rigid bronchoscopy as the instrument of choice. The criticism of using the flexible bronchoscope is the concern with losing the FB in the narrow subglottic area, causing asphyxiation. In the rare event of this happening (although we are not aware of any published reports), immediate intubation can be performed to secure the airway. Extraction can then proceed through an endotracheal tube. An alternative is to reintroduce the flexible bronchoscope to push the FB into airways that are more peripheral. In most cases, however, there is no need to sedate and control ventilation completely because removal of FBs by flexible bronchoscopy is well tolerated. In addition, conscious sedation does not inhibit the cough reflex, which can facilitate FB removal. With the development of the laryngeal mask airway, flexible bronchoscopy can be performed with reasonable airway control even with deeper sedation. 53 Hemoptysis is a rare complication of FB removal and, admittedly, this is better controlled with a rigid bronchoscope. The rigid bronchoscope allows one to suction, remove the FB, and ventilate at the same time. However, in careful hands, this is extremely rare. Rees 54 described a single case of hemoptysis with FB removal from his review of 2,500 similar cases. There is no reason to favor rigid over flexible bronchoscopy in FB retrieval for fear of massive hemoptysis. 10,33 FOREIGN BODY REMOVAL TECHNIQUE We attempt to remove all airway FBs during the initial bronchoscopic procedure with the patient under local anesthesia and conscious sedation. Premedication with intramuscular meperidine and hydroxyzine is maintained further by using intravenous sedation with morphine sulfate and midazolam as needed. The secret of successful FB removal is to take every care and precaution not to push the foreign body distally into the airways. In general, our procedure has been to use the Fogarty balloon to dislodge the FB and to drag the object, in a retrograde fashion, bringing it proximal to the trachea before attempting removal. 24,33 The Fogarty balloon catheter is positioned just distal to the FB. The balloon is then inflated and the FB is pulled out from the subsegments to the trachea (Fig. 6). Once in the trachea, the FB is then easily amenable to removal via a basket or a forceps. Often, we have also asked the patient to sit up and cough up the FB once it has been brought up to the upper trachea. We use this technique for friable FBs. This has in of our patients. the cryoprobe can be used to secure the FB and its (A, B) Use of a Fogarty catheter in the removal of an endobronchial foreign body. from J, et al. bronchoscopy for foreign body in airway. common is the that the FB is removed through the working channel of the bronchoscope. The FB is removed this The to removing FBs in being able to secure the object by either grasping or it with a forceps or basket. Once the object is all grasping and are removed from the patient as a unit. the every attempt should be made to contact of the FB by it in the of the airway. Bronchoscopy is performed using the approach FB removal is to avoid losing the FB in the narrow In in which an FB is in a the flexible bronchoscope allows removal the rigid system. The flexible bronchoscope is passed through the endotracheal tube. However, with a large FB, the endotracheal may need to be withdrawn in with the bronchoscope and the FB. can then be performed. Removal of a sharp FB is a and needs To remove this type of FB, the is to the sharp Once the sharp end is it can be and Grasping the or the other end of a instrument will the in because it will most be in the a laser can be used to dislodge the sharp end from the to blunt the object to prevent fixation in the airway. We use the flexible bronchoscope as the preferred instrument for both diagnosis and removal of airway FBs in adults. A of a large series of flexible bronchoscopic removal of FBs a success rate of 86% in more than procedures with flexible bronchoscopy. The rigid bronchoscope should be for cases in which the flexible bronchoscope which should be a rare event in trained