Bronchoscopy Clinic: Emerging options for managing foreign-body aspiration

Endobronchial foreign bodies can be life-threatening, but once they are detected, they can usually be removed, leading to prompt resolution of symptoms. Chest radiography and CT scanning can be helpful in some cases, but bronchoscopy is necessary for definitive diagnosis and treatment.

In adults, an attempt can be made during the diagnostic examination to remove the foreign body with the flexible bronchoscope, with the patient under local anesthesia. This may help avoid further invasive procedures. When diagnosis is delayed, complications, such as unresolving pneumonia, lung abscess, recurrent hemoptysis, and bronchiectasis, may occur.

In this article, we will describe 2 cases of tracheobronchial tree foreign-body aspiration that were managed with flexible fiberoptic bronchoscopy.

Case 1

A 62-year-old man presented with a history of cough and chest pain over 1 day. The cough was dry and irritating without expectoration. He complained of nonpleuritic pain in the lower right side of the chest. There was no history of dyspnea or hemoptysis. He reported that while driving earlier in the day, he had swallowed his denture plate.

Physical examination revealed a well-built adult. Respiratory system examination revealed impaired air entry at the right base; no additional sounds were heard. Findings from further systemic examination were normal.

Routine laboratory studies, including hemogram and biochemistry, yielded normal results. A chest radiograph showed a homogeneous opacity with a sharp border in the right middle lobe (Figure 1). On the basis of the history and radiographic findings, a diagnosis of right middle lobe foreign-body aspiration was made.

The patient underwent flexible fiberoptic bronchoscopy, during which the foreign body was visualized in the intermediate bronchus. After several attempts, the foreign body was caught with biopsy forceps and was pulled through the bronchoscope into the patient's mouth and removed (Figure 2).

Case 2

A 55-year-old man presented with worsening right-sided pleuritic chest pain and shortness of breath. The symptoms had developed nearly 1 week previously, when he swallowed a piece of wire mesh at the factory where he worked. He also complained of cough, which over the past 2 days had become productive of purulent sputum.

Workup at presentation demonstrated leukocytosis (18,000 white blood cells/µL). An anteroposterior chest radiograph showed diffuse, hazy opacification of the right lower lobe region. A CT scan of the chest revealed right middle and lower lobe infiltrates and partial atelectasis (Figure 3).

Flexible fiberoptic bronchoscopy was performed, and the foreign body was visualized in the intermediate bronchus (Figure 4). A cryoprobe was passed through the operating channel of the bronchoscope. Once in contact with the foreign body, the cryoprobe was activated until the point of contact was frozen, causing adherence of the foreign body to the cryoprobe. The bronchoscope, along with the cryoprobe and attached foreign body, was pulled from the trachea through the mouth and removed.

Discussion

Foreign-body aspiration causes approximately 500 to 2000 deaths per year in the United States, with about half of these deaths occurring in children younger than 4 years.^1,2 Among children, foreign-body aspiration occurs most frequently in those aged 3 months to 6 years. About 50% of cases occur in children younger than 2 years, and 90% occur in children younger than 4 years.

Items most commonly aspirated by children are balloons, balls, and small objects. Hot dogs and peanuts are commonly aspirated foods.

Foreign-body aspiration is rare in adults who have a normal swallowing reflex. Most cases in adults occur in persons who are in the sixth or seventh decade of life, ages at which airway protective mechanisms are less likely to function adequately. Risk factors for aspiration include neurologic dysfunction, facial trauma, trauma with loss of consciousness, intubation, dental procedures, underlying pulmonary disease, and use of alcohol or sedatives. In adults, foreign bodies may include bone fragments, vegetables, parts of dental prostheses, and broncholiths.

In many cases, the aspiration of a foreign body is followed by cough and wheezing that may persist, usually without respiratory distress. Upper airway involvement may cause complete obstruction at the trachea or larynx. In some patients, upper airway involvement causes only an abnormality of the voice. Complete obstruction of a bronchus causes atelectasis, while partial obstruction may cause local hyperinflation, pneumothorax, or pneumomediastinum. Aspiration of vegetable matter may produce a chronic suppurative pneumonitis.

In a series of 43 adults who had foreign-body aspiration, chronic cough was present in 67%, hemoptysis in 23%, fever in 19%, and dyspnea in 16%; a history of choking was reported in only 7%.³ A history of foreign-body aspiration may not be present in all cases. Therefore, the possibility of this diagnosis should be considered whenever there is sudden onset of choking and intractable cough with or without vomiting.

Overall, the clinical triad considered to be diagnostic of foreign-body aspiration consists of wheezing, coughing, and diminished or absent breath sounds; however, patients may be asymptomatic. Patients without a history of foreign-body aspiration may present with a history of fever, breathlessness, and wheezing or with features of nonresolving pneumonia. Since the signs and symptoms are typically nonspecific, a good clinical history is mandatory for making an accurate diagnosis.

On physical examination, patients may show decreased breath sounds on one side and localized wheezing. Most foreign bodies lodge in the right main or intermediate bronchus or in the right lower lobe bronchus. In the upright person, these sites are direct entry from the trachea. The left main bronchus is smaller than the right main bronchus and is slightly angled. In the supine person, material usually enters the right main bronchus, then falls into the orifice of the right upper lobe. Less common sites for foreign bodies are the left lower lobe bronchus and left main bronchus. Occasionally, the trachea and, in rare instances, the left lower segmental bronchus are the sites of obstruction.

Radiologic assessment starts with anteroposterior and lateral views of the chest and neck. Radiopaque foreign bodies can be visualized on plain radiographs, although at times they are misinterpreted as being a normal part of the chest. Other indirect signs of an airway foreign body include reabsorption atelectasis beyond the site of bronchial obstruction and pulmonary infiltrates reflecting an inflammatory reaction.

A CT scan is helpful in visualizing radiopaque foreign bodies and alveolar collapse. It can also demonstrate airway radiolucent foreign bodies, which cannot be visualized on plain radiographs. CT scans can show a foreign body within the lumen of the tracheobronchial tree and the 3-dimensional position of a foreign body within the thorax⁴; CT can also reveal lobar atelectasisand lobar pneumonia caused by foreign-body aspiration(Figure 3). Prolonged retention of a bronchial foreign body may result in bronchiectasis and mucoid impaction.

When foreign-body aspiration is diagnosed based on radiographic findings or when clinical suspicion is high, the patient should undergo endoscopy for removal of the foreign body. Methods of extracting a foreign body from the tracheobronchial tree include rigid bronchoscopy, laryngoscopy,⁵ flexible bronchoscopy, and thoracotomy.

In children with foreign-body aspiration, rigid bronchoscopy offers good visualization through the use of ventilation bronchoscopes. This technique is preferred for the removal of a tracheobronchial foreign body,⁶ mainly because the rigid instrument provides a better view of the foreign body and it allows for the use of a much wider range of type and size of forceps. This is especially true in children, in whom adequate control of the airway is difficult to achieve when a flexible fiberoptic bronchoscope is used.

Flexible fiberoptic bronchoscopy has been reported to be successful in removing most foreign bodies in adults.⁷ Because this procedure is easier to perform than rigid bronchoscopy and can be done under local anesthesia, it is preferred by most bronchoscopists.⁷ Flexible fiberoptic bronchoscopy has been shown to be more useful when the foreign body is more peripherally located.⁸ During flexible fiberoptic bronchoscopy, fluoroscopy can also be used to help locate distal foreign bodies⁹; the instruments shown to be most useful for removal are alligator forceps and the wire basket.¹⁰

Occasionally, interventional radiologists perform endobronchial foreign-body extraction, largely via a Fogarty balloon catheter. In these cases, the foreign body is first located by a flexible fiberoptic bronchoscope. Next, the Fogarty catheter is deployed through the instrument channel of the bronchoscope, then moved beyond the foreign body. The balloon tip is inflated and pulled proximally against the object until it is wedged against the bronchoscope. Then the bronchoscope, foreign body, and Fogarty balloon catheter are withdrawn as a unit.¹¹

Flexible fiberoptic bronchoscopy can also be used in patients who are already intubated at the time of initial presentation. In this setting, it is best to avoid positive pressure ventilation, because it could cause more distal impaction of the foreign body, resulting in an exacerbation of air trapping distal to the foreign body.

Another method for removing foreign bodies is cryotherapy (as was done in Case 2). Cryotherapy is usually used to cause coagulation necrosis of tissue and destruction of a tumor by repeated cycles of cold application followed by thawing. However, it can also be used for removal of granulation tissue, blood clots, mucous plugs, or foreign bodies.¹²

During cryotherapy, the cryoprobe is cooled by the Joule-Thomson effect. When nitrous oxide or liquid nitrogen is fed under pressure into the hollow cryoprobe, the gas rapidly expands, absorbing heat in the process. This has the effect of reducing the temperature of the probe of nitrous oxide-based units to between 265°C (285°F) and 285°C (2121°F). The cryoprobe then acts as a heat sink by removing heat from the adjacent region, which causes cryoadherence.

Cryoprobes can be used in both rigid and flexible bronchoscopes.¹³ When the flexible bronchoscope is used, the cryoprobe is passed through its operating channel. It then attaches to the foreign body by cryoadherence, after which the cryoprobe, bronchoscope, and foreign body are removed as a unit. If the nature of the foreign body is known, an identical foreign body can be used to practice the technique of retrieval in vitro. We were able to do this in Case 2, because the patient provided us with an identical piece of wire mesh.

After a foreign body is removed using flexible fiberoptic bronchoscopy, a "second look" should be undertaken; this allows for the identification of additional foreign bodies, complications of foreign-body aspiration, and iatrogenic injuries. Postoperatively, most patients should be observed overnight, if possible, for airway distress. One should consider an antibiotic regimen for any patients with fever, preoperative pneumonia, or vegetable matter aspiration.

When the foreign body has been in the patient for more than 2 to 3 weeks, surrounding fibrosis or impaction may have occurred. In this situation, the foreign body cannot be removed by bronchoscopy; a thoracotomy may be required.⁶ Complications of either foreign-body aspiration or its surgical treatment include airway edema and respiratory distress, postobstructive pneumonia, postobstructive hypoxemia, bronchiectasis, hemoptysis, airway perforation, airway stenosis, development of an inflammatory polyp at the site of lodgment or scarring, and a retained foreign body.

When used to diagnose foreign-body aspiration and to remove foreign bodies in adults, flexible fiberoptic bronchoscopy is a generally safe procedure that avoids the unnecessary use of general anesthesia and reduces hospital costs. Despite the advances in optical technology, experience and proper training are crucial to optimizing the outcome and minimizing the risk of complications.

References:

REFERENCES

1. Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults.

Ann Intern Med.

1990; 112:604-609.
2. Sanford CC. Aspirated foreign bodies in children.

Am Fam Physician.

1979;20:104-108.
3. Chen CH, Lai CL, Tsai TT, et al. Foreign body aspiration into the lower airway in Chinese adults.

Chest.

1997;112:129-133.
4. Zissin R, Shapiro-Feinberg M, Rozenman J, et al. CT findings of the chest in adults with aspirated foreign bodies.

Eur Radiol.

2001;11: 606-611.
5. Umapathy N, Panesar J, Whitehead BF, Taylor JF. Removal of a foreign body from the bronchial tree--a new method.

J Laryngol Otol.

1999;113:851-853.
6. Baharloo F, Veyckemans F, Francis C, et al. Tracheobronchial foreign bodies: presentation and management in children and adults.

Chest.

1999;115:1357-1362.
7. Cunanan OS. The flexible fiberoptic bronchoscope in foreign body removal. Experience in 300 cases.

Chest.

1978;73(5 suppl):725-726.
8. Zavala DC, Rhodes ML. Foreign body removal: a new role for the fiberoptic bronchoscope.

Ann Otol Rhinol Laryngol.

1975;84(5 pt 1):650-656.
9. Nalaboff KM, Solis JL, Simon D. Endobronchial foreign body extraction: a new interventional approach.

Chest.

2001;120:1402-1405.
10. Debeljak A, Sorli J, Music E, Kecelj P. Bronchoscopic removal of foreign bodies in adults: experience with 62 patients from 1974-1998.

Eur Respir J.

1999;14:792-795.
11. Kosloske AM. The Fogarty balloon technique for the removal of foreign bodies from the tracheobronchial tree.

Surg Gynecol Obstet.

1982;155:72-73.
12. Mathur PN, Wolf KM, Busk MF, et al. Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction.

Chest.

1996;110:718-723.
13. Maiwand MO, Homasson JP. Cryotherapy for tracheobronchial disorders.

Clin Chest Med.

1995;16:427-443.