Distal airway foreign bodies: Importance of a stepwise approach, knowledge of equipment and utilization of other services' expertise

Organic vs. Inorganic Tracheobronchial Airway Foreign Body Aspiration: Does Type/Duration Matter?

OBJECTIVE

We sought to determine the time course of clinical and histologic differences between aspirated inorganic and organic foreign bodies.

STUDY DESIGN

In-vivo.

METHODS

Twenty Sinclair miniature swine (Sus scrofa domesticus) were divided into two groups-inorganic or organic foreign bodies. Either an organic (peanut) or an inorganic (Lego) foreign body was placed within a bronchus and left for 3, 5, 7, 14 or 21 days. The airway was reassessed at the predetermined endpoint at which time endoscopic, gross, and histopathological findings were documented. Specimens were scored with a pathologic scoring system to assess injury severity from the foreign body.

RESULTS

Foreign bodies were successfully placed in all 20 swine. Two animals required early euthanasia due to respiratory compromise. The foreign body was identified grossly in eight (40%) animals. An additional three (15%) had microscopic evidence suggestive of a previous foreign body of an undetermined duration. There was no difference in injury severity between organic and inorganic foreign bodies. The 3-day group had injuries limited to the bronchial lining, whereas the longer duration groups had bronchial and adjacent lung parenchymal involvement. There was no difference in injury severity between days 5 and 21.

CONCLUSIONS

Airway foreign bodies initially cause bronchial damage. After 5 days, the foreign body causes lung parenchymal changes. There was no difference in airway lesion severity between organic and inorganic foreign bodies.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:490-495, 2021.

Foreign body aspiration in adult airways: therapeutic approach

Tracheobronchial foreign body (FB) aspiration is an uncommon but potentially life-threatening event in adults. Symptoms typically consist of a choking event followed by cough and dyspnea, however, these findings are inconsistent and symptoms may mimic more chronic lung diseases such as asthma or chronic obstructive pulmonary disease. Chest radiography and computed tomography can provide information regarding the location and characteristics of foreign bodies and aid in diagnosis. Bronchoscopy remains the gold standard for diagnosis and management of FB aspiration. The authors describe the typical clinical presentation, diagnostic evaluation, and bronchoscopic management of foreign bodies in adult airways with a focus on bronchoscopic techniques and potential complications of FB extraction.

Effects of different bronchoalveolar lavage methods on tracheobronchial foreign body patients

OBJECTIVES/HYPOTHESIS

To compare the different effects of bronchoalveolar lavage (BAL) with diverse combinations of lidocaine, epinephrine, and dexamethasone on pediatric patients with an inhaled tracheobronchial foreign body (TFB).

STUDY DESIGN

Randomized controlled study.

METHODS

Two hundred forty cases of pediatric patients with inhaled TFB were included in this study, and were randomly divided into four groups using three kinds of drugs for BAL, namely 0.9% saline (S) group, 2% lidocaine with diluted epinephrine (LE) group, 2% lidocaine with diluted epinephrine and 0.5% dexamethasone (LED), control group (C) without BAL. The incidences of intraoperative or postoperative complications and recovery periods were compared. Meanwhile, the concentrations of interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α in BAL fluids and plasma were evaluated by enzyme-linked immunosorbent assay.

RESULTS

The incidences of bronchospasm, hypoxemia, and postoperative fever were significantly lower in the LED group than other groups (P < .001). Fever after the TFB removal procedure appeared later in the LED group than the other groups. The improvement and healing periods in the LE and LED groups were significantly shorter than those in the C and S groups (P < .001). The concentrations of IL-1β, IL-6, and TNF-α in BAL fluids were significantly higher in the LE and LED groups than those in the S group (P < .001), but those in the plasma of the C and S groups were lower compared with the LE and LED groups (P < .001).

CONCLUSIONS

BAL with lidocaine, epinephrine, and dexamethasone could promote recovery for TFB patients and reduce incidences of complications, possibly by regulating release of proinflammatory cytokines.

LEVEL OF EVIDENCE

1b.

Retrieval of endobronchial foreign bodies in children: involving the cardiac catheterization lab

Endobronchial foreign body impaction is a common occurrence, especially in the pediatric population. Bronchoscopic techniques are the standard of care for their retrieval. However, the most distally located foreign bodies are often difficult to retrieve using these techniques. A novel approach using biplane fluoroscopy, with tools usually used for intravascular foreign body retrieval, has been recently described in adults by interventional radiologists. We are the first to report 2 cases in children using this approach for distally impacted endobronchial foreign body retrieval in the cardiac catheterization laboratory. We used a collaborative approach, using flexible bronchoscopy and fluoroscopically guided catheters to reach the foreign body. The first case involved a 16-year-old girl who presented with a 4-day history of aspiration of a staple pin, which we successfully retrieved. The second case involved a 10-year-old boy who presented with a 2-month history of aspiration of the plastic eraser cap of a mechanical pencil. We were successful in reaching the distal lobule where it was lodged. However, we were unable to grasp the foreign body because of the presence of a chronic inflammatory exudate around it owing to the subacute to chronic presentation. There were no complications in either case. Thus, a collaboration of the pulmonology and interventional cardiology teams in the cardiac catheterization laboratory represents a safe and effective alternative to bronchoscopy in the management of distally placed endobronchial foreign bodies in children. Early recognition and intervention is imperative for the successful retrieval of an endobronchial foreign body.

The proximal bronchoplasty retrieval technique for removal of embedded distal airway foreign bodies

OBJECTIVES

To describe a novel technique for removal of embedded distal airway foreign bodies with emphasis on procedural steps and management.

METHODS

The proximal bronchoplasty retrieval (PBR) technique is described including indications, rationale, surgical technique, and clinical decision making. Two representative cases are described in detail in order to demonstrate the technique.

RESULTS

The PBR technique was successfully used to remove the two described embedded distal airway foreign bodies after other attempts had failed.

CONCLUSION

Airway foreign bodies which have been present for several days or weeks are associated with edema and granulation tissue which often embeds the foreign body and may prevent removal due to proximal airway narrowing. We present a novel technique using endoscopic balloon dilation bronchoplasty to enlarge the airway proximal to the foreign body and enable removal with two example cases presented herein. The PBR technique allowed for removal of otherwise "stuck" distal airway foreign bodies.