The role of flexible bronchoscopy accomplished through a laryngeal mask airway in the treatment of tracheobronchial foreign bodies in children

I-gel® as airways management in a challenging adult tracheobronchial foreign body aspiration

Tracheobronchial foreign body (TFB) aspiration is an uncommon but potentially life-threatening event. This case report discusses the successful extraction of a metallic screw aspirated by a 48-year-old woman with intellectual disability, using flexible bronchoscopy through the i-gel® laryngeal mask under general anesthesia. The i-gel® device proved effective in maintaining airway access and facilitating bronchoscopy, emphasizing its utility in challenging cases. The report underscores the significance of careful assessment, skillful intervention, and multidisciplinary teamwork in managing TFB aspirations, especially in uncooperative patients with comorbidities.

Flexible bronchoscopy for foreign body aspiration in children: A single-centre experience

BACKGROUND

The technological evolution of bronchoscopy has led to the widespread adoption of flexible techniques and their use for both diagnostic and therapeutic purposes. Currently, there is an active debate regarding the comparative efficacy and safety of rigid vs flexible bronchoscopy in the treatment of foreign body aspiration.

AIM

To evaluate our experience with tracheobronchial foreign body extraction using flexible bronchoscopy and provide a literature overview.

METHODS

This was a single-centre retrospective study. Twenty-four patients were enrolled between January 2017 and January 2023. Medical records of patients aged below 18 years who were admitted to authors' affiliated institution with a suspected diagnosis of foreign body aspiration were collected from hospital's database to Microsoft Excel 2019. Data were analysed using MedCalc Statistical Software.

RESULTS

Patient ages varied from 9 months to 11 years. The median age was 23.5 months, 95% confidence interval (CI) 19.49-44.77. We observed age clustering in children with foreign body aspiration at our institution with three age subgroups: (1) 0-25 months; (2) 40-60 months; and (3) 120-140 months. We expectancy of an organic tracheobronchial foreign body was significantly higher in 0-25 months subgroup than that in older ones when subgroups 40-60 and 120-140 months were combined together (odds ratio = 10.0, 95%CI: 1.44-29.26, P = 0.0197). Successful foreign body extraction was performed in all cases. Conversion to a rigid bronchoscope was not required in any of the cases. No major complications (massive bleeding, tracheobronchial tree perforation, or asphyxia) were observed.

CONCLUSION

Flexible bronchoscopy is an effective and safe method for tracheobronchial foreign body extraction in children.

Comparison of rigid bronchoscopy and flexible bronchoscopy for the management of foreign body aspiration in children

OBJECTIVE

To compare clinical outcomes of flexible and rigid bronchoscopies for the management of foreign body aspiration (FBA) in different airway locations, especially in unilateral main bronchus, in children, so as to provide some suggestions to assist clinical decisions.

METHODS

The medical records of children diagnosed with FBA in Qingdao Women and Children's Hospital Affiliated to Qingdao University from January 2020 to June 2022 were retrospectively reviewed. The following information was collected: demographics, radiological findings, endoscopic findings, foreign body locations, duration of operation, operation cost, and intraoperative and postoperative complications.

RESULTS

182 children were included in the study with the median age of 1.3 years (interquatile range, 1.0-1.8). Among whom, 124 cases (68.1 %) were male and 58 cases (31.9 %) were female. 11 cases (6.0 %) had the foreign bodies located in the trachea (larynx to carina), 3 cases (1.6 %) located in the trachea and lower bronchus, 1 case (0.5 %) located in bilateral main bronchus, 135 cases (74.2 %) located in unilateral main bronchus, 4 cases (2.2 %) located in main and lobar bronchus, and 28 cases (15.4 %) located in the lobar or segmental bronchus. Among all the included children, 84 cases (46.2 %) received rigid bronchoscopy (RB) and 98 cases (53.8 %) received flexible bronchoscopy (FB). 131 cases with the foreign bodies located in unilateral main bronchus received one type of bronchoscopy (RB or FB). They were divided into two groups according to the location of foreign body relative to the midpoint of main bronchus, the proximal bronchus group and the distal bronchus group. In the proximal bronchus group, duration of operation using RB and FB was 15 (12.5-27.5) min and 15 (14.5-30.0) min, respectively (Z = 0.000, P = 1.000). The intraoperative and postoperative complication rate using RB and FB was 15.4 % and 9.1 %, respectively (χ2 = 0.008, P = 0.927). Operation cost of FB was significantly higher than that of RB (t = -13.396, P = 0.000). In the distal bronchus group, duration of operation using RB was 20 (13.5-25.0) min, which was drastically shorter than that of FB (25 (20.0-35.0) min) (Z = -2.947, P=0.003). Operation cost of FB was still found to be significantly higher than RB (t = -20.456, P=0.000). No significant difference was found in complication rate of RB (14.3%) compared to FB (8.3%) (χ2=0.251, P=0.616).

CONCLUSIONS

When foreign bodies are lodged in unilateral main bronchus, RB could be chosen as the first-choice procedure with advantages in duration of operation and operation cost, especially for patients in China. Regardless of duration of operation and operation cost, FB is also a safe and efficient therapeutic procedure to remove inhaled foreign bodies in children, except for those located in the trachea and asphyxiating foreign bodies.

The Transition of Pediatric Tracheobronchial Foreign Body Cases in the Past 36 Years: A Retrospective Single-Center Study in Japan

Tracheobronchial foreign bodies (TFBs) are pediatric airway emergencies frequently seen. We aimed to examine the changes in the clinical characteristics of pediatric TFB patients in a single institution within the past 36 years. We retrospectively reviewed the data of 85 patients aged 0-10 years with TFBs lodged in the trachea or bronchus admitted at the Department of Otolaryngology-Head and Neck Surgery at Tohoku University Hospital between 1986 and 2021. We also compared the characteristics, diagnostic methods, and treatments of the previous 64 cases (1986-2005) with those of the recent 21 cases (2006-2021). The number of TFB patients decreased later in this study (3.2 vs. 1.3 patients per year). The proportion of TFB patients aged > 3 years was significantly higher in the later period (6.3% vs. 23.8%, p = 0.038). Peanut was the most common cause of TFBs in both periods, and the overall incidence of peanut aspiration significantly decreased in the later period (68.8% vs. 38.1%, p = 0.019). No patient had an undetected TFB for more than 1 month after the onset of symptoms in the later period. Foreign body extraction using rigid bronchoscopy was performed in all patients earlier, whereas flexible bronchoscopy was used in 14.3% later. Our study revealed a recent trend in the clinical characteristics of pediatric TFB patients in a single institution in Northeast Japan. The prevention and treatment of pediatric TFBs should be considered following the recent trends.

Foreign body aspiration in children - being safe and flexible

PURPOSE OF REVIEW

Anesthesia for foreign body removal in children can be quite challenging. Even though rigid bronchoscopy is considered the gold standard for foreign body removal, there is increasing evidence for successful foreign body removal using flexible bronchoscopy. This review discusses the recent implications for flexible bronchoscopy for the purpose of foreign body removal and will compare these findings to rigid bronchoscopy.

RECENT FINDINGS

During the last few years, several observational studies on foreign body removal by flexible bronchoscopy have been published, with promising results.

SUMMARY

Flexible bronchoscopy is a feasible and safe method for removing aspirated foreign bodies in children. In order to improve patient safety during the procedure, it is necessary for a pediatric anesthetist and a pediatric pulmonologist to work closely together. The anesthetist can take care of the administration of the anesthetic and maintenance of the vital functions, and the pulmonologist can carry out a safe and fast bronchoscopy. In the case of foreign body removal by flexible bronchoscopy, the anesthesiological procedure of choice should be general anesthesia with controlled ventilation via a laryngeal mask.

A combination of supraglottic airway and bronchial blocker for one-lung ventilation in infants undergoing thoracoscopic surgery

Objectives

One-lung ventilation (OLV) for children under the age of two years is difficult. The authors hypothesize that a combination of a supraglottic airway (SGA) device and intraluminal placement of a bronchial blocker (BB) may provide an appropriate choice.

Design

A prospective method-comparison study.

Setting

Second Affiliated Hospital of Xi'an Jiaotong University, China.

Participants

120 patients under the age of two years undergoing thoracoscopic surgery with OLV.

Interventions

Participants were randomly assigned to receive intraluminal placement of BB with SGA (n = 60) or extraluminal placement of BB with endotracheal tube (ETT) (n = 60) for OLV.

Measurements and main results

The primary outcome was the length of postoperative hospitalization stay. The secondary outcomes were the basic parameters of OLV and investigator-defined severe adverse events. The postoperative hospitalization stay was 6 days (interquartile range, IQR 4-9) in SGA plus BB group compared with 9 days (IQR 6-13) in ETT plus BB group (P = 0.034). The placement and positioning duration of SGA plus BB was 64 s (IQR 51-75) compared with 132 s (IQR 117-152) of ETT plus BB (P = 0.001). The values of leukocyte (WBC) and C-reactive protein (CRP) of SGA plus BB group on the first day of post-operation were 9.8 × 10⁹/L (IQR 7.4-14.5) and 15.1 mg/L (IQR 12.5-17.3) compared with 13.6 × 10⁹/L (IQR 10.8-17.1) and 19.6 mg/L (IQR 15.0-23.5) of ETT plus BB group (P = 0.022 and P = 0.014).

Conclusion

There were few if any significant adverse events in the intervention group (SGA plus BB) for OLV in children under the age of two years, and this method seems worthy of clinical application. Meanwhile, the mechanism for this novel technique to shorten the length of postoperative hospitalization stay needs to be further explored.

Risk factors associated with reintubations in children undergoing foreign body removal using flexible bronchoscopy: a single-center retrospective cross-sectional study

Background

Reintubation is a severe complication during foreign body (FB) removal that uses flexible bronchoscopy.

Objective

To investigate the incidence and risk factors for reintubations in children undergoing FB extraction by flexible bronchoscopy in a single center.

Design

A retrospective cross-sectional study.

Setting

All children with foreign body aspiration at Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University from January 2015 to December 2020.

Patients

Children with FB removal using a flexible bronchoscopy were enrolled in the trial according to the inclusion criteria.

Measurements

Both multivariable and logistic regression analyses were used to analyze the association between characteristic data and reintubations. The results were presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

In total, 244 patients met with the inclusion criteria and were included in the analysis. Among those participants, 28 children (11.5%) underwent reintubations after FB removal by flexible bronchoscopy. Independent factors associated with reintubations were identified as operative time ≥ 60 min [OR: 3.68, 95% CI (1.64–8.82)] and ASA ≥ III [OR: 5.7, 95% CI (1.23–26.4)].

Conclusions

Children undergoing FB removal by a flexible bronchoscopy may encounter with a high incidence of postoperative reintubations. Both long operative duration and a severe physical status cause a growing risk of reintubations.

A systematic review of using flexible bronchoscopy to remove foreign bodies from paediatric patients

AIM

Our aim was to summarise the evidence about flexible bronchoscopy for paediatric airway foreign body aspiration cases.

METHODS

We searched the PubMed database from 1 January 2001 to 9 October 2021 for peer-review papers published in English on the use, and success rates, of flexible bronchoscopy as the first-line treatment for foreign body aspiration cases. This process identified 243 potential papers.

RESULTS

We studied 23 papers comprising 2588 cases of foreign body aspiration and flexible bronchoscopy successfully removed the foreign bodies in 87.1% of cases. Complication rates were low in the 983 patients studied in 18 papers. The foreign bodies were organic materials in 78.3% of 1371 patients and mainly lodged in the right bronchial tree in 50.5% of 1402 patients. General anaesthesia was used before flexible bronchoscopy in 14/23 studies and laryngeal mask airways were mostly used in 10/23 studies to secure the airway during the procedure. Ancillary equipment was used to assist the foreign body removal in 57.3% of 1808 cases and these were usually baskets.

CONCLUSION

Flexible bronchoscopy was a feasible and safe therapeutic procedure for selected foreign body aspiration cases. Future studies need to focus on comparing the clinical outcomes of flexible and rigid bronchoscopies.

Delayed diagnosis of foreign body aspiration in children

AIMS

To assess the diagnostic and therapeutic difficulties as well as the long-term complications of prolonged endobronchial foreign body retention.

METHOD

Between January 2000 and May 2021, 794 patients with suspected foreign body aspiration (FBA) were hospitalized in our department. A total of 12 patients with a delayed diagnosis of over 1 month were included. FBAs were confirmed by flexible or rigid endoscopy. A retrospective analysis of medical records was performed.

RESULTS

Six male patients and six female patients were hospitalized due to prolonged FBA. The average age was 6.90 years (range: 1-13 years). The average duration of the foreign body retention was 2.60 years (2 months to 9 years). A choking event was found in eight cases. Coughing and wheezing were the main symptoms and signs. A misdiagnosis of asthma was made for five patients. Two atypical clinical presentations led to diagnosis of endobronchial foreign body, unilateral pleurisy, and hemoptysis. We report one case of an occult foreign body externalized spontaneously through a pneumo-pleuro-cutaneous fistula. The most common clinical and radiological findings were of pneumonia and atelectasis. Computed tomography showed localized bronchiectasis in three patients. FBAs were removed with a rigid bronchoscope in eight cases. Other extractions were carried out with a flexible endoscope. The foreign bodies were most frequently of vegetable origin, such as seeds and peanuts. A granulation tissue was observed in seven cases. Bronchial stenosis and bronchiectasis are the most common late complications. Only one patient needed a surgical intervention.

CONCLUSIONS

FBA should always be considered in the differential diagnosis of chronic or recurrent respiratory diseases, even in the absence of a previous choking event. Clinical and radiological findings should be carefully evaluated for a possible FBA. Delay in diagnosis and treatment of FBA should be avoided in order to prevent complications. Open surgery may be required when lung abscess has occurred.

Adult with mass burnt lime aspiration: A case report and literature review

BACKGROUND

Foreign body aspiration mainly occurs in children, which can cause a severe concurrent syndrome and even death without timely treatment. As a rare foreign body, aspiration of lime is seldom reported, and most cases involve a small amount of hydrated lime. Although the symptoms are usually severe, the prognosis is good after suitable treatment. Experience of treatment for lime aspiration is lacking, and this report provides novel evidence for treatment of mass burnt lime aspiration using bronchoscopy.

CASE SUMMARY

We report an adult with a large amount of burnt lime aspiration. Because of delay in clearance of the inhaled lime in the trachea and bronchus at the local hospital, he suffered several severe complications, including complete occlusion of the right primary bronchus, aeropleura, aerodermectasia, pneumomediastinum, secondary infection and hypoxemia at 4 d after injury. After transferring to our department, bronchoscopy was immediately carried out to clear the lime in the major airway, using foreign body forceps, biopsy forceps, puncture needle, and hairbrush. The patient’s condition recovered rapidly and at 3-months’ follow-up, he demonstrated good recovery of the bronchus and lung parenchyma.

CONCLUSION

After mass lime aspiration, flexible fiberoptic bronchoscopy is suggested as early as possible, using clamping, flushing or cryotherapy.

From rigid to flexible bronchoscopy: a tertiary center experience in removal of inhaled foreign bodies in children

Rigid bronchoscopy is the procedure of choice for removal of inhaled foreign bodies. In this retrospective study, we assessed the safety and efficacy of flexible bronchoscopy use in the removal of inhaled foreign bodies in children. One hundred eighty-two patients (median age of 24 months, 58% males) underwent an interventional bronchoscopy for the removal of inhaled foreign body between 2009 and 2019, 40 (22%) by flexible, and 142 (78%) by rigid bronchoscopy. 88.73% of rigid and 95% of flexible bronchoscopies were successful in foreign bodies removal (p value = 0.24). Complication rate was higher among rigid bronchoscopy (9.2% vs. 0%, p = 0.047). From 2017 onwards, following the implementation of flexible bronchoscopy for foreign bodies removal, 64 procedures were performed, 33 (51.6%) flexible, and 31 (48.4%) rigid. Procedure length was shorter via flexible bronchoscopy (42 vs 58 min, p = 0.016). Length of hospital stay was similar.Conclusion: In our hands, flexible bronchoscopy is an efficient and safe method for removal of inhaled foreign bodies in children, with shorter procedure time and minimal complication rate. Flexible bronchoscopy could be considered as the procedure of choice for removal of inhaled foreign bodies in children, by an experienced multidisciplinary team. What is Known: • Rigid bronchoscopy is currently the gold standard for removal of inhaled foreign bodies in children. • Rigid bronchoscopy has a relatively high complication rate compared to flexible bronchoscopy. What is New: • Flexible bronchoscopy is a short, safe, and efficient procedure to remove inhaled foreign bodies in children, compared to rigid bronchoscopy. • Flexible bronchoscopy could be proposed as the procedure of choice for removal of inhaled foreign bodies in children, if an experienced operator is available.

Comparative Effects of Dexmedetomidine and Midazolam on Dreaming of Patients Undergoing Flexible Bronchoscopy During General Anesthesia

Background

The aim of this study was to compare the effects of dexmedetomidine versus midazolam on the dreaming of patients undergoing flexible bronchoscopy during general anesthesia.

Material/Methods

Patients undergoing flexible bronchoscopy under general anesthesia were randomly divided into a dexmedetomidine group (Group D, n=40) and a midazolam group (Group M, n=40). In group D, patients received 0.5 μg/kg dexmedetomidine and in group M patients received 0.05 mg/kg midazolam intravenously 10 min prior to induction. After bronchoscopy and recovery, a modified Brice questionnaire was used to immediately evaluate the incidence of dreaming of patients. Dreamers were required to complete a 5-point Likert scale survey regarding the contents of their dreams (emotion, voice and movement, memorability) if dreaming was reported. Ramsay Sedation Scale score (Ramsay score) and Visual Analogue Scale (VAS) score were assessed and recorded.

Results

Patients in group D had higher Ramsay scores and VAS scores (2.9±0.6 and 79.4±4.0, respectively) than group M (2.4±0.7 and 75.0±6.0, respectively), with a statistically significant difference (P<0.05) between groups. The incidence and memorability of dreaming were significantly lower in group D (17.5%) than group M (37.5%, P<0.05), whereas no significant difference was found in emotion, voice, and movement scores of dreaming.

Conclusions

Compared to midazolam, pre-injection of dexmedetomidine before induction significantly decreased the incidence of dreaming in patients undergoing flexible bronchoscopy during general anesthesia, without producing undesirable effects on the content of dreams (most of them were pleasant), produces a more efficacious sedation effect during the recovery period and improves the comfort level and satisfaction of patients.

Observation of the clinical efficacy of dexmedetomidine in flexible bronchoscopy under general anesthesia: clinical case experience exchange

Object

To investigate the clinical efficacy and safety of dexmedetomidine in flexible bronchoscopy under general anesthesia.

Methods

A total of 114 patients were randomly divided into intervention group A and control group B. Group A received dexmedetomidine, fentanyl, and propofol as anesthesia, while Group B received fentanyl and propofol only. Changes in heart rate, mean arterial pressure, pulse oxygen saturation, stress indices (blood cortisol, adrenaline, and norepinephrine levels), incidence of adverse events, anesthesia dose, duration of procedure, and recovery time were compared between the groups at specific time points T0, T1, and T2 during bronchoscopy.

Results

There was no statistical difference between the groups at T0. At T1 and T2, pulse oxygen saturation, mean arterial pressure, heart rate, and stress indices in group A were significantly more favorable than those in group B. The incidence of adverse events (5.26%) in group A was significantly lower than that in group B (17.54%), and patients in group A required less propofol and had a faster recovery time than patients in group B.

Conclusion

Dexmedetomidine use in flexible bronchoscopy under general anesthesia is safe and effective and decreases the stress response in synergy with propofol to provide hemodynamic stability.