Beyond removal of endobronchial foreign body

Clinical features and treatment outcomes of airway foreign body aspiration in adults

Background

There are few reports comparing flexible and rigid bronchoscopy in adult foreign body (FB) aspiration. The aim of this retrospective study was to review the clinical characteristics, outcomes and factors associated with success in adult patients who underwent flexible or rigid bronchoscopy for airway FB removal.

Methods

We retrospectively reviewed the records of 103 patients who underwent bronchoscopy to remove airway FB at Samsung Medical Center, South Korea from January 1999 to March 2017.

Results

The median patient age was 64 years, and 70% were males. Among the 54 patients who underwent flexible bronchoscopy as first-line treatment, 43 (80%) patients had their FB successfully removed. Previous attempts at other hospitals was significantly associated with failed flexible bronchoscopy [9/11 (82%) vs. 3/43 (7%), P<0.001]. Delayed diagnosis (median 29 vs. 5 days, P=0.074) and peripherally located airway FB [9/12 (75%) vs. 23/48 (48%), P=0.115] were factors that trended towards flexible bronchoscopy failure. All of the 59 patients who underwent rigid bronchoscopy had their FB successfully removed. Rigid bronchoscopy was preferred to flexible bronchoscopy in patients with no comorbidities [38/59 (64%) vs. 18/44 (41%), P=0.018], previous attempts at other hospitals [34/59 (58%) vs. 4/44 (9%), P<0.001], delayed diagnosis (median 162 vs. 5 days, P<0.001), and hard FBs [48/62 (77%) vs. 21/49 (43%), P<0.001].

Conclusions

Our data suggest that previous failed attempts and delayed diagnosis are associated with flexible bronchoscopy failure. However, rigid bronchoscopy could be effective in removing an airway FB even in these cases. Further studies to identify factors to facilitate optimal patient selection will minimize failure rates and optimize resource utilization.

Infections causing central airway obstruction: role of bronchoscopy in diagnosis and management

Central airway obstructive infections (CAOI) are challenging medical conditions that may represent an advanced and complicated process of ongoing infections. The epidemiology of CAOI is unknown as well as the pathophysiology and the mechanism of development. This is due to sparse data in the literature that consists mainly of case reports and retrospective case series. CAOI can be caused by fungal, bacterial, parasitic and viral infections. Most patients with CAOI can be diagnosed clinically and with chest imaging, which demonstrate obstruction of the central airways. However, bronchoscopy is commonly used to confirm and obtain a specific diagnosis to guide specific therapy. In recent years, interventional pulmonology (IP) is becoming widely available and offer a minimally invasive approach for the management of central airway diseases such as cancers, benign strictures, and other conditions. Various bronchoscopic modalities are used to treat central airway obstruction (CAO), such as mechanical debulking, endobronchial laser therapy, electrocautery, argon plasma coagulation, cryotherapy, and airway stenting. In patients with CAOI, the role of therapeutic bronchoscopy is not clearly defined, but many isolated reports in the literature described bronchoscopic intervention in combination with medical therapy as the initial management approach. In this paper, we present cases of CAOI that underwent bronchoscopic intervention as part of their management. We described the infectious etiology, locations, bronchoscopic findings and bronchoscopic modalities for airway management.

Endoscopic intervention of lower airway foreign matter in adults-a different perspective

BACKGROUND

Lower airway foreign matter (FM) is uncommonly encountered in adults. This study reviews FM in the lower airway that required bronchoscopic intervention.

METHODS

A retrospective review of patients with FM in the lower airway seen at a tertiary hospital between 1996 and 2014 was undertaken.

RESULTS

Lower airway FM was removed in 80 out of 18,650 bronchoscopies performed. Forty-seven were males, with mean age of 50.8 (range, 29-78) years and mean symptom duration of 10.3 months (range, 1 day -20 years). The most common symptoms were persistent cough, followed by dyspnea, hemoptysis, episodes of choking and fever. Three-quarters of the patients had risk factors of either aspiration or iatrogenic cause for FM in the airway. FM identified following bronchoscopy was classified as: organic (31.3%), inorganic (46.3%) and endogenous matter (22.4%). Iatrogenic etiology was evident in four-fifths of the patients with inorganic FM (stents being the most common). Forty-eight (60.0%) patients had FM removed via flexible bronchoscopy, and the remainder via rigid bronchoscopy. The majority (27 out of 32) of FM removed by rigid bronchoscopy could not be removed using the flexible scope. This was primarily due to retrieval of stents [24] could only be done with the rigid bronchoscope. There were four FM-related complications (three bronchostenosis, one actinomycosis).

CONCLUSIONS

There is an increasing indication for bronchoscopists to retrieve FM, particularly of iatrogenic and endogenous sources, lodging in the lower airway of adults. There may be a reversing trend in the utilization of rigid bronchoscopy, mainly due to the increasing need to remove airway stents as more are deployed.