Fogarty balloon–assisted extraction of an impacted friable foreign body causing complete left main bronchus obstruction: A case report

Abstract

Foreign body aspiration (FBA) in adults is uncommon but can lead to significant morbidity due to delayed or atypical presentation. Flexible bronchoscopy is the preferred diagnostic and therapeutic modality, although extraction may be challenging depending on the foreign body's characteristics. We report a case of severe airway obstruction caused by a soft organic foreign body successfully managed using a Fogarty balloon catheter technique.

A 73-year-old man with schizophrenia presented with severe hypoxemia and complete left lung atelectasis. Imaging demonstrated complete obstruction of the left main bronchus by an ovoid foreign body. Following endotracheal intubation, flexible bronchoscopy revealed a whole grape tightly impacted in the bronchus. Conventional forceps extraction attempts failed because of the grape's smooth and friable surface. A longitudinal channel was created through the grape, enabling insertion of a 5-French Fogarty balloon catheter. Balloon inflation and gentle traction allowed successful removal.

This technique may represent an effective rescue strategy for extracting large, soft organic airway foreign bodies.

Graphical abstract

A 73-year-old man with schizophrenia presented with severe hypoxemia and complete left lung atelectasis caused by obstruction of the left main bronchus by an aspirated grape. Flexible bronchoscopy identified the foreign body, but conventional forceps extraction failed due to the grape's smooth and friable surface. Creation of a small channel through the grape allowed insertion of a Fogarty balloon catheter, enabling successful removal and rapid clinical recovery.

1. Introduction

Foreign body aspiration (FBA) in adults is uncommon but may cause significant morbidity due to delayed or atypical presentation, leading to obstructive pneumonitis, atelectasis, hypoxemic respiratory failure, or fatal airway obstruction. Flexible bronchoscopy is the preferred initial diagnostic and therapeutic approach in adults, with high success rates when appropriate retrieval devices are used. Risk factors for adult FBA include impaired airway protective reflexes and dysphagia, commonly associated with neurologic disease, intoxication, advanced age, and psychiatric illness. Patients with schizophrenia are particularly vulnerable due to swallowing dysfunction, sedation, impaired attention during meals, and medication effects.

2. Case report

A 73-year-old man with schizophrenia was admitted with severe hypoxemia and complete left lung atelectasis. Chest radiography and computed tomography revealed complete obstruction of the left main bronchus by an ovoid foreign body (Fig. 1).

Fig. 1.

Chest CT

Legend: The image shows an ovoid foreign body completely obstructing the left main bronchus with associated left lung atelectasis (coronal section lung window).

The patient was transferred to the operating room and placed on high-flow nasal cannula oxygen. Following induction of intravenous general anesthesia with neuromuscular blockade, he underwent endotracheal intubation with an 8.5 mm endotracheal tube. Mechanical ventilation was initiated in volume-controlled mode (tidal volume 450 mL, respiratory rate 16 breaths per minute, PEEP 10 cm H₂O) with an FiO₂ of 100% due to severe hypoxemia.

As a rigid bronchoscope was not available at the time, we proceeded with flexible bronchoscopy. A therapeutic bronchoscope (Olympus BF-1TQ180; working channel 2.8 mm) was introduced through the endotracheal tube using a swivel adapter. Bronchoscopy revealed a normal trachea and main carina, with no abnormalities in the right bronchial tree. In the left main bronchus, approximately 15 mm distal to the carina, a smooth, dark, ovoid foreign body consistent with a whole grape was identified, completely obstructing the airway lumen.

Initial 3 attempts to grasp the foreign body using forceps (Olympus FB-211D) were unsuccessful due to its smooth and friable nature. Using the same forceps in a closed position, a longitudinal tract was carefully created through the center of the grape in a single attempt using blunt compression. The forceps were then withdrawn, and a 5-French Fogarty balloon catheter (Edwards Lifesciences 620405F) was introduced through the working channel of the bronchoscope. The catheter was advanced through the previously created tract, and the balloon was gently inflated distal to the foreign body.

Controlled traction was applied, successfully dislodging the grape from its impacted position in the left main bronchus. The bronchoscope, Fogarty catheter, and foreign body were then withdrawn together, pulling the grape to the distal end of the endotracheal tube. The entire assembly (endotracheal tube, bronchoscope, and foreign body) was removed en bloc (Fig. 2).

Fig. 2.

Removed foreign body.

Legend: The image presents the retrieved grape adherent to the Fogarty balloon catheter after en-bloc extraction with the bronchoscope and endotracheal tube.

The patient was immediately reintubated and mechanical ventilation was resumed. Repeat bronchoscopy confirmed clearance of the airway and allowed suctioning of post-obstructive secretions. The patient was subsequently extubated and recovered fully without complications.

3. Discussion

Foreign body aspiration (FBA) in adults is an uncommon but potentially life-threatening condition, typically occurring in patients with predisposing factors such as neurological impairment, psychiatric disease, or impaired airway protective reflexes [1,2]. Clinical presentation is often nonspecific and may be delayed, frequently resulting in complications such as atelectasis, post-obstructive pneumonia, or respiratory failure, as demonstrated in the present case [2,3].

Flexible bronchoscopy is widely regarded as the first-line diagnostic and therapeutic modality in adults, with high reported success rates [4,5]. However, optimal management increasingly relies on an interventional bronchoscopy approach tailored to the characteristics of the foreign body and the clinical scenario. Rigid bronchoscopy remains the gold standard in cases of severe airway obstruction, large or centrally located foreign bodies, or when airway control is critical, as it provides superior suction, ventilation, and access to a broader range of extraction tools [2,6]. Its availability, however, may be limited in urgent settings.

Alternative extraction techniques have been increasingly adopted in flexible bronchoscopy. Cryoprobe extraction allows adhesion of organic material to the probe tip through freezing, facilitating removal, particularly in friable material [6]. Retrieval baskets, such as Dormia baskets, are useful for irregular or mobile foreign bodies, enabling envelopment and controlled extraction [6]. Nevertheless, both techniques have limitations: cryoprobes require sufficient contact surface and may be less effective for smooth objects, while baskets may fail to secure round, slippery foreign bodies such as grapes.

The Fogarty balloon catheter represents a valuable adjunct in selected cases and has been described in several reports as an effective rescue technique when standard methods fail [7,8]. Its principal indication is in smooth, round, or impacted foreign bodies that are difficult to grasp with forceps or baskets. By advancing the catheter distal to the obstruction and inflating the balloon, proximal traction can be applied, facilitating dislodgement and en bloc extraction while potentially reducing fragmentation risk [[6], [7], [8]]. In the present case, the creation of a central tract within the foreign body enabled reliable catheter positioning and effective traction, overcoming the limitations imposed by the grape's smooth and friable structure.

Despite its advantages, the Fogarty technique has important limitations. It requires the ability to pass the catheter distal to the foreign body, which may not be feasible in cases of complete impaction without prior manipulation. There is also a risk of distal displacement or airway trauma if balloon inflation is not carefully controlled. Contraindications include situations where distal airway access cannot be safely achieved or where there is concern for perforation or bleeding. Furthermore, it does not provide the same level of airway control as rigid bronchoscopy and should be used cautiously in unstable patients.

In conclusion, this case highlights the importance of a flexible, tool-adapted approach to foreign body extraction in adults. While rigid bronchoscopy remains the gold standard in severe cases, flexible bronchoscopy with adjunctive techniques can be highly effective when rigid instrumentation is unavailable. The Fogarty balloon catheter, particularly when combined with a tract-creation maneuver, represents a simple and valuable option for the extraction of smooth, impacted organic foreign bodies, provided its indications and limitations are carefully considered.

Ethics and consent statement

As an emergent case in a schizophrenic patient we have obtained a verbal phone call consent from the appointed legal guardian and a separate consent recently for publication of images without patients’ identifiable data or photo.

Funding statement

The authors received no funding for this work.

CRediT authorship contribution statement

Yael Shapira-Galitz: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Evgeni Gershman: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.