Abstract
Rigid bronchoscopy is the gold standard treatment for pediatric tracheobronchial foreign bodies. This procedure gives jitters to young ENT surgeons. The only aim of this study is to aware young ENT surgeons of different challenges they may face during bronchoscopy and their subsequent management. Clinical and demographic presentations of airway foreign bodies are also presented. This prospective observational study was conducted from Jan 2013 to Jan 2020 on patients with tracheobronchial foreign bodies. Patients were divided in four Groups (A, B, C and D) on the basis of mode of presentation. Rigid bronchoscopies using basic instruments without the use of telescope/telescopic forceps in patients fulfilling the inclusion/exclusion criteria were done by first author under the supervision of senior authors. The challenges and difficulties encountered and their subsequent management were noted. Out of seventy cases, maximum patients (50) were in the age group of 2–6 years. Majority of patients (76.2%) in Group A and B in total reported to hospital within 0–2 days. Majority of patients in Group A and B as a whole were educated as per our criteria while majority in group C were uneducated. Cough was the most common symptom seen in all groups at the time of examination. Decreased air entry abnormal breath sounds on examination were seen in 75%, 73%, and 100% of (patients in) Group A, B and C, respectively while it was normal for Group D. Most common X-ray finding was Hyperinflation followed by normal X-ray in group A and B. Most common Grade of modified Cormack–Lehane on direct laryngoscopy was Grade 1. Most common foreign body was nuts/legumes/pulses. Difficulty in inserting appropriate size rigid bronchoscope through vocal cords, Intraoperative drop in oxygen saturation, breakage of foreign bodies into pieces, stucking of forceps into tracheal mucosa, stucking of foreign body in sub glottis while removing and bleed/edema in old foreign bodies were main problems encountered. Rigid bronchoscopy is a life saving procedure. The sophisticated telescopes/forceps and other gadgets may not be always available. The young ENT surgeon should be well acquainted with basic instruments and their usage. The common difficulties/challenges faced should not cause panic as these challenges can be easily overcomed with simple maneuvers.
Keywords: Rigid bronchoscope, Basic instruments, Challenges, Hyperinflation, Tracheostomy, Chest-X-ray
Introduction
Pediatric tracheobronchial foreign body aspiration is a serious life threatening condition contributing significantly to infant and child mortality especially in developing countries. It contributes to about 7% of mortality in children between age group 0–3 years [1]. The commonly put forth reasons for the increased susceptibility of children to foreign body aspiration are poor chewing ability; less airway protection reflex; adventurous nature; lack of molars for proper mastication and habit of exploring objects with mouth, and eating while crying or playing [2].
The most common presentation to Emergency Department is difficulty breathing, continuous cough and wheezing. Most of the times a definitive history of foreign body aspiration preceding the symptoms is present. A proper history which is most important is first taken and then if patient is stable X-ray Neck and Chest is done. In some doubtful cases Computed tomography (CT) or flexible bronchoscopy is advised. The gold standard for treatment of foreign body aspiration is rigid bronchoscopy once high suspicion is established.
The first bronchoscopy was performed by Gustav Killian in 1897 [3]. This procedure since then has evolved tremendously with the introduction of new types of bronchoscopes, invention of telescopes/telescopic forceps and better anaesthetic facilities. Amid so much of changes, human tracheobronchial has not changed/evolved. The risks/challenges and uncertainties associated with pediatric rigid bronchoscopy is still haunting most of young ENT surgeons doing or willing to do this procedure for foreign body aspiration more so when it is done without the use of telescope and telescopic forceps. The procedure gives shakes and jitters to young and causes tachycardia in experienced ENT bronchoscopists in some situation.
The sophisticated instruments which has been added over the decades in the list of bronchoscopy are very costly/are prone to wear and tear and are difficult to procure in Government hospitals. In view of this a young ENT surgeon should know how to do bronchoscopy with conventional instruments within limited resources.
This study on pediatric foreign bodies and their management by rigid bronchoscopy using conventional instruments was done over a period of 7 years. The cases were done exclusively by First author under the supervision and guidance of senior authors.
The data is presented to the readers in its original form to share my experience with young ENT surgeons planning to do rigid bronchoscopy with basic instruments in this era of technology. The only aim of this paper is to make them aware of different presentations of airway foreign bodies and common challenges they may encounter during bronchoscopy with conventional instruments and simple solutions for these challenges. The challenges and their management are routinely encountered by trained bronchoscopist but have never been published for the benefit of young ENT surgeons. This paper and observations may not be relevant to a trained bronchoscopist and this experience is not directed to them. No statistical analysis was done as we don’t intend to give any statistical significance to our study as that is not our aim.
Materials and Methods
This study is a Prospective Observational Study conducted in Department of ENT of Government Medical college Srinagar for a period of 7 years from Jan. 2013 to Jan. 2020. All cases of rigid bronchoscopy done personally by First author under the Guidance of other authors with the following Inclusion and Exclusion Criteria were enrolled in the study:
Inclusion Criteria
Patients with witnessed history of foreign body inhalation followed by classic history of cough/chocking/distress.
Patients without witnessed history but sudden onset of cough/chocking/distress without any preceding respiratory complaints/fever.
Chronic history of cough/respiratory complaints referred by paediatrician/private practitioner for rigid bronchoscopy to rule out foreign body.
Chronic history of cough/respiratory complaints with or without pneumonic infiltrations/consolidation on X-ray referred by paediatrician for therapeutic bronchoscopy after finding foreign body on CT Thorax.
Incidental findings of foreign body on X-ray chest done as part of routine Pre Anaesthetic check up for some surgery.
Exclusion Criteria
Patients > 12 years of age.
Patients with sputum positive tuberculosis
Refusal to give high risk consent in all patients by guardians and death on table consent in some patients
Patients in sepsis.
Patients were telescopic forceps were used during bronchoscopy
Either the patients came directly to our OPD/Emergency or were referred from different hospitals to our center, as our center is the only one in whole valley performing rigid bronchoscopy in paediatric patients.
After careful history and examination, most patients were directly shifted to theatre for rigid bronchoscopy while in some patients either CT scan or Flexible bronchoscopy was done prior to rigid bronchoscopy.
In many stable patients fasting status of at least 4 h was ensured prior to rigid bronchoscopy while in majority, rigid bronchoscopy was done without the prior fasting status of patient.
All cases were done under general anaesthesia with relaxation. Premedication was given and patients were induced by sevoflurane and propofol. Initial relaxation was done by succinylcholine at the dose of 2–3 mg/kg and further relaxation was ensured by atracurium. 100% oxygen was delivered via Ayres T piece connected to bronchoscope.
Instruments Used (Fig. 1a, b)
Fig. 1.
Basic instruments used in bronchoscopy. a Long red horizontal bar showing different sizes of rigid bronchoscopes from Karlstorz; yellow horizontal bar showing two alligator forceps; solid red arrow shows simple suctions used; yellow small arrow shows glass cap of bronchoscope; black arrow showing prism of bronchoscope to which fiberoptic cable of light source attaches. b A single bronchoscope with forceps inserted. Long red arrow shows that forceps passes only few millimeters from tip of bronchoscope; black arrow shows the area where prism attaches; long yellow arrow shows the black tape mark on the forceps; small light green arrow shows the opening where the anesthesia T piece attaches
The instruments used were rigid bronchoscope from KARL STORZ of different sizes from 3.5 to 6, straight long alligator forceps and Long suctions. No telescope or telescopic forceps were used for this study as these instruments are costly, prone to wear and tear, difficult to procure in a Government set up and were reserved to be used in difficult cases by Senior authors of this paper but those cases were not included in study.
Technique of Bronchoscopy
Standard Head and Neck position for rigid bronchoscopy was given
Direct laryngoscopy was done with appropriate size blade
Different maneuvers were done if glottis was not clearly visualized
Larynx (glotic area particularly) was sprayed with 10% Xylocaine to prevent postoperative laryngospasm
Appropriate sized bronchoscope with ventilating ports was introduced through vocal cords and once passed beyond glottis, direct laryngoscope was pulled out.
Anaesthesiologist connected the anaesthesia circuit with gases with a special port designed in the bronchoscopes so that the same bronchoscope acts as an endotracheal tube and manual ventilation was given.
Anaesthesiologists was told to auscultate to ensure bronchoscope was in trachea because it can go to esophagus in some cases.
Trachea was inspected and to enter right main bronchus, head was turned to left and vice versa
Once foreign body was visualized, the transparent glass cover of bronchoscope was removed and forceps introduced through bronchoscope to remove foreign body.
A white adhesive/black plastic tape was wrapped all around the forceps handle at a distance equals the length of bronchoscope plus about 3 mm in cases where there was difficulty in seeing and grasping the foreign body simultaneously so that FB could be removed blindly without grasping the surrounding mucosa
FB was removed without excessive pull and it was ensured that no mucosa has been grasped. In case of some resistance felt while pulling especially when F.B. was removed using 3.5 sized Storz bronchoscope, forceps were released and foreign body re-grasped.
Different maneuvers were done as discussed to tackle challenges during bronchoscopy.
Patients with either of the parents with an education of more or equal to high school were labeled as Educated while under high school were labeled as undedicated. In each group if more than 50% parents were falling in the particular group, whole group was designated as such.
Patients were divided into 4 groups as far the way they have presented to the department.
(Group A) Witnessed inhalation of foreign body followed immediately by Cough/Chocking
(Group B) Foreign body inhalation not witnessed, but sudden history of cough/respiratory difficulty without any preceding respiratory tract infection/fever.
- (Group C) Chronic history of Cough on and off/Fever/Respiratory difficulty. No history of witnessed foreign body. In this group pts were further divided into those
- Treated for Asthma
- Treated for Tuberculosis
- Treated with on and off antibiotics for recurrent respiratory tract infections.
(Group D) No history at all but incidentally picked up
Modified Cormack–Lehane Classification of laryngeal view on direct laryngoscopy was noted in all patients.
Intraoperative challenges and their management done along with all relevant details of patients were noted on predesigned Proforma.
Patient was observed in either wards or intensive care units. Usually next morning X-ray was repeated.
Results and Observations
In this study seventy patients were included based on inclusion and exclusion criteria. Number of patients in different age groups were recorded.
The maximum patients (50) were in the age group of 2–6 years followed by (10) patients in the age group 1–2 years, 6 patients were in the age group of 6–10 years. The minimum patients (4) were seen in the age group more than 10 years. No patient was less than 1 year. Males and females were 62% and 38% of study population.
Majority of patients were in the group A (63%) followed by Group B (22%), Group C (14%) and Group D (1%).
Majority of patients (41 out of 44) of Group A presented within 0–2 days to hospital followed by 3 within 3–7 days. Majority of patients (10 out of 15) of Group B presented within 3–7 days to hospital and 4 of them within 0–2 days. days. Majority of patients in Group A and B as a whole were educated as per our criteria while majority in group C were uneducated. Majority of patients in Group A and B were from Rural background while all patients in group C were from rural background. Out of 10 patients in group C, two F.B. reported between 1 and 2 years after the start of symptoms and out of them one F.B. was 2 year old and the other was 1.6 years old based on the duration of symptoms. Three patients had symptoms of < 6 month duration while 5 patients had 6–12 months duration (Table 1).
Table 1.
History and demographic profile of patients
| Different groups of patient in context of the way of presentation | No of patients | Time of presentation to hospital (days) and no. of patients | Education of parents till high school (majority > 50%) | Urban/rural | |
|---|---|---|---|---|---|
| Witnessed inhalation of foreign body followed immediately by cough and chocking (Group A) | 44 (63%) | 0–2 | 41 | Edu | U = 15 |
| R = 25 | |||||
| 3–7 | 3 | Edu | U = 0 | ||
| R = 3 | |||||
| 8–14 | 1 | N. edu. | R = 1 | ||
| > 15 | x | x | x | ||
| F.B. inhalation not witnessed, but sudden history of cough/respiratory difficulty (Group B) | 15 (22%) | 0–2 | 4 | Edu | U = 4 |
| 3–7 | 10 | Edu | U = 2 | ||
| R-8 | |||||
| 8–14 | 1 | Non. edu. | R = 1 | ||
| > 15 | x | x | x | ||
| Chronic history of cough (on and off)/fever/respiratory difficulty. No history of witnessed foreign body (Group C) | 10 (14%) | ||||
| Treated for asthma | 2 | < 6 months | 3 | Non. edu. | R = 10 |
| Treated for tuberculosis | 3 | 6 months–1 year | 5 | U = 0 | |
| Treated with on and off antibiotics in periphery | 5 | 1–2 years | 2 | ||
| No history at all but incidentally picked up (Group D) | 1 (1%) | Edu | R = 1 | ||
| Total | |||||
| R = 49 (70%) | |||||
| U = 21 (30%) | |||||
In Group A majority (35 out of 44) (79.5%) had cough at the time of examination. Cyanosis was seen in 3 patients while oxygen saturation less than 85% was seen in 7 patients (16%). On examination this group had decreased air entry in 33 (75%) patients while air entry was normal in 11 patients (25%). Stridor was seen in 3 patients. Most common X-ray finding was Hyperinflation seen in 21 (47%) of patients followed by normal in 16 (36%), partial collapse in 4 (9%), total collapse in 3 (8%). Radiopaque foreign body was seen in 4 patients (9%). The most common location of foreign body was right main bronchus and its divisions in 30 (68%) followed by left main bronchus and its divisions in 11 (25%), trachea in 2 (5%) and subglottis in 1 (2%) patient. Organic foreign bodies (Fig. 2a) especially nuts/pulses/legumes inhalation were seen in 31 patients (70%). Rajma inhalation in 4 patients (9%). Whistles and plastics in 3 (7%) of patients. Pen cap and toy bulb inhalation was seen in 2 and I patient respectively (Fig. 2b, Table 2a).
Fig. 2.
a Some organic foreign bodies removed. Most common were nuts. b Some inorganic foreign bodies removed. Patients with Pen cap and Toy parts had history of chronic cough/fever on and off of 2 years and 1.6 years duration respectively
Table 2.
(a) Clinico-radiological findings at time of presentation, (b) clinico-radiological findings
| Clinical findings at the time of examination | X-ray findings | Bronchoscopy findings | Aspirated material | |
|---|---|---|---|---|
| (a) | ||||
| Witnessed inhalation of foreign body immediately followed by cough and chocking (Group A) (n = 44) | Normal air entry = 11 | Normal = 16 | FB in trachea = 2 | Nuts/pulses/legumes = 31 |
| Decreased air entry/abnormal breath sounds = 33 | Hyperinflation = 21 | Subglottis = 1 | Pins = 3 | |
| Stridor/whistling sound = 3 | Partial collapse = 4 | Right main bronchus = 30 | Whistles/other plastics = 3 | |
| Cough = 35 | Total collapse = 3 | Left main bronchus = 11 | Pen caps = 2 | |
| Cyanosis = 3 | FB opacity = 4 | Toy bulb with metal tip = 1 | ||
| Ox. sat < 85% = 7 | Pneumonic infiltrations/Consolidation = 0 | Rajma = 4 | ||
| F.B. inhalation not witnessed but sudden history of cough/respiratory difficulty (Group B) (n = 15) | Normal air entry = 4 | Normal = 4 | FB in trachea = 1 | Nuts/pulses/legumes = 10 |
| Decreased air entry/abnormal breath sounds = 11 | Hyperinflation = 8 | Subglottis = x | Pins = 1 | |
| Stridor/whistling sound = 1 | Partial collapse = 2 | Right main bronchus = 11 | Whistles/other plastics = 1 | |
| Cough = 12 | Total collapse = 1 | Left main bronchus = 3 | Pen caps = x | |
| Cyanosis = 1 | FB opacity = 1 | Toy bulbs/Toy parts = 1 | ||
| O. sat < 85% = 3 | Pneumonic infiltrations/consolidation = x | Rajma = 2 | ||
| Clinical findings at the time of examination | X-ray findings | Bronchoscopy findings | Aspirated material | |
|---|---|---|---|---|
| (b) | ||||
|
Chronic history of Cough (on and off) fever/respiratory difficulty. No history of witnessed foreign body Treated for asthma Treated for tuberculosis Treated with on and off antibiotics in periphery (Group C) (n = 10) |
Normal air entry = x | Normal = x | FB in trachea = x | Nuts/pulses/legumes = 3 |
| Decreased air entry/abnormal breath sounds = 10 | Hyperinflation = x | Subglottis = x | Pins = x | |
| Stridor/whistling sound = x | Partial collapse = 4 | Right main bronchus = 7 | Whistles/other plastics = 3 | |
| Cough = 10 | Total collapse = 1 | Left main bronchus = 3 | Pen caps = 1 | |
| Cyanosis = x | FB opacity = x | Toy bulbs/Toy parts = 3 | ||
| O. sat < 85% = 1 | Pneumonic infiltrations/ | Rajma = x | ||
| Consolidation = 5 | ||||
| No history at all but incidentally picked up (Group D) (n = 1) | Normal air entry = 1 | Normal = 1 | FB in trachea | Nuts/pulses/legumes = x |
| Decreased air entry/abnormal breath sounds = x | Hyperinflation = x | Subglottis | Pins = x | |
| Stridor/whistling sound = x | Partial collapse = x | Right main bronchus = 1 | Whistles/other plastics = x | |
| Cough = x | Total collapse = x | Left main bronchus | Pen caps = x | |
| Cyanosis = x | FB opacity = 1 | Toy bulbs/toy parts = 1 (small Hollow Mettalic tube) | ||
| O. sat < 85% = x | Pneumonic infiltrations = x | Rajma = x | ||
In Group B majority (12 out of 15) (80%) had cough at the time of examination. Cyanosis was seen in 1 patients while oxygen saturation less than 85% was seen in 3 patients (20%). On examination this group had decreased air entry/added sounds in 11 (73%) patients while air entry was normal in 4 patients (27%). Stridor was seen in 1 patients. Most common X-ray finding was Hyperinflation seen in 8 (53%) of patients followed by normal in 4 (27%), partial collapse in 2 (13%), total collapse in 1 (7%). Radiopaque foreign body was seen in 1 patients (7%).
The most common location of foreign body was right main bronchus and its divisions in 11 (73%) followed by left main bronchus and its divisions in 3 (20%), trachea in 1 (7%). Organic foreign bodies especially nuts/pulses/legumes inhalation were seen in 10 patients (67%). Rajma inhalation in 2 patients (13%). Whistles and plastics in 1 (7%) of patients. Toy bulb inhalation was seen in 1 (7%). Pin was seen in 1 patient (7%) (Table 2a).
In Group C majority (10 out of 10) (100%) had cough at the time of examination while oxygen saturation less than 85% was seen in 1 patients (10%). On examination this group had decreased air entry/added sounds in all 10 (100%) patients. Most common X-ray finding was consolidation seen in 5 patients (50%) followed by partial collapse in 4 (40%), total collapse in 1 (10%). The most common location of foreign body was right main bronchus and its divisions in 7 (70%) followed by left main bronchus and its divisions in 3 (30%). Organic foreign bodies especially nuts/pulses/legumes inhalation were seen in 3 patients (30%). Whistles and plastics in 3 (30%) of patients. Toy bulb inhalation was seen in 3 (30%). Pen cap inhalation in 1 patient (10%) (Table 2b).
In Group D only one patient was seen and referred from surgery department after emergency laparotomy was done for intestinal obstruction. This patient of 3 years of age was found to have a radiopaque foreign body on X-ray ordered while preanaesthetic check up was being done. After discharge from surgery department, bronchoscopy was done and foreign body retrieved from right main bronchus. On auscultation, air entry was normal and X-ray was normal except for radiopaque shadow (Table 2b).
Combining all the groups together most common X-ray finding was hyperinflation seen in 42% of patients followed by normal X-ray in 30% of patients, partial collapse in 14%, total collapse in 7% and consolidation in 7%. foreign body in total could be visualized in 9% of cases (Fig. 3a). CT scan was ordered in 8 patients (11%) and foreign body was visualised in all 8 cases. On CT scan Consolidation was most common finding seen in 62% of cases followed by collapse in 38%, compensatory hyperinflation of normal lung in 38%, bronchiectasis in 25% of cases (Fig. 3b, Table 3).
Fig. 3.
a Different X-ray findings noted. b CT on left side of a patient with unwitnessed rajma inhalation with typical air between the cotyledons. CT on right side is showing collapse and bronchiectasis and is of a patient who had history of 2 years and pen cap was removed
Table 3.
X-ray and CT findings in total
| X-ray findings (n = 70) | No of cases | Percentage of total cases |
|---|---|---|
| Total collapse | 5 | 7 |
| Partial collapse | 10 | 14 |
| Hyperinflation | 29 | 42 |
| Normal | 21 | 30 |
| Pneumonic infiltration/consolidation | 5 | 7 |
| FB opacity | 6 | 9 |
| CT Findings (n = 8) | Percentage of total CT scans done | |
|---|---|---|
| FB seen in all cases | 8 | 100 |
| Collapse | 3 | 38 |
| With bronchiectasis | 2 | |
| Without bronchiectasis | 1 | |
| Compensatory hyperinflation of normal lung | 3 | 38 |
| Normal | x | x |
| Consolidation/pneumonic infiltrations | 5 | 62 |
Most common Grade of modified Cormack–Lehane on direct laryngoscopy was Grade 1 in 44% followed by Grade 2a in 32%, Grade 2b in 20%, Grade 3 in 4% and Grade 4 in none (Table 4).
Table 4.
Modified Cormack–Lehane classification
| Grade | Description | No of patients (n = 70) | Percentage |
|---|---|---|---|
| 1 | Full view of glottis | 31 | 44 |
| 2a | Partial view of glottis | 22 | 32 |
| 2b | Only posterior extremity of glottis seen or only arytenoids cartilages | 14 | 20 |
| 3 | Only epiglottis seen, none of the glottis seen | 3 | 4 |
| 4 | Neither glottis nor epiglottis seen | x | x |
Various difficulties and challenges were encountered during bronchoscopy in this study period and appropriate management was done. The first difficulty which was faced was difficulty in inserting rigid bronchoscopes through vocal cords. None of the patient in C.L. Grade 1 had difficulty in inserting bronchoscope while 20 difficulties were faced in C.L. Grade 2a, 2b and 3 with 5, 12 and 3 patients respectively in each grade.
As seen in Table 5a different ways very used to solve these problems. Application of Xylocaine jelly to tip of bronchoscope was used to mange such problem in 7 (35%) of our patients followed by combined maneuvers in 9 (45%). Backward external laryngeal pressure followed by upward and rightward pressure (BURP) in 3 (15%) and change of Laryngoscopic blade in 1 (5%).
Table 5.
Difficulties/challenges encountered while doing bronchoscopy and their management. a Difficulty in inserting rigid bronchoscope through vocal cords and management done (n = 20)
| C-L grade | No of patients | Blade of laryngoscope changed to appropriate size | Xylocaine jelly applied to the tip of bronchoscope | Direct laryngoscopic position of Head and Neck checked and corrected | Backward external laryngeal pressure followed by upward and rightward pressure (BURP) | Combined maneuver done |
|---|---|---|---|---|---|---|
| (a) | ||||||
| 1 | x | x | x | x | x | x |
| 2a | 5 | x | 3 | x | 2 | x |
| 2b | 12 | 1 | 4 | x | 1 | 6 |
| 3 | 3 | x | x | x | x | 3 |
| 4 | x | x | x | x | x | x |
| Difficulties/challenges encountered | No. of patients | Management done | |
|---|---|---|---|
| Pulling Bronchoscope from bronchus to Carina and closing the glass cap of bronchus till the time saturation rises after removing forceps. Also checking for leak of anesthesia gas through some opening in bronchoscope (from some extra port in different models of rigid bronchoscope) | Removing the Bronchoscope from trachea in view of NO increase in Spo2 after pulling bronchoscope to carina after no obvious reason of fall in saturation found Blockage of ventilation ports seen and removed (blockage due to blood clots/xylocaine jelly) |
||
| (b) | |||
| Drop in oxygen saturation (< 75%) | 30 | 28 | 2 |
| Foreign body (organic) breaking (total organic = 50) | 40 | x | x |
| Foreign body (inorganic) pulled but not passing out through vocal cords (total inorganic = 20) | 3 | x | x |
| Foreign body removed from bronchus but slipped in subglottis/trachea while pulling up | 3 | x | x |
| Difficulties/challenges encountered | Management done | ||
|---|---|---|---|
| Removal in piece meals | Inorganic Foreign bodies pushed back to the bronchus and Re-removed with/without tracheostomy | ||
| With trach. | Without trach. | ||
| (b) | |||
| Drop in oxygen saturation (< 75%) | x | x | x |
| Foreign body (organic) breaking (total organic = 50) | 40 | x | x |
| Foreign body (inorganic) pulled but not passing out through vocal cords (total inorganic = 20) | x | 3 | x |
| Foreign body removed from bronchus but slipped in subglottis/trachea while pulling up | x | 1 | 2 |
| Difficulties/challenges encountered | No. of patients | Management done | |
|---|---|---|---|
| Suctioning and Instillation of 1 in 10 thousand Adrenaline 2–3 ml through bronchoscope or passing of cotton dipped in above solution into the area of edema | Removal done blindly by forceps already marked with a white adhesive/black plastic tape at a distance equal to length of bronchoscope plus 3 mm and grasping Foreign body smoothly and leaving the grasp of Foreign body once resistance is felt while pulling the forceps | ||
| (c) | |||
| Old foreign body with surrounding edema/bleed/pus | 5 | 5 | x |
| Foreign body visible through 3.5 sized bronchoscope but removal not possible under vision | 6 | x | 6 |
| Forceps getting stuck in bronchus while removing FB | 5 | x | x |
| Sharp foreign body or pin embedded in mucosa | 2 | x | x |
| Small pieces of foreign body in segmental bronchus | 6 | x | x |
| Difficulties/challenges encountered | Management done | ||
|---|---|---|---|
| Opening and closing the forceps and turning it right and left and never pulling it | Foreign Body upper end embedded in mucosa, pushed further down into bronchus so that upper part of it was visible and then safely removing it | F.B. Piece (s) in segmental bronchus not removed and left to come out with cough | |
| (c) | |||
| Old foreign body with surrounding edema/bleed/pus | x | x | x |
| Foreign body visible through 3.5 sized bronchoscope but removal not possible under vision | x | x | x |
| Forceps getting stuck in bronchus while removing FB | 5 | x | |
| Sharp foreign body or pin embedded in mucosa | x | 2 | x |
| Small pieces of foreign body in segmental bronchus | x | x | 6 |
Most of the organic bodies 40 out of 50 in our study broke while removing and were removed in piece meals and in six such cases a piece slipped into segmental bronchus and was left to come out with coughing and these patients were followed for 5 months and none had clinical or X-ray signs or symptoms of residual F B. in Follow up period (Table 5b).
Drop in oxygen saturation below 75% was second most challenge encountered and it was seen in 30 cases (43%) of cases which was managed by pulling the bronchoscope up to carina. In two cases the above maneuver failed and no obvious cause of fall in saturation was noticed. Bronchoscope was removed and inspected. In both cases ventilating ports were blocked by blood ± Xylocaine jelly (Table 5b).
Three inorganic foreign bodies could not be removed via glottis and were reinserted back into the bronchus of their initial lodgement. Tracheostomy was done. Foreign body pulled back again with forceps and removed by assistant once it reached the tracheostoma. Tracheostomy site closed primarily but skins closure delayed (Table 5b).
In three patients while removing foreign body, it slipped below vocal cords and subsequently replaced back into the initial bronchus where it was placed and in two cases removed without tracheostomy while in one cases couldn’t be removed via glottis and removed via tracheostoma (Table 5b).
In five patients edema/pus was seen surrounding the foreign body and in some cases the tissue surrounding the foreign body started bleeding once instrumentation was done. After suctioning, adrenaline diluted into concentration of 1:10,000 was instilled as drops into the area and also cotton dipped in same solution was taken to the area and area wiped with it. In all cases edema settled after few minutes (Table 5c).
In Six cases with the use of 3.5 sized bronchoscope, Foreign body was removed blindly taking precautions not to tear mucosa by applying white adhesive/black tape on forceps as a mark up to which safely forceps were inserted to remove the foreign body. The mark was kept at a distance equal to length of bronchoscope plus 3 mm. In five patients while removing foreign body, the forceps got stuck somewhere in mucosa, gentle opening and closing the forceps along with rotatory movement of forceps solved the problem and safely forceps were retrieved out of bronchus (Table 5c).
In two cases pin was seen embedded into the mucosa of trachea, pin was pushed further down into bronchus so that upper part of pin was visible and then safely removed (Table 5c). In 3 cases while removing the foreign body a sudden decrease in the intensity of light was noted inside the bronchoscope despite fully functional light source. The prism through which light goes into the bronchoscope had somehow been covered by thin layer of secretions. The prism was cleaned and reinserted. The Intensity of light reverted to normal.
In total 14 (20%) patients went CT and Flexible bronchoscopy before doing Rigid bronchoscopy. Eight patients underwent CT scan in this study. The most common indication was Chronic history of Cough/on and off fever/respiratory difficulty (Group C) in 5 patients while 3 patients choose to be sure of FB before undergoing rigid bronchoscopy. Six patients underwent flexible bronchoscopy. The most common indication of flexible bronchoscopy was F.B. inhalation not witnessed but sudden history of cough/respiratory difficulty (Group B) in 3 patients, chronic history of cough/on and off fever/respiratory difficulty (Group C) in 2 patients while 1 patients choose to be sure of FB before undergoing rigid bronchoscopy (Table 6).
Table 6.
Need for CT or flexible bronchoscopy
| No. of CT scans done and Indications (n = 8) | No of patients | Percentage of respective group |
|---|---|---|
| Witnessed Inhalation of foreign body followed immediately by cough and chocking | x | x |
| F.B. inhalation not witnessed but sudden history of cough/respiratory difficulty | x | x |
| Chronic history of cough/on and off fever/respiratory difficulty. No history of witnessed foreign body (n = 10) | 5 | 50 |
| Patients preference to be sure of foreign body after explaining the risks of bronchoscopy | 3 | x |
| No of flexible Bronchoscopy done and Indications (n = 6) | ||
|---|---|---|
| Witnessed Inhalation of foreign body followed immediately by cough and chocking | x | x |
| F.B. inhalation not witnessed but sudden history of cough/respiratory difficulty (n = 15) | 3 | 20 |
| Chronic history of cough/on and off fever/respiratory difficulty. No history of witnessed foreign body (n = 10) | 2 | 20 |
| Patients preference after explaining the risks of bronchoscopy | 1 | x |
Two Foreign bodies, one Pin in (Group A) and one Pen cap in (Group C) could not be retrieved as pin had migrated to segmental bronchus while pen cap was stuck in left main bronchus in a 2 year old child. Patients were referred to CVTS Department for open thoracotomy.
Fortunately, the mortality rate was zero in this study. X-ray reverted to normal within 24 h after removal of foreign bodies in Group A and B. The X-ray did not revert to normal after 24 h in Group C and it took different duration ranging from days to weeks to revert. The X-ray of two patients with long standing foreign bodies (Pen cap and toy part) of more than 1 year duration did not revert to absolutely normal even after months of follow up. They are under follow up of Pediatrics and Physical and Rehabilitative department.
Discussion
Foreign-body aspirations (FBA) are a leading cause of death in children. Delays in diagnosis and treatment can be fatal [1]. Among the seventy patients who fulfilled the inclusion and exclusion criteria, maximum patients 44 (62%) were males while 26 (38%) patients were females. Majority (50) were in the age group of 2–6 years. The least number (4) were seen in age group 10–12 years. No patient was less than 1 year old.
These findings are not different from what has been observed in literature [1, 3–5].
We divided patients into four Goups (A, B, C and D) on the basis of the mode of presentation. Most common presentation was Group A where Foreign body inhalation was witnessed with classical symptoms of cough/chocking followed by Group B with classical Foreign body symptoms but unwitnessed. Group C comprised of patients with neglected foreign body presenting as chronic cough/fever on and off.
Majority of patients 76.2% in Group A and B in total reported to hospital within 0–2 days. This is in accordance with a study by Mustafa Erman Dorterleret al [1] in which 63% of patients presented to hospital within 1 day while in contrast another study [3] only 14% presented in first 24 h of aspiration.
The patients in group C presented within 2 years of onset of symptoms. In two cases where a pan cap and toy part was removed, patients had a duration of 2 year and 1.6 years of symtoms, respectively. Patients with nuts in 3 cases reported earlier within 6 months.
Majority of patients in Group A and B as a whole were educated as per our criteria while majority in group C were uneducated. Majority of patients in Group A and B were from Rural background while all patients in group C were from rural background. Similarly rural preponderance was seen in study by [1] and [5]. The probable reason of such preponderance are living conditions in rural areas and parents from the rural areas have no knowledge of scientific feeding and lack the knowledge of risks of improper feeding.
Cough was the most common symptom in all groups at the time of examination with percentage distribution as 79.5%, 80% and 100% in Group A, B and C respectively. Cyanosis in group A, B and C was seen in 7%,7% and 0 percent respectively. The patient in group D had no symptoms.
The initial event of sudden cough/chocking is short lived and the child may be asymptomatic when brought to emergency department after sometime and that is the reason why all patients in Group A and B did not have cough at the time of examination in hospital. The symptoms again start after a quiscent period and eventually cough is the main complaint in all old foreign bodies as seen in all 100% of case in Group C. Similar to our study Chuan-Shan Zang et al. [5] and Srppnath et al. [6] and Sinha [7] reported cough as predominate symptom
Decreased air entry abnormal breath sounds on examination were seen in 75%, 73%, 100% of (patients in) Group A, B, C while it was normal for Group D. Similar results were obtained in the studies by Banerjee et al. [8] and Inglis and Wagner [9]. wherein decreased air entry was seen as predominant finding.
Normal air entry without added sounds was seen in 25%, 27% and 0% of patients in Group A, B and C respectively. Similarly as reported in review article by Zur et al. [4], 14–45% of patients with foreign body had a normal physical exam preoperatively. It is obvious that large number of patients will have normal auscultation which does not exclude foreign body. The initial cough and chocking followed by persistent/intermittent cough is the most definitive clue of foreign body inhalation.
Since most foreign bodies are radiolucent, their presence is established by indirect signs like air trapping, collapse, consolidation. The X-ray findings depends on whether FB obstructs inspiratory, expiratory or both air flows leading to different types of obstruction patterns like bypass value, check value, stop valve and ball valve obstructions, each obstruction giving a specific X-ray finding [10].
Most common X-ray finding was Hyperinflation/Obstructive emphysems/Air trapping followed by normal X-ray in group A and B. Group C patients had collapse in 50% of patients while another 50% had consolidation. In group C two patients with FB of duration 1.6 and 2 years has bronchiectasis on CT scan. Radioopaque foreign bodies on X-ray in Group A and B was seen in 9% and 7% respectively. Combining all the groups together most common X-ray finding was hyperinflation seen in 42% of patients followed by normal X-ray in 30% of patients, partial collapse in 14%, total collapse in 7% and consolidation in 7%. CT scan was ordered in 8 patients (11%) and foreign body was visualised in all 8 cases. On CT scan Consolidation was most common finding in 62% of cases followed by collapse in 38%, compensatory hyperinflation of normal lung was seen in 38% of cases and bronchiectasis was seen in 25% of cases. Hyperinflation has been seen to be most common findings in other studies [1, 11].
We found normal X-ray in 30% of our cases in total while in one study normal chest x-rays was seen in (46%) [1] and in another study by Merchant et al. [11] 19% had normal X-rays. The proportion of normal radiographs reported in the literature varies from 8% to more than 80%, depending on the study and location of FB [12]. It is clear from our study and what has been reported in literature that if the clinician only relies on the X-ray-chest finding and does not take into consideration strong history, significant number of foreign bodies will be missed.
The type of airway foreign body varies from generation to generation and country to country. Food matters (like nuts, beans, pieces of chicken, and meat) are the most commonly aspirated foreign body for all generations and nations [13]
Most common F.B. was nuts/legumes/pulses and among them few cases of rajma seeds inhalation were seen with typical air between two cotyledons on CT as seen in one case. The consumption of dry fruits is quite high in our population. Similarly findings were noted in other studies [1, 5]. However, in contrast, in a study by Milind Chitnis et al. the majority (78%) of the aspirated foreign bodies were non-food products.
Whistles and toy parts were also seen in some patients in our study. Whistles were seen acquired by the children as they are distributed free with some toffees/candies or chips to attract children to these products. Inorganic F.B. were seen in 20 (29%) of our cases while a study by Vikas Sinha et al. found it in 26% [3]
The most common location of FB was in right main bronchus followed by left in all groups. With regard to site of impaction or lodgment of FBs, most studies [5] have reported the preferential lodgment of FBs in children in the right main bronchus as compared to the left main bronchus as seen on our study. In contrast Ahmed and Shuiabu [14] and Yeh et al. [15] noted left as the main site of lodgement.
Tracheal foreign body was seen in 3 (4%) of our patients. Subglottic foreign body was seen in 1 patient. Tracheal foreign bodies were similarly noted in low percentage of patient 4.5% by Girardi et al. [16]. In contrast Theophilus Adjeso [17] noted it in 21.2% were located in trachea.
Most common Grade of modified Cormack–Lehane on direct laryngoscopy was Grade 1 in 44% followed by Grade 2a in 32%, Grade 2b in 20%, Grade 3 in 4% and Grade 4 in none.
In a study by L. K. D. KOH et al. [18] Grade 1 was seen in 73.9%, Grade 2a in 21%, Grade 2b in 3.3% and grade 3 in 1.6% and grade 4 in 0.2%. In western population as reported by Yentis and Lee [18] Grade 2a and 2b is seen in 30.5% which is quite low as compared to our population. Grading of different populations can vary and one should have probable knowledge of percentage of different Grades in local population so that bronchoscopist is aware of probability of difficulties expected and will be ready for management.
Young ENT surgeons intending to do bronchoscopy fears most about the complications and difficulties associated with this procedure. This paper is actually intended to allay their fears and give them confidence. Most experienced bronchoscopist must be already doing much more than what is experienced in this paper but the need of the time is to share such simple experiences for our young ENT surgeons.
Once from history and examination. it is clear that patient is case of foreign body inhalation, young ENT surgeon should gear up for bronchoscopy. Before actual bronchoscopy is done by a young ENT surgeon, he/she should master the art of direct laryngoscopy thoroughly and should request anaesthesia colleague for some endotracheal intubations.
Needless to say that in case some senior ENT is doing paeditric bronchocopy in the same hosiptal, one should not be hesitant in assisting cases.
The first difficulty/challenge which was faced was difficulty in inserting appropriate size rigid bronchoscope through vocal cords in 20 patients with 5, 12 and 3 each in CL Grade 2a, 2b and 3. One should not panic in such situation. Neither should bronchoscope be passed blindly in such situations except in rare cases. Different simple ways very used to solve these problems.
Grade 2a patients (5) were managed by Application of Xylocaine jelly to tip of bronchoscope and by Backward external laryngeal pressure followed by upward and rightward pressure (BURP) only.
In Grade 2b and 3, a single maneuver may not be always fruitful to make vocal cords visible. In such cases, combined maneuvers are successful in introduction of bronchoscope through vocal cords under vision in almost all cases. In case even after all these maneuvers, glottis is still not visible, one should not loose hope and insert bronchoscope blindly just under the edge of epiglottis. It will pass through glottis easily after xylocaine jelly has been applied which acts as a lubricant.
Sometimes the blade used for direct laryngoscopy is not appropriate for age. Anaesthesiologists help may be sought in choosing the blade. These maneuvers are well known in anaesthetic practice. Application of only external laryngeal pressure (BURP) converted nearly half of the study population from a higher CL grade to a lower CL grade in one study done by Koh et al. [18]. Such maneuvers are routinely done by anesthesiologist but have so far not been published for bronchoscopy.
While removing organic foreign bodies with conventional instruments without the aid of telescope, they are bound to break and even with the use of latest forceps and gadgets, a significant numbers may break. Most of the organic bodies 40 out of 50 in our study broke while removing and were removed in piece meals and in six such cases a piece slipped into segmental bronchus and was left to come out with coughing and these patients were followed for 5 months and none had clinical or X-ray signs or symptoms of F B inhalation in Follow up period.
One should never attempt to remove a small piece of FB which has slipped down into segmental bronchus and in doing so tracheal mucosa/wall injury is a definite consequence especially while doing bronchoscopy without the aid of telescope as done in our study.
During removal of foreign body, our group feels it is a dictum that unless saturation drops bronchoscopy is not done correctly. Inserting the bronchoscope into either of the main bronchus especially left main bronchus lower down, oxygen saturation will fall as the unobstructed bronchus is not ventilated properly. The anesthesiologist should be told to inform as and when the saturation starts dropping. The anesthesiologist can allow drop to an extend which may vary from institution to institution/anesthesiologist to anesthesiologist/case to case but in most of the cases when it starts dropping below 75% some intervention to increase it becomes necessary. In few cases saturation can drop below 50% and rarely can reach below 10%. Drop in saturation occurs during instrumentation as anaesthesia gases and oxygen leaks from the side of bronchoscope facing surgeon and this leak can rarely make bronchoscopist drowsy.
Drop in oxygen saturation below 75% was second most challenge encounterd and it was seen in 30 cases (43%) of cases which was managed by pulling the bronchoscope up to carina, removing the forceps and closing the bronchoscope by glass cap which was already removed for inserting the forceps. In two cases the above maneuver failed and no obvious cause of fall in saturation was noticed. Bronchoscope was removed and inspected. In both cases ventilating ports were blocked by blood ± xylocaine jelly.
So pulling bronchoscope up to carina, closing all ports and ventilating by anesthesiologist will increase oxygen saturation in almost all cases. One should ask anesthesiologist for any increased effort needed by him/her in ventilating and in that case ensure the tip of bronchoscope and ventilating ports are not blocked as seen in two of our cases.
Rarely inorganic Foreign bodies when pulled may not come out of the glottis and this scenario was seen in three of our inorganic foreign bodies which could not be removed via glottis. They were reinserted back into the bronchus of their initial lodgement. Tracheostomy was done. Foreign body pulled back again with forceps and removed by assistant once it reached the tracheostoma. Tracheal incision closed primarily but skins closure delayed. This scenario should be kept in mind when doing bronchoscopy for whistles and pen caps. In case of strong suspicion of this scenario, we suggest to give tracheostomy incision on skin, identify trachea, put two stay sutures on the two sides of intended tracheal incision. But don’t incise the trachea. With this maneuver in case foreign body gets stuck in subglottis, a surgeon can incise trachea within seconds and pull foreign body through it or can ventilate the child without any fear through tracheostomy opening.
In case while removing foreign body it slips in subglottis, one should try to replace it back to bronchus and re remove it or as already discussed can be removed via tracheostomy. This scenario was seen in three of our patients and one of them needed tracheostomy.
Old neglected foreign bodies especially organic sometimes give tough time. One can encounter pus, granulations and edema of tracheal wall mucosa so much so that sometimes actual foreign body may be obscured by the above findings. In such cases as seen in 5 of our patients one should give more time in preparing the area of removal rather can pulling blindly. The first step that was done was suctioning the area followed by instilling about 2–3 ml of adrenaline 1 in 10 thousand concentrations and sometimes application of cotton swabs soaked in this solution to the area. One can go to higher concentration of adrenaline but never use pure adrenaline as tracheal mucosa can rapidly absorb the adrenaline and result in ventricular arrhythmia as seen in one of our case where we individually applied pure adrenaline soaked swabs to the affected area. Few minutes were given for it to act and local response was dramatic in all cases in terms of decrease in edema.
We used bronchoscopes of sizes from 3.5 to 6.0 from Karl Storz. We used a bit oversized bronchoscopes as it becomes easier to visualize and grasp foreign bodies simultaneously with bigger sized bronchoscopes. No difficulty was felt in simultaneous visualization and grasping of foreign body in bronchoscopes of size 4 and more. In six cases with the use of 3.5 sized bronchoscope no such simultaneous clear visualization and grasping was possible. Foreign body was removed blindly taking precautions not to tear mucosa by applying white adhesive/black tape as a mark up to which safely we went to remove the foreign body. The mark was kept at a distance equal to length of bronchoscope plus 3 mm. In cases of resistance felt while removing foreign bodies in such cases, grasp was immediately released, foreign body was regrasped. With the above simple maneuver no threading tears of mucosa or tracheal wall were encountered. So a young ENT surgeon intending to do bronchoscopy should always mark the appropriate length of the forceps while using conventional forceps especially with 3.5 sized bronchoscope.
Pin inhalation is seen in our population as a consequence of religious and social obligations. Muslim young girls in our area after the age of 10 years starts covering their head with headscarf tied with these small pins. They have the habit of keeping pins in mouth while attaching pins to headscarf and sometimes do inhale these pins. We observed pins in four of our cases. Usually the upper end gets embedded in mucosa of trachea as seen in (two of) our cases. In such cases Pin should be pushed further down into bronchus so that upper part of pin is visible and then safely removed as done in our cases. The location of pins should be always checked just before the bronchoscopy, sometimes they come out and enter into the digestive tract or go deeper into segmental bronchus from which retrieval via rigid bronchoscope is difficult.
In five patients while removing foreign body, the forceps got stuck somewhere in mucosa, gentle opening and closing the forceps along with rotatory movement of forceps solved the problem and safely forceps were retrieved out of bronchus. This condition happened in 4 out of 6 cases done with 3.5 bronchoscope. The bronchoscopist should never pull forcefully the stuck forceps else be prepared for a casualty. Rarely does intensity of the light in the bronchoscope decreases suddenly as was seen in three of our cases. Always check the light source cable and clean the prism in such cases.
The need for flexible bronchoscopy and CT arises when the diagnosis is in doubt especially in a long standing foreign body presenting as consolidation or treated for sputum negative tuberculosis or asthma There are few cases were parents insist on flexible bronchoscopy or CT to be sure about the presence of foreign body.
Conclusion
Tracheobonchial foreign body aspiration is a well known emergency. ENT surgeons should be aware of their presentations. History of foreign body aspiration followed by chocking/coughing is diagnostic of foreign body even when X-ray is normal. The role of imaging should be clear. There is a need by young ENT surgeon those willing to do bronchoscopy, to do few direct laryngoscopy with endotracheal intubations. The sophisticated telescopes/forceps and other gadgets may not be always available. The young ENT surgeon should be well acquainted with basic instruments and their usage. There are many challenges which almost every bronchoscopist face and these challenges should not cause barrier between ENT surgeon and Bronchoscopy moreso when these challenges can be easily overcomed with simple maneuvers.
Funding
The research did not receive any funding.
Availability of Data and Materials
The cases in this study are patients coming to our hospital as foreign body aspiration as ours is the only hospital in valley doing rigid bronchoscopies.
Conflict of interest
None.
Consent to Participate
Proper consent taken from patient whenever needed.
Consent for Publication
No consent was required as data was collected from patients indoor files.
Ethical Approval
No such approval was necessary as it was purely a observational study.
Footnotes
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Contributor Information
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The cases in this study are patients coming to our hospital as foreign body aspiration as ours is the only hospital in valley doing rigid bronchoscopies.