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Retrieval of an endobronchial foreign body using a guide wire and angioplasty catheter.

SUMMARY

We report the use of a guide wire and angioplasty balloon catheter to retrieve an endobronchial foreign body after failure of conventional techniques. The foreign body was a pen top that had a small lumen, which allowed passage of the wire and use of the balloon catheter for retrieval. The difficulty of retrieval of such objects and the limitations of the equipment usually used for this procedure are discussed.

Key Words: endobronchial foreign body, anaesthesia, angioplasty balloon catheter, guide wire

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Aspiration of an endobronchial foreign body occurs most commonly in children between the ages of one and three years and is unusual in older age groups. Retrieval of such objects is usually relatively straightforward using ventilating bronchoscopes and 'grabbing' forceps. We present a case of a 13-year-old male who aspirated a small plastic end piece of a ballpoint pen. This foreign body proved impossible to remove using conventional rigid bronchoscopic equipment. A second attempt using different equipment including a guide wire and angioplasty catheter was successful.

CASE HISTORY

A 13-year-old male was admitted to a local district general hospital, having accidentally aspirated the end piece of a ballpoint pen. This plastic foreign body was approximately 5 mm in length, with a diameter of 3 to 4 mm and a hole 1 mm in diameter in its centre. He had initially choked and coughed, but had been unable to cough the foreign body out. The coughing then settled but he was left with an audible whistle on breathing.

On admission to the district hospital he was comfortable and not complaining of any chest pain or discomfort, or shortness of breath. He did complain of a wheezing or whistling sound when breathing. He was previously healthy and taking no medication. On examination, he was not in respiratory distress, had a haemoglobin oxygen saturation by pulse oximetry of 98% in room air and a respiratory rate of 18 to 22 breaths per minute. There was an audible whistle/ wheeze on breathing and on auscultation there was a transmitted biphasic wheeze throughout the chest. A chest X-ray showed no evidence of a foreign body, hyperinflation, lobar collapse or consolidation.

Flexible laryngoscopy carried out in the district hospital showed no foreign body in the pharynx or larynx and, despite a good view into the trachea as far as the carina, no foreign body was seen.

The patient was then transferred to our centre with a presumptive diagnosis of a foreign body in a bronchus. He was brought fully fasted to theatre on the day of admission for a diagnostic bronchoscopy.

Intravenous access was gained prior to inhalational induction with oxygen and sevoflurane. When sufficient depth of anaesthesia was attained, direct laryngoscopy was performed and the vocal cords sprayed with lignocaine (total 80 mg). Anaesthesia was maintained using oxygen and sevoflurane with the patient breathing spontaneously, initially through a nasopharyngeal airway and then during rigid bronchoscopy through the side-arm of the rigid Storz ventilating bronchoscope. The foreign body was not visualised via the Storz bronchoscope. A laryngeal mask airway (LMA) was then inserted and, with the patient still breathing spontaneously, flexible bronchoscopy was performed via the LMA. A blue plastic foreign body was identified, firmly lodged in the second division of the right main bronchus. A number of unsuccessful attempts were made to remove this using 'grabbers' and attempts using an embolectomy catheter failed, as it was not possible to pass it through the bronchoscope channel. Finally, a urology 'Dormia basket' was passed through the hole in the foreign body under direct vision. Despite this being achieved, when the basket was withdrawn it collapsed and passed through the foreign body without dislodging it. After repeated unsuccessful attempts the procedure was abandoned, the patient was given dexamethasone 6 mg (0.1 mg/kg) and anaesthesia was discontinued.

Following this episode the opinion of the thoracic team was sought. Further bronchoscopy, possibly followed by thoracotomy for bronchotomy or lobectomy was considered, should the foreign body prove impossible to remove endoscopically. The risk of localised infection and subsequent bronchiectasis was thought to be significant should the foreign body remain.

The patient was returned to theatre two days later for another attempt at bronchoscopic removal of the foreign body by the anaesthetic and thoracic team. He was anaesthetised on this occasion using an intravenous induction, was paralysed with a muscle relaxant and ventilated. He was intubated with a size 9.0 cuffed endotracheal tube and maintained with oxygen, sevoflurane and a remifentanil infusion. Flexible bronchoscopy showed the foreign body remained in the second division of the right bronchus. A 0.32 mm diameter, 150 cm length J-tipped guide wire was inserted via the bronchoscope through the suction channel under direct vision through the lumen of the foreign body. The bronchoscope was then removed. An angioplasty catheter (PTA Balloon Dilatation Catheter, BARD Opti-plast, length 75 mm, balloon diameter 4 mm) was then passed over the guide wire, with the bronchoscope passed alongside to visualise the passage of the catheter balloon through the hole. Once this had been noted, the balloon was inflated with saline and the wire, catheter, bronchoscope and endotracheal tube all removed together (Figures 1 and 2). The patient was then re-intubated, the muscle relaxant reversed and anaesthesia ended. There were no postoperative sequelae.

[FIGURE 1 OMITTED]

DISCUSSION

Aspiration of a foreign body in childhood is a rare but potentially devastating condition. Inhalation of a foreign body is a significant cause of mortality in the paediatric population, with most deaths occurring at the time of aspiration. It is more frequently seen in children under six years of age, with a peak incidence between the ages of one to three years (1), boys presenting more frequently than girls. Under the age of three years, there is a greater risk of inhalation and airway obstruction as the airway reflexes are not as well developed and the major airways are narrow. The commonest inhaled foreign bodies are peanuts, the airway obstruction further complicated by release of nut oils leading to inflammation, oedema and added narrowing of the airway (1).

Where the foreign body lodges in the airway depends on the relative size and shape of the foreign body and the airways. Although a preference for the right has been suggested, there is no bronchial side preponderance, with the foreign body as likely to be found in the left as in the right lung (2). Some are found in the trachea, but the majority lodge in the proximal airways. Death is usually caused by complete airway obstruction when the foreign body lodges in the larynx or upper airway and generally occurs before the child reaches hospital. Delayed complications commonly relate to infection associated with a retained foreign body.

[FIGURE 2 OMITTED]

Children with aspiration of a foreign body commonly have a history of a coughing or choking episode (1,3). If the incident is not witnessed, the diagnosis may be difficult, especially in the preverbal child. Other symptoms include stridor, coughing, audible wheeze and difficulty breathing. If the foreign body passes into the bronchi, the patient may be symptom free for a period. Following this period, the patient may present with recurrent haemoptysis and symptoms consistent with bronchitis, pneumonia and bronchiectasis, such as chronic cough productive of sputum, and wheeze (3,4). On examination the child may be tachypnoeic, have audible stridor, have unilateral or bilateral decreased breath sounds, wheeze, crepitations and may be pyrexial. Rare signs include subcutaneous emphysema and pneumothorax. Other diagnoses to be considered are tracheobronchitis, asthma, pneumonia and tuberculosis (5).

Chest X-rays are usually performed, but are of limited benefit with very few demonstrating either the foreign body or signs resulting from its presence. Radio-opaque foreign bodies may be seen on plain films and the radiological changes that can be demonstrated include atelectasis, signs of consolidation and emphysematous changes, secondary to a 'check-valve' mechanism (6,7). The check-valve mechanism occurs when air is inhaled but cannot be expelled, causing hyperinflation distal to the foreign body. This requires assessment of an expiratory film with the usual inspiratory chest X-ray. Atelectasis may occur early or late. Early atelectasis is usually caused by a ball-valve mechanism, where the foreign body moves during expiration and re-impacts during inspiration; the negative pressure generated leading to collapse. Late atelectasis is usually caused by a stop-valve mechanism, where obstruction due to a large or swelling foreign body leads to a gradual collapse.

Anaesthetic technique

A standard anaesthetic preoperative assessment should be made, with particular emphasis on the respiratory system, eliciting signs and symptoms of airway obstruction and respiratory distress. The patient should be fasted, although the timing of surgery will depend on the severity of signs of upper airway obstruction (8). Preoperative physiotherapy has been advocated in patients presenting with pneumonia, and antibiotics and steroids may be used for the treatment of infection and oedema respectively.

The choice of anaesthetic technique will be guided by the presence and severity of signs of upper airway obstruction. We use the following technique. Should the patient be stridulous, it is mandatory, in the authors' opinion, to perform a spontaneously breathing technique until the source of the obstruction is identified. This will generally be performed using sevoflurane in 100% oxygen. Following a gaseous induction the larynx is sprayed with lignocaine in a dose of up to 3 mg/kg. The patient is then settled and a nasopharyngeal airway is inserted to maintain anaesthesia during the diagnostic bronchoscopy. The use of the nasopharyngeal airway allows a Hopkins rod bronchoscope to be used for the first diagnostic pass. This telescope has no ventilatory attachments, but has superb optics. Alternatively, a Storz ventilating bronchoscope could be used and anaesthesia maintained by connecting the circuit to the sidearm of the bronchoscope.

In those patients without stridor, but with presumed lower airway foreign bodies, a spontaneous breathing technique can again be used for the initial diagnostic bronchoscopy but is not essential. Should the foreign body be impacted in the lower airways it may then be preferable to change to a technique using paralysis and positive pressure ventilation to enable removal of the foreign body. A review of the literature on spontaneous versus controlled ventilation (9) noted that case series of aspirated foreign body removals rarely commented on the anaesthetic technique used. This resulted in difficulty in comparing the two methods of ventilation, but the small studies published showed similar good outcomes with either spontaneous or controlled ventilation.

Equipment

It is interesting in our case that the conventional equipment used for rigid bronchoscopy did not visualise the foreign body. The foreign body was small and the patient was relatively mature, allowing for the foreign body to lodge in the distal airways. If the foreign body could have been visualised, then grasping forceps may have easily removed the object. However, in this case we had to use a fibreoptic bronchoscope to visualise the object. The bronchoscope we used has an outer diameter of 3.5 mm and fits easily into the right main bronchus of a teenager. Using the flexible scope, the object was easily visualised, but the grasping forceps were too small and unable to hold the object. A Dormia basket was also passed via the channel of the flexible bronchoscope through the object but collapsed on withdrawal of the scope, failing to dislodge it.

The use of a wire passed through the channel of a fibreoptic scope is well described for use in paediatric fibreoptic intubation (10) but, to our knowledge, the use of an angioplasty catheter for this purpose has not been described. These angioplasty catheters are used in our ENT practice for the dilatation of tracheal and bronchial stenosis, and the 4 mm balloon on this occasion threaded easily over the wire through the lumen of the foreign body. The fibroptic bronchoscope was re-passed, to check its position before blowing the balloon up with saline, and continuous visualisation was achieved during the removal of the foreign body.

In conclusion, bronchial foreign bodies may be difficult to visualise and remove in older children using Storz rigid bronchscopes and the use of a flexible fibreoptic bronchoscope may be necessary. Should grasping equipment prove inadequate, alternative techniques, such as the wire and balloon catheter described here, may be successful, obviating the need for open surgery.

Accepted for publication on December 5, 2006.

REFERENCES

(1.) Baharloo F, Veyckemans F, Francis C. Tracheobronchial foreign bodies. Presentation and management in adults and children. Chest 1999; 115:1357-1362.

(2.) Cohen SR, Herbert WI, Lewis GB, Geller KA. Foreign bodies in the airway. Five-year retrospective study with special reference to management. Ann Otol Rhinol Laryngol 1980; 89:437442.

(3.) Hoeve LJ, Rombout J, Pot DJ. Foreign body aspiration in children. The diagnostic value of signs, symptoms and preoperative examination. Clin Otolaryngol 1993; 18:55-57.

(4.) Wiseman NE. The diagnosis of foreign body aspiration in children. J Pediatr Surg 1984; 19:531-535.

(5.) Lloyd Thomas AR, Bush GH. All that wheezes is not asthma. Anaesthesia 1986; 41:181-185.

(6.) Mu LC, Sun DQ, He P Radiological diagnosis of aspirated foreign bodies in children: a review of 343 cases. J Laryngol Oto11990;104:778-782.

(7.) Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001; 11:861-872.

(8.) Inglis AF, Wagner DV Lower complication rates associated with bronchial foreign bodies over the last 20 years. Ann Otol Rhinol Laryngol 1992; 101:61-66.

(9.) Farrell PT Rigid bronchoscopy for foreign body removal: anaesthesia and ventilation. Paediatr Anaesth 2004; 14:84-89.

(10.) Walker RWM, Allen DL, Rothera MR. A fibreoptic intubation technique for children with mucopolysaccharidoses using the laryngeal mask airway. Paediatr Anaesth 1997; 7:421-426.

G. BRIGGS *, R. W M. WALKER ([dagger])

Department of Anaesthesia, Manchester Children's Hospital, Manchester, United Kingdom

* ER.C.A., Specialist Registrar in Anaesthesia.

([dagger]) D.C.H., F.R.C.A., Consultant Paediatric Anaesthetist.

Address for reprints: Dr R. W M. Walker, 73 Church Road, Urmston, Manchester M419EJ, U.K.
COPYRIGHT 2007 Australian Society of Anaesthetists
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Article Details
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Author:Briggs, G.; Walker, R.W.M.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:4EUUK
Date:Jun 1, 2007
Words:2315
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