Airway management during retrieval of the very large aspirated foreign body: a method for the flexible bronchoscope.

Abstract

The flexible fiberoptic bronchoscope is effective for the removal of most small foreign bodies from the tracheobronchial tree [1], but if the patient requires intubation, the lumen of the endotracheal tube may be smaller than the foreign body to be removed. The rigid bronchoscope is preferred for the removal of large objects [2,3], but insertion of the bronchoscope may be contraindicated if oropharyngeal or cervical spine injuries are present. We describe the use of the flexible bronchoscope for the removal of a foreign body from the tracheobronchial tree in a patient with combined oral and cervical spine injuries, despite finding that the foreign body was larger than the lumen of the indwelling endotracheal tube. Case Report A 37-yr-old man sustained three bullet wounds to the neck and jaw and one bullet wound to the left arm. Cervical spine radiographs demonstrated a fracture of the lateral facet of the fifth cervical vertebra. On a posteroanterior chest radiograph, a bullet was superimposed on the right mainstem bronchus; there was neither pneumothorax nor pneumomediastinum. A No. 8 endotracheal tube was inserted using a percutaneous retrograde technique, because a bronchoscope was not readily available. Computed tomograms of the head, neck, and thorax confirmed the C-5 fracture and localized the bullet within the right mainstem bronchus. Examination of the oropharynx revealed that one of the bullets passed through the posterior left mandible into the oropharynx without an exit wound; it was believed that this bullet had been aspirated after penetrating the jaw. Flexible fiberoptic bronchoscopy through the endotracheal tube was performed. The bullet was lodged in the right mainstem bronchus without evidence of other injury to the airway. The bullet was grasped with a biopsy forceps but proved too large to be withdrawn through the endotracheal tube. Rigid bronchoscopy was believed to be contraindicated in the presence of a cervical spine injury. A second endotracheal tube was "loaded" over a second flexible bronchoscope, which was passed through the mouth alongside the indwelling endotracheal tube into the left mainstem bronchus. The bullet was visualized with the first bronchoscope through the original endotracheal tube and grasped with a biopsy forceps. The bullet, the biopsy forceps, the original bronchoscope, and the original endotracheal tube were removed together from the patient. The second bronchoscope remained in the left mainstem bronchus, and the airway was readily reintubated by sliding the second endotracheal tube down over this bronchoscope into the airway. Prophylactic drainage of the prevertebral space was performed. The patient recovered uneventfully and was discharged on the 10th postoperative day. Figure 1.Figure 1: A second bronchoscope with a second endotracheal tube "loaded" is passed alongside the first endotracheal tube into the left mainstem bronchus. The original bronchoscope, the biopsy forceps, the bullet, and the original endotracheal tube are removed together, and the trachea is reintubated with the second endotracheal tube.Discussion Retrieval of the very large foreign body from the tracheobronchial tree is best performed with a rigid bronchoscope. However, in patients with oropharyngeal or cervical spine injuries, this may be contraindicated. We believe the use of two flexible bronchoscopes and two endotracheal tubes as described allows safe extraction of larger foreign bodies while maintaining airway control.