Removal of an Endobronchial Foreign Body Using an Ultrathin Flexible Bronchoscope and a Novel Suction System

Abstract

To the Editor: Foreign body aspiration in children is a serious condition and a pediatric emergency. If the diagnosis is delayed, complications such as persistent pneumonia, recurrent attacks of bronchospasm, lung abscess, recurrent hemoptysis, and bronchiectasis may develop, necessitating surgical intervention.1 We report a case of a persistent pneumonia of 3 weeks duration in an infant from aspiration of peanuts that was successfully managed by using an ultrathin flexible bronchoscope and a handmade suction system and a balloon catheter. Three weeks before the admission, a healthy 8-month-old boy suffered with productive cough and fever and was diagnosed with acute bronchitis. Despite the medical treatment, his symptoms persisted. A chest computed tomography (CT) scan revealed findings suggestive of a foreign body in the left main bronchus and a left lower lobe pneumonia (Fig. 1A).FIGURE 1: A, Chest computed tomography scan showing a suspected foreign body in the left main bronchus and pneumonia in the left lower lobe (red circle). B, Handmade suction system. C, Many small pieces of peanuts and white discharge can be seen. D, The foreign body, which is half of a peanut, is shown.Under general anesthesia, an ultrathin flexible bronchoscope, 2.2 mm in diameter (BF-N20; Olympus, Tokyo, Japan) was inserted into the endobronchial tree through the endotracheal tube, 4.5 Fr in diameter. There was a thick white discharge in the left main bronchus and a foreign body, which was a piece of peanut, was observed. The scope was too slim and had no suction port. We made a handmade suction system by placing a small cut over the proximal end of a conventional suction catheter and inserted the bronchoscope into the tubing (Fig. 1B). We attempted to aspirate the foreign body with this modified suction device. However, it resulted in fragmentation of the peanut emitting moderate amount of white discharge from the distal airways (Fig. 1C). A 5.2 Fr balloon angioplasty catheter was then passed by the side of the bronchoscope placing the balloon distal to the foreign body. The balloon was then inflated with air and used to push the foreign body in a retrograde manner (pull). This maneuver allowed the foreign body to be brought proximally without further fragmentation. A split portion of the peanut was easily removed using the suction. (Fig. 1D). Patient’s symptoms promptly resolved, and there was no further recurrence of his pneumonia. Foreign body aspiration is a common pediatric emergency. More than 80% of cases of foreign body aspiration occur during early childhood, with a peak incidence between the ages of 10 and 24 months.2 Only 17.2% of patients with proven foreign bodies did not have an eyewitness to the aspiration episode, and only 20% of foreign bodies are radiopaque. Most of the aspirated foreign bodies in the pediatric age group are food particles, especially nuts or seeds. The diagnosis of a pediatric airway foreign body is more difficult because the patients are unable to communicate and delay in the treatment is not uncommon.3 The bronchoscopic removal of a foreign body among infants is not without challenges as fragmentation or distal migration of the foreign body can occur.4,5 Traditionally, rigid bronchoscopy was the procedure of choice for the removal of foreign bodies in children.6 However, flexible bronchoscopy is increasingly being used for the indication.7,8 Flexible bronchoscope has many advantages compared with rigid bronchoscope. Most importantly, its small diameter and flexibility enable to reach foreign bodies located in distal airways, which are difficult to access with a rigid bronchoscope. Second, flexible bronchoscope may allow simultaneous retrieval of fluids, especially mucus or blood clots, without requiring separate suction catheter.8 When the diagnosis is delayed, such as in our case, and if the foreign body is nuts or seeds, fragmentation is likely with the use of rigid instruments. We always perform the flexible bronchoscopy first before giving consideration to the rigid scope. The weakness of the ultrathin flexible bronchoscope could be the lack of a suction port, as one in our case. Our handmade suction system appeared to be useful to overcome this weak point. Flexible bronchoscopy combined with our handmade suction system and balloon catheter might come handy in similar situations. Yoshimitsu Hirai, MD, PhD* Shoji Oura, MD, PhD* Tatsuya Yoshimasu, MD, PhD* Issei Hirai, MD, PhD† Yozo Kokawa, MD, PhD* Rie Nakamura, MD* Mitsumasa Kawago, MD* Takuya Oohashi, MD* Haruka Nishiguchi, MD* Mariko Honda, MD* Yoshitaka Okamura, MD, PhD* *Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University †Department of Breast and General Thoracic Surgery, Naga Municipal Hospital, Wakayama, Japan