Management Of Airway Foreign Bodies Research Articles

Expert consensus on the clinical application of single-use (disposable) flexible bronchoscopes

Single-use (disposable) flexible bronchoscope is widely used clinically both in China and abroad and has become an important tool for diagnostic and therapeutic procedures in respiratory diseases. The lightweight, portability, and non-reusability of the single-use flexible bronchoscope makes its use not only similar to that of conventional flexible bronchoscope, but with additional applications and indications. Currently, single-use flexible bronchoscopes are used in pulmonology, critical care medicine, infectious diseases, anesthesia, emergency departments and other clinical settings. Chinese Respiratory Endoscopy Experts have developed a consensus on the clinical application of disposable bronchoscopy in China after extensive online and offline consultation, questionnaire surveys and extensive solicitation of opinions. This consensus was developed using clinical experiences gained and lessons learned during clinical practices over the past ten years to standardize and rationalize use of single-use flexible bronchoscope. The consensus addressed nine key issues concerning single-use flexible bronchoscope: definition, construction, benefits, application scenarios, preoperative preparation, sedation, anesthesia requirements, disinfection processes and training requirement ans management. Finally, twelve recommendations were developed. The consensus used the modified GRADE methodology to grade the evidence evaluation and recommendations. This is the current state of consensus on single-use flexible bronchoscope in China, and we hope to improve the standardized application of single-use flexible bronchoscope in China in the future. Summary of consensus opinions: 1. Definition and structure of single-use flexible bronchoscope.A single-use flexible bronchoscope, also known as a disposable flexible bronchoscope, includes two parts: a portable touch screen display and different types of bronchoscopes.2. The advantages of single-use flexible bronchoscope.[Consensus Opinion 1]: Single-use flexible bronchoscope is sterile (strongly recommended 86.7%).[Consensus Opinion 2]: The cost of single-use flexible bronchoscope is relatively low (strongly recommended at 53.3%).[Consensus Opinion 3]: Single-use flexible bronchoscope is portable and easy to use (strongly recommended at 80%).[Consensus Opinion 4]: Single-use flexible bronchoscope can be used as a complementary tool for teaching and scientific research (strongly recommended at 80%).3. The value of single-use flexible bronchoscope in the diagnosis and treatment of pulmonary infection.[Consensus Opinion 5]: For infectious diseases, unexplained pneumonia, and multi-drug resistant organisms (MDRO), the use of disposable bronchoscopy is recommended(strongly recommended at 90%).4. Application of single-use flexible bronchoscope in the diagnosis and treatment of critically ill patients.[Consensus Opinion 6]: Single-use flexible bronchoscope can be used immediately to manage patients with difficult airways in emergency situations (strongly recommended 53.3%).[Consensus Opinion 7]: Single-use flexible bronchoscope can be used immediately for the management of airway foreign bodies and hemoptysis in emergency situations (strongly recommended 80%).5. Application of single-use flexible bronchoscope in the diagnosis and treatment with complex bronchoscopic procedures.[Consensus Opinion 8]: For complex bronchoscopic procedures, when multiple endoscopic surgeries are required in addition to current endoscopic procedures, given the vulnerability of reusable bronchoscope to damage during the procedures, the use of a single-use flexible bronchoscope combined with a reusable bronchoscope for "dual endoscopic surgery" is recommended (strongly recommended 26.7%).6. Application of single-use flexible bronchoscope in preoperative preparation.[Consensus Opinion 9]: When managing critically ill patients or patients requiring emergency airway management, preoperative preparation can be temporarily delayed (strongly recommended 93.7%).7. Application of single-use flexible bronchoscope in sedation and anesthesia.[Consensus Opinion 10]: Use of single-use flexible bronchoscope for topical anesthesia. For complex procedures, choose topical anesthesia with tracheal intubation or supraglottic airways in general anesthesia (66.7% is strongly recommended).8. Does single-use flexible bronchoscope require standardized training?[Consensus Opinion 11]: The use of disposable bronchoscope requires standardized and systematic training (strongly recommended 93.3%).9. Cleaning and disinfection requirements for single-use flexible bronchoscope.[Consensus Opinion 12]: Single-use flexible bronchoscope is disposable and does not require disinfection (strongly recommended 93.3%).

Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting

BackgroundAirway foreign body can be a life-threatening issue in pediatric and adult patients, and the majority of these patients will first present to the emergency department. ObjectiveThis article provides a narrative review of the diagnosis and management of airway foreign bodies for the emergency clinician. DiscussionForeign bodies in the upper and lower airways are potentially life threatening. This affects all age groups but is more common in pediatric patients. A history of a witnessed ingestion or aspiration event should raise the clinical suspicion for an aspirated foreign body. Patients with upper-airway foreign bodies are more likely to present in respiratory distress when compared with lower-airway foreign bodies, which often present with more subtle signs. Stridor, drooling, and wheezing suggest respiratory distress, but the presenting clinical picture is often unclear and may only include a cough. Immediate intervention is required in the patient with hemodynamic instability or respiratory distress. Airway management including laryngoscopy, fiberoptic bronchoscopy, and cricothyrotomy may be needed in these patients, with the emphasis on removing the obstructing foreign body and securing the airway. Specialist consultation can assist in retrieving the foreign body and managing the airway. If the patient is stable, imaging and specialist consultation for potential operating room intervention should be considered. ConclusionsAn understanding of the presentation, evaluation, and management of the patient with an airway foreign body is essential for emergency clinicians.

Tooth Aspiration in a Patient with Traumatic Brain Injury.

Tooth aspiration is a rare issue in the course of patients with trauma and may remain undiagnosed for a long period, resulting in delayed complications, such as atelectasis and recurrent infections. Flexible bronchoscopy is considered the preferred primary procedure for the management of airway foreign bodies in adults. However, it may cause intracranial hypertension in trauma patients with concomitant head injuries. We herein report a case of a patient with traumatic brain injury who underwent tooth aspiration using flexible bronchoscopy, with continuous monitoring of intracranial pressure (ICP). The importance of a thorough review of radiographs and chest computed tomography for foreign body aspiration in trauma patients was highlighted, particularly in a maxillofacial trauma, as tooth aspiration may remain undiagnosed for extended periods. Moreover, the difficulty in maintaining the ICP within normal limits during bronchoscopy in patients with traumatic brain injury was reinstated, and the need for continuous monitoring of the cerebral hemodynamics and harmonization was emphasized, with recommendations for bronchoscopy via an endotracheal tube.

Foreign body retrieval using a flexible video-bronchoscope in a child

While several articles describe clinical management of foreign bodies (FBs) in proximal airways, most using a rigid bronchoscope; flexible bronchoscopy and its utility in management of airway FB is unclear. This case report aims to highlight the ever increasing evidence of use of flexible video-bronchoscopes in FB removal from airways with minimal sedation and complications, when performed by an expert. A 13-month-old male child presented with a history of peanut aspiration and its removal using a flexible video-bronchoscope under minimal sedation. Rigid bronchoscopy remains the gold standard for removal of proximal airway FB. There is growing evidence that flexible video-bronchoscopy can be used for retrieval too, albeit by expert hands.

Airway foreign bodies: A critical review for a common pediatric emergency.

Airway foreign bodies (AFBs) is an interdisciplinary area between emergency medicine, pediatrics and otolaryngology. It is a life-threatening condition that is not infrequently seen; however, it is poorly covered in medical literature. Accidental aspiration of an element into airways is a widespread clinical scenario among children under 3 years, predominantly males. Moreover, it is the leading cause of infantile deaths and the fourth one among preschool children. A systemic search was conducted in July 2015 using PubMed/PubMed Central Database of The National Center for Biotechnology Information (NCBI) (http://www.ncbi.nlm.nih.gov/). A total of 1 767 articles were identified and most of them were meta-analyses, systematic reviews, and case series. Those thoroughly discussing assessment and management of AFBs were retrieved. AFBs episodes may be either witnessed or missed. Presence of a witness for the inhalation is diagnostic. The later usually present with persistent active cough. A classical triad of paroxysmal cough, wheezing, and dyspnoea/decreased air entry was reported, though many presentations have inconsistent findings. Hence, diagnosis requires high index of clinical suspicion. Flexible fibro-optic bronchoscopy is the gold standard of diagnosis, whereas inhaled objects are best retrieved by rigid bronchoscopes. Close supervision of pediatrics is the hallmark of prevention. Caregivers should ensure a safe surrounding milieu, including the toys their offspring play with. Immediate complications result from direct obstruction or injury by the inhaled object. Alternatively, prolonged lodging traps air and induces inflammatory response causing atelectesis and pneumonia, respectively.

Foreign Body Inhalation in the Adult Population: Experience of 25,998 Bronchoscopies and Systematic Review of the Literature.

Foreign body aspiration is an uncommon entity in adults. Herein, we describe our experience with flexible bronchoscopy in the removal of tracheobronchial foreign bodies in adults. We also conducted a systematic review of the literature on the topic of foreign body inhalation in adults managed with flexible bronchoscopy. The bronchoscopy database (from 1979 to 2014) was reviewed for subjects > 12 y of age with a history of foreign body aspiration managed with flexible bronchoscopy. Demographic, clinical, and bronchoscopy data were collected and analyzed. PubMed was reviewed for studies describing the use of flexible bronchoscopy for foreign body extraction in adults. During the study period, a total of 25,998 flexible bronchoscopies were performed. Of these, 65 subjects (mean age of 32.8 y, 49 males) were identified who had undergone bronchoscopy for foreign body aspiration. Nonresolving pneumonia (30.6%), direct foreign body visualization (24.6%), and segmental collapse (18.4%) were the most common radiological abnormalities. Foreign bodies were identified in 49 cases during bronchoscopy and successfully removed in 45 (91.8%) subjects with no major complications. Metallic (41%) and organic (25.6%) foreign bodies were the most common. Shark-tooth (44.9%) and alligator (32.6%) were the most commonly used forceps in retrieving the foreign bodies. The systematic review yielded 18 studies (1,554 subjects with foreign body inhalation). In adults, the proportion of flexible bronchoscopy (6 studies, 354/159,074 procedures) performed for the indication of foreign bodies among the total flexible bronchoscopies was 0.24% (95% CI 0.18-0.31). The overall success of flexible bronchoscopy (18 studies, 1,185 subjects) for foreign body extraction was 89.6% (95% CI 86.1-93.2). Foreign body aspiration is a rare indication for flexible bronchoscopy in adults. Flexible bronchoscopy has a high success rate in removal of inhaled foreign body and can be considered the preferred initial procedure for management of airway foreign bodies in adults.

Thoracotomy for Bronchial Foreign Bodies: A Propos of 3 Cases

Objective: To report 3 cases of bronchial foreign bodies removed by thoracotomy Patients and Methods: Retrospective study was conducted from January 1st 2005 to December 31 2011 in the ENT Clinic of NTH of Fann. During this 7-year period, 96 cases of foreign bodies of lower respiratory tract were managed with 63 cases of bronchial location. Bronchoscopic removal was achieved in 60 cases but failed in 3 cases. Removal of bronchial foreign bodies was finally performed through thoracotomy. Results: In 3% (3/96 cases), thoracotomy was performed. The patients were 5, 8 and 12 years old. The foreign bodies were non organic (nail, pearl, dolphin-like hair styling accessory). Chest X-ray showed one case of radiolucent object. Bronchoscopic removal failed twice or 3 times, in each case. Therefore, external thoracic surgery was done: 2 bronchotomies and 1 right posterior inferior lobectomy. Posterior lateral thoracic incision was used. No complication occurred. Conclusion: Bronchoscopy remains the gold standard treatment in the management of airway foreign bodies. Because of recent technological improvements in instrumentation, external thoracic surgery is avoided.

Retained Denture in Oropharynx

Purpose: To describe an unusual case of a denture retained in the oropharynx for one year and highlight current management of airway foreign bodies. Study design: A case report and brief review of the literature. Results: A 27 year old man sustained a gunshot wound to the neck and underwent exploratory surgery and tracheotomy at an outside hospital. Nine months after this injury, he presented to our clinic with dysphagia, aphonia, and tracheotomy dependence. Normal anatomic landmarks were not visible by indirect laryngoscopy and imaging suggested a possible plate-like prosthesis in the oropharynx. Diagnostic direct laryngoscopy revealed a foreign body firmly lodged in the base of tongue and vallecula. Removal of the foreign body revealed a partial denture. Postoperatively, the patient reported that he could not locate the denture after his injury and had obtained a new prosthetic. The missing partial denture was lodged in his oropharynx for one year. Conclusions: While aspiration or dislodgement of dental appliances is common, this is an interesting case of a young man with a retained denture in his oropharynx for 12 months. During this time, the patient tolerated a near regular diet although swallowing was uncomfortable. Suspicion of a denture foreign body was low in this instance owing to the fact that the patient was young at presentation and did not endorse or disclose the loss of a dental appliance at the time of initial injury.

Bronchoscopic techniques for removal of foreign bodies in children's airways

The management of airway foreign bodies (AFB) can be a dramatic situation in the emergency treatment of children and different techniques have been used to improve the therapeutic success and minimize risks. to describe the bronchoscopic techniques used in the treatment of AFB in children referred to the Service of Respiratory Endoscopy of HC-FMUSP. Retrospective analysis of 78 children who underwent bronchoscopy for foreign body removal, at our Service from February 2003 to April 2008. 78 patients with an AFB, aged 08 months to 14 years, with 39 being organic and 39 inorganic foreign bodies. Nine foreign bodies were located in the central airway (four in the larynx and five in the trachea), 34 in the right bronchial tree and 33 in the left bronchial tree. There was bilateral aspiration in two cases. All patients were initially submitted to diagnostic flexible bronchoscopy. A rigid bronchoscope was used in 39 cases; a flexible bronchoscope in 23 and an association of techniques in 15 cases (rigid bronchoscopy, flexible bronchoscopy, suspension laryngoscopy, and fluoroscopy). Although the rigid bronchoscopy is considered the main tool for the removal of foreign bodies from airways, other useful techniques deserve attention as part of the medical training. The knowledge and association of different methods in pediatric bronchoscopy add the benefits of one method to another, minimizing the chances of therapeutic failure.

Rigid tracheobronchoscopy in the management of airway foreign bodies: 10 years experience in Kosovo

To review the incidence of tracheobronchial foreign body aspiration in the population of Kosovo and to evaluate the clinical features and management of tracheobronchial foreign body aspiration during a 10-year period. Tertiary medical institution, ENT/Head and Neck Surgery Clinic, University Clinical Center, Prishtina, Kosovo. We retrospectively reviewed the medical records of patients with tracheobronchial foreign body aspiration who underwent rigid tracheobronchoscopy between January 1994 and December 2003. During a 10-year period, 244 rigid tracheobronchoscopy procedures were performed when foreign body aspiration was suspected. In 182 patients (75%), a foreign body was found and extirpated. Of these, 107 (59%) were male and 75 (41%) were female; 124 patients (68%) were aged 0-3 years and 36 (20%) were aged 4-7 years. The most commonly extirpated foreign bodies were peanuts (30% of cases) followed by beans (22.5%) and corn kernels (9%). Of 176 plain chest radiographs, 65% showed no signs of foreign bodies. Two patients (1.1%) died as result of complications related to foreign body aspiration. Rigid bronchoscopy represents a safe and effective tool in the management of foreign body aspiration. However, the high percentage of false-negative results on chest radiography in our series warrants further investigation.

How we do it: management of tracheobronchial foreign bodies in children

Foreign body aspiration remains an important pathology in children. Management of airway foreign bodies must be undertaken in specialized units with experienced staff and known protocols. Development and improvement of rigid bronchoscopes, with advances in anaesthesia have increased the efficacy and the safety of removing endotracheal foreign bodies. A video monitor is advantageous in coordinating the procedure and reducing the stress of the team. Utilization of Fogarty's catheters can be beneficial.

Flexible bronchoscopic management of airway foreign bodies in children.

Flexible bronchoscopic management of airway foreign bodies in children.

Flexible Bronchoscopic Management of Airway Foreign Bodies in Children

To evaluate experience with the flexible bronchoscopic management of tracheobronchial foreign bodies (TFBs) in children (age < or = 16 years). All pediatric bronchoscopies performed by the bronchoscopy section at Mayo Clinic Rochester from 1990 through June 2001 for the suspicion of TFBs were reviewed. Information analyzed included the types of bronchoscope (rigid vs flexible) and techniques used, success rates of extraction of TFBs, and complications. Of the 94 children suspected of having TFBs, 39 children (28 boys and 11 girls; mean age, 47.3 months) were found to have 40 TFBs. The flexible bronchoscope was used exclusively to extract TFBs in 24 patients, and in 2 patients in whom the rigid bronchoscopic procedure was unsuccessful. Flexible bronchoscopy was performed through an endotracheal tube in 19 children. In the other five children, the procedure was accomplished through a laryngeal mask airway (LMA). In two additional patients in whom the rigid bronchoscopic procedure was unsuccessful, the instrument served as a conduit for the passage of the flexible bronchoscope. The extraction instruments employed included ureteral stone baskets and stone forceps. Since 1994, all extractions of TFBs were successfully accomplished with the flexible bronchoscope. Complications occurred in four patients who underwent rigid bronchoscopy, and included postbronchoscopy laryngeal edema manifested by stridor, cough, and respiratory distress. These resolved quickly with medical therapy. Flexible bronchoscopic extraction of pediatric TFBs can be performed safely with minimal risks and complications. In our experience, it was successful in all children in whom it was employed. Nevertheless, we caution that provisions be made to provide immediate rigid bronchoscopic management, should the attempts at flexible bronchoscopic extraction fail.

The choking child: What happens before the ambulance arrives?

Objective. To compare pre-EMS intervention (bystander intervention) with EMS intervention (performed by fire department/EMS personnel) in the management of airway foreign bodies in children. Methods. First-responding paramedic run reports for 1994 in the metropolitan area (city and county fire departments) pertaining to acute foreign body airway obstruction in children (aged 0–15 years) were reviewed. Data regarding age, gender, type of foreign body, method by which the airway was cleared, and mode of transportation were extracted. Results. There were 103 runs with an age distribution as follows: 0–11 months 39.8%; 1–5 years 50.5%; and >6 years 9.7%. Fifty-eight (56.3%) involved males and 45 (43.7%) involved females. Eighty-five percent of the airways were cleared before EMS arrival. Thirty-eight percent were self-cleared by the child. The chance of airway clearance before EMS arrival increased with increasing age: 78% of the children aged 0–11 months, 88.5% of the children 1–5 years of age, and 100% of the children aged 6 years or older had their airways cleared before EMS arrival. Forty-four percent of the children were not transported, and 27% were transported by private vehicle. Coins and food were the two most common foreign bodies. Conclusion. The majority of airway foreign bodies were cleared before EMS arrival, especially in older children. This supports CPR training of new parents and the general population and has training implications for the EMS provider in managing the pediatric airway.

Utility of conventional radiography in the diagnosis and management of pediatric airway foreign bodies.

Pediatric airway foreign bodies are potentially life-threatening situations. The otolaryngologist is often consulted to aid in the diagnosis and management of these difficult cases. Although radiographic studies are often obtained, the decision for surgical intervention is usually based on a suspicious history and physical examination. Our hypothesis is that radiographic imaging should not alter the decision for surgical intervention. We retrospectively reviewed the cases of pediatric airway foreign bodies managed by the otolaryngology department at St Louis Children's Hospital between December 1990 and June 1996 with both radiographic imaging and operative intervention. Ninety-three cases of potential aspiration were identified, with a median patient age of 20 months. The most common presenting signs and symptoms were aspiration event (n = 82), wheezing (n = 76), decreased breath sounds (n = 47), cough (n = 39), respiratory distress (n = 17), fever (n = 16), pneumonia (n = 14), and stridor (n = 7). At the time of endoscopy, 73 patients were found to have an airway foreign body. The sensitivity and specificity of the imaging studies in identifying the presence of an airway foreign body in the 93 patients were 73% and 45%, respectively. Our decision for operative intervention was based on the history and physical examination, and was not changed in the presence of a negative radiographic study. The routine use of radiography should not alter the management of airway foreign bodies, providing that there is a well-equipped endoscopic team familiar with airway foreign bodies.