MANAGEMENT OF FOREIGN BODY ASPIRATION (FBA) AND CENTRAL AIRWAY OBSTRUCTION IN ADULTS. FIBROPTIC vs. RIGID BRONCHOSCOPY

1. MANAGEMENT OF FOREIGN BODY ASPIRATION (FBA)
AND CENTRAL AIRWAY OBSTRUCTION IN ADULTS :
FIBROPTIC vs. RIGID BRONCHOSCOPY
Bassel Ericsoussi, MD
Pulmonary and Critical Care Fellow
University of Illinois Medical Center at Chicago

2. INTRODUCTION
• Gustav Killian (the father of
bronchoscopy ) (1860-1921)
• In 1897 extracted a pork
bone from the trachea of a
German farmer using an
esophagoscope
Killian, G. Meeting of the Society of Physicians of Freiburg.
Dec 17, 1897, Munchen Med Wschr 1989; 45:378.
2Bassel Ericsoussi, MD

3. • Fiberoptic bronchoscopy: for diagnostic evaluation
• Rigid bronchoscopy: for removal of foreign bodies
• FBA
– Adults: often subtle, and diagnosis requires careful clinical
assessment
– In children: life-threatening (choking episode)
INTRODUCTION
3Bassel Ericsoussi, MD

4. EPIDEMIOLOGY
• Fifth most common cause of unintentional-injury mortality in the
United States
• More common in children (80 % in pts < 15 yr)
• Uncommon in adults
• Increased risk of dying following FBA:
– Children < 1 yr
– Elderly > 75 yr
4Bassel Ericsoussi, MD

5. • The nature of the FB is highly variable
– In children: nuts and other organic material
– Young or middle-aged adults: nail or pin aspiration
• The most frequently aspirated food particles:
– vegetable matters, bones, and watermelon seeds
5Bassel Ericsoussi, MD

6. Acute Food Asphyxiation
• Older pts (dentition problems, swallowing disorders, or
Parkinsonism)
• Annual incidence of 0.66/100,000 population
• Cafe Coronary: fatal or near fatal food asphyxiation caused by
incompletely chewed meat
• FB usually meat
• In the supraglottic position in about one-third of cases
• Can be removed with
– Magill forceps
– Manually by sticking the middle and index fingers down the throat
6Bassel Ericsoussi, MDMittleman RE; Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction.
JAMA 1982 Mar 5;247(9):1285-8.

7. Bassel Ericsoussi, MD 7

8. 8Bassel Ericsoussi, MD

9. PRESENTATION AND DIAGNOSIS
• In adults acute presentation is rare
– The FB usually is wedged distally in lower lobe
bronchi
• Dyspnea (only 25 %)
• Coughing (80 %)
• Fever, hemoptysis, chest pain, or wheeze
• Adults do not always recall a history of choking
• The diagnosis is frequently overlooked
9Bassel Ericsoussi, MD

10. 10Bassel Ericsoussi, MD

11. 11Bassel Ericsoussi, MD

12. 12Bassel Ericsoussi, MD

13. DIAGNOSTIC FIBEROPTIC
BRONCHOSCOPY
• The diagnostic procedure of choice for FBA in adults
• FB removal should not be attempted during a
diagnostic bronchoscopy
– Unless the operator is skilled in the extraction
technique, and the appropriate equipments are
available
• The bronchoscopist must be able to convert
immediately to the extraction procedure using a
rigid bronchoscope in the setting of complete central
airway obstruction
13Bassel Ericsoussi, MD

14. FBs THAT CAN BE REMOVED
EASILY USING SIMPLE SUCTION
• Soft beans
• Bronchial soot plugs
14Bassel Ericsoussi, MD

15. 15Bassel Ericsoussi, MD

16. TECHNICALASPECTS
• Fiberoptic Bronchoscopy:
– Allows precise identification and localization of
FBs
– Facilitates the choice of rigid bronchoscope and
type of forceps
– Shorten the duration of the rigid bronchoscopy
procedure
16Bassel Ericsoussi, MD

17. 17Bassel Ericsoussi, MD

18. POTENTIAL COMPLICATIONS OF
FB EXTRACTION
• FB becomes wedged distally: postobstructive
atelectasis
• Loss of the foreign body:
– Obstruction of the contralateral mainstem
bronchus
– Obstruction of the central airway, potentially
causing asphyxia
• Hemorrhage: FB is completely encased in bulky and
bleeding granulation tissue
18Bassel Ericsoussi, MD

19. 19Bassel Ericsoussi, MD

20. 20Bassel Ericsoussi, MD

21. When FBA is suspected, fiberoptic
bronchoscopy should be performed
in a room equipped for resuscitation,
definitive airway management,
mechanical ventilation, and rigid
bronchoscopy
21Bassel Ericsoussi, MD

22. FOREIGN BODY REMOVAL
• Once the diagnosis is established, extraction must be
performed without delay.
– Do not postpone foreign body extraction (FBE) in
pts with an acute post-obstructive pneumonia
22Bassel Ericsoussi, MD

23. GRANULATION
• Mucosal inflammation and accumulation of bulky
granulation tissue
– Within few hours
• Organic FBs (peanuts, high oil content )
– Within few weeks/months
• Chronically impacted sharp or rusty FBs
• Iron or nortriptyline pills aspiration
23Bassel Ericsoussi, MD

24. 24Bassel Ericsoussi, MD

25. ROLE OF CORTICOSTEROIDS
• No prospective trials
• Indication
– FB is completely encased in bulky and bleeding
granulation
• Short course (12 to 24 hours) of IV corticosteroid (1-
2 mg/kg prednisolone or equivalent)
– Cleveland Clinic Experience
• May result in dislodgement of the FB
– These pts should remain under observation until
the extraction procedure
25Bassel Ericsoussi, MDBanerjee A et al. Laryngo-tracheo-bronchial foreign bodies in children.
J Laryngol Otol 1988 Nov;102(11):1029-32

26. • Prophylactic use of corticosteroids to decrease the
incidence of post-operative subglottic edema. is not
recommended and it should be avoided
• Post-operative subglottic edema:
– Parenteral corticosteroids
– Aerosolized epinephrine
– Helium-oxygen therapy (heliox)
Bassel Ericsoussi, MD 26
ROLE OF CORTICOSTEROIDS

27. 27Bassel Ericsoussi, MD

28. THE ROLE OF POSITIONAL MANEUVERS
• Lateral decubitus and Trendelenburg
• Young and healthy adults
• Small, movable FB (fruit pit or bead)
• Worth trying prior to bronchoscopy
– May result in spontaneous expectoration of the FB, or bring it into a
more proximal position prior to definitive management
28Bassel Ericsoussi, MD

29. RIGID BRONCHOSCOPY
• Excellent access to the subglottic airways
• Allowing gas exchange and coaxial passage of
multiple instruments
– Optical forceps
• Direct visualization of the FB and optically-guided grasping
– Rigid telescope and a forceps can be used coaxially
through the bronchoscope
• General anesthesia
• Procedure time rarely exceeds 10 minutes
29Bassel Ericsoussi, MD

30. 30Bassel Ericsoussi, MD

31. Bassel Ericsoussi, MD 31

32. TECHNIQUE
• Do not push the FB distally
– Postobstructive atelectasis
• If blood and secretions are present proximal to the FB, these
should be cleared by careful suctioning
– Epinephrine (0.25 mg) may be instilled for hemostasis and
in order to shrink the swollen mucosa encasing the FB
Bassel Ericsoussi, MD 32

33. Bassel Ericsoussi, MD 33

34. PROPER GRASPING TECHNIQUE
• Smooth and rounded FBs
– Foreign body forceps (smooth) are preferred
• Sharp or irregular FBs
– Alligator forceps are preferred
Bassel Ericsoussi, MD 34

35. Bassel Ericsoussi, MD 35

36. Bassel Ericsoussi, MD 36

37. PROPER GRASPING TECHNIQUE
• Large and hard FBs (pistachio shells)
– Breaking the FB into two or three fragments may
help extraction
• Friable FBs (peanuts)
– Vigorous grasping should be avoided
• May result in maceration and distal wedging of small
fragments
Bassel Ericsoussi, MD 37

38. Bassel Ericsoussi, MD 38

39. PROPER GRASPING TECHNIQUE
• Heavy FBs (metallic FBs)
– Tend to move distally due to gravity
– May be helpful to place the patient in the
Trendelenburg position
Bassel Ericsoussi, MD 39

40. COAXIAL MOVEMENT
• Both the instruments (the bronchoscope and the forceps)
and FB are withdrawn en masse from the trachea
• The FB can be lost accidentally
– Blocked in the narrow glottic area
– Inappropriate coaxial movement between the bronchoscope and
the forceps, causing the tip of the bronchoscope to push the FB
out of the forceps' cups or jaws
Bassel Ericsoussi, MD 40

41. Bassel Ericsoussi, MD 41

42. FLEXIBLE BRONCHOSCOPY
• Equipments for FBs removal
– FB forceps (smooth)
– Alligator forceps
– Grasping claws
– Snares
– Balloon-tipped catheters
– Magnets
– New "zero tip" baskets
Bassel Ericsoussi, MD 42

43. 43Bassel Ericsoussi, MD

44. Bassel Ericsoussi, MD 44

45. • May be used as an alternative to rigid bronchoscopy
for extraction
• Success rates in adults range from 60 to 90 %
• Can be cumbersome
Bassel Ericsoussi, MD 45
FLEXIBLE BRONCHOSCOPY

46. RISKS ASSOCIATED WITH
FIBEROPTIC EXTRACTION
• Accidental migration of the FB
into the contralateral lung
– Due to insufficient grasping with
the fiberoptic forceps
– Less likely to occur with rigid
forceps used for rigid
bronchoscopy
Bassel Ericsoussi, MD 46Castro, M, Midthun, DE, Edell, ES, et al. Flexible bronchoscopic removal of foreign bodies from pediatric airways.
J Bronchol 1994; 1:92.

47. RISKS ASSOCIATED WITH
FIBEROPTIC EXTRACTION
• Impossible simultaneous FB
manipulation and suctioning with
flexible bronchoscope
– FB is completely encased in
bulky, friable and bleeding
granulation tissue
Bassel Ericsoussi, MD 47

48. • Unsuccessful attempts may
push the FB distally into a
wedged position
Bassel Ericsoussi, MD 48
RISKS ASSOCIATED WITH
FIBEROPTIC EXTRACTION

49. ADVANTAGES OF FIBROPTIC BRONCHOSCOPY
• Fiberoptic is superior to rigid bronchoscopy in the
setting of
– Distally wedged FB
– Mechanically ventilated patients
– The presence of spine, craniofacial, or skull fractures
• The use of a laryngeal mask airway (LMA) allows
ventilation and easy access to the central airways
under general anesthesia
Bassel Ericsoussi, MD 49Limper AH; Prakash UB. Tracheobronchial foreign bodies in adults.
Ann Intern Med 1990 Apr 15;112(8):604-9.

50. Bassel Ericsoussi, MD 50

51. SECOND LOOK INSPECTION
• Once the FB is removed
– Reintubate the trachea with the bronchoscope
– The airways are carefully reexamined
– Rule out another FB or residual fragments
– If doubt persists, a repeat fiberoptic bronchoscopic
examination a few days later should be considered
Bassel Ericsoussi, MD 51Kim, IG, Brummitt, WM, Humphry, A, et al. Foreign body in the airway: a review of 202 cases.
Laryngoscope 1973; 83:347.

52. RECOMMENDATIONS
• Fiberoptic bronchoscopy under local anesthesia as the first
procedure for diagnosis and extraction in adults and children over 12
years old
• In case of asphyxiating FB, rigid bronchoscopy is the initial
procedure of choice
• Short course of corticosteroids before FB removal when a well-
tolerated FB is encased in bulky and bleeding granulation tissue
• Prophylactic use of corticosteroids to decrease the incidence of post-
operative subglottic edema. is not recommended and it should be
avoided
• Prophylactic use of ABx is not recommended
Bassel Ericsoussi, MD 52