Impacted foreign body bronchus: Role of percussion in removal.

Sir,

Foreign body (FB) aspiration is a life-threatening emergency, which requires prompt removal, but sometimes FB remains undetected.[1] Most of the foreign bodies are organic in nature, the common ones being nuts and seeds in children and food and bones in adults.

A 10-year-old female child with a history of ingestion of tamarind seed 4 months ago, accompanied by transient cough was referred to our center. On examination, air entry was markedly reduced in the middle and lower zones of the right lung. Chest X-ray showed right sided consolidation. Computed tomography of the chest revealed soft-tissue lesion with surrounding air meniscus in right main bronchus with consolidation of the right middle lobe.

Patient was taken for elective bronchoscopic removal of FB under general anesthesia. Injection glycopyrrolate 0.004 mg/kg was given IV and oropharynx was sprayed with 4% of lignocaine spray. Then patient was induced with injection ketamine 2 mg/kg IV and injection Succinylcholine 2 mg/kg IV. Maintenance was achieved with intermittent Succinylcholine and halothane in 100% O2. Ventilation was maintained with side port of the rigid bronchoscope. Only tiny fragments of the FB at a time could be removed. After about 20 min, the patient's SpO2 suddenly decreased due to slippage of FB into left main bronchus. After failure in maintaining saturation with bag and mask, intubation was done with 6 mm endotracheal tube. The air entry in the left lung was severely diminished. Repeat bronchoscopy was done. Many tiny fragments of FB were removed with a significant improvement in saturation. Expecting complete removal of FB, patient was re-intubated and ventilated and saturation maintained above 92%. Patient was shifted to intensive care unit (ICU) and was put on Ventilator. After 2 h, saturation fell down to 70%. Urgent chest X-ray revealed collapsed left lung. Patient was shifted back to operation theatre. Several failed attempts of bronchoscopic removal of FB were made. Patient was then placed in right lateral position and vigorous chest physiotherapy with percussion of the chest wall was given, following which a large piece of FB was removed from left main bronchus and saturation increased dramatically to 95%. Patient was re-intubated and shifted to ICU. Repeat chest X-ray showed bilateral clear lung fields. Patient was discharged from the hospital after 14 days with no neurological sequelae.

Bronchoscopy for removal of aspirated FB is an accepted gold standard.[2] It can be performed under spontaneous or controlled respiration. We preferred controlled respiration as the FB was of organic nature and was expected to be swelled up due to fluid absorption. Owing to prolonged retention of FB, formation of granulation tissue as well as difficult extraction was anticipated.

Migratory FB has always posed unique danger of compromising healthy lung ventilation requiring urgent intervention.[3] Like in our case, slippage of FB into uninvolved main bronchus made things worse. Intraoperative vigorous chest physiotherapy was an important maneuver performed in our case, which facilitated removal by dis-impaction of FB.[4] Intraoperative postural drainage is another method facilitating FB removal.[5]

We want to highlight that intraoperative percussion of the chest wall may be a useful additional intervention in certain situations to dislodge an impacted FB from the bronchial walls.