Foreign body removal by flexible bronchoscopy using retrieval basket in children.

OBJECTIVES: Aspiration of foreign bodies into the tracheobronchial tree is a common accident in children. This study aimed to evaluate the safety and outcome of foreign body removal by flexible bronchoscopy using a retrieval basket in children.
METHODS: This was a retrospective study of children treated for foreign bodies in the airway via flexible bronchoscopy using a retrieval basket at a tertiary hospital in Korea between February 2014 and October 2017. The medical records of the patients were retrospectively reviewed and analyzed.
RESULTS: A total of 20 children underwent foreign body removal from the airway via flexible bronchoscopy using a retrieval basket. The median age of the patients was 16 (range, 10-21.5) months, and 12 (60%) were male. Foreign bodies removed included 16 (80%) organic items including peanuts, almond, and beans, and 4 (20%) inorganic items including a plastic bag, metal screw, spring, and Lego brick. The locations of the foreign bodies included the central airway (n = 5; trachea, n = 4; subglottic area, n = 1), right bronchial tree (n = 9), and left bronchial tree (n = 6). Successful removal was observed in 18 (90%) cases. The only complication that occurred was mild laryngeal edema (n = 2) after the procedure; both improved with corticosteroid administration.
CONCLUSION: Flexible bronchoscopic extraction of a foreign body in the airway using a retrieval basket in children can be performed successfully with minimal complications.

Aspiration of a foreign body is a common problem in the pediatric population. Especially, infant and young children are injured more frequent by a foreign body in the airway.[1] A delay in the diagnosis of an aspirated foreign body can increase morbidity and mortality, ranging from life-threatening airway obstruction to recurrent infection and wheezing or coughing.[2] Early diagnosis and treatment is important if the clinical history suggests foreign body aspiration, even if physical and radiologic findings are negative.

Rigid bronchoscopy was formerly the preferred treatment method for the removal of a foreign body in the airway.[3] However, foreign body extraction using rigid bronchoscopy can be difficult, especially with peanuts, because they are likely to fragment and cause tissue reaction with formation of granulation tissue.[4] Wood and Gauderer[5] reported 7% negative rates of rigid bronchoscopy in case of initial evaluation and 5% in the total number of rigid bronchoscopies. In another study, negative rigid bronchoscopy rates were 16% (initial rigid bronchopy) and 9% (total number rigid bronchoscopies).[4]

Flexible bronchoscopy has replaced rigid bronchoscopy as the diagnostic and therapeutic tool for cases with airway foreign body. Flexible bronchoscopy causes less trauma and is very helpful for identifying and localizing foreign bodies because it can reach more distal bronchial regions.[6] The present study aimed to evaluate the safety and outcome of foreign body removal by flexible bronchoscopy using a retrieval basket in children.

Methods

This was a retrospective cohort study of patients who underwent foreign body removal from the airway through flexible bronchoscopy using a retrieval basket at Seoul Saint Mary's Hospital between February 2014 and October 2017. We retrospectively reviewed their medical records and radiologic examination data. The patients were confirmed to have a foreign body by flexible bronchoscopy upon suspicion based on history, clinical symptoms, signs, and radiologic findings.

Model FG-51D, FG-52D, and FG-55D retrieval baskets (Olympus Co., Tokyo, Japan) were used to extract foreign bodies in the airway [Figure 1]. They are three- or four-stranded baskets with an opening width of 9–14 mm and 1.2 mm channel size. The flexible bronchoscopy instrument was a model BF-XP260F device (Olympus Co.; distal end outer diameter 2.8 mm) or model BF-260 device (Olympus Co.; distal end outer diameter 4.9 mm).

Figure 1

The retrieval basket

This retrospective analysis was approved by the Institutional Review Board at Seoul Saint Mary's Hospital, the Catholic University of Korea, Seoul, South Korea (Protocol Number: KC17RESI0170).

Results

Twenty patients underwent foreign body removal from the airway through flexible bronchoscopy using a retrieval basket. The median age of the 20 patients was 16 (range, 10–21.5) months and 12 (60%) were male. Foreign body removal from the airway using the retrieval baskets was successful in 18 patients. The two patients who had successful removal of foreign bodies in the airway experienced laryngeal edema after the procedure. Both were mild and improved with corticosteroid administration [Table 1].

Table 1

Demographic and clinical characteristics (n=20)

Most patients (n = 11) presented with cough when admitted to the hospital. Other symptoms included tachypnea and/or dyspnea, cyanosis, and vomiting. Three patients were diagnosed as pneumonia at first. However, there were no response of treatment, and the foreign body in airway was found in a chest computed tomography scan. The patients were referred to our hospital. Three patients had no symptom of foreign body aspiration. Ten patients (40%) presented with wheezing and five (20%) had reduced breath sound. Other presenting signs were crackles and stridor. Six patients (30%) had normal breath sound [Table 2]. Chest X-ray was normal in 55% of cases, showed air trapping in 7 cases (35%).

Table 2

Symptoms and clinical signs on the day of admission

Removed foreign bodies in airway included 16 (80%) organic items including peanuts (n = 9), almonds (n = 3), beans (n = 2), pumpkin seeds (n = 1), and peach pit (n = 1). There were 4 (20%) inorganic items that included a piece of plastic bag (n = 1), metal screw (n = 1), spring (n = 1), and Lego brick (n = 1) [Table 3].

Table 3

Nature of foreign bodies in the 20 patients

Overall, 5 (25%) foreign bodies were located in the central airway (trachea, n = 4; subglottic area, n = 1), 9 (45%) in the right bronchial tree, and 6 (30%) in the left bronchial tree [Table 4].

Table 4

Anatomic location of foreign bodies in the 20 patients

Discussion

It is clear that extraction of foreign bodies in the airway using the flexible bronchoscope has many advantages. The smaller size and better navigational properties of the flexible bronchoscope permit examination of the lower airways with less trauma, which is not possible with the rigid bronchoscope.[7] In addition, it can be used for several procedures, such as bronchoalveolar lavage, transbronchial, or endobronchial biopsies as occasion demands.[8] Numerous studies have reported the successful removal of airway foreign body using flexible bronchoscopy [Table 5].

Table 5

Previous studies of foreign body removal through flexible bronchoscopy in children

However, the use of flexible bronchoscopy for the extraction of airway foreign bodies in children has been hampered by the small caliber of the suction channel and lack of appropriate instruments available to grasp the airway foreign bodies.[2] Even though many studies attempted to use various types of instruments, such as forceps or baskets, for extraction of foreign bodies in the airway,[2910111213] the lack of standard equipment for foreign body removal in airway has been a hindrance.

We extracted foreign bodies in the airway of children through flexible bronchoscopy using retrieval baskets (FG-51D, FG-52D, or FG-55D; Olympus Co.). The retrieval basket is uniquely designed for foreign body removal in the airway. It is composed of three or four strands to stably grasp objects. It is small enough to pass the channel and can unfold sufficiently to wrap around the objects in the airway. These properties may enable successful removal of foreign bodies and may also minimize accidental dislodgement. In our study, 20 children underwent foreign body removal using this system. Eighteen (90%) cases were successful.

The procedure failed in two patients. One patient was a 19-month-old male with an almond lodged in left lower lobe of the bronchus. First, he failed to remove foreign body by the rigid bronchoscopy from another hospital. We tried flexible bronchoscopy using retrieval basket after transfer, but it also did not work. A few days later, bronchostomy was performed and the foreign body was finally removed. The other one was an 8-month-old female with a metal screw in the right lower lobe bronchus. She first failed in flexible bronchoscopy using retrieval basket and therefore tried again with the rigid bronchoscopy. However, there was a trouble in security of sight, and also, the foreign body was located in distal area. This method also could not be a solution and the patient had to be transferred to another hospital for surgical treatment. These objects were difficult to remove by both flexible and rigid bronchoscopy due to their tight position in the distal portion of the lower airway. Surgical management was necessary to remove the two foreign bodies. There were two minor complications of laryngeal edema immediately after the procedure in patients who had successful removal of foreign bodies. Both cases improved with corticosteroid administration.

All of the patients were preschool children, in agreement with other studies. Endoh et al.[12] reported 24 cases of airway foreign body removal using flexible bronchoscopy; all the patients were under 5 years of age. A study from Germany also reported cases of foreign body aspiration with the majority in preschool-aged children.[10] Younger children are at the highest risk for accidental foreign body aspiration because they tend to put small objects into their mouths and do not have molars to chew certain foods adequately.[14] It is important that parents and caretakers should be educated to withhold foods, such as peanuts, until the child is capable to chew them properly and to keep small objects, such as pins, out of their child's reach.

There are some limitations in the present study. First, this is a retrospective study from a single institution. Second, this study has a limitation of stemming from its small sample size. Studies including a larger number of foreign body aspiration cases from multicenters would be helpful in further assessing the clinical utility of the retrieval basket.

Conclusion

The retrieval basket can be a safe, reliable, and effective instrument for extracting airway foreign bodies in pediatric patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.