Fogarty Catheter: An Indispensable Tool to Complement the Ingenuity of the Endoscopist for Extraction of Airway "Foreign Body with a Hole".

Introduction: The extraction of smooth spherical objects is challenging as they are difficult to grasp within the jaws of the forceps and tend to slip distally. Objective: The authors herein have shared their experience with the use of a Fogarty catheter (FC) for safe extraction of smooth and spherical "foreign body (FB) with a hole." Materials and
Methods: Report on pediatric cases (n = 4) of airway "FB with a hole" wherein the FC was used for their extraction. Mean age was 27.5 months (range: 17 months-39 months). The male: female ratio was 3:1. The technique of FB extraction with a FC has been described, including the principle of the technique, indications, and contra-indications, technical problems and troubleshooting.
Results: The FB spectrum included a necklace bead (n = 2), nonnecklace bead (n = 1) and a fragmented end-piece of the housing of a ball-pen (n = 1). The locations of the FBs were right main bronchus (n = 1), secondary bronchus on the right (n = 1), and in the left main bronchus (n = 2). Successful removal of FB with use of FC during rigid broncoscopy was possible. The bead had to be rotated in n = 2 patients to align the hole with the FC. Problems associated with threading the hole and disimpaction of the FB have been highlighted. No complications were observed. The advantages and limitation of the technique have been discussed. Conclusions: The use of FC with the described technique offers a safe, effective and reproducible method for removal of airway "FB with a hole" in a controlled environment while minimizing the possibility of iatrogenic injury to the wall of the surrounding airways. Copyright:

INTRODUCTION

Aspiration of a foreign body (FB) could be life-threatening. Early diagnosis and prompt removal are important to reduce the morbidity and contain the mortality. The extraction of smooth spherical objects is challenging as they are difficult to grasp within the jaws of the forceps and tend to slip, relocating distally. Besides, repeated instrumentation of the trachea-bronchial tree can be traumatic. In the absence of well-defined protocol for safe extraction of such objects, the success of the procedure is dependent upon multiple factors including the ingenuity and agility of the endoscopist.

The Fogarty® arterial embolectomy catheter (Edward Lifesciences) was designed in 1961 by Dr. Thomas J Fogarty to remove soft, fresh emboli or thrombi from the arterial system. Since then, the device has been deployed in diverse situations such as threading of tracheoesophageal fistula during bronchoscopy prior to definitive surgery,[1] temporary intra-luminal occlusion of the common iliac artery to minimize blood loss during pelvic surgery (internal tourniquet)[2] or as a bronchial blocker for single-lung ventilation.[3] The authors herein have shared their experience with the use of a Fogarty catheter (FC) for safe extraction of “FB with a hole” which defy the grasp of the conventional forceps from the pediatric airway. It is suggested that this simple and universally available device should be considered an “integral” component of the bronchoscopy set-up while handling airway FBs.

MATERIALS AND METHODS

The report is based on the prospectively collected data on pediatric cases of airway “FB with a hole” wherein the FC was used for their extraction. All the cases (n = 4) were managed in the same department under the supervision of the senior author. The mean age was 27.5 months (range: 17 months–39 months). The male: female ratio was 3:1. Three patients presented directly to the casualty in the authors' institute, while one patient underwent a rigid bronchoscopy in another center. The FB was visualized in the right main bronchus, but the extraction failed. He was then referred to the authors' institute.

Treatment protocol for airway foreign bodys

Patients with suspected FB aspiration usually present to the casualty/emergency. Generally, a chest radiograph is sufficient [Patients 1, 2, 4; Table 1; Figure 2a]; rarely, computed tomography of the chest in patients with inconsistent history or atypical presentation [Patient 3; Table 1] may be indicated.

Table 1

Clinical and case details of cases included in the report

	Patient 1	Patient 2	Patient 3	Patient 4
Age (months)	39	17	35	19
Sex	Female	Male	Male	Male
Nature of FB	Necklace bead	Bead (some toy; not a necklace)	Partially fragmented end-piece of a ball pen	Necklace bead
Characteristics of the FB	Smooth surface, hole within, outer diameter 7.5 mm	Smooth surface, hole within, outer diameter 8 mm	cylinder, both ends open, outer diameter~9 mm	Smooth surface, hole within
Anatomical location	Left main bronchus	Left main bronchus	Right main bronchus	Right main bronchus at initial bronchoscopy; in secondary bronchus at second broncoscopy
Confirm history available	Yes	No; but history of child playing with the beads	No	Yes
Duration	12 h	4 h	5 months	3 days
Presenting symptoms	None; parents gave a history of bead aspiration	Irritable child, cough, tachypnoea, dysnoea	Recurrent respiratory infection	Wheeze and respiratory distress
Previous procedure	None	None	None	Rigid bronchoscopy elsewhere; bead visualized but retrieval failed
Chest radiography	Suggestive of a bead in left main bronchus	Non-contributory	Evidence of infection in right hemi-thorax; direct evidence of FB lacking	Mild right-sided hyperinflation
Need for further investigations (CT scan, etc.)	None	None	CT Scan documented presence of FB in right main bronchus; surrounded by granulation tissue	None
Procedure	Rigid bronchoscopy	Rigid bronchoscopy	Rigid bronchoscopy	Rigid bronchoscopy
Attempt with coventional forceps	Yes, failed. FB moved distally	Yes, failed. FB moved distally	Yes, failed	Not attempted
Total duration of procedure (min)	15 min	10 min	21 min	18 min
Fogarty size	3 Fr	4 Fr	3 Fr	3 Fr
Duration from fogarty insertion to FB engagement	~3 min	~90 s	~45 s	~3 min
Mechanism of extraction from airway after FB was engaged	FB was contained within the sheath	FB was sandwiched between tip of sheath and fogarty balloon	FB was contained within the sheath	FB was sandwiched between tip of sheath and fogarty balloon
Extubation of patient on-table	Yes	Yes	No; patient was ventilated for one day and extubated in HDU	Yes
Postoperative course	Uneventful, discharged within 24 h procedure	Uneventful, discharged within 24 h of procedure	Patient had pneumonia, required intravenous antibiotics for 5 days; recovered uneventfully	Uneventful, discharged within 24 h of procedure
Complications	None	None	None	None

CT: Computed tomography, FB: Foreign body

Figure 2

(a) Chest X-ray PA view of Patient 1 showing the presence of a hollow bead in the left main bronchus (highlighted by the white arrow) just distal to the carina. (b) Patient 1: After threading the Fogarty catheter through the bead, the balloon is inflated with air to lock the bead. (c) Patient 3: After threading the Fogarty catheter through the fragmented component of the ball pen, the balloon is inflated with air. (d) Patient 3: The fragmented component of the ball pen is sandwiched between the tip of the bronchoscopy sheath and the inflated balloon. Images 2B-D are trying to demonstrate the intra-bronchial events through ex vivo simulation

Subsequently, the patient is taken up for rigid bronchoscopy and FB removal.

Technique of foreign body extraction with a Fogarty catheter

Aim of technique

(a) To assist in safe and effective removal of airway “FB with a hole” which defy the grasp of the conventional forceps, (b) To maintain control of the object during extraction, and (c) To prevent/minimize the iatrogenic damage to the surrounding tissues during bronchoscopy and FB removal.

Principle of technique

A catheter with an inflatable balloon is threaded through the hole in the FB. Inflation of the balloon will not only provide grasp, but the retrieval of the FB will occur in a controlled environment by sandwiching the FB between the tip of the bronchoscopy sheath and the balloon.

Indications

(a) Bronchoscopic removal of airway “FB with a hole,” (b) endoscopic retrieval of similar FBs in the esophagus or other body cavities.[4]

Contra-indications

(a) FBs which do not have a hole, (b) when the diameter of the hole is not big enough to accommodate the smallest size (2Fr) of FC available.

Prerequisites

(a) Classical bronchoscopy set-up with (preferably) optical or nonoptical grasping forceps with different jaw designs [Figure 1]. (b) FC of appropriate size (and maybe one size smaller) with an intact inflation-deflation mechanism [Figure 1-inset picture].

Figure 1

The authors suggest keeping a Fogarty catheter as an integral part of bronchoscopy set-up for removal of airway foreign bodys. (Inset): It is important to check that the inflation and deflation mechanism is intact ahead of the procedure

Procedure

Rigid bronchoscopy is performed, and the FB is identified. Suctioning of the secretion over and around the FB will provide a clear vision of the hole.

Technical problems

(a) It is difficult to grasp smooth and spherical FBs with the conventional forceps, (b) A grasp, if at all is usually temporary and the object tends to slip upon withdraw attempt [Figure 3], (c) Distal relocation on slipping, (d) the more distal the FB is located, the narrower is the airway and lesser is the space available to open the jaws of the forceps, and (e) repeated instrumentation also inflicts iatrogenic trauma to the wall of the surrounding bronchus.

Figure 3

Diagrammatic depiction of the mechanics involved in grasping the smooth spherical foreign body with the jaws of the forceps. (1) Bronchial wall, (2) Bronchial mucosa with varying degrees of edema depending upon duration of foreign body and its nature (organic vs. inorganic), (3) Intra-bronchial passage, (4) Smooth, spherical foreign body; necklace bead intended to be depicted in the figure, and (5) Optical alligator foreign body forceps. (A) Direction of forceps applied by the closing jaws of the optical alligator foreign body forceps. (B) The equator of the spherical foreign body. It may be noted that the jaws will rarely reach beyong the equator. The airway is narrow and limits the permissible size of the jaws and their width. (C) The foreign slips the grasp and is displaced distally as a result of cumulative effect of the forces applied by the jaws of the forceps. The smooth surface and the spherical shape both predispose to such an event

The Fogarty technique

FC of appropriate size with the balloon fully collapsed is introduced through the side-port of the bronchoscopy sheath and advanced into the airways. The tip is directed through the hole in the FB and across it so that the region of the balloon is beyond the FB. The balloon is inflated with air to lock the FB [Figure 2b; Patient 1].

The FC is withdrawn. Depending upon size, the FB is either contained inside the bronchoscopy sheath or sandwiched between sheath-tip and the inflated balloon [Figure 2c and d; Patient 3]. The bronchoscopy set-up is withdrawn en masse.

Troubleshooting

The procedure may be facilitated by the following maneuvers: (a) Proper suctioning of secretions and blood (if any) around the FB for better vision, (b) application of adrenaline-soaked pledget to the mucosa of the granulation tissue or the mucosa of the airways if the site if oozing and obstructing the vision, (c) use of 2% xylocaine jelly over the tip of the FC for lubrication, and (d) use of smaller sized FC to smooth passage through the hole in the FB.

Patience is the key to success

Caution

(a) The alignment of the foreign may not be favorable to inserting the FC; it may need to be rotated with the help of the conventional, (preferably) optical forceps. There is a risk of pushing the FB distally and caution is warranted.

(b) FBs with a sharp edge which could cause a linear injury to the surrounding mucosa during pulling. Such FBs are best managed by the Kangaroo technique.[56]

Posttechnique

Check bronchoscopy to (a) ascertain that additional FBs are not present, (b) suctioning of mucus collected distal to the FB, (c) confirm that contra-lateral airways are clear, (d) evaluate any injury to the airways during the process of FB extraction, and (e) hemostasis from the granulation tissue or mucosal injury (if any).

Postprocedure chest radiograph is performed six hours after the procedure.[78]

RESULTS

The clinical details of the patients (n = 4) included in the study cohort are summarized in Table 1.

The FB spectrum included necklace beads (n = 2), nonnecklace toy bead (n = 1), and a fragmented end-piece of the housing of a ball-pen (n = 1). Confirmed history of aspiration of a FB was available in two patients. One of them was also carrying a sample of the aspirated bead at presentation. History of the child playing with and mouthing beads while the event happened could be elicited from the mother in one patient, although she was not aware of aspiration. One patient presented with an off-and-on respiratory infection for 5 months with no suggestion of FB aspiration.

The locations of the FBs were variable: Right main bronchus (n = 1), secondary bronchus on the right (n = 1), and in the left main bronchus (n = 2). Two patients presented with acute respiratory symptoms (Patient 2 and 4) while one was asymptomatic (Patient 1), and one had a history of respiratory tract infection for the past 5 months (Patient 3).

Reduced air entry on the affected side was present in only one patient consistent with hyperinflation of ipsilateral lung upon chest radiography (Patient 4). The same child had presented to the emergency room with wheeze and respiratory distress. The absence of reduced air entry clinically and its manifestations upon radiology may be explained by the presence of a hole within the FB permitting air to pass through.

The relative orientation of the hole in the FB and the FC was discordant in two patients (Patients 1 and 4), it was possible to rotate the bead by gentle manipulation with the conventional forceps. The fragmented piece of ball pen had a wide aperture and threading the Fogarty was easy.

The mucosal edema was not tenacious in either of the cases. The beads are inorganic, and the granulation is generally minimal to absent. In Patient 4, the bead was impacted in the secondary bronchus attributable to failed attempts at FB removal. Disimpaction was possible by insinuating the closed jaws of the optical forceps between the bead and the bronchial wall.

The FB was contained within the sheath in two cases (Patient 1 and 3) and sandwiched between the sheath and balloon in two cases (Patient 1 and 4).

No intra- or postoperative complications were documented in either patient.

DISCUSSION

From sucking on the mother's breasts to exploring and investigating the objects within reach, mouthing is an important component of child development. However, this habit predisposes them to FB aspiration. With the diversity of spectrum, it is not possible to design a dedicated instrument for each type of FB. Interruption with normal respiration and potential to cut off the airway completely makes the situation life-threatening.

Anatomy of the Fogarty catheter

It is a long, thin, malleable plastic catheter with an inflatable balloon at its distal end. The Fogarty arterial embolectomy catheter comes in sizes arising from 2 Fr to 7 Fr and length varying from 40 cm to 80 cm. The inflated balloon diameter is 4, 5, and 9 mm for Fogarty of sizes 2, 3, and 4 Fr, respectively. The balloon has been designed to be symmetrical after inflation so that it makes a uniform contact with the vessel wall to ensure even pressure and precise traction.[9] This anatomy ensures uniform pressure on the surrounding bronchi thereby minimizing the possibility of trauma to the bronchial walls or slipping of the balloon through the hole in the bead. Designed for embolectomy initially, the catheter was patented in 1969 and has saved innumerable limbs worldwide. Over the years, the catheter has found utility over a diverse range of surgical problems.[10]

Fogarty catheter versus Foley catheter

In case of FC, the balloon is hand-tied to the catheter with the “recessed winding” technique to prevent substantial increase in the combined diameter of the balloon and the catheter body. Contrarily, the Foley catheter is 1–2 mm wider than the declared size in the region of the balloon.[11] Second, FC is available for sizes as small as 2 Fr while the smallest sized foleys catheter is 6 Fr in size.

Initial use of Fogarty catheter for foreign body removal and its limitation

The first description of the use of FC for removal of airway FB was in dogs[12] followed by dis-impaction of a carrot from the left main bronchus of a 1-year-old child.[13]

The necklace bead is a unique amalgamation of handicap and virtue

Necklace beads and similar FBs which have a spherical configuration and a smooth outer surface are generally difficult to grasp. Firstly, an effective grasp is possible if the spherical object is held beyond the equator which may not be possible due to airway lumen [Figure 3]. The bead tends to slip distally when held with the conventional forceps. Second, the smooth surface of the bead which is smeared with the mucoid secretions makes the bead prone to defy the grasp. Thirdly, with every failure of grasp, it is likely that the bead migrates and re-locates distally into the narrower airways.[14]

However, the beads have a hole in the center carved to accommodate the string, which keeps the beads of the necklace in place, but it is generally large enough to accommodate the 3Fr FC. The hole permits free passage of FC if large enough and aids in its extraction.

Advantages of the Fogarty technique

The Fogarty technique offers several advantages. (a) It is possible to remove the sharp and spherical “FB with a hole” in a controlled environment, (b) after the FB is engaged to the inflated balloon, mild-to-moderate tug on the FC also helps to disimpact the FB from narrower airways and mucosal edema without having to insinuate the forceps between the FB and the bronchial walls forcefully, (c) FBs which have sharp edges can inflict trauma to the surrounding walls during retrieval; it is possible to contain such objects within the bronchoscopy sheath, and (d) objects which are larger than the bronchoscopy sheath may be sandwiched between the tip of the sheath and the inflated balloon.

Limitation of the Fogarty technique

(a) When there is a discordance between the axis of the hole inside the FB and the axis of the FC, re-alignment of the object with the conventional forceps is tricky and may result in distal dislodgement of FB, (b) rupture of the balloon due to excess air-pressure or re-use over more than one case may lead to loss of control over the FB, and (c) cost of Fogarty's catheter (single use recommended).

CONCLUSIONS

The use of FC with the described technique offers a safe, effective, and reproducible method for removal of airway “FB with a hole” in a controlled environment while minimizing the possibility of iatrogenic injury to the wall of the surrounding airways.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.