Overview
Definition:
Bronchoscopy is an endoscopic procedure used to visualize the airways, diagnose pathology, and perform therapeutic interventions within the tracheobronchial tree
Foreign body removal (FBR) via bronchoscopy is a critical application aimed at extracting inhaled objects that obstruct or endanger the airway.
Epidemiology:
Foreign body aspiration is most common in young children (1-3 years) and the elderly, with peak incidence in toddlers due to their exploratory behavior and immature motor skills
In adults, it is often associated with impaired consciousness, alcohol intoxication, or underlying neurological conditions
Prevalence varies by geographic location and socioeconomic factors, but is a significant cause of pediatric respiratory emergencies.
Clinical Significance:
Prompt and effective foreign body removal is crucial to prevent immediate airway compromise, such as asphyxiation, as well as delayed complications like pneumonia, lung abscess, bronchiectasis, and atelectasis
Bronchoscopy serves as both a diagnostic and therapeutic modality, enabling direct visualization and intervention, thus improving patient outcomes and reducing morbidity.
Indications
Indications For Bronchoscopy:
Suspected foreign body in the airway
Hemoptysis of unknown origin
Persistent cough or wheezing
Suspected malignancy or airway stenosis
Evaluation of trauma to the chest or airway
Collection of specimens (biopsy, bronchoalveolar lavage)
Therapeutic interventions like stent placement or dilatation.
Indications For Fbr:
Confirmed presence of an endobronchial foreign body causing significant symptoms
Acute airway obstruction
Recurrent pneumonia in a specific lobe or segment
Suspicion of aspiration in patients with altered mental status or neurological deficits
Objects visualized on imaging that are potentially lodged in the airway.
Contraindications:
Absolute contraindications are rare but include severe hypoxemia refractory to supplemental oxygen, hemodynamic instability, or inability to intubate/ventilate
Relative contraindications include severe coagulopathy, recent myocardial infarction, severe uncontrolled asthma, and patient refusal.
Diagnostic Approach
History Taking:
Detailed history of choking episode: onset, type of object (radiopaque vs
radiolucent), mechanism of aspiration, witness to the event
Associated symptoms: cough, dyspnea, stridor, hemoptysis, fever
Past medical history: neurological deficits, cognitive impairment, history of seizures, alcohol abuse, gastroesophageal reflux disease (GERD).
Physical Examination:
Assess airway patency and respiratory distress: tachypnea, retractions, accessory muscle use, stridor, wheezing, decreased breath sounds
Look for signs of cyanosis
Palpate for subcutaneous emphysema
Percuss for dullness (consolidation/atelectasis) or hyperresonance (air trapping).
Investigations:
Chest X-ray (AP and lateral views, inspiratory and expiratory views for air trapping): may reveal radiopaque foreign body, atelectasis, or pneumonia
CT scan of the chest: superior for visualizing radiolucent foreign bodies, identifying their exact location, and assessing associated lung pathology
Bronchoscopy: the gold standard for diagnosis and removal
Arterial Blood Gas (ABG): to assess oxygenation and ventilation status.
Management
Initial Management:
Ensure airway patency and adequate oxygenation
Monitor vital signs closely
If immediate airway obstruction is present, consider Heimlich maneuver or emergency cricothyroidotomy/tracheostomy
Administer supplemental oxygen
Intubation may be necessary for severe respiratory distress.
Pre Bronchoscopy Preparation:
NPO status for at least 6-8 hours
Informed consent
Pre-medication with anticholinergics (e.g., glycopyrrolate) to reduce secretions and bronchodilators if bronchospasm is present
Sedation or general anesthesia may be required
IV access established
Cardiac and pulse oximetry monitoring.
Bronchoscopic Procedure:
Flexible bronchoscopy: typically performed under conscious sedation and local anesthesia
Useful for smaller airways and diagnostic biopsies
Rigid bronchoscopy: usually performed under general anesthesia with spontaneous ventilation or controlled ventilation
Preferred for FBR due to larger working channel, better optics, and ability to use specialized grasping instruments and ventilation techniques (e.g., Sanders jet ventilation).
Foreign Body Removal Techniques:
Selection of appropriate instruments: forceps (alligator, grasping), baskets (Dormia), Fogarty catheters, aspiration catheters, endobronchial brushes
Techniques include grasping, pushing the object distally into a larger bronchus for removal, using a broncho-suction catheter, or employing a "bagging" technique with a rigid bronchoscope
Careful manipulation to avoid trauma to the airway mucosa and further impaction
If removal is not possible, consider bronchoscopic fragmentation or referral for surgical removal.
Postoperative Care
Immediate Post Procedure:
Monitor vital signs, oxygen saturation, and respiratory status closely
Assess for signs of bleeding, pneumothorax, or laryngospasm
Maintain NPO until gag reflex returns
Pain management as needed.
Monitoring For Complications:
Watch for delayed complications such as fever, increased cough, purulent sputum, dyspnea, or hemoptysis, which may indicate post-obstructive pneumonia or lung abscess
Serial chest X-rays may be required.
Follow Up:
Typically a follow-up appointment within 1-2 weeks
Chest X-ray to ensure resolution of atelectasis or infiltrates
Depending on the foreign body and patient's condition, further bronchoscopy may be considered to ensure complete airway clearance and healing.
Complications
Early Complications:
Laryngospasm
Bronchospasm
Hypoxemia
Bleeding
Pneumothorax
Vocal cord injury
Dental trauma
Bronchial perforation
Airway mucosal injury.
Late Complications:
Post-obstructive pneumonia
Lung abscess
Bronchiectasis
Atelectasis
Granuloma formation
Tracheoesophageal fistula (rare)
Persistent cough.
Prevention Strategies:
Careful selection of instruments
Gentle manipulation of airways
Adequate visualization during the procedure
Thorough post-procedure monitoring
Prompt treatment of post-obstructive pneumonia
Educating parents about choking hazards in children.
Key Points
Exam Focus:
Indications and contraindications for bronchoscopy and FBR
Differences between flexible and rigid bronchoscopy
Common foreign bodies and their typical locations
Management of pediatric vs
adult FBR
Complications of bronchoscopy and FBR
Role of imaging in FBR.
Clinical Pearls:
In pediatric patients, a negative chest X-ray does not rule out a foreign body
Always obtain inspiratory and expiratory films in suspected cases of radiolucent foreign body to detect air trapping
Rigid bronchoscopy is generally preferred for FBR due to better control and larger instruments
Consider pushing a non-obstructing foreign body distally if it cannot be grasped, to facilitate removal from the mouth
Be prepared for immediate airway management during bronchoscopy.
Common Mistakes:
Inadequate history taking regarding the choking event
Delaying bronchoscopy when indicated
Attempting FBR with inappropriate instruments or technique
Failure to identify and manage post-obstructive pneumonia
Not considering differential diagnoses of airway lesions.