Role of fob in FB extraction

1. Role Of FOB in FB
Extraction
By
DrMahmoud E. Abolmagd
Assistant Lecturer of pulmonary and
critical care medicine
Mansoura university

2. INTRODUCTION

3. INTRODUCTION
• Foreign body aspiration is a worldwide health problem
which often results in life threatening complications.
• More than two thirds of foreign body aspirations occur
among children younger than 3 years.
• Organic materials such as nuts, seeds, and bones are most
commonly aspirated.
• There is a wide range of clinical presentation, and often
there is not a reliable witness to supply the clinical history,
especially in children.

4. INTRODUCTION-cont
• When diagnosis is delayed, complications of a retained
foreign body such as unresolving pneumonia, lung abscess,
recurrent haemoptysis, and bronchiectasis may necessitate
a surgical resection.
• Boys are affected more frequently than girls.

5. INTRODUCTION-cont
• It has been reported that 40–70% of foreign body
aspirations occur in the right bronchial system, 30–40% in
the left bronchial system, and 10–20% in the laryngo-
tracheal region .
• It has been reported that the success rate of rigid
bronchoscopy is 98%, while that of FOB is only 60–75% .

6. PATHOGENESIS

7. PATHOGENESIS
• There is a bimodal age distribution, with a second peak
around age 10.
• The younger group is more vulnerable because of the lack
of adequate dentition and immature swallowing
coordination.
• Additionally, among children of this age, introducing
objects into their mouths is their way of exploring the
world.

8. PATHOGENESIS-cont
• In adults, FBA is caused mostly by the failure of airway
protective mechanisms, such as alcohol intoxication, poor
dentition, sedative or hypnotic drug use, senility, mental
retardation, primary neurological disorders with
impairment of swallowing or mental status, trauma with
loss of consciousness, seizure, and general anaesthesia.
• Less frequently, accidental aspiration of any material (food
parts, small toy parts, etc) in the mouth during laughing,
crying, or sneezing can occur in all age groups.

9. PATHOGENESIS-cont
• In adults, the right bronchial system is more likely to be
obstructed by aspirated foreign bodies.
• The preponderant right sided location of the foreign body is
not found in children because the left mainstem bronchus
is closer in size to the right mainstem bronchus; in addition,
the left mainstem bronchus does not branch at the same
acute angle as in adults.
• When a foreign body is inhaled into the distal bronchial
system without causing an acute obstruction, it may remain
silent for a while depending on its nature.

10. PATHOGENESIS-cont
• Organic materials cause a more severe mucosal
inflammation, and granulation tissue may develop in a few
hours.
• Objects such as beans, seeds, and corn can absorb water,
and with subsequent swelling, partial obstruction can
change to total obstruction.
• Patients who have inhaled small inorganic materials usually
remain asymptomatic for a longer period of time unless
total obstruction of a distal airway is caused.

11. CLINICAL PRESENTATION

12. CLINICAL PRESENTATION
• The severity of the symptoms during the presentation of an
aspirated foreign body can vary depending on the site of
impact as well as the nature of the foreign body.
•
• Even though it is not common, occlusion of the larynx with
an aspirated large object can cause an acute and dramatic
presentation, and a brief period of choking and gagging
may be associated with hoarseness, aphonia, and cyanosis.
• The Heimlich manoeuvre is recommended for these
instances.

13. CLINICAL PRESENTATION-cont
• In the presence of long standing aspirated foreign bodies,
recurrent haemoptysis, and symptoms consistent with
recurrent bronchitis, pneumonia, and bronchiectasis, such
as chronic productive/unproductive cough, and wheezing,
may exist.
• Diagnostic triad present in less than 50% of cases. The triad
consists of unilateral wheeze, cough, and ipsilaterally
diminished breath sounds.
• The symptoms and examination can mimic asthma, croup
or pneumonia.

14. IMAGING STUDIES

15. IMAGING STUDIES
• In up to 40% of patients with suspected airway FBs, the
chest radiograph is normal.
• The standard posteroanterior chest roentgenogram is
commonly performed in patients with suspected airway FB
aspiration.
• Inspiratory and expiratory views as well as lateral neck
radiographs may also help.

16. IMAGING STUDIES-cont
• radiographic findings in cases of suspected foreign body
aspiration include:
• a) Normal findings (25%).
• b) Signs of air trapping .
• c) Mediastinal shift.
• d) Atelectasis.
• e) Pneumonia (Acute or recurrent).
• f) Lobar collapse.
• g) Radiopaque foreign body.

19. FOREIGN BODY REMOVAL AND
UTILITY OF
FLEXIBLE BRONCHOSCOPY

20. FOB
• The bronchoscopes with 4.9 mm outer diameter and a 2.2
mm diameter working channel are used in patients older
than 12 years of age.
• Although bronchoscopes with 3.5 mm or 2.7 mm outer
diameter with 1.2 mm diameter working channels are
available for younger patients.

21. FOB-cont
• Rigid bronchoscope provides greater access to the
subglottic airways, ensuring correct oxygenation and easy
passage of the telescope and grasping forceps during the
extraction of a large foreign body.
• Rigid bronchoscope allows a very efficient airway
suctioning in case of a massive bleed.

22. FOB-cont
• The adult flexible bronchoscope can be used through the
nasal passage, oral passage, and tracheostomy stoma, with
or without an endotracheal tube.
• In children, oral insertion is ideal.
• A large-diameter endotracheal tube or a laryngeal mask
airway will allow an adequate channel for oral insertion of
the broncoscope.

23. FOB-cont
• Flexible bronchoscope has many advantages over a rigid
bronchoscope in the initial diagnosis of a foreign body.
• First, flexible bronchoscopy is a relatively easy and a safe
procedure in experienced hands.
• Second, with the use of a flexible bronchoscope under local
anaesthesia for the visualisation of airways, removal of the
foreign body can be attempted and avoids the added cost,
risk, and morbidity of a secondary invasive procedure such
as rigid bronchoscopy under general anaesthesia.

24. FOB-cont
• Third, fibreoptic bronchoscopy is superior to rigid
bronchoscopy in cases of distally wedged foreign bodies, in
mechanically ventilated patients or in cases of spine, jaw, or
skull fractures preventing rigid bronchoscope manipulation.
• The success rate of the flexible bronchoscope in removing
foreign bodies can be as high as 100% in experienced hands
when a careful case selection is made.

25. FOB-cont
• Another important advantage of fibreoptic bronchoscopy
applies when severe complications occur due to a long
retained foreign body.
• Nonbronchoscopic techniques have included the use of
systemic steroids to decrease edema of the airway mucosa
so that expectoration of the FB is facilitated.

26. FOB-cont
• When considering extraction of a FB with the flexible
bronchoscope, an important initial step is to determine
how the airway is secured.
• If a patient is in significant respiratory distress because of
major airway obstruction caused by the FB, rigid
bronchoscopy is the procedure of choice.

27. FOB-cont
• Postbronchoscopic complications occur in 5% of cases, and
are usually secondary to a foreign body inflammatory
reaction.
• These reactions include atelectasis, pneumonia, retained
fragments, vocal cord swelling, bronchospasm or
laryngospasm, pneumomediastinum, bleeding from
foreign-body-induced perforation, and death .

28. Ancillary Instruments
• The primary ancillary instruments used for extraction of FBs
using the flexible bronchoscope have largely been derived
from those used in gastroenterologic and urologic
procedures.
• These include the ureteral stone baskets and stone forceps
used for the removal of ureteral stones.
• These pass easily through the working channel of a
pediatric flexible bronchoscope with a working channel
diameter of>1.0 mm.

29. ureteral stone baskets

31. Ancillary Instruments-cont
• Standard adult bronchoscope can be used with
other types of ancillary equipment such as :-
- Bronchoscopic biopsy and grasping forceps.
- Fogarty balloon catheter.
- YAG laser contact tip.
- Pronged snares.
- Suction.

32. Fogarty balloon catheter

33. Ancillary Instruments-cont
• When the Fogarty balloon catheter is utilized, it is passed
beyond the FB and the balloon is inflated and then slowly
withdrawn.
• This is often successful in bringing an FB from a distal
position in the bronchial tree to a more proximal one
where it can be more easily grasped.
• The cryotherapy probe has also been used to extract airway
FBs. In this situation, the cryotherapy probe is placed
against the FB, which adheres to it and is then removed.

34. Complications of FB
extraction

35. Complications of FB extraction
• Complications of FB extraction include :-
- laryngeal edema.
- stridor.
- fever.
- airway obstruction if the FB is dropped
inadvertently in the trachea.

36. Complications of FB extraction-cont
• If a FB is dropped and significant tracheal obstruction
occurs, the bronchoscope should be used to immediately
push the FB back into one of the mainstem bronchi.
• This will allow adequate ventilation of at least one lung
while alternative plans are formulated.

37. Controversy

38. Controversy
• One report states that the flexible fiberoptic instruments
are not indicated because they may cause dangerous
consequences such as displacement of the foreign body to
a difficult to access position, or fragmentation of the
foreign body.
• Another declares that rigid bronchoscopy is the only
procedure that allows diagnosis and removal of the foreign
body.

39. Controversy-cont
• Flexible bronchoscopy has the advantages of being widely
available, relatively easy and safe in experienced hands,
and possible to perform with local anesthetic and conscious
sedation.

40. INTRODUCTION
• Foreign body aspiration is a worldwide health
problem
which often results in life threatening
complications.

43. Our Department
experience

47. Case Senario
• Male patient called Mosaad Abdel Nabi , from
Sammanod , Farmer , non smoker.
• One year ago , he had cough , expectoration
of whitish sputum , dysnea on less than
ordinary effort .
• No hemoptysis , no chest pain , no other
relevant medical history.

48. Case Senario-cont
• He was admitted to Mahalla chest hospital
with the same condition within the last year
with no improvement .
• General examination : NAD .
• On auscultation : bilateral vesicular breath
sound with generalized exp.wheezes.

49. Case Senario-cont
• LAB : all parameters were normal .
• Virology markers : - ve .

51. Case Senario-cont
• FOB done on 5/4/2014 :
- Right bronchial tree : NAD .
- Left bronchial tree : polypoidal mass totally
obstructing left lower lobe bronchus .
• BAL taken and was +ve for Aspergillus Flavus.

52. Case Senario-cont
• FOB done on 14/4/2014 :
- Right bronchial tree : NAD .
- Left bronchial tree : polypoidal mass totally
obstructing left lower lobe bronchus .

53. Case Senario-cont
• Trials for extraction were done by Forceps and
Cryo probe , and extracted by Forceps .
• Granulation tissue around the FB was
destructed with Electro-cautery probe .

60. HOME TAKEAWAYS

61. HOME TAKEAWAYS
• The medical history and a high index of clinical suspicion of
FB are more useful than physical examination findings or
radiographic studies (unless a radiopaque FB is visualized)
in the determination of FB.
• Bronchoscopy is indicated in all cases to inspect the
tracheobronchial tree and assess for FB.

62. HOME TAKEAWAYS-cont
• Flexible bronchoscopy is emerging as a useful tool in
extraction of FBs in both adults and children.
• Rigid bronchoscopy should be available should attempts
with the flexible bronchoscope fail.