MANAGEMENT OF FOREIGN BODY ASPIRATION (FBA)
AND CENTRAL AIRWAY OBSTRUCTION IN ADULTS :
FIBROPTIC vs. RIGID BRONCHOSCOPY
Ba...
INTRODUCTION
• Gustav Killian (the father of
bronchoscopy ) (1860-1921)
• In 1897 extracted a pork
bone from the trachea o...
• Fiberoptic bronchoscopy: for diagnostic evaluation
• Rigid bronchoscopy: for removal of foreign bodies
• FBA
– Adults: o...
EPIDEMIOLOGY
• Fifth most common cause of unintentional-injury mortality in the
United States
• More common in children (8...
• The nature of the FB is highly variable
– In children: nuts and other organic material
– Young or middle-aged adults: na...
Acute Food Asphyxiation
• Older pts (dentition problems, swallowing disorders, or
Parkinsonism)
• Annual incidence of 0.66...
Bassel Ericsoussi, MD 7
8Bassel Ericsoussi, MD
PRESENTATION AND DIAGNOSIS
• In adults acute presentation is rare
– The FB usually is wedged distally in lower lobe
bronch...
10Bassel Ericsoussi, MD
11Bassel Ericsoussi, MD
12Bassel Ericsoussi, MD
DIAGNOSTIC FIBEROPTIC
BRONCHOSCOPY
• The diagnostic procedure of choice for FBA in adults
• FB removal should not be attem...
FBs THAT CAN BE REMOVED
EASILY USING SIMPLE SUCTION
• Soft beans
• Bronchial soot plugs
14Bassel Ericsoussi, MD
15Bassel Ericsoussi, MD
TECHNICALASPECTS
• Fiberoptic Bronchoscopy:
– Allows precise identification and localization of
FBs
– Facilitates the choi...
17Bassel Ericsoussi, MD
POTENTIAL COMPLICATIONS OF
FB EXTRACTION
• FB becomes wedged distally: postobstructive
atelectasis
• Loss of the foreign b...
19Bassel Ericsoussi, MD
20Bassel Ericsoussi, MD
When FBA is suspected, fiberoptic
bronchoscopy should be performed
in a room equipped for resuscitation,
definitive airway...
FOREIGN BODY REMOVAL
• Once the diagnosis is established, extraction must be
performed without delay.
– Do not postpone fo...
GRANULATION
• Mucosal inflammation and accumulation of bulky
granulation tissue
– Within few hours
• Organic FBs (peanuts,...
24Bassel Ericsoussi, MD
ROLE OF CORTICOSTEROIDS
• No prospective trials
• Indication
– FB is completely encased in bulky and bleeding
granulation
...
• Prophylactic use of corticosteroids to decrease the
incidence of post-operative subglottic edema. is not
recommended and...
27Bassel Ericsoussi, MD
THE ROLE OF POSITIONAL MANEUVERS
• Lateral decubitus and Trendelenburg
• Young and healthy adults
• Small, movable FB (fru...
RIGID BRONCHOSCOPY
• Excellent access to the subglottic airways
• Allowing gas exchange and coaxial passage of
multiple in...
30Bassel Ericsoussi, MD
Bassel Ericsoussi, MD 31
TECHNIQUE
• Do not push the FB distally
– Postobstructive atelectasis
• If blood and secretions are present proximal to th...
Bassel Ericsoussi, MD 33
PROPER GRASPING TECHNIQUE
• Smooth and rounded FBs
– Foreign body forceps (smooth) are preferred
• Sharp or irregular FBs
...
Bassel Ericsoussi, MD 35
Bassel Ericsoussi, MD 36
PROPER GRASPING TECHNIQUE
• Large and hard FBs (pistachio shells)
– Breaking the FB into two or three fragments may
help e...
Bassel Ericsoussi, MD 38
PROPER GRASPING TECHNIQUE
• Heavy FBs (metallic FBs)
– Tend to move distally due to gravity
– May be helpful to place the ...
COAXIAL MOVEMENT
• Both the instruments (the bronchoscope and the forceps)
and FB are withdrawn en masse from the trachea
...
Bassel Ericsoussi, MD 41
FLEXIBLE BRONCHOSCOPY
• Equipments for FBs removal
– FB forceps (smooth)
– Alligator forceps
– Grasping claws
– Snares
– B...
43Bassel Ericsoussi, MD
Bassel Ericsoussi, MD 44
• May be used as an alternative to rigid bronchoscopy
for extraction
• Success rates in adults range from 60 to 90 %
• Can...
RISKS ASSOCIATED WITH
FIBEROPTIC EXTRACTION
• Accidental migration of the FB
into the contralateral lung
– Due to insuffic...
RISKS ASSOCIATED WITH
FIBEROPTIC EXTRACTION
• Impossible simultaneous FB
manipulation and suctioning with
flexible broncho...
• Unsuccessful attempts may
push the FB distally into a
wedged position
Bassel Ericsoussi, MD 48
RISKS ASSOCIATED WITH
FIB...
ADVANTAGES OF FIBROPTIC BRONCHOSCOPY
• Fiberoptic is superior to rigid bronchoscopy in the
setting of
– Distally wedged FB...
Bassel Ericsoussi, MD 50
SECOND LOOK INSPECTION
• Once the FB is removed
– Reintubate the trachea with the bronchoscope
– The airways are carefully...
RECOMMENDATIONS
• Fiberoptic bronchoscopy under local anesthesia as the first
procedure for diagnosis and extraction in ad...
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Management Of Foreign Body Aspiration (FBA) And Central Airway Obstruction In Adults Fibroptic vs. Rigid Bronchoscopy

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MANAGEMENT OF FOREIGN BODY ASPIRATION (FBA) AND CENTRAL AIRWAY OBSTRUCTION IN ADULTS. FIBROPTIC vs. RIGID BRONCHOSCOPY

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Management Of Foreign Body Aspiration (FBA) And Central Airway Obstruction In Adults Fibroptic vs. Rigid Bronchoscopy

  1. 1. MANAGEMENT OF FOREIGN BODY ASPIRATION (FBA) AND CENTRAL AIRWAY OBSTRUCTION IN ADULTS : FIBROPTIC vs. RIGID BRONCHOSCOPY Bassel Ericsoussi, MD Pulmonary and Critical Care Fellow University of Illinois Medical Center at Chicago
  2. 2. INTRODUCTION • Gustav Killian (the father of bronchoscopy ) (1860-1921) • In 1897 extracted a pork bone from the trachea of a German farmer using an esophagoscope Killian, G. Meeting of the Society of Physicians of Freiburg. Dec 17, 1897, Munchen Med Wschr 1989; 45:378. 2Bassel Ericsoussi, MD
  3. 3. • Fiberoptic bronchoscopy: for diagnostic evaluation • Rigid bronchoscopy: for removal of foreign bodies • FBA – Adults: often subtle, and diagnosis requires careful clinical assessment – In children: life-threatening (choking episode) INTRODUCTION 3Bassel Ericsoussi, MD
  4. 4. EPIDEMIOLOGY • Fifth most common cause of unintentional-injury mortality in the United States • More common in children (80 % in pts < 15 yr) • Uncommon in adults • Increased risk of dying following FBA: – Children < 1 yr – Elderly > 75 yr 4Bassel Ericsoussi, MD
  5. 5. • The nature of the FB is highly variable – In children: nuts and other organic material – Young or middle-aged adults: nail or pin aspiration • The most frequently aspirated food particles: – vegetable matters, bones, and watermelon seeds 5Bassel Ericsoussi, MD
  6. 6. Acute Food Asphyxiation • Older pts (dentition problems, swallowing disorders, or Parkinsonism) • Annual incidence of 0.66/100,000 population • Cafe Coronary: fatal or near fatal food asphyxiation caused by incompletely chewed meat • FB usually meat • In the supraglottic position in about one-third of cases • Can be removed with – Magill forceps – Manually by sticking the middle and index fingers down the throat 6Bassel Ericsoussi, MDMittleman RE; Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction. JAMA 1982 Mar 5;247(9):1285-8.
  7. 7. Bassel Ericsoussi, MD 7
  8. 8. 8Bassel Ericsoussi, MD
  9. 9. PRESENTATION AND DIAGNOSIS • In adults acute presentation is rare – The FB usually is wedged distally in lower lobe bronchi • Dyspnea (only 25 %) • Coughing (80 %) • Fever, hemoptysis, chest pain, or wheeze • Adults do not always recall a history of choking • The diagnosis is frequently overlooked 9Bassel Ericsoussi, MD
  10. 10. 10Bassel Ericsoussi, MD
  11. 11. 11Bassel Ericsoussi, MD
  12. 12. 12Bassel Ericsoussi, MD
  13. 13. DIAGNOSTIC FIBEROPTIC BRONCHOSCOPY • The diagnostic procedure of choice for FBA in adults • FB removal should not be attempted during a diagnostic bronchoscopy – Unless the operator is skilled in the extraction technique, and the appropriate equipments are available • The bronchoscopist must be able to convert immediately to the extraction procedure using a rigid bronchoscope in the setting of complete central airway obstruction 13Bassel Ericsoussi, MD
  14. 14. FBs THAT CAN BE REMOVED EASILY USING SIMPLE SUCTION • Soft beans • Bronchial soot plugs 14Bassel Ericsoussi, MD
  15. 15. 15Bassel Ericsoussi, MD
  16. 16. TECHNICALASPECTS • Fiberoptic Bronchoscopy: – Allows precise identification and localization of FBs – Facilitates the choice of rigid bronchoscope and type of forceps – Shorten the duration of the rigid bronchoscopy procedure 16Bassel Ericsoussi, MD
  17. 17. 17Bassel Ericsoussi, MD
  18. 18. POTENTIAL COMPLICATIONS OF FB EXTRACTION • FB becomes wedged distally: postobstructive atelectasis • Loss of the foreign body: – Obstruction of the contralateral mainstem bronchus – Obstruction of the central airway, potentially causing asphyxia • Hemorrhage: FB is completely encased in bulky and bleeding granulation tissue 18Bassel Ericsoussi, MD
  19. 19. 19Bassel Ericsoussi, MD
  20. 20. 20Bassel Ericsoussi, MD
  21. 21. When FBA is suspected, fiberoptic bronchoscopy should be performed in a room equipped for resuscitation, definitive airway management, mechanical ventilation, and rigid bronchoscopy 21Bassel Ericsoussi, MD
  22. 22. FOREIGN BODY REMOVAL • Once the diagnosis is established, extraction must be performed without delay. – Do not postpone foreign body extraction (FBE) in pts with an acute post-obstructive pneumonia 22Bassel Ericsoussi, MD
  23. 23. GRANULATION • Mucosal inflammation and accumulation of bulky granulation tissue – Within few hours • Organic FBs (peanuts, high oil content ) – Within few weeks/months • Chronically impacted sharp or rusty FBs • Iron or nortriptyline pills aspiration 23Bassel Ericsoussi, MD
  24. 24. 24Bassel Ericsoussi, MD
  25. 25. ROLE OF CORTICOSTEROIDS • No prospective trials • Indication – FB is completely encased in bulky and bleeding granulation • Short course (12 to 24 hours) of IV corticosteroid (1- 2 mg/kg prednisolone or equivalent) – Cleveland Clinic Experience • May result in dislodgement of the FB – These pts should remain under observation until the extraction procedure 25Bassel Ericsoussi, MDBanerjee A et al. Laryngo-tracheo-bronchial foreign bodies in children. J Laryngol Otol 1988 Nov;102(11):1029-32
  26. 26. • Prophylactic use of corticosteroids to decrease the incidence of post-operative subglottic edema. is not recommended and it should be avoided • Post-operative subglottic edema: – Parenteral corticosteroids – Aerosolized epinephrine – Helium-oxygen therapy (heliox) Bassel Ericsoussi, MD 26 ROLE OF CORTICOSTEROIDS
  27. 27. 27Bassel Ericsoussi, MD
  28. 28. THE ROLE OF POSITIONAL MANEUVERS • Lateral decubitus and Trendelenburg • Young and healthy adults • Small, movable FB (fruit pit or bead) • Worth trying prior to bronchoscopy – May result in spontaneous expectoration of the FB, or bring it into a more proximal position prior to definitive management 28Bassel Ericsoussi, MD
  29. 29. RIGID BRONCHOSCOPY • Excellent access to the subglottic airways • Allowing gas exchange and coaxial passage of multiple instruments – Optical forceps • Direct visualization of the FB and optically-guided grasping – Rigid telescope and a forceps can be used coaxially through the bronchoscope • General anesthesia • Procedure time rarely exceeds 10 minutes 29Bassel Ericsoussi, MD
  30. 30. 30Bassel Ericsoussi, MD
  31. 31. Bassel Ericsoussi, MD 31
  32. 32. TECHNIQUE • Do not push the FB distally – Postobstructive atelectasis • If blood and secretions are present proximal to the FB, these should be cleared by careful suctioning – Epinephrine (0.25 mg) may be instilled for hemostasis and in order to shrink the swollen mucosa encasing the FB Bassel Ericsoussi, MD 32
  33. 33. Bassel Ericsoussi, MD 33
  34. 34. PROPER GRASPING TECHNIQUE • Smooth and rounded FBs – Foreign body forceps (smooth) are preferred • Sharp or irregular FBs – Alligator forceps are preferred Bassel Ericsoussi, MD 34
  35. 35. Bassel Ericsoussi, MD 35
  36. 36. Bassel Ericsoussi, MD 36
  37. 37. PROPER GRASPING TECHNIQUE • Large and hard FBs (pistachio shells) – Breaking the FB into two or three fragments may help extraction • Friable FBs (peanuts) – Vigorous grasping should be avoided • May result in maceration and distal wedging of small fragments Bassel Ericsoussi, MD 37
  38. 38. Bassel Ericsoussi, MD 38
  39. 39. PROPER GRASPING TECHNIQUE • Heavy FBs (metallic FBs) – Tend to move distally due to gravity – May be helpful to place the patient in the Trendelenburg position Bassel Ericsoussi, MD 39
  40. 40. COAXIAL MOVEMENT • Both the instruments (the bronchoscope and the forceps) and FB are withdrawn en masse from the trachea • The FB can be lost accidentally – Blocked in the narrow glottic area – Inappropriate coaxial movement between the bronchoscope and the forceps, causing the tip of the bronchoscope to push the FB out of the forceps' cups or jaws Bassel Ericsoussi, MD 40
  41. 41. Bassel Ericsoussi, MD 41
  42. 42. FLEXIBLE BRONCHOSCOPY • Equipments for FBs removal – FB forceps (smooth) – Alligator forceps – Grasping claws – Snares – Balloon-tipped catheters – Magnets – New "zero tip" baskets Bassel Ericsoussi, MD 42
  43. 43. 43Bassel Ericsoussi, MD
  44. 44. Bassel Ericsoussi, MD 44
  45. 45. • May be used as an alternative to rigid bronchoscopy for extraction • Success rates in adults range from 60 to 90 % • Can be cumbersome Bassel Ericsoussi, MD 45 FLEXIBLE BRONCHOSCOPY
  46. 46. RISKS ASSOCIATED WITH FIBEROPTIC EXTRACTION • Accidental migration of the FB into the contralateral lung – Due to insufficient grasping with the fiberoptic forceps – Less likely to occur with rigid forceps used for rigid bronchoscopy Bassel Ericsoussi, MD 46Castro, M, Midthun, DE, Edell, ES, et al. Flexible bronchoscopic removal of foreign bodies from pediatric airways. J Bronchol 1994; 1:92.
  47. 47. RISKS ASSOCIATED WITH FIBEROPTIC EXTRACTION • Impossible simultaneous FB manipulation and suctioning with flexible bronchoscope – FB is completely encased in bulky, friable and bleeding granulation tissue Bassel Ericsoussi, MD 47
  48. 48. • Unsuccessful attempts may push the FB distally into a wedged position Bassel Ericsoussi, MD 48 RISKS ASSOCIATED WITH FIBEROPTIC EXTRACTION
  49. 49. ADVANTAGES OF FIBROPTIC BRONCHOSCOPY • Fiberoptic is superior to rigid bronchoscopy in the setting of – Distally wedged FB – Mechanically ventilated patients – The presence of spine, craniofacial, or skull fractures • The use of a laryngeal mask airway (LMA) allows ventilation and easy access to the central airways under general anesthesia Bassel Ericsoussi, MD 49Limper AH; Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med 1990 Apr 15;112(8):604-9.
  50. 50. Bassel Ericsoussi, MD 50
  51. 51. SECOND LOOK INSPECTION • Once the FB is removed – Reintubate the trachea with the bronchoscope – The airways are carefully reexamined – Rule out another FB or residual fragments – If doubt persists, a repeat fiberoptic bronchoscopic examination a few days later should be considered Bassel Ericsoussi, MD 51Kim, IG, Brummitt, WM, Humphry, A, et al. Foreign body in the airway: a review of 202 cases. Laryngoscope 1973; 83:347.
  52. 52. RECOMMENDATIONS • Fiberoptic bronchoscopy under local anesthesia as the first procedure for diagnosis and extraction in adults and children over 12 years old • In case of asphyxiating FB, rigid bronchoscopy is the initial procedure of choice • Short course of corticosteroids before FB removal when a well- tolerated FB is encased in bulky and bleeding granulation tissue • Prophylactic use of corticosteroids to decrease the incidence of post- operative subglottic edema. is not recommended and it should be avoided • Prophylactic use of ABx is not recommended Bassel Ericsoussi, MD 52

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