Combined Thoracoscopy and Bronchoscopy for Airway Foreign Body Retrieval

Abstract

Introduction: Foreign body aspiration is one of the most common medical emergencies in the pediatric group.¹ Peanuts, seeds, food particles, hardware, and pieces of toys are the most frequent.² Foreign body cases present more often among male children 3 Rigid bronchoscopy is widely recommended as the procedure of choice for both diagnosis and treatment⁴; flexible bronchoscopy is sometimes helpful in cases of distant airway foreign body because of the smaller diameter and flexibility.⁴ Thoracotomy, bronchotomy, and/or pulmonary resection might be needed in cases of retained foreign body.⁴ Lobectomy is sometimes indicated for management of lobar collapse; severe airway bleeding during retrieval, chronic infections, or inability to remove the foreign body through bronchoscopy.⁵ However, surgical options for retrieval when bronchoscopy is unsuccessful are scarce. We present a novel technique using a combined approach involving thoracoscopy and bronchoscopy for the management of a difficult airway foreign body. Materials and Methods: One case of airway foreign body aspiration in a 23-month-old child (12 kg) is shown. Initial bronchoscopy was performed to remove almond fragments from the right and left main stem, one of the pieces was unable to be retrieved and remained impacted in the left upper lobe bronchus. The patient was positioned in the right lateral decubitus. Lung deflation was avoided by insufflating the chest cavity with carbon dioxide flowing through a Veress needle. Thoracoscopy with three small incisions was made to triangulate toward the apex of the left chest; simultaneous flexible bronchoscopy was performed to identify the area of impaction. Continuous ventilation was ensured by intermittent withdrawals of the endoscope. Almond fragment was dislodged by blunt graspers compression in the left upper bronchus while is being monitored under endoscopic view. It should be noted that extracorporeal membrane oxygenation was a backup in case of a loss of the airway. Results: In this report by combining two endoscopic techniques “bronchoscopy” and “thoracoscopy,” we effectively demonstrated the possibility of foreign body retrieval under minimally invasive conditions. The infant had an uneventful recovery with an excellent pneumothorax tolerance, was discharged on postoperative day 2, and has continued doing well on 6 months follow-up. Conclusions: Guidelines for the treatment of foreign body aspiration are well established. Endoscopic instruments such as embolectomy catheters can often serve as accessory tools for the retrieval of foreign body during bronchoscopy. Each patient and clinical presentation is unique, and the retrieval of the object may be challenging. We believe this approach spared our patient from a larger surgical intervention that could have resulted in a greater recovery time and potential morbidity. We consider this case to be useful reference for the management of similar cases in the future. No competing financial interests exist. Runtime of video: 3 mins 39 secs