|Year : 2018 | Volume
| Issue : 1 | Page : 26-29
Foreign Body Aspirations − Retrieval of Aspirated Pin Through Flexible Bronchoscope
Mrinal Sircar, Rajesh Gupta, Ankit Bhatia, Sujeet Singh
Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
|Date of Web Publication||3-Jan-2018|
Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Foreign body (FB) aspirations are a frequent cause for distress, particularly among young children. The type of FB may determine the symptoms as well as treatment modality. Flexible bronchoscopy armed with a variety of accessories is the cornerstone of treatment involving removal of aspirated FBs. Removal of sharps particularly pins and needles is challenging because of the high chances of airway mucosa injury while in the process of removal. We present two similar cases of removal of sharp pins by using flexible bronchoscopy.
Keywords: Drawing pin, flexible bronchoscopy, foreign body, sharp
|How to cite this article:|
Sircar M, Gupta R, Bhatia A, Singh S. Foreign Body Aspirations − Retrieval of Aspirated Pin Through Flexible Bronchoscope. J Assoc Chest Physicians 2018;6:26-9
|How to cite this URL:|
Sircar M, Gupta R, Bhatia A, Singh S. Foreign Body Aspirations − Retrieval of Aspirated Pin Through Flexible Bronchoscope. J Assoc Chest Physicians [serial online] 2018 [cited 2019 Dec 16];6:26-9. Available from: http://www.jacpjournal.org/text.asp?2018/6/1/26/220989
| Introduction|| |
Foreign body (FB) aspiration is relatively frequent problem in children. Most frequently encountered FBs aspirated include peanuts, batteries, coins, etc. Aspiration of sharp items such as cardboard pins is less common because of their sharp geometry which makes it less amiable to be kept in mouth and subsequently aspiration. We present two cases of accidental aspirations of sharp objects such as cardboard/drawing pin by two 12 year olds while in school, which could be retrieved with flexible bronchoscope successfully.
| Case 1|| |
A 12-year-old male child was referred to us with a history of aspirating a drawing pin while in school. He complained of throat pain, though was hemodynamically stable. Systemic examination was unremarkable. Chest X-ray [Figure 1] showed a FB in the right mid zone. Noncontrast computed tomography (NCCT) [Figure 1] chest was showed a metallic pin-like FB in right bronchus intermedius. Patient was intubated electively and fiberoptic bronchoscopy (FOB) was performed through the endotracheal tube; the metallic tip was seep protruding cranially in the right lower lobe bronchus. The pin [Figure 2] was grasped with toothed forceps (aligning latter with the length of the pin), withdrawn into the endotracheal tube and the forceps with pin in its grasp, bronchoscope, and the endotracheal tube were removed together en bloc. Postprocedure X-ray was normal. The procedure was uncomplicated, and the patient was discharged home after overnight observation.
|Figure 1: X-ray and computed tomography thorax showing the metallic object|
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| Case 2|| |
An 12-year-old boy presented in the emergency room due to accidental aspiration of a cardboard pin while playing in an arts class in school. He complained of throat pain and bouts of coughing but was otherwise stable. Clinical examination was unremarkable. Chest X-ray showed a needle like metallic radiopaque object in the right mid zone [Figure 1]. NCCT thorax [Figure 3] confirmed the location of the pin in the right intermediate bronchus. Flexible FOB was performed under conscious sedation through the oral route. The cardboard pin was seen lying in a pool of secretions in the right lower lobe bronchus with the sharp metallic end projecting cranially and its green base occluding the right lower lobe bronchus. The sharp end was grasped linearly with a toothed forceps to avoid injury to the airway. The pin was then taken out en-masse along with the bronchoscope [Figure 4]. The repeat chest X-ray after the procedure was normal. The procedure was uncomplicated, and the patient was discharged home after overnight observation.
|Figure 3: X-ray and computed tomography thorax showing the metallic opacity|
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| Discussion|| |
Mortality and morbidity rates caused by FB aspiration are much higher in children and adolescents because of the relatively narrow airway and less mature protective mechanisms. Diagnosis of FB aspiration relies on the history given by the patient; however in younger children, a definite history may not always be available. A triad of symptoms mainly paroxysmal coughs, wheezing, and breathlessness are seen, although many other presentations have inconsistent findings. Our patients themselves gave the history of aspirating a pin; hence, it was easy to diagnose the cause of their distress. The material of the aspirated FB varies but can be broadly divided into organic and inorganic FB aspiration. Inorganic materials such as pen caps, coins, magnets, and marbles are the most commonly aspirated while organic materials include nuts, seeds, etc. The signs and symptoms of aspiration of FBs vary depending upon on the type and size of FB, its location in the respiratory tract, and the length of time it remains in the tracheobronchial system. Organic substances induce more severe mucous inflammation. On the other hand, patients who aspirate small inorganic bodies tend to be asymptomatic in the long term, unless full obstruction of a terminal airway is caused. FB aspiration can lead to near complete airway obstruction, asphyxia and death. However many a times the symptoms may not be seen during the initial period of aspiration and the patient may present later with complications. FBs that are aspirated are commonly lodged in the bronchi, less frequent in the larynx and trachea. Irritation and inflammation caused by the FBs can cause bronchitis, tracheitis and other complications such as lung abscess, bronchiectesis, obstructive emphysema, pneumopathy, pleural effusion, and rarely pneumomediastinum. Metallic aspirations tend to be easily visualized by X-rays and, thus, do not pose a problem in locating radiologically. However in few cases, a 3D-computed tomography is used for better localization of FBs. The aspirated FBs usually rest into the right main bronchus because of anatomical considerations however, if the FB is aspirated during inspiration, small diameter objects such as needles may also be found entering the left main bronchus. Presently FB removal is carried out mostly through bronchoscopic techniques. Initial cases reported were mostly through rigid bronchoscope but subsequently flexible FOB gained popularity. The rigid bronchoscope is preferred in pediatric patients, because it provides better subglottic access, better oxygenation, and better management of bleeding if any. However, flexible bronchoscope is the preferred modality in most centers for adults. Fiberoptic flexible bronchoscopy can be performed safely, very rapidly, and safely under local anesthesia with minimal sedation is usually the first intervention. It avoids the added risk, cost as well as morbidity of an invasive procedure such as rigid bronchoscopy under general anesthesia. Several bronchoscopic techniques are used for retrieval which includes toothed or blunt forceps, Dormia baskets, cages, polypectomy snare, and Fogarty balloons. There is danger of serious injury from a sharp FB during retrieval. This risk can be reduced if the object is retrieved inside the barrel of a rigid bronchoscope and the bronchoscope, forceps for retrieval and the FB are removed en bloc. However, the use of flexible bronchoscope has certain advantages; when it is introduced via an endotracheal tube, the FB can be retrieved inside latter after gasping with forceps and when withdrawn en bloc along with bronchoscope; endotracheal tube can similarly reduce risk of airway injury. In the first case, the patient was intubated electively for the procedure. In the other patient described, we were unable to get consent for intubation despite persistent counseling − perhaps family feared this would mean the child would be put on a mechanical ventilator. Hence, we proceeded with the retrieval using flexible bronchoscope without intubation after informed consent regarding possible higher risk.
Thoracotomy by surgeons is rarely required for the removal of FBs and should be kept in standby. Despite the advances in the techniques and optics, proper training is required to minimize the complications in FB removal using bronchoscopic techniques.
| Conclusion|| |
FB removal can be performed using flexible bronchoscopes which have an added advantage of the procedure being done under local anesthesia or rarely conscious sedation. Intubation and en bloc retrieval of the FB may make the procedure safer, preventing airway injury with the sharp object during retrieval.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]