What is the recommended procedure for foreign body removal in the airway of adults?

Foreign Body Removal in Adult Airways

For adult airway foreign body removal, rigid bronchoscopy is the recommended first-line procedure for large or complex foreign bodies, while flexible bronchoscopy with appropriate tools can be effective for smaller or more distal objects. 1

Initial Management Algorithm

1. For conscious patients with partial obstruction:

   • Encourage effective coughing as the first intervention 1
   • If coughing is ineffective, administer up to 5 sharp back blows between the shoulder blades
   • If back blows fail, perform up to 5 abdominal thrusts (Heimlich maneuver) 1

2. For unconscious patients:

   • Position patient on a firm surface
   • Begin chest compressions (similar to CPR technique) 1
   • Perform visual inspection of the oropharynx
   • Remove visible foreign bodies using Magill forceps (avoid blind finger sweeps) 1

Advanced Management

Bronchoscopic Approach Selection

• Rigid Bronchoscopy - First choice for:

  • Large or complex foreign bodies
  • Foreign body aspiration with respiratory distress
  • Cases requiring controlled ventilation
  • Previous failed attempts with flexible bronchoscopy
  • Hard foreign bodies (e.g., bones, teeth) 2, 3
  • Massive hemoptysis
  • Central airway obstruction

• Flexible Bronchoscopy - Consider for:

  • Smaller or peripheral foreign bodies
  • Stable patients without respiratory distress
  • Distal airway foreign bodies beyond reach of rigid scope 4
  • Patients with contraindications to general anesthesia

Procedural Considerations

For rigid bronchoscopy:

• Perform in a negative pressure room when possible 2
• Use controlled ventilation with the rigid scope functioning as an endotracheal tube
• Minimize air leaks using rubber caps on ports and plastic covering or gauze packing 2

For flexible bronchoscopy:

• Multiple modalities may be employed including forceps, loop, basket, knife, electromagnet, and cryotherapy 4
• Success rates of approximately 80-90% have been reported 4, 3
• Consider combining with additional tools (e.g., endobronchial blocker) for challenging cases 5

Diagnostic Evaluation

• Neck and chest radiographs to identify radiopaque foreign bodies and assess for complications
• CT scans for better visualization of non-radiopaque objects and surrounding tissue 1
• Consider non-contrast CT to confirm foreign body presence before proceeding to bronchoscopy in stable patients 2

Clinical Pearls and Pitfalls

• Common pitfall: Delayed diagnosis - associated with flexible bronchoscopy failure and complications 3
• Important consideration: Up to 20% of bronchoscopies performed for suspected foreign bodies are negative, but this is preferable to missing a foreign body 1
• Warning sign: Consultation with specialists is recommended even with low suspicion 1
• Complication awareness: Foreign body aspiration can lead to obstructive pneumonitis, atelectasis, bronchiectasis, lung abscess, and other serious complications 6
• Special consideration: In cases where the foreign body is radiopaque and located distally, fluoroscopic guidance may assist with removal 7

Remember that the clinical presentation of foreign body aspiration in adults is often non-specific, with symptoms like chronic cough, hemoptysis, fever, and dyspnea being more common than the classic choking presentation 6. This can lead to delayed diagnosis and increased complications.