From the Guidelines
Rigid bronchoscopy is the preferred method for foreign body (FB) removal from the airway, as it provides better airway control, superior suction capability, and allows ventilation during the procedure. The procedure should be performed under general anesthesia with the patient in a supine position, as suggested by the American College of Chest Physicians clinical practice guideline 1.
Pre-procedure Preparation
Begin by administering appropriate premedication including glycopyrrolate 0.01 mg/kg IV to reduce secretions and dexamethasone 0.5 mg/kg IV to minimize airway edema. For anesthesia induction, use propofol 2-3 mg/kg IV with maintenance via total intravenous anesthesia to allow for ventilation through the bronchoscope side port.
Bronchoscope Selection and Insertion
Select an appropriately sized rigid bronchoscope based on patient age and size, typically ranging from 3.0 mm for infants to 7.0 mm for adults. After insertion, maintain oxygenation through the side port while carefully advancing the scope under direct visualization.
Foreign Body Removal
For FB removal, use optical forceps that match the type of foreign body (grasping forceps for solid objects, basket forceps for round objects, and suction for small or friable items). Always maintain visualization of the FB during extraction and withdraw both the bronchoscope and FB together as a unit to prevent dislodgment.
Post-procedure Care
Following removal, perform a complete airway inspection to check for additional fragments or injury. Post-procedure, monitor for complications including laryngeal edema, bronchospasm, or pneumothorax, as these can significantly impact morbidity, mortality, and quality of life 1.
The use of rigid bronchoscopy for FB removal is supported by the most recent and highest quality study available, which emphasizes the importance of therapeutic bronchoscopy in managing central airway obstruction 1. While the certainty of evidence is very low, the recommendation is made based on the best available data and prioritizes patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Indications for Rigid Bronchoscope in FB Removal
- Massive hemoptysis, foreign body removal, airway stenosis, laser resection, and pediatric bronchoscopy are the most common indications for the rigid bronchoscope 2
- Tracheobronchial foreign body aspiration is a significant cause of childhood morbidity and mortality, and rigid bronchoscopy is used for its removal 3
- Rigid bronchoscopy under general anesthesia enables performing diagnostic and/or therapeutic procedures in the tracheobronchial tree, including foreign body removal in adults 4
Anesthesia for Rigid Bronchoscopy
- Improved anesthetic agents have improved the safety and comfort of the procedure for patients having either diagnostic or therapeutic procedures 2
- Sevoflurane induction followed by a combination of sevoflurane and continuous infusion of propofol resulted in fewer adverse events than sevoflurane induction followed by TIVA with propofol and remifentanyl during rigid bronchoscopy for airway foreign body removal in children with spontaneous ventilation 3
- General anesthesia is usually total intravenous anesthesia, using short acting agents, and ventilation can be spontaneous or insured using high-frequency jet ventilation 4
Success Rate and Complications
- Rigid bronchoscopy has a high success rate in removing foreign bodies, with a success rate of 99.3% in one study 3
- Adverse effects such as intraoperative coughing, breath holding, body movement, bronchospasm, and laryngospasm can occur, but are less frequent with certain anesthesia techniques 3
- Complications such as bleeding, pneumothorax, pneumomediastinum, or the need for thoracotomy are rare, but can occur 3, 5
- Thoracotomy may be necessary in cases where the foreign body is inaccessible or cannot be removed by rigid bronchoscopy 5
Instrumentation and Techniques
- The rigid bronchoscope is a unique and invaluable instrument that allows evaluation, control, and therapeutic manipulation of the proximal tracheobronchial tree 2
- Alligator forceps and the wire basket are useful instruments for removing foreign bodies 6
- The choice of instrumentation and technique may depend on the location and type of foreign body, as well as the patient's condition and anatomy 6