From the Guidelines
Rigid bronchoscopy is the preferred method for foreign body removal from the airway, as it provides better airway control, allows for ventilation during the procedure, and offers superior suction capability and a wider range of retrieval instruments. The procedure should be performed in an operating room under general anesthesia with the patient spontaneously breathing when possible, as suggested by the American College of Chest Physicians clinical practice guideline 1. Prior to the procedure, a thorough history, physical examination, and imaging studies (chest X-ray, CT scan if needed) should be obtained. The patient should be fasting for at least 6 hours before the procedure. Premedication may include atropine (0.01-0.02 mg/kg) to reduce secretions and midazolam (0.05-0.1 mg/kg) for anxiolysis.
During the procedure, the patient should be positioned supine with the neck extended (sniffing position). The appropriate size rigid bronchoscope should be selected based on the patient's age and airway size. Ventilation can be maintained through the side port of the bronchoscope. Various retrieval instruments should be available, including optical forceps, basket forceps, and suction catheters. After removal of the foreign body, a final inspection of the airway should be performed to ensure complete removal and assess for any complications.
Some key points to consider when performing rigid bronchoscopy for foreign body removal include:
- The use of general anesthesia/deep sedation over moderate sedation for therapeutic bronchoscopy, as suggested by the American College of Chest Physicians clinical practice guideline 1
- The use of either jet ventilation or controlled/spontaneous assisted ventilation for patients with symptomatic malignant or nonmalignant central airway obstruction undergoing rigid therapeutic bronchoscopy with general anesthesia 1
- The potential complications of rigid bronchoscopy, including laryngeal edema, bronchospasm, pneumothorax, and respiratory failure, and the use of dexamethasone (0.5-1 mg/kg) to reduce airway edema.
It is also important to note that the European Respiratory Society/American Thoracic Society statement on interventional pulmonology lists foreign body removal as one of the primary indications for rigid bronchoscopy, and highlights the importance of selecting the appropriate size rigid bronchoscope based on the patient's age and airway size 1.
From the Research
Guidelines for Rigid Bronchoscope for Foreign Body Removal
- The use of rigid bronchoscopy is effective in removing foreign bodies from the airways, especially in cases where there is a risk of coughing during the procedure or when the foreign body is embedded in the bronchial mucosa 2, 3.
- Rigid bronchoscopy can be performed under general anesthesia, and the use of virtual reality-aided presurgical planning can be helpful in simulating the clinical situation and planning the removal of the foreign body 2.
- The technique of rigid bronchoscopy involves the insertion of a rigid bronchoscope into the airway, followed by the use of grasping forceps or other instruments to remove the foreign body 3, 4.
- The choice of anesthesia and ventilation technique is important, and the use of dexmedetomidine has been shown to be effective in providing deep anesthesia and ideal conditions for rigid bronchoscopic airway foreign body removal without respiratory depression or hemodynamic instability 5.
- Rigid bronchoscopy is an invaluable tool for the management of airway disorders, and its indications include foreign body aspiration, central airway obstruction, and massive hemoptysis 6.
- The complications of rigid bronchoscopy can include bleeding, perforation of the airway, and respiratory depression, and the procedure should only be performed by trained and experienced interventional pulmonologists 6.
Indications for Rigid Bronchoscopy
- Foreign body aspiration 2, 3, 4
- Central airway obstruction 6
- Massive hemoptysis 6
- Granulation tissue formation around the foreign body 2
Contraindications for Rigid Bronchoscopy
- None specifically mentioned in the studies, but the procedure should be performed with caution in patients with certain medical conditions, such as severe respiratory disease or cardiovascular disease 6.