Endourologic Removal of Upper Airway Foreign Objects: Case Report

By Mark Horowitz, Michael E. Mitchell, and Andy lngliss Seattle, Washington

0 The authors report on removal of upper airway foreign bodies using endourology baskets and stone graspers in a patient who did not respond to standard upper airway management. The procedure was safe and effective with localization and successful removal of most of the stone burden. Copyright o 7996 by WA Saunders Company

INDEX WORDS: Endoscopy, foreign bodies, airway.

A SPIRATION is lodgment of foreign bodies in the larynx, trachea, or bronchi. Most foreign bodies

are small enough to pass through the vocal cords and subglotic area and lodge in a main stem or lobar bronchus. Actual or potential airway obstruction can result in life-threatening emergencies. In 1984 aspira- tion of a foreign object was the cause of 271 deaths in children less than 5 years of age in the United States.’ Rigid fiberoptic bronchoscopy with the aid of biopsy forceps, Dormia baskets, and Fogarty balloon cath- eters remains the treatment of choice for upper airway foreign bodies. Controlled ventilation must be maintained throughout the extraction procedure. In few instances, an open surgical procedure entails less risk than endoscopic extraction.2 We report a case of failure to remove upper airway foreign bodies using standard techniques. The use of endourologic stone graspers and helical baskets introduced through both rigid and flexible bronchoscopes helped clear most of a significant stone burden.

CASE REPORT

A 6-year-old healthy boy was playing at the beach with his friends. He was buried up to his neck and aspirated when sand and pebbles were kicked in his face. When it was recognized that he was in distress, he was lifted out of the sand and brought to the lifeguard station. Perioral cyanosis was noted, and the boy experi- enced labored breathing and a decreased level of consciousness. He was intubated and transported to our emergency room.

The patient required peak inspiratory pressures between 80 and 100 cm HzO. Bilateral pneumothoraces developed, and placement of three chest tubes was required. Crepitus developed over his chest, abdomen, and groin, and a Terbutaline drip was started because of significant air trapping. Abdominal films showed a pneumoperitoneum, and chest films showed gravel and rocks in his trachea with occlusion of multiple bronchi (Fig 1). An arterial blood gas test showed a pH level of 7.19, COz level of 60 mm Hg, and Oz level of 135 mm Hg. A second blood gas test taken 1 hour later showed a pH level of 7.17, COz level of 71 mm Hg, and 02 level of 49 mm Hg.

Fig 1. Preoperative chest film shows multiple rocks and stones in main stem bronchi and distal airways.

The patient was taken to the operating room for bronchoscopic removal of the foreign matter from the bronchial tree. He was placed on femoral-femoral cardiopulmonary bypass to allow better oxygenation and control of his COz levels during bronchoscopy.

Rigid and flexible bronchoscopy allowed inspection of the entire respiratory tract. Multiple unsuccessful attempts were made to remove the stones with the use of irrigation, suction, biopsy forceps, and Fogarty catheters. The use of urologic stone graspers and four-wire helical baskets (Figs 2 and 3) passed in an antegrade

From the Departments of Urology and Otolaryngoiogy, Chzldren S Hospital and Medical Center, Seattle, WA.

Address reprint requests to Mark Horowitz, MD, Department of Urology, Children’s Hospital and Medical Center, 4800 Sand Pointe Way NE, Seattle, WA 9810.5.

Copyright o 1996 by W.B. Saunders Company 0022-346819613112-0034$03.00/O

hUrna~Of~ediatrlC SUrgeQC Vol31, No 1’2 (December), 1996: pp 1727-1728 1727

1728 HOROWITZ, MITCHELL, AND INGLISS

Fig 2. Microvasive 3.OF three-wire stone retrieval grasping forceps.

Fig 3. Microvasive 4.5F four-wire stone retrieval Segura basket.

Fig 4. Stone burden found in upper airway of &year-old boy.

Fig 5. Postoperative chest film shows near-complete resolution of aspirated stones.

manner through the bronchoscope allowed for near complete clearance of the stone burden (Fig 4). The patient was removed from bypass, and good 02 saturation levels were maintained.

Postoperatively the patient was transferred to the intensive care unit, where he remained for 7 days. He was extubated on the 5th postoperative day and maintained 02 saturation levels of at least 97% on room air. He tolerated solid food on postoperative day 6 and was discharged in good spirits on postoperative day 10. Postoperative chest films showed near-complete resolution of the stones from the upper airway (Fig 5).

DISCUSSION

The first endoscope, developed in the 1890s by Adolf Kussmaul, consisted of an open-ended tube illuminated by the reflected light of a gasoline lamp.3 Modern pediatric endoscopy began with the develop- ment of the Hopkins rod lens system in the early 1950s.

The indications for rigid bronchoscopy include diagnostic evaluation, removal of foreign bodies, removal of thick secretions, and the establishment of an airway. Rigid bronchoscopy offers certain advan- tages over flexible bronchoscopy such as the ability to pass varying types of endoscopic forceps appropriate for removal of foreign bodies and easier ventilation. Visualization of the smaller terminal airways is lim- ited with the rigid bronchoscope, and the flexible bronchoscope offers easier access to these areas.4 The primary advantage of flexible bronchoscope is the ability to safely examine the airways of infants and children, ensuring their comfort without the use of general anesthesia. Manipulation of foreign bodies with the flexible bronchoscopes currently available is extremely difficult and should not be attempted except under special circumstances, and with the use of flexible wire graspers.5

Urologic technology was applied to assist in the management of this patient. Flexible bronchoscopy was successful in this patient perhaps because he was on cardiopulmonary bypass. The use of stone grasp- ers and helical baskets saved this patient from an open and often morbid procedure. The use of en- dourology equipment by trained personnel can aid other clinicians in the removal of foreign bodies.

REFERENCES 1. Hoskin AS: Accident Facts, Chicago, National Safety Coun-

cil, 1987, p 8 2. Marks SC, Marsh BR, Dudgeon DL: Indications for open

surgical removal of airway foreign bodies. Ann Otol Rhino1 Laryngol102:690-694,1993

3. Gaus SL, Bersi G: Advances in endoscopy of infants and children. J Pediatr Surg 6:199-231, 1971

4. Bryarly R, Hirokawa R: Pediatric Respiratory Disease: Diag- nosis and Treatment. Philadelphia, PA, Saunders, 1993, p 108

5. Wood RE: Pediatric Respiratory Disease: Diagnosis and Treatment. Philadelphia, PA, Saunders, 1993, p 113