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The Maleficent Nut in Bronchus – Elusive Foreign Body Retrieved with Flexible Bronchoscopy using Cryoprobe and Forceps

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Amal Johnson et al.: The Maleficent Nut in Bronchus

Case Report

The Maleficent Nut in Bronchus – Elusive Foreign Body Retrieved with Flexible Bronchoscopy using Cryoprobe and Forceps

Amal Johnson1, Sridhar2, R.Narasimhan3 and Anand Murugesan4
1,2Post graduate –Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India
3 Senior Consultant Pulmonologist, Apollo Hospitals, Greams Road, Chennai, India
4 Anaesthesiologist, Apollo Hospitals, Greams Road, Chennai, India

ABSTRACT:

Foreign body aspiration (FBA) is relatively rare in adults. In non life threatening aspiration, patients seldom recall the history of aspiration and the clinical presentation is mostly subtle and inconsistent. Chest Xray directly identify foreign body in only a minority of patients. CT chest has better resolution in detection but it does entail limitations. Though rigid bronchoscopy remains the gold standard for retrieval of FB especially in children, now with new dedicated instruments Flexible bronchoscopy has become the most commonly used diagnostic and therapeutic modality in majority of patients. Herein, we describe a patient with a smooth, spherical FB impacted in a segmental bronchus retrieved with substantial difficulty using cryoprobe and forceps.

Keywords: Foreign Body, Patient, Flexible, Bronchoscopy, Aspiration
Corresponding Author: Dr. Narasimhan.R, Senior Consultant Department of Respiratory Medicine. Email: drrnarasimhan@gmail.com

How to cite this article: Amal Johnson, Sridhar, R.Narasimhan and Anand Murugesan, The Maleficent Nut in Bronchus – Elusive Foreign Body Retrieved with Flexible Bronchoscopy using Cryoprobe and Forceps, JAPT 2018; 1:36-41

INTRODUCTION

The incidence of foreign body aspiration in adults compared to children is very low(1). In non life threatening FB aspiration, presentation is often misleading when the initial choking event gets unnoticed. The majority of the FB gets lodged in the Right Lower Lobe Bronchus and its basal segments because of the more vertical course (2). When the diagnosis is not established immediately, retained FBs may lead to recurrent pneumonia, bronchiectasis, recurrent hemoptysis, pneumothorax, lung abscess, pneumomediastinum
and other complications(3).

Chest Xray directly identify the FB in only a minority of patients since most FB are organic and radiolucent(4). CT chest is better for identification of FB and associated complications, pre procedural planning, predict the tools needed for retrieval but the sensitivity depends upon the slice thickness and radio density of FB(5). Though rigid bronchoscopy remains the gold standard for retrieval of FB especially in children, now with new dedicated instruments, Flexible bronchoscopy has supplanted rigid bronchoscopy as the diagnostic and
therapeutic modality of choice for non life threatening FBA in adults, especially in smaller FB of lower airway(6-10). Cryoprobe is very effective in retrieval of organic FB, tablets, blood clots and Access this article online those with significant surrounding granulation .It

freezes the object/tissue enabling quick and easy removal (11-13). Herein, we describe a patient with a smooth, spherical FB impacted in segmental bronchus retrieved with substantial difficulty using cryoprobe and forceps.

CASE REPORT

A 51 year old ex chronic smoker, old treated pulmonary tuberculosis on regular OP follow up for bilateral emphysematous lungs with large subpleural bullae , bilateral fibrobronchiectasis, and an asymptomatic left lower lobe aspergilloma came with complaints of increased cough and breathing difficulty for 3 weeks. Patient vaguely recalled an history of aspiration 2 months back. On examination, patient was tachypneic, dyspneic with right sided wheeze and Spo2 – 92 % on room air. ABG on room air showed PH 7.47. PCO2 35.5,PO2 70.1, HCO3 25.6. Chest Xray showed a suspicious new onset right sided lung hyperinflation (Figure 1). CT chest showed a well defined rounded 9*7mm soft tissue density seen in Right Lower Lobe(RLL) bronchus(Figure2, Figure3). Flexible Bronchoscopy with Oxygen Supplementation done as diagnostic procedure revealed bilateral dilated and scarred bronchus, thick purulent secretions in right lower lobe and a smooth, yellowish intrabronchial lesion in RLL lateral segment bronchus with surrounding edematous mucosa(Figure 5). Biopsy taken from the lesion revealed vegetable matter. Patient was planned for FB extraction.

PRE PROCEDURAL PLANNING

Based on the character (smooth, organic), location(impacted in RLL lateral segment) of FB with the pre existing lung disease and hypoxemia at rest in this patient, after consultation with the procedural team(Bronchoscopist, Anesthesiologist, nurses, assistant) it was decided to retrieve the FB with flexible bronchoscope(Olympus, Working Channel Diameter 2.8mm) under General Anaesthesia with cryoprobe(ERBE, Germany, outer diameter 2.4mm)

PROCEDURE

After intubation with Endotracheal tube(ET) size 8, flexible bronchoscopy introduced through swivel port , complete airway survey done. Gentle positive airway pressure given by Anaesthesiologist in this patient with bullous lung. After clearing out secretions, flexible bronchoscopy placed at centre of FB in RLL lateral segment bronchus and saline rinsing was done to increase cryoadhesiveness. Cryoprobe(Figure 4) was introduced through working channel , placed to contact with the FB, was frozen for 5 seconds and adherent FB with the cryoprobe was mobilized to trachea slowly. The FB detached from the cryoprobe in the trachea the possible reason would be the partial adherence attributed by the shape, oil content and the solid nature of the FB. The FB was a spherical nut and it was moving in the trachea. To avoid any contact with the wall and causing complications, the cryoprobe was withdrawn. Grasping rat forceps was introduced and with great difficulty the eluding FB was caught hold . It was not possible to maintain a coaxial plane to

remove FB via ET tube. Therefore, the FB was retrieved en-bloc with bronchoscope, cryoprobe and ET tube. Reintubation was done promptly and airway secured. Flexible Bronchoscopy was again introduced for post retrieval survey. No retained fragments seen and no bleeding observed. Purulent secretions sent for culture. Patient was extubated safely and shifted to recovery room. Post operative vitals were stable with Spo2-96% on room air. Patient became comfortable after 1 hour and discharged after 4hr observation with oral antibiotics and oral glucorticoids for 1 week.

Fig 6

DISCUSSION

In adults, most FB aspirations are non life threatening. The nature of aspirated FB is highly variable and the type of FB impacts the nature of tissue reaction in the airway. Sharp inorganic materials cause direct airway injury whereas organic materials cause inflammation and granulation tissue in the airway. The predisposing risk factors for aspiration are drug/alcohol intoxication, loss of consciousness from trauma, neuromuscular diseases and old age affecting swallowing, iatrogenic causes. 10% of patients have no risk factors(14). FB aspiration is more in male and average age affected is 50 to 60(15-17). Patient recollection of FB aspiration is below 50% and below 30% over 65 years(6,8,10,15,17). Multiple case series have shown cough as the most common symptom, with dyspnea, wheezing, hemoptysis, chest pain being less common(17-20). In 2-10% patients, the FB may be identified incidently on imaging(14,18,21). Physical examination in suspected FB aspiration may reveal wheeze on affected side. Standard Chest Xray should be obtained in all patients but they directly identify FB in only 25% of patients(23) . It can demonstrate indirect signs and complications like atelectasis, hyperinflation, bronchiectasis and lobar consolidation. In 14-35% of patients, the chest radiography is entirely normal(4,5,23,24). CT chest is more sensitive for identification of FB and has become the standard radiological investigation in suspected FB(5). The most important aspect of FB extraction is pre procedural planning which involve discussion of the size, nature, location, anticipated approach with backup plan in emergency. When planned an extraction with anaesthesia, both conscious sedation and general anaesthesia with endotracheal tube/Laryngeal mask airway is available and the selection depends upon the patient. ET tube provide a stable airway and allow for positive pressure ventilation which is needed in patients with hypoxemia(22). Flexible Bronchoscopy enables complete airway survey for diagnosis of non asphyxiating FB and has a success rate of more than 90% in retrieval (6,9,10,16,18,19,25,26). Significant bleeding and acute respiratory distress caused by large FB , although rare can be managed comparatively better in rigid bronchoscopy and this is a limitation in flexible bronchoscopy. The various instruments available for FB retrieval are forceps with varying size and tips, magnetic probe, snare, basket,balloon catheter and cryoprobe. The choice of tool depends upon the nature of the FB. Cryoprobe-based therapy is based on the Joule–Thomson physical principle whereby a liquefied gas under pressure that exits through a small orifice undergoes rapid conversion and expansion to the gaseous form. This liquid–gas conversion is accompanied by a dramatic temperature drop that is captured in the cryoprobe tip (27). Apart from ablation of benign and malignant lesions of the airways, recanalisation of the airways and endobronchial/ transbronchial biopsy. Cryoprobe is very effective in retrieval of organic FB, blood clots, those with significant surrounding granulation and tablets which have high propensity to disintegrate during removal with forceps and cause grave toxic reaction(13,28, 29). When using the cryoadhesion technique, the frozen probe tip is abruptly pulled away from adherent tissue during the rapid freezing phase. In this case, tissue removal, rather than tissue injury and cell death, is the goal. It can be used in both flexible and rigid bronchoscopy. The ability of FB to cryoadhere depends upon the water content of the object(27). The complication that one needs to be careful in cryoextraction is the possibility of bleeding during procedure.

CONCLUSION

Foreign body in the lower airways can be removed safely and successfully with flexible bronchoscopy using dedicated instruments. Even in the hands of an expert bronchoscopist skilled in usage of multiple devices, the procedure can get testing at times. Proper pre procedural planning and availability of a skilled team significantly reduces failure. Cryotherapy is avant garde and its use in selected FB extraction is very safe and successful as in this case.

ACKNOWLEDGEMENT

We sincerely thank the management of Apollo Hospitals for their consistent support in our pursuit for excellence.

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