(Chest. 2001;120:1402-1405.)
© 2001
American College of Chest Physicians
Endobronchial Foreign Body Extraction*
A New Interventional Approach
Kenneth M. Nalaboff, MD;
J. Louis Solis, MD and
Daniel Simon, MD
*
From the North Shore University Hospital-NYU School of Medicine, Manhasset, NY.
Correspondence to: Kenneth M. Nalaboff, MD, North Shore University Hospital-NYU School of Medicine, 300 Community Dr, Manhasset, NY 11030
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Abstract
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Endobronchial foreign bodies are often difficult to diagnose as
the cause of obstructive pneumonias and atelectasis, but once
discovered, they can generally be removed, leading to immediate and
dramatic resolution of symptoms. The use of flexible fiberoptic and
rigid bronchoscopy to extract foreign bodies is well-known. Thoracotomy
is generally reserved as a last resort due to the inherent risks of the
procedure. We describe a new technique for foreign body removal
utilizing steerable hydrophilic guidewires, standard sheaths, and a
snare device commonly utilized in intravascular foreign body
retrieval.
Key Words: bronchi • foreign bodies • radiology, interventional
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Introduction
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Endobronchial
foreign bodies are often difficult to diagnose as the cause of
obstructive pneumonias and atelectasis, but once discovered, they can
generally be removed, leading to immediate and dramatic resolution of
symptoms. The use of flexible fiberoptic and rigid bronchoscopy to
extract foreign bodies is well-known.1
2
3
4
Thoracotomy is
generally reserved as a last resort due to the inherent risks of the
procedure. One interventional radiologic technique for extracting
endobronchial foreign bodies, utilizing a Fogarty balloon catheter, had
been reported as early as 1968,5
6
7
but is employed
infrequently, and carries the risk of catheter disruption and
introduction of further foreign bodies into the tracheobronchial
tree.8
We describe a new technique for foreign body
removal utilizing steerable hydrophilic guidewires, standard sheaths,
and a snare device commonly utilized in intravascular foreign body
retrieval.
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Case Report
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An 87-year-old man was transferred to our institution following
treatment in a burn center, which necessitated a tracheostomy, due to
injuries suffered in a kitchen accident. His clinical course at the
burn center was complicated by empyemas. While under our care, he
underwent a CT scan of the chest to assess the status of his pleural
collections. This demonstrated a partly metallic, right middle lobe,
endobronchial foreign body (Fig 1
). Retrospective examination of serial chest radiographs (Fig 2
) revealed that this foreign body had been present since hospital
admission 2 weeks earlier. It was not detected on prior radiographs,
because previous readers had assumed that it lay outside the patient
along with the innumerable life supporting and monitoring devices being
utilized. Although the foreign body was causing no apparent parenchymal
process, removal of the foreign body was thought to be imperative in
order to optimize the respiratory status of this ventilator-dependent
patient with a history of pulmonary complications.
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Figure 2.. Retrospective examination of previous chest
radiographs identified the partially metallic object (arrow) overlying
the medial aspect of the right lung base. Note pigtail catheters placed
to drain pleural collections.
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The pulmonology department was consulted for the purpose of
bronchoscopic removal. Their attempts at removal of the foreign body
without and with fluoroscopic guidance were unsuccessful, as the object
could not be reached with the bronchoscopic forceps due to its location
deep within the bronchial tree. Because the radiographs had come to the
attention of the interventional radiology section, we offered our
assistance in retrieving this foreign body. An alternative technique
was then successfully applied through a tracheostomy tube utilizing an
Amplatz snare device (Cooks; Spencer, IN) within the angiography suite.
There were no complications. Twelve days following the procedure, while
awaiting transfer to an extended care facility, the patient sustained a
fatal traumatic head injury unrelated to the interventional procedure.
Technique
While the patient’s cardiopulmonary status was closely
monitored, but without conscious sedation or general anesthesia, we
directed a 5F Berenstein glide catheter (Angiodynamics; Queensbury, NY)
through the patient’s tracheostomy tube and into the right mainstem
bronchus. Ten milliliters of 1% lidocaine were administered via the
catheter into the right middle lobe. Under fluoroscopic guidance, a
0.035-inch diameter Terumo glide wire (Meditech; Watertown, MA) was
employed to guide the catheter into the appropriate subsegment. The
Terumo glide wire is a "torqueable" wire, meaning that the operator
can apply a twisting motion at the proximal end of the guidewire that
results in rotation of the flexible distal end. This allows the tip to
be rotated so that it can be pointed toward the appropriate direction
at branching points in the tracheobronchial tree. A small amount of
nonionic low osmolar dye was then administered through the Berenstein
catheter. This did not prove to be helpful, yet it did not obscure
visualization. We confirmed our presence in the appropriate subsegment
by slightly agitating the object with the glide wire. The glide wire
was then advanced beyond the foreign body, and the Berenstein catheter
was manipulated over the glide wire to a point about 2 cm distal to the
object.
At this point, the Terumo glide wire was exchanged for a 10-mm Amplatz
"gooseneck" snare system (Microvena; White Bear Lake, MN). The
snare was deployed just distal to the foreign body, and several passes
were made to secure the object by pulling the open snare proximally
over it. After firmly securing the proximal tip of the foreign body
(Fig 3
), we were still unable to extract it because of compression by the
surrounding pulmonary parenchyma. This was likely due to both its
distal bronchial position and surrounding edema. Since we had been able
to pass the snare around the foreign body, we inferred that it had not
been epithelialized. Any excessive traction would have resulted in
parenchymal damage.
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Figure 3.. Fluoroscopic image demonstrates an Amplatz snare
catheter securing the proximal tip of the foreign body. The surrounding
parenchymal opacities represent nonionic low osmolar dye that had been
injected in order to assist in localizing the object.
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We then removed the Berenstein catheter over the snare and exchanged it
for an 18F sheath (Cook; Bloomington, IN). The sheath was inserted over
the snare as far as possible, to a point where the bronchi became
smaller than the diameter of the 18F sheath. This was located about 2
cm proximal to the foreign body. The Berenstein catheter was then
reinserted through the sheath and over the snare. At no point during
these exchanges did the foreign body disengage from the snare. While
maintaining constant tension on the Amplatz snare, the Berenstein
catheter was pushed snugly against the object in order to tighten the
deployed snare. Gentle pressure downward on the sheath managed to
compress the parenchyma to such an extent that the physical distance
between the end of the sheath and the proximal tip of the ensnared
foreign body was only a few millimeters. We had effectively wedged the
foreign body between the 18F sheath and the coaxial combination of the
5F Berenstein catheter and deployed the 10-mm Amplatz snare. When firm
traction was applied to the coaxial catheter combination, it only
needed to be pulled out from the pulmonary parenchyma immediately
surrounding it and into the sheath. The foreign body could therefore
not cause any damage along its exit trajectory (Fig 4
).
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Figure 4.. The "snare technique." An Amplatz
"gooseneck" snare catheter is deployed through a 5F Berenstein
catheter. Once the foreign body has been secured, the Berenstein
catheter is pushed distally, while maintaining tension on the snare, in
order to tighten the snare. The 18F sheath is then gently pushed
downward in order the compress the surrounding lung parenchyma, so that
the engaged foreign body would only have to traverse the smallest
possible intraparenchymal distance before being pulled into the sheath.
The sheath, catheters, and foreign body could then be withdrawn as a
single unit.
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The foreign body, which proved to be a broken thermometer tip, was
successfully removed through the tracheostomy tube. The patient
tolerated the procedure with only minimal discomfort. The total
fluoroscopy time was 25 min.
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Discussion
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The problem of foreign bodies in the upper food and air passages
have plagued humanity since antiquity, as illustrated by Aesop’s fable
of a stork removing a bone from the throat of a wolf. Endoscopes were
first developed largely in response to the need to extract such foreign
bodies. More recently, angiographers have developed a parallel
technique for extracting foreign bodies from vascular structures, not
using endoscopes, but rather catheters, snares, and fluoroscopy. This
case report illustrates a situation where a newer, different technology
was able to solve a problem in which the standard endoscopic approach
was unsuccessful. We think our case report is important because it may
expand the arsenal of the pulmonologist and otolaryngologist in
removing endobronchial foreign bodies without requiring thoracotomy.
This "snare technique" is applicable in many situations when a
flexible fiberoptic bronchoscope is too large to reach an object.
Although our patient had a tracheostomy tube in place, an endotracheal
tube or a nasopharyngeal or oropharyngeal airway could be utilized in
the same way, providing a controlled access point to the lower
respiratory tract. The patient would require sedation in these
settings. The assistance of the pulmonologist to locate the foreign
body and provide intrabronchial anesthesia would be helpful, but not
necessary.
Until now, the occasional endobronchial foreign body extraction by the
interventional radiologist has been largely accomplished with the use
of a Fogarty balloon catheter. The foreign body is first located and
visualized by a flexible fiberoptic bronchoscope. The Fogarty catheter
is then deployed through the instrument channel of the bronchoscope and
beyond the foreign body. At this point, the balloon tip is inflated and
pulled proximally against the object until it is wedged against the
bronchoscope. The bronchoscope, foreign body, and Fogarty catheter are
then withdrawn as a unit.5
6
7
The main risk is catheter
disruption with separation of the balloon-bearing portion, which could
result in catheter tip embolization.8
Use of the snare
catheter in endobronchial foreign body extraction would have many of
the same indications as a Fogarty balloon catheter, while avoiding some
of the pitfalls, and without necessitating bronchoscopic guidance.
There are no elastic components within the snare catheter that could
fragment and embolize to the tracheobronchial tree. Either approach,
though, would involve a similarly low risk of fragmenting the foreign
body.
The snare technique could serve as an acceptable alternative to
flexible fiberoptic bronchoscopy when a foreign body is located in the
peripheral tracheobronchial tree. A snare catheter could be passed more
distally than a Fogarty catheter as well. Deployment of the balloon
requires enough potential space for inflation, while the snare needs
only to be passed beyond the foreign body. Potential drawbacks to this
approach, however, might include a more limited shape of foreign body
that could be manipulated or extracted. Objects that were round in
shape might not have a surface that could be firmly snared. Sharp
objects, however, would be more amenable to extraction by the snare
catheter and would eliminate the possibility of balloon catheter
puncture and disruption. Another potentially difficult situation would
be cases in which a foreign body has been chronically present and has
incited an inflammatory response that has occluded a bronchus. In this
situation, if a hydrophilic guidewire could be negotiated past the
occlusion, a recanalization procedure could be attempted. Otherwise,
foreign body retrieval would not be possible.
Bronchoscopic foreign body removal carries a remote risk of
pneumothorax and serious bleeding.9
10
For the snare
technique that we describe, there exist no published data regarding the
risks of pneumothorax or serious bleeding. One can, however,
extrapolate from available data regarding the risks of serious
complications during snare removal of intravascular foreign bodies. In
the largest modern published series describing intravascular foreign
body retrieval primarily with the snare device, the only reported
complications were two cases of vasospasm.11
There were no
instances of serious bleeding.
Using the amount billed to patients at our institution as a surrogate
for cost, the cost of the guidewire/snare technique is approximately
$2,072 and the cost of bronchoscopic extraction is $2,400. Thus,
foreign body retrieval via the guidewire/snare technique is an
economically viable alternative.
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Conclusion
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Although we have only one case to illustrate the snare technique,
we believe that we will be able to assist the pulmonologist and
otolaryngologist in their approach to endobronchial foreign body
extraction. A snare could be passed more peripherally in the
tracheobronchial tree than either the flexible fiberoptic bronchoscope
or the Fogarty catheter and extract more distally lodged foreign
bodies. There is less need for guiding bronchoscopy, and there is only
minimal risk of fragmentation of the catheter. Possible limitations
include very smooth, rounded foreign bodies that would not be amenable
to being grasped by the snare and thus might be better approached using
a balloon catheter.
Received for publication September 23, 1999.
Accepted for publication March 27, 2001.
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References
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Zavala, DC, Rhodes, ML (1975) Foreign body removal: a new role for the fiberoptic bronchoscope. Ann Otol 84,650-656
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TOP
Abstract
Introduction
