Volume 4, Issue 2 , Pages 75-76, March 2009
Impacted foreign body in secondary bronchus: Chest percussions during therapeutic bronchoscopy
Article Outline
Summary
We report a case of 1-year 7-month-old boy who presented with impacted peanut in the secondary bronchus. An alternative method of dislodging the impacted foreign body was used in this case with concomitant chest percussions during rigid bronchoscopy. This method helped to dislodge the peanut successfully.
Keywords: Bronchus foreign body, Bronchoscopy
1. Case report
A 1-year 7-month-old boy was presented to the Accident and Emergency Department of Hospital Tengku Ampuan Afzan, Kuantan, Malaysia with a history of sudden onset of difficulty in breathing following a bout of cough. A positive history of foreign body inhalation was given by the parents. The boy put a few peanuts into his mouth given by his older sister and began to cough profusely a few times and followed by shortness of breath. However, there was no episode of cyanosis following that episode. Chest X-ray shown a hyperinflated, hypertranslucent right lung field. Based on the positive history of foreign body inhalation and X-ray findings, urgent rigid bronchoscopy under general anaesthesia was performed. During bronchoscopy (the first bronchoscope used was size 3), there were few pieces of peanuts were found lodged in the lower end of right main bronchus but not totally blocking the airway. These pieces of peanuts were successfully removed using a crocodile forceps. On further examination (second bronchoscope used was size 2.5), there was another piece of peanut tightly lodged in the right secondary bronchus that was irretrievable by using the crocodile forceps due to restricted view. Chest percussion was then performed with the patient's body turned to the left side and with the rigid bronchoscope in place. During percussion, the peanut was seen to move slowly toward the beak of bronchoscope and subsequently on rest on the distal end of bronchoscope (Fig. 1). Hence the foreign body was removed successfully. The boy was discharged well 2 days after the procedure.
Fig. 1.
The impacted peanut seen rest on distal of the rigid bronchoscope after chest percussion.
2. Discussion
Paediatric airway foreign bodies are potentially life-threatening condition that need prompt diagnosis and intervention. This is not an uncommon problem for a young child to present at ENT clinics with foreign body in the tracheobronchial tree as the habit of putting anything within reach into the mouth is the nature of a young children. Such a situation is further worsened by the inadequate ability of young children to chew, activities of frequent, vigorous, uninhibited inspiration when they lough or cry. Children also tend to playing and running around while they are eating. The presence of foreign bodies in the airway has posed great challenges to ENT surgeons in term of it management of such conditions due to various clinical presentations [1]. Hence, there is difficulty to establish proper diagnosis and subsequent managements. It is potentially a very serious condition that may result in acute respiratory embarrassment, chronic and irreversible lung injury or death could result. It has been reported that 55% of patients with foreign bodies in the airway are between 1 and 3 years old and 7–10% is less than 1-year old [2].
In current practice, the procedure of choice for removing foreign bodies in the tracheobronchial tree is by using rigid bronchoscope which is done under general anaesthesia with the success rate of 99%. In certain conditions where foreign body migrated distally and could not be grasped with crocodile forceps, thoracotomy and bronchotomy has been performed [2]. Other authors have described the usage of a combination of rigid and flexible bronchoscope in removal distally placed foreign body [3]. In present case, we were able to remove the peanut pieces at the lower end of right main bronchus successfully using the standard rigid bronchoscopy procedure (size 3) but failed to reach the smaller piece that was lodged in the right secondary bronchus due to restricted view and difficulty in grasping the foreign body during instrumentation. We used one size smaller of bronchoscope (size 2.5) when advancing into the right secondary bronchus. At that stage we attempted chest percussion by rolling the patient into the left lateral position and started the chest tapping, while maintaining the rigid bronchoscope in place. During this procedure, we were able to see that the foreign body and mucous slowly moving toward the beak of the bronchoscope and move right into the distal end of the bronchoscope. With this method, the presence of effective mucociliary function helped us in moving the foreign body from the distal to proximal airway with the assistance of chest percussion. Chest physiotherapy has been used years ago to facilitate airways clearance that included chest percussion, postural drainage, chest vibration and shaking the chest wall. It is an effective technique to increase mucous clearance in many lung pathologies [4].
In conclusion, concurrent chest percussion at bronchoscopy is helpful in removing an impacted foreign body in the tracheobronchial tree.
References
- . Migrating foreign body in the bronchus. International Journal of Pediatric Otorhinolaryngology. 2003;67:1123–1126
- . Foreign body aspiration in children: diagnosis and treatment. Pediatric Surgery International. 2003;19:485–488
- . Combined rigid and flexible endoscopic remocal of a BB foreign body from a peripheral bronchus. International Journal of Pediatric Otorhinolaryngology. 1999;47:77–80
- . Nonpharmacological airway clearance therapies: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:250–259
PII: S1871-4048(08)00052-X
doi:10.1016/j.pedex.2008.07.001
© 2008 Elsevier Ireland Ltd. All rights reserved.
Volume 4, Issue 2 , Pages 75-76, March 2009
