International Journal of Pediatric Otorhinolaryngology 95 (2017) 109e113

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International Journal of Pediatric Otorhinolaryngology

j o u r n a l h o m e p a g e: h t t p : / / w w w. i j p o r l o n l i n e . c o m /

Retrieval of tracheobronchial foreign bodies by short flexible

endoscopy in children
Wen-Jue Soong a, b, *, Pei-Chen Tsao a, b
, Yu-Sheng Lee a, Chia-Feng Yang a

a
Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
b
Institute of Emergency and Critical Care Medicines, School of Medicine, National Yang-Ming University, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t
Article history: Objectives: Flexible endoscopy (FE) is frequently used to diagnose tracheobronchial foreign bodies
Received 23 September 2016
(TBFB). However, it is still controversial for retrieval of TBFB in pediatric field. This study aims at
Received in revised form
reporting and evaluating our experiences of using short-length FE with a non-invasive ventilation (NIV)
27 January 2017
Accepted 28 January 2017
technique and intensive care unit (ICU) support in retrieving pediatric TBFB.
Available online 16 February 2017 Methods: A retrospective review of the hospital database and FE videos of pediatric patients aged less
than 18 year-old who were diagnosed of TBFB and managed in our hospital over a 17-year period (1999
Keywords:
e2015). The demographic data were collected and analyzed. A NIV technique of providing nasopha-
Airway foreign body ryngeal oxygen with intermittent nose closure and abdominal compression was routinely performed in
Flexible bronchoscopy procedural sedated patients throughout the whole FE procedures.
Foreign body retrieval Results: Sixty-six consecutive patients with 76 TBFB were enrolled. Among them, 72 (94.7%) TBFB in 64
Non-invasive ventilation patients were successfully retrieved at the first attempt of FE immediately after the diagnosis was made.
PhO2 -NC-AC There were 13 iatrogenic TBFB in patients who already had coexisting airway problems. The median age
was 16 months (range 1.5 monthse17 years) and the median body weight was 10.5 kg (range 3.5
e48.5 kg). Seventy (70/72, 97.2%) TBFB were retrieved by short-length FE and among them, 55 pro-
cedures (55/72, 76.4%) used FE with no working channel. No significant acute or late adverse effects were
noted. The mean retrieval procedural time was 23.6 ± 15.1 min.
Conclusion: Using short-length FE with this NIV technique, appropriate sedation and ICU support is a
safe, simple and effective modality for the retrieval of TBFB immediately after confirming the diagnosis
in
pediatric patients.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction pediatric population [12] because their inherent narrow airways

Tracheobronchial foreign bodies (TBFB) in children often result
in significant morbidity and life-threatening emergency [1e5] that
makes the early recognition and prompt retrieval essential. Tradi-
tionally, flexible endoscopy (FE) is mainly used for diagnostic pur-
pose, whereas the rigid endoscopy (RE) serves for retrieval [5,6].
RE requires specialized facilities that may prevent timely
management in emergencies and is not applicable for obstructed
upper airway, restricted cervical motion, and distal airway
approach. Therefore, FE has been increasingly used as an
alternative for TBFB retrieval in adult [7e11]. However,
controversies of using FE persist in the
* Corresponding author. Department of Pediatrics, Taipei Veterans General Hos-
pital, No. 201, Section 2, Shih-Pai Road, Beitou, Taipei 11217, Taiwan.
E-mail address: wjsoong@vghtpe.gov.tw (W.-J. Soong).
challenge the accommodated instrumentation of FE itself, artificial
airway and accessories within those small lumens. Additionally,
lack of adequate size of working channel (WC) and retrieval in-
struments also hamper FE use in these vulnerable infants and
small children.
With advances in techniques and instruments, successful TBFB
retrieval by FE in pediatrics has gradually increased [13e16],
showing that diagnose and removal of objects can be carried out
in the same FE sessions, saving both time and labor. However,
the existing reports have used the classical flexible endoscopes of
long- length 60 cm and may require the artificial airway and
ventilator support. In our hospital for more than two decades, we
have been using a different approach by using short-length
flexible endo- scopes with a non-invasive ventilation (NIV)
based on nasopha- ryngeal oxygen with intermittent nose
closure and abdominal compression (termed “PhO2-NC-AC”
ventilation) [17], without any

http://dx.doi.org/10.1016/j. ijporl.2017.01.033
0165-5876/© 2017 Elsevier B.V. All rights reserved.
 W.-J.
W.-J.
Soong
Soong
et al.
et /al.International
/ International
Journal
Journal
of Pediatric
of Pediatric
Otorhinolaryngology
Otorhinolaryngology
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95 (2017)
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109e113
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 W.-J.
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et al.
et /al.International
/ International
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of Pediatric
of Pediatric
Otorhinolaryngology
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f
artificial mask, bag, airway or causing dif- ficulty in r the diagnosis in the first FE
ventilator. The diagnosis was advancing the FE or removing a sessions. Their median age
g
made and TBFB were TBFB. Significant bleeding was m was 16 months (range 1.5
retrieved in procedural defined as the need for ice- e monthse17 years) and the
n
sedated patients in the same cold saline lavage or t median body weight was 10.5
FE sessions in pediatric transfusion or beyond. . kg (range 3.5e48.5 kg).
intensive care unit (ICU). Thirteen patients had
This study aims at 3 coexisting pulmonary
analyzing and reporting our . problems: 5 with TB
experiences of the diagnosis metallic stent, 5 with
and retrieval of TBFB with R TBFB- associated pneumonia,
the modality of using short- e 2 infants undergoing recent
length FE with this NIV, s laser supra- glottoplasty 2
u
appropriate sedation and ICU days before for their severe
l
sup- port in our pediatric t laryngomalacia [18] and one
patients. s infant with severe upper
airway obstruction due to a
2 Seventy-six TBFB in 66 huge tongue tumor and
. consecutive children (37 depending on tracheostomy
boys) were enrolled (Fig. 1). tube. All FE were smoothly
M Among them, 72 (94.7%) performed with patients
e under procedural sedation
TBFB were successfully
t and this NIV support. The
h retrieved from 64 children (35
boys) immediately after mean dosages of associated
o
d confirming medications were intravenous
s midazolam 0.6 ± 0.2 (range
0.3e1.0) mg/kg, ketamine
This is a retrospective 2.7 ± 0.6 (range 1.0e4.0)
mg/kg, and topic Xylocaine 4.7
study at our hospital, a
± 1.4 (range
tertiary pediatric referral
4
center, from 1999 to 2015.
.
Patients with age less than 0
18 year-old, diagnosed of e
TBFB aspiration and 6
managed by FE were .
enrolled. Their medical 5
records and FE videos of the )
retrieval pro- cedures were
reviewed and analyzed. This m
study was approved by the g
/
Committee for the
k
Protection of Human g
Subjects in Research (VGHIRB .
number: 2014-07-003AC). Four TBFB in 3 patients
The following data were were not retrievable because
collected and analyzed: (1) of difficulty in approaching
de- mographic data of the foreign bodies with FE.
gender, age, and body Three of them were located
weight at time of pro- at upper bronchi and one at
cedures; (2) types and distal right lower bronchi.
locations of TBFB; types of They were all remnants after
flexible endoscopes, their main parts had already
Fig. 1. Numbers and locations of the 76
retrieving instruments and tracheobronchial foreign bodies: white been removed at
sedative medications; (3) circles, retrieved and black circles, approachable sites. No further
total procedure times, failed. retrieval with RE or surgery
complications and outcomes. *
i was attempted afterward and
Significant procedure- a there had been no associated
related adverse events were t
r sequel for more than 5 years
recorded. Significant asphyxia o during follow-up.
was defined as any g
e Four flexible endoscopes
requirement for traditional n had been used as shown in
resuscitation of endotracheal i
c Table 1. Both endoscopes I
intubation, cardiac and II are short-length
compression or intravenous m without WC which had
adrenergic drugs. Airway e retrieved 55 TBFB.
t
spasm was defined as a Endoscopes III and IV have
laryngeal or tracheobronchial l one WC and had retrieved
(TB) lumen contraction 17 TBFB. The WC could
 W.-J.
W.-J.
Soong
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et al.
et /al.International
/ International
Journal
Journal
of Pediatric
of Pediatric
Otorhinolaryngology
Otorhinolaryngology
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accommodate a tiny one year later. Another 3
flexible basket or forceps. were residual stent
Among the 72 successful fragments which were
retrievals of TBFB, 70 (97.2%) retrieved during follow up FE
used short-length FE and after their main stent portion
55 (76.4%) used had already been removed
endoscopes without WC. by RE. Three silicon
When using the tracheostomy tubes
endoscopes without a WC, accidently dropped into the
the selected retrieve carina during manipulation
instrument was orally and they were all
introduced into the TB immediately retrieved by
lumen (Fig. 2) and followed forceps with FE from the tra-
by nasal insertion of the FE cheostomy stoma. Two rolls of
alongside and proximal to aluminum foil tape were
the TBFB (Fig. 3). Then, under originally wrapped over
visual control of the FE, endotracheal tube to avoid
endoscopist preceded laser burns during
various retrieval supraglottoplasty. Both
manipulations (Fig. 4). unexpectedly remained in
Only one single TBFB was the tracheal lumen after
found in 57 patients, 2 TBFB extubation and were
in 6 pa- tients (the trachea retrieved at follow-up FE [18].
and right main bronchus in 2 A failed retrieval TBFB was a
patients, both right and left metallic fragment of a
bronchi in 4 patients) and 3 reverse-grasping forceps tip
TBFB (one in the trachea and after RE in the referring
2 in the right bronchi) in one hospital failed to remove an
patient. Thirty-six TBFB were aspirated pen cap in a 9
retrieved solely by the year-old boy but left this
basket, 22 solely by forceps fractured in- strument inside
and 14 requiring both the right distal bronchus.
balloon and forceps. After the successful
Types, numbers and
locations of TBFB are shown
in Table 2. Peanuts, beans
and seeds were the
leading aspirated objects.
Further, four patients had
pen caps aspiration, three at
the right intermediate
bronchus and one at the left
main bronchus. These four
patients were all transferred
from other hospitals after
RE failed. All these aspirated
pen caps were successfully
extracted in our first FE
attempts [19].
In the 13 (17.1%) iatrogenic
TBFB, 12 were successfully
retrieved, which included 7
metallic mesh stents, 3
silicon tracheostomy tubes, 2
aluminum foil tapes, and 1
forceps fragment (the failed
retrieval). Of the metallic
stents, 4 were full-structured
stents. Two stents were
urgently removed from the
left bronchus just following
the premature dislodgement
during placement, one was
removed from the trachea
due to stent migration two
days after placement, and
one was electively removed
from the left main bronchus
 W.-J.
W.-J.
Soong
Soong
et al.
et /al.International
/ International
Journal
Journal
of Pediatric
of Pediatric
Otorhinolaryngology
Otorhinolaryngology
95 (2017)
95 (2017)
11 109e113
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Table 1
Flexible endoscope types, retrieval instruments, numbers and locations of the tracheobronchial foreign bodies.
 W.-J.
W.-J.
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et /al.International
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of Pediatric
of Pediatric
Otorhinolaryngology
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Flexible endoscope Main instrument Foreign body locations and numbers

OD, WC, WL
Trachea Bronchus

Subglottis Mid-trachea Carina Right Left

I 3.0 mm, nil, 30 cm Basket 3 2 3 3

Balloon* 2 1 3 2
Forceps 1 2

II 3.2 mm, nil, 30 cm Basket 2 3 3 6 2

Forceps 3 2 4 2
Balloon* 1 3 2

III 4.8 mm, 2.0 mm, 36 cm Basket 1 2 1 3 2

Forceps 1 1 3 1

IV 3.6 mm, 1.5 mm, 60 cm Forceps 1

Subtotal 4 15 12 26 15
Total 72

OD ¼ out diameter; WC ¼ working channel; WL ¼ working length; I ¼ ENT-30PS, Machida, Japan; II ¼ ENF-V2, Olympus, USA; III ¼ ENF-VT2, Olympus, USA; IV ¼ LF-2,
Olympus, USA; *may combine with forceps.

removal of the pen cap by our FE, the metal object was not found
endoscopically [19]. This boy had no associated symptoms after-
ward and a follow up chest radiograph 8 years later showed no
evidence of this foreign body.
The mean retrieval procedural time was 23.6 ± 15.1 min (range,
3e65 min). There were no significant immediate complications. All
episodes of bradycardia and oxygen desaturation (<85%) were
transient and rapidly restored to acceptable levels within 30 s by
this NIV and no further advanced management was required.
Forty- three patients (43/64, 67.2%) were discharged within one
day after the retrieval, 21 patients had coexisted and TBFB-
associated res- piratory diseases that necessitated further
hospitalizations. The mean hospital stay was 2.5 ± 1.8 days
(range, 1e7 days).

Fig. 2. Sequentially, an oxygen catheter inserts via right nostril, a balloon catheter via
mouth, a short flexible endoscope via patient's left nostril and the endoscopist's
fingers around the mouth and nose; assistant's hand over abdomen. There is no
mask or artificial airway and easy to simultaneously manipulate the endoscope,
instruments and provides ventilation during procedure.
Fig. 3. The side-by-side technique of flexible endoscopy with retrieval instruments in
tracheobronchial lumen.
4. Discussion
Maintaining a proper airway with adequate ventilation,
oxygenation and keeping clear endoscopic view are crucial for the
success of FE, particularly during those complicated interventions
including retrieving TBFB. FE is quick, simple and easily accessible
to most pulmonologists and otolaryngologists who are capable of
manipulating FE to approach both upper and lower airways.
Therefore, FE may consider using in suspicion of TBFB [20], espe-
cially when in distal bronchi. It does not require specialized
surgical teams or operating room services, and decreases the
waiting time, lessens medical expenses and reduces the
associated risks [21]. However, debates still exist whether it
should be further used for retrieval of TBFB in small pediatric
patients [22]. In case that RE is not emergency available on one
hand, or difficult approach in tough upper airway, restricted
cervical extension, presence of intra- tracheal device (stent
used in double stage LTRs or a t-tube) or wound, or distal
located TBFB in bronchial airway on the other hand, then there
may consider that the less invasive technique and flexible
instrument of FE may be the choice of interventional tool.
During the extraction of TBFB in respiratory compromised pa-
tients, the most common concern is that the endoscope itself may
obstruct the limited airway and impair ventilation. The NIV tech-
nique we have been using can provide both inspiration and expi-
ration simply by the intermittent maneuver of doing nose-closure
followed by abdomen-compression [17]. The set-up only requires
the insertion of small oxygen catheter positioned in pharyngeal
region with an appropriate oxygen flow. It surpasses the
traditional positive pressure ventilation support by eliminating
the space- occupying respiratory supporting devices including
ventilation
Fig. 4. Representative images of the flexible endoscopy retrieving tracheobronchial foreign bodies (FB): (a) suctioning secretions with a big tube during procedure, (b) proximal
view of the balloon catheter pulling FB, (c) an inflated balloon beyond FB, (d) laryngeal view of FB retrieval, (e) forceps catching a peanut, and (f) two inflated balloons in both
main bronchi retrieving a carina FB.

Table 2
Types, numbers and locations of the tracheobronchial foreign bodies retrieved by flexible endoscopy.
a
Types of foreign bodies Number (%) Locations (number)

Vegetables Peanut 18 (25.0) RB(7), LB(4), T(4), C(3)

Bean 12 (16.7) C(3), RB(5), LB(4)
Seed 9 (12.5) T(2), RB(4), LB(3)
Animal foods Meat 5 (6.9) T(3), C(2)
Fishbone 4 (5.6) S(2), T(1), C(1)
Crab, shrimp 2 (2.8) S(2)
Stationeries Pen cap 4 (5.6) RB(3), LB(1)
Balloon 3 (4.1) C(2), T(1)
Plastic toy 3 (4.1) RB(3)
b
Iatrogenic Metallic stent 7 (9.7) LB(3), T(2), RB(2)
Silicon T-tube 3 (4.1) RB(2), C(1)
c
Foil paper 2 (2.8) T(2)
Total 72 (100)
a
C ¼ carina; LB ¼ left bronchus; RB ¼ right bronchus; S ¼ subglottis; T ¼ trachea.
b
Included 4 full-structure stents and 3 stent fragments.
c
Protective aluminum foil paper over the endotracheal tube [23].
bag, facemask, laryngeal mask
airway, endotracheal tube or
venti- lator. It causes less
impediment, no airway
distortion, and no sharing of
the limited airway. This NIV
creates a pneumatic stent
effect to preserve and may
even expand the natural
space of both upper and
lower airways during nose-
closure, which can easily
accommodate and
simultaneously manipulate
FE, retrieval in- struments,
and maintain optimal
ventilation flow and pressure.
The endoscopist himself can
optionally control the rate
and the infla- tion pressure to
get dynamic and
comprehensive inspection in
the target airway lumens.
Therefore, FE with this NIV
can significantly facilitate
both diagnostic as well as
therapeutic yields. Previous
animal [23] and human [17]
studies with FE have already
demon- strated that this
NIV provided
cardiopulmonary support
and rapidly corrected acute
hypoxemia and hypercapnia
in at-risk
subjects.
Compared with traditional
long FE, short-length FE is
easier to manipulate which
allow the operator's right
hand manipulate around the
patient's face and optionally
perform the nose (mouth)-
closure of this NIV to provide
positive pressure ventilation.
In the absence of the
facemask or artificial airway,
the short endoscope is able to
reach the common locations
of TBFB in infants and small
children. In this series, only 5
out of the 76 extractions used
long FE with small OD (3.6
mm) but only 2 cases
succeeded. Endoscopes
without WC also have their
merit as more optical fibers
equipped can enhance better
visual quality.
In this report, 12 of 13
iatrogenic TBFB were
successfully retrieved, all of
which were located inside the
abnormal and diffi- cult
airways. These invasive FE
procedures should be
performed by
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This study was supported,
in part, by research grants of