Endobronchial Foreign Body Extraction

Endobronchial Foreign Body Extraction

contact with the bronchial wall is suboptimal. Finally, current bronchoscopy ports have proved to be an imperfect means of securing the blocker in pla...

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contact with the bronchial wall is suboptimal. Finally, current bronchoscopy ports have proved to be an imperfect means of securing the blocker in place, and dislocation during surgical manipulation is likely. The AEBS was designed to overcome these drawbacks of the current endobronchial blocker technology5–7 (Figs 3, 4). For the indication of intrabronchial hemorrhage, the fiberoptically wire-guided direction of the blocker allows it to be placed visually in any part of the bronchial system or near the ostium of a single lung segment. Removal of the wire after placement provides a lumen for manipulation within the blocked area. After selective isolation of a single lobe, the remaining parts of the lung are endoscopically cleared and suctioned. Finally, because a single lobe can be targeted, the improvements in gas exchange can be greater than if an entire lung is isolated. It must be emphasized that the emergency airway management that we have reported on here does not represent a curative method but should be understood as an appropriate procedure to gain time to perform or complete urgent interventions. Thus, it may serve as a bridge to emergency surgery, such as laparotomy or thoracotomy and lobectomy. In the present case, we gained 45 min after the blockade of the lower lobe and another 20 min after blockade of the left mainstem bronchus, during which we ensured sufficient ventilation. There are no studies at present on the use of this technique in similar emergency situations, but our experience prompts us to recommend it as an alternative that is well-suited to be performed with the currently used methods of airway management in the presence of severe pulmonary hemorrhage. ACKNOWLEDGMENT: We thank Jane Neuda for editorial assistance.

during one-lung anesthesia [letter]. Anesth Analg 1990; 71: 311–312 10 Arndt GA, Kranner PW, Lorenz DC. Axial placement of an endobronchial blocker [letter]. Can J Anaesth 1994; 41:1126 – 1127 11 Slinger PD, Lesiuk L. Flow resistances of disposable doublelumen, single-lumen, and Univent tubes. J Cardiothorac Vasc Anesth 1998; 12:142–144

Endobronchial Foreign Body Extraction* A New Interventional Approach Kenneth M. Nalaboff, MD; J. Louis Solis, MD; and Daniel Simon, MD

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. (CHEST 2001; 120:1402–1405) Key words: bronchi; foreign bodies; radiology, interventional

References 1 Castelli I, Schla¨ pfer R, Stulz P. Das Thoraxtrauma. Anaesthesist 1995; 44:513–530 2 Devitt JH, McLean RF, Koch JP. Anesthetic management of acute blunt thoracic trauma. Can J Anaesth 1991; 38:506 –510 3 Kapral S, Mauritz W. Polytrauma: definition und pathopysiologie. In: VanAken H, Reinhart K, Zimpfer M, eds. Ains Band 2 Intensivmedizin. Stuttgard, Germany: Thieme, 1999; 1194 –1214 4 Glinz W. Evaluation of thoracic injuries. In: Border JR, ed. Blunt multiple trauma: comprehensive pathophysiology and care. New York, NY: Marcel Dekker, 1990; 391– 408 5 Arndt GA, Kranner PW, Rusy DA, et al. Single-lung ventilation in a critically ill patient using a fiberoptically directed wire-guided endobronchial blocker. Anesthesiology 1999; 90: 1484 –1486 6 Arndt GA, Buchika S, Kranner PW, et al. Wire-guided endobronchial blockade in a patient with a limited mouth opening. Can J Anaesth 1999; 46:87– 89 7 Arndt GA, DeLessio ST, Kranner PW, et al. One-lung ventilation when intubation is difficult: presentation of a new endobronchial blocker. Acta Anaesthesiol Scand 1999; 43: 356 –358 8 Inoue H, Shohtsu A, Ogawa J, et al. Endotracheal tube with movable blocker to prevent aspiration of intratracheal bleeding. Ann Thorac Surg 1984 37:497– 499 9 Larson CE. A device for endobronchial blocker placement 1402

foreign bodies are often difficult to E ndobronchial 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– 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 1968,5–7 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. *From the North Shore University Hospital-NYU School of Medicine, Manhasset, NY. Manuscript received September 23, 1999; revision accepted March 27, 2001. Correspondence to: Kenneth M. Nalaboff, MD, North Shore University Hospital-NYU School of Medicine, 300 Community Dr, Manhasset, NY 11030 Selected Reports

Figure 1. CT scan of the chest reveals a right middle lobe metallic endobronchial foreign body (arrow).

Case Report 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. 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,

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.

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

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.

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 CHEST / 120 / 4 / OCTOBER, 2001

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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). 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.

Discussion

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.

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. We then removed the Berenstein catheter over the snare and exchanged it for an 18F sheath (Cook; Bloomington, IN). The 1404

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.5–7 The main risk is catheter Selected Reports

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.

Conclusion 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.

References 1 Zavala DC, Rhodes ML. Foreign body removal: a new role for the fiberoptic bronchoscope. Ann Otol 1975; 84:650 – 656 2 Lillington GA, Ruhl RA, Peirce TH, et al. Removal of endobronchial foreign body by fiberoptic bronchoscopy. Am Rev Respir Dis 1976; 113:387–391 3 Heinz GJ IQ, Richardson RH, Zavala DC. Endobronchial foreign body removal using the bronchofiberoscope. Ann Otol 1978; 87:50 –53 4 Lan RS, Lee CH, Chiang YC, et al. Use of fiberoptic bronchoscopy to retrieve bronchial foreign bodies in adults. Am Rev Respir Dis 1989; 140:1734 –1737 5 Ullyot DG, Norman JC. The Fogarty catheter, an aid to bronchoscopic removal of foreign bodies. Ann Thorac Surg 1968; 6:185–186 6 Hunsicker RC, Gartner WS. Fogarty catheter technique for removal of endobronchial foreign body. Arch Otolaryngol 1977; 103:103–104 7 Kosloske A. The Fogarty balloon technique for the removal of foreign bodies from the tracheobronchial tree. Surg Gynecol Obstet 1982; 155:72–73 8 Treen DC, Falterman KW, Arensman RM. Complications of the Fogarty catheter technique for removal of endobronchial foreign bodies. J Pediatr Surg 1989; 24:613– 615 9 Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med 1990; 112:604 – 609 10 Baharloo F, Veyekemans F, Francis C, et al. Tracheobronchial foreign bodies. Chest 1999; 115:1357–1362 11 Egglin TK, Dickey KW, Rosenblatt M, et al. Retrieval of intravascular foreign bodies. AJR Am J Roentgenol 1995; 164:1259 –1264

Primary Pulmonary Plasmacytoma* A Case Report James N. Wise, MD; Robert F. Schaefer, MD; and Raymond C. Read, MD, FCCP

Most extramedullary plasmacytomas are associated with the upper respiratory tract. Primary pulmonary plasmacytomas are rare, and the treatment is surgical excision. This malignancy advances to multiple myeloma in a minority of patients. The patient in our case report is the first to experience renal failure due to hematologic monoclonal gammopathy. Postoperatively, serum protein electrophoresis reverted to normal. (CHEST 2001; 120:1405–1407) Key words: primary pulmonary plasmacytoma; renal failure CHEST / 120 / 4 / OCTOBER, 2001

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