- Email: [email protected]
The role of flexible bronchoscopy accomplished through a laryngeal mask airway in the treatment of tracheobronchial foreign bodies in children
Accepted Manuscript The Role of Flexible Bronchoscopy Accomplished Through a Laryngeal Mask Airway in the Treatment of Tracheobronchial Foreign Bodies in Children Alev Suzen, Suleyman Cuneyt Karakus, Nazile Erturk PII:
S0165-5876(18)30609-8
DOI:
https://doi.org/10.1016/j.ijporl.2018.12.006
Reference:
PEDOT 9292
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 2 October 2018 Revised Date:
5 December 2018
Accepted Date: 5 December 2018
Please cite this article as: A. Suzen, S.C. Karakus, N. Erturk, The Role of Flexible Bronchoscopy Accomplished Through a Laryngeal Mask Airway in the Treatment of Tracheobronchial Foreign Bodies in Children, International Journal of Pediatric Otorhinolaryngology, https://doi.org/10.1016/ j.ijporl.2018.12.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: The Role of Flexible Bronchoscopy Accomplished Through a Laryngeal Mask
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Airway in the Treatment of Tracheobronchial Foreign Bodies in Children
Authors and affiliations: Alev Suzen1, MD; Suleyman Cuneyt Karakus2, Assoc. Prof.; Nazile Erturk2, Asist. Prof. 1
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Department of Pediatric Surgery, Mugla Sıtkı Kocman University, Research and Training Hospital, Mugla, Turkey.
2
Corresponding author:
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Department of Pediatric Surgery, Mugla Sıtkı Kocman University, Faculty of Medicine, Mugla, Turkey.
Alev Suzen, MD
Department of Pediatric Surgery,
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Mugla Sıtkı Kocman University, Research and Training Hospital, Mugla, Turkey.
e-mail: [email protected]
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Telephone: 00 90 505 2103440
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Fax: 00 90 252 2123599
Address: Department of Pediatric Surgery, Mugla Sıtkı Kocman University Training and Research Hospital, 48000, Mugla, Turkey
Financial support: None
Conflict of interest: None
ACCEPTED MANUSCRIPT Abstract Introduction: We here present our experience with children who underwent flexible bronchoscopy for removal of inhaled tracheobronchial foreign bodies under general
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anesthesia via a laryngeal mask airway (LMA). Materials and Methods: A total of 24 (16 male and 8 female, mean age: 30.75±29.68 months) patients who underwent flexible bronchoscopy under general anesthesia using a LMA for
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suspicion of tracheobronchial foreign bodies between July 2016 and April 2018 were retrospectively reviewed.
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Results: The mean duration of admission to hospital was 162.56±309.56 hours. Sixteen (66.7%) patients were found to have tracheobronchial foreign bodies. All procedures were successfully accomplished through a LMA by using basket forceps, a Fogarty catheter and a suction without any need for rigid bronchoscopy. 11 (68.7%) of tracheobronchial foreign
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body locations were right bronchial, 3 (18.8%) were left bronchial and 2 (12.5%) were tracheal. The types of extracted tracheobronchial foreign bodies were organic in 14 (87.5%) and non-organic in 2 (12.5 %). There were no complications except laryngeal edema noted in
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2 (8.3%) patients, relieved within 48 hours. The mean time of postoperative hospitalisation
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was 2.42±0.97 days.
Conclusion: Flexible bronchoscopy accomplished through a LMA is a safe, easy and effective technique, not only as a diagnostic procedure, but also as the initial therapeutic modality for retrieving tracheobronchial foreign bodies in children with high success and low complication rates. With further reports aforementioned, we hope that the flexible bronchoscopy will become a standard method in children.
ACCEPTED MANUSCRIPT 1.Introduction Rigid bronchoscopy (RB) is considered to be the preferred way for extraction of tracheobronchial foreign bodies (TBFBs) in children with a success rate greater than 97% and
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a complication rate between 2 to 22% [1]. Laryngeal oedema, pneumothotax, tracheal tear and hypoxia are the most frequent and serious complications of RB [1,2]. Although flexible bronchoscope is considered to be a diagnostic tool to decrease the negative RB rate, recent publications about flexible bronchoscopy (FB) as a therapeatic procedure for TBFBs in
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children have been an increasing trend.
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There are various ways to enter the pediatric airway during FB such as direct application, face mask, laryngeal mask airway (LMA) and intubation tube. Introducing the flexible bronchoscope through a LMA has been suggested as an optimal solution in adults to facilitate the procedure while maintaining ventilation [3,4]. We here present our experience with children who underwent FB for removal of inhaled TBFBs under general anesthesia via
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a LMA, with particular emphasis on the advantages and disadvantages of FB through a LMA.
ACCEPTED MANUSCRIPT 2.Materials and Methods A total of 24 patients who underwent FB under general anesthesia using a LMA with the suspicion of TBFBs at Mugla Sıtkı Kocman University Education and Training Hospital
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between July 2016 and April 2018 were retrospectively reviewed. First, informed consents were obtained from the patients' parents before the procedure. A flexible pediatric bronchoscope (Karl Storz GmbH, Tuttlingen, Germany) was passed
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through the swivel connector, which was connected the LMA (i-gel; Berkshire, United Kingdom; size of the mask depending on the age) and anesthesia equipment. Then, topical
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administration of 2% lidocaine solution was applied over the vocal cords via the suction channel of the flexible bronchoscope to reduce the incidence of laryngospasm. If a TBFB was identified, an attempt was made to extract it with the help of a basket forceps (Boston Scientific Zero Tip, IN, USA) or a Fogarthy catheter (ISOMED, Chambly, France) passed
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through the suction channel of the bronchoscope. The TBFB was grasped, and then the bronchoscope, the TBFB and the LMA were pulled out en masse. The final removal of TBFBs, extracted up to the oropharynx by using Fogarthy catheter, was performed through
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the mouth by laryngoscope. Immediately after the removal of the TBFB, FB was performed again to exclude the presence of other TBFBs, fragments of the removed TBFB, or structural
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alterations. During the procedure of all flexible FBs, a complete set of rigid bronchoscopes (Karl Storz GmbH, Tuttlingen, Germany) together with removal tools were always available for a second treatment option if necessary. The patients were typically hospitalised for at least 24 hours and a chest X-ray was performed after the procedure. The collected data included age, gender, duration of symptoms, physical examination at admission, radiographic findings, types and locations of TBFB, types of retrieving instruments, length of hospital stay, complications and outcomes.
ACCEPTED MANUSCRIPT 3.Results Demographic characteristics, preoperative signs, symptoms and radiologic findings of patients are given in Table 1. The mean age of patients was 30.75±29.68 (12-144) months; 5 (20.83%)
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of them were 4 years old or older. The mean duration of admission to hospital in children with TBFB was 6.77±12.90 (0.02-60) days. Five patients (20.83%) were diagnosed as pneumonia at first and referred to our department more than 10 days after the onset of symptoms. Sixteen (66.7%) patients were found to have TBFBs. All procedures were successfully accomplished
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respectively through a LMA by using basket forceps, a Fogarty catheter and a suction in 13
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(81.2%), 2 (12.5%) and 1(6.3%) patients without any need to RB. 11 (68.7%) of TBFB locations were right bronchial, 3 (18.8%) were left bronchial and 2 (12.5%) were tracheal. The types of extracted TBFBs were organic in 14 (87.5%) and non-organic in 2 (12.5 %). Only one TBFB was found in 14 (87.5%) and two TBFBs in 2 (12.5 %) patients (Table 2). The only complications were laryngeal edema noted in 2 (8.3%) patients. Both were mild and
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subsided within 48 hours with corticosteroid administration. The mean time of postoperative hospitalisation was 2.42±0.97 (1-4) days. Since most of the patients were referred to our
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tertiary hospital from rural areas, the length of hospitalization was extended in order to
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prevent post-discharge adverse events.
ACCEPTED MANUSCRIPT 4.Discussion Aspiration of TBFBs is a common and potentially life-threatening emergency in pediatrics. Diagnosis of aspirated TBFBs in pediatric population can be very difficult without
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an adult witness because 80 % of TBFB aspirations occur in children under 3 years of age who are unable to communicate in detail [1]. In a study with 1027 patients, only 53.4% had a history confirming the diagnosis of an TBFB aspiration [5]. Clinical features may present with acute symptoms such as stridor, paroxysmal cough, wheezing, dyspnea, cyanosis, and
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respiratuar failure. Common signs of TBFBs include wheezing, rales and decreased breath
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sounds. However, these symptoms and signs are very common in children with respiratory infections and aspiration of TBFBs can also be clinically silent in 12-25% of patients [6,7]. Undiagnosed TBFBs often result in recurrent pneumonia, atelectasis, and bronchiectasis, when the acute symptoms and signs have been missed [8]. Chest X-ray can be a useful rapid diagnostic tool, but only 4 to 20% of TBFBs are radiopaque [9]. Therefore, indirect signs of
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TBFBs include loss of volume on the affected side, obstructive emphysema, pneumonia, or pneumothorax are more commonly detected. In our study, we detected abnormal X-ray
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findings in 58.3% of our patients, one of whom had a radiopaque punched metal. There is no doubt that FB is a preferred procedure for the initial diagnosis of a foreign
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body due to its very high sensitivity and specificity [1,2,10-12]. Decreased rate of negative RBs and potential complications were also reported in this diagnostic approach [13]. The flexible bronchoscope was developed in 1968 by Ikeda, and the first research into foreign body removal with flexible bronchoscope was published in 1978 by Cunanan in 300 patients older than 10 years of age with a success rate of 89% [14,15]. Although the RB is still considered to be the safest and preferred technique in removing aspirated foreign bodies, the management of TBFBs by larger flexible bronchoscopes with adequate working channels has become a more widely used modality in adults. Sehgal et al reported 89.6% overall success
ACCEPTED MANUSCRIPT rate of FB (18 studies, 1185 adult patients) for foreign body extraction in their systematic review of the literature and suggested the FB the preferred initial procedure for management of airway foreign bodies in adults [16]. Rigid bronchoscopy has the advantage of ventilation safety compared to flexible one in children who have narrower airways. Both European
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Respiratory Society (ERC,2003) and American Thoracic Society (ATS, 2015) recommend RB for retrieving TBFBs in children [11]. Nevertheless, due to technological advances in the use of flexible bronchoscope and additional instruments in recent years, there has been an
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increasing number of publications preferring FB as a first procedure for retrieving TBFBs in children with the success rate as high as 100% in experienced hands [17,18]. Tang et al
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reported a large series of 1027 consecutive pediatric foreign body aspiration cases with 91.3% successfully removed by FB with disposable grasping forceps or biopsy forceps. Rigid bronchoscopy was performed when FB was unsuccessful [5]. In our study, all extractions of TBFBs were successfully accomplished with FB without any need for RB in full agreement
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with the studies mentioned previously. We also sucessfully removed the peanuts from a 18month-old-girl presented with dyspnea and cyanosis. Consequently, flexible bronchoscope
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can safely be used in TBFBs of children with acute symptoms requiring prompt retrieval. A flexible bronchoscope has many advantages over a rigid bronchoscope in the initial
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diagnosis and removal of a TBFB (Table 3). Firstly, FB is a relatively easy and safe procedure in the hands of an expert [5,19]. Futhermore, gaining sufficient expertise is more diffucult in RB than FB, especially for pediatric pulmonologists and otorhinolaryngologists [11]. Secondly, flexible bronchoscope is more widely available in many centers, whilst there are only few centers with the option of RB. Therefore, FB can be performed in a widespread fashion in local hospitals and it prevents the unnecessary transfer of patients to tertiary centers. It is also lifesaving in cases of respiratuary distress, which hinders patients from refering to tertiary hospitals. Since rigid video bronchoscope system had been absent in our
ACCEPTED MANUSCRIPT hospital at first, we compulsorily performed FB and, as we have come to the realisation of progressive effectiveness of the procedure, FB has become our priority for all of our patients. Thirdly, the field of vision is greater than a rigid bronchoscope; this facilitates the examination of upper lobe bronchi and apical divisions of lower lobe bronchi [20]. Fourthly,
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FB is superior to RB in cases of distally migrated foreign bodies which are inaccessible by rigid bronchoscope [2,20]. Interestingly enough, Ramirez-Figueroa JL et al reported 2 patients with distally migrated TBFBs which could not be retrieved with the rigid
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bronchoscope. These were removed with the flexible bronchoscope inserted through the rigid bronchoscope [19]. Fifthly, the positive pressure ventilation used in RB would make removal
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more difficult by pushing the TBFB distally [21]. Sixthly, flexible bronchoscope, which is less traumatic in the respiratory tract, has the ability to suck clear secretions in the airway. Finally, it is also suitable for use in mechanically ventilated patients or in cases of spine, jaw, or skull fractures preventing rigid bronchoscope manipulation [22]. Nevertheless, it may be
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necessary to use the association of techniques in the management of difficult cases so rigid video bronchoscope system should be available as a back up.
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Maintaining a proper airway with adequate ventilation and oxygenation are crucial to the success of bronchoscopy. Rigid bronchoscopy needs general anesthesia with endotracheal
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intubation. Tracheal intubation may increase resistance to ventilation during FB because of the narrowing of the diameter of the airway. Introducing the flexible bronchoscope through a LMA has been suggested an ideal solution in childen in order to facilitate the procedure as it maintains optimal ventilation [23]. In our department, we solely use LMA during FB, which further provides stability for the guidance of the bronchoscope and sufficient room for the airway foreign body removal. There are various ways to enter the pediatric airway during FB apart from LMA and intubation tube. Soong et al succesfully retrieved 94% of TBFBs by short flexible bronchoscope in children who are under sedation with a non-invasive
ACCEPTED MANUSCRIPT ventilation based on nasopharyngeal oxygen with intermittent nose closure and abdominal compression in intensive care unit [24]. However, LMA is more succesful than non-invasive ventilation techniques in reducing the risk of gastric inflation and aspiration [25]. Rigid broncoscopy has a wide range of instruments, such as grasping forceps, roth net
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retriewers and endoscopic baskets [2]. Lack of adequate size of working channel and retrieval instruments have been the limitations of FB in pediatrics until recently. With advances in techniques and instruments successful TBFB retrieval by FB in children has gradually
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increased, which indicated that the diagnose and removal of objects can be carried out in the same FB sessions as time and workforce saving. We used Fogarty catheters, ureteral stone
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baskets, and suction for retrieval of TBFBs. Additionally, biopsy forceps, polypectomy snares and alligator forceps were used in reported studies [5,18,6]. Endoh et al reported 3-pronged foreign body grasping forceps for FB instead of standard grasping forceps which are usually insufficient for foreign bodies due to weaker tips. However, they also reported intraoperative
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complications including hypoxemia in 2 cases and pneumothorax in 1 case and ventilator management for a total of 8 cases, which causes us to discredit this newly developed instrument [27]. Cryoprobe and endobronchial blocker were also reported to remove foreign
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bodies from the airways via flexible bronchoscope [10,21]. Additionally, Matsushita et al reported a multiport airway adaptor for removing a bronchial foreign body by FB to use
[28].
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thicker forceps alongside the flexible bronchoscope through the adaptor in pediatric patients
ACCEPTED MANUSCRIPT 5.Conclusion Flexible bronchoscopy accomplished through a LMA is a safe, easy and effective technique, not only as a diagnostic procedure, but also as the initial therapeutic modality for retrieving TBFBs in pediatric patients with high success and low complication rates. With
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further reports aforementioned, we hope that the FB will become a standard method in children. However, no strong evidence suggests that only one approach is to be used to extract TBFBs. Careful preoperative planning and experience in pediatric airway management are
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crucial in preventing complications and obtaining high success rates. Only a well-designed randomized prospective study will be able to to determine the feasibility, safety, and efficacy
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of FB in comparison with RB in pediatric population.
Acknowlegments
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None
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Conflict of interest
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None
ACCEPTED MANUSCRIPT References [1] A.M. Salih, M. Alfaki, D.M Alam-Elhuda, Airway foreign bodies: A critical review for a common pediatric emergency, World. J. Emerg. Med. 7 (2016) 5-12
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[2] E.K. Choi, S. Lee, D. Lee, S.J. Park, Successful removal of an intractable mucoid impaction in the bronchus using a Fogarty catheter with flexible bronchoscopy, Saudi. J. Anaesth. 12 (2018) 121-124
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[3] J.O Dich-Nielsen, P. Nagel, Flexible fiberoptic bronchoscopy via the laryngeal mask, Acta
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Anaesthesiol Scand. 37(1993) 17-19.
[4] C.J. McNamee, B. Meyns, K.M. Pagliero, Flexible bronchoscopy via the laryngeal mask: a new technique, Thorax 46(1991) 141-142.
[5] L.F. Tang, Y.C. Xu, Y.S. Wang, C.F. Wang, G.H Zhu, X.E. Bao, et al., Airway foreign
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body removal by flexible bronchoscopy: experience with 1027 children during 2000-2008, World J. Pediatr. 5(2009) 191-195.
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[6] D.N. Campbell, E.K. Cotton, J.R. Lilly, A dual approach to tracheobronchial foreign bodies in children, Surgery, 91(1982) 178-182.
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[7] L. Traissac, J.P. Attali, Our experience with laryngo-tracheo-bronchial foreign bodies in children apropos of 113 cases, J. Fr. Otorhinolaryngol. Audiophonol. Chir. Maxillofac. 30(1981) 575-579.
[8] D. Passàli, M. Lauriello, L. Bellussi, G.C. Passali, F.M. Passali, D. Gregori, Foreign body inhalation in children: an update, Acta Otorhinolaryngol. Ital. 30(2010) 27-32
ACCEPTED MANUSCRIPT [9] A. Hitter, E. Hullo, C. Durand, C.A. Righini, Diagnostic value of various investigations in children with suspected foreign body aspiration: review, Eur. Ann. Otorhinolaryngol. Head Neck Dis. 128(2011) 248-252.
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[10] I.S. Sehgal, S. Dhooria, D. Behera, R. Agarwal. Use of cryoprobe for removal of a large tracheobronchial foreign body during flexible bronchoscopy, Lung India, 33(2016) 543-545. [11] D. Schramm, K. Ling, A. Schuster, T. Nicolai, Foreign body removal in children:
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Recommendations versus real life-A survey of current clinical management in Germany, Pediatr. Pulmonol, 52(2017) 656-661.
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[12] D. Divisi, S. Di Tommaso, M. Garramone, W. Di Francescantonio, R.M. Crisci, A.M. Costa, et al., Foreign bodies aspirated in children: role of bronchoscopy Thorac. Cardiovasc. Surg. 55(2007) 249-252.
[13] B. Mansour, N. Elias, Foreign body aspiration in children with focus on the role of
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flexible bronchoscopy: a 5 year experience, Isr. Med. Assoc. J. 17(2015) 599-603. [14] S. Ikeda, Atlas of flexible bronchofiberoscopy, University Park Press, Baltimore, 1974.
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[15] O.S. Cunanan, The flexible fiberoptic bronchoscope in foreign body removal. Experience
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in 300 cases, Chest, 73(1978) 725–726. [16] I.S. Sehgal, S. Dhooria, B. Ram, N. Singh, A.N. Aggarwal, D. Gupta, et al., Foreign body inhalation in the adult population: experience of 25,998 bronchoscopies and systematic review of the literature, Respir. Care. 60(2015) 1438-1448. [17] K.L. Swanson, U.B. Prakash, D.E. Midthun, E.S. Edell, J.P. Utz, J.C. McDougall, et al. Flexible bronchoscopic management of airway foreign bodies in children, Chest. 121(2002) 1695-1700.
ACCEPTED MANUSCRIPT [18] T. Tenenbaum, G. Kähler, C. Janke, H. Schroten, S. Demirakca, Management of foreign body removal in children by flexible bronchoscopy, J Bronchology Interv Pulmonol. 24(2017), 21-28
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[19] J.L. Ramírez-Figueroa, L.G. Gochicoa-Rangel, D.H. Ramírez-San Juan, M.H. Vargas, Foreign body removal by flexible fiberoptic bronchoscopy in infants and children, Pediatr. Pulmonol. 40(2005) 392–397
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[20] T. Paradis, M. Wollenberg, B. Tieu, Extraction of a large central airway foreign body using flexible bronchoscopy combined with an endobronchial blocker, Case Rep. Surg.
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2016(2016) 3179184
[21] R.S. Litman, J. Ponnuri, I. Trogan, Anesthesia for tracheal or bronchial foreign body removal in children: an analysis of ninety-four cases, Anesth. Analg. 91(2000) 1389-1391
112(1990). 604–609
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[22] A.H. Limper, U.B. Prakash, Tracheobronchial foreign bodies in adults, Ann. Intern. Med.
[23] C.E. Skoulakis, P.G. Doxas, C.E. Papadakis, E. Proimos , P. ,J.G. Bizakis
et al.,
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Bronchoscopy for foreign body removed in children. A review and analysis of 210 cases, Int.
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J. Pediatr. Otorhinolaryngol. 53(2000) 143–148 [24] W.J. Soong, Y.S. Lee, Y.H. Soong, P.C. Tsao , C.F. Yang , M.J. Jeng et al., Tracheal foreign body after laser supraglottoplasty: a hidden but risky complication of an aluminum foil tape-wrapped endotracheal tube, Int. J. Pediatr. Otorhinolaryngol. 74(2010) 1432-1434 [25] L.V. Simon , K.D. Torp, Airway, laryngeal mask. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan 9.
ACCEPTED MANUSCRIPT [26] A. Hata, T. Nakajima, K. Ohashi, T. Inage , K. Tanaka , Y. Sakairi et al., Mini grasping basket forceps for endobronchial foreign body removal in pediatric patients, Pediatr. Int. 59(2017) 1200-1204
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[27] M. Endoh, H. Oizumi, N. Kanauchi, H. Kato, H. Ota, J. Suzuki, et al., Removal of foreign bodies from the respiratory tract of young children: Treatment outcomes using newly developed foreign-body grasping forceps, J. Pediatr. Surg. 51(2016) 1375-1379
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[28] K Matsushita , K Uchida , K Otake Y. Nagano, Y. Koike,M. Inoue, et al., The
"multiport airway adapter" in flexible bronchoscopy for peripheral bronchial foreign bodies in
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children, Int. J. Pediatr. Otorhinolaryngol. 79(2015) 2470-2472
ACCEPTED MANUSCRIPT Table legends Table 1. Demographic characteristics, preoperative signs, symptoms and radiologic findings of patients.
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Table 3. Advantages of flexible and rigid bronchoscopy
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Table 2. Anatomic location, number and nature of foreign bodies (n=16)
ACCEPTED MANUSCRIPT Table 1. 30.75±29.68 (12-144)
4 (16.7%) 20 (83.3%) 10 (41.7%) 14 (58.3%)
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16 (66.7%) 7 (29.2%) 1 (4.2%)
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16 (66.7%) 8 (33.3%)
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Mean age, months (range) Gender Male Female Symptoms Wheezing Cough Dyspnea Physical examination Normal Abnormal Chest X-ray Normal Abnormal
ACCEPTED MANUSCRIPT Table 2.
2 (12.5%) 11 (68.7%) 3 (18.8%) 14 (87.5%) 2 (12.5 %)
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14 (87.5%) 2 (12.5 %)
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Nature Organic Non-organic Anatomic location Trachea Right bronchus Left bronchus Number of foreign bodies 1 2
ACCEPTED MANUSCRIPT Table 3. Flexible bronchoscopy
Rigid bronchoscopy
Higher diagnostic and therapeutic value
Higher therapeutic value
More widely available
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Facilitates the examination of upper lobe bronchi and apical divisions of lower lobe bronchi
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More providers ( pediatric pulmonologists, otorhinolaryngologists, pediatric surgeons, intensivists, thoracic surgeons)
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Relatively easy technical nuances and learning curve
Superior in cases of distally migrated foreign bodies Less traumatic
Superior in cases of large or stuck foreign bodies
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Has the ability to suck clear secretions in the airway Suitable for use in mechanically ventilated patients or in cases of spine, jaw, or skull fractures
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Performed using LMA or under sedation
Has a wide range of instruments
S0165-5876(18)30609-8
DOI:
https://doi.org/10.1016/j.ijporl.2018.12.006
Reference:
PEDOT 9292
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 2 October 2018 Revised Date:
5 December 2018
Accepted Date: 5 December 2018
Please cite this article as: A. Suzen, S.C. Karakus, N. Erturk, The Role of Flexible Bronchoscopy Accomplished Through a Laryngeal Mask Airway in the Treatment of Tracheobronchial Foreign Bodies in Children, International Journal of Pediatric Otorhinolaryngology, https://doi.org/10.1016/ j.ijporl.2018.12.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: The Role of Flexible Bronchoscopy Accomplished Through a Laryngeal Mask
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Airway in the Treatment of Tracheobronchial Foreign Bodies in Children
Authors and affiliations: Alev Suzen1, MD; Suleyman Cuneyt Karakus2, Assoc. Prof.; Nazile Erturk2, Asist. Prof. 1
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Department of Pediatric Surgery, Mugla Sıtkı Kocman University, Research and Training Hospital, Mugla, Turkey.
2
Corresponding author:
M AN U
Department of Pediatric Surgery, Mugla Sıtkı Kocman University, Faculty of Medicine, Mugla, Turkey.
Alev Suzen, MD
Department of Pediatric Surgery,
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Mugla Sıtkı Kocman University, Research and Training Hospital, Mugla, Turkey.
e-mail: [email protected]
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Telephone: 00 90 505 2103440
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Fax: 00 90 252 2123599
Address: Department of Pediatric Surgery, Mugla Sıtkı Kocman University Training and Research Hospital, 48000, Mugla, Turkey
Financial support: None
Conflict of interest: None
ACCEPTED MANUSCRIPT Abstract Introduction: We here present our experience with children who underwent flexible bronchoscopy for removal of inhaled tracheobronchial foreign bodies under general
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anesthesia via a laryngeal mask airway (LMA). Materials and Methods: A total of 24 (16 male and 8 female, mean age: 30.75±29.68 months) patients who underwent flexible bronchoscopy under general anesthesia using a LMA for
SC
suspicion of tracheobronchial foreign bodies between July 2016 and April 2018 were retrospectively reviewed.
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Results: The mean duration of admission to hospital was 162.56±309.56 hours. Sixteen (66.7%) patients were found to have tracheobronchial foreign bodies. All procedures were successfully accomplished through a LMA by using basket forceps, a Fogarty catheter and a suction without any need for rigid bronchoscopy. 11 (68.7%) of tracheobronchial foreign
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body locations were right bronchial, 3 (18.8%) were left bronchial and 2 (12.5%) were tracheal. The types of extracted tracheobronchial foreign bodies were organic in 14 (87.5%) and non-organic in 2 (12.5 %). There were no complications except laryngeal edema noted in
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2 (8.3%) patients, relieved within 48 hours. The mean time of postoperative hospitalisation
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was 2.42±0.97 days.
Conclusion: Flexible bronchoscopy accomplished through a LMA is a safe, easy and effective technique, not only as a diagnostic procedure, but also as the initial therapeutic modality for retrieving tracheobronchial foreign bodies in children with high success and low complication rates. With further reports aforementioned, we hope that the flexible bronchoscopy will become a standard method in children.
ACCEPTED MANUSCRIPT 1.Introduction Rigid bronchoscopy (RB) is considered to be the preferred way for extraction of tracheobronchial foreign bodies (TBFBs) in children with a success rate greater than 97% and
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a complication rate between 2 to 22% [1]. Laryngeal oedema, pneumothotax, tracheal tear and hypoxia are the most frequent and serious complications of RB [1,2]. Although flexible bronchoscope is considered to be a diagnostic tool to decrease the negative RB rate, recent publications about flexible bronchoscopy (FB) as a therapeatic procedure for TBFBs in
SC
children have been an increasing trend.
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There are various ways to enter the pediatric airway during FB such as direct application, face mask, laryngeal mask airway (LMA) and intubation tube. Introducing the flexible bronchoscope through a LMA has been suggested as an optimal solution in adults to facilitate the procedure while maintaining ventilation [3,4]. We here present our experience with children who underwent FB for removal of inhaled TBFBs under general anesthesia via
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EP
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a LMA, with particular emphasis on the advantages and disadvantages of FB through a LMA.
ACCEPTED MANUSCRIPT 2.Materials and Methods A total of 24 patients who underwent FB under general anesthesia using a LMA with the suspicion of TBFBs at Mugla Sıtkı Kocman University Education and Training Hospital
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between July 2016 and April 2018 were retrospectively reviewed. First, informed consents were obtained from the patients' parents before the procedure. A flexible pediatric bronchoscope (Karl Storz GmbH, Tuttlingen, Germany) was passed
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through the swivel connector, which was connected the LMA (i-gel; Berkshire, United Kingdom; size of the mask depending on the age) and anesthesia equipment. Then, topical
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administration of 2% lidocaine solution was applied over the vocal cords via the suction channel of the flexible bronchoscope to reduce the incidence of laryngospasm. If a TBFB was identified, an attempt was made to extract it with the help of a basket forceps (Boston Scientific Zero Tip, IN, USA) or a Fogarthy catheter (ISOMED, Chambly, France) passed
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through the suction channel of the bronchoscope. The TBFB was grasped, and then the bronchoscope, the TBFB and the LMA were pulled out en masse. The final removal of TBFBs, extracted up to the oropharynx by using Fogarthy catheter, was performed through
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the mouth by laryngoscope. Immediately after the removal of the TBFB, FB was performed again to exclude the presence of other TBFBs, fragments of the removed TBFB, or structural
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alterations. During the procedure of all flexible FBs, a complete set of rigid bronchoscopes (Karl Storz GmbH, Tuttlingen, Germany) together with removal tools were always available for a second treatment option if necessary. The patients were typically hospitalised for at least 24 hours and a chest X-ray was performed after the procedure. The collected data included age, gender, duration of symptoms, physical examination at admission, radiographic findings, types and locations of TBFB, types of retrieving instruments, length of hospital stay, complications and outcomes.
ACCEPTED MANUSCRIPT 3.Results Demographic characteristics, preoperative signs, symptoms and radiologic findings of patients are given in Table 1. The mean age of patients was 30.75±29.68 (12-144) months; 5 (20.83%)
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of them were 4 years old or older. The mean duration of admission to hospital in children with TBFB was 6.77±12.90 (0.02-60) days. Five patients (20.83%) were diagnosed as pneumonia at first and referred to our department more than 10 days after the onset of symptoms. Sixteen (66.7%) patients were found to have TBFBs. All procedures were successfully accomplished
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respectively through a LMA by using basket forceps, a Fogarty catheter and a suction in 13
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(81.2%), 2 (12.5%) and 1(6.3%) patients without any need to RB. 11 (68.7%) of TBFB locations were right bronchial, 3 (18.8%) were left bronchial and 2 (12.5%) were tracheal. The types of extracted TBFBs were organic in 14 (87.5%) and non-organic in 2 (12.5 %). Only one TBFB was found in 14 (87.5%) and two TBFBs in 2 (12.5 %) patients (Table 2). The only complications were laryngeal edema noted in 2 (8.3%) patients. Both were mild and
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subsided within 48 hours with corticosteroid administration. The mean time of postoperative hospitalisation was 2.42±0.97 (1-4) days. Since most of the patients were referred to our
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tertiary hospital from rural areas, the length of hospitalization was extended in order to
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prevent post-discharge adverse events.
ACCEPTED MANUSCRIPT 4.Discussion Aspiration of TBFBs is a common and potentially life-threatening emergency in pediatrics. Diagnosis of aspirated TBFBs in pediatric population can be very difficult without
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an adult witness because 80 % of TBFB aspirations occur in children under 3 years of age who are unable to communicate in detail [1]. In a study with 1027 patients, only 53.4% had a history confirming the diagnosis of an TBFB aspiration [5]. Clinical features may present with acute symptoms such as stridor, paroxysmal cough, wheezing, dyspnea, cyanosis, and
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respiratuar failure. Common signs of TBFBs include wheezing, rales and decreased breath
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sounds. However, these symptoms and signs are very common in children with respiratory infections and aspiration of TBFBs can also be clinically silent in 12-25% of patients [6,7]. Undiagnosed TBFBs often result in recurrent pneumonia, atelectasis, and bronchiectasis, when the acute symptoms and signs have been missed [8]. Chest X-ray can be a useful rapid diagnostic tool, but only 4 to 20% of TBFBs are radiopaque [9]. Therefore, indirect signs of
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TBFBs include loss of volume on the affected side, obstructive emphysema, pneumonia, or pneumothorax are more commonly detected. In our study, we detected abnormal X-ray
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findings in 58.3% of our patients, one of whom had a radiopaque punched metal. There is no doubt that FB is a preferred procedure for the initial diagnosis of a foreign
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body due to its very high sensitivity and specificity [1,2,10-12]. Decreased rate of negative RBs and potential complications were also reported in this diagnostic approach [13]. The flexible bronchoscope was developed in 1968 by Ikeda, and the first research into foreign body removal with flexible bronchoscope was published in 1978 by Cunanan in 300 patients older than 10 years of age with a success rate of 89% [14,15]. Although the RB is still considered to be the safest and preferred technique in removing aspirated foreign bodies, the management of TBFBs by larger flexible bronchoscopes with adequate working channels has become a more widely used modality in adults. Sehgal et al reported 89.6% overall success
ACCEPTED MANUSCRIPT rate of FB (18 studies, 1185 adult patients) for foreign body extraction in their systematic review of the literature and suggested the FB the preferred initial procedure for management of airway foreign bodies in adults [16]. Rigid bronchoscopy has the advantage of ventilation safety compared to flexible one in children who have narrower airways. Both European
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Respiratory Society (ERC,2003) and American Thoracic Society (ATS, 2015) recommend RB for retrieving TBFBs in children [11]. Nevertheless, due to technological advances in the use of flexible bronchoscope and additional instruments in recent years, there has been an
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increasing number of publications preferring FB as a first procedure for retrieving TBFBs in children with the success rate as high as 100% in experienced hands [17,18]. Tang et al
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reported a large series of 1027 consecutive pediatric foreign body aspiration cases with 91.3% successfully removed by FB with disposable grasping forceps or biopsy forceps. Rigid bronchoscopy was performed when FB was unsuccessful [5]. In our study, all extractions of TBFBs were successfully accomplished with FB without any need for RB in full agreement
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with the studies mentioned previously. We also sucessfully removed the peanuts from a 18month-old-girl presented with dyspnea and cyanosis. Consequently, flexible bronchoscope
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can safely be used in TBFBs of children with acute symptoms requiring prompt retrieval. A flexible bronchoscope has many advantages over a rigid bronchoscope in the initial
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diagnosis and removal of a TBFB (Table 3). Firstly, FB is a relatively easy and safe procedure in the hands of an expert [5,19]. Futhermore, gaining sufficient expertise is more diffucult in RB than FB, especially for pediatric pulmonologists and otorhinolaryngologists [11]. Secondly, flexible bronchoscope is more widely available in many centers, whilst there are only few centers with the option of RB. Therefore, FB can be performed in a widespread fashion in local hospitals and it prevents the unnecessary transfer of patients to tertiary centers. It is also lifesaving in cases of respiratuary distress, which hinders patients from refering to tertiary hospitals. Since rigid video bronchoscope system had been absent in our
ACCEPTED MANUSCRIPT hospital at first, we compulsorily performed FB and, as we have come to the realisation of progressive effectiveness of the procedure, FB has become our priority for all of our patients. Thirdly, the field of vision is greater than a rigid bronchoscope; this facilitates the examination of upper lobe bronchi and apical divisions of lower lobe bronchi [20]. Fourthly,
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FB is superior to RB in cases of distally migrated foreign bodies which are inaccessible by rigid bronchoscope [2,20]. Interestingly enough, Ramirez-Figueroa JL et al reported 2 patients with distally migrated TBFBs which could not be retrieved with the rigid
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bronchoscope. These were removed with the flexible bronchoscope inserted through the rigid bronchoscope [19]. Fifthly, the positive pressure ventilation used in RB would make removal
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more difficult by pushing the TBFB distally [21]. Sixthly, flexible bronchoscope, which is less traumatic in the respiratory tract, has the ability to suck clear secretions in the airway. Finally, it is also suitable for use in mechanically ventilated patients or in cases of spine, jaw, or skull fractures preventing rigid bronchoscope manipulation [22]. Nevertheless, it may be
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necessary to use the association of techniques in the management of difficult cases so rigid video bronchoscope system should be available as a back up.
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Maintaining a proper airway with adequate ventilation and oxygenation are crucial to the success of bronchoscopy. Rigid bronchoscopy needs general anesthesia with endotracheal
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intubation. Tracheal intubation may increase resistance to ventilation during FB because of the narrowing of the diameter of the airway. Introducing the flexible bronchoscope through a LMA has been suggested an ideal solution in childen in order to facilitate the procedure as it maintains optimal ventilation [23]. In our department, we solely use LMA during FB, which further provides stability for the guidance of the bronchoscope and sufficient room for the airway foreign body removal. There are various ways to enter the pediatric airway during FB apart from LMA and intubation tube. Soong et al succesfully retrieved 94% of TBFBs by short flexible bronchoscope in children who are under sedation with a non-invasive
ACCEPTED MANUSCRIPT ventilation based on nasopharyngeal oxygen with intermittent nose closure and abdominal compression in intensive care unit [24]. However, LMA is more succesful than non-invasive ventilation techniques in reducing the risk of gastric inflation and aspiration [25]. Rigid broncoscopy has a wide range of instruments, such as grasping forceps, roth net
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retriewers and endoscopic baskets [2]. Lack of adequate size of working channel and retrieval instruments have been the limitations of FB in pediatrics until recently. With advances in techniques and instruments successful TBFB retrieval by FB in children has gradually
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increased, which indicated that the diagnose and removal of objects can be carried out in the same FB sessions as time and workforce saving. We used Fogarty catheters, ureteral stone
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baskets, and suction for retrieval of TBFBs. Additionally, biopsy forceps, polypectomy snares and alligator forceps were used in reported studies [5,18,6]. Endoh et al reported 3-pronged foreign body grasping forceps for FB instead of standard grasping forceps which are usually insufficient for foreign bodies due to weaker tips. However, they also reported intraoperative
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complications including hypoxemia in 2 cases and pneumothorax in 1 case and ventilator management for a total of 8 cases, which causes us to discredit this newly developed instrument [27]. Cryoprobe and endobronchial blocker were also reported to remove foreign
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bodies from the airways via flexible bronchoscope [10,21]. Additionally, Matsushita et al reported a multiport airway adaptor for removing a bronchial foreign body by FB to use
[28].
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thicker forceps alongside the flexible bronchoscope through the adaptor in pediatric patients
ACCEPTED MANUSCRIPT 5.Conclusion Flexible bronchoscopy accomplished through a LMA is a safe, easy and effective technique, not only as a diagnostic procedure, but also as the initial therapeutic modality for retrieving TBFBs in pediatric patients with high success and low complication rates. With
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further reports aforementioned, we hope that the FB will become a standard method in children. However, no strong evidence suggests that only one approach is to be used to extract TBFBs. Careful preoperative planning and experience in pediatric airway management are
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crucial in preventing complications and obtaining high success rates. Only a well-designed randomized prospective study will be able to to determine the feasibility, safety, and efficacy
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of FB in comparison with RB in pediatric population.
Acknowlegments
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None
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Conflict of interest
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None
ACCEPTED MANUSCRIPT References [1] A.M. Salih, M. Alfaki, D.M Alam-Elhuda, Airway foreign bodies: A critical review for a common pediatric emergency, World. J. Emerg. Med. 7 (2016) 5-12
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[2] E.K. Choi, S. Lee, D. Lee, S.J. Park, Successful removal of an intractable mucoid impaction in the bronchus using a Fogarty catheter with flexible bronchoscopy, Saudi. J. Anaesth. 12 (2018) 121-124
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[3] J.O Dich-Nielsen, P. Nagel, Flexible fiberoptic bronchoscopy via the laryngeal mask, Acta
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Anaesthesiol Scand. 37(1993) 17-19.
[4] C.J. McNamee, B. Meyns, K.M. Pagliero, Flexible bronchoscopy via the laryngeal mask: a new technique, Thorax 46(1991) 141-142.
[5] L.F. Tang, Y.C. Xu, Y.S. Wang, C.F. Wang, G.H Zhu, X.E. Bao, et al., Airway foreign
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body removal by flexible bronchoscopy: experience with 1027 children during 2000-2008, World J. Pediatr. 5(2009) 191-195.
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[6] D.N. Campbell, E.K. Cotton, J.R. Lilly, A dual approach to tracheobronchial foreign bodies in children, Surgery, 91(1982) 178-182.
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[7] L. Traissac, J.P. Attali, Our experience with laryngo-tracheo-bronchial foreign bodies in children apropos of 113 cases, J. Fr. Otorhinolaryngol. Audiophonol. Chir. Maxillofac. 30(1981) 575-579.
[8] D. Passàli, M. Lauriello, L. Bellussi, G.C. Passali, F.M. Passali, D. Gregori, Foreign body inhalation in children: an update, Acta Otorhinolaryngol. Ital. 30(2010) 27-32
ACCEPTED MANUSCRIPT [9] A. Hitter, E. Hullo, C. Durand, C.A. Righini, Diagnostic value of various investigations in children with suspected foreign body aspiration: review, Eur. Ann. Otorhinolaryngol. Head Neck Dis. 128(2011) 248-252.
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[10] I.S. Sehgal, S. Dhooria, D. Behera, R. Agarwal. Use of cryoprobe for removal of a large tracheobronchial foreign body during flexible bronchoscopy, Lung India, 33(2016) 543-545. [11] D. Schramm, K. Ling, A. Schuster, T. Nicolai, Foreign body removal in children:
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Recommendations versus real life-A survey of current clinical management in Germany, Pediatr. Pulmonol, 52(2017) 656-661.
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[12] D. Divisi, S. Di Tommaso, M. Garramone, W. Di Francescantonio, R.M. Crisci, A.M. Costa, et al., Foreign bodies aspirated in children: role of bronchoscopy Thorac. Cardiovasc. Surg. 55(2007) 249-252.
[13] B. Mansour, N. Elias, Foreign body aspiration in children with focus on the role of
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flexible bronchoscopy: a 5 year experience, Isr. Med. Assoc. J. 17(2015) 599-603. [14] S. Ikeda, Atlas of flexible bronchofiberoscopy, University Park Press, Baltimore, 1974.
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[15] O.S. Cunanan, The flexible fiberoptic bronchoscope in foreign body removal. Experience
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in 300 cases, Chest, 73(1978) 725–726. [16] I.S. Sehgal, S. Dhooria, B. Ram, N. Singh, A.N. Aggarwal, D. Gupta, et al., Foreign body inhalation in the adult population: experience of 25,998 bronchoscopies and systematic review of the literature, Respir. Care. 60(2015) 1438-1448. [17] K.L. Swanson, U.B. Prakash, D.E. Midthun, E.S. Edell, J.P. Utz, J.C. McDougall, et al. Flexible bronchoscopic management of airway foreign bodies in children, Chest. 121(2002) 1695-1700.
ACCEPTED MANUSCRIPT [18] T. Tenenbaum, G. Kähler, C. Janke, H. Schroten, S. Demirakca, Management of foreign body removal in children by flexible bronchoscopy, J Bronchology Interv Pulmonol. 24(2017), 21-28
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[19] J.L. Ramírez-Figueroa, L.G. Gochicoa-Rangel, D.H. Ramírez-San Juan, M.H. Vargas, Foreign body removal by flexible fiberoptic bronchoscopy in infants and children, Pediatr. Pulmonol. 40(2005) 392–397
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[20] T. Paradis, M. Wollenberg, B. Tieu, Extraction of a large central airway foreign body using flexible bronchoscopy combined with an endobronchial blocker, Case Rep. Surg.
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2016(2016) 3179184
[21] R.S. Litman, J. Ponnuri, I. Trogan, Anesthesia for tracheal or bronchial foreign body removal in children: an analysis of ninety-four cases, Anesth. Analg. 91(2000) 1389-1391
112(1990). 604–609
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[22] A.H. Limper, U.B. Prakash, Tracheobronchial foreign bodies in adults, Ann. Intern. Med.
[23] C.E. Skoulakis, P.G. Doxas, C.E. Papadakis, E. Proimos , P. ,J.G. Bizakis
et al.,
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Bronchoscopy for foreign body removed in children. A review and analysis of 210 cases, Int.
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J. Pediatr. Otorhinolaryngol. 53(2000) 143–148 [24] W.J. Soong, Y.S. Lee, Y.H. Soong, P.C. Tsao , C.F. Yang , M.J. Jeng et al., Tracheal foreign body after laser supraglottoplasty: a hidden but risky complication of an aluminum foil tape-wrapped endotracheal tube, Int. J. Pediatr. Otorhinolaryngol. 74(2010) 1432-1434 [25] L.V. Simon , K.D. Torp, Airway, laryngeal mask. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan 9.
ACCEPTED MANUSCRIPT [26] A. Hata, T. Nakajima, K. Ohashi, T. Inage , K. Tanaka , Y. Sakairi et al., Mini grasping basket forceps for endobronchial foreign body removal in pediatric patients, Pediatr. Int. 59(2017) 1200-1204
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[27] M. Endoh, H. Oizumi, N. Kanauchi, H. Kato, H. Ota, J. Suzuki, et al., Removal of foreign bodies from the respiratory tract of young children: Treatment outcomes using newly developed foreign-body grasping forceps, J. Pediatr. Surg. 51(2016) 1375-1379
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[28] K Matsushita , K Uchida , K Otake Y. Nagano, Y. Koike,M. Inoue, et al., The
"multiport airway adapter" in flexible bronchoscopy for peripheral bronchial foreign bodies in
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children, Int. J. Pediatr. Otorhinolaryngol. 79(2015) 2470-2472
ACCEPTED MANUSCRIPT Table legends Table 1. Demographic characteristics, preoperative signs, symptoms and radiologic findings of patients.
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Table 3. Advantages of flexible and rigid bronchoscopy
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Table 2. Anatomic location, number and nature of foreign bodies (n=16)
ACCEPTED MANUSCRIPT Table 1. 30.75±29.68 (12-144)
4 (16.7%) 20 (83.3%) 10 (41.7%) 14 (58.3%)
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16 (66.7%) 7 (29.2%) 1 (4.2%)
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16 (66.7%) 8 (33.3%)
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Mean age, months (range) Gender Male Female Symptoms Wheezing Cough Dyspnea Physical examination Normal Abnormal Chest X-ray Normal Abnormal
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2 (12.5%) 11 (68.7%) 3 (18.8%) 14 (87.5%) 2 (12.5 %)
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14 (87.5%) 2 (12.5 %)
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Nature Organic Non-organic Anatomic location Trachea Right bronchus Left bronchus Number of foreign bodies 1 2
ACCEPTED MANUSCRIPT Table 3. Flexible bronchoscopy
Rigid bronchoscopy
Higher diagnostic and therapeutic value
Higher therapeutic value
More widely available
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Facilitates the examination of upper lobe bronchi and apical divisions of lower lobe bronchi
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More providers ( pediatric pulmonologists, otorhinolaryngologists, pediatric surgeons, intensivists, thoracic surgeons)
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Relatively easy technical nuances and learning curve
Superior in cases of distally migrated foreign bodies Less traumatic
Superior in cases of large or stuck foreign bodies
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Has the ability to suck clear secretions in the airway Suitable for use in mechanically ventilated patients or in cases of spine, jaw, or skull fractures
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Performed using LMA or under sedation
Has a wide range of instruments