Discussion:
Aspiration of a foreign body is commonly reported among children. It can
be life-threatening and it can lead to life-long morbidities like
chronic suppurative lung disease. Since its first use by Gustav
Killian,extraction of trachea-bronchial foreign bodywith
rigidbronchoscopy is presently considered the
gold-standard1. Failure of rigid bronchoscopic removal
necessitates thoracotomy and bronchotomy. The rate of failed extraction
of airway foreign bodies after first rigid bronchoscopy varies from 0.3
to 7% 1,2.
Although rigid bronchoscopy is considered the gold standard for foreign
body removal, many recent reports suggest that in experienced hands
Flexible bronchoscopy done under conscious sedation alsoto be safe and
effective2,3.The obvious advantage of flexible
bronchoscopic foreign body removal include the ability to reach airways
difficult to access through a rigid bronchoscope (notably right upper
lobe and basal segments of lower lobe bronchi). If performed under
conscious sedation, there are reduced risks of general anesthesia and
dependence on busy operation theatres. The main disadvantage of flexible
bronchoscopy is that it further narrows the airway and compromises
ventilation, unlike a rigid scope where ventilation can be controlled
through the scope.Flexible through rigid scope technique thus combines
the best of both: supported ventilation through the rigid scope and
access to the deeper airways through flexible scope.
Although there are few reports of sequentially combined use of flexible
and rigid scopes there are scarce reports of flexible through rigid
scopytechnique for removal of airway foreign body. Ruegemeret al
reported an eight year boy who aspirated a ‘ball-bearing’ in right lower
lobe bronchus and could not be removed on two rigid bronchoscopic
removal attempts using optical FB forceps, ball-bearing forceps, Segura
wire basket, rigid FB basket and Fogarty catheter4.
After steroids for 48 hours it was removed using four-wire helical
basket inserted through the suction channel of flexible bronchoscope
which was inserted through rigid bronchoscope4.
Eyekpeghaet al reported a 6-year-old boy who had a history suggestive of
an aspirated base cap of a pen but still it could not be visualized
despite two rigid and one flexible scopies5. The
foreign body was finally demonstrated on a CECT imaging and removed by
combined rigid and flexible scopy5.
Conclusion: This report highlights that flexible bronchoscopy
througha rigid bronchoscopeis a feasible option in distal airway foreign
body, not amenable to rigid scopyalone. This obviates the need for more
invasive surgeries like thoracotomy and bronchotomy.