In 2021, Rijid bronchoscopy was performed in 10 patients with suspected FBA in the thoracic surgery clinic of our hospital. Except for one patient, all of them were in the pediatric patient group. In Table 1, the demographic data of the patients, anamnesis, physical examination and imaging findings, type of interventional procedure, length of stay, follow-up, and mortality data are shown.
Chest X-ray was used as a radiological examination in all patients except the 42-year-old adult patient. The patient intubated in the emergency department has no imaging examination. In a patient with a history of aspiration only two days ago, left lower lobe pneumonia (Fig. 2A) was found on a chest X-ray, and left hilar atelectasis (Fig. 2B) was also found in a newly developed aspiration.) In addition, a foreign body was observed in the intermediate bronchus in the thorax computed tomography of the adult patient (Fig. 3). Chest X-ray was normal in other patients.
All of the patients underwent rigid bronchoscopy with the newly defined technique. While any foreign bodies were not detected in 3 patients, the organic foreign bodies were removed in 7 patients. The foreign organic bodies could be removed by fragmentation in 3 patients. Foreign organic body could be removed by fragmentation in 3 patients. The foreign bodies were completely removed in all cases without the need for repeated intubation or ambu ventilation and mortality wasn’t seen during the procedure. The only patient who was intubated in the emergency room due to the respiratory arrest at home was taken to the pediatric intensive care unit after rigid bronchoscopy. In the follow-up, the hypoxemia improved and when the FiO2 was decreased to 40% on the 1st day, the PO2 pressure was observed above 100 mmHg. After transference to the upper center with a pre-diagnosis of the hypoxic brain, the patient died on the first day due to bilateral pneumothorax that developed during transport.
While two patients who underwent the operation were discharged from the hospital on the first post-operative day, six of the patients were discharged from the hospital on the same day. The intubated patient was transferred to the intensive care unit. The patient with obstructive pneumonia was transferred to pediatrics one day after the procedure and was discharged on the 3rd day. No additional pathology was observed in the patients.
After the procedure starts and the rigid bronchoscope is placed, the ventilation circuit is closed during the foreign body detection and removal moves. In order to prevent hypoxia that may occur during this period, firstly, 100% oxygen is applied with positive pressure ventilation to saturate the patient, and short-acting muscle relaxants are preferred . Desaturation can be seen very rapidly in children during an apnea episode. Since the rigid bronchoscope can also be used as an endotracheal tube, a cuffed intubation tube is not usually needed, on the other hand, due to the possibility that desaturation cannot be corrected with a rigid bronchoscope, it should be kept ready during the procedure [4, 7]. In our experience with rigid bronchoscopy, we sometimes had serious ventilation problems during the procedure, especially in pediatric patients and also adult patientswith low respiratory capacity. The problem probably stems from the inability of these patients to achieve sufficient oxygen saturation when the circuit is interrupted by 100% oxygen administration due to lung reserve deficiencies. Although methods such as closing the patient's oral cavity with a sponge are used to overcome this problem, results are not always obtained. The ventilation problem sometimes caused the operation to be tried repeatedly and sometimes it prevented the complete removal of the fragmented foreign bodies. In our series of 10 patients, 9 of whom were pediatric patients, who were applied with rigid bronchoscope with cuff, no ventilation problems were experienced in any patient.
All of our patients, except 3, were children under the age of 3, and all of them were witnessed aspiration, except for the intubated patient. It was stated that the patient, who was intubated, had his elder brother with him, and when his parents heard the sound of crying from the other room, they saw that the child had become bruised. Anamnesis is the most important tool in the initial evaluation in FBA . Since children under the age of one are not left alone for a long time without their parents, aspiration stories are mostly witnessed. Also, it is stated in the literature that 73% of FBA in the 1–18 age group are witnessed . In our clinic, rigid bronchoscopy is performed independently of radiology in witnessed aspirations, while evaluation is made with examination findings and radiology in unwitnessed aspirations. Pneumonic infiltration was observed in the lower lobe of the left lung in chest X-ray in a case with suspected aspiration 2 days ago. Complications caused by aspiration are not only related to foreign body location but also related to the elapsed time . While lung imaging findings are generally normal in the first period, secondary findings are usually observed starting from the 3rd day . In one of our cases with witnessed aspiration, hilar atelectasis was found on the chest X-ray taken at the time of presentation, which may indicate that findings can also be observed in the early period. Therefore, we recommend bronchoscopy to patients with suspected aspiration in the anamnesis, regardless of their radiological findings.
As it is known, since FBA mimics diseases such as croup and asthma, the diagnosis may be delayed, and the wrong treatment may be applied . In addition, unnecessary procedures can be performed with radiological findings related to other diseases in cases without foreign body suspicion, who was found to be positive for COVID-19 in the follow-up. In addition to chest X-ray, as in our adult patient, tomography can detect organic bodies in the airways that are not observed on chest X-ray, so it can be used in appropriate patients to confirm the diagnosis of FBA.
The primary value of our study is the innovation thought against the main difficulty that limits the comfort of the procedure in rigid bronchoscopy. Although a smaller rigid bronchoscope is used to pass through the intubation tube, with the introduction of optical forceps, the procedure can be performed more easily with these principles.
The main limitation is the lack of processing times. However, the new method aims to increase the efficiency of the procedure and reduce complications due to hypoxia and repeated intubation rather than the duration of the procedure.
In conclusion, we think that the use of rigid bronchoscope together with the intubation tube as described in our study is a low-cost recommendation that increases the effect of the procedure and can be routinely used in pediatric and adult patients with respiratory failure who can be considered as a risk group.