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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 78-80

Retrieval of aspirated iatrogenic, sharp foreign body using fiberoptic bronchoscope


1 Department of Anesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission19-Mar-2020
Date of Decision31-Mar-2020
Date of Acceptance01-Apr-2020
Date of Web Publication11-May-2020

Correspondence Address:
Dr. Priyanka Gupta
Department of Anesthesia, 5th Floor, Medical College Building, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_30_20

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  Abstract 

Foreign body (FB) aspiration into the tracheobronchial tree is a fairly common occurrence in the pediatric age group. The most common FBs aspirated are organic materials. However, aspiration of iatrogenic FB is rare and infrequently reported. It is a challenge to retrieve a sharp and pointed FB without further injuring the tracheobronchial tree. We report an unusual case of sharp and pointed dental instrument aspiration in a 4-year-old boy, which was safely removed by a flexible fiberoptic bronchoscope and sequestering the FB within the endotracheal tube without injuring the tracheobronchial mucosa.

Keywords: Aspiration, bronchoscopy, Hand ProTaper, iatrogenic, pediatric


How to cite this article:
Thirunavukkarasu M, Mishra A, Gupta P, Kumar S, Gupta G. Retrieval of aspirated iatrogenic, sharp foreign body using fiberoptic bronchoscope. Bali J Anaesthesiol 2020;4:78-80

How to cite this URL:
Thirunavukkarasu M, Mishra A, Gupta P, Kumar S, Gupta G. Retrieval of aspirated iatrogenic, sharp foreign body using fiberoptic bronchoscope. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Jul 13];4:78-80. Available from: http://www.bjoaonline.com/text.asp?2020/4/2/78/284189


  Introduction Top


Foreign body (FB) in the tracheobronchial tree is a serious and potentially fatal emergency at any age. FB aspiration is a leading cause of death in children aged between 1 and 4 years.[1] Children aged ≤4 years are more susceptible to FB injuries due to the absence of molars.[2] The most common FB aspirated in children are nuts and seeds.[3] They are most commonly lodged into the right main bronchus, as it is wider, shorter, and more vertical than the left main bronchus.[4]

In medical institutions, patients undergoing oropharyngeal procedures in intensive care, dental departments, and in operating rooms may be at risk of complications of iatrogenic FB aspiration. After obtaining the written informed consent from the parents, we like to report a rare iatrogenic incident: a sharp instrument (hand ProTaper – used for shaping pulp canals) in dental surgery that fell into the tracheobronchial tree while conducting the procedure, which was removed strategically taking the sharp-pointed part inside the endotracheal tube (ET) with a flexible fiberoptic bronchoscope.


  Case Report Top


A 4-year-old boy (13 kg) was admitted to the emergency department with a history of accidental aspiration of sharp and pointed operating instrument (hand ProTaper). The device was 3 cm in size and used for shaping the pulp canals in root canal treatment [Figure 1]a. The accident took place about

30 min before admission.
Figure 1:(a) Foreign body lodged in the right bronchus. (b) 3 cm long, sharp, and pointed foreign body after retrieval. (c) Chest X-ray showing radio-opaque foreign body in the right bronchus. (d) Chest x-ray after the removal of foreign body

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The patient had presented with symptoms of persistent cough since the aspiration. However, he was not in respiratory distress and exhibited no stridor. His peripheral oxygen saturation was 97% in room air with a respiration rate of 26 breaths per minutes. Other vital signs were unremarkable. Auscultation did not reveal any signs of obstruction or any abnormal sound.

A sharp, pointed FB was observed in the right main bronchus [Figure 1]b upon radiological investigation. After getting written informed consent from his parents, the patient was taken to the operating room [Figure 1]c. The patient was premedicated with glycopyrrolate 0.01 mg/kg intramuscularly. All standard (American Society of Anesthesiologists) ASA monitors were attached. After adequate preoxygenation, the patient was induced with inhalation of sevoflurane.

Following the loss of eyelash reflex, a 22G peripheral intravenous access was secured. Fentanyl 1.5 mcg/kg and atracurium 0.5mg/kg were administered. The patient was intubated with a 5.5-mm uncuffed ET, which was snuggly passed through the glottis. A 4.2-mm flexible bronchoscopy (FOB) was available in our institution. Before induction of the patient, it was observed that 4.2 mm size FOB was able to pass through 5.5 mm size uncuffed ET.

FOB was introduced through the ET, and sharp part of the FB was observed pointing cephalad in the right main bronchus [Figure 1]d. As the FB had sharp end, there was a risk of it being impacted and also injuring the tracheobronchial tree on removal. Hence, we decided to advance the ET under the guidance of the FOB to the carina and was fixated there. The patient was ventilated with low tidal volume and higher respiratory rate to minimize the risk of further caudad movement of FB with intermittent positive pressure ventilation. The sharp part of FB was grasped by wire forceps passed through the FOB and dragged inside the ET. Both bronchoscope and ET were removed simultaneously, while FB being held with the wire forceps.

The rest of the procedure was uneventful. The patient was reintubated with 5.0-mm uncuffed ET, and anesthesia was maintained with oxygen, nitrous oxide, sevoflurane, and fentanyl until spontaneous respiratory efforts were present. We also administered IV dexamethasone (0.1mg/kg) and two puffs of salbutamol inhaler through the ET. We used neostigmine (0.05 mg/kg) and glycopyrrolate (0.01 mg/kg) for reversal, and then he was extubated gently.

He was sent to the postanesthesia care unit for observation. After 2 h, a bedside chest X-ray was retaken, which showed no evidence of FB. The patient was discharged 2 days after the procedure.


  Discussion Top


Aspiration of FB during dental procedure is reported to be the second most common cause of FB aspiration.[5] These FBs can be dentures, tooth, restorative cement, instruments implant parts, and gauze packs. Ingestion or aspiration of dental material or instrument during dental treatment may lead to serious complications. These foreign objects can be of various sizes and shapes, ranging from small, large, elongated, round, sharp, and blunt and can get wedged anywhere either in the gastrointestinal or the respiratory tract. Following the confirmation of FB aspiration, immediate treatment in the form of bronchoscopic or surgical removal of FB is instituted.

The FB aspirated, in this case, was a Hand ProTaper. It is used for shaping the pulp canals in nearly all the patients undergoing root canal treatment. This instrument has a sharp cutting edge with the tapering end.

The common approach with FBs lodged in the tracheobronchial tree is to use smooth inhalational and spontaneous ventilation or intravenous induction with muscle relaxation and intermittent positive pressure ventilation. In this case, we opted for muscle relaxation with intermittent positive pressure ventilation as the FB was lodged at the entrance of the right main bronchus and was easy to ventilate. Hence, we decided to intubate this patient and try to remove and secure the FB within the ET. We had a flexible bronchoscope of 4.2 mm size only. Hence, before we started the procedure, we tested if it can pass through the 5.5-mm uncuffed ET.

To avoid the impaction of the pointed needle of FB in the trachea, the ET was advanced as far as possible near the FB under the guidance of bronchoscopy. The ET worked as a lumen of rigid bronchoscope and helped in taking out the FB after dragging it inside the lumen with the help of forceps. On the entire procedure, both bronchoscope and ET helped in avoiding any injury to the trachea and prevented the loss of FB into the tracheal lumen.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tan HK, Brown K, McGill T, Kenna MA, Lund DP, Healy GB. Airway foreign bodies (FB): A 10-year review. Int J Pediatr Otorhinolaryngol 2000;56:91-9.  Back to cited text no. 1
    
2.
Reilly JS, Cook SP, Stool D, Rider G. Prevention and management of aerodigestive foreign body injuries in childhood. Pediatr Clin North Am 1996;43:1403-11.  Back to cited text no. 2
    
3.
Chapin MM, Rochette LM, Annest JL, Haileyesus T, Conner KA, Smith GA. Nonfatal choking on food among children 14 years or younger in the United States, 2001-2009. Pediatrics 2013;132:275-81.  Back to cited text no. 3
    
4.
Naragund AI, Mudhol RS, Harugop AS, Patil PH, Hajare PS, Metgudmath VV. Tracheo-bronchial foreign body aspiration in children: A one-year descriptive study. Indian J Otolaryngol Head Neck Surg 2014;66 Suppl 1:180-5.  Back to cited text no. 4
    
5.
Tiwana KK, Morton T, Tiwana PS. Aspiration and ingestion in dental practice: A 10-year institutional review. J Am Dent Assoc 2004;135:1287-91.  Back to cited text no. 5
    


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