As radiographic studies cannot exclude foreign body aspiration, children and adults who present acutely with a history consistent with foreign body aspiration (choking, sudden paroxysmal coughing) and any abnormal physical findings (wheezing, diminished breath sounds) should undergo bronchoscopy for removal of the presumed foreign body. With that presentation, there is no indication for additional studies. In the hands of experienced bronchoscopists, a tracheobronchoscopy has minimal risk and is associated with few complications.

At this time, most bronchoscopies for a suspected foreign body aspiration are performed as a rigid (open tube) bronchoscopy, so that the airway can be controlled and the patient ventilated as the foreign body is removed. The use of sophisticated optical grasping forceps, snares, Dormia stone basket,19-22 or Fogarty balloon23-27 allows removal in 97 to 99% of foreign bodies identified.

Some clinicians have used flexible bronchoscopy as an initial diagnostic technique in children who have a history suspicious for foreign body aspiration but do not have conclusive evidence of aspiration (ie, no findings on physical examination and normal or near-normal radiographs).16,28 Performed with local anesthesia, this flexible examination of the airway might obviate the need for general anesthesia and rigid bronchoscopy if the airway is normal. If a foreign body is identified, then rigid bronchoscopy is performed to remove the material. Others have disagreed with these recommendations, noting that extraction of the foreign body can be performed successfully with the flexible bronchoscope in up to 80% of the cases.29 However, these reported series are small and the authors, experienced in both flexible and rigid tracheobronchoscopy, were capable of performing rigid bronchoscopy if problems arose during attempts at flexible bronchoscopic extraction. At the present, in most centers, open tube bronchoscopy appears safer than the flexible bronchoscopy and is the preferred method for extraction of foreign bodies in the pediatric population.

In adults, both flexible bronchoscopy and rigid bronchoscopy have been used successfully to remove foreign bodies.30-33 The flexible bronchoscope may mitigate the need for general anesthesia for extraction of the foreign body, but like the pediatric patient, there is greater risk with the use of this technique if the foreign body is lost. Several groups, most notably the Mayo group, have used flexible bronchoscopy in adults and children with success.

figure 36-3 Metal bearing in the bronchus intermedius, in a young adult with a history of pica. Distal atelectasis of the right middle and lower lobes is appreciated.

Currently, the flexible bronchoscope allows a more limited choice of instrumentation, its diameter is more likely to obstruct the airway (particularly in pediatric patients), and it may not be as well suited as the rigid bronchoscope for retrieval and extraction of foreign bodies.34 We feel that the rigid bronchoscope allows a greater margin of safety and prefer this technique to the use of flexible bronchoscopy in children and adults. Flexible bronchoscopy has some advantage over rigid bronchoscopy in its ability to retrieve more distal tracheobronchial foreign bodies. Flexible bronchoscopy should also be considered in those patients who have cervical or maxillofacial trauma, who are intubated and in whom there is concern for aspiration.35

In the rare instances where the foreign body is too large to pass retrograde through the glottis, a tracheostomy should be performed, the foreign body extracted, and a tracheostomy tube placed. Once the patient is stable, the tracheostomy tube can be removed and allowed to close secondarily, usually within 48 to 72 hours.

Occasionally, foreign bodies will move to a remote position in the bronchial tree or there may be a marked delay in presentation for care. Either of these features may lead to secondary pulmonary complications, including bronchiectasis, localized pneumonia, and lung abscess formation (Figure 36-6). In such instances, if the foreign body cannot be reached by endoscopic means (flexible or rigid), then a thoracotomy with bronchotomy and extraction of the foreign body and/or resection of the affected lung segment is appropriate. The subset of patients who require this more extensive surgery is small and in the current

era will account for only 1 to 3% of cases of aspiration. Most patients requiring a thoracotomy for extraction have a delayed presentation, often found to be months or years after the aspiration event.

The use of chest physical therapy, postural drainage, and inhaled bronchodilator therapy was briefly recommended as an alternative to bronchoscopy in the treatment of foreign body aspiration, as it appeared to be "safe" and was effective in 85% (24 of 28) of the children treated.36,37 However, even in those initial reports, 2 infants were noted to have "serious" episodes of respiratory or cardiorespiratory arrest. A later and larger study from the same institution found a much lower success rate with this conservative management (25% vs 85%) and acknowledged that there is a definite risk to this management.38 They recommended conservative therapy in an intensive care unit setting only for a 24-hour period and concluded that undertaking this therapy was inappropriate for foreign bodies present for greater than 4 weeks.38 By 1980, with continued improvement in endoscopic instrumentation, coupled with a low success rate and a small but potentially life-threatening risk with conservative management, inhalation therapy and postural drainage was considered contraindicated as treatment for foreign body aspiration.39

figure 36-5 Bronchiectasis of the right lower and middle lobes complicating radiolucent foreign body aspiration. The child had a history of recurrent right-sided pneumonia for over 2 years prior to evaluation and surgical treatment.

Physical therapy with percussion and dependent drainage may help to mobilize distal secretions in those patients with atelectatic lung segments complicating foreign body obstruction, but only after the foreign body has been removed endoscopically.

With an acute aspiration event, antibiotics and steroids are not routinely given. If there is evidence of an infection distal to the impacted foreign body, then broadspectrum antibiotics (second generation cephalosporin plus clindamycin, ampicillin-sulbactam) may be appropriate. Steroids may be appropriate in those instances where the foreign body has resulted in airway narrowing secondary to inflammation. In most instances, even in the smaller airway with young children, steroids are not indicated and have not been proven to be beneficial. As a result, antibiotics and/or steroids should be considered on a case-by-case basis and their use dependent on bronchoscopic findings.

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