James R. Roberts MD, FACEP, FAAEM, FACMT, in Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 2019 If the FB is not removed or cannot be removed, an FB reaction may
occur. Some FBs produce an inflammatory reaction or infection a few days after introduction into the body. Other objects may not cause problems for weeks, months, or even years until they flare up for no apparent reason. The primary factors that affect the extent of tissue reactions are contamination and whether the material is inert or reactive with human tissue. Reactive FBs, such as wood, will generally produce inflammation eventually, whereas inert FBs, such as bullets, rarely do. Some inert
FBs carry dirt particles, pieces of clothing, or other sources of bacterial contamination. Expeditious removal may be necessary, even if the FB itself is relatively small and unlikely to cause a reaction. A purulent bacterial infection may develop in the presence of any FB; therefore, any abscess or cellulitis that recurs or wounds that do not heal as expected should always be investigated for retained FBs.75,76 Karpman and
coworkers found a 15% rate of infection (S. aureus and Enterobacteriaceae) in a series of 25 patients treated for cactus thorn injuries on the extremities.58 Certain thorns (black thorns, rose thorns), redwood and northwest cedar splinters, toothpicks, hair, and stingray or sea urchin spines are noted for their ability to initiate chronic FB reactions. Sea urchin spines and other marine FBs are covered with slime, calcareous material, and other debris that
commonly initiate an FB granuloma. The inflammatory reaction seen with cactus thorns may be an allergic reaction to fungus found on the cactus plant. Many FB reactions are thought to result from an inflammatory response to organic material, or they may represent infection from bacteria introduced at the time of the wound. Clinically evident reactions may be delayed for weeks or even years after injury (Fig. 36.40). The chronic infection or
inflammatory reaction may not be accompanied by the production of pus, but it may be quite painful or result in loss of function. FBs may also be associated with the formation or development of a chronic pseudotumor, a sinus tract, or an osteomyelitis-like lesion of bone and soft tissue.75 In addition, organic material has been noted to induce chronic tenosynovitis, chronic monarticular synovitis, and chronic bursitis. Rapidly
traveling projectiles with considerable inherent heat (e.g., bullets) are less likely to cause infection but are more apt to cause other difficulties. Damage to surrounding areas can occur during passage through tissue. Rarely do retained lead FBs, such as bullets or shotgun pellets, leach out lead into the general circulation and produce systemic lead poisoning unless they are in contact with synovium (Fig. 36.41). If this process does occur, it may take years to develop and can
result in vague or nondescript symptoms (e.g., fatigue, arthralgia, headache, or abdominal pain) many years after the initial injury. Elevated blood lead levels are more likely to occur if body fluids such as joint, pleural, peritoneal, or cerebrospinal fluid bathe the lead. Bullets retained in muscle or other soft tissue are not likely to produce any sequelae related to their lead content. However, Farrell and colleagues reported unsuspected elevated lead levels in patients with retained lead
fragments who were seen in the ED with a variety of complaints.77 Lead levels of up to 50 µg/dL were reported. Levels greater than 45 µg/dL are generally considered an indication for chelation therapy. The relationship between the retained lead and the symptoms was unclear, but this report verifies the observations of others that retained lead FBs in selected areas can significantly elevate blood lead levels and may produce symptomatic plumbism.
James R. Roberts MD, FACEP, FAAEM, FACMT, in Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 2019
If the FB is not removed or cannot be removed, an FB reaction may occur. Some FBs produce an inflammatory reaction or infection a few days after introduction into the body. Other objects may not cause problems for weeks, months, or even years until they flare up for no apparent reason. The primary factors that affect the extent of tissue reactions are contamination and whether the material is inert or reactive with human tissue. Reactive FBs, such as wood, will generally produce inflammation eventually, whereas inert FBs, such as bullets, rarely do. Some inert FBs carry dirt particles, pieces of clothing, or other sources of bacterial contamination. Expeditious removal may be necessary, even if the FB itself is relatively small and unlikely to cause a reaction.
A purulent bacterial infection may develop in the presence of any FB; therefore, any abscess or cellulitis that recurs or wounds that do not heal as expected should always be investigated for retained FBs.75,76 Karpman and coworkers found a 15% rate of infection (S. aureus and Enterobacteriaceae) in a series of 25 patients treated for cactus thorn injuries on the extremities.58 Certain thorns (black thorns, rose thorns), redwood and northwest cedar splinters, toothpicks, hair, and stingray or sea urchin spines are noted for their ability to initiate chronic FB reactions. Sea urchin spines and other marine FBs are covered with slime, calcareous material, and other debris that commonly initiate an FB granuloma. The inflammatory reaction seen with cactus thorns may be an allergic reaction to fungus found on the cactus plant.
Many FB reactions are thought to result from an inflammatory response to organic material, or they may represent infection from bacteria introduced at the time of the wound. Clinically evident reactions may be delayed for weeks or even years after injury (Fig. 36.40). The chronic infection or inflammatory reaction may not be accompanied by the production of pus, but it may be quite painful or result in loss of function. FBs may also be associated with the formation or development of a chronic pseudotumor, a sinus tract, or an osteomyelitis-like lesion of bone and soft tissue.75 In addition, organic material has been noted to induce chronic tenosynovitis, chronic monarticular synovitis, and chronic bursitis.
Rapidly traveling projectiles with considerable inherent heat (e.g., bullets) are less likely to cause infection but are more apt to cause other difficulties. Damage to surrounding areas can occur during passage through tissue. Rarely do retained lead FBs, such as bullets or shotgun pellets, leach out lead into the general circulation and produce systemic lead poisoning unless they are in contact with synovium (Fig. 36.41). If this process does occur, it may take years to develop and can result in vague or nondescript symptoms (e.g., fatigue, arthralgia, headache, or abdominal pain) many years after the initial injury. Elevated blood lead levels are more likely to occur if body fluids such as joint, pleural, peritoneal, or cerebrospinal fluid bathe the lead. Bullets retained in muscle or other soft tissue are not likely to produce any sequelae related to their lead content. However, Farrell and colleagues reported unsuspected elevated lead levels in patients with retained lead fragments who were seen in the ED with a variety of complaints.77 Lead levels of up to 50 µg/dL were reported. Levels greater than 45 µg/dL are generally considered an indication for chelation therapy. The relationship between the retained lead and the symptoms was unclear, but this report verifies the observations of others that retained lead FBs in selected areas can significantly elevate blood lead levels and may produce symptomatic plumbism.
Bronchoscopy: Flexible and Rigid; Esophagoscopy: Flexible and Rigid; Mediastinoscopy; and Anterior Mediastinotomy
John C. Kucharczuk MD, in Surgical Pitfalls, 2009
Removal of foreign bodies
Evacuation of tracheal stenosis
Placement of nonexpandable stents
Control of massive hemoptysis
Evaluation of tracheobronchial mobility
Evaluation of airway invasion or adherence by esophageal tumors
Palliation of airway obstruction by tumor (“coring out”)
Inappropriate Patient for Rigid Bronchoscopy
The preoperative assessment of patients undergoing rigid bronchoscopy includes examination of the neck and oral cavity. Severe cervical arthritis with a contracted neck makes rigid bronchoscopy difficult. Poor dentition and loose teeth are at risk during rigid bronchoscopy, and removable dental work such as bridges and dentures should be taken out prior to the procedure. The presence of a mature tracheostomy, conversely, is not a contraindication to rigid bronchoscopy. The tracheostomy device can be removed and the patient intubated with the rigid scope from above or, in some circumstances, directly through the stoma, with particular care being taken to avoid injury to the posterior membranous portion of the trachea. Likewise, rigid bronchoscopy can be performed through the mature stoma in patients who have undergone total laryngectomy.
Inability to position the patient appropriately, resulting in an inability to safely perform the procedure. Complications can range from minor damage to the dentition to life-threatening perforation of the pharynx or airway.
Grade 1–5 complication
Select an alternative method for airway visualization and intervention.
Adequately evaluate the patient preoperatively. Do not attempt rigid bronchoscopy on patients with a fixed cervical spine or an inability to be positioned appropriately.
Inadequate Cooperation between Surgeon and Anesthesiologist
The performance of rigid bronchoscopy with the patient under general anesthesia requires close coordination between the anesthesiologist and the surgeon. While the anesthesiologist institutes the appropriate monitoring and intravenous access, the surgeon should prepare the rigid bronchoscope along with its light source and supporting hardware. During “routine” rigid bronchoscopy, general anesthesia is induced with a combination of intravenous and inhalation anesthetics. Secretions are aspirated from the posterior pharynx, and the patient is mask-ventilated. A muscle relaxant is then administered to allow easier placement of the rigid bronchoscope. Patients with large mediastinal masses or near-complete obstructing tracheal tumors represent a particular challenge and, as such, require special anesthetic consideration. Placement of these patients in a supine position or administration of general anesthesia with a muscle relaxant can lead to complete airway obstruction and life-threatening hypoxemia. In these patients, the airway should first be anesthetized with local agents. Patients should remain in a somewhat upright position while general anesthesia is slowly induced with intravenous agents. During this phase, the anesthesiologist assists the patient's spontaneous ventilation. Use of muscle relaxants should be avoided until the airway is secure. Once anesthetized, the patient should be quickly positioned and intubated with the rigid scope. Ventilation through the anesthesia circuit connected to the side port of the ventilating scope can then begin. If a nonventilating scope is used, insufflation of oxygen via a Venturi apparatus can be used to maintain oxygenation.
Inadequate control of the airway resulting in hypercarbia, hypoxemia, and death.
Grade 3/4/5 complication
Both the surgeon and the anesthesiologist must understand the conduct of the procedure and work together as a team. It is helpful to review the planned procedure with the entire operating room team as well as to have a contingency plan in case of a loss of the airway.
The procedure should be performed by a cohesive group of anesthesiologists, surgeons, and nurses. The entire team must understand the procedure before starting.
Inability to Place the Rigid Bronchoscope
When the surgeon is ready to introduce the rigid bronchoscope, the patient should be positioned supine with the neck slightly flexed (“sniffing position”). The surgeon stands behind the patient's head, secretions are suctioned from the posterior pharynx, and tooth guards are placed. The surgeon controls the patient's head by gripping the maxilla with the middle and ring fingers of the left hand. The index finger and thumb of this same hand hold the scope in the manner in which one holds a pool stick. The right hand grasps the scope at the level of the eyepiece. The instrument is introduced with the bevel down and advanced until the epiglottis is visualized. The scope is placed just under the leading edge of the epiglottis, which is then gently elevated to reveal the vocal cords. Elevation is achieved by the use of the left thumb. Use of the patient's teeth or gums as a fulcrum to elevate the epiglottis results in damage to the teeth and must be avoided. One should avoid advancing the scope further than 1 cm beyond the tip of the epiglottis because this places the scope beyond the larynx.
When the vocal cords are visualized, the scope is rotated 90° to the right and advanced into the trachea. Once in the trachea, the scope is rotated back to its original position. The supporting pillow can then be removed from behind the head and the table headboard can be lowered to extend the neck. Ventilation is begun either through the side port with an eyepiece in place or via the Venturi apparatus if a nonventilating scope is being used.
Inability to insert the rigid bronchoscope can result from a number of causes: inadequate training, inability to position the patient appropriately, and inadequate visualization owing to secretions or blood. Complications can range from having to convert to an alternative technique, minor damage to dentition, life-threatening perforation of the pharynx or airway, and even loss of airway control and death.
Grade 1–5 complication
If the patient is an inappropriate candidate for rigid bronchoscopy or the operator is not sufficiently trained, an alternative method for airway visualization and intervention should be selected.
Adequately evaluate the patient preoperatively.
Inadequate Visualization of the Airway
The patient's head should be turned to the side opposite that which you wish to examine. When passing the scope into the right main stem, for example, the patient's head should be turned slightly to the left. We typically hold ventilation and remove the eyepiece when advancing the scope. If closer inspection of the airway is required, a Hopkins rod telescope is passed through an adapter on the main channel of the rigid scope. These telescopes provide magnification as well as a variety of angled views. If telescopes are not available, a flexible bronchoscope can be passed through the rigid scope.
Advancing a rigid bronchoscope with inadequate visualization of the airway will likely result in airway perforation, necessitating thoracotomy and complex reconstruction.
Grade 3–5 complication
The best strategy is not to advance a rigid bronchoscope in the airway unless a clear lumen can be seen ahead.
The patient's head is manipulated to align the long axis of the airway with the scope, allowing the scope to be passed with clear visualization of the distal lumen.
Recover the Patient
After rigid bronchoscopy, the patient is recovered from general anesthesia in a postanesthesia care unit. Those patients undergoing laser ablation of an obstructing lesion or relief of airway obstruction by a “coring technique” utilizing the rigid bronchoscope should be hospitalized and observed overnight to ensure that an adequate airway has been achieved.
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Paul W. Flint MD, FACS, in Cummings Otolaryngology: Head and Neck Surgery, 2021
Foreign Body Removal
Foreign body aspiration is one of the most common indications for therapeutic bronchoscopy. There is a bimodal incidence of airway aspiration, peaking in children 1 to 2 years old and in adults older than 70. Aspiration risk factors in adults include alcohol intoxication, poor dentition, old age, seizure, trauma, sedative and hypnotic drug use, dysphagia, neurologic movement disorder, and general anesthesia. In adults, foreign bodies are most commonly found in the right-sided airways, but, in children, they are found equally in the left and right airways, as a result of the equal size and angulation of the mainstem bronchi.
The most important consideration when preparing for bronchoscopic removal of a foreign body is availability of all necessary endobronchial tools. Both flexible and rigid bronchoscopes can be used to remove foreign bodies, although the success rate of rigid bronchoscopy is superior to flexible bronchoscopy (99.9% vs. 86% to 91%, respectively).87-95
Foreign body removal using the flexible bronchoscope is a three-step process of (1) dislodging the foreign body, (2) grasping or securing the object with endobronchial accessories, and (3) removal of the foreign body with the bronchoscope as a single unit. Care should be taken to prevent dropping it at the level of the vocal cords, endotracheal tube, or laryngeal mask airway. A variety of endobronchial accessories (forceps, grasping claws, snares, baskets, and magnets) (seeFig. 71.3B) are available for foreign body extraction. A cryoprobe catheter is an excellent tool for removing organic foreign objects, blood clots, and mucous plugs.
Serious complications can accompany removal of a foreign body, including central airway obstruction, hypoxemia, bronchospasm, and bleeding. Objects can also migrate, and their fragments can lodge in distal airways.
Intravascular Foreign Body Retrieval
In Diagnostic Imaging: Interventional Procedures (Second Edition), 2018
Removal of FB that is malpositioned or has embolized○
Migrated/maldeployed stents (arterial/venous)○
Embolization coils, plug occluders○
Guidewire, sheath, diagnostic catheter fragments•
Removal of fractured venous access catheter fragments•
Removal of malpositioned/migrated IVC filter•
Other accessible intravascular FBs○
Shrapnel, ballistic fragment removal
Extensive thrombus attached to FB•
Intravascular FB with extreme indwelling time○
May be endothelialized, incorporated into vessel○
May no longer pose clinical threat to patient•
FB location with overly excessive removal risk○
Intracardiac FB perforating myocardium–
Removal might precipitate pericardial tamponade○
FB causing significant perforation of vessel wall–
Removal could cause vessel laceration/hemorrhage•
Patient with short life expectancy
CT imaging is preferred○
Best evaluation of FB and adjacent structures
Things to check○
Appropriate clinical history/physical examination○
Details regarding intravascular FB–
Type and location of FB–
How long FB has been indwelling–
Circumstances causing FB–
Potential complications associated with removal–
Potential complications if not removed○
Current medications and allergies○
Creatinine, glomerular filtration rate, CBC, coagulation studies□
Prefer normal Cr; eGFR > 60–
Complete blood count (CBC)□
Platelet count > 50,000/μL–
Form baseline for intracardiac/pulmonary FB–
Potential for arrhythmias during retrieval of intracardiac/pulmonary FBs○
If indicated, conscious sedation•
Materials for gaining vascular access○
Arterial/venous access sheath–
May require large caliber or long sheath□
Depends on retrieval system/tool used□
Depends on type/size of FB to be retrieved○
Flush catheter (e.g., pigtail)□
May use in combination with tip-deflecting wire–
Selective catheter (e.g., Cobra, Kumpe, Davis)□
For catheterization of target vessel□
Positioning guidewire/snare/sheath adjacent to FB–
Angioplasty (PTA) balloon catheters□
May use for repositioning/redeploying stents○
FB retrieval devices–
Amplatz GooseNeck snare (Covidien)□
Single snare loop; diameters from 5-35 mm□
Placed through 4- to 6-Fr catheter□
Snare forms 90° angle relative to catheter□
Microsnare available for microcatheter use–
Atrieve vascular snare kit (Angiotech)□
3 noninterlaced loops; range of diameters□
Placed through 3.2- to 7-Fr catheter–
Curry retriever (Cook Medical)□
Single loop design
Dotter retriever (Cook Medical)□
30 x 70 mm helical loop basket□
Good for retrieving round FBs–
EN snare (Merit Medical)□
3 interlaced nitinol loops; range of diameters□
Mini snare system uses 3.2-Fr catheter□
Standard snare system uses 6- to 7-Fr catheter–
Expro Elite Snare/Micro Elite Snare (Vascular Solutions)□
0.035“ or 0.014” (use with microcatheter)□
0.014″ (use with microcatheter)–
Various flexible and rigid designs□
Endobronchial biopsy forceps have “alligator jaws”; may be used to grasp FB□
Usually requires large-diameter sheath□
Very effective for engaging/grasping FB–
Indy OTW Retriever (Cook Medical)□
4 loop nitinol wire snare; 40-mm basket
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Corneal Abrasions and Removal of Corneal or Conjunctival Foreign Bodies
Grant C. Fowler MD, in Pfenninger and Fowler's Procedures for Primary Care, 2020
Corneal or Conjunctival Foreign Body Removal
Noninfected, small, recent corneal or conjunctival foreign body.
The contraindications (those that should be referred to ophthalmology) are the same as those for “Fluorescein Examination of the Cornea and Conjunctiva,” as well as the following:•
Signs or symptoms that suggest infection, such as edema and clouding of the cornea surrounding the foreign body, ulceration exceeding the size of the foreign body, or purulent discharge•
Large metal foreign body or foreign body with potential to cause a large rust ring (e.g., embedded in the cornea for longer than 24 hours)•
Deeply or centrally embedded foreign body or one that has healed and is covered by epithelium
Topical ophthalmic anesthetic•
Sterile cotton-tipped applicators•
Bright white and cobalt-blue light sources•
Magnification as previously listed (it may be necessary to have an assistant hold the magnifier to allow the operator to use both hands)•
Isotonic ophthalmic irrigant, such as Dacriose, Ringer lactate, or sterile saline•
Snellen chart or equivalent visual acuity chart•
Sterile 18-gauge needle with small syringe•
Sterile dental burr or cornea drill (optional)
Note: Instead of an 18-gauge needle, a tuberculin syringe with a 26-gauge needle, a sterile eye, or a small, sterile chalazion curette may be substituted, depending on user experience.
Preprocedure Patient Preparation
Instruct the patient that it will be important to fix their gaze on a distant object, maintain that gaze, and hold the head motionless, regardless of what is seen or experienced. The patient will have the urge to blink, but it will be important to keep the eye open. Inform the patient that the eye will be numb from the local anesthetic, but that he or she may feel pressure during the procedure. The patient should know that you will need to touch him or her.
Advise the patient of possible complications and that referral may be necessary regardless of outcome. Some clinicians obtain signed informed consent.
Controversy exists about the use of a swab or a spud to remove a corneal foreign body and whether this causes more damage. Only experienced users should consider a swab or spud, and they should use them only for a small foreign body. The swab will be more successful with a very recent, superficial foreign body. Irrigation alone is not usually successful unless the foreign object is very recent, consists of carbon, or is water soluble. The patient’s tears would normally have already washed away anything that irrigation would remove.
Endoscopic Approach to Intravesical Foreign Bodies
Petrişor A. Geavlete, ... Bogdan Geavlete, in Endoscopic Diagnosis and Treatment in Urinary Bladder Pathology, 2016
The ultimate goal of treatment is the complete removal of foreign bodies, avoiding possible secondary complications that may include lesions of the bladder and urethra, peritonitis, urinary tract infections, urethrorrhagia, or hematuria.
Rarely, foreign bodies may be eliminated spontaneously during urination (DiDomenico et al., 1997).
After diagnosing this condition, analgesics and anticholinergics will be administered to control pain and irritative urinary symptoms. Also, antibiotic prophylaxis of urinary tract infections or of urosepsis is recommended in patients with pre-existing infections. The extraction of intravesical foreign bodies can be performed endoscopically, percutaneously, laparoscopically, or by open surgery. The type of approach will be chosen according to the general status of the patient; the integrity of the urinary tract; and the size, shape, and nature of the intravesical object.
The vast majority of intravesical foreign bodies can be extracted, in whole (Fig. 6.11) or after fragmentation (Fig. 6.12), by endoscopic approach. The use of this type of approach is limited only by the size of the foreign bodies, the bulky ones being difficult to extract transurethrally.
Figure 6.11. JJ catheter fragment extracted using forceps.
Figure 6.12. Calcified vesical transfixiant thread extracted using forceps after lithotripsy.
The intravesical fragmentation of large foreign bodies, especially using a holmium:YAG (Ho:YAG) laser, may overcome these difficulties (Bedke et al., 2010).
If potentially severe additional damage is produced during the extraction maneuvers, the intervention will be stopped and a new method of approach will be considered or it will be converted to open surgery.
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Foreign Body Removal
Ruth Ann Pannell MD, Joe Pagane MD, in Pediatric Emergency Medicine, 2008
Complications of a retained foreign body as well as of foreign body removal after exploration include wound infection, cellulitis, abscess formation, septic arthritis, osteomyelitis, and chronically draining wounds.43,48,50,54 Wound exploration and foreign body removal can injure adjacent structures or cause scarring. Complications associated with hemostasis, whether by tourniquets or by the use of vasoactive agents, include vascular damage, neurapraxia, and thrombosis. These complications can be greatly reduced by keeping tourniquet time to 20 to 30 minutes and by not using vasoactive agents on devitalized tissue or at end-organ sites.50,54,55
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The Difficult Pediatric Airway
Ranu R. Jain, Mary F. Rabb, in Benumof and Hagberg's Airway Management, 2013
6 Foreign Body Aspiration
Foreign body aspiration is a cause of significant morbidity and mortality in the pediatric population. Young children are at increased risk for foreign body aspiration, with children less than 2 years old most often affected.388 A second peak of aspiration occurs between ages 10 and 11 years.389 Most of the deaths occur in children younger than 1 year. The objects most frequently aspirated are food products. There is only a slight propensity for the object to lodge on the right side because of symmetrical bronchial angles in children under 15 years old. The left main stem bronchus is displaced by the aortic knob by age 15, creating a more obtuse angle at the carina.390
Witnessed events are easier to diagnose. A history of choking, gagging, or coughing is usually given. Patients may be asymptomatic at the time or may develop symptoms of acute distress. A persistent cough, wheezing, or recurrent pneumonia may be the initial sign if the aspiration occurred in the past. The American Academy of Pediatrics has developed guidelines for the management of choking episodes. For children under 1 year, back blows and abdominal thrusts with the child in a head-down position are recommended. The Heimlich maneuver is reserved for older children and adults.391
Classically, peanuts should be removed promptly because of the inflammatory reaction to the peanut oil. Emergency removal is indicated if the patient is in distress or if the foreign body is in a precarious location. If the patient is stable, radiographs may be taken to assist in localizing and identifying the foreign body. If the foreign body is radiopaque, it is easily identified. Radiolucent foreign bodies may demonstrate soft tissue density in or narrowing of the airway.13 Indirect signs of air trapping, mediastinal shift, or atelectasis may be present. Lateral decubitus films are helpful in infants and younger children because they cannot cooperate with expiratory films.390 The downside lung should be deflated unless it is obstructed with a foreign body.389
In general, inhalation induction without cricoid pressure is the favored technique for removal of foreign bodies in the airway, regardless of the type of object, according to a postal survey of members of the Society for Pediatric Anesthesia.388 (For foreign bodies in the upper esophagus, a rapid-sequence induction without cricoid pressure was the preferred technique, whereas for objects in the lower esophagus and stomach, a rapid-sequence induction with cricoid pressure was chosen.) Cricoid pressure may cause harm if the foreign body is sharp or positioned in the larynx. If the case is not an emergency, one can wait until the appropriate nothing-by-mouth time has passed. In a retrospective review of anesthetic management for tracheobronchial foreign body removal, neither spontaneous nor controlled ventilation was associated with an increased incidence of adverse events.392
With an inhalation induction, a prolonged induction may occur because of airway obstruction. CPAP at 5 to 10 cm H2O and assisted ventilation may be needed at times to maintain a patent airway. After an adequate level of anesthesia is obtained, topicalization of the airway may decrease the incidence of coughing or laryngospasm. Use of a ventilating rigid bronchoscope allows ventilation during the procedure. High oxygen flow rates may be needed to overcome the presence of an air leak around the FOB. Communication between the anesthesiologist and the endoscopist is crucial because this is a shared airway. The patient may require intermittent ventilation if desaturation occurs during the FOB. When the foreign body is grasped, the glottis should be relaxed for removal. Short-acting muscle relaxants, propofol, or deeper inhalational anesthesia may be used. The forceps and the bronchoscope are removed from the trachea as a single unit.354 Dislodgement of foreign bodies at the glottic or subglottic area has been reported.393 If a foreign body is dislodged and obstructs the trachea, the bronchoscope must be used to push the foreign body into a main stem bronchus to enable ventilation of one lung. FOB with tracheotomy removal of a bronchial foreign body has been used successfully to remove an object that was too large to pass through the subglottis.394
When the foreign body is removed, the patient is usually intubated with an appropriate-size ETT. Depending on the amount of edema from the procedure, the patient should be able to be extubated. Postoperatively, racemic epinephrine (0.5 mL of 2.25% solution in 3 mL of saline) may be used for stridor. Dexamethasone is often given for edema.
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Respiratory System Diseases of Nonhuman Primates
Linda J. Lowenstine, Kent G. Osborn, in Nonhuman Primates in Biomedical Research (Second Edition), Volume 2, 2012
Rhinoscopy and bronchoscopy provide the opportunity for direct visualization of the areas, biopsy of suggestive or obvious lesions, removal of foreign bodies, and regional lavage, brushing, or even biopsy of the lung for culture and cytology. For anterior rhinoscopy, a variety of equipment can be used, from an otoscope to a rigid pediatric arthroscope to a flexible fiberoptic endoscope (FOE). Flexible fiberoptic technology has tremendously improved the ability to perform these procedures (Strumpf et al., 1979; Muggenburg et al., 1982; Moser, 1994; McKiernan, 1995). The flexible FOE is composed of fiberoptic bundles that provide both illumination and visualization pathways. One or more small channels traverse the FOE, through which instruments can be passed, fluids delivered, and suction applied with retrieval of cells for cytology (Tate et al., 2004). An FOE is most useful for posterior rhinoscopy, although a dental mirror may provide some visualization of the nasopharynx. The major contraindication for endoscopic examination, particularly in the lower respiratory system, is lack of experience, which both reduces the diagnostic and therapeutic potential and increases the risks (e.g., hypoxia, laryngospasm, and bronchospasm, pneumothorax, and biopsy-associated hemorrhage). Thomas et al. (2006) describe the use of human nasal cannulas during bronchoscopy procedures as an aid in maintaining adequate oxygen delivery in pig-tailed macaques.
Pleuroscopy, thoracoscopy, and mediastinoscopy are procedures that can yield important information and samples (Moser 1994). These techniques can involve the use of rigid or flexible devices. As with rhinoscopy and bronchoscopy, operator experience is a key to minimizing risks and maximizing diagnostic and therapeutic potential.
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Andranik Ovassapian, in Essence of Anesthesia Practice (Third Edition), 2011
First performed by Killian in 1895. Its use has declined continuously after introduction of fiberoptic bronchoscope.•
Performed for removal of foreign body, massive hemoptysis, to dilate tracheobronchial strictures, laser resection of airway tumors, and stent placement
Depends on nature of disease•
Cardiac arrhythmias, hypoxemia, increased BP and HR, myocardial infarction•
Incidence of reintubation reported at 0.39% when panendoscopy performed for upper airway path
Ventilation, oxygenation in pts with chronic lung disease, airway pathology•
Endoscopist, anesthesiologist share airway, complicating ventilatory management•
Postbronchoscopy ventilatory failure
Assoc with severe CV response manifested with tachycardia, Htn•
Bleeding from biopsy site could be troublesome•
Level of the lesion critical•
Ventilation performed through side arm•
Requires communication with surgeon throughout procedure
ICD-9-CM Code: 146.9 (Oropharyngeal cancer)
Indications and Usual Treatment
Removal of foreign bodies•
Management of major hemoptysis•
Establishing emergency airway•
Dilation of tracheobronchial stricture•
Laser resection of airway tumors•
Bronchoscopy in infants, small children•
Bronchoscopy, esophagoscopy, laryngoscopy for staging of oropharyngolaryngeal malignant lesions•
Biopsy of endobronchial lesion•
Evaluation of the lower airway•
Placement of stent
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How is a foreign body removed from the ear canal?
If the object is easy to see and grasp, gently remove it with tweezers. Use water. Only wash out the ear canal if you don't think there is a hole in the eardrum and no ear tubes are in place. Use a rubber-bulb syringe and warm water to wash the object out of the canal.
What is removal of foreign body?
Foreign Body Removal refers to the retrieval of foreign objects that have been introduced into the body, sometimes by accident. Foreign substances can be introduced into various parts of the body including ear, eye, nose, finger, leg, foot, stomach, skin, breathing tract (airway) and more.