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Tracheoscopy, Bronchoscopy, and Airway Foreign Bodies


Introduction

Rigid tracheoscopy and bronchoscopy are important methods for evaluating the airway in infants and children. During this procedure, a rigid telescope with or without a rigid ventilating bronchoscope is inserted transorally to evaluate the larynx, trachea, and bronchi. Rigid tracheoscopy and bronchoscopy can be both diagnostic and therapeutic, because a variety of airway abnormalities can be discovered and treated. Instruments such as optical forceps, nonoptical instruments, lasers, and balloons can be passed through the bronchoscope to treat a variety of different airway conditions. It is important for all Otolaryngologists to be familiar with the instruments and techniques required for rigid tracheoscopy and bronchoscopy.

Flexible fiberoptic bronchoscopy is another technique used to evaluate the airway in infants and children; this procedure is more commonly performed by Pulmonologists. Rigid airway endoscopy and flexible bronchoscopy can be complementary methods to evaluate the airway in children. Each technique has its own indications, but they are sometimes performed together.

Foreign bodies of the airway can lead to significant morbidity and mortality in children. They are the fourth most common cause of accidental death in toddlers, accounting for about 3000 deaths per year in the United States. Aspiration of foreign bodies occurs most commonly in children younger than 5 years of age. Foreign bodies of the airway must be in the differential diagnosis in this age group for all nonspecific pulmonary symptoms, such as coughing and wheezing. Approximately half of the patients with foreign bodies of the airway do not have a history of a witnessed foreign body aspiration event. Therefore, clinical history, physical examination, and radiologic studies are important tools to help determine which patients should undergo bronchoscopy. Prompt diagnosis of aspiration of a foreign body and its removal using rigid bronchoscopy are critical in preventing morbidity and mortality.

Key Learning Points

  • Rigid tracheoscopy and bronchoscopy are important methods for evaluating the airway in infants and children; it is important for all Otolaryngologists to be familiar with these techniques.

  • Rigid tracheoscopy and bronchoscopy can be performed with a Hopkins rod telescope alone or with a rigid ventilating bronchoscope (which can also have a Hopkins rod telescope to improve visualization).

  • Tracheoscopy and bronchoscopy can be used to diagnose and treat a variety of abnormalities involving the larynx, trachea, and bronchi.

  • Flexible bronchoscopy can be a useful technique in evaluating certain airway abnormalities in children, particularly abnormalities involving the more distal airway.

  • For rigid airway endoscopy, the Hopkins rod telescope or bronchoscope is typically introduced through direct laryngoscopy.

  • Rigid bronchoscopy is an important technique for the diagnosis and treatment of foreign bodies of the airway in children.

  • Foreign bodies of the airway can lead to significant morbidity and mortality in children, and delay in diagnosis can increase the risk of complications.

  • Aspiration of the foreign body occurs most commonly in children younger than 5 years of age.

  • The most common foreign bodies of the airway are food products (nuts and seeds), followed by pieces of plastic toys, and then metal objects.

  • The most common site for foreign bodies of the airway is the right main stem bronchus.

Preoperative Period

History

  • History of previous surgeries, including previous direct laryngoscopy and rigid bronchoscopy procedures, previous airway surgery, or history of tracheotomy

  • History of endotracheal intubation or a stay in the intensive care unit

  • Ask about personal or family history of problems with anesthesia.

  • History of abnormalities of the spine, spine surgery, or abnormalities of the brain

  • History of stridor or stertor: inspiratory, expiratory, or biphasic; duration; severity; exacerbating or mitigating factors

  • History of witnessed aspiration of a foreign body

  • History of coughing, choking, gagging, dyspnea, respiratory distress, wheezing, hoarseness, or dysphagia

  • Only about 50% of patients with aspiration of a foreign body have a witnessed aspiration event.

Physical Examination

  • Standard anesthesia physical examination

  • Ability of the patient to extend the neck

  • Ability of the patient to open the mouth and expose oropharynx to enable direct laryngoscopy, which is important for the introduction of a rigid telescope or a rigid ventilating bronchoscope

  • Mallampati classification can be used to predict ease of direct laryngoscopy.

  • Patients with a foreign body of the larynx can have hoarseness, aphonia, respiratory distress, or significant stridor.

  • Patients with a foreign body of the trachea may present with the classic physical examination triad of an audible slap (impact of mobile foreign body against the wall of the trachea), palpable thud over the trachea, or asthmatoid wheeze over the trachea.

  • Patients with a foreign body of the bronchi may have wheezing and decreased air entry with decreased breath sounds on the obstructed side.

  • 5% to 40% of patients who have a foreign body have no obvious findings on physical examination.

Imaging

  • Radiographs of the cervical spine in flexion and extension should be obtained in children with Down syndrome or other disorders with concern for instability of the cervical spine, although the diagnostic accuracy of this technique has been debated.

  • Patients with significant respiratory distress should not be taken to radiology for imaging prior to undergoing airway endoscopy in the operating room.

  • Most foreign bodies of the airway are radiolucent (about 80%).

  • Posteroanterior (PA) and lateral chest radiographs in the inspiratory and expiratory phase can be obtained in the assessment of patients with possible foreign body aspiration. Air trapping on the side of a foreign body is the most common abnormal radiographic finding in patients with a foreign body of the airway; this finding can be accentuated in the expiratory phase.

  • In patients who are unable to cooperate with inspiratory and expiratory phase radiographs, lateral decubitus radiographs can be obtained. In lateral decubitus films, air trapping can be seen when the foreign body side is dependent (“down”).

  • PA and lateral neck radiographs can sometimes reveal evidence of a foreign body of the larynx or subglottis.

  • The most common radiographic abnormalities in patients with aspiration of a foreign body include air trapping or hyperinflation and atelectasis ( Fig. 198.1 ).

    Fig. 198.1, Inspiratory, A, and expiratory, B, chest radiographs of a patient with an almond in the right main stem bronchus, demonstrating air trapping and hyperinflation of the right lung. C, Endoscopic view of the almond in the right main stem bronchus.

  • About 40% of patients with a foreign body of the airway have a completely normal chest radiographs.

Indications

  • Rigid tracheoscopy and bronchoscopy are used to evaluate the airway in infants and children with a variety of conditions; these techniques can be both diagnostic and therapeutic.

  • Almost all children with biphasic or expiratory stridor require evaluation via rigid airway endoscopy in the operating room.

  • Children with isolated inspiratory stridor can often be evaluated first in the office via flexible fiberoptic nasolaryngoscopy; however, if laryngomalacia or another etiology for the inspiratory stridor is not seen on flexible laryngoscopy, these patients also should undergo rigid airway endoscopy in the operating room to evaluate the entire airway.

  • The rigid ventilating bronchoscope can be used as a tool to secure the airway in patients with significant airway obstruction who cannot be intubated with an orotracheal tube by traditional techniques.

  • Patients with suspected aspiration of a foreign body should undergo rigid tracheoscopy and bronchoscopy for diagnosis and, if present, treatment of the foreign body.

  • Patients with subglottic or tracheobronchial pathology such as a stricture, web, or granulation tissue can undergo rigid tracheoscopy and bronchoscopy and subsequent endoscopic treatment of the abnormalities with lasers, balloon dilation, optical instruments, and/or injection of steroids.

  • Infants and children with chronic tracheostomy dependence often undergo interval rigid airway endoscopy for surveillance of complications of the tracheostomy tubes, such as suprastomal granulation tissue or tracheal erosion at the tip of the cuff of the tracheostomy tube.

  • Patients with acute bacterial tracheitis often must undergo rigid tracheoscopy and bronchoscopy for débridement of thick mucopurulent secretions and desquamated epithelium.

  • Patients with plastic bronchitis often require rigid airway endoscopy for débridement of obstructing bronchial casts. This relatively rare disorder, characterized by obstruction of the large airways by thick mucus plugs and bronchial casts, can occur in patients with asthma, cystic fibrosis, sickle cell disease with acute chest syndrome, and cyanotic congenital heart disease following palliation surgery.

  • Flexible bronchoscopy provides improved visualization of the distal airway.

  • There are a variety of indications for flexible bronchoscopy, including chronic cough, recurrent pneumonia, unexplained or persistent wheezing, and hemoptysis.

Contraindications

  • Multiple medical comorbidities or medically fragile patients at significant increased risk for anesthesia (relative contraindication)

  • Inability to extend the neck due to cervical spine instability, cervical spine fusion, or diseases involving the cranio-cervical junction (such as severe Chiari malformation) make rigid airway endoscopy challenging.

  • Ankylosis of the temporomandibular joints or other abnormalities of the oral cavity and oropharynx, making direct laryngoscopy very difficult; flexible bronchoscopy can be an alternative in these patients

Preoperative Preparation

  • History, physical examination, and imaging studies as described above

  • Discussion of risks and benefits with patient and family. Risks of procedure include injury to the teeth, injury to the aerodigestive tract, inability to successfully remove a foreign body, and the possible need for open surgery.

Operative Period

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