Discussion:
Aspiration of a foreign body is commonly reported among children. It can be life-threatening and it can lead to life-long morbidities like chronic suppurative lung disease. Since its first use by Gustav Killian,extraction of trachea-bronchial foreign bodywith rigidbronchoscopy is presently considered the gold-standard1. Failure of rigid bronchoscopic removal necessitates thoracotomy and bronchotomy. The rate of failed extraction of airway foreign bodies after first rigid bronchoscopy varies from 0.3 to 7% 1,2.
Although rigid bronchoscopy is considered the gold standard for foreign body removal, many recent reports suggest that in experienced hands Flexible bronchoscopy done under conscious sedation alsoto be safe and effective2,3.The obvious advantage of flexible bronchoscopic foreign body removal include the ability to reach airways difficult to access through a rigid bronchoscope (notably right upper lobe and basal segments of lower lobe bronchi). If performed under conscious sedation, there are reduced risks of general anesthesia and dependence on busy operation theatres. The main disadvantage of flexible bronchoscopy is that it further narrows the airway and compromises ventilation, unlike a rigid scope where ventilation can be controlled through the scope.Flexible through rigid scope technique thus combines the best of both: supported ventilation through the rigid scope and access to the deeper airways through flexible scope.
Although there are few reports of sequentially combined use of flexible and rigid scopes there are scarce reports of flexible through rigid scopytechnique for removal of airway foreign body. Ruegemeret al reported an eight year boy who aspirated a ‘ball-bearing’ in right lower lobe bronchus and could not be removed on two rigid bronchoscopic removal attempts using optical FB forceps, ball-bearing forceps, Segura wire basket, rigid FB basket and Fogarty catheter4. After steroids for 48 hours it was removed using four-wire helical basket inserted through the suction channel of flexible bronchoscope which was inserted through rigid bronchoscope4.
Eyekpeghaet al reported a 6-year-old boy who had a history suggestive of an aspirated base cap of a pen but still it could not be visualized despite two rigid and one flexible scopies5. The foreign body was finally demonstrated on a CECT imaging and removed by combined rigid and flexible scopy5.
Conclusion: This report highlights that flexible bronchoscopy througha rigid bronchoscopeis a feasible option in distal airway foreign body, not amenable to rigid scopyalone. This obviates the need for more invasive surgeries like thoracotomy and bronchotomy.