RESULTS:
190 patients underwent interventional bronchoscopy for removal of inhaled FB, eighth were eliminated; five for combined use of flexible and rigid bronchoscopies during the same procedure and three for ingestion rather than inhalation of FB (figure 1). 182 patients were eligible (median age of 24 months [Inter quartile range (IQR) 16 months – 8 years], 58% males); 40 (22%) by flexible bronchoscopy and 142 (78%) by rigid bronchoscopy. The demographic details and time interval from admission to procedure were similar between the groups (Table 1). Most of the FB were of organic origin (59%), located in the right main bronchus or its distal branches (53%) and were removed by grasping forceps (19%), when using rigid bronchoscopy or by retrieval basket(45%), when using flexible bronchoscopy (Tables 2a & 2b). Regarding efficacy; 88.73% of rigid bronchoscopies and 95% of flexible bronchoscopies were successful in the removal of FB (p value=0.24). 38 out of 40 (95%) flexible bronchoscopies were successful in removing the FB, while two had failed. In both cases, the FB was metal pin, which was located in the left main bronchus. Both were successfully removed by rigid bronchoscopy during the same procedure. 126 out of 142 (90%) rigid bronchoscopies were successful in removing the FB, while 16 had failed. Out of those that failed; 4 were successfully removed by flexible bronchoscopy during the same procedure, 4 were successfully removed by flexible bronchoscopy in a delayed procedure and 4 were successfully removed by rigid bronchoscopy in a delayed procedure, (usually 2-4 days later, after initiation of systemic steroid and antibiotic treatment), while 2 of them required intubation and pediatric intensive care unit (PICU) admission. 4 additional patients were intubated and admitted to the PICU, stabilized and then, 3 were transferred to a different hospital, where the FB was removed by successful flexible bronchoscopy and one went through thoracotomy in our institution with successful removal of the FB. The complication rate during or post procedure was higher among rigid compared to flexible bronchoscopy; 9.2% vs. 0, respectively (p value=0.047). Most of the complications were disintegrating of the FB (n=7, 6.3%), intubation requiring PICU admission (n=7, 6.3%) and bleeding (n=2). Some patients had more than one complication. Out of the patients that needed intubation; two inhaled organic FB (nut, peanut) that disintegrated, two inhaled metal pin (Hijab) and two had plastic pen cover, that turn out to be one of the most difficult FB to remove, due to its round shape and slippery characteristic. One patient was intubated before the bronchoscopy and not as a consequence of the procedure, because he was unstable. Throughout the first period of the study (2009-2017) 118 procedures were performed; 111 (94%) rigid bronchoscopies and 7 (6%) flexible bronchoscopies. We found no statistical significance in procedure length between flexible and rigid bronchoscopies; 61 min’ vs. 48 min’, respectively (p value 0.408) (Table 3a). From 2017 onwards, after implementation of the flexible bronchoscopies for extraction of inhaled FB, 64 procedures were performed; 33 (51.6%) flexible bronchoscopies and 31 (48.4%) rigid bronchoscopies. Procedure length was found to be significantly shorter by 16 minutes, via flexible compared to rigid bronchoscopy; 42 min’ vs. 58 min’, respectively (p value 0.016) (Table 3b). No statistically significant difference was found in LOS after rigid compared to flexible bronchoscopy (39 vs 33 hours, p value 0.649).