|Year : 2014 | Volume
| Issue : 2 | Page : 90-93
Failure of bronchoscopy in airway obstruction: A case series
Muffazzal Rassiwala, Brijesh Kumar Lahoti, Rajkumar Mathur, Ashok Laddha, Shashi Shankar Sharma
Department of Surgery, M.G.M. Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
|Date of Web Publication||23-Jun-2014|
Department of Surgery, M.G.M. Medical College and M.Y. Hospital, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Bronchoscopy in this modern era has proved its utility and superiority far beyond imagination and has surpassed and replaced the majority of the surgical procedures. However, there have been certain limitations to the applicability of this vital technique especially in a country where we face lack of proper equipments and trained personnel at all health centers. This case series with review of literature examines the spectrum of limitations of bronchoscopy and the rare cases encountered, which leads to the surgical alternatives for managing intrabronchial pathology based on relevant current literature.
Keywords: Bronchotomy, foreign body, human papilloma virus, recurrent respiratory papillomatosis, respiratory tract obstruction
|How to cite this article:|
Rassiwala M, Lahoti BK, Mathur R, Laddha A, Sharma SS. Failure of bronchoscopy in airway obstruction: A case series. J Assoc Chest Physicians 2014;2:90-3
|How to cite this URL:|
Rassiwala M, Lahoti BK, Mathur R, Laddha A, Sharma SS. Failure of bronchoscopy in airway obstruction: A case series. J Assoc Chest Physicians [serial online] 2014 [cited 2022 Aug 18];2:90-3. Available from: https://www.jacpjournal.org/text.asp?2014/2/2/90/135125
| Introduction|| |
Respiratory tract obstruction in children is a common condition, which may be life-threatening. It is most commonly due to accidental foreign body ingestion, followed by tumors arising from the bronchus. Aspiration of foreign body results in significant morbidity and mortality in children. Foreign body in bronchus is usually managed by bronchoscopy, though open surgical procedure may be rarely needed and in certain circumstances it is lifesaving. We report three cases of life-threatening bronchial obstruction in children due to different etiology which required emergency bronchotomy.
| Case reports|| |
A 4-year-old boy came to an emergency department with complaints of severe difficulty in breathing for past 2 days with history of ingestion of foreign body (safety pin) 2 days back. Child was admitted at the district hospital where fiber-optic bronchoscopy was done and removal was attempted by ear, nose, and throat (ENT) surgeons, but could not succeed hence tracheostomy was done. Bronchoscopy revealed that foreign body was a safety pin with open ends and was in sub-glottis. On the attempt of removal, it got dislodged and passed in left main bronchus, which was confirmed by a repeat chest X-ray [Figure 1]a]. Patient, when referred to Department of Pediatric Surgery, was in severe respiratory distress and open surgery was planned. Left thoracotomy was performed, intra-operatively left lung was found collapsed. Left bronchus was approached by dissecting pulmonary hilum, and foreign body was removed by bronchotomy [Figure 1]b]. Post-operatively collapse of the left lung and respiratory distress persisted probably due to the mucosal injury to the upper respiratory tract which was managed by nebulization with salbutamol respule and n-acetyl cysteine respule and active chest physiotherapy. Patient showed good recovery and intercostal chest drain was removed on 7 th post-operative day. Tracheostomy tube was weaned off and removed on day 12 and the patient was discharged.
|Figure 1: (a) Chest X-ray showing an open safety pin at the junction of left main bronchus division. (b) Left thoracotomy followed by bronchotomy showing the tip of the safety pin inside the left main bronchus|
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A 10-year-old boy presented with severe respiratory distress with past history of bronchoscopic excision of papillomatous growth obstructing left main bronchus 3 years back. Child was advised further treatment but refused and went home. On admission child was in severe respiratory distress with respiratory rate - 44/min, pulse - 120/min. Chest auscultation revealed markedly decreased air entry on the left side. Patient was unable to maintain oxygen saturation at room air, child cannot lie down and able to sit only. Computed tomography chest showed complete collapse of the left lung [Figure 2]a]. ENT surgeons had no facilities for bronchoscopic micro-debridement by LASER and since previous bronchoscopic excision of growth was inadequate hence child was referred for open surgery. Resection of the tumor was done by left thoracotomy with bronchotomy [Figure 2]b]. On the attempt of extubation child went into bronchospasm and had to be reintubated with elective ventilator support. Arterial blood gas analysis revealed respiratory acidosis. Patient had cardiac arrest twice and was revived with direct current cardio-version. After 2 days of intensive care, patient was successfully weaned off from ventilator support and extubated. Patient showed good recovery, and was discharged. Biopsy reports confirmed mass to be papilloma and since it was a recurrence hence diagnosed as recurrent respiratory papillomatosis (RRP).
|Figure 2: (a) Computed tomography chest X-ray showing left lung collapse. (b) Resection of the intrabronchial tumor by left thoracotomy followed by bronchotomy|
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An 8-year-old boy came to an emergency department with complaints of severe difficulty in breathing for past 10 days with history of ingestion of foreign body (pearl) 10 days back. Chest X-ray showed the presence of a white round opacity at right paratracheal region [Figure 3]a]. Child was admitted at the hospital where rigid bronchoscopic removal was attempted by ENT surgeons but could not succeed as it was a rounded slippery object. Patient, when referred to Department of Pediatric Surgery, was in severe respiratory distress, so open surgery was planned. Right thoracotomy was performed. Right bronchus was approached by dissecting pulmonary hilum, and foreign body was removed by bronchotomy, which was a round bead (pearl) of size 2.8 cm × 1.9 cm [Figure 3]b]. Post-operatively, patient recovery was uneventful and the patient was discharged after 3 days.
|Figure 3: (a) Chest X-ray showing a round opacity at the right paratracheal region. (b) Right thoracotomy followed by bronchotomy showing a black round foreign body inside the right intermediate bronchus|
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| Discussion|| |
Aspiration of foreign bodies results in significant morbidity and mortality in children. The majority of foreign body aspirations occur in children <4 years of age. Immature dentition, poor food control, activity during feeding, and propensity to explore the environment orally are some of the reasons why children are susceptible to foreign body aspiration. 
There are three pathophysiological considerations for aspirated foreign bodies:
- The anatomy of the lodgment site
- The physical properties of the foreign body (size, shape, and composition)
- The local tissue reaction to the foreign body.
In a child in an upright position, the right-sided airways are direct entries from the trachea. The left main bronchus is smaller than the right main bronchus and is slightly angled. In a child in a supine position, material is more likely to enter the right main bronchus (46%), followed by left main bronchus (25%), trachea (13%), and larynx (3%). 
Once a bronchial foreign body is identified, rigid bronchoscopy is almost always successful in removal of the aspirated object. For affected children, care at a tertiary center with a full array of pediatric bronchoscopic and anesthetic equipment and expertise is highly recommended.
Stable children suspected of unilateral foreign body aspiration are all candidates for bronchoscopy. However, bronchoscopy should not be considered for:
- Upper airway aspirations, including laryngeal or pharyngeal aspirations presenting with upper airway obstruction signs and symptoms, including stridor, croupy cough, hoarseness, and aphonia
- Bilateral bronchial foreign body aspiration
- Clinically unstable children with decreased level of consciousness, airway compromise, respiratory failure (abnormalities of oxygenation and ventilation), or shock.
Our third case was unique as it was an iatrogenically displaced foreign body in the left main bronchus leading to severe respiratory distress. Foreign body with round and slippery surface may be difficult to remove by bronchoscopy and as in our patient failure to remove the foreign body leads the child toward respiratory failure. Open surgical removal in an emergency was the only choice in our case. Bronchotomy done in this case was proved to be lifesaving.
RRP is a disease caused by the human papilloma virus (HPV).  Warty growths in the upper airway may cause significant airway obstruction or voice change. RRP has a bimodal age distribution and manifests most commonly in children younger than 5 years (juvenile-onset RRP [JORRP]) or in persons in the fourth decade of life (adult-onset RRP).
HPV, the virus associated with cutaneous warts, genital condyloma, and cervical cancer, causes RRP.  While more than 20 types of HPV can cause genital warts, only two of these, HPV-6 and HPV-11, cause the vast majority of cases of RRP.  The disease associated with HPV-11 is more severe  thus, in children with HPV-11-associated disease, as many as 70% may require tracheostomy, compared with <20% of children infected with HPV-6.
The cause of JORRP is peripartum transmission of the virus from an infected mother. Vaginal delivery is a risk factor, but cesarean delivery is not completely protective.  The classic triad for increased risk of JORRP includes being firstborn, vaginal delivery, and having a mother younger than 20 years.  Suspected sexual abuse in children older than 5 years who acquire RRP. The mode of transmission of the virus in adults with RRP is unknown, but sexual transmission is probable.  In our case, the cause of RRP was not known.
Papillomas may develop anywhere in the respiratory tract, from the nose to the lung; however, 95% of cases involve the larynx. The sites of the respiratory system involvement have been described more completely for JORRP; 52% of children have only laryngeal involvement. The trachea is the next most commonly involved site. However, 31.8% of children had papillomas in areas outside of the trachea and larynx (e.g., oropharynx, nasopharynx, mouth, bronchi, and lung parenchyma). In our case bronchus was involved, which was a rare presentation.
Treatment usually involves repeated debulking of the warty growths by angiolytic laser or micro-debridement coupled with intralesional cidofovir therapy in patients with moderate or severe disease. ,,,, Although surgical management remains the mainstay therapy for RRP, some form of adjuvant therapy may be needed in up to 20% of cases.  The most widely accepted indications for adjuvant therapy are a need for more than four surgical procedures per year, rapid regrowth of papillomata with airway compromise, or distal multisite spread of disease.  Adjuvant therapies include photodynamic therapy, indole 3-carbinol, ribavarin, acyclovir, retinoid and interferon treatment appears to slow the rate of growth without curing the disease. ,,,,,,,
Endoscopic ablation by LASER is the best treatment. The use of micro-debridement using angled oscillating blades that incorporate suction and irrigation or the use of pulsed dye laser is now the preferred resection method at many centers. 
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[Figure 1], [Figure 2], [Figure 3]