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Published on: July 19, 2024
Rigid-Flexible Bronchoscopy With Holmium Laser Cauterization for Pine Nut Shell Removal and Balloon Dilation for
Danli Wang1,2, Feizhou Zhang1,2,3, Nan Zhang2,4
1Department of Pulmonology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
Insights
Foreign body aspiration (FBA) in children requires prompt diagnosis and management. Combined rigid-flexible bronchoscopy and holmium laser fragmentation effectively removed a challenging pine nut shell, preventing further complications.
Area of Science:
- Pediatric Pulmonology
- Interventional Bronchoscopy
- Emergency Medicine
Background:
- Foreign body aspiration (FBA) is a critical pediatric emergency, particularly in toddlers, often caused by food or small objects.
- Delayed diagnosis of FBA can lead to severe respiratory complications, including pneumonia, atelectasis, and airway stenosis.
- Symptoms of FBA vary but can include cough, dyspnea, wheezing, and respiratory failure.
Purpose of the Study:
- To report a case of successful foreign body removal in a pediatric patient.
- To highlight the efficacy of combined rigid-flexible bronchoscopy for challenging FBA cases.
- To demonstrate the utility of holmium laser fragmentation and balloon dilation for post-FBA stenosis.
Main Methods:
- A 16-month-old girl with suspected FBA underwent chest CT, revealing a pine nut shell in the right lower lobe.
- Combined rigid-flexible bronchoscopy was performed, utilizing holmium laser to fragment the foreign body.
- Sequential balloon dilation was employed to manage post-procedural airway stenosis.
Main Results:
- The pine nut shell was successfully fragmented and removed using the combined bronchoscopy technique.
- Post-removal, the patient developed B9/B10 bronchial stenosis, which significantly improved after balloon dilation.
- The patient's respiratory symptoms resolved, and ventilation was restored.
Conclusions:
- Combined rigid-flexible bronchoscopy offers a synergistic approach for removing large, rigid foreign bodies in sub-main bronchi.
- Holmium laser fragmentation is a safe and effective method for disintegrating hard foreign bodies with minimal airway trauma.
- Sequential balloon dilation is a viable treatment for post-FBA bronchial stenosis, optimizing pediatric FBA outcomes.
Abstract:
BACKGROUND Foreign body aspiration (FBA) is a life-threatening pediatric emergency, most common in 1-3-year-olds due to immature swallowing reflexes and exploratory oral behaviors. Common aspirated items include nuts, food particles and small toys, presenting with variable symptoms such as cough, dyspnea, wheezing or acute respiratory failure. Delayed diagnosis or improper management causes severe complications like post-obstructive pneumonia, atelectasis, bronchiectasis and irreversible airway stenosis, increasing morbidity and treatment complexity. CASE REPORT A 16-month-old girl was admitted with persistent cough, progressive dyspnea, intermittent fever, hoarseness, and occasional cyanosis that developed 6 days after accidental pine nut ingestion. Initial flexible bronchoscopy at a local hospital failed due to the foreign body's rigid texture and deep impaction in the right lower lobe basilar bronchus. Chest CT confirmed a pine nut shell in the B9/B10 segmental bronchus with surrounding inflammation. She was transferred for combined rigid-flexible bronchoscopy to establish a secure airway and enable precise visualization before holmium laser fragmentation broke the shell into retrievable fragments for complete removal. Two-week follow-up showed symptomatic B9/B10 stenosis, which improved significantly after sequential 3.5 mm and 4.0 mm balloon dilation. Her respiratory symptoms resolved and imaging confirmed restored lobar ventilation. CONCLUSIONS Rigid-flexible bronchoscopy synergy benefits removal of large rigid foreign bodies in sub-main bronchi by combining rigid bronchoscopy's airway security with flexible bronchoscopy's maneuverability and visualization. Holmium laser safely fragments hard foreign bodies with minimal airway trauma, and sequential balloon dilation effectively treats post-FBA stenosis. Individualized application guided by clinical assessment and imaging optimizes pediatric FBA outcomes.
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