Friday, December 15, 2017

Foreign body aspiration - Flexible or rigid bronchoscopy?

Foreign body aspiration (FBA) - Which bronchoscopy should you do? Flexible or rigid?

#TLDR:
Life threatening - Rigid bronchoscopy
Diagnosis not clear - Flexible bronchoscopy

Children - Rigid bronchoscopy
Adults - Flexible bronchoscopy

Mnemonic: childRen thReatening - Rigid bronchoscopy

So first ask - is this a life threatening FBA? Yes - Rigid bronchoscopy (after airway stabilization of course)

Then ask - Is the diagnosis clear? No - Flexible bronchoscopy

If the diagnosis is clear and the FBA is not life threatening - See the age.

If it is a child - Rigid bronchoscopy
If it is an adult - Flexible bronchoscopy

Here's a looooong copy paste explanation from UpToDate:

CHILDREN

Stable patients with a high clinical suspicion of FBA usually should proceed to bronchoscopy, even if the plain radiographs are normal or inconclusive. Alternatively, CT can be performed first to help clarify the diagnosis, if the provider judges that negative imaging would be sufficient to preclude bronchoscopy. Flexible rather than rigid bronchoscopy may be used for diagnostic purposes in cases in which the diagnosis is unclear, or if the FBA is known but the location of the object is unclear.

We suggest rigid rather than flexible bronchoscopy for removal of most aspirated FBs in children (Grade 2C); this procedure should be performed by an experienced operator. Flexible bronchoscopy is also used to remove the FB in some centers with high levels of experience in this technique.

ADULTS

In patients with life-threatening asphyxiation, initial support should be focused on treating airway obstruction and respiratory failure. Once the airway is secured, a laryngoscopic evaluation of the oropharynx should be performed immediately to diagnose and retrieve a supraglottic/glottic foreign body. If a foreign body is not seen, rigid bronchoscopy is generally the procedure of choice when the foreign body is suspected to be in the trachea or major bronchi.

Flexible bronchoscopy is preferred over rigid bronchoscopy in most patients, and especially in those with non-life-threatening, distally-wedged, foreign bodies, as well as in those who are mechanically ventilated, and in those with spine, craniofacial, or skull fractures that prevent the manipulation required for rigid bronchoscopy. Many types of ancillary equipment are available including a variety of forceps including rubber tip, baskets, grasping claws, snares, balloon-tipped catheters, and magnet tip probes.

Rigid bronchoscopy, is preferred for the extraction of large obstructing foreign bodies in the central airways, and for complex foreign bodies that cannot be removed by flexible bronchoscopy. Extraction is typically achieved with forceps.

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