Indian Pediatrics 2003; 40:761-765 

This study was undertaken to evaluate the merits and demerits of pediatric bronchoscopy with or without the use of Hopkins telescope in 60 pediatric patients at the Otolaryngology clinic of tertiary level teaching hospital. Group-I comprised of 30 children who underwent a non-telescopic procedure, while Group-II included another 30 who went through a telescopic-guided removal using standard forceps. It was observed that due to better illumination, higher optical resolution and magnification owing to the use of the telescope, foreign body removal using this technique was completed with minimal complications. The precision in foreign body removal using telescopic-guided procedure in Group-II cases was immense though the operative time in comparison to the non-telescopic one was found to be statistically higher (P = 0.0019). This group also had a shorter hospital stay. The use of standard forceps in place of optical forceps gave an easier maneuverability through small-sized pediatric bronchoscopes, thereby giving an edge over the latter.

Key words: Foreign body removal, Rigid-bronchoscopy, Telescopic-guided.

The management protocol for broncho-scopic foreign body extrication has undergone tremendous change with the advent of better optical systems and intense cold light source. The introduction of Hopkins telescope in the late 1960s(l) added a touch of finesse to the operative procedure, dramatically enhancing its therapeutic efficacy. Over the past few decades, a few studies have been conducted evaluating the merits and demerits of the non-telescopic and the telescopic-aided proce-dures(2,3). This study attempts to compare the merits and demerits of telescopic- guided standard forceps over non-telescopic bron-choscopy for foreign body removal in our set up.

Subjects and Methods

This comparative study was conducted on 60 children (<12years of age) who under- went bronchoscopy for removal of suspected foreign body at the Otolaryngology department of Lady Hardinge Medical College and associated hospitals. Group-I comprised of 30 children who underwent non-telescopic foreign body removal before the hospital could acquire telescopes. Group-II comprised of another 30 pediatric patients who underwent a telescopic-guided broncho-scopic removal, using the standard forceps. The latter group was operated upon between May 1998 and March 1999. Both the groups included in this study were operated upon by the same surgeon (NNM).

All patients were evaluated either as emergency or outpatient department (OPD) cases. A detailed history of the patient was elicited from the parents. The factors assessed included time of aspiration and the type of foreign body ingested, history of subsequent cough and respiratory distress, history of fever with or without an associated history of noisy breathing (stridor), cyanotic spells or loss of consciousness. A thorough general physical examination and a proper systemic evaluation of the patients was carried out subsequently. Chest X-rays in full inspiratory and expiratory phases, wherever possible, were obtained. A high-risk consent for bronchoscopy and tracheostomy was taken prior to the procedure. Following a detailed questionnaire and a thorough evaluation of the 60 pediatric patients, the study parameters were compara-tively analysed. The parameters used to evaluate each exercise included the number of attempts at introduction of forceps, broncho-scopic insertions and telescopic insertions. The forceps were not successful at extricating the foreign body on every attempt. The study records the number of times a foreign body slipped out of the grasp of forceps. It also records the abrasions to the mucosa and whether the subsequent bleeding was controllable. The operative time required for the two groups, the complications encountered and their percentages, the number of check bronchoscopies in either category, the duration of the hospital stay post-operatively and finally, the percentage of mortality and morbidity were the other important parameters recorded.

The equipment used for the procedure included laryngoscopes, Karl Storz rigid ventilating bronchoscopes in the sizes 2.5, 3.0, 3.7 and 5.0 and a Hopkins telescope with a diameter of 2.9 mm and a length of 36 cm, a cold halogen light source, fibre-optic cable, suction-tips; besides standard forceps of various sizes and shapes were the other essential requisites for the procedure. Optical forceps were not used during the study

The technique used for telescopic bronchoscopy was similar to the non-telescopic procedure. Following the intro-duction of the bronchoscope and visualization of the bronchial segments, the Hopkins telescope was introduced to visualize the main and segmental bronchi. With 2.5 mm and 3.0 mm bronchoscopes, it was not possible to introduce both the telescope and forceps at the same time. In such a situation, the telescope and forceps were used alternately. Telescopic photography was simultaneously conducted for the study with the help of a Ricoh camera using a 400 ASA colour roll. The end of the telescope was adjusted to a distance of 2.2 cm from the resolution target to obtain good - quality photographs. Student’s t-test was used to evaluate the differences between means in the two groups.

Results

The patient sample group comprised primarily of children between 0-3 years with a male: female ratio of 3:1. The various clinical manifestations were in the form of respiratory distress (95%), cough (91.7%), fever (50%), cyanosis (55%) and stridor (53.3%). The maximum duration for which the aspirated foreign body was found was three months, while the least was 3 hours. In the non-telescopic group, the time elapsed between inhalation and intervention of foreign body ranged from 3 hours to 45 days (median = 2 days). In the telescopic group, this range was 4 hours to 90 days (median=3 days). However, for 8 patients in the non-telescopic group and 6 patients in the telescopic group, the time period of inhalation could not be ascertained despite clinical suspicion since the foreign body was there for an unknown period of time. This time interval between inhalation and extrication was almost similar in two groups and did not influence results between two groups. In the radiological evaluation, a normal pre-operative radiological picture was observed in 63.3% of the cases. In 16.7% of cases, hyper-inflated lung fields were seen, 15.0% had collapse consolidation and 5.0% had pneumonitis. The various organic foreign bodies extricated in the two groups are shown in Table I.

TABLE I
Characteristics of Bronchial Foreign Bodies

	Group-I (n = 30)	Group-II (n = 30)
Peanuts	13(43.3)	20(66.7)
Gram seeds	3(10.0)	3(10.0)
Tamarind	2(6.7)	2(6.7)
Almonds	3(10.0)	0
Soya bean	3(10.0)	0
Whistles	0	1(3.3)
Plastic toys	1(3.3)	0
Brick pieces	1(3.3)	0
No foreign body	4(13.3)	4(13.3)

Figures in parentheses indicate percentages.

TABLE II

	Comparison Between Non-Telescopic and Telescopic Bronchoscopy

	Group-I (n = 30)	Group-II (n = 30)
Bronchoscopic insertions	40	40
Foreign body drops	30	15
Forceps introduction	75	45
Abrasions	18	15
Check bronchoscopy	6	2
Controlled bleeding	5	1
Uncontrolled bleeding	Nil	Nil
Post-operative stridor	1	1
Mortality	Nil	Nil
Operative time taken	10-35 min	13-45 min
Hospital stay	0-14 days	0-8 days

 

The parameters used to evaluate the operative procedure are depicted in Table II. Mean number of bronchoscopic insertions (1.3 ± 0.9 vs. 1.3 ± 0.8; P >0.05), foreign body drops (1.0 ± 0.4 vs. 0.5 ± 0.5; P = 0.001) and grasping attempts during the foreign body removal (2.5 ± 1.0 vs. 1.5 ± 0.9; P = 0.001) were compared in the two groups. Mean number of mucosal abrasions were 0.6 ± 1.0 and 0.5 ± 0.9 in the two groups respectively (P = 0.69). Controllable bleeding was not different between two groups (0.17 ± 0.5 vs. 0.04 ± 0.2; P = 0.146). The final exercise of evaluation of the two groups included the following parameters: the total operative time taken, the number of check bronchoscopies performed, the complications encountered, the hospital stay, mortality figures and incidence of post-operative stridor. The first parameter dealing with the total operative time taken varied between 10-35 minutes and 13-45 minutes in the non-telescopic group and the telescopic group respectively. Mean operative time for the Group-I was 13.3 ± 4.7 minutes, compared to 20.1 ± 9.0 minutes in Group-II (P = 0.002). Mean number of check bronchoscopies required in the Group-I was 0.2 ± 0.6 vs. 0.07 ± 0.3 in Group-II (P = 0.235).

The major complications encountered in the non-telescopic group were pneumothorax 2(6.7%) and further impaction of the foreign body in 3(10%). In the telescopic category, further impaction of the foreign body owing to the accidental pushing down of the object during the procedure, was recorded in 3(10%).

The non-telescopic group showed a prolonged hospital stay. In this group, 46.7% of the patients were admitted for a period of 0-4 days, 30% had a stay of 4-8 days, 10% stayed for 8-12 days while 13.3% were under observation for more than 12 days. In the telescopic group, however, 86.7% of the patients had a hospital stay of 0-4 days, while the remaining 13.3% were under observation for a period of 4-8 days (P = 0.006).

Discussion

Telescopic bronchoscopy as illustrated in the article scores over the non-telescopic procedure in several ways. It permits complete foreign body removal, thereby lowering the number of check bronchoscopies. A faster recuperation, seen in the telescopic group, helps reduce the post-operative stay. Besides the better surgical results, alternate use of standard forceps and telescope is useful in infants, where the use of optical forceps may not be possible due to its larger diameter. Unlike optical forceps, the axis of standard forceps can be changed to some extent during the procedure, and this is very helpful in few cases. Above all, telescopic bronchoscopy can be used as a good teaching tool for the residents.

The 4.0 mm telescope, which provides an excellent optical resolution, leads to high airway resistance pressures(3,4). In our study, we used the 2.9 mm Hopkins telescope. Though the provision for measurement of airflow pressures and airway resistance was not available in our set-up, our results did not show any complications because of pulmonary pressure changes.

Despite the inherent advantages, tele-scopic bronchoscopies take a longer operative time, as seen from this and a previous(l) study. This is because the precision required to image the object requires spending additional time, the lower end of the endoscopic telescope needs to be placed at a distance of 2.2 cm from the resolution test target for perfect imaging(3). Secondly, secretions and at times, blood, tend to obscure the telescopic end. Therefore, the telescope needs to be withdrawn, cleaned and reinserted. Finally, the endoscopic telescope, being an additional instrument, needs to be maneuvered through the bronchoscope. Despite the additional time taken, the complications that might arise are taken care of by the use of good ventilating bronchoscopes and intensive post-operative monitoring.

Cases in Group-II who underwent repeat bronchoscopy were not due to missed foreign bodies as in Group-I. The need for check bronchoscopy in this category was due to incomplete retrieval of the foreign body pieces because of surrounding mucosal edema obscuring the field. The telescopes otherwise give a close-up wide-angle magnified view of the foreign body. Its greater optical resolution and illumination helps visualize the bronchial segments and foreign bodies with greater accuracy(5).

In our study, we have used standard forceps in place of optical forceps (forceps carried in the sheath attached to the body of the telescope). When the standard forceps are used with the telescope they can be put in different axis thus increasing the maneuverability to extricate the foreign body. This is to some extent more helpful than the use of optical forceps in few cases. The second advantage that standard forceps offer over the optical variety becomes clear when the procedure is being conducted on infants and very small children. Since the diameter of the bronchoscopes used in this group is very small, it does not permit the use of optical forceps. But, with the standard forceps an alternating use of the telescope and the forceps can be performed to extricate the foreign body which otherwise would not have been possible. There is a learning curve involved in this procedure and therefore the results of a new surgeon in this field cannot be compared with an experienced surgeon. Whichever method is used (telescopic or non-telescopic), the complication rate and the outcome of the procedure is largely dependent on the experience of the surgeon rather than the technique used. In our study, both the procedures have shown minimal complica-tions and excellent results, but the removal of foreign body through the telescopic technique was more precise, causing lesser damage to the surrounding soft tissues. The para- mount importance of avoidance of mucosal trauma has been emphasized in an earlier study(6). The lower hospital stay of patients who underwent a telescopic procedure can be attributed to precision in foreign body extrication leading to faster recuperation.

Contributors: NNM and TP designed the study, TP collected data, NNM and TP formulated results and drafted manuscript. NNM performed bronchoscopic removal of foreign bodies on both the groups.

Funding: None.

Competing interests: None stated.

 References

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