and pills. It is unclear what the best approach to minimize tracheobronchial tree stenosis post-FB retrieval is, however, experimental bronchoalveolar lavage with lidocaine, epinephrine, and dexamethasone has been shown to decrease proin ammatory cytokines [54].

Airway Management

Rigid Vs. Flexible Bronchoscopy

Traditionally, the gold standard method for FB retrieval has been rigid bronchoscopy. This said, the decision to use rigid or exible bronchoscopy depends signifcantly on institutional practices, operator experience, equipment availability, stability of the patient, and size of FB and potential injury it can cause to mucosa or vocal cords while being retrieved. The success rates for rigid bronchoscopy in retrieval of foreign bodies are reported between 95 and 100% [22, 23, 43], compared to exible bronchoscopy which has reported rates of success between 61 and 90% [22, 42, 43, 55]. In our practice, we avoid viewing rigid and exible bronchoscopy as mutually exclusive techniques, but more as valuable complementary tools. Each patient is unique and their clinical presentation should guide the selection of the best method for FB retrieval. Patient safety should always outweigh the bronchoscopist’s personal preference and equipment availability. If rigid bronchoscopy is required for safe retrieval of a FB, then arrangements should be made for this to occur, including the transfer of a patient to a specialized center.

Flexible bronchoscopy has the beneft of not only acting as a diagnostic tool and aid in procedure planning but can also be used for therapeutic FB retrieval with various instruments that can be inserted through the working channel of the bronchoscope. It has the beneft of being able to be performed with moderate sedation. When usingexible bronchoscopy, a therapeutic bronchoscope with a working channel of 2.8–3.2 mm is recommended to allow passage of all available retrieval instruments. The transnasal route should be avoided as the nasal passage may be too nar-

row to allow passage of the retrieved FB with increased risk of losing the FB within these airways. In patients with upper airway/tracheal FBs, stridor, or respiratory failure, rigid bronchoscopy is the preferred tool because of its capability to protect the airway and maintain oxygenation and ventilation. Rigid bronchoscopy also allows the use of various specialty instruments that are designed for FB retrieval. Additionally, rigid bronchoscopy almost always uses a exible bronchoscope through it, allowing many more options. In children, rigid bronchoscopy is almost always recommended as airway size limits ventilation when a exible bronchoscope is used.

Retrieval Procedure

As in any therapeutic procedure, preparation is of the utmost importance prior to onset of procedure. Always ensure that all potential equipment, personnel, and medications are available. Anticipation of complications is the best preventive strategy for such circumstances. Trendelenburg positioning can allow the FB to fall toward main airways if mobilized. When a central airway obstruction (i.e. trachea) is encountered, particularly in an unstable patient, consider distal advancement of the FB to allow for improved ventilation. Many FBs will have induced airway injury or stimulated certain in ammatory pathways. Blood, pus, and other secretions will often cover and/or surround the FB. Clear visualization of the FB is a priority and allows examination of various characteristics of the FB and the airways surrounding it, such as size, proximity to surrounding airways, and whether the FB is free-laying or adherent by granulation tissue and/or adhesions. Also, assess for the presence of surrounding in ammation, blood, and bleeding potential during FB manipulation. Topical epinephrine can be instilled in such circumstances to minimize bleeding.

Retained FBs have a higher potential for the development of associated granulation tissue and may require tissue resection in order to release the FB. Tissue debulking can be achieved mechanically or with ablative therapies (i.e. laser,