Removal of foreign bodies (FB) is by far the most common procedural challenge for the bronchoscopist. The US Centers for Disease Control (CDC) report almost 200,000 accidents per year resulting in nonfatal injury from foreign body aspiration in children less than 10 years of age [19]. These numbers may be even larger in other parts of the world, with a recent report from Algeria, where the authors state: “Foreign body aspiration is a real public health problem in Algeria” [20].

The decision about the need for intervention for suspected FB was addressed in a retrospective study of 160 children [21] aimed at exploring the best clinical and radiological predictors for finding a FB via bronchoscopy. Foreign body aspiration (FBA) was proven bronchoscopically in 122 (76 %). In multivariate analyses independent predictors of FBA were focal hyperinflation on chest radiograph, witnessed choking, and white blood cell count greater than 10,000/mL. Once there is suspicion of FBA, Martinot [22] proposed a management algorithm to assist in the decision between flexible versus rigid bronchoscopy based on the experience with 83 children. The authors propose rigid bronchoscopy to be performed first in case of asphyxia, a radiopaque FB, or association of unilaterally decreased breath sounds and obstructive emphysema. In any other case, flexible bronchoscopy is to be performed first for diagnostic purposes. They comment that if the algorithm was applied retrospectively to the 83 children in their study, it would have decreased the negative first rigid bronchoscopy rate to 4 %. They concluded that flexible bronchoscopy was a safe and cost-saving diagnostic procedure in children with suspected FB aspiration.

Rigid rather than flexible bronchoscopy has been advocated as the preferred instrument for extraction of foreign bodies since the early days of pediatric bronchoscopy [23] and continues to be the predominant practice [20]. Age appears to be a factor in decision-making. To this end, a study involving 102 infants (mean age 10.5 months, the youngest being 2 months old) with FBA, rigid bronchoscopy was used exclusively with a high success rate [24].

While the value of flexible bronchoscopy, as pointed out by Martinot et al. [22] is now widely accepted, the conventional teaching on extraction of aspirated FB points to the primacy of rigid over flexible bronchoscopy for such procedures because of its obvious advantages for visualization and instrumentation. It is conceivable, however, that this ongoing preference that emerges in literature is colored by fear of litigation if not abiding by “conventional” practice. This may create a distorted impression of limited value for flexible bronchoscopy. For the purist amongst the readers a “Cochranian” settlement of the question cannot emerge from literature that lacks any attempt for a controlled approach, neither is it likely that such evidence will emerge. The following segment attempts to provide experience on the role of flexible bronchoscopy for FBA.

Successful use of flexible bronchoscopy for extraction of FB has emerged over time, and some authors prefer flexible scopes for FBA. In a review of the Mayo Clinic Pediatric experience (1990–2001) [25] the authors preferentially used flexible bronchoscopy for extraction of FB in children. In their experience the procedure was successful and safe in children who underwent the procedure. The authors advise however that provisions be made to secure immediate rigid bronchoscope availability should the flexible bronchoscopic procedure be unsuccessful. Encouraged by previous reports of success and motivated by local circumstances or availability of relative expertise in flexible bronchoscopy, another publication [26] espoused flexible bronchoscopy for FBA. While this recommendation may be appropriate for some environments, our own experience is that we do not perform flexible bronchoscopy for suspected FB until immediate availability of rigid bronchoscopy is secured, along the lines of Swanson et al. [25].

A valid, and likely incontrovertible indication for preference of flexible over rigid bronchoscopy is FB that is lodged distally, beyond the reach of the rigid bronchoscope. Such conditions clearly justify an attempt of extraction with the more maneuverable flexible scope, yet may pose unique challenges as a result of angulation and depth of penetration into the bronchial tree with ever decreasing bronchial diameters as more distal branches are involved. Figure 3.2 depicts successful forceps extraction of a pin from a distal airway via flexible scope.

An important complicating factor can be posed by a FB that is imbedded in the surrounding tissue, often a granulation reaction, rendering the object invisible. Such circumstances may lead to surgical intervention and resection of the involved segment. Two reports however address such conditions with the use of interim procedures or techniques in an attempt to loosen the embedded foreign body, in both cases an aspirated tooth, followed by successful extraction by using urologic baskets, balloon catheters or by forceps [27, 28]. These techniques included the use of topical and parenteral steroids and the use of argon plasma coagulation. The authors did not comment on late outcomes or complications of the interim procedures. The comment to make however is that these reports potentially understate the risk of dislodgement of the FB, which is often the argument cited to act with minimal delay when suspected.

With peripheral location of the FB or with bronchial lumina that are narrow in pediatric patients, visual limitation can complicate use of the flexible scope and instrumentation for extraction of a distal FB. This occurs when forceps passed through the working channel obstructs the field of vision within the narrow bronchus. Two studies describe the use of fluoroscopy [29] and image intensifier [30] to guide the grasping forceps for extraction of FB embedded in tissue past direct vision.

A detailed discussion on the sedation/anesthesia elements of flexible bronchoscopy is beyond the scope of this chapter. We will limit the comments on the topic to state that diagnostic procedures are mostly done through a nasal route, and recently often via laryngeal mask airway (LMA). A study of 1,947 procedures spanning the years 1988–2003 preferred use of LMA for flexible bronchoscopy in children 2 years of age and older, and complication rates were lower with the LMA (1.9 %) compared to the nasal route (3.5 %) [31].

In the context of this segment on FBA, while LMA is unlikely to be the choice approach when FBA is suspected, its use was reported in five cases in which FB was an incidental finding during a routine procedure and removed without difficulty and without the need to switch from the LMA to the conventional endotracheal tube [32].

Cast or plastic bronchitis is a disorder characterized by formation of tenacious casts within the tracheobronchial tree. Spontaneously coughed up casts can draw attention to this uncommon condition. The distribution can be patchy or involving central segments of the airways when casts assume the shape of bronchial branching. Severe and sometimes life threatening obstruction can result. A comprehensive review of the topic is offered by Madsen et al. [33]. The underlying mechanisms involved in formation of casts are varied and overall not well understood; however, children with asthma who have particularly tenacious secretions may be affected and often improve with aggressive asthma therapies. At risk, albeit uncommonly, are children with various congenital heart disease, and in particular those who undergo Fontan procedures. A variety of therapies, all anecdotal, have been suggested for the cardiac-related conditions. It has been claimed that Bronchoscopy for removal of casts that obstruct large airways can be lifesaving but our experience has often found it difficult and extremely time-consuming due to the gelatinous consistency of the deposited material that renders suctioning, lavage, or removal by forceps difficult or unsuccessful.

Pulmonary Alveolar Proteinosis (PAP) is a rare pediatric disorder consisting of accumulation of phospholipid-proteinaceous material in the alveoli. Primary variety generally presents in infancy and early childhood and the acquired variety manifests in the older age groups. The underlying pathology is related to abnormal surfactant homeostasis and predominantly to defects in GM-CSF signaling. Shah et al. [34] and Mallory [35] comprehensively reviewed the topic. High resolution chest computerized tomographic scans (HRCT) with “crazy paving” patterns and flexible bronchoscopy with bronchoalveolar lavage are typically the key to the diagnosis when it yields milky fluid from affected segments with the extracellular substance staining with PAS [36]. The cytology is dominated by foamy macrophages [34, 35]. The most commonly considered procedure for a therapeutic intervention for PAP is a whole lung which is both challenging and time consuming. There are a number of approaches to the placement of the endotracheal tube (ETT) and isolation of the lung that is to be lavaged [37, 38]; The role of bronchoscopy is to secure the placement of the ETT and positioning of the balloon to prevent overflow of fluid into the ventilating lung. In essence a balloon catheter is placed in one main bronchus to seal off the entire lung that is to be lavaged with large amounts of saline, while ventilation is entirely dependent on the contralateral bronchus and lung. In exceptional cases where whole lung lavage is not feasible, a more arduous approach is that of direct segmental or subsegmental BAL [39, 40].

An extension of the concept of lung lavage was reported by Ciravegna et al. [41], in a case of an 8-year-old diagnosed with exogenous lipoid pneumonia due to aspiration of mineral oil that was administered for constipation. The diagnosis was supported by CT scan and BAL fluid (BALF) that was milky-appearing, yielding a high number of lipid-laden alveolar macrophages, as well as diffuse, free droplets of oil between alveolar cells on histology. Lung lavage was performed in the affected segments resulting in rapid clinical and radiologic improvement. A broader experience for the same diagnosis was reported in a study of 10 children with lipoid pneumonia secondary to mineral oil aspiration [42]. The authors took a stepwise BAL approach, which resulted in overall favorable outcomes.

Sand aspiration to the lung in a 3-year-old with near-drowning was reported [43]. BAL was done when the child continued to have persistent wheezing and high ventilatory requirement and sand was detected in the BALF. Sequential lung washing followed by exogenous surfactant led to rapid improvement and subsequent recovery in PFTs. In a reported case of accidental instillation of activated charcoal into the lung by a misplaced gastric tube [44], an attempt was made to lavage the charcoal from the lung. While charcoal particles were observed in the BALF, the therapeutic effect could not be assessed since the case was complicated by severe pleural involvement.