Retrieving difficult aspirated pen caps by balloon catheter with short working-length flexible endoscopy and noninvasive ventilation support in intensive care unit.

OBJECTIVES: Aspirated pen cap (APC) is a clinical challenging issue in children because of the difficulty in both making diagnosis and performing extraction. In case of failed retrieval by rigid endoscopy (RE), more invasive surgical approaches are recommended. The objective of this study is to introduce a new retrieval technique of APC by using laser and balloon catheter (BC) guided with flexible endoscopy (FE) and supported by a novel non-invasive ventilation (NIV) in the intensive care unit (ICU) setting. METHODS: We retrospectively review the charts and FE video records of our pediatric cases with the diagnosis of APC in the past decade, 2004-2014. RESULTS: Four consecutive cases with bronchial APC which had failed extraction with RE were transferred to our hospital. All of them were under procedural sedation, topical anesthesia, NIV support and ICU monitoring. After FE confirmed the diagnosis and location, a BC parallel to the endoscope was manipulated to pass through the cap hole of the APC. Two APCs required laser pretreatment before retrieval: one debulked the entrenched granulation whereas another enlarged the size of cap hole. Guide wires also were required in three cases to assist the BC to pass through the cap hole. All four APCs were successfully retrieved on their first attempts with no significant complications. CONCLUSIONS: FE assisted by laser, guide wire and BC, with this NIV support and ICU monitoring is a feasible, safe and effective modality for retrieving those difficult bronchial APCs in pediatric cases.

Life-threatening anaphylactic reaction after the administration of airway topical lidocaine.

A 9-year-old boy who developed a life-threatening anaphylaxis reaction of the airway and subsequent dyspnea and circulation collapse because of instilled the topical lidocaine into the airway within 2 min before performing flexible bronchoscopy (FB). FB revealed swollen airway mucosa and extensive foamy secretion that severely compromised the ventilation lumen. Rapid detection with FB and immediate resuscitation, including prompt administration of epinephrine, volume expander, and positive pressure ventilation with pure oxygen via an endotracheal tube, were successfully save the patient's life.

Tracheal foreign body after laser supraglottoplasty: a hidden but risky complication of an aluminum foil tape-wrapped endotracheal tube.

Wrapping of the endotracheal tube with aluminum foil tape can prevent laser-beam-induced ignition of the tube during laryngoplasty. However, this modified endotracheal tube may pose complications. Two newborn infants had a portion of the foil tape trapped in their trachea after extubation from laser supraglottoplasty. One infant was totally asymptomatic. The other infant's symptoms were masked by the concurrent tracheomalacia. Both residual tapes were radiolucent on chest radiographs. Flexible endoscopy was the suitable and safe modality for an accurate diagnosis and immediate retrieval of the residual tapes in one session.