Bronchoscopic Foreign Body Removal

OVERVIEW

Flexible bronchoscopy is first‑line in most adults (>90% success) for airway foreign body removal, while rigid bronchoscopy remains essential for large, sharp, proximal, or asphyxiating objects.

• See Airway Foreign Bodies for causes, pathophysiology, complications, clinical features, investigations, and management overview.

INDICATIONS FOR BRONCHOSCOPY

Flexible bronchoscopy is usually first line for most AFB situations:

• CT shows AFB
• CT negative but suspicion high
• Persistent unexplained respiratory symptoms
• Recurrent same‑lobe infection
• Localised wheeze or obstruction

However, flexible bronchoscopy should not be performed if indications for rigid bronchoscopy are present:

• Asphyxiating FBs
• Large objects (>1.5 cm diameter)
• Sharp objects
• Proximal tracheal/ main bronchial AFB
• Massive bleeding
• Failed flexible bronchoscopy

PRE‑PROCEDURAL PLANNING

Assess:

• the AFB
  • Size
  • Shape
  • Substance
  • Site
• the patient
  • Oxygenation, ventilation
  • Airway anatomy
  • Comorbidities
  • Anaesthesia tolerance (including allergies and airway reactivity)

To inform the following plan:

• Imaging
  • CT is ideal for localisation and assessing granulation, but not always feasible in unstable patients or required in children where radiation exposure is of greater concern 
• Flexible versus Rigid Bronchoscopy
  • Rigid: asphyxiating FBs, large/sharp/impacted objects, need for ventilation control.
  • Flexible: stable patients, distal FBs, diagnostic evaluation.
  • Many cases benefit from combined use (flexible through rigid barrel).
• Primary Airway Device
  • Not required for awake bronchoscopy with topical anaesthesia
  • SGA (LMA): allows oxygenation during flexible bronchoscopy; useful in children.
  • ETT: protects airway but may limit instrument size; often removed for rigid bronchoscopy.
  • Rigid barrel: best for control, ventilation, and tool access.
• Primary and Backup Tools
  • Primary: forceps, baskets, cryoprobe, Fogarty balloon.
  • Backup: electrocautery, suction catheters, secondary forceps sizes.
  • Ensure all tools match the working channel of the chosen scope.
• Backup Airway Plans
  • Which techniques are likely to be effective?
    • FMV (bag‑mask ventilation), SGA insertion, ETT intubation, FONA (front‑of‑neck access) for “can’t intubated, can’t oxygenate” (CICO)
  • Rigid bronchoscopy should always be available when flexible bronchoscopy  is attempted for FB extraction

FLEXIBLE VERSUS RIGID BRONCHOSCOPY

Flexible bronchoscopy advantages

• High success rate (~90%) for FB retrieval
• Excellent for small/ smooth/ peripheral FBs
• Widely available in almost all hospitals
• No need for general anaesthesia in many cases
• Excellent access to distal airways
• Can be used through an ETT or LMA
• Lower desaturation risk during the procedure
• Allows granulation tissue removal and inspection for fragments

Flexible bronchoscopy disadvantages

• Limited airway protection
• Limited bleeding control
• Loss of airway possible during extraction
• Not suitable for some FBs (see below for rigid bronchoscopy indications)
• Does not provide a secure airway (unless intubated and ETT is not removed)
• Limited ability to control major bleeding
• Cannot reliably protect vocal cords from sharp objects
• Smaller working channel means can only use smaller tools
• Risk of losing the object during extraction through the glottis or ETT
• Less safe or effective for large, sharp, or impacted objects

Rigid bronchoscopy advantages

• gold standard for large, sharp, or proximal AFBs
• Provides a stable, protected airway
• Better control of bleeding (tamponade, large suction) – preferred in massive haemorrhage or airway trauma
• Allows use of larger, stronger retrieval tools
• Protects vocal cords when removing sharp objects
• Allows flexible bronchoscope to be used through the barrel

Rigid bronchoscopy disadvantages

• Requires general anaesthesia
• Limited availability (equipment + expertise)
• Cannot reach distal airways
• More technically demanding
• Not suitable in some anatomies (retrognathia, cervical immobilisation)
• Risk of dental or glottic injury

Feature	Flexible Bronchoscopy	Rigid Bronchoscopy
Airway control	Poor – no secure airway	Excellent – stable, protected airway
Anaesthesia	Often no GA required	Requires general anaesthesia
Access	Excellent for distal airways	Limited to central airways
Tool size / strength	Small working channel; smaller tools	Large, strong tools; better grip
Bleeding control	Limited	Excellent (tamponade, large suction)
Sharp object protection	Poor	Excellent – protects vocal cords
Large object removal	Difficult	Ideal
Availability	Widely available	Limited to specialist centres
Operator skill	Moderate	High; specialised training
Use in trauma	Good for distal debris, clots	Best for bleeding, teeth, shrapnel
Risk profile	Loss of airway, object dislodgement	Dental/glottic injury; more invasive
Success rate	~90% for adult FB retrieval	Highest success for complex FBs

RETRIEVAL TOOLS & TECHNIQUES

Figure. Examples of retrieval tools for flexible bronchoscopy, including forceps (e.g. two-prong, alligator, rubber tip), Dormia basket, snare or loop, coagulation forceps, coagulation knife, and probe for cryotherapy. Image from Fang et al (2015), available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4358882/

Tool	Best For	Technique	Notes
Forceps	Metal, bone, dentures, sharp objects	grasp edge → twist/rock → withdraw as single unit	Types: standard biopsy, rat‑tooth, shark‑tooth, alligator, rubber‑tipped
Snare	Large, rigid, irregular objects (broncholiths, dental prostheses)	open loop → abut → angle → tighten → extract	Excellent for bulky or irregular shapes
Basket	Smooth, round objects (peanuts, seeds, beads)	pass beyond → open → cage → tighten → withdraw	Avoid excessive traction to prevent fragmentation
Balloon catheter (Fogarty)	Distal or impacted objects; objects with central lumen	pass beyond → inflate with saline → pull proximally	Useful for dislodgement prior to forceps extraction
Cryoprobe	Semisolid, water‑rich material (blood clots, mucus plugs, food slurry)	freeze to –20°C → ice adhesion → withdraw en bloc	Avoid in active bleeding (risk of mucosal adhesion)

Type of FB matched to tool

• Graspable FB: serrated rigid forceps / rat‑tooth forceps.
• Smooth/rounded FB: basket or fish‑net forceps.
• Organic FB: cryoprobe (“adheres the object to the frozen probe tip”).
• Impacted FB: Fogarty balloon.
• Sharp FB: fine grasping forceps with withdrawal into rigid barrel.
• Granulation‑covered FB: electrocautery debridement.
• Large objects FB: en bloc removal of bronchoscope, forceps, and FB.

CRITICAL CARE SCENARIOS

Common types of FB and typical scenarios encountered in critical care:

Type of FB	Typical Scenario	Best Tool / Approach
Blood clots	Haemorrhage, anticoagulation, post‑procedure bleeding, pulmonary contusion (trauma)	Suction, forceps, cryoprobe
Mucus plugs	Prolonged ventilation, weak cough, dehydration, neuromuscular disease, rib fractures	Suction ± cryo, lavage
Aspirated food or gastric contents	Reduced consciousness, vomiting during intubation, TBI, intoxication	Basket or forceps; flexible bronchoscopy first
Teeth and dental fragments	Facial trauma, difficult intubation, maxillofacial fractures	Forceps; CT localisation helpful
Iatrogenic airway fragments	ETT cuff rupture, suction catheter tips, bite block fragments, bronchoscopy tool failure	Forceps or snare
Tracheostomy‑related debris	Broken inner cannula, valve components, gauze, secretions	Forceps; suction; consider rigid if large
Burn or inhalation injury debris	Soot, sloughed mucosa, fibrin casts in thermal/smoke injury	Suction, lavage, cryo for adherent debris
Penetrating trauma fragments	Bullet/shrapnel fragments, bone splinters, glass	Snare or rigid bronchoscopy
Broncholiths or calcified material	Chronic infection (TB, histoplasmosis), lymph node erosion	Snare or forceps
Large obstructing casts	Plastic bronchitis, inhalation injury, severe inflammation	Cryoextraction or basket

References and Links

LITFL CCC

• Airway foreign bodies

Journal articles

• Chi J, Bai Y. Bronchoscopic management of airway foreign bodies in adults: a narrative educational review. Front Med (Lausanne). 2026 Mar 4;13:1779715. doi: 10.3389/fmed.2026.1779715. PMID: 41859138; PMCID: PMC12996173.
• Fang YF, Hsieh MH, Chung FT, Huang YK, Chen GY, Lin SM, Lin HC, Wang CH, Kuo HP. Flexible bronchoscopy with multiple modalities for foreign body removal in adults. PLoS One. 2015 Mar 13;10(3):e0118993. doi: 10.1371/journal.pone.0118993. PMID: 25768933; PMCID: PMC4358882.
• Goyal R, Sehgal IS, Agarwal R. Foreign body removal. Curr Opin Pulm Med. 2026 Jan 1;32(1):63-73. doi: 10.1097/MCP.0000000000001225. Epub 2025 Oct 10. PMID: 41076577.
• Hewlett JC, Rickman OB, Lentz RJ, Prakash UB, Maldonado F. Foreign body aspiration in adult airways: therapeutic approach. J Thorac Dis. 2017 Sep;9(9):3398-3409. doi: 10.21037/jtd.2017.06.137. PMID: 29221325; PMCID: PMC5708401.