Estimated reading time: 7 minutes
This case study discusses a challenging presentation, and the methods used to ultimately successfully remove a tracheal foreign body from Snoop, a four-year-old male neutered Irish wolfhound who presented to High Street Vet Surgery with sudden onset haemoptysis.
Prior to presentation Snoop had been well with no prior health issues, and his history was mostly unremarkable with no known incident triggering this haemoptysis and no reported access to any rodenticides.
On physical examination it was noted that Snoop had some increased upper respiratory tract sounds. He was also observed to be coughing/retching with a marked hacking sound and bringing up large amounts of saliva with frank blood present, including some blood clots up to about 5cm in size.
Full blood work including haematology, biochemistry and clotting times (APPT/PT) was performed with no significant findings. An intravenous catheter was placed to allow venous access as Snoop’s haemoptysis escalated and he started to develop some mild-moderate dyspnoea. The decision was made to take some upper respiratory and thoracic radiographs under intravenous sedation with a full oropharyngeal examination.
A pre-medication was given subcutaneously (0.04mg/kg Acepromazine and 0.3mg/kg Methadone), followed by Propofol given intravenously to affect. At this point a laryngoscope was utilised to complete a full oropharyngeal examination, and almost immediately a foreign body was visible within the tracheal lumen causing intermittent complete obstruction of the airway.
As the patient coughed/breathed, the foreign body could be visualised descending distally down the trachea then ascending proximally towards the arytenoid cartilages. Episodes of increasingly severe dyspnoea were associated with periods of time when the foreign body was at the most proximal edge of the tracheal lumen where it would become stuck behind the arytenoid cartilages and cause complete occlusion of the tracheal lumen.
The owners were contacted and advised that Snoop had a tracheal foreign body that was life-threatening, and permission was sought for further treatment and attempted removal.
The patient was managed with a Propofol total intravenous anaesthetic (TIVA) as he could not be intubated with a tracheal foreign body present. As much as possible the patient was supported with high flow oxygen via mask or fly by.
Initial attempts included the use of large haemostats, allis tissue forceps and bone holders to secure the foreign body when easily visualised at the entrance of the tracheal lumen. However due its size and friable nature and the inability to achieve a firm grip, these methods were not successful.
At this point the foreign body was repeatedly descending the trachea distally where it could no longer be visualised. This was likely due to the intravenous anaesthetic agent depressing the ongoing cough reflex which had been pushing the foreign body proximally up the trachea.
With the foreign body no longer in sight, a non-rigid endoscope was utilised to pinpoint its location. This showed that it was lodged in one of the bifurcations of the bronchi which allowed the patient to stabilise and maintain a SpO2 of 100%.
The biopsy tool was placed down the biopsy channel of the endoscope, and used to grip onto the foreign body and attempt removal. The biopsy tool had a 2mm bite which was the largest bite available for the size of the channel in our scope. This was effective for pulling the foreign body proximally, but the grip would repeatedly fail at the point of pulling it through the arytenoids at the proximal edge of the tracheal lumen.
The team at High Street Veterinary Surgery persevered with repeated attempts trying multiple variations of the above; a large rigid alligator forceps tool placed alongside the scope was trialled, a snare tool was utilised, and the patient was placed in a head-down trajectory with external force applied to the thoracic wall. Despite all of these attempts, the foreign body proved to be incredibly elusive.
Snoop’s owner was kept up to date throughout this time and warned that the patient was extremely unstable and at a high risk of respiratory arrest followed by cardiopulmonary arrest.
After approximately three hours a new technique was attempted where a foley catheter was taped to the scope with the tip of the foley catheter extending approximately 4cm past the end of the scope tip. This was passed down the trachea with the foreign body pulled flush to the scope tip and the foley placed distal to the foreign body. The foley balloon was then inflated with 2CC of saline behind the foreign body.
It is worth noting that the foreign body was hypothesised to be a palm seed. With the possible palm seed secured at the tip of the scope between the biopsy tool grip proximally and the foley balloon distally, the scope was slowly withdrawn, allowing the palm seed to ascend the trachea until becoming lodged at the arytenoids. Firm pressure was utilised but dishearteningly the foley balloon ruptured and the palm seed was once again lost down the trachea into a bronchi branch.
At this point all options were reviewed and discussed with the clinical team, a medicine specialist, as well as the owner. Possible pathways covered were:
1. Try to wedge the palm seed in a branch of the bronchi, recover patient from TIVA and send dog with owners to the closest specialist referral centre. This would involve an eight-hour car journey and the possibility of patient death.
2. Attempt a thoracotomy at High Street Veterinary Surgery.
3. Consider humane euthanasia.
After discussion it was decided one more attempt to remove the foreign body would be made. If this was unsuccessful, Snoop’s owner would choose humane euthanasia.
The final removal attempt utilised the following method:
• A deep plain of general anaesthesia under propofol TIVA to reduce any cough reflex and spasticity of the arytenoid cartilages.
• Two foley catheters were secured to the endoscope tip extending approximately 3-4cm past the scope tip, with associated balloons inflated with 2CC of saline once extended past the palm seed within the tracheal lumen.
• A 2mm biopsy punch tool was used to grip onto the palm seed and pull it in flush to the scope tip to allow the foley catheter balloons to be inflated.
Finally, after four hours, the foreign body was removed and confirmed to be a… palm seed.
Snoop recovered from his TIVA uneventfully, and was given a meloxicam injection at a dose of 0.2mg/kg followed by meloxicam oral once daily at a dose of 0.1mg/kg for 10 days. He was also placed on Amoxyclav 23mg/kg twice daily and Baytril 10mg/kg once daily for 10 days.
The patient was discharged the following morning and on subsequent rechecks was found to have recovered fully with a slight cough that was improving daily.
Dr Kirsty Downing BVSC (Hons)
Clinical director at High Street Veterinary Surgery
Veterinarian Dr Kirsty Downing spent most of her childhood in South Africa. In 2007 her family decided to migrate to Australia.
Due to her love of interacting with animals and supporting the human-animal bond, Dr Downing pursued a veterinary career.
In 2014, Dr Downing graduated from the University of Queensland with a Bachelor of Veterinary Science with Honours.
After spending time in Western NSW and Northern QLD working in mixed animal practices, Dr Downing joined the High Street Veterinary Surgery family in December 2017.
With 10 years of experience, Dr Downing has tackled some major trauma cases including traumatic diaphragmatic tears, extensive de-gloving injuries, traumatic injuries penetrating into abdominal and/or thoracic cavities, prostatic abscesses, GDVs, and those involving the removal of standard intestinal foreign bodies.
