Retrieval of Dental Foreign Bodies via Bronchoscopy During Extracorporeal Membrane Oxygenation in a 9-Year-Old Boy

Introduction

Extracorporeal membrane oxygenation (ECMO) is an advanced extracorporeal life support modality for severe, reversible cardiac and respiratory failure refractory to conventional therapies. It diverts venous blood through an extracorporeal circuit with a centrifugal pump and membrane oxygenator, which oxygenates blood, removes carbon dioxide, and maintains perfusion [1].

ECMO has 2 primary modes: venovenous (VV-ECMO) for respiratory support alone, and venoarterial (VA-ECMO) for combined respiratory and circulatory support. It temporarily replaces heart and lung function to allow organ recovery or definitive therapy and is used in critical care for conditions such as severe acute respiratory distress syndrome (ARDS), refractory cardiogenic shock, or post-cardiac arrest syndrome, when conventional ventilation or inotropic support fails [2,3].

Pediatric falls from heights are a critical global public health issue affecting children and adolescents [4]. Key risks include environmental hazards, such as unsecured windows and balconies, developmental vulnerabilities, such as poor impulse control in preschoolers and risk-taking or suicidal behaviors in adolescents, and inadequate supervision [5]. Injuries primarily involve multisystem trauma, with craniocerebral injuries as the leading cause of mortality, including intracranial hemorrhage and skull fractures, concurrent thoracic and limb fractures, and complications such as hemorrhagic shock, ARDS, and sepsis [6]. Therapeutic challenges include hemodynamic instability, neurocritical needs, and delayed care in resource-limited settings. Prevention involves environmental modification, behavioral interventions, and policy advocacy. Global disparities persist, with developing nations facing higher incidence and mortality due to limited trauma resources, highlighting the need for integrated solutions [7].

We present a case of a 9-year-old boy who sustained a fall from the seventh floor, in whom dental foreign bodies were identified in the lungs. These foreign bodies were successfully retrieved via flexible bronchoscopy (FB) under ECMO support.

Case Report

Following a family altercation, a 9-year-old boy fell from the seventh floor; he was partially buffered by a canopy during the fall. On initial presentation, he had immediate loss of consciousness, no response to verbal stimuli, altered mental status, absent purposeful limb movements, Kussmaul respirations, concurrent otorrhagia, and epistaxis. Emergency medical services transported him to a local hospital, where head and cervical spine computed tomography (CT) showed multiple fractures and high-attenuation nodular opacities in the right main bronchus and right lower lobe bronchus. Local hospital interventions consisted of endotracheal intubation, norepinephrine infusion, intravenous etamsylate, and tetanus prophylaxis. Despite these measures, his oxygenation remained refractory, prompting transfer to our institution. Emergency non-contrast head, neck, and chest CT at our center confirmed multiple fractures and identified high-attenuation opacities in the right middle bronchus (including its superior segment) and left lower lung (Figure 1A, 1B).

On physical examination, vital signs were temperature 38.3°C, heart rate 138 beats per minute, respiratory rate 21 breaths per minute, and blood pressure 121/51 mmHg. Pulse oximetry was 95% under mechanical ventilation via endotracheal tube. The Glasgow Coma Scale score was 3 (E1V1M1). Bilateral pupils were equal, round, and 1.5 mm in diameter, with absent light reflexes. Left zygomatic arch swelling was present, accompanied by multiple facial abrasions. Epistaxis and mandibular irregular contusions were noted. Bilateral breath sounds were coarse, with diminished air entry over the right lung. No rhonchi or rales were auscultated. Cardiac rhythm was regular, without murmurs. The abdomen was soft and flat, with no palpable masses. Assessment of abdominal tenderness and rebound was limited due to the patient’s unresponsiveness. Multiple contusions were observed on the extremities, anterior chest, and abdomen. The right upper arm had deformity, with no other limb deformities. Limb tone was normal, while muscle strength testing was not feasible due to the lack of cooperation. Extremities were cool, with a capillary refill time of 3 seconds.

The intensivist in the surgical intensive care unit promptly initiated a multidisciplinary consultation involving departments of heart failure and circulatory support, respiratory medicine, neurosurgery, thoracic surgery, and anesthesiology. The recommendations of physicians from each specialty are detailed in Table 1.

Prior to ECMO initiation, despite maximal conventional ventilatory support (fraction of inspired oxygen 100%, positive end-expiratory pressure 15 cmH2O, tidal volume 6 mL/kg), the patient demonstrated refractory hypoxemia with a PaO2/FiO2 ratio of only 84 mmHg, meeting diagnostic criteria for severe ARDS. Multiple recruitment maneuvers and neuromuscular blockade failed to improve oxygenation status. Echocardiographic assessment revealed reduced left ventricular ejection fraction (40%) and evidence of pulmonary hypertension (estimated right ventricular systolic pressure 55 mmHg). These findings clearly indicated the need for urgent ECMO initiation to manage progressive cardiopulmonary failure, a decision independent of the planned FB.

After communication with the family, emergency procedures were performed. VA-ECMO was selected for this patient due to the presence of transient hypotension with a nadir blood pressure of 85/45 mmHg that required vasopressor support with norepinephrine at 0.5 μg/kg/min, echocardiographic evidence of myocardial dysfunction characterized by a left ventricular ejection fraction of 40%, and suspected pulmonary hypertension, with an estimated right ventricular systolic pressure of 55 mmHg. These combined findings indicated the need for both respiratory and circulatory support, which justified the choice of VA-ECMO rather than VV-ECMO.

Given that the patient was a pediatric polytrauma case with a high risk of secondary hemorrhage, we implemented a modified anticoagulation strategy by administering only 10 mg of heparin to the ECMO circuit with heparin-bonded cannulae instead of using standard systemic heparinization at 100 U/kg. This approach aimed to balance the risk of circuit thrombosis against the risk of bleeding complications. During ECMO support, we monitored activated clotting time (target range, 180–220 s), circuit pressures (maintaining arterial line pressure below 300 mm Hg), visual inspection for thrombus formation, and clinical signs of bleeding. No thrombotic complications or significant bleeding events were observed during the procedure. The hemodynamic parameters measured before and after ECMO initiation are summarized as follows: heart rate was 119 beats per minute and 122 beats per minute, respectively, arterial oxygen saturation was 98.8% and 99.3%, respectively, pulse oxygen saturation was 95% and 96%, respectively, partial pressure of arterial oxygen was 168 mmHg and 228 mmHg, respectively, and serum bicarbonate was 22.8 mmol/L and 22.1 mmol/L, respectively. The ECMO cannulae were equipped with a heparin-bonded coating. For cannulation, the right internal jugular vein was used for venous access, and the right common carotid artery was used for arterial access.

After successful ECMO setup, endoscopy was performed through the endotracheal tube, revealing white reflective objects in the right upper lobe and left lower lobe (Figure 2A, 2D). Initial attempts with FB successfully retrieved a small tooth fragment from the right upper lobe using a foreign body basket, as shown in Figure 2B and 2C. However, the larger intact tooth in the left lower lobe proved challenging because of its size and shape. After 3 unsuccessful attempts with FB using various instruments, including forceps, nets, and baskets, we transitioned to rigid bronchoscopy, based on failure to extract the object after multiple FB attempts, the risk of fragmenting the foreign body with continued FB manipulation, and the need for better airway control during extraction of the large object. Repeated attempts with large foreign body forceps, nets, and foreign body baskets were made, and finally, an entire tooth (left maxillary first permanent molar) was successfully retrieved from the left lower lobe (Figure 2E–2I). As identified by the stomatologist, the maxillary left first permanent incisor and another dental fragment were successfully retrieved (Figure 3).

After the operation, reintubation was performed, and ECMO was weaned off. The child’s vital signs were stable, and subsequent treatment was continued. On the second postoperative day, a repeated bedside FB was performed, revealing abundant white secretions in all bronchial lumens, which decreased after thorough lavage. Bedside chest radiograph on the second postoperative day revealed no obvious signs of residual foreign bodies in both lungs (Figure 1C).

Discussion

The successful retrieval of intrabronchial dental foreign bodies in this critically ill pediatric patient highlights the critical role of ECMO in facilitating high-risk interventional procedures amid hemodynamic instability. ECMO served as a physiologic support platform enabling the FB intervention, rather than directly contributing to resolution of the airway obstruction. This distinction is important to avoid conceptual overreach regarding ECMO’s therapeutic role.

For this child with refractory hypoxemia unresponsive to conventional ventilation, ECMO delivered robust cardiorespiratory support, sustaining adequate oxygenation and perfusion throughout the FB intervention. This stability was pivotal since manipulating airway foreign bodies, particularly rigid, irregularly shaped objects like teeth, inherently risks transient airway obstruction or further injury, which could have been fatal without such life-sustaining support. While ECMO-facilitated bronchoscopy has been reported previously [8], our case presents several incremental contributions including successful management of a pediatric polytrauma patient with multiple injuries, retrieval of an intact permanent tooth rather than just fragments, and implementation of a modified minimal anticoagulation strategy tailored to the trauma setting. These elements distinguish our case from prior reports and provide additional evidence for the feasibility of this approach in complex clinical scenarios.

ECMO is an advanced cardiorespiratory life-support modality for pediatric patients with severe, reversible cardiac/respiratory failure refractory to optimal conventional therapy. It temporarily replaces or augments pulmonary gas exchange and systemic circulation. Blood is diverted from the patient’s circulation and oxygenated, and carbon dioxide is cleared via an artificial membrane lung, then returned to the body to maintain adequate tissue oxygenation and hemodynamic stability, thus bridging the critical period for organ recovery or definitive intervention [9]. In pediatrics, ECMO is indicated for life-threatening conditions including neonatal respiratory distress syndrome, meconium aspiration syndrome, congenital diaphragmatic hernia, fulminant myocarditis, post-cardiotomy low cardiac output syndrome, and refractory cardiac arrest [10]. Its use requires meticulous patient selection, multidisciplinary collaboration, and careful management of complications, critical given pediatric patients’ unique physiological vulnerabilities [11]. Notably, ECMO serves not only as rescue therapy but also a platform for definitive interventions in unstable patients, expanding the therapeutic window for intractable pediatric cardiorespiratory crises [12].

FB for retrieving hard, elongated foreign bodies, such as intact teeth, poses unique challenges, particularly in pediatric airways. With irregular anatomy and potential impaction in bronchial lumens, dental foreign bodies raise the risk of mucosal laceration, bleeding, or fragment dislodgment into distal airways. In the present case, repeated manipulation with forceps, baskets, and nets, compounded by the small caliber of pediatric bronchi, underscored the technical complexity of retrieving large, rigid foreign bodies. ECMO mitigated these risks by withstanding transient hypoxemia or hemodynamic fluctuations during instrument manipulation, enabling the team to prioritize complete, safe retrieval without compromising the patient’s stability [8]. It is noteworthy that the location of the foreign body identified by FB did not completely align with that on chest CT, which may be attributed to positional changes of the foreign body caused by the child’s movement during transport for external examinations. This indirectly confirms that FB-guided exploration and retrieval of the foreign body represent the gold standard for foreign body diagnosis. However, in recent years, artificial intelligence has developed rapidly. In pediatric cases of airway foreign bodies, artificial intelligence can be clinically leveraged to assess whether FB is necessary. After all, FB is an invasive procedure [13].

Beyond the acute intervention, this case highlights the critical need for targeted family education and focused attention to pediatric mental health in preventing such traumatic incidents [14]. Pediatric falls from heights often stem from inadequate supervision or environmental hazards (eg, unsecured windows), underscoring the value of caregiver education on home safety measures. Additionally, the precipitating event of a family conflict prior to the fall emphasizes the need to attend to children’s emotional and behavioral health, as impulsive actions during distress can result in severe injury. Integrating mental health screening and family counseling into post-trauma care can help identify underlying vulnerabilities and reduce recurrence risk [15,16].

Conclusions

This case shows ECMO can be a life-sustaining platform for removing life-threatening intrabronchial dental foreign bodies via FB in hemodynamically unstable pediatric patients. This approach is for exceptional life-threatening situations precluding safe conventional airway intervention. Although this case does not set definitive indications or protocols for ECMO-facilitated bronchoscopy, it supports ECMO as a procedural bridge in select pediatric airway emergencies. Successful outcomes emphasize multidisciplinary collaboration, strict patient selection, and individualized management for future similar cases.