ration. In our experience, iron pill aspiration is notorious for its sequelae of bronchial in ammation and recurrent stenosis which is relatively diffcult to manage.

Iron pill aspiration-related bronchostenosis behaves very similarly to severe autoimmune in ammatory disorders such as granulomatosis with polyangiitis (GPA, formerly known as Wegener’s disease) and sarcoidosis. Bronchostenosis can be severe to the point where lobar/segmental collapse may develop with/without post-obstructive pneumonia. In our practice, we treat iron pill-associated bronchostenosis with balloon bronchoplasty and resection of necrotic tissue. These cases always require surveillance bronchoscopies to assess for recurrent bronchostenosis, which is common, and need for repeat therapeutic interventions. There are case reports of topical mitomycin C, a chemotherapeutic agent, used in conjunction with balloon bronchoplasty and treatment of such bronchostenosis cases [30, 31]. Mitomycin can be applied with a concentration of 0.2 mg/mL to the affected area for a total duration of 5 min. In severe cases of recurrent airway obstruction, an airway stent may be considered. From our experience, iron pill-­ induced bronchostenosis does resolve, but usually requires three to fve interventions.

Follow-Up and Sequelae

Historically, the mortality related to foreign bodies in the nineteenth century was estimated to be 23%; however, this changed profoundly with the advent of bronchoscopy with literature now suggesting mortality in FB aspiration cases seeking medical help to be less than 1% [24, 27, 61, 62]. Over the past century, further advances in medicine, diagnostic and therapeutic bronchoscopy have drastically improved the morbidity and mortality attributed to this condition.

The majority of acute FB retrieval cases with minimal signs of airway injury do not require any subsequent diagnostic interventions (i.e. bronchoscopy, imaging, etc.). Associated mucosal in ammation from FB aspiration is common and is expected to resolve in a majority of cases.

While literature is lacking, we recommend fol- low-­up bronchoscopy in certain circumstances for acute FB cases. When severe airway in ammation, endobronchial obstruction from associated granulation tissue, or stenosis is encountered, it is our practice to perform a follow-up bronchoscopy 4–6 weeks later to assess for resolution or progression of fndings. It is important to recognize that severe in ammation from a relatively acute FB may foreshadow undesired sequelae to occur, similar to other benign in ammatory airway disorders.

Unlike acute FBs, chronic/retained FBs are almost always associated with in ammation, infection, granulation tissue, fbrosis, or some degree of stenosis. For these cases, our practice is to routinely perform a follow-up bronchoscopy 4–6 weeks after retrieval. Some of these cases may require further interventions similar to other benign airway disorders (i.e. balloon dilation, tissue resection, etc.). Subsequent follow-up bronchoscopies should be determined on a case-to-case basis. Patients with retained FBs in segmental or subsegmental airways may have associated atelectasis and/or chronic regional changes (i.e. fbrosis, bronchiectasis, scarring, etc.). These changes do not require routine follow-­up and should be assessed on a case-to-case basis.

Iatrogenic airway injury from retrieval should be followed up with a follow-up bronchoscopy on a case-to-case basis. Small mucosal injury/ tears can occur during retrieval and may not require any further escalation. As mentioned above, larger tears and/or perforations may require intervention and should be followed up with a bronchoscopic exam and preferably in a multidisciplinary manner with thoracic surgery and/or otolaryngology consultation. If after FB retrieval, the patient fails to improve as expected from a symptom standpoint or an infection occurs in the previous FB-involved region, one must consider if there is a retained FB that was not visualized during bronchoscopic retrieval. If there is any doubt, repeat CT imaging (preferably thin cut, high-resolution) with a follow-up bronchoscopy to assess for retained fragments, additional FB presence, or subsequent unexpected changes in the airway from the initial FB.

Conclusion

While airway FB aspiration and retrieval are less commonly encountered and vary from center to center, it does, however, represent the origins of interventional pulmonology and bronchoscopy. In the hands of well-trained bronchoscopists, bronchoscopic FB retrieval represents the gold standard treatment for airway FBs. Rigid and/or exible bronchoscopy combined with a vast arsenal of available instruments allows for various approaches and therapeutics not only for retrieval but for its associated complications.

Retained FBs are a very important subset of patients, as this population commonly presents with nonspecifc respiratory complaints secondary to the FB-associated in ammatory cascade and its sequelae such as airway in ammation, granulation tissue, airway stenosis, and/or post-­ obstructive pneumonia. A high level of suspicion must be maintained to avoid misdiagnosis and/or delay in treatment. Clinical presentation, FB location, and/or presence of in ammatory sequelae should guide the bronchoscopist on the selection of the bronchoscopic approach (rigid and/or exible bronchoscopy). Regardless, adequate training and knowledge are required not only to successfully perform bronchoscopic retrieval but also to competently manage all possible complications. When encountering a high-­ risk patient or a complication from retrieval, a multidisciplinary approach involving interventional pulmonology, otolaryngology, and/or thoracic surgery should be applied to formulate the best plan of action for each patient.

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Defnition

Hemoptysis is de ned as the expectoration of blood from the lower respiratory tract. Bleeding from the upper airway is excluded from this de nition.

In most cases the amount of bleeding is slight, the patient has hemoptoic expectoration (blood-­ streaked sputum), and hemoptysis is self-limited. In other cases the amount is higher (evident hemoptysis) or may even present massive hemoptysis (expectoration of fresh blood in important quantities).

Massive hemoptysis usually refers to the expectoration of large amounts of blood and/or the rapidity of this bleeding and accounts for 20% of hemoptysis [1]. The amount of expectorated blood in 24 h is usually used to differentiate between massive and non-massive hemoptysis. However, this de nition varies widely in the literature, with values ranging from an expectorated blood volume of 100–1000 mL during a period of time that is also variable. Dif culty is even higher considering that hemoptysis is dif cult to quan-

R. Cordovilla (*)

Interventional Pulmonology Unit, University Hospital of Salamanca, Salamanca, Spain

e-mail: rcordovilla@usal.es

J. A. Cascón

Interventional Pulmonology Unit, Hospital Central de Asturias, Oviedo, Spain

e-mail: jcasconh@huca.es

tify: it could be both overestimated and underestimated by patients. Underestimation may occur when part of the blood is retained in the tracheobronchial tree.

It is therefore preferable to use the term life-­ threatening hemoptysis, de ned as that having clinical consequences, potentially fatal. This risk is determined by the total volume of bleeding, its velocity, and the patient’s cardiopulmonary reserve [2]. As risk indicators, the amount of hemoptysis (greater than 100 mL), the presence of airway obstruction, respiratory failure, and hemodynamic instability should be considered [3]. Since 150 mL is the total volume of conduction airways, asphyxia due to clot formation along with cardiocirculatory collapse is usually the cause of death, not exsanguination. Mortality of untreated threatening hemoptysis is high, up to 80% with adequate management [4], so it is very important to have immediate assessment of the patient and identi cation of the causes of bleeding in order to start an appropriate treatment and avoid a fatal outcome.

Etiology ofHemoptysis

The causes of hemoptysis are multiple and varied.

Before detailing, it is important to know the system of vascularization of the lung.