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

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. We retrospectively review the charts and FE video records of our pediatric cases with the diagnosis of APC in the past decade, 2004-2014. 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. 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.