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Re: ‘PulmoNAILy’ injury: surgical management of rare tracheobronchial foreign body aspiration in an adult

We read with great interest the article by Hon et al. in this esteemed journal. The authors described an accidental inhalation of a nail that ended up with a thoracotomy after several failed bronchoscopy attempts. We believe the authors have provided valuable insight into the case. Nevertheless, we would like to make a few comments. It was interesting that the patient went through two flexible bronchoscopies; the second attempt using a cryoprobe under general anaesthesia. The choice of procedure for foreign body (FB) removal depends on the presentation, FB characteristics, location of the dislodgement, duration of the FB in the airway and local expertise. In recent times, flexible bronchoscopy has been supported as the primary diagnostic and therapeutic modality for managing tracheobronchial FB aspiration, with reported success rates surpassing 90%. Nonetheless, rigid bronchoscopy remains the gold standard for the FB removal from the tracheobronchial tree under direct vision. The second attempt should probably be attempted using rigid bronchoscopy. It was mentioned in the article that the difficulty in grasping the nail was likely due to its position where the proximal point of contact for the forceps was the tip of the nail. This suggests that the procedure was deemed technically challenging and thus, the use of a rigid bronchoscopy may be a better option due to its larger diameter which enables the passage of various grasping devices, including a flexible bronchoscope. Another point to highlight is the method of placing the patient in a Trendelenburg position during the procedure to reduce the risk of the FB migrating distally, which was not mentioned in this case. Indeed, bronchoscopic cryotherapy is a useful tool to remove FB that is difficult to clamp. A magnetic probe may also be useful in this case.