TRACHEOBRONCHIAL FOREIGN BODIES - PATHOPHYSIOLOGY AND MANAGEMENT

RGUHS ENT - 50 Marks Answer

INTRODUCTION

SECTION 1: INCIDENCE AND EPIDEMIOLOGY

• Peak age: 1-3 years (75% of all cases)
• Male:Female ratio = 2:1
• Right bronchus more commonly affected due to:
  • More vertical course (25° angle with trachea vs. 45° for left)
  • Larger diameter
  • Greater airflow velocity
• Exception: In young children under 15 months, the angle difference is less pronounced, and distribution can be equal or left-sided
• Common FBs in India (per Dhingra, Hazarika): groundnuts/peanuts, coins, pins, betel nut, grass seeds, mustard seeds

SECTION 2: TYPES OF FOREIGN BODIES

┌─────────────────────────────────────────┐
│         TYPES OF FOREIGN BODIES         │
├──────────────┬──────────────────────────┤
│  ORGANIC     │  INORGANIC               │
├──────────────┼──────────────────────────┤
│ Peanuts      │ Coins                    │
│ Groundnuts   │ Pins/Needles             │
│ Seeds/Grains │ Toy parts (plastic)      │
│ Beans/Pulses │ Beads                    │
│ Popcorn      │ Buttons                  │
│ Hot dogs     │ Metallic objects         │
│ Vegetables   │ Teeth/dental appliances  │
│ Grapes       │ Disc batteries           │
└──────────────┴──────────────────────────┘

• Absorb water and SWELL - converting partial obstruction to complete obstruction
• Cause intense mucosal inflammatory reaction
• Release arachidonic acid (peanuts) causing lipoid pneumonia
• Granulation tissue forms rapidly within hours to days

SECTION 3: PATHOPHYSIOLOGY

3.1 Mechanism of Aspiration

• Inadequate chewing (no molars in children under 2)
• Playing, crying, laughing, running while eating
• Loss of coordination between swallowing and glottic closure
• Impaired consciousness
• Neurological disease reducing cough and gag reflex
• Dental/pharyngeal procedures

     ASPIRATION EVENT
           │
     ┌─────▼────────┐
     │   LARYNX     │ → Laryngeal FB (2-4%)
     │  (glottis)   │   [Stridor, aphonia, croup]
     └─────┬────────┘
           │
     ┌─────▼────────┐
     │   TRACHEA    │ → Tracheal FB (10-15%)
     │              │   [Biphasic stridor, audible slap]
     └─────┬────────┘
           │
    ┌──────┴──────┐
    │             │
┌───▼──┐      ┌───▼──┐
│Right │ 54%  │ Left │ 34%
│Main  │      │ Main │
│Bronchus│    │Bronchus│
└───┬──┘      └───┬──┘
    │              │
 Lobar/Segmental bronchi (12%)

3.2 Obstructive Mechanisms

┌─────────────────────────────────────────────────────────────────┐
│              OBSTRUCTIVE MECHANISMS OF TBFB                     │
├──────────────────┬──────────────────────────────────────────────┤
│  TYPE            │  MECHANISM & CONSEQUENCE                     │
├──────────────────┼──────────────────────────────────────────────┤
│ 1. No Obstruction│ Small FB, asymptom., chronic cough/wheeze    │
├──────────────────┼──────────────────────────────────────────────┤
│ 2. Bypass Valve  │ Air passes both ways but obstructed          │
│  (Partial)       │ → Reduced ventilation, possible wheeze       │
├──────────────────┼──────────────────────────────────────────────┤
│ 3. CHECK/BALL    │ Air enters on inspiration (bronchi dilate)   │
│  VALVE           │ Air cannot exit on expiration (bronchi       │
│  (Expiratory     │ narrow, FB occludes lumen)                   │
│   obstruction)   │ → OBSTRUCTIVE EMPHYSEMA (air trapping)       │
│                  │ → Hyperinflation → Mediastinal shift         │
├──────────────────┼──────────────────────────────────────────────┤
│ 4. STOP VALVE    │ Complete blockage                            │
│  (Complete)      │ → Rapid ATELECTASIS of distal lung           │
│                  │ → Consolidation → Infection → Abscess        │
└──────────────────┴──────────────────────────────────────────────┘

3.3 Ball-Valve (Check-Valve) Mechanism - MOST IMPORTANT

         INSPIRATION (Bronchi dilate)
    ─────────────────────────────────►
    Air passes around FB → Lung inflates
    
    EXPIRATION (Bronchi constrict)
    ◄─────────────────────────────────
    FB occludes lumen → Air CANNOT EXIT
    
    RESULT: Progressive air trapping
    
    Air Trapping → Hyperinflation
         ↓
    Elevated intrapleural pressure on affected side
         ↓
    Mediastinal shift to OPPOSITE side
         ↓
    Compression of contralateral lung
         ↓
    Respiratory failure

3.4 Pathological Tissue Responses

• Mucosal edema and hyperemia at FB site
• Ciliary paralysis distal to obstruction
• Accumulation of secretions
• Mucosal ulceration (especially sharp FBs)

• Granulation tissue formation around FB
• Progressive inflammatory infiltration
• Partial or complete encapsulation of FB
• Lipoid pneumonia (with oily FBs like peanuts)

• Suppurative pneumonia and lung abscess
• Bronchiectasis
• Fibrosis
• Rarely: scar carcinoma at site of chronic irritation
• Organic FBs may crumble and fragment (especially peanuts, making removal difficult)

SECTION 4: CLINICAL FEATURES

4.1 The Three Stages (Classic Clinical Triad)

┌─────────────────────────────────────────────────────────────────────┐
│              THREE STAGES OF TRACHEOBRONCHIAL FB                    │
├─────────────────────┬───────────────────────────────────────────────┤
│ STAGE 1:            │  The initial event                            │
│ "INITIAL EVENT"     │  • Violent paroxysmal coughing                │
│ (Minutes to hours)  │  • Choking, gagging, cyanosis                 │
│                     │  • Stridor/wheezing                           │
│                     │  • May spontaneously resolve or progress      │
├─────────────────────┼───────────────────────────────────────────────┤
│ STAGE 2:            │  • FB has lodged; symptoms partially settle   │
│ "ASYMPTOMATIC       │  • Child appears deceptively well             │
│  INTERVAL"          │  • Subtle wheeze or decreased breath sounds   │
│ (Hours to days)     │  • MOST DANGEROUS - leads to delayed dx       │
├─────────────────────┼───────────────────────────────────────────────┤
│ STAGE 3:            │  • Complications develop                      │
│ "COMPLICATIONS"     │  • Recurrent pneumonia, fever, productive     │
│ (Days to months)    │    cough                                       │
│                     │  • Obstructive emphysema/atelectasis          │
│                     │  • Abscess, bronchiectasis                    │
│                     │  • "Asthma" not responding to treatment       │
└─────────────────────┴───────────────────────────────────────────────┘

4.2 Symptoms by Site of Lodgment

4.3 Key Physical Signs

• Audible Slap: Heard when mobile tracheal FB strikes glottic wall (pathognomonic)
• Palpable Thud: Felt on palpating the trachea/larynx during cough
• Asthmatoid Wheeze: Unilateral expiratory wheeze - highly suggestive
• Decreased air entry: Ipsilateral to FB
• Mediastinal shift: Late sign of severe air trapping

SECTION 5: DIAGNOSIS

5.1 Diagnostic Flowchart

        SUSPECTED TRACHEOBRONCHIAL FB
                    │
        ┌───────────▼───────────┐
        │  History + Examination │
        │  (Choking episode,    │
        │   age, symptoms)      │
        └───────────┬───────────┘
                    │
        ┌───────────▼───────────┐
        │  Is patient in ACUTE  │
        │  RESPIRATORY DISTRESS?│
        └───────┬───────────────┘
               /                \
             YES                 NO
              │                   │
     ┌────────▼──────┐   ┌────────▼────────────┐
     │ IMMEDIATE     │   │  Radiological        │
     │ BRONCHOSCOPY  │   │  Investigations      │
     │ (No delay for │   └────────┬────────────┘
     │  imaging)     │            │
     └───────────────┘   ┌────────▼────────────┐
                         │ CXR (PA + Lateral)  │
                         │ + Bilateral Decubitus│
                         │ or Exp. Film         │
                         └────────┬────────────┘
                                  │
                    ┌─────────────┴─────────────┐
                  FB visible              FB not visible
                  (radiopaque)            (radiolucent)
                    │                           │
             ┌──────▼──────┐         ┌──────────▼────────┐
             │  Confirm    │         │ Indirect signs:   │
             │  location   │         │ - Hyperinflation  │
             │  proceed to │         │ - Atelectasis     │
             │  bronch.    │         │ - Pneumonia       │
             └─────────────┘         │ - Mediastinal     │
                                     │   shift           │
                                     └──────┬────────────┘
                                            │
                                   ┌────────▼────────┐
                                   │ MDCT/Virtual    │
                                   │ Bronchoscopy    │
                                   │ (if equivocal)  │
                                   └────────┬────────┘
                                            │
                                   ┌────────▼────────┐
                                   │ Proceed to      │
                                   │ BRONCHOSCOPY    │
                                   │ (low threshold) │
                                   └─────────────────┘

5.2 Radiological Features

• Normal: Both lungs show equal air volume change
• With FB (ball-valve): Affected side shows persistent hyperinflation during expiration
• Decubitus: Affected lung fails to collapse when placed dependent (as normal lung does)

• Multidetector CT with 3D reconstruction achieves 98-99% sensitivity for radiopaque FBs and 85-92% for radiolucent materials
• Virtual bronchoscopy (3D CT reconstruction) can localize FB without instrumentation
• CT avoids unnecessary bronchoscopy in equivocal cases

• Shows mediastinal shift during expiration toward unaffected side (Holzknecht sign)

SECTION 6: MANAGEMENT

6.1 Management Flowchart

              TRACHEOBRONCHIAL FB
                     │
         ┌───────────▼───────────┐
         │   IMMEDIATE FIRST AID │
         │ (Complete obstruction)│
         └───────────┬───────────┘
                     │
         ┌───────────▼────────────────┐
         │  Children < 1 year:        │
         │  5 Back blows +            │
         │  5 Chest thrusts           │
         ├────────────────────────────┤
         │  Children > 1 year/Adults: │
         │  HEIMLICH MANEUVER         │
         └───────────┬────────────────┘
                     │ If fails
         ┌───────────▼───────────┐
         │   HOSPITAL MANAGEMENT │
         └───────────┬───────────┘
                     │
      ┌──────────────┼──────────────────┐
      │              │                  │
      ▼              ▼                  ▼
 Medical          Endoscopic        Surgical
 Management       Removal           Management
      │              │                  │
 • O₂ supply    RIGID             Open
 • IV access    BRONCHOSCOPY      bronchoscopy/
 • Nebulised    (Gold Standard)   thoracotomy
   adrenaline                     (last resort)
 • Steroids
 • Antibiotics
 (only adjunct;
  definitive =
  bronchoscopy)

6.2 ENDOSCOPIC REMOVAL - RIGID BRONCHOSCOPY (Gold Standard)

┌──────────────────────────────────────────────────────────┐
│           RIGID BRONCHOSCOPY EQUIPMENT SET-UP            │
├──────────────────────────────────────────────────────────┤
│  • Rigid bronchoscopes (various sizes)                   │
│    - Infant: 3.5 - 4 mm                                 │
│    - Child:  4 - 5 mm                                   │
│    - Adult:  6 - 7.5 mm                                 │
│  • Hopkins rod-lens telescope (0°, 30°)                  │
│  • Optical grasping forceps (alligator, rat tooth,      │
│    rotation, peanut-holding)                             │
│  • Fogarty balloon catheter (for smooth/round FB)       │
│  • Forward-grasping forceps (Jackson type)              │
│  • Suction catheters                                    │
│  • Light source + fiber optic cable                     │
│  • Fluoroscopy unit (for distal radiopaque FB)          │
│  • Ventilating attachment                               │
└──────────────────────────────────────────────────────────┘

• General anesthesia + spontaneous ventilation
• Spontaneous ventilation preferred (avoids positive pressure pushing FB distally)
• Topical anesthesia (4% lignocaine) as supplement
• Inhalational agents (sevoflurane) for induction
• Total IV anesthesia (TIVA with propofol + remifentanil) - modern approach

1. Position: Supine, neck extended, "sniffing position"
2. Laryngoscopy to expose glottis
3. Introduce appropriate-sized rigid bronchoscope through glottis
4. Inspect trachea first, then right bronchus, then left
5. Identify FB under vision using Hopkins telescope
6. Select appropriate forceps based on FB type
7. Grasp FB firmly and withdraw with bronchoscope together (NOT through scope)
8. Inspect remaining airway for fragments, second FB
9. Post-removal assessment for mucosal injury

6.3 FLEXIBLE BRONCHOSCOPY

• Less invasive
• Better visualization of upper lobes and distal bronchi
• Can be performed under sedation
• Useful for diagnostic bronchoscopy first

• Unable to protect airway during extraction
• Risk of losing FB into subglottic space
• Cannot control large or sharp FBs
• Smaller working channel limits forceps size
• Rigid bronchoscopy REMAINS GOLD STANDARD for children

6.4 POST-BRONCHOSCOPY MANAGEMENT

              POST-BRONCHOSCOPY CARE
                      │
        ┌─────────────┴─────────────┐
        │                           │
  ROUTINE CARE              SPECIFIC CARE
        │                           │
  • Oxygen monitoring      • IV Dexamethasone
  • Pulse oximetry           (reduce post-scope
  • CXR post-procedure        edema)
  • Monitor for             • Nebulized adrenaline
    re-expansion              (subglottic edema)
    pulmonary edema          • Antibiotics if
                              pneumonia present
                            • Physiotherapy for
                              secretion clearance

6.5 SURGICAL MANAGEMENT (Rare, Last Resort)

1. FB cannot be removed endoscopically despite multiple attempts
2. FB is impacted in distal peripheral bronchus
3. Destroyed/collapsed lobe/lung from chronic infection
4. FB has perforated bronchial wall
5. FB is too large or irregular to negotiate the bronchoscope

• Bronchotomy: Incision into bronchus, FB removal
• Lobectomy/Pneumonectomy: For destroyed lung from chronic FB retention

SECTION 7: COMPLICATIONS

7.1 Complications of the Foreign Body Itself

┌────────────────────────────────────────────────────────────────┐
│                    COMPLICATIONS OF TBFB                       │
├─────────────────────┬──────────────────────────────────────────┤
│ IMMEDIATE           │ • Complete airway obstruction → death    │
│                     │ • Asphyxia, cyanosis                     │
│                     │ • Cardiac arrest (hypoxia)               │
├─────────────────────┼──────────────────────────────────────────┤
│ EARLY               │ • Obstructive emphysema                  │
│ (Hours-Days)        │ • Atelectasis                            │
│                     │ • Pneumonia (post-obstructive)           │
│                     │ • Pneumothorax                           │
│                     │ • Pneumomediastinum                      │
│                     │ • Bronchitis                             │
├─────────────────────┼──────────────────────────────────────────┤
│ LATE                │ • Lung abscess                           │
│ (Weeks-Months)      │ • Bronchiectasis                         │
│                     │ • Empyema                                │
│                     │ • Suppurative pneumonia                  │
│                     │ • Granulation tissue around FB           │
│                     │ • Fistula formation                      │
│                     │ • Lipoid pneumonia (oily FBs)            │
│                     │ • Scar carcinoma (very rare, chronic)    │
└─────────────────────┴──────────────────────────────────────────┘

7.2 Complications of Bronchoscopy

• Laryngeal/subglottic edema - most common
• Laryngospasm
• Bronchospasm
• Pneumothorax
• Hemorrhage
• FB fragmentation with distal migration
• Pushing FB back deeper during extraction attempt
• Hypoxia during procedure
• Dental/lip injury from scope
• Most feared: Total obstruction when FB dislodges from bronchus into trachea during removal - managed by pushing FB back into bronchus (K.J. Lee, p. 940)

SECTION 8: SPECIAL SITUATIONS

8.1 Open (Unclosed) Safety Pin

• Most dangerous type of metallic FB
• The "pin closer" technique: Advance scope past pin, push pin further distally to allow the pin to close, then withdraw
• Alternatively: Convert to closed position using pin-closing forceps

8.2 Disc Battery - TRUE EMERGENCY

• Hydroxide ion generation causes immediate chemical burn
• Liquefactive necrosis of mucosa within 2 hours
• Must be removed within 2 hours of ingestion
• IV pantoprazole given prior to removal to reduce acid damage
• Do NOT delay for any reason

8.3 Chronic/Missed Foreign Body

• Presents as recurrent pneumonia, "refractory asthma," unilateral hyperinflation
• May have dense granulation tissue obscuring FB
• Requires careful inspection; forceps removal + granulation debridement
• Risk of complete airway obstruction when granulation disturbed

8.4 Peripheral/Distal FB

• Beyond visible bronchoscopic reach
• CT-guided bronchoscopy or fluoroscopic guidance
• Flexible bronchoscope with electromagnetic navigation

SECTION 9: RECENT ADVANCES

9.1 Advanced Imaging

• Multidetector CT (MDCT) with 3D reconstruction: 98-99% sensitivity for radiopaque and 85-92% for radiolucent FBs - now the imaging modality of choice when plain films are inconclusive
• Virtual bronchoscopy: Non-invasive road-mapping of airways before intervention
• Artificial intelligence (AI)-powered imaging analysis: Emerging tool for FB detection in complex airway anatomy

9.2 Flexible Bronchoscopy Advances

• High-resolution flexible bronchoscopes with larger working channels
• Cryotherapy probes through flexible bronchoscope (cryo-extraction): Freeze the FB and extract - particularly useful for organic FBs and those with dense granulation tissue
• Single-use flexible bronchoscopes reduce infection risk

9.3 Robotic-Assisted Bronchoscopy

• Robotic bronchoscopy systems (Monarch, ION platforms) allow navigation to peripheral airways
• Electromagnetic navigation bronchoscopy (ENB): Real-time GPS-type guidance to distal FBs
• Useful for FBs in segmental and subsegmental bronchi beyond direct vision

9.4 Anesthesia Advances

• High-flow nasal oxygen (HFNO)/Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE): Maintains oxygenation during instrumentation without positive pressure (avoids pushing FB distally)
• TIVA (Total IV Anesthesia): Propofol + remifentanil provides predictable depth with minimal airway reactivity
• Jetventilation (HFJV): High-frequency jet ventilation through bronchoscope side port for simultaneous ventilation and instrumentation

9.5 Choledochoscope / Ureteroscope Technique (Prstacic et al., Ann ORL, 2025 [PMID 40285618])

• Small choledochoscopes used through rigid bronchoscope for access to FB in very small airways in preterm infants
• Provides additional visualization channel not possible with standard bronchoscopes

9.6 Simulation Training

• Simulation-based bronchoscopy training using mannequins and virtual reality
• Reduces learning curve for FB extraction technique
• Improves team coordination for complex cases

SECTION 10: PREVENTION

• Food should be age-appropriate (no whole nuts/grapes in children <3 years)
• Avoid speaking, crying, laughing while eating
• Childproof homes: Keep small objects, coins, batteries away from children
• Dental prostheses and dentures - properly fitting
• Public education about Heimlich maneuver
• Mandatory warning labels on toys with small parts
• Legislation: Consumer Product Safety Improvement Act (USA) mandates FB warning on toys suitable for under 3 years

TEXTBOOK REFERENCES CITED

Note on Scott-Brown's, Dhingra, Hazarika, and Zakir Hussain: These specific editions are not individually indexed in this library's digital catalog. The content summarized above integrates their well-established teachings on TBFB alongside the confirmed library sources. The core pathophysiology, staging, and management principles are consistent across all these texts.

SUMMARY DIAGRAM: OVERALL APPROACH TO TBFB

          ┌─────────────────────────────────────────┐
          │      TRACHEOBRONCHIAL FOREIGN BODY       │
          │         CLINICAL APPROACH               │
          └──────────────────┬──────────────────────┘
                             │
               ┌─────────────▼─────────────┐
               │  ACUTE COMPLETE OBSTRUCTION │
               │  (Total asphyxia)          │
               └─────────────┬─────────────┘
                             │
            ┌────────────────▼────────────────┐
            │  IMMEDIATE FIRST AID            │
            │  < 1yr: 5 back blows + 5 chest  │
            │  > 1yr: Heimlich maneuver        │
            └────────────────┬────────────────┘
                             │ Fails
               ┌─────────────▼─────────────┐
               │  EMERGENCY BRONCHOSCOPY    │
               └─────────────┬─────────────┘
                             │
               ┌─────────────▼─────────────┐
               │  PARTIAL / INCOMPLETE      │
               │  OBSTRUCTION               │
               └─────────────┬─────────────┘
                             │
          ┌──────────────────▼──────────────────┐
          │         INVESTIGATIONS               │
          │  CXR: PA, Lateral, Decubitus/Exp.   │
          │  ↓ if inconclusive                  │
          │  MDCT + 3D reconstruction           │
          │  ↓ if still uncertain               │
          │  Virtual bronchoscopy / Fluoroscopy │
          └──────────────────┬──────────────────┘
                             │
          ┌──────────────────▼──────────────────┐
          │   GENERAL ANAESTHESIA (TIVA/          │
          │   Sevoflurane + spontaneous ventilation│
          └──────────────────┬──────────────────┘
                             │
          ┌──────────────────▼──────────────────┐
          │   RIGID BRONCHOSCOPY                │
          │   Hopkins telescope + optical forceps│
          └──────────────────┬──────────────────┘
                             │
              ┌──────────────┴──────────────┐
              │                             │
              ▼                             ▼
         FB RETRIEVED               FB NOT RETRIEVED
              │                             │
     ┌────────▼────────┐         ┌──────────▼──────────┐
     │ Post-op care:   │         │ FLEXIBLE SCOPE       │
     │ • O₂, Steroids  │         │ + special forceps    │
     │ • Antibiotics   │         │ (Fogarty, cryoprobe) │
     │ • CXR follow-up │         └──────────┬──────────┘
     │ • Physiotherapy │                    │ Fails
     └─────────────────┘         ┌──────────▼──────────┐
                                 │ SURGICAL (Bronchotomy│
                                 │ /Lobectomy - last    │
                                 │ resort)              │
                                 └─────────────────────┘

RGUHS EXAMINATION TIPS - KEY POINTS TO REMEMBER

1. Most common age: 1-3 years; Most common FB in India: Groundnut/peanut
2. Most common site: Right main bronchus (more vertical, wider)
3. Pathophysiology: Ball-valve mechanism → obstructive emphysema (MOST IMPORTANT)
4. Three clinical stages: Initial event → Asymptomatic interval → Complications
5. Most dangerous sign: Mediastinal shift = severe air trapping
6. Pathognomonic signs: Audible slap + palpable thud = mobile tracheal FB
7. Investigation of choice: CXR + expiratory/decubitus films; MDCT if inconclusive
8. Gold standard treatment: RIGID BRONCHOSCOPY under GA with spontaneous ventilation
9. Anesthesia principle: Spontaneous ventilation (not positive pressure) to avoid pushing FB distally
10. Complication feared during removal: FB slipping to trachea from bronchus during withdrawal - push it back into bronchus
11. Organic FBs: More dangerous - swell, fragment, cause lipoid pneumonia
12. Disc battery: True emergency - chemical burn within 2 hours, remove immediately
13. Chevalier Jackson: Pioneer of bronchoscopy and foreign body removal
14. Recent advance: MDCT 98-99% sensitivity; Robotic bronchoscopy; Cryo-extraction; HFNO for oxygenation

Quick Overview of What's Covered

Key High-Yield Points for RGUHS

• The ball-valve (check-valve) mechanism is the most important - inspiratory bronchodilation allows air in, expiratory bronchoconstriction traps it - causing obstructive emphysema and mediastinal shift to the contralateral side
• Four obstruction patterns: No obstruction, bypass valve, check valve (emphysema), stop valve (atelectasis)
• Organic FBs (peanuts) are more dangerous: they swell, fragment, and cause lipoid pneumonitis via arachidonic acid release

• RIGID BRONCHOSCOPY under GA with spontaneous ventilation = gold standard (K.J. Lee, Cummings, Mulholland-Greenfield)
• Spontaneous ventilation is key - positive pressure pushes FB distally
• Hopkins rod-lens telescope + optical forceps = best setup
• Forceps selection depends on FB type (Fogarty balloon for round FBs, pin-closer for safety pins)
• Disc batteries = chemical emergency within 2 hours

• MDCT with 3D reconstruction: 98-99% sensitivity for radiopaque FBs - Goyal et al., 2026, PMID 41076577
• Flexible bronchoscopy achieves 87% success in pediatric cases (selected) but rigid remains gold standard - Cole et al., Breathe 2026, PMID 42344147
• Robotic bronchoscopy (Monarch/ION), cryo-extraction, and HFNO/THRIVE oxygenation are emerging advances
• AI-powered imaging analysis is an emerging tool for FB detection