Mahajan, Jai Kumar MCh; Rathod, Kirti K. MS; Bawa, Monika MCh; Rao, Katragadda L.N. MCh, FACS
Tracheobronchial foreign body aspiration (FBA) can be a life-threatening emergency for children and accounts for an important proportion of accidental deaths.1,2 FBA may also cause a chronic lung injury if not managed properly.3 The diagnosis and treatment require the highest degree of suspicion for the signs and symptoms of FBA.4 The epidemiology of FBA may vary from place to place, and knowledge of the culture and practices in the community is required to plan the strategies for prevention. This study analyzes the clinical and bronchoscopic findings in children who were suspected to have FBA over a period of 10 years and their outcome and management.
Between January 2000 and September 2009, the principal investigator (J.K.M) performed emergency bronchoscopy in 184 consecutive patients admitted to the Pediatric Surgery Department, for suspected FBA. Case records of all these patients were studied for demographic data, indications of bronchoscopy, bronchoscopic findings, and the requirement of other ancillary procedures. Statistical analysis was performed with SPSS version 17 using Fischer exact test and 2-tailed P value as a measure of significance.
The age of the patients ranged from 2 months to 12 years (mean=2 y, 7 mo). There were 134 (72.83%) boys and 50 (27.17%) girls. Of the 184 patients, 28 (15.22%) were <1-year of age, 123 (66.84%) were between 1 and 3 years, 13 (7.06%) were between 3 and 5 years, and 20 (10.86%) were >5 years of age. Of the 166 (90.21%) cases in which the FBs were found, 99 (53.80%) were right sided, 35 (19.02%) in the left bronchus, 25(14.13%) in the trachea, and 1 was located at the vallecula. Six patients (3.26%) had bilateral FBs, whereas in 18 (9.79%) cases, no foreign body (FB) was found (Table 1). Of the 166 cases, where the FBs were found on bronchoscopy, 128 (77.1%) had organic matter (peanuts, hard nuts, tamarind seed, apple piece, grams, green peas), and nonorganic FBs (metal pins, plastic pieces, whistle, pen cap, stone, wood pieces) were found in 38 (22.9%) cases (Table 2). Before the age of 3 years, 87.7% (122/139) of the children had FBA of organic origin, whereas 77.7% (21/27) of the older children had nonorganic FBA (P<0.0001). Among the aspirations after the age of 5 years (school-going), the majority (13/16, 81.2%) of the FBA were inorganic in nature in the form of pen caps, whistle tops, and the safety pins. Seven children had aspiration of pen caps.
Table 3 shows age-wise distribution of all the patients, compared on the basis of history, symptoms, findings on auscultation, and chest radiography. It can be observed that in very young patients (<1 y), none of the studied parameters were significantly different from the rest of the age groups. However in the patients aged from 1 to 3 years, the history of witnessed FBA was present in significantly less children (P=0.04), whereas in contrast, a history of sudden onset respiratory symptoms was more frequent compared with the patients in other age groups (P<0.0001). Similarly, in 3 to 5-year-old patients, the history of sudden onset of respiratory symptoms was less frequently seen in comparison with other patients (P=0.0004). The findings of asymmetric breath sounds and an abnormal chest radiograph were significantly higher in older patients (5 to 12 y) (P=0.023 and P=0.0063, respectively).
Of the 166 patients, 163 (98.2%) had successful retrieval of the FB in the first attempt at bronchoscopy, and 3 (1.8%) patients required a repeat attempt for removal of residual FBs. There was a seasonal variation noted in our patients. Sixty-four percent (118/184) of the patients presented during the winter months from October to March and 35.87% (66/184) of the children were seen in the months from April to September (Fig. 1).
In 18 patients, in whom no FB was found, the decision to perform a bronchoscopy was based on their history. In 2 patients, aged 2 and 6 months, both babies were witnessed being fed nuts by their siblings and choked. Five patients were referred by their pediatricians for persistent respiratory symptoms, and 11 patients from the emergency department underwent bronchoscopy based on the history of respiratory distress of sudden onset and the asymmetric breath sounds on auscultation. None of these 11 patients had a history of witnessed FBA.
Seven patients were being treated for medical ailments including bronchial asthma, tuberculosis, and chronic bronchitis for a period varying from 3 months to 1 year (mean 5.71 mo). Most of these patients (5/7) were children >3 years of age. These patients were referred for the bronchoscopic examination because of atypical clinical features and a poor response to the medications. All of them were found to have a variety of nonopaque FBs on bronchoscopic examination (peanut-3, pea-1, maize-1, plastic piece-1, whistle part-1).
A surgical intervention was required in 3 of the cases. Two of them had failed bronchoscopic extraction. In one case, a 12-year-old patient, presented with a chronic productive cough and occasional fever since 1 year. X-ray of the chest showed bronchiectatic changes in the lung parenchyma and a nail in the region of the left main bronchus (Fig. 2). On bronchoscopy, there was a lot of granulation tissue and the nail could be identified but it was firmly embedded. As the nail could not be extracted, the bronchoscopy was abandoned and the patient was taken up for a thoracotomy. At thoracotomy, the left main bronchus was identified and the FB was palpated. The bronchus was opened longitudinally approximately 0.5 to 1 cm proximal to the actual site of impaction so as to perform the bronchotomy in a healthy area. After extraction of the FB, the opening was closed with interrupted 5.0 Prolene sutures. The other case involved an 8-year-old child who had aspirated a plastic pen cap, which was lodged with its closed end toward the bronchoscope and could not be extracted. After unsuccessful bronchoscopy, the child underwent a thoracotomy. After localization of the FB, the bronchus was opened longitudinally for its extraction. Case 3 involved a 3 ½-year-old girl who had an unrecognized aspiration of a metal spring 4 months before evaluation. She had occasional hoarseness of her voice, but no respiratory distress. An episode of upper respiratory tract infection led to an acute exacerbation of her symptoms and hospitalization. The patient had sudden onset of severe respiratory distress and was taken for an urgent bronchoscopy. On indirect laryngoscopy, there was inflamed granulation tissue at the vallecula near the vocal cords, which was bleeding on touch; hence, a tracheostomy was established. The cervical x-ray later on showed a metal spring, which was removed 2 weeks later. In all the 3 cases, neither the children nor the parents initially remembered the aspirations; however, on repeated questioning they recalled the episode in case number 1 and 3.
One child, with bilateral FBs, presented with subcutaneous emphysema in the neck and upper chest and severe respiratory distress. Peanuts were removed from both mainstem bronchi and the patient was put on mechanical ventilation. The subcutaneous emphysema settled and did not require insertion of a chest tube. The child was gradually weaned off the ventilator and discharged on the tenth postoperative day.
There were 2 deaths in our series. One child had a prolonged period of hypoxia at home before being transferred to a local hospital, where the patient was promptly intubated and referred to our center. The child underwent bronchoscopy and removal of the FB and was put on mechanical ventilation. However, the child had hypoxic brain damage and after extensive neurological assessment, the parents decided to discontinue treatment. Another child had associated congenital heart disease. He underwent a bronchoscopy for removal of the FB and had a difficult perioperative period. The child required ventilation and died due to ventilator-related complications and cardiac failure.
Tracheobronchial FBA is one of the most common causes of death due to acute asphyxia in children.5–7 In the literature, the clinical history has been considered to be an important diagnostic tool.1,8,9 The classical clinical presentation of cough, wheeze, and decreased airflow is seen in <40% of the patients and a few can be completely asymptomatic. FBA can lead to a variable degree of respiratory distress, atelectasis, chronic cough, and recurrent pneumonia.6,10 In our patients, a witnessed history of choking was more evident either in very young (<1 y) or the older (5 to 12 y) patients, whereas respiratory distress of sudden onset was the commonest reason to perform bronchoscopy in the group of children (1 to 3 y) with the highest incidence of FBA (P<0.0001) (Table 3). The younger children are likely to be under constant supervision of the parents, and the older children, themselves, were forthcoming with the history.
The majority of reports indicate that male children are more commonly affected, accounting for 60% to 66% of cases.11–13 In our data, the male preponderance was higher (72.8%) than in previous reports. In general, the male predominance has been attributed to a higher level of physical activity among boys.9 In addition, our study confirms that most of the FBA occur before the fifth year of life (89.14%), likely because of inadequate dentition, a relatively high position of the epiglottis, and the immature swallowing coordination mechanism in these children. A few studies have also shown a higher incidence of FBA (16.8%) in children >12 years of age.12 It is likely that in presenting symptoms, the most frequent age group involved and the type of aspirated FB may differ from region to region across the world. We also observed a significant increase in the number of patients during the winter season, which can be attributed to an increased intake of nuts and dried fruits in India during these months. In contrast, a higher incidence was observed during the summer months in a report from Egypt.14 Hence, such audits can be utilized to formulate the preventive policies as per the local needs.
The most commonly aspirated FBs in children are organic materials such as nuts and seeds. Commonly aspirated inorganic substances include beads, coins, pins, small parts of toys, and pen caps.13,15 In this study, the FBs of organic origin were more common (77.1%) compared with the nonorganic FBs (22.9%), a finding similar to the other reports. However, in our series, FBA of organic origin were more common in younger children (<3 y) in contrast to their older counterparts in whom nonorganic FBA were more frequently seen (P<0.0001). This finding has not been highlighted in previous reviews. Older patients are more likely to aspirate nonorganic FBs because of their wider exposure to a variety of materials, especially during the school hours.
FBs were found in 90.2% of our patients who underwent bronchoscopy and similar results have also been reported in other studies.16–19 Some investigators have suggested that the negative bronchoscopy rates should not exceed 10% to 15%,8,20 whereas others have described the false-negative rates as high as up to 59%.20,21 Bronchoscopy is a relatively safe procedure and its role in planning the course of the treatment is invaluable, even when it is negative. At the same time, neglected FBA may lead to prolonged morbidity, as it occurred in 7 of our patients. Choking can also occur in younger patients when a large piece of a nut passes through a relatively small esophagus, compressing the trachea, and this can mimic FBA as was seen in 2 of our patients. The bronchoscopy conclusively rules out a suspected FBA in such a situation.
Although most of the aspirated FBs are radiolucent, chest radiographs are still thought to be important for the decision making in suspected cases.22 A few reported series show that the chest radiographs are pathologic in up to 97% of patients with FBA.1,2,20,21 It may reveal the hyperinflation, air trapping, mediastinal shift, pneumonia, atelectasis, pneumothorax, and sometimes an opacification of the whole lung.21 In our patients, the chest x-rays were very helpful (90%) in the older patients (5 to 12 y), although these patients were less symptomatic (30%) (Table 3). Various reports have analyzed the utility of witnessed history, clinical symptoms, and radiology in predicting the need for bronchoscopy; however, the relative role of each of these determinants in various age groups has not been reported previously and may differ as was seen in our study.
A rigid ventilating bronchoscope remains the instrument of choice in the management of FBA in the pediatric population. Availability of optical forceps has not only simplified the procedure but also made it less hazardous. A rigid bronchoscopy in children below 12 months of age requires good technical skill because of the smaller airways and also because the risk of bronchospasm is higher in this age group compared with the older children.12 Irritation caused by the FB, bronchoscope itself, and the prolonged procedure are the factors contributing to the occurrence of bronchospasm. Thus, it is imperative to choose an appropriately sized bronchoscope and limit the time of the procedure to approximately 20 minutes to avoid laryngeal edema and bronchospasm.23 Rarely, one can stage the procedure, if repeated attempts failed in complete extraction of the FB due to friable, edematous mucosa and the poor visibility, as it occurred in 3 of our cases. The second attempt was less difficult in all the 3 patients.
A few investigators have shown promising results with the flexible bronchoscopy and recommend its use as the initial procedure of choice.24 They opined that a flexible bronchoscope can retrieve the FBs from the areas inaccessible to a rigid bronchoscope; however, they had to resort to the rigid bronchoscopy in 8.7% of their patients. Nonetheless, flexible bronchoscopy is less invasive, more cost effective, does not require general anesthesia, and seems more helpful in children with insufficient historical, clinical, or radiologic findings for FBA. Many a times, the flexible bronchoscopy is used for a diagnostic purpose only and once a FB is detected, the rigid bronchoscopy is performed for its retrieval.25 Similarly, the flexible bronchoscope can be passed through a rigid bronchoscope to access more peripheral airways.
The need for an open surgical intervention such as tracheostomy, thoracotomy, bronchotomy, and/or pulmonary resection ranges from 0.3% to 4% in various published series.26,27 In a review of 6693 cases of airway FBs, 2.5% required a thoracotomy and another 2% required a tracheostomy.28 Three of our patients in this series underwent a surgical intervention. In the first case, a 3.5-year-old female child who had a FB at the vallecula near the vocal cords, an endoscopic extraction without the tracheostomy would have risked the airway compromise. The published literature also describes the role of tracheostomy in similar conditions.28,29 Two patients, in whom, the FBs were embedded in the bronchii for a long period, underwent a thoracotomy and bronchotomy. Intense manipulation during the bronchoscopy has been reported to cause a total rupture of the bronchus.6 Both of these patients had an uneventful postoperative recovery. Pen cap aspirations have also been reported to have a higher requirement for the surgical intervention,26 but only 1 of the 7 of our patients needed it. The direction of the open end of the cap may determine the outcome of bronchoscopy. The use of tracheostomy has been described when the pen cap cannot be extracted across the vocal cords.26
The reported mortality rate from FB inhalation is between 0% and 1.8%.27,30 The mortality rate in our study was 1.08%. One of the patients had a prolonged hypoxia before reaching the hospital and the other had an associated congenital heart disease, which decompensated after bronchoscopy.
FBA in children is a serious and life-threatening condition that requires immediate intervention. The symptoms are usually nonspecific and the chest x-ray is mostly inconclusive. Hence, children with a suspicious history or the symptoms should undergo prompt bronchoscopy. If the methods of removal are appropriate for the type of FB, favorable outcomes with lower mortality and morbidity rates will be seen. Parental education and the awareness are important to avoid a preventable cause of mortality.
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