Indian Pediatrics 2002; 39:1006-1010 

Foreign Body Aspiration

From the Departments of Pediatrics, Kalawati Saran Children’s Hospital, New Delhi and *Otorhino-laryngology, Smt. Sucheta Kriplani Hospital, Lady Hardinge Medical College, New Delhi, India.

Correspondence to: Dr. Arvind Sehgal, 26, UCO Apartments, Sector-9, Rohini, Delhi 110 085, India.

E-mail: [email protected]

Manuscript received: November 22, 2001, Initial review completed: April 19, 2002,
Revision accepted: August 13, 2002.

Objective:To analyze the clinical and radiological profile of foreign body aspiration in children reaching a tertiary care center and identify areas of possible interventions for proper management of such cases. Setting: Tertiary level teaching hospital. Subjects:
Case records of patients suspected to have foreign body aspiration over the past four years were analyzed. Clinico-radiological features, types and location of foreign bodies were studied. Results: Of 75 children who underwent rigid bronchoscopy, 70 had tracheo-bronchial foreign bodies. History of choking was elicited in 90% cases. In 30% cases chest radiographs were non-contributory, while the commonest finding (63%) was distal emphysema. Over three-fourth of the cases were below the age of 2 years. Vegetative foreign bodies, mainly peanuts, were commonly present. In many cases, referral was delayed as the diagnosis was missed initially. Conclusion: Foreign body aspiration remains a common unintentional childhood injury due to improper exposure of young children to otherwise innocuous looking nuts and other small objects.

Key words: Foreign body, Rigid bronchoscopy, Tracheobronchial aspiration.

FOREIGN body aspiration is an important cause of pediatric morbidity and mortality, particularly in children between the age of 6 months and five years(1). It is potentially life threatening event and may also cause chronic lung injury, if not properly managed. The symptoms and signs can be confused with those of asthma, and the roentgenographic findings with those of pneumonia. Foreign bodies may cause chronic pulmonary infections, bronchiectasis and lung abscess. An early diagnosis and management of the patient with an inhaled foreign body offers a diagnostic challenge to the physician. This study reviews the clinical data of children admitted to our hospital with suspected foreign body inhalation. It reviews the clinical presentation, so as to define the features which could facilitate early diagnosis.

The medical records of all children admitted with suspected foreign body aspiration to Kalawati Saran Children Hospital, New Delhi, between January 1997 and December 2000, were analyzed retrospectively. The following data was collected: sex, age, residence, duration of illness, availability of definitive history, need for tracheostomy, bronchoscopic procedure, associated findings on bronchoscopy, number, type and location of the foreign body and duration of hospital stay after its removal, and complications. All patients suspected of foreign body aspiration were subjected to rigid bronchoscopy under general anesthesia. Patients in whom no foreign body was found were excluded from final analysis.

Seventy-five children were admitted with suspected foreign body aspiration during this period. No foreign body was found in 5 subjects and they were excluded from the analysis. Of 70 subjects with foreign body aspiration, 48 (68.5%) were boys and 22 (31.5%) were girls. Most patients (77%) were below 2 years of age; the median age was 1.5 years (range 20 days–9 years). An equal number of children came from urban and rural communities. Twenty patients (31.4%) reported within 24 hours of the event. The median duration of symptoms prior to admission was 72 hours. There was a delay of more than 2 weeks in 11 (15%) cases, the maximum gap between the onset and referral being 30 days. A definite history of choking following foreign body aspiration was present in 63 (90%) cases. Chief clinical features are depicted in Table 1.

Chest radiographs were helpful in providing evidence of possible foreign body aspiration in 49 patients. Radiological features of air trapping were seen in 44 (62.8%) cases, while collapse/atelectasis was seen in 35(50%) cases. Mediastinal shift was seen in 10% cases while a radio-opaque foreign body was evident in 3 cases (4.2%). Normal radiograph or one showing non-specific findings was present in 30%.

Table I- Clinical Features of Patients with Foreign Body Aspiration

Features

Number (N = 70)

Choking

63

(90)

Paroxysmal cough

57

(81)

Fast breathing

57

(81)

Stridor

50

(71)

Decreased air entry

47

(67)

Wheezing

35

(50)

Fever

20

(29)

Cyanotic episodes

8

(11)

Syncope

4

(6)

Figures in parenthesis refer to percentages.

Details of treatment received prior to referral were available in only 7 cases. The treatment received included antibiotics, intravenous fluids, oxygen supplementation and bronchodilators. Flexible bronchoscopy had been performed and presence of a foreign body confirmed in one patient before referral.

Table II- Location of Foreign Bodies

Location*

Number (N = 97)

Trachea

13

Carina

13

Right main bronchus

45

Left main bronchus

21

Subglottis

2

Cricopharynx

2

Pyriform fossa

1

* In 70 subjects, 97 foreign bodies were detected.

Bronchoscopy showed tracheobronchial edema or granulation tissue (40%), inflammation (30%) and purulent secretions in 15% cases. A single foreign body was present in 50 (71%) cases while multiple (two in 19% and three in 10%) foreign bodies were seen in the rest of the cases. In about half the cases, foreign body was impacted in right main bronchus. The location of foreign bodies is shown in Table II. The foreign body was vegetative in most (61) cases while it was inorganic in the rest. Most foreign bodies (42, 60%) were peanuts, followed by pulses and seeds (13 cases) and almond (4 cases). A check bronchoscopy was performed in all patients at the same sitting to look for multiple or remnant foreign bodies. In 2 cases there was fragmentation of foreign body during removal and all the fragments were removed at the same sitting. Majority (64.2%) of patients were discharged within 3 days of removal while 9 patients stayed in the hospital for more than 7 days because of complications like fever, bronchospasm, bleeding and air leaks. One patient was subjected to tracheostomy as a metallic foreign body was impacted in subglottis. Three patients with persistent symptoms required a repeat bronchoscopy and showed edema and secretions with no remaining foreign bodies. Two patients died, both had severe respiratory distress and respiratory failure by the time they were taken up for bronchoscopy.

Tracheobronchial foreign body aspiration is an important life threatening condition in young children. While aspiration of foreign body into the tracheobronchial tree occurs in all age groups, infants and small children suffer most commonly. The anatomic relation of the larynx, shouting, crying and playing while eating and lack of parental supervision contributes to this hazard. Most patients in the present study were below 2 years of age, which is similar to that reported in other series(2,3). The natural urge to explore objects by mouthing, lack of molar teeth to crush nuts and lack of supervision by adults may result in peaking of foreign body aspiration in this age group. The male-female ratio in our study was 2.1:1, which is in concurrence with previous data(4). In our study, the median duration of symptoms was 3 days prior to admission with one patient reaching as late as 30 days after the aspiration. Weissberg, et al. reported that 18% of their patients were referred after a delay of 1-month(4).

The fact that about 15% of patients arrived at the hospital more than 2 weeks after inhalation is of concern, bearing in mind that a positive history of aspiration was obtained in 90% patients. Some of the patients were treated before referral with antibiotics and bronchodilators, before suspecting a foreign body. In patients who had been referred more than 7 days after onset of symptoms, medical staff had often ignored the event of choking when the initial assessment was made. Factors, which may delay the diagnosis, include (a) parental negligence and wrong diagnosis by the doctor, (b) lack of symptoms, particularly after the acute initial phase of dyspnea and (c) diverse clinical features due to inhalation of foreign body.

Common clinical features included choking (90%), paroxysmal cough and fast breathing followed by stridor and decreased air entry. The triad of wheezing, paroxysmal cough and decreased air entry, considered highly suggestive of foreign body aspiration, was seen in 35% of our cases as compared to 39% in other studies(5). In a previous study, one symptom out of the triad was present in over 96% patients with foreign body aspiration. In our study, 81.4% of the patients had at least one of the symptoms present(6).

Chest radiograph is important for diagnosis, though fluoroscopy being a dynamic modality can be very useful when chest skiagram in inspiratory phase is inconclusive. Since the most common aspirated objects are vegetative and thus radiolucent, their presence is usually established by the indirect signs of atelectasis or air trapping due to partial obstruction. In younger patients who may not be able to cooperate, assisted expiratory technique using pressure over the patient’s epigastrium, applied during maximal exhalation, will result in a radiograph that is a sensitive indicator of air trapping.

Emphysema or hyperinflation was the commonest finding in the present study. Other studies have also reported a high frequency (60%) of this finding(7). It needs to be pointed out that chest radiograph is normal in as many as 9-30% cases (6-8). Radiographs were normal in 30% of our cases. The presence of x-ray findings is related to size, type, shape and location of foreign body and pattern and length of bronchial obstruction. The sensitivity and specificity of imaging in identifying the presence of foreign body was found to be 73% and 45% respectively(9).

In accordance with previous studies which showed that peanuts were the commonest foreign body(6-10), we also encountered this as the commonest cause. It is recommended that small children should not have access to such food items. The type of foreign body aspirated commonly depends on local eating habits. In one study, watermelon seeds were the commonest(2). Vegetative foreign bodies are more dangerous as they swell with bronchial secretions causing increasing obstruction. They can also cause an allergic and chemical bronchitis (vegetable bronchitis). During bronchoscopy, such vegetative foreign bodies may be dispersed as smaller fragments in distal bronchi, as happened in 2 of our cases.

Multiple foreign bodies were seen in a high percentage of patients (28%) in the present as compared to 9-11% in previous studies(6,9). In more than half the cases, the foreign body was lodged in the right main bronchus. This is in agreement with the findings of other authors (8,11), and is probably determined by anatomical factors. There were 2 deaths in this study while the current mortality rates with improved instrumentation and anesthetic techniques are less than 1%(12). Mortality was observed in patients who had been in distress and respiratory failure for considerable period of time prior to bronchoscopy.

Considering that most common culprit was the ‘innocuous’ peanut, we feel a large number of these cases could have been avoided if the parents, family and the health care providers were sensitized to the hazards of exposing small children below 3 years to nuts and certain small parts in the toys.

To conclude, it is important for the clinician to have a high index of suspicion, especially in patients with sudden appearance of a wheeze without a previous history of asthma, especially if unilateral. It is recommended that patients satisfying the following criteria should be subjected to bronchoscopy; (i) history of definite or suspected foreign body aspiration; (ii) features of foreign body aspiration, e.g., choking, wheezing, stridor and paroxysmal cough; (iii) recurrent chest infections with no apparent cause, when bronchial asthma has been excluded; and (iv) chest radiograph suggestive of foreign body aspiration. Foreign body aspiration is a dramatic event with potentially lethal sequelae. Education is the best preventive measure for decreasing the incidence of this problem.

Contributors: AS and VS designed the study. AS collected the data, AS, VS and JC formulated results and drafted the manuscript. NNM did the bronchoscopic removal of foreign bodies.

Funding: None.

Competing interests: None stated.

 References

1. Blumhagen JD, Wesenberg RL, Brooks JG, Cottan EK. Endotracheal foreign bodies: Difficulties in diagnosis. Clin Pediatr 1980; 19: 480-484.

2. Rothmann BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children. Ann Otalogy 1980; 89: 434-436.

3. Fadl FA, Omer MTA. Tracheobronchial foreign bodies: A review of children admitted for bronchoscopy at King Fahd Specialist Hospital, Al Gassim, Saudi Arabia. Ann Trop Pediatr 1997; 17: 309-313.

4. Weissberg D, Schwartz I. Foreign bodies in the tracheobronchial tree. Chest 1991; 5: 730-733.

5. Denny MK, Berkas EM, Snider TH. Foreign body bronchiectasis. Dis Chest 1968; 53: 613-616.

6. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg 1994; 29: 682-684.

7. Hughes CA, Baroody FM, Marsh BR. Pediatric tracheobronchial foreign bodies: Historical review from the John Hopkins Hospital. Ann Otol Rhinol Laryngol 1996; 105: 555-561.

8. Wiseman NE. The diagnosis of foreign body aspiration in childhood. J Pediatr Surg 1984; 19: 531-535.

9. Silva AB, Muntz HR, Clary R. Tracheobronchial foreign bodies. Ann Otol Rhinol Laryngol 1998; 107: 834-838.

10. Yamamoto S, Suzuki K, Itaya T, Yamamoto E, Baba S. Foreign bodies in the airway: Eighteen-year retrospective study. Acta Otolaryngol (Stockh) 1996; suppl 25: 6-8.

11. Cataneo AJM, Reibscheid SM, Ruiz Rl, Ferrari GF. Foreign body in the tracheobronchial tree. Clin Pediatr 1997; 49: 701-705.

12. Cohen SR, Herbert WI, Lewis GB Jr., Geller KA. Foreign bodies in the airway. Five-year retrospective study with special reference to management. Ann Otol Rhinol Laryngol 1980; 89: 437-442.