Eur J Cardiothorac Surg 1998;14:388-392
© 1998 Elsevier Science NL
Tracheobronchial foreign body aspirations in childhood: a 10-year experience
Fahri O
uzkaya,
Yiit Akçal
,
Cemal Kahraman,
Mehmet Bilgin,
Atalay 
ahin
Department of Thoracic and Cardiovascular Surgery, Erciyes University Medical Faculty, Kayseri, Turkey
Received 9 March 1998;
received in revised form 15 June 1998;
accepted 8 July 1998.
Corresponding author. Tel.: +90 542 4146468; fax: +90 352 4377683; e-mails: yakcali@service.raksnet.com.tr and okaya@erciyes.edu.tr
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Abstract
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Objective: Tracheobronchial foreign body aspirations comprise the majority of accidental deaths in childhood. Diagnostic delay may cause an increase in mortality and morbidity in cases without acute respiratory failure. We report our diagnostic and therapeutic modalities. Methods: In our department, bronchoscopy was performed on 548 patients with the diagnosis of tracheobronchial foreign body aspirations (from 1987 to 1997). Of these cases, 55.6% were male and 44.4% female. Their ages ranged from 2 months to 16 years (average 5.5 years). Diagnosis was made on history, physical examination, radiological methods and bronchoscopy. Results: Foreign bodies were localized in the right bronchial tree in 312 cases (56.9%), the left in 126 cases (23.0%) and in the trachea in 62 cases (11.3%). Foreign body was not found during bronchoscopy in 48 cases (8.7%). The majority of the foreign bodies were vegetable matters. Foreign bodies were removed with bronchoscopy in all but two cases which underwent limited thoracotomy. In the late period, pulmonary resection was performed in five cases because of irreversible complications. After bronchoscopy, hypoxia developed in four patients, requiring mechanical ventilation. Pneumothorax developed in two cases and mediastinal emphysema in two. Four patients (0.7%) died because of respiratory failure. Conclusion: Proper use of diagnostic techniques provides a high degree of success, and the treatment modality to be used depending on the type of the foreign body is mostly satisfactory.
Key Words: Foreign body aspiration • Bronchoscopy
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Introduction
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Tracheobronchial foreign body aspirations (TBFBAs) in childhood are frequently emergency conditions, comprising an important proportion of accidental deaths
[1]
[2]. Delay in diagnosis and, consequently, a series of chronic pulmonary pathologic conditions may occur in the cases without acute respiratory failure. Diagnostic and therapeutic techniques currently employed for TBFBAs were reviewed, together with their outcomes.
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Patients and methods
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In our department, 548 cases with the diagnosis of TBFBA were treated from January 1987 to November 1997. Of these patients, 305 (55.6%) were male and 243 (44.4%) were female. The average age was 5.5 years (range 2 months–16 years) (
Fig. 1
). Plain chest radiography (CXR) was required in all but 25 (4.5%) patients who underwent immediate bronchoscopy owing to acute respiratory distress following history and physical examination. The emergency bronchoscopy was performed on the patients who had acute respiratory failure with aspirated foreign body (FB) without performing any radiological examination, whereas CXR was taken on the patients without any major respiratory distress before bronchoscopy. Computed tomography was used to determine the presence of lung complications due to FB in late period.
The onset of the symptoms varied from 30 min to 5 years. The most frequently presented symptom was cough (83%) (Table 1). FB was found during bronchoscopy in 475 of 488 patients with the history of FBA. Eight of the remaining 13 patients had a history of expectorated FB. The rate of positive diagnosis was 99% in cases with history of aspirated FB. A total of 570 bronchoscopies using a rigid bronchoscope in appropriate size and under general anesthesia was done. Bronchoscopy was repeated once or twice in 17 (3.1%) of cases, for reasons such as the necessity of a recession in bronchoscopy due to the prolongation in the process of removing the FB, and the physical and radiological examinations after bronchoscopy suggestive of the ongoing presence of a foreign body. Beaded needles (
Fig. 2
a) were removed by a grasper and/or aspirator, the cylinder-shaped plastic pencil caps (
Fig. 2b) by means of grasping from both sides of the cap, and the beadlike FB by Fogarty balloon catheter (
Fig. 2c). Following the removal of the fragments smaller than the bronchoscope diameter, and of the FBs capable of defragmenting, the bronchus distal to FB and other bronchi were controlled. The FBs larger than bronchoscope diameter were removed together with the bronchoscope after FB were grasped with forceps, aspirator or balloon catheter. In suspected cases, the bronchoscope was reinserted to check the rest of FB fragments. The specimen for microbiologic culture was taken during bronchoscopy from those with complaints of chronic respiratory infection in 87 cases. Prophylactic antibiotics (the second-generation cephalosporines) were administered for 1–3 days to the patients who inhaled vegetable matters and had detected findings causing infection. If any specific microrganism was isolated from bronchial lavage taken at the time of bronchoscopy, the treatment continued with appropriate antibiotics.
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Fig. 2. (a) A beaded needle. (b) A pencil and its cap. (c) A bead and Fogarty balloon catheter passed through it.
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Results
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Foreign bodies were found in the right bronchial tree in 312 cases (56.9%), in the left in 126 cases (23.0%) and in the trachea in 62 cases (11.3%). Radiographic demonstration of FB depends on its opacity (
Fig. 3
). Atelectasis and hyperinflation were the most frequently presented radiologic findings (
Fig. 4
a,b) (Table 2). The most frequent FB was vegetable matter such as cereal grains and softening and expanding of these in the tracheobronchial tree was observed to absorb water (Table 3). Table 4 summarizes the management of FB. Post-bronchoscopically the patients were followed up in the hospital, usually for less than 24 h. Mechanical ventilation was required in six cases after bronchoscopy. Mortality rate was 0.7% (Table 5).
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Discussion
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Among the diagnostic methods employed in FB aspiration, history is the most important. History cannot be obtained from younger children who are left alone during the FB aspiration, and the case may go unnoticed. In some cases where older children are involved, the fear of being punished, in the event of their mentioning the incident to their elders in the family may cause them to refrain from doing so. It is a not remote possibility that the elder children avoid giving history for fear that their negligence is revealed. A careful and persistent history can provide an accurate diagnosis. In the literature, history has been considered an important diagnostic method
[1]
[3]
[4].
In the literature, the rate of roentgenographically normal appearance was about 10%
[2]
[3]
[5] as compared with 14% of our cases. In some series the rate at which no physical examination finding is seen may rise up to 39%
[5]. However this rate was 15.5% in our series. Bronchoscopy should be used as a diagnostic method in cases where the possibility of FB aspiration cannot be ruled out through history, physical and radiological examination. Upon diagnosis, early bronchoscopy is necessary because the earlier the bronchoscopy the lesser the complications. Fiberoptic bronchoscopes, which are less suitable for small children because of the small diameter of the trachea and glottis, are not acceptable. Some children with respiratory complaints wrongly have long been receiving treatment for pneumonia or asthma only because these current diagnostic methods were ineffective. Their definite diagnosis and treatment were provided by bronchoscopy, which was resorted to after unresponsiveness to previous treatment. Mantor et al. reported that morbidity evaluated in cases where medical treatment without bronchoscopy was used curatively
[3]. Some foreign bodies enlarge absorbing water in the tracheobronchial tree
[6]. Cereal grains, especially cooked ones, in the tracheobronchial system absorb water and expand. Ventilation in the other bronchial system, is more reliable even if it prolongs the duration of bronchoscopy. On the contrary, the attempts to remove a large piece at a time require that the bronchoscope be pulled out together with the piece and necessitate a further bronchoscopy to check for additional FBs in the distal segment. Unexpected high incidence (16.8%) of TBFA in children above 12 years was due to the aspiration of beaded needles (`turban' needles) which were pinned by girls in this age group. Beaded needles are used when wearing a headcover and held between the lips since both hands are busy for fastening the head cover, they are susceptible to air movements because their beads are made of a very light substance. They are extremely easy to aspirate in inspiratory movements such as speaking and coughing
[7]. In TBFBA, bronchiectasis and pulmonary damage can occur as complications of the late period
[8]. Removal of a cylindrical object with one end open, by holding bilaterally, has been considered an effective method. Yüksek et al., in their description of the method to remove of FB of the same kind, reported that they made a hole in the middle through which to insert a stiletto and remove the object
[9].
Bronchoscopy in children under 12 months requires skill because technical difficulties due to small instrumentation and bronchospasm commonly occurs when compared to older children. The irritation caused by the FB and bronchoscopy may cause laryngospasm and/or bronchospasm. Boorish contact of the bronchoscope or forceps with the bronchial wall, and the prolongation of bronchoscopy can be considered to be factors which contribute to spasm. It has been reported that a bronchoscope with appropriate diameter should be chosen and the procedure should be limited to 20 min in order to avoid possible subglottic and laryngeal oedema and bronchospasm after bronchoscopy
[10]. One reason for post-operative respiratory insufficiency, is that the pus accumulating distal to the removed FB is diffused into the entire bronchial system. In cases where pus distal to FB such as lung abscess due to FB, is verified by CT, pus is aspirated dislodging FB before it is removed because pus would not spread in bronchial tree. This technique seems to be employable. Pneumonia, the most frequent complication after bronchoscopy in the literature
[5], did not occur in our cases because of the intensive antibiotics, chest physiotherapy and cool mist provided, especially after the aspiration of oily seeds. TBFBA, one of the leading causes of accidental child deaths at home, does rarely cause deaths after the victim is safely brought to hospital
[10]
[11]. The cases, except two patients who had serious anoxic cerebral damage due to TBFBA and respiratory failure due to inhaled cement powder and died, might not have ended with death, if FBs, of softened bean and plastic toy pieces with accumulated pus distally, had been removed by the methods as mentioned above.
TBFBA can be identified using the existing diagnostic methods and, if the methods of removal are appropriate for the type of the FB is used, favorable outcomes with lower mortality and morbidity rates will be seen.
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References
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- Vane D.W., Pritchard J., Colville C.W., West K.W., Eiger H., Grosfeld J.L. Bronchoscopy for aspirated foreign bodies in children. Arch Surg 1988;123:885-888.[Abstract]
- Black R.E., Johnson D.G., Matlak M.E. Bronchoscopic removal of aspirated foreign bodies in children. Jour Ped Surg 1994;29:682-684.
- Mantor P.C., Tuggle D.W., Tunell W.P. An appropriate negative bronchoscopy rate in suspected foreign body aspiration. Am Jour Surg 1989;158:622-624.
- Steen K.H., Zimmermann T. Tracheobronchial aspiration of foreign bodies in children: a study of 94 cases. Laryngoscope 1990;100:525-530.[Medline]
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- Akçali Y., Ouzkaya F., Kahraman Ç., et al. Bronchiectasis. diagnosis and surgical treatment. Turk Arch Surg (Kayseri) 1997;2:47-54.
- Yüksek T., Solak H., Odaba
D., Yeniterezi M., Ozpinar C., Ozergin U. Dangerous pencils and new technique for removal of foreign bodies. Chest 1992;102:965-967.[Abstract/Free Full Text]
- Al-Hilou R. Inhalation of foreign bodies by children: review of experience with 74 cases from Dubai. Jour Laring Otol 1991;105:466-470.
- Elhassani N.B. Tracheobronchial foreign bodies in the Middle East. J Thorac Cardiovasc Surg 1988;96:621-625.[Abstract]
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Abstract
Introduction
