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Eur J Cardiothorac Surg 2005;28:369-374
© 2005 Elsevier Science NL
Original articles |
a Cardiothoracic Surgery, Mansoura University, 35516, Egypt
b Anaesthesia and ICU, Mansoura University, 35516, Egypt
c ENT, Mansoura University, 35516, Egypt
d Pediatrics, Mansoura University, 35516, Egypt
Received 24 February 2005; received in revised form 10 May 2005; accepted 11 May 2005.
* Tel.: +20 10 6166470; fax: +20 50 2265471. (Email: sameh001{at}yahoo.com).
Abstract
Objective: This retrospective study aims to compare the early and late clinical and management aspects of tracheobronchial aspirated foreign body (AFB), to evaluate the factors associated with delayed diagnosis of foreign body aspiration (FBA) in children and to compare clinical, radiological and bronchoscopic findings in the patients with suspected FBA. A retrospective review of a 10-year experience (from 1995 to 2005). A 1512-bed Mansoura University Hospital and 184-bed Mansoura University Emergency Hospital. Methods: The medical records of 3300 patients who underwent bronchoscopy for suspected FBA were reviewed. The data were analysed in three groups: the patients with negative bronchoscopy for FBA (group I), early (group II) and delayed diagnosis (group III). Foreign body was removed using the rigid bronchoscope with or without using the extracting forceps (Egyptian novel technique [Sersar IS, Abdulla AK, Abulela SA, Elsaeid AS, Abdulmageed NA. A novel technique to remove an inhaled foreign body without using a forceps. J Cardiovasc Dis 2004;2(4):157–158] described in the hand made illustration). Results: The majority of the patients with FBA were between 3 and 10 years of age. The penetration syndrome and decreased breath sounds were determined in a significantly higher number of the patients with FBA. The plain chest radiography revealed radio-opaque foreign bodies (FBs) in 23.56% of all patients with FBA. Pneumonia and atelectasis were significantly more common in the groups with negative bronchoscopy and with delayed diagnosis (P<0.01). The FBs were most frequently of vegetable origin, such as seeds and peanuts. A significant tissue reaction with inflammation and postbronchoscopic complications were more common in the delayed cases. The novel technique was used since then in 100 cases (4.62%) with a history of FBI (Pins and or small rounded materials). It was successful in 73 (73%) cases of non-impacted inhaled pins. Use of forceps was needed in 21 (21%) cases. Rebronchoscopy despite using both techniques was needed in six (6%) cases within 72h. Failed extraction of the inhaled FB occurred in three cases (3%) for whom bronchotomy was needed. Conclusions: Bronchoscopy is indicated on appropriate history and on suspicion. To prevent delayed diagnosis, characteristic symptoms, signs and radiological findings of FBA should be checked in all suspected cases. As clinical and radiological findings of FBA in delayed cases may mimic other disorders, the clinician must be aware of the likelihood of FBA.
Key Words: Foreign bodies • Radiography • Bronchoscopy
1. Introduction
Children tend to place and explore most objects in their mouths, so there is a significant risk of foreign body aspiration (FBA). Morbidity and mortality increase in the younger age group, presumably because children of a young age have narrow airways and immature protective mechanisms [2]. In one series, 78% of those who died after FBA were between 2 months and 4 years of age [3].
FBA is a life-threatening emergency and requires prompt removal, but sometimes it may remain undetected due to atypical history or misleading clinical and radiological findings [4,5]. Delayed diagnosis can occur when parents under-appreciated symptoms or when physicians overlook clinical and radiological findings. Inflammation and granulation tissue develop around the foreign body (FB) in delayed cases, and thus it is not uncommon for patients to be treated for other disorders such as persistent fever, asthma or recurrent pneumonia for a long period of time [6,7]. The diagnosis and removal of the object becomes much more difficult in such cases. Foreign body aspiration is one of the most common and serious problems among children accounting for 7% of lethal accidents in infants aged 1–3 years [2–4].
Coughing, choking, acute dyspnoea, and sudden onset of wheezing are the main symptoms of foreign body aspiration. Clinically, the problem is often apparent; however, symptoms can subside spontaneously and quickly even when a foreign body remains. Radiographic features depend on the size, location, duration, and nature of the foreign body. The chest radiograph may demonstrate a variety of findings including air trapping, atelectasis, consolidation, and bilateral overaeration [5].
Foreign body aspiration may result in either airway compromise and death or serious sequels such as recurrent pulmonary infections, atelectasis, and bronchiectasis. In order to prevent these complications, prompt diagnosis and removal of foreign body is mandatory [3,4,7,8].
Because of the risks of overlooked foreign body aspiration, even when there is a little suspicion or doubtful history, bronchoscopy is often performed for both definite diagnosis and treatment. Contrary to the general impression that bronchoscopy is simple and safe in paediatric patients, serious complications may occur even in experienced hands [8,10].
Therefore, definition of ideal diagnostic methods those minimise needless bronchoscopy for conditions that mimic airway foreign bodies and avoid delay when patients with foreign body require bronchoscopy is of utmost importance. Virtual bronchoscopy is a noninvasive technique that provides an internal view of trachea and major bronchi by three-dimensional (3D) reconstruction. The volumetric imaging data acquired by helical computed tomography (CT) can be manipulated and additional multiplanar and 3D reconstructions can be obtained. The use of virtual bronchoscopy technique in adults has been described [11–17].
It has been reported in the evaluation of suspected compression or narrowing of the trachea and main bronchi and in the treatment of esophageal atresia in infants and children [18,19].
2. Materials and methods
From January 1995 to February 2005, the medical records of 3300 children who underwent bronchoscopy for suspected FBA were reviewed. Age and sex of the patients, symptoms and signs, duration of symptoms before bronchoscopy, radiological and bronchoscopic findings including the type and the location of the FB were analysed in three groups. In group I (n=1135), patients had a negative bronchoscopy for FB; in group II (n=1900), patients received the diagnosis of FBA within 1 week of aspiration; in group III (n=265), the diagnosis of FBA was delayed beyond 1 week after aspiration. The diagnosis of FBA was confirmed by bronchoscopic examination. The inhaled FB was removed using a forceps or without using a forceps (Egyptian novel technique) which is a new technique to remove a foreign body (FB) from the airway using the rigid bronchoscope without using the extracting forceps. (Illustration).
It depends on:
The statistical analysis was performed mainly for groups (2) and (3) with an analysis of variance (ANOVA) followed by Tukey's procedure and post hoc tests chi-square tests and Student's t test for independent samples or 
2. The statistical significance level was fixed at a P-value <0.05.
3. Results
3.1 Clinical and radiological findings
Age and sex of the patients witnessed ingestions, signs and symptoms determined in the history, physical examinations, and duration of symptoms before bronchoscopy are listed in Table 1 . The difference was not significant for sex distribution (P>0.05). The mean age difference was significant between groups I and II (P<0.01). The number of the patients under the age of 1 year was significantly higher in group I than groups II and III (P<0.01), and the number of the patients above the age of 3 years in group (2) was significantly more than groups (1) and (3). The majority of the patients with FBA were between 3 and 10 years of age (929 patients) (48.89% in group II) and between 1 and 3 years (63 patients) (30.94% in group III).
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A plain chest radiograph was routinely obtained in all suspected cases, but 100 patients underwent emergency bronchoscopic removal of the FB without undergoing pre-bronchoscopic radiography or coming with a CT chest and no plain chest X-ray is done (3.03%). Paired inspiratory and expiratory films are theoretically ideal, but were not routinely feasible due to lack of cooperation as most of our patients were younger than school age.
Radiological findings on plain chest radiography are listed in Table 1. The radiographs revealed radio-opaque FBs in 467 endobronchial tree and 12 in the oesophagus. The number of the radio-opaque FBs was significantly higher in group II than group III (P<0.05). Emphysema was more common in children with FBA. Obstructive emphysema (Air traping) was significantly higher in groups II (P<0.01) and III (P<0.05) than group I. Atelectasis and pneumonia were significantly more common in groups I and III compared with group II (P<0.01). The number of normal radiographs was significantly higher in group I than the other groups with FBA (P<0.05). Atelectasis was determined in 317 patients (9.6%), from whom 3.09% were negative. Fifty records of chest fluoroscopy were found, and 41 were positive for air trapping and mediastinal shift suggesting FBA, which was later confirmed by bronchoscopy. Nine hundred patients had some significant clues in their histories and/or physical examinations, but they had negative radiographs, or the patients were too young to cooperate to produce an appropriate film. Two hundred and fifty computed tomography (CT) records of the chest were found. CT was performed for the differential diagnosis of suspected cases having atypical histories, clinical and radiological findings. Virtual bronchoscopy was done in three cases only as the history was not highly suspicious and the general anaesthesia was a major concern.
The complications were recorded in 147 patients (4.45%). They were significantly higher in groups III (P<0.01) and II (P<0.05) than group I. They included irreversible arrest in four cases, major airway injury requiring repair in 10 cases, barotrauma needing an ICT in 15 cases, failure to extract the FB in 44 cases who required rebronchoscopy, from whom 24 patients required re-rebronchoscopy. Bronchotomy was done in 13 cases of impacted FB with distal airway obstruction. Pulmonary resections were done in seven cases and all were in group III. Laryngeal oedema was recorded in 67 cases of whom 25 cases required temporary tracheostomy (Table 2 ).
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The diagnosis of FBA is elusive in delayed cases. Children may present with no history of aspiration or atypical history with non-specific symptoms [4,5,8,9].
Accurate history and a high index of suspicion are needed to prevent delayed diagnosis and the complications.
Age of the patient is one of the significant criteria in diagnosis of the suspected cases. As we observed in our study, whether it is an early or delayed presentation, approximately 52.29% of FBA (1726 patients) occur below the age of 3 years. We found that the incidence of FBA increases between 1 and 3 years of age. We also determined that the possibility of negative bronchoscopy in suspected cases is significantly high under the age of 1 year. This may be due to mucous plugs, which can mimic FBA, causing obstruction of the bronchioles because the airways of infants of this age are narrower. The high rate of negative bronchoscopy may be due to the fact that CT was unavailable or unreliable at a time in out centre; the patients could not be trusted to return for outpatient follow-up and we usually broaden the scope of indications for rigid bronchoscopy.
The most common signs and symptoms of FBA are choking, coughing, wheezing and decreased breath sounds [12,13]. Of all these signs and symptoms, the most predictive one is witnessed aspiration associated with a choking episode (penetration syndrome). Long-standing FBs can cause significant inflammation and tissue reactions; and with delayed presentation, additional symptoms and signs of unresolved or recurrent pneumonia and persistent cough may occur [8–10]. In our study, we also showed that the clinical signs and symptoms of pneumonia were found in a significantly higher number of the patients with delayed diagnosis.
Radio-opacity of FBs prevents misinterpretation of the symptoms and provides an early and accurate diagnosis. In the present study, only (479 patients) 15.72% of all FBs were radio-opaque and we also found that the number of the radio-opaque FBs was significantly less in the group with delayed diagnosis. The type of FB is an important factor that determines the progress of the pathology caused by the lodgement. As we determined in our study, most aspirated FBs are radiolucent and most frequently of food origin [12–15]. In children younger than 3 years, 80% of airway FBs are found to be food or other radiolucent items [13]. If the clinician only trusts the radiological findings and does not consider an early bronchoscopy in patients with strong history, the diagnosis can be delayed if there are no indirect signs indicating the presence of a radiolucent object on the plain chest radiograph. This is important, because the longer a FB is left in situ, the greater the inflammatory response and the likelihood of complications. The inflammatory response is much more significant with food particles. Because of their oil content, most frequently inhaled vegetable matters, such as peanuts, seeds and nuts set up intense inflammatory responses, thus narrowing the airway further, causing consolidation to develop distal to the obstruction. Obstructive emphysema is the typical indirect radiological sign of a radiolucent inhaled object. Hyperinflation due to a check valve obstruction by the object and reflex oligaemia due to hypoventilation cause unilateral hyperlucent lung [2]. In our study, the most significant indirect radiological signs of FBA we found were emphysema, atelectasis and pneumonia. While emphysema was observed in both early and delayed presentation of FBA, atelectasis and pneumonia were determined significantly in higher number of the patients with delayed diagnosis. In persistent bronchial obstruction, pneumonia develops in 9–26% of cases [17–19]. In the present study, 222 patients (6.72%) of which the patients with FBA had pneumonia, but the number increased significantly with delayed presentation (in 27.16%). In the delayed cases, the bronchoscopic evaluation showing intense inflammatory changes with increased granulation and mucoid secretion confirmed our pre-bronchoscopic clinical and radiological findings suggesting pneumonia. Plain chest radiography shows atelectasis in approximately 25% of the patients with FBA [17–19]. In this study, atelectasis was determined in (317 cases) 9.6% of the patients with FBA, and in the delayed cases it increased to 32.7%. With persistent lodgement, the object may progress distally resulting in complete endobronchial obstruction and mucosal inflammation with oedema, granulation and viscous secretion, which aggravates the pathology and may result in atelectasis (Figs. 3 and 4 ).
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In the presence of normal radiographs and a strong history, the radiologist and clinician, depending on their experiences and facilities, should decide whether the child should undergo fluoroscopy or bronchoscopy. If an expiratory film cannot be obtained due to lack of cooperation, or negative radiological findings are present, then fluoroscopy may help to detect the presence of a FB. If present, air trapping and shift of mediastinal structures to the opposite side can be easily identified at fluoroscopy. We do rigid bronchoscopy for suspected history with any chest trouble with persistent radiologic abnormalities. Although CT occasionally demonstrates an opacity not visualised on the plain film, it should not be considered as one of the initial diagnostic methods for FBA. CT may help with the differential diagnosis of suspected cases having atypical histories, clinical and radiological findings with delayed presentation and complications. The differential diagnosis in such cases include tracheobronchial obstructions caused by external compression of airways (e.g. enlarged lymph node, tumours, cardiac enlargement) or intra-luminal obstructions (e.g. tumours, granulomatous tissue, as in tuberculosis, secretions and mucous plugs as in bacterial pneumonia, cystic fibrosis, asthma, pulmonary abscess and acute laryngotracheobronchitis). Virual bronchoscopy was done for three cases. It was helpful to diagnose an endobronchial obstruction. Rigid bronchoscopy showed the FBI as the cause of this obstruction.
Children with FBA may present with atypical or misleading history, clinical and radiological findings. Misdiagnosis such as asthma, pneumonia, croup and reactive airway diseases may lead to a delayed diagnosis. To prevent complications caused by delayed diagnosis, the clinician must maintain a high index of suspicion. In suspected cases, a more extensive history and physical examination should be obtained. Regardless of radiological findings, when FBA is the suspected diagnosis in a patient with a history of a witnessed episode of choking, a transient cyanosis and coughing, an early bronchoscopic examination should be considered. Negative radiography and fluoroscopy should not preclude bronchoscopy in patients with a strong history.
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The authors present their thanks to Professor Mohammed Mounir Elsaeid, MD, Professor Shabban A. Abulela, MD and Professor Abed Abdel Samea Mowafy, MD for their assistance, advice and support.
References
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