Lower Airway Foreign Body Aspiration in Children An N.
Shirazy Majd, M.D.,* Howard
Analysis of 13
Cases
C. Mofenson, M.D., F.A.A.P.,**
Joseph Greensher, M.D., F.A.A.P.† This analysis of thirteen cases of lower airway foreign body aspiration in children reveals a high incidence of aspiration into the left main bronchus, and an increased incidence in older children. Early identification of nonradio opaque foreign bodies such as food and plastic toys is difficult in the absence of a positive history. Suggestions are offered for prevention, early
detection, and treatment.
FOREIGN
BODY aspiration is the greatest of accidental death in homes among children under 6 years of age. 1.2 Safety pins have been the most frequently aspirated items in infants under one year, with coins and nuts being more common in the 2 to 4 year group.’ According to the National Safety Council, approximately 2,900 deaths occur annually in the United States from inhalation or ingestion of foreign bodies.4 Jackson and Jackson, who reviewed over 3,000 incidents of foreign bodies in the air and food passages, found that carelessness was the primary mechanism in 87 percent. There often was a history of too-rapid eating, improper chewcause
*
Pediatric Resident at Nassau Hospital, Mineola, New York. ** Professor of Clinical Pediatrics, at State University of New York at Stony Brook, Attending Pediatrician at Nassau Hospital, Mineola, New York. &dag er; Associate Professor of Clinical Pediatrics, at State University of New York at Stony Brook, Attending Pediatrician at Nassau Hospital, Mineola, New York. From the Pediatric Department, Nassau Hospital, Mineola, New York, 11501.
ing, laughing, running with food in the mouth, or just holding in the mouth a potential foreign body such as a pin, nail, nut or small toy. Peanuts and peanut candy are frequent offenders.5 Other predisposing conditions can be drug .
alcohol intoxication, seizures, anesthesia states, or head trauma with unconsciousness, in any of which the cough reflex may be temporarily depressed or absent. A decreased gag reflex such as may exist in familial dysautonomia and some cases of cerebral palsy also enhances the chance of aspiration. A foreign body should be suspected in any young child who has a sudden episode of or
choking, coughing, gagging, aphonia or dysphonia, or wheezing or dyspnea, despite complete clearing of these symptoms soon afterward.~ In a non-asthmatic child, a persisting croupy cough or wheezing which is unresponsive to epinephrine should arouse suspicion of foreign body aspiration. Physical findings of tracheal or cardiac impulse shift, persistent or recurrent pneumonia (particu13
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on March 3, 2015
if always in the same segment), localized atelectasis or emphysema, or a lung abscess should prompt a search for a foreign body in
larly
the airway. We here present
a
recent case
of lower
foreign body, and reairway aspiration view ten years’ experiences in a community hospital. It emphasizes the difference we have encountered from the classic description of foreign body aspiration. In the classical case the foreign body is more likely to enter the right bronchus and rarely occurs in children over 4 years of age. Suggestions for improving the recognition of this condition and the prevention of this hazard will be discussed. of a
Case Report A 26-month-old white boy was hospitalized beof a four day history of fever and coughing. There was a questionable history of an aspiration episode two weeks earlier. At that time the mother found parts of a toy train in the child’s mouth and extracted two plastic couplings after slapping him on the back. Later, when the child developed mild wheezing, he was taken to the Emergency Room of a local hospital where a nega-
cause
-~--
FIG. 2. This decubitus film of the chest with the patient lying on his left side reveals no significant shift of the heart into the left hemithorax nor any discrepancy in lucency of the left or right hemithorax. Normally, on a decubitus film, the heart will shift into the dependent lung due to poorer aeration of the dependent side.
tive chest
x-ray was
obtained and he
was
dis-
’
charged.
When we first saw him his temperature was ~ QfJ.4; breath sounds were decreased on the left side of the chest, and wheezing was heard at
the left base. A chest x-ray revealed an infiltration in the region of the lingula and adjacent portion of the lower lobe on the left side; no radioopaque foreign body was seen. W.B.C. was l!,900/mms with ~8~‘~ PMNS. Cold ag~Iutinin test was negative. A blood culture showed no growth. Nose and throat cultures grew normal flora, and bronchial washings showed no
growth.
i
FIG. 1. An upright PA chest film two days after admission reveals a tingular infiltrate adjacent to the left heart border as well as a suggestion of increased luency of the left hemithorax as compared with the
right.
He was given antimicrobial therapy with Ampicillin without clinical benefit. A repeat chest film two days later showed the same infiltration in the left lung, and increased lucency in the left hemithorax (Fig. 1). A left lateral decubitus film of the chest demonstrated lack of normal compressibility of the dependent lung (Fig. 2). A later PA chest film taken at a greater degree of expiration indicated marked hvperlucency of the left lung field with a shift of the heart and mediastinum toward the right hemithorax (Fig. 3). The diagnosis was made of obstructive emphysema behind a partially occluding endobronchial lesion. Bronchoscopy removed a plastic screw from the left main bronchus (Fig. 4).
14
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on March 3, 2015
Review of Cases Thirteen cases of foreign body aspiration into the lower airway were admitted to Nassau Hospital from January 1965 to January 9’74.’ (Eleven of them ranged in age from 0 to 4 years, there were 9 boys among them, and 10 had a suggestive history.) Here is a summary of the findings in these 13 cases:
Symptoms: Wheezing, 10 Cough, 10 Respiratory Dis-
Stridor, 3
Cyanosis, 2
FiG. 4. Plastic
screw removed from the left main bronchus.
Fever, 1
tress, 6
Physical Findings: Wheezing, l I
Type
Cyanosis,
2
physema, 7 Shift of Mediastinum, 4 Elevated Dia-
Sunflower seed, 1 Plastic screw, I
Location:
X-Ray Findings: em-
Foreign Body:
Carrot, 2 Food, 3
Diminished breath sounds, 8
Obstructive
of
Peanut, 6
Right
Atelectasis, 2 Infiltration, 2
Radio-opaque foreign body,
main
bronchus, 8 0
Left main
bronchus, 5
Discussion
The
foreign body is said to be more likely the right bronchus because of its size and less acute angle with the large
phragm, 2
to enter
trachea, but in this series of 13
cases, five left-sided. Early detection of a foreign body in the lower airway requires a high index of suspicion and specific questioning about the . ossibility of aspiration. This information may not be volunteered and the aspiration may have taken place months, or even years prior to admission. The physical examination in suspect cases should emphasize the location of the cardiac impulse and the trachea, the presence of retractions of the chest, wheezing, and focal suppression of breath sounds. Proper radiologic studies are essential: the choice of x-ray views will depend on the presumed location of the object. There should be both inspiratory and expiratory x-ray films of the chest, including right and left decubitus views in questionable cases. Fluoroscopy may be necessary. Lung scan has been successful. were
Treatment Fi~. 3. This PA erect chest film which is iess of an inspiratory effort than Figure 1 reveals a shift of the heart and mediastinum toward the right side with increased hyperlucency of the left lung field.
’
The location determines the urgency of Upper airway foreign bodies are a direct threat to life and require immediate removal. treatment.
15
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on March 3, 2015
Lower airway foreign bodies typically need less-urgent attention. The necessary bronchoscopy should be a planned elective procedure. When fever and purulent secretions are present as signs of secondary bac-
terial infection, this should be treated first with antimicrobial agents and the patientt should be well hydrated prior to endoscopy. Postural drainage in conjunction with aerosol therapy can be useful, particularly when the object could not be reached by a bronchoscope. Caution: This maneuver carries the risk of the foreign body shifting dangerously; therefore it should be done in intensive care by the endoscopiSt.7
chemical pneumonia with tendency to chronic lung disease. A recent recommendation would have replaced the copper in pennies with an aluminum alloy. These would no longer be radioopaque and would be more difficult to localize when aspirated. Fortunately the price of copper has dropped and the U.S. Treasury Department will continue producing copper
pennies.9 Acknowledgments We thank Dr. Louis Ferraro, Director of Nassau
Hospital Pathology Department, Dr. Mark Gershwind of Nassau Hospital Radiology Department, and Mrs. Sylvia Davis for their assistance. References
Prevention
Physicians who care for young children should emphasize to the parents the dangers of playing with small objects less than 3 cm in diameter. The government-proposed toy standards for the under three-year age group require that these be a minimum of 1.25 inches in diameter and should not fit into the confines of a specified truncated circular cylinder 2.25 inches long.8 Older children likewise should be taught not to hold foreign bodies in their mouths. Two of our patients were over 4 years of age. One of these, a 10 year old, aspirated a peanut at a football game. Hard, smooth vegetable-type foods such as peanuts should be avoided with young children. These are easily aspirated and cause not only obstruction, but a severe
1. Leonidas, J. C.: Radionuclide the
diagnosis
of endobronchial
lung scanning
foreign bodies
in in
children. J. Pediatr. 83: 628, 1973. Bunker, P. G.: Practical points about detecting and removing foreign bodies, Consultant, September 1965, p. 30. 3. National Safety Council: Accident facts. Chicago, The National Safety Council, 1969, pp. 12 and 81. 4. National Safety Council: Accident facts, 1975. 2.
5.
Jackson, C., and Jackson, C. L.: Diseases of the air and Food Passages of Foreign Body Origin.
Philadelphia,
W. B. Saunders Co., 1907, pp. 30-
38. 6.
Yonkers, A. J., and Yarington, Jr.,
C. T.:
Foreign
bodies in the air and food passages. Paediatrician 1: 146, 1972/73. 7. Cotton, E. K. et al.: Removal of aspirated foreign bodies by inhalation and postural drainage. Clin. Pediatr. 12: 270, 1973. 8. Federal Register 25:2179, No. 14, Monday, Jan. 27, 1973.
9.
Heller, R. M.
et al.: The
problem
with the
replace-
copper pennies by aluminum pennies, Pediatrics 54: 684, 1974. ment of
16
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on March 3, 2015
Shirazy Majd, M.D.,* Howard
Analysis of 13
Cases
C. Mofenson, M.D., F.A.A.P.,**
Joseph Greensher, M.D., F.A.A.P.† This analysis of thirteen cases of lower airway foreign body aspiration in children reveals a high incidence of aspiration into the left main bronchus, and an increased incidence in older children. Early identification of nonradio opaque foreign bodies such as food and plastic toys is difficult in the absence of a positive history. Suggestions are offered for prevention, early
detection, and treatment.
FOREIGN
BODY aspiration is the greatest of accidental death in homes among children under 6 years of age. 1.2 Safety pins have been the most frequently aspirated items in infants under one year, with coins and nuts being more common in the 2 to 4 year group.’ According to the National Safety Council, approximately 2,900 deaths occur annually in the United States from inhalation or ingestion of foreign bodies.4 Jackson and Jackson, who reviewed over 3,000 incidents of foreign bodies in the air and food passages, found that carelessness was the primary mechanism in 87 percent. There often was a history of too-rapid eating, improper chewcause
*
Pediatric Resident at Nassau Hospital, Mineola, New York. ** Professor of Clinical Pediatrics, at State University of New York at Stony Brook, Attending Pediatrician at Nassau Hospital, Mineola, New York. &dag er; Associate Professor of Clinical Pediatrics, at State University of New York at Stony Brook, Attending Pediatrician at Nassau Hospital, Mineola, New York. From the Pediatric Department, Nassau Hospital, Mineola, New York, 11501.
ing, laughing, running with food in the mouth, or just holding in the mouth a potential foreign body such as a pin, nail, nut or small toy. Peanuts and peanut candy are frequent offenders.5 Other predisposing conditions can be drug .
alcohol intoxication, seizures, anesthesia states, or head trauma with unconsciousness, in any of which the cough reflex may be temporarily depressed or absent. A decreased gag reflex such as may exist in familial dysautonomia and some cases of cerebral palsy also enhances the chance of aspiration. A foreign body should be suspected in any young child who has a sudden episode of or
choking, coughing, gagging, aphonia or dysphonia, or wheezing or dyspnea, despite complete clearing of these symptoms soon afterward.~ In a non-asthmatic child, a persisting croupy cough or wheezing which is unresponsive to epinephrine should arouse suspicion of foreign body aspiration. Physical findings of tracheal or cardiac impulse shift, persistent or recurrent pneumonia (particu13
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on March 3, 2015
if always in the same segment), localized atelectasis or emphysema, or a lung abscess should prompt a search for a foreign body in
larly
the airway. We here present
a
recent case
of lower
foreign body, and reairway aspiration view ten years’ experiences in a community hospital. It emphasizes the difference we have encountered from the classic description of foreign body aspiration. In the classical case the foreign body is more likely to enter the right bronchus and rarely occurs in children over 4 years of age. Suggestions for improving the recognition of this condition and the prevention of this hazard will be discussed. of a
Case Report A 26-month-old white boy was hospitalized beof a four day history of fever and coughing. There was a questionable history of an aspiration episode two weeks earlier. At that time the mother found parts of a toy train in the child’s mouth and extracted two plastic couplings after slapping him on the back. Later, when the child developed mild wheezing, he was taken to the Emergency Room of a local hospital where a nega-
cause
-~--
FIG. 2. This decubitus film of the chest with the patient lying on his left side reveals no significant shift of the heart into the left hemithorax nor any discrepancy in lucency of the left or right hemithorax. Normally, on a decubitus film, the heart will shift into the dependent lung due to poorer aeration of the dependent side.
tive chest
x-ray was
obtained and he
was
dis-
’
charged.
When we first saw him his temperature was ~ QfJ.4; breath sounds were decreased on the left side of the chest, and wheezing was heard at
the left base. A chest x-ray revealed an infiltration in the region of the lingula and adjacent portion of the lower lobe on the left side; no radioopaque foreign body was seen. W.B.C. was l!,900/mms with ~8~‘~ PMNS. Cold ag~Iutinin test was negative. A blood culture showed no growth. Nose and throat cultures grew normal flora, and bronchial washings showed no
growth.
i
FIG. 1. An upright PA chest film two days after admission reveals a tingular infiltrate adjacent to the left heart border as well as a suggestion of increased luency of the left hemithorax as compared with the
right.
He was given antimicrobial therapy with Ampicillin without clinical benefit. A repeat chest film two days later showed the same infiltration in the left lung, and increased lucency in the left hemithorax (Fig. 1). A left lateral decubitus film of the chest demonstrated lack of normal compressibility of the dependent lung (Fig. 2). A later PA chest film taken at a greater degree of expiration indicated marked hvperlucency of the left lung field with a shift of the heart and mediastinum toward the right hemithorax (Fig. 3). The diagnosis was made of obstructive emphysema behind a partially occluding endobronchial lesion. Bronchoscopy removed a plastic screw from the left main bronchus (Fig. 4).
14
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on March 3, 2015
Review of Cases Thirteen cases of foreign body aspiration into the lower airway were admitted to Nassau Hospital from January 1965 to January 9’74.’ (Eleven of them ranged in age from 0 to 4 years, there were 9 boys among them, and 10 had a suggestive history.) Here is a summary of the findings in these 13 cases:
Symptoms: Wheezing, 10 Cough, 10 Respiratory Dis-
Stridor, 3
Cyanosis, 2
FiG. 4. Plastic
screw removed from the left main bronchus.
Fever, 1
tress, 6
Physical Findings: Wheezing, l I
Type
Cyanosis,
2
physema, 7 Shift of Mediastinum, 4 Elevated Dia-
Sunflower seed, 1 Plastic screw, I
Location:
X-Ray Findings: em-
Foreign Body:
Carrot, 2 Food, 3
Diminished breath sounds, 8
Obstructive
of
Peanut, 6
Right
Atelectasis, 2 Infiltration, 2
Radio-opaque foreign body,
main
bronchus, 8 0
Left main
bronchus, 5
Discussion
The
foreign body is said to be more likely the right bronchus because of its size and less acute angle with the large
phragm, 2
to enter
trachea, but in this series of 13
cases, five left-sided. Early detection of a foreign body in the lower airway requires a high index of suspicion and specific questioning about the . ossibility of aspiration. This information may not be volunteered and the aspiration may have taken place months, or even years prior to admission. The physical examination in suspect cases should emphasize the location of the cardiac impulse and the trachea, the presence of retractions of the chest, wheezing, and focal suppression of breath sounds. Proper radiologic studies are essential: the choice of x-ray views will depend on the presumed location of the object. There should be both inspiratory and expiratory x-ray films of the chest, including right and left decubitus views in questionable cases. Fluoroscopy may be necessary. Lung scan has been successful. were
Treatment Fi~. 3. This PA erect chest film which is iess of an inspiratory effort than Figure 1 reveals a shift of the heart and mediastinum toward the right side with increased hyperlucency of the left lung field.
’
The location determines the urgency of Upper airway foreign bodies are a direct threat to life and require immediate removal. treatment.
15
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on March 3, 2015
Lower airway foreign bodies typically need less-urgent attention. The necessary bronchoscopy should be a planned elective procedure. When fever and purulent secretions are present as signs of secondary bac-
terial infection, this should be treated first with antimicrobial agents and the patientt should be well hydrated prior to endoscopy. Postural drainage in conjunction with aerosol therapy can be useful, particularly when the object could not be reached by a bronchoscope. Caution: This maneuver carries the risk of the foreign body shifting dangerously; therefore it should be done in intensive care by the endoscopiSt.7
chemical pneumonia with tendency to chronic lung disease. A recent recommendation would have replaced the copper in pennies with an aluminum alloy. These would no longer be radioopaque and would be more difficult to localize when aspirated. Fortunately the price of copper has dropped and the U.S. Treasury Department will continue producing copper
pennies.9 Acknowledgments We thank Dr. Louis Ferraro, Director of Nassau
Hospital Pathology Department, Dr. Mark Gershwind of Nassau Hospital Radiology Department, and Mrs. Sylvia Davis for their assistance. References
Prevention
Physicians who care for young children should emphasize to the parents the dangers of playing with small objects less than 3 cm in diameter. The government-proposed toy standards for the under three-year age group require that these be a minimum of 1.25 inches in diameter and should not fit into the confines of a specified truncated circular cylinder 2.25 inches long.8 Older children likewise should be taught not to hold foreign bodies in their mouths. Two of our patients were over 4 years of age. One of these, a 10 year old, aspirated a peanut at a football game. Hard, smooth vegetable-type foods such as peanuts should be avoided with young children. These are easily aspirated and cause not only obstruction, but a severe
1. Leonidas, J. C.: Radionuclide the
diagnosis
of endobronchial
lung scanning
foreign bodies
in in
children. J. Pediatr. 83: 628, 1973. Bunker, P. G.: Practical points about detecting and removing foreign bodies, Consultant, September 1965, p. 30. 3. National Safety Council: Accident facts. Chicago, The National Safety Council, 1969, pp. 12 and 81. 4. National Safety Council: Accident facts, 1975. 2.
5.
Jackson, C., and Jackson, C. L.: Diseases of the air and Food Passages of Foreign Body Origin.
Philadelphia,
W. B. Saunders Co., 1907, pp. 30-
38. 6.
Yonkers, A. J., and Yarington, Jr.,
C. T.:
Foreign
bodies in the air and food passages. Paediatrician 1: 146, 1972/73. 7. Cotton, E. K. et al.: Removal of aspirated foreign bodies by inhalation and postural drainage. Clin. Pediatr. 12: 270, 1973. 8. Federal Register 25:2179, No. 14, Monday, Jan. 27, 1973.
9.
Heller, R. M.
et al.: The
problem
with the
replace-
copper pennies by aluminum pennies, Pediatrics 54: 684, 1974. ment of
16
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on March 3, 2015
