CLINICAL
REVIEW
Tracheobronchial Foreign Bodies in Adults Andrew H. Limper, MD; and Udaya B. S. Prakash, MD
Study Objective: To define the clinical spectrum of tracheobronchial foreign body aspiration in adults, assess predisposing conditions, evaluate the efficacy of bronchoscopy, and determine outcome and complications. Design: Retrospective analysis of a consecutive clinical series. Setting: A tertiary care, referral-based medical center. Patients: Sixty consecutive adult patients (over 16 years of age) evaluated for tracheobronchial foreign body aspiration. Interventions: All 60 patients had bronchoscope evaluation; 59 of them had foreign bodies identified and removal was attempted using either rigid or flexible fiberoptic bronchoscopy. Main Results: Of 60 consecutive patients, 25 had underlying impairment of protective airway mechanisms (primary neurologic disorders, trauma with loss of consciousness, or sedative or alcohol use). Fifty-seven were successfully managed with bronchoscopy. Fiberoptic bronchoscopy was successful in 14 of 23 patients, and rigid bronchoscopy was successful in 43 of 44 patients, including 6 of 7 patients in whom previous fiberoptic bronchoscopy had failed. Thoracotomy was required in 3 patients. Complications of bronchoscopy were rare and not serious. Chronic complications of prolonged foreign body impaction included bronchiectasis in 3 patients. Conclusions: Although rare, tracheobronchial foreign body aspiration in adults can occur in various clinical settings. High clinical suspicion is necessary for diagnosis. Removal of foreign bodies can usually be accomplished with bronchoscopy.
Aspiration of foreign bodies into the tracheobronchial tree is much commoner in children than in adults (1-8). Annual death rates from foreign body aspiration in the United States range from 500 to 2000, with more than half occurring in children between the ages of six months and four years (9-11). Although a review (12) in 1982 analyzed 141 fatalities associated with acute food asphyxiation (the Cafe coronary syndrome), there have been no reports on large series of adults with nonasphyxiating tracheobronchial foreign bodies. The classic monograph on tracheobronchial foreign bodies, done by Jackson and colleagues (13) in 1937, summarized the cases of 191 adults with tracheobronchial foreign bodies. However, earlier diagnosis, availability of antibiotics, and newer bronchoscopy instruments make it difficult to compare the clinical features and treatment of these reported cases with those of current tracheobronchial foreign body aspiration cases. A review of more recent reports (14-19) reveals a paucity of information on this topic, particularly in adults, with only a few case reports in the literature. Details of chronic complications in adults as a result of tracheobronchial foreign body aspiration are also scanty in the reports. Management of tracheobronchial foreign body aspiration has evolved substantially, mostly because of wider application of fiberoptic bronchoscopy in clinical practice. The instrument of choice for extracting tracheobronchial foreign bodies in children is the rigid bronchoscope (4, 13). Traditionally, rigid bronchoscopy has also been the preferred treatment for adults (13). Recent reports (20-22) have suggested that fiberoptic bronchoscopy may be a valuable therapeutic option for adults, although large clinical series using this technique have not been reported. To define the clinical spectrum of tracheobronchial foreign body aspiration in adults, assess predisposing conditions, evaluate the efficacy of bronchoscopy, and determine outcome and complications, we report our experience with adults who were evaluated at the Mayo Clinic and Mayo Medical Center hospitals.
Patients and Methods
Annals of Internal Medicine. 1990;112:604-609. From the Mayo Clinic and the Mayo Medical School, Rochester, Minnesota. For current author addresses, see end of text. 604
Using the Mayo Clinic medical record registry and cross index system, we did a retrospective analysis of all patients over 16 years of age who were evaluated at the Mayo Clinic for tracheobronchial foreign body aspiration between 1956 and 1989. "Tracheobronchial foreign body" was defined as any solid object aspirated below the level of the vocal cords. Patients with aspiration of regurgitated gastric contents were excluded from this study. Over the 33-year period, 60 such patients were identified. We reviewed the clinical records of these patients to determine the nature of the aspirated object, the duration and presence of symptoms (including cough, fever, and hemoptysis), and the presence of associated abnormalities on standard chest roentgenogram. In addition, we tried
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to identify any factors that might impair neurologic functioning or the normal deglutition mechanism, thus predisposing the patient to tracheobronchial foreign body aspiration. All 60 patients had diagnostic bronchoscopy; 59 of them had foreign bodies identified and removal attempted bronchoscopically. The bronchoscopic records of all patients were abstracted to determine the site of foreign body impaction in the tracheobronchial tree, the methods of attempted bronchoscopic removal (using either rigid or fiberoptic bronchoscopy), and the success of such treatments. Before 1970, all bronchoscopies were done using the rigid bronchoscope (18 cases). After 1970, the choice between the rigid bronchoscope (19 cases) and the fiberoptic bronchoscope (23 cases) was made by the individual bronchoscopist. Those patients whose foreign bodies were not identified or could not be removed bronchoscopically were managed with thoracotomy (3 patients), and the operative records of these patients were likewise reviewed. Long-term complications of foreign body lodgment in the tracheobronchial tree were also reviewed and results recorded. Results Of the 60 adult patients evaluated at the Mayo Clinic for tracheobronchial foreign body aspiration, 42 were men, yielding a male-to-female ratio of 2.4:1. The median age was 60 years (range, 18 to 88 years). A predominance of cases was noted in the seventh decade of life (18 patients), with the remainder of cases evenly distributed in the other decades. The nature of the aspirated foreign body was highly variable (Table 1). The most commonly aspirated objects were food items (24 patients), with peanuts leading the list (7 patients). Vegetable matter accounted for 17 of these aspirations, with the remaining seven caused by meat and bones. The patients in this group were readily aware of the aspiration event and, in general, had normal sensoria and no reported use of alcohol or other sedatives. The second predominant group of aspirated objects (19 patients) consisted of dental equipment or prostheses, tracheostomy tube segments, and endotracheal tube appliances inadvertently lost during dental or medical procedures. These aspirations were identified immediately at the time of the associated procedures. The final group of aspirated objects (17 patients) included such miscellaneous items as straight pins, coins, buttons, stones, pieces of plastic, teeth, and a beverage can pull-tab. Most patients who were evaluable had symptoms associated with tracheobronchial foreign body aspiration. Symptoms were not evaluable in 12 patients, because aspiration occurred while patients were comatose secondary to trauma (6 patients) or under general anesthesia (3 patients). Records of symptoms were unavailable for 3 patients. Cough was the commonest manifestation, present in 45 of 48 patients. Temperature elevation to at least 38 °C was recorded in 11 patients, and hemoptysis was noted in 9 patients. Dyspnea was seen in 8 patients and chest pain in 4. Only 1 evaluable patient denied all related pulmonary symptoms. His aspirated foreign body, a coin, was detected coincidentally on a chest roentgenogram obtained during evaluation for an unrelated injury (Figure 1). In most cases, diagnosis was made promptly, with symptoms present for a median of 10 days before bronchoscopic examination (range, 1 hour to 13 years). However, diagnosis was delayed in several cases due to patients neglecting their symptoms
Table 1. Types of Tracheobronchial Aspirated by 60 Adults
Foreign
Bodies
Object
Cases n
Food particles Vegetable matter Meat and bones Total Iatrogenic aspirations Dental appliances Medical appliances Total Miscellaneous Straight pins Safety pin Piece of plastic drinking straw Stone Coin Beverage can pull-tab Tooth Pine needle Button Grass inflorescence Vitamin tablet Metal toy Denture fragment Thermometer Thumb tack Total
17 7 24 10 9 19
17
or to failed attempts at diagnosis or treatment before referral for bronchoscopic evaluation at our institution. Various underlying conditions were detected that contributed to tracheobronchial aspiration of foreign bodies (Table 2). Eleven patients had primary neurologic disorders, including seizures, brain tumors, Parkinson disease, mental retardation, cerebral palsy, and conditions caused by recent cerebrovascular accidents. Dental procedures, with their associated supine position and local anesthesia, commonly predisposed patients toward tracheobronchial foreign body aspiration. Medical procedures, particularly those involving cleaning, replacing, or manipulating tracheostomy or endotracheal tubes had a similar effect. Trauma with associated loss of consciousness and cervicofacial injury and alcohol or sedative use were also found to contribute to tracheobronchial foreign body aspirations. The standard chest roentgenogram was useful in locating the site of foreign body impaction in 41 of 57 cases. Metallic and other radiopaque foreign bodies were easily found on standard chest roentgenogram (Figure 1, left). Additional findings such as volume loss or atelectasis and postobstructive infiltrates provided additional indications of location when the aspirated object lacked substantial radiopacity (Figure 1, right). Additionally, air-trapping and mediastinal shift on postexpiration roentgenogram were helpful in finding foreign bodies in 3 cases. In 59 cases, the sites of foreign body impaction were confirmed bronchoscopically and, in 1 case, determined by thoracotomy (Figure 2). Although the right lower lobe was the commonest site of impaction (17 cases), foreign body aspiration was noted in all lobes, including the upper lobes. In general, impaction of foreign bodies was commoner in the right than in the left and in the lower than in the upper lobes.
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Figure 1. Left. Posteroanterior chest roentgenogram showing a radiopaque density in the right upper lobe bronchus that proved to be an occultly aspirated penny. Right. Posteroanterior chest roentgenogram showing the presence of an infiltrate behind the heart. This infiltrate was due to chronic left main stem bronchial obstruction from an aspirated beverage can pull-tab. The pull-tab escaped detection on the film, because it was made of aluminum and, therefore, not significantly radiopaque.
All but 3 patients were successfully treated with bronchoscope retrieval. Various grasping forceps, telescope forceps, and basket forceps were used through the bronchoscope. In our series, rigid bronchoscopy was successful in 43 of 44 patients (98%), including 6 of 7 patients in whom fiberoptic bronchoscopy had failed. Since the clinical application of fiberoptic bronchoscopy in 1970, 42 patients were evaluated for foreign body aspiration. At the discretion of the bronchoscopist, fiberoptic bronchoscopy was attempted in 23 patients and was successful in 14 patients (60%). Of note, fiberoptic bronchoscopy was particularly useful in two cases in which the object had impacted in airways too distal for access with the rigid open tube bronchoscope. The fiberoptic bronchoscope also proved useful in one case in which severe cervicofacial trauma precluded the neck hyperextension necessary for rigid bronchoscopic examination. In this case, the fiberoptic bronchoscope and
Table 2. Factors Predisposing Adults chial Foreign Body Aspiration Condition
to TracheobronPatients n
Primary neurologic disorders Cerebrovascular accidents Parkinson disease Seizures Mental retardation Primary brain neoplasm Cerebral palsy Total Dental procedures Medical procedures Traumatic loss of consciousness Alcohol or sedative use 606
3 2 2 2 1 1 11 10 9 6 5
basket forceps were used to remove an aspirated tooth impacted in the left lower lobe bronchus. Two patients for whom bronchoscopic removal attempts failed and one patient in whom the foreign body was not diagnosed at the time of bronchoscopy required thoracotomy. All three foreign objects were impacted in distal basilar segments of the lower lobes, with two in the left lower lobe and one in the right lower lobe. Distal location, bleeding, and the formation of granulation tissue were cited as reasons contributing to the failure of bronchoscopic removal in two patients, whereas the third patient presented with significant hemoptysis due to localized bronchiectasis of the right lower lobe. The presence of a foreign body was not suspected after a normal bronchoscopic examination, but thoracotomy revealed a grass inflorescence (the seeds of grass inflorescence, also known as fox tail or cheat grass; see Discussion) impacted in a distal branch of the right lower lobe. As has been the practice at our institution, most bronchoscopies (both the rigid and fiberoptic procedures) in adults have been done with topical anesthesia, using 2% xylocaine and supplemental sedation with benzodiazapines. In our series, 44 successful attempts and 1 failed attempt were done with such local anesthesia. An additional 14 procedures, including 12 successful removals were done with general anesthesia, using thiopental and inhalational anesthetic agents. Acute complications from foreign body extraction were uncommon. Bleeding due to bronchoscopy itself occurred in three patients, spontaneously abating in each case. In no case did bronchoscopic manipulation lead to acute airway compromise. One of the three patients who required thoracotomy sustained an acute myocardial infarction during a 2-hour attempt at the
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local hospital to retrieve an aspirated dental crown. After prolonged manipulation with the fiberoptic bronchoscope, the foreign body that initially had been in the left main stem bronchus had slipped into the distal bronchi of the left lower lobe. The patient was referred to our institution for surgical removal of the foreign body. Chronic complications of long-standing foreign body impaction were noted in four patients. In three patients, chronic airway obstruction resulted in bronchiectasis that was not reversed by removal of the foreign body. In one patient, chronic airway narrowing has been noted but has not led to functional deficit. Discussion The single diagnostic factor leading to discovery of tracheobronchial foreign body aspiration is a high clinical index of suspicion. Although foreign body aspiration is frequently suspected in children with acute or recurrent pulmonary symptoms, it is rarely considered in adults with subacute or chronic respiratory symptoms, unless a clear history of an aspiration event can be obtained. The diagnosis can be confirmed by visualizing the foreign body by chest roentgenogram or with bronchoscopy. Non-radiopaque foreign bodies may be easily missed on routine chest roentgenogram but may be suggested by associated atelectasis or infiltration in the postobstructive region or by air trapping and hyperinflation on postexhalation chest roentgenogram (4, 7, 8). In selected cases, specialized studies such as localized tomography, computed tomography, or bronchog-
Figure 2. Sites of tracheobronchial foreign body impaction in adults as assessed by bronchoscopy. Circled numerals indicate number of foreign bodies impacted at each location. One in the trachea; 6 in the right main stem; 8 in the bronchus intermedins; 1 in therightupper lobe; 4 in therightmiddle lobe; 17 in the right lower lobe; 10 in the left main stem; 2 in the left upper lobe; and 11 in the left lower lobe.
raphy may be useful in identifying an otherwise occult foreign body. Interestingly, occult foreign body aspiration in adults can remain undetected for years, leading to erroneous diagnosis of asthma, bronchitis, or chronic pneumonia (13, 23, 24). In the series by Jackson and colleagues (13), the longest duration of foreign body retention in the tracheobronchial tree was 40 years. In our series, a patient had a chronic cough and recurrent infiltration on chest roentgenogram for 10 years due to an occultly inspired beverage can pull-tab. This metallic foreign body had escaped detection by standard chest roentgenogram, because it was made of aluminum. Similar difficulties in detecting aluminum foreign bodies were reported by Rogers and colleagues (18). The site of lodgment of the foreign body depends on the anatomic structure of the tracheobronchial tree and the body posture of the person at the time of aspiration. In our patients, the commonest site of impaction was the right lower lobe bronchi, accounting for 28% of cases. Of the 191 patients in the series by Jackson and colleagues (13), the right lower lobe was the site of impaction in 56%, followed by the left lower lobe in 33%. Interestingly, the commonest type of foreign body in our series was vegetable matter, whereas nearly half of the foreign bodies removed by Jackson and colleagues (13) were shawl pins, straight pins, and safety pins. Some of the unusual foreign bodies among our patients included grass inflorescence, a piece of drinking straw, and stone. The latter was aspirated during a cave-in accident at a quarry; this case was similar to another reported case (25). Early complications of tracheobronchial foreign body aspiration may include acute dyspnea, asphyxia, cardiac arrest, laryngeal edema, and pneumothorax. Late complications include bronchiectasis, hemoptysis, bronchial stricture, development of inflammatory polyps at the site of lodgment, and diminished perfusion to the lung on the side of lodgment (26-32). One of our patients developed extensive bronchiectasis of the left lower lobe with recurrent hemoptysis as a result of chronic foreign body impaction. Another patient presented with acute onset of hemoptysis due to localized bronchiectasis of the right lower lobe. At thoracotomy, chronic impaction of a grass inflorescence was discovered in the area of bronchiectasis. Several cases of tracheobronchial aspiration of grass inflorescence (fox tail or cheat grass) have been reported (33-35). When aspirated with the spikes pointed backwards, the grass inflorescence is almost impossible to dislodge by coughing. Inflammatory polyps or granulation tissue may develop with chronic impaction and obscure the foreign body. Removal of the impacted foreign body in such cases requires bronchoscopic resection of the granulation tissue before extraction. Endobronchial bleeding as a result of foreign body extraction is usually mild, and life-threatening hemorrhages are exceedingly rare (36). The definitive treatment of tracheobronchial foreign body aspiration is removal as soon as possible. As early as 1897, Killian (37) described removal of a foreign body with a rigid bronchoscope. Although it is universally agreed that the rigid bronchoscope is the instrument of choice for extracting foreign bodies in children,
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the widespread availability of the fiberoptic bronchoscope has prompted some bronchoscopists to use it for removal of foreign bodies in adults (20, 22, 32, 38-40). Zavala and colleagues (21) showed the feasibility of fiberoptic bronchoscopic removal of aspirated foreign bodies in animals. Some investigators (20) have suggested that the fiberoptic bronchoscope may be superior to the rigid bronchoscope because of its greater visibility and range. Although the fiberoptic bronchoscope has greater visibility and range, we disagree that it is superior to the rigid bronchoscope for extracting foreign bodies. In our retrospective series, fiberoptic bronchoscopy was successful in only 60% of patients. In contrast, a 98% success rate was associated with rigid bronchoscopy. However, we found that fiberoptic bronchoscopy was advantageous in specific cases in which the foreign body was impacted too far distally to be reached with the rigid bronchoscope or in cases in which cervical instability precluded rigid bronchoscopic examination. Additional arguments can be made for the continued use of rigid bronchoscopy in treatment of tracheobronchial foreign body aspiration in adults. First, rigid bronchoscopy is rapidly done, usually within minutes, whereas fiberoptic bronchoscopic removal may be a more lengthy procedure. Second, diverse instruments are available for use with the rigid bronchoscope to extract virtually any shape of object from the tracheobronchial tree. Although there are various types of baskets, grasping claws, electromagnets, balloon catheters, suction tubes, and other instruments that can be used through the fiberoptic bronchoscope, they are rather flimsy and ill-suited to grasp and extract all foreign bodies (41-47). In addition, the rigid bronchoscope enables the bronchoscopist to control the airway throughout the procedure, thereby ensuring rapid and safe extraction of the foreign body while providing optimal ventilation for the patient. Currently, the main reason for bronchoscopists to attempt removal of tracheobronchial foreign bodies by fiberoptic bronchoscopy is lack of adequate training in application of rigid bronchoscopy, which is largely due to the versatility, ease of use, and widespread availability of the fiberoptic bronchoscope. Because foreign bodies are not usually suspected in adults, their discovery by fiberoptic instrument is frequently unanticipated. Bronchoscopists who are untrained in rigid bronchoscopy may be tempted to extract the foreign body with the fiberoptic instrument. Nevertheless, fiberoptic bronchoscopy does have a distinct advantage over rigid bronchoscopy in the treatment of some types of tracheobronchial foreign bodies. Fiberoptic bronchoscopy is suitable for retrieving foreign bodies in the peripheral bronchi, in mechanically ventilated patients, and in patients whose necks are unstable due to cervical or maxillofacial trauma and for removing small foreign bodies that can be securely grasped with fiberoptic instruments. Large foreign bodies that are round or smooth are best approached with the rigid bronchoscope. Potential complications of attempting to remove large foreign bodies with a fiberoptic bronchoscope include displacement and impaction of the foreign body in the lobar or main stem bronchus, 608
resulting in acute hypoxia, or shearing off of the foreign body in the narrow subglottic area, leading to acute asphyxia. As suggested by Zavala and colleagues (4548), fiberoptic bronchoscopy augments rigid bronchoscopy. As fiberoptic bronchoscopy becomes increasingly popular, the use of the rigid bronchoscope will further diminish, except for its limited use in laser bronchoscopy and removal of tracheobronchial foreign bodies in children. Clearly, continued training in the techniques of rigid bronchoscopy and development of better instruments for use via the fiberoptic bronchoscope for extraction of tracheobronchial foreign bodies in adults are needed. Requests for Reprints: Udaya B.S. Prakash, MD, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905. Current Author Addresses: Dr. Limper: Respiratory and Critical Care Division, Washington University Medical School, Box 8052, 660 South Euclid, St. Louis, MO 63110. Dr. Prakash: Division of Thoracic Diseases and Internal Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905.
References 1. Banerjee A, Rao KS, Khanna SK, et al. Laryngo-tracheo-bronchial foreign bodies in children. J Laryngol Otol. 1988;102:1029-32. 2. Puhakka H, Kero P, Erkinjuntti M. Pediatric bronchoscopy during a 17-year period. Int J Pediatr OtorhinolaryngoL 1987;13:171-80. 3. Kramer TA, Riding KH, Salkeld LJ. Tracheobronchial and esophageal foreign bodies in the pediatric population. J Otolaryngol. 1986; 15:355-8. 4. Mantel K, Butenandt I. Tracheobronchial foreign body aspiration in childhood. A report on 224 cases. Eur J Pediatr. 1986;145:211-6. 5. Blazer S, Naveh Y, Friedman A. Foreign body in the airway. A review of 200 cases. Am J Dis Child. 1980;134:68-71. 6. Al-Naaman YD, Al-Ani MS, Al-Ani HR. Non-vegetable foreign bodies in the bronchopulmonary tract in children. J Laryngol Otol. 1975;89:289-97. 7. Elhassani NB. Tracheobronchial foreign bodies in the Middle East. A Baghdad Study. J Thorac Cardiovasc Surg. 1988;96:621-5. 8. Abdulmajid OA, Ebeid AM, Motaweh MM, Kleibo IS. Aspirated foreign bodies in the tracheobronchial tree: report of 250 cases. Thorax. 1976;31:635-40. 9. National Safety Council. Accident Facts. Chicago: National Safety Council Press; 1980:7. 10. Sanford CC. Aspirated foreign bodies in children. Am Fam Physician. 1979;20:104-8. 11. Cohen SR, Herbert WI, Lewis GB Jr, Geller KA. Foreign bodies in the airways. Five-year retrospective study with special reference to management. Ann Otol Rhinol Laryngol. 1980;89:437-42. 12. Mittleman RE, Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction. JAMA. 1982;247:1285-8. 13. Jackson C, Jackson CL. Diseases of the Air and Food Passages of Foreign Body Origin. Philadelphia: WB Saunders Co; 1936. 14. McGuirt WF, Holmes KD, Feehs R, Browne JD. Tracheobronchial foreign bodies. Laryngoscope. 1988;98:615-8. 15. Casson AG, Guy JR. Foreign-body aspiration in adults. Can J Surg. 1987;30:193-4. 16. Brischetto MJ, Malouf J, Taylor RW. Foreign-body pneumonitis associated with tracheostomy. Crit Care Med. 1984;12:689-90. 17. Hannan SE, Pratt DS, Hannan JM, Brienza LT. Foreign body aspiration associated with the use of an aerosol inhaler. Am Rev Respir Dis. 1984;129:1025-7. 18. Rogers LF, Igini JP. Beverage can pull-tabs. Inadvertent ingestion or aspiration. JAMA. 1975;233:345-8. 19. Kullbom TL, Adwers J. Unusual complication associated with severe maxillofacial trauma. Oral Surg Oral Med Oral Pathol. 1974; 37:355-8. 20. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 48-1983. A 14-year-old boy with recurrent hemoptysis and a right-lower-lobe infiltrate. N Engl J Med. 1983;309:1374-81. 21. Zavala DC, Rhodes ML. Experimental removal of foreign bodies by fiberoptic bronchoscopy. Am Rev Respir Dis. 1974;110:357-60. 22. Lillington GA, Ruhl RA, Peirce TH, Gorin AB. Removal of endobronchial foreign body by fiberoptic bronchoscopy. Am Rev Respir Dis. 1976;113:387-91. 23. Hussain A. Neglected foreign body in the right bronchial tree. Int Surg. 1976;61:366-7.
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24. Abrol BM, Chattopadhyay AK. Forgotten bronchial foreign body. J Indian Med Assoc. 1973;61:224. 25. Wales J, Jackimczyk K, Rosen P. Aspiration following a cave-in. Ann Emerg Med. 1983;12:99-101. 26. Poukkula A, Ruotsalainen EM, Jokinen K, Palva A, Nuorviita J. Long-term presence of a denture fragment in the airway (a report of two cases). J Laryngol Otol. 1988;102:190-3. 27. Tarkka M, Anttila S, Sutinen S. Bronchial stenosis after aspiration of an iron tablet. Chest. 1988;93:439-41. 28. Berman DE, Wright ES, Edstrom HW. Endobronchial inflammatory polyp associated with a foreign body. Successful treatment with corticosteroids. Chest. 1984;86:483-4. 29. Rubenstein RB, Bainbridge CW. Fiberoptic bronchoscopy for intraoperative localization of endobronchial lesions and foreign bodies. Chest. 1984;86:935-6. 30. Karnik AS, Deresinski S, Lourenco RV. Decreased pulmonary perfusion with bronchial foreign body. Am Rev Respir Dis. 1973; 107:127-9. 31. Chopra S, Simmons DH, Cassan SM, Becker S, Ben-Isaac FE. Bronchial obstruction by incorporation of aspirated vegetable material in the bronchial wall. Am Rev Respir Dis. 1975;112:717-20. 32. Kovnat DM, Anderson WM, Rath GS, Snider GL. Hemoptysis secondary to retained transpulmonary foreign body. Diagnosis by fiberoptic bronchoscopy 28 years after injury. Am Rev Respir Dis. 1974;109:279-82. 33. Jackson C. Grasses as foreign bodies in therapy bronchus and lung. Laryngoscope. 1952;62:897-923. 34. Woolley PV Jr. Grass inflorescence as foreign bodies in respiratory tract. J Pediatr. 1955;46:704-6. 35. Hilman BC, Kurzweg FT, McCook WW Jr, Liles AE. Foreign body aspiration of grass inflorescences as a cause of hemoptysis. Chest. 1980;78:306-9.
36. Rees JR. Massive hemoptysis associated with foreign body removal. Chest. 1985;88:475-6. 37. Killian G. Meeting of the Society of Physicians of Freiburg; December 17, 1897. Munchen Med Wschr. 1898;45:378. 38. Ikeda S. Atlas of Flexible Bronchoscopy. Baltimore: University Park Press; 1974. 39. Barrett CR Jr, Vecchione JJ, Bell AL Jr. Flexible fiberoptic bronchoscopy for airway management during acute respiratory failure. Am Rev Respir Dis. 1974;109:429-34. 40. Wanner A, Landa JF, Nieman RE Jr, Vevaina J, Delgado I. Bedside bronchofiberscopy for atelectasis and lung abscess. JAMA. 1973; 224:1281-3. 41. Moss R, Kanchanapoon V. Stone basket extraction of a bronchial foreign body [Letter]. Arch Surg. 1986;121:975. 42. Inhaled foreign bodies [Editorial]. Br Med J [Clin Res]. 1980;282: 1649-50. 43. Dajani AM. Bronchial foreign-body removed with a Dormia basket. Lancet. 1971;1:1076-7. 44. Kosloske AM. The Fogarty balloon technique for the removal of foreign bodies from the tracheobronchial tree. Surg Gynecol Obstet. 1982;155:72-3. 45. Zavala DC, Rhodes ML. Foreign body removal: a new role for the fiberoptic bronchoscope. Ann Otol Rhinol Laryngol. 1975;84:650-6. 46. Heinz GJ 3d, Richardson RH, Zavala DC. Endobronchial foreign body removal using the bronchofiberscope. Ann Otol Rhinol Laryngol. 1978;87:50-2. 47. Fieselmann JF, Zavala DC, Keim LW. Removal of foreign bodies (two teeth) by fiberoptic bronchoscopy. Chest. 1977;72:241-3. 48. Zavala DC, Rhodes ML, Richardson RH, Bedell GN. Fiberoptic and rigid bronchoscopy: the state of the art [Editorial]. Chest. 1974; 65:605-6.
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REVIEW
Tracheobronchial Foreign Bodies in Adults Andrew H. Limper, MD; and Udaya B. S. Prakash, MD
Study Objective: To define the clinical spectrum of tracheobronchial foreign body aspiration in adults, assess predisposing conditions, evaluate the efficacy of bronchoscopy, and determine outcome and complications. Design: Retrospective analysis of a consecutive clinical series. Setting: A tertiary care, referral-based medical center. Patients: Sixty consecutive adult patients (over 16 years of age) evaluated for tracheobronchial foreign body aspiration. Interventions: All 60 patients had bronchoscope evaluation; 59 of them had foreign bodies identified and removal was attempted using either rigid or flexible fiberoptic bronchoscopy. Main Results: Of 60 consecutive patients, 25 had underlying impairment of protective airway mechanisms (primary neurologic disorders, trauma with loss of consciousness, or sedative or alcohol use). Fifty-seven were successfully managed with bronchoscopy. Fiberoptic bronchoscopy was successful in 14 of 23 patients, and rigid bronchoscopy was successful in 43 of 44 patients, including 6 of 7 patients in whom previous fiberoptic bronchoscopy had failed. Thoracotomy was required in 3 patients. Complications of bronchoscopy were rare and not serious. Chronic complications of prolonged foreign body impaction included bronchiectasis in 3 patients. Conclusions: Although rare, tracheobronchial foreign body aspiration in adults can occur in various clinical settings. High clinical suspicion is necessary for diagnosis. Removal of foreign bodies can usually be accomplished with bronchoscopy.
Aspiration of foreign bodies into the tracheobronchial tree is much commoner in children than in adults (1-8). Annual death rates from foreign body aspiration in the United States range from 500 to 2000, with more than half occurring in children between the ages of six months and four years (9-11). Although a review (12) in 1982 analyzed 141 fatalities associated with acute food asphyxiation (the Cafe coronary syndrome), there have been no reports on large series of adults with nonasphyxiating tracheobronchial foreign bodies. The classic monograph on tracheobronchial foreign bodies, done by Jackson and colleagues (13) in 1937, summarized the cases of 191 adults with tracheobronchial foreign bodies. However, earlier diagnosis, availability of antibiotics, and newer bronchoscopy instruments make it difficult to compare the clinical features and treatment of these reported cases with those of current tracheobronchial foreign body aspiration cases. A review of more recent reports (14-19) reveals a paucity of information on this topic, particularly in adults, with only a few case reports in the literature. Details of chronic complications in adults as a result of tracheobronchial foreign body aspiration are also scanty in the reports. Management of tracheobronchial foreign body aspiration has evolved substantially, mostly because of wider application of fiberoptic bronchoscopy in clinical practice. The instrument of choice for extracting tracheobronchial foreign bodies in children is the rigid bronchoscope (4, 13). Traditionally, rigid bronchoscopy has also been the preferred treatment for adults (13). Recent reports (20-22) have suggested that fiberoptic bronchoscopy may be a valuable therapeutic option for adults, although large clinical series using this technique have not been reported. To define the clinical spectrum of tracheobronchial foreign body aspiration in adults, assess predisposing conditions, evaluate the efficacy of bronchoscopy, and determine outcome and complications, we report our experience with adults who were evaluated at the Mayo Clinic and Mayo Medical Center hospitals.
Patients and Methods
Annals of Internal Medicine. 1990;112:604-609. From the Mayo Clinic and the Mayo Medical School, Rochester, Minnesota. For current author addresses, see end of text. 604
Using the Mayo Clinic medical record registry and cross index system, we did a retrospective analysis of all patients over 16 years of age who were evaluated at the Mayo Clinic for tracheobronchial foreign body aspiration between 1956 and 1989. "Tracheobronchial foreign body" was defined as any solid object aspirated below the level of the vocal cords. Patients with aspiration of regurgitated gastric contents were excluded from this study. Over the 33-year period, 60 such patients were identified. We reviewed the clinical records of these patients to determine the nature of the aspirated object, the duration and presence of symptoms (including cough, fever, and hemoptysis), and the presence of associated abnormalities on standard chest roentgenogram. In addition, we tried
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to identify any factors that might impair neurologic functioning or the normal deglutition mechanism, thus predisposing the patient to tracheobronchial foreign body aspiration. All 60 patients had diagnostic bronchoscopy; 59 of them had foreign bodies identified and removal attempted bronchoscopically. The bronchoscopic records of all patients were abstracted to determine the site of foreign body impaction in the tracheobronchial tree, the methods of attempted bronchoscopic removal (using either rigid or fiberoptic bronchoscopy), and the success of such treatments. Before 1970, all bronchoscopies were done using the rigid bronchoscope (18 cases). After 1970, the choice between the rigid bronchoscope (19 cases) and the fiberoptic bronchoscope (23 cases) was made by the individual bronchoscopist. Those patients whose foreign bodies were not identified or could not be removed bronchoscopically were managed with thoracotomy (3 patients), and the operative records of these patients were likewise reviewed. Long-term complications of foreign body lodgment in the tracheobronchial tree were also reviewed and results recorded. Results Of the 60 adult patients evaluated at the Mayo Clinic for tracheobronchial foreign body aspiration, 42 were men, yielding a male-to-female ratio of 2.4:1. The median age was 60 years (range, 18 to 88 years). A predominance of cases was noted in the seventh decade of life (18 patients), with the remainder of cases evenly distributed in the other decades. The nature of the aspirated foreign body was highly variable (Table 1). The most commonly aspirated objects were food items (24 patients), with peanuts leading the list (7 patients). Vegetable matter accounted for 17 of these aspirations, with the remaining seven caused by meat and bones. The patients in this group were readily aware of the aspiration event and, in general, had normal sensoria and no reported use of alcohol or other sedatives. The second predominant group of aspirated objects (19 patients) consisted of dental equipment or prostheses, tracheostomy tube segments, and endotracheal tube appliances inadvertently lost during dental or medical procedures. These aspirations were identified immediately at the time of the associated procedures. The final group of aspirated objects (17 patients) included such miscellaneous items as straight pins, coins, buttons, stones, pieces of plastic, teeth, and a beverage can pull-tab. Most patients who were evaluable had symptoms associated with tracheobronchial foreign body aspiration. Symptoms were not evaluable in 12 patients, because aspiration occurred while patients were comatose secondary to trauma (6 patients) or under general anesthesia (3 patients). Records of symptoms were unavailable for 3 patients. Cough was the commonest manifestation, present in 45 of 48 patients. Temperature elevation to at least 38 °C was recorded in 11 patients, and hemoptysis was noted in 9 patients. Dyspnea was seen in 8 patients and chest pain in 4. Only 1 evaluable patient denied all related pulmonary symptoms. His aspirated foreign body, a coin, was detected coincidentally on a chest roentgenogram obtained during evaluation for an unrelated injury (Figure 1). In most cases, diagnosis was made promptly, with symptoms present for a median of 10 days before bronchoscopic examination (range, 1 hour to 13 years). However, diagnosis was delayed in several cases due to patients neglecting their symptoms
Table 1. Types of Tracheobronchial Aspirated by 60 Adults
Foreign
Bodies
Object
Cases n
Food particles Vegetable matter Meat and bones Total Iatrogenic aspirations Dental appliances Medical appliances Total Miscellaneous Straight pins Safety pin Piece of plastic drinking straw Stone Coin Beverage can pull-tab Tooth Pine needle Button Grass inflorescence Vitamin tablet Metal toy Denture fragment Thermometer Thumb tack Total
17 7 24 10 9 19
17
or to failed attempts at diagnosis or treatment before referral for bronchoscopic evaluation at our institution. Various underlying conditions were detected that contributed to tracheobronchial aspiration of foreign bodies (Table 2). Eleven patients had primary neurologic disorders, including seizures, brain tumors, Parkinson disease, mental retardation, cerebral palsy, and conditions caused by recent cerebrovascular accidents. Dental procedures, with their associated supine position and local anesthesia, commonly predisposed patients toward tracheobronchial foreign body aspiration. Medical procedures, particularly those involving cleaning, replacing, or manipulating tracheostomy or endotracheal tubes had a similar effect. Trauma with associated loss of consciousness and cervicofacial injury and alcohol or sedative use were also found to contribute to tracheobronchial foreign body aspirations. The standard chest roentgenogram was useful in locating the site of foreign body impaction in 41 of 57 cases. Metallic and other radiopaque foreign bodies were easily found on standard chest roentgenogram (Figure 1, left). Additional findings such as volume loss or atelectasis and postobstructive infiltrates provided additional indications of location when the aspirated object lacked substantial radiopacity (Figure 1, right). Additionally, air-trapping and mediastinal shift on postexpiration roentgenogram were helpful in finding foreign bodies in 3 cases. In 59 cases, the sites of foreign body impaction were confirmed bronchoscopically and, in 1 case, determined by thoracotomy (Figure 2). Although the right lower lobe was the commonest site of impaction (17 cases), foreign body aspiration was noted in all lobes, including the upper lobes. In general, impaction of foreign bodies was commoner in the right than in the left and in the lower than in the upper lobes.
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Figure 1. Left. Posteroanterior chest roentgenogram showing a radiopaque density in the right upper lobe bronchus that proved to be an occultly aspirated penny. Right. Posteroanterior chest roentgenogram showing the presence of an infiltrate behind the heart. This infiltrate was due to chronic left main stem bronchial obstruction from an aspirated beverage can pull-tab. The pull-tab escaped detection on the film, because it was made of aluminum and, therefore, not significantly radiopaque.
All but 3 patients were successfully treated with bronchoscope retrieval. Various grasping forceps, telescope forceps, and basket forceps were used through the bronchoscope. In our series, rigid bronchoscopy was successful in 43 of 44 patients (98%), including 6 of 7 patients in whom fiberoptic bronchoscopy had failed. Since the clinical application of fiberoptic bronchoscopy in 1970, 42 patients were evaluated for foreign body aspiration. At the discretion of the bronchoscopist, fiberoptic bronchoscopy was attempted in 23 patients and was successful in 14 patients (60%). Of note, fiberoptic bronchoscopy was particularly useful in two cases in which the object had impacted in airways too distal for access with the rigid open tube bronchoscope. The fiberoptic bronchoscope also proved useful in one case in which severe cervicofacial trauma precluded the neck hyperextension necessary for rigid bronchoscopic examination. In this case, the fiberoptic bronchoscope and
Table 2. Factors Predisposing Adults chial Foreign Body Aspiration Condition
to TracheobronPatients n
Primary neurologic disorders Cerebrovascular accidents Parkinson disease Seizures Mental retardation Primary brain neoplasm Cerebral palsy Total Dental procedures Medical procedures Traumatic loss of consciousness Alcohol or sedative use 606
3 2 2 2 1 1 11 10 9 6 5
basket forceps were used to remove an aspirated tooth impacted in the left lower lobe bronchus. Two patients for whom bronchoscopic removal attempts failed and one patient in whom the foreign body was not diagnosed at the time of bronchoscopy required thoracotomy. All three foreign objects were impacted in distal basilar segments of the lower lobes, with two in the left lower lobe and one in the right lower lobe. Distal location, bleeding, and the formation of granulation tissue were cited as reasons contributing to the failure of bronchoscopic removal in two patients, whereas the third patient presented with significant hemoptysis due to localized bronchiectasis of the right lower lobe. The presence of a foreign body was not suspected after a normal bronchoscopic examination, but thoracotomy revealed a grass inflorescence (the seeds of grass inflorescence, also known as fox tail or cheat grass; see Discussion) impacted in a distal branch of the right lower lobe. As has been the practice at our institution, most bronchoscopies (both the rigid and fiberoptic procedures) in adults have been done with topical anesthesia, using 2% xylocaine and supplemental sedation with benzodiazapines. In our series, 44 successful attempts and 1 failed attempt were done with such local anesthesia. An additional 14 procedures, including 12 successful removals were done with general anesthesia, using thiopental and inhalational anesthetic agents. Acute complications from foreign body extraction were uncommon. Bleeding due to bronchoscopy itself occurred in three patients, spontaneously abating in each case. In no case did bronchoscopic manipulation lead to acute airway compromise. One of the three patients who required thoracotomy sustained an acute myocardial infarction during a 2-hour attempt at the
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local hospital to retrieve an aspirated dental crown. After prolonged manipulation with the fiberoptic bronchoscope, the foreign body that initially had been in the left main stem bronchus had slipped into the distal bronchi of the left lower lobe. The patient was referred to our institution for surgical removal of the foreign body. Chronic complications of long-standing foreign body impaction were noted in four patients. In three patients, chronic airway obstruction resulted in bronchiectasis that was not reversed by removal of the foreign body. In one patient, chronic airway narrowing has been noted but has not led to functional deficit. Discussion The single diagnostic factor leading to discovery of tracheobronchial foreign body aspiration is a high clinical index of suspicion. Although foreign body aspiration is frequently suspected in children with acute or recurrent pulmonary symptoms, it is rarely considered in adults with subacute or chronic respiratory symptoms, unless a clear history of an aspiration event can be obtained. The diagnosis can be confirmed by visualizing the foreign body by chest roentgenogram or with bronchoscopy. Non-radiopaque foreign bodies may be easily missed on routine chest roentgenogram but may be suggested by associated atelectasis or infiltration in the postobstructive region or by air trapping and hyperinflation on postexhalation chest roentgenogram (4, 7, 8). In selected cases, specialized studies such as localized tomography, computed tomography, or bronchog-
Figure 2. Sites of tracheobronchial foreign body impaction in adults as assessed by bronchoscopy. Circled numerals indicate number of foreign bodies impacted at each location. One in the trachea; 6 in the right main stem; 8 in the bronchus intermedins; 1 in therightupper lobe; 4 in therightmiddle lobe; 17 in the right lower lobe; 10 in the left main stem; 2 in the left upper lobe; and 11 in the left lower lobe.
raphy may be useful in identifying an otherwise occult foreign body. Interestingly, occult foreign body aspiration in adults can remain undetected for years, leading to erroneous diagnosis of asthma, bronchitis, or chronic pneumonia (13, 23, 24). In the series by Jackson and colleagues (13), the longest duration of foreign body retention in the tracheobronchial tree was 40 years. In our series, a patient had a chronic cough and recurrent infiltration on chest roentgenogram for 10 years due to an occultly inspired beverage can pull-tab. This metallic foreign body had escaped detection by standard chest roentgenogram, because it was made of aluminum. Similar difficulties in detecting aluminum foreign bodies were reported by Rogers and colleagues (18). The site of lodgment of the foreign body depends on the anatomic structure of the tracheobronchial tree and the body posture of the person at the time of aspiration. In our patients, the commonest site of impaction was the right lower lobe bronchi, accounting for 28% of cases. Of the 191 patients in the series by Jackson and colleagues (13), the right lower lobe was the site of impaction in 56%, followed by the left lower lobe in 33%. Interestingly, the commonest type of foreign body in our series was vegetable matter, whereas nearly half of the foreign bodies removed by Jackson and colleagues (13) were shawl pins, straight pins, and safety pins. Some of the unusual foreign bodies among our patients included grass inflorescence, a piece of drinking straw, and stone. The latter was aspirated during a cave-in accident at a quarry; this case was similar to another reported case (25). Early complications of tracheobronchial foreign body aspiration may include acute dyspnea, asphyxia, cardiac arrest, laryngeal edema, and pneumothorax. Late complications include bronchiectasis, hemoptysis, bronchial stricture, development of inflammatory polyps at the site of lodgment, and diminished perfusion to the lung on the side of lodgment (26-32). One of our patients developed extensive bronchiectasis of the left lower lobe with recurrent hemoptysis as a result of chronic foreign body impaction. Another patient presented with acute onset of hemoptysis due to localized bronchiectasis of the right lower lobe. At thoracotomy, chronic impaction of a grass inflorescence was discovered in the area of bronchiectasis. Several cases of tracheobronchial aspiration of grass inflorescence (fox tail or cheat grass) have been reported (33-35). When aspirated with the spikes pointed backwards, the grass inflorescence is almost impossible to dislodge by coughing. Inflammatory polyps or granulation tissue may develop with chronic impaction and obscure the foreign body. Removal of the impacted foreign body in such cases requires bronchoscopic resection of the granulation tissue before extraction. Endobronchial bleeding as a result of foreign body extraction is usually mild, and life-threatening hemorrhages are exceedingly rare (36). The definitive treatment of tracheobronchial foreign body aspiration is removal as soon as possible. As early as 1897, Killian (37) described removal of a foreign body with a rigid bronchoscope. Although it is universally agreed that the rigid bronchoscope is the instrument of choice for extracting foreign bodies in children,
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the widespread availability of the fiberoptic bronchoscope has prompted some bronchoscopists to use it for removal of foreign bodies in adults (20, 22, 32, 38-40). Zavala and colleagues (21) showed the feasibility of fiberoptic bronchoscopic removal of aspirated foreign bodies in animals. Some investigators (20) have suggested that the fiberoptic bronchoscope may be superior to the rigid bronchoscope because of its greater visibility and range. Although the fiberoptic bronchoscope has greater visibility and range, we disagree that it is superior to the rigid bronchoscope for extracting foreign bodies. In our retrospective series, fiberoptic bronchoscopy was successful in only 60% of patients. In contrast, a 98% success rate was associated with rigid bronchoscopy. However, we found that fiberoptic bronchoscopy was advantageous in specific cases in which the foreign body was impacted too far distally to be reached with the rigid bronchoscope or in cases in which cervical instability precluded rigid bronchoscopic examination. Additional arguments can be made for the continued use of rigid bronchoscopy in treatment of tracheobronchial foreign body aspiration in adults. First, rigid bronchoscopy is rapidly done, usually within minutes, whereas fiberoptic bronchoscopic removal may be a more lengthy procedure. Second, diverse instruments are available for use with the rigid bronchoscope to extract virtually any shape of object from the tracheobronchial tree. Although there are various types of baskets, grasping claws, electromagnets, balloon catheters, suction tubes, and other instruments that can be used through the fiberoptic bronchoscope, they are rather flimsy and ill-suited to grasp and extract all foreign bodies (41-47). In addition, the rigid bronchoscope enables the bronchoscopist to control the airway throughout the procedure, thereby ensuring rapid and safe extraction of the foreign body while providing optimal ventilation for the patient. Currently, the main reason for bronchoscopists to attempt removal of tracheobronchial foreign bodies by fiberoptic bronchoscopy is lack of adequate training in application of rigid bronchoscopy, which is largely due to the versatility, ease of use, and widespread availability of the fiberoptic bronchoscope. Because foreign bodies are not usually suspected in adults, their discovery by fiberoptic instrument is frequently unanticipated. Bronchoscopists who are untrained in rigid bronchoscopy may be tempted to extract the foreign body with the fiberoptic instrument. Nevertheless, fiberoptic bronchoscopy does have a distinct advantage over rigid bronchoscopy in the treatment of some types of tracheobronchial foreign bodies. Fiberoptic bronchoscopy is suitable for retrieving foreign bodies in the peripheral bronchi, in mechanically ventilated patients, and in patients whose necks are unstable due to cervical or maxillofacial trauma and for removing small foreign bodies that can be securely grasped with fiberoptic instruments. Large foreign bodies that are round or smooth are best approached with the rigid bronchoscope. Potential complications of attempting to remove large foreign bodies with a fiberoptic bronchoscope include displacement and impaction of the foreign body in the lobar or main stem bronchus, 608
resulting in acute hypoxia, or shearing off of the foreign body in the narrow subglottic area, leading to acute asphyxia. As suggested by Zavala and colleagues (4548), fiberoptic bronchoscopy augments rigid bronchoscopy. As fiberoptic bronchoscopy becomes increasingly popular, the use of the rigid bronchoscope will further diminish, except for its limited use in laser bronchoscopy and removal of tracheobronchial foreign bodies in children. Clearly, continued training in the techniques of rigid bronchoscopy and development of better instruments for use via the fiberoptic bronchoscope for extraction of tracheobronchial foreign bodies in adults are needed. Requests for Reprints: Udaya B.S. Prakash, MD, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905. Current Author Addresses: Dr. Limper: Respiratory and Critical Care Division, Washington University Medical School, Box 8052, 660 South Euclid, St. Louis, MO 63110. Dr. Prakash: Division of Thoracic Diseases and Internal Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905.
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