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Tracheobronchial Foreign Body Aspiration in Children Harpal Singh and Ankit Parakh CLIN PEDIATR published online 17 October 2013 DOI: 10.1177/0009922813506259 The online version of this article can be found at: http://cpj.sagepub.com/content/early/2013/10/15/0009922813506259
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CPJXXX10.1177/0009922813506259Clinical PediatricsSingh and Parakh
Commentary
Tracheobronchial Foreign Body Aspiration in Children
Clinical Pediatrics XX(X) 1–5 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813506259 cpj.sagepub.com
Harpal Singh, MD1 and Ankit Parakh, MD, DNB, MNAMS1 Introduction Foreign body aspiration is a common pediatric problem and requires prompt diagnosis and management.1 The spectrum of manifestation of foreign body aspiration often varies from acute life-threatening airway obstruction to a persistent pneumonia, recurrent wheezing, or may remain asymptomatic for a longer period.2,3 Because of lack of specific clinical manifestation, diagnosis is often difficult and can lead to various serious and long-term complications.4 There is requirement of a specific clinical or radiological diagnostic criterion that can help health care personnel identify the accidents at an earlier stage even at a primary health care level. Rigid bronchoscopy is the first choice for foreign body removal. But recent literature has shown that fiberoptic bronchoscopy is a better and easier modality not only for diagnosis but also for retrieval foreign body from airways.5-7
Epidemiological Aspect The preliminary Medline search of literature till 2011 yielded more than 20000 cases of foreign body aspiration in children. Except for few studies, most of have shown consistency in age at presentation, sex of patient, symptomatology, location of foreign body, and type of foreign body.8-17 Although spectrum of radiological abnormalities is almost similar but predominant radiological manifestation has varied from study to study.3,18 Researches have been done on sensitivity and specificity of various clinical and radiological manifestations but till now no specific clinical or radiological diagnostic criteria has been established.15,19 The first bronchoscopy was done by Gustav Killian20 in 1897 with rigid esophagoscope and successfully removed a foreign body from a farmer’s airway. Further advancement in technology such as internal light source, image magnification, fiber-optic light source, and Hopkins telescope improved the image quality and successful removal rate of foreign body by bronchoscopy. Before the advancement of these technologies mortality rate was as high as 50%, which has been reduced now less than 1%.21 There is growing evidence in the favor of flexible bronchoscopy as a primary modality of removal of
foreign body aspiration in children. The clinical data of 39 children with tracheobronchial foreign bodies whose foreign body were removed in the Bronchoscopy Section of Mayo Clinic Rochester were analyzed. The flexible bronchoscope was used exclusively to extract tracheobronchial foreign bodies in 24 patients, and in 2 patients in whom the rigid bronchoscopic procedure was unsuccessful with minimal complication.22 Similarly, among 59 patients with foreign body aspiration, flexible bronchoscopy was attempted as an initial therapeutic procedure in 23 patients at tertiary level pediatric hospital in Mexico. The procedure was successful in 21 (91.3%) of patients.23 A larger analysis of flexible bronchoscopic removal of 1027children with foreign body aspiration has shown that it was successful in 938 (91.3%) patients with transient hypoxia and minimal bleeding as a complication in very few patients.7
Clinical Spectrum Foreign body aspiration is not an uncommon problem in pediatric practice. Because of lack of specific clinical manifestation, the condition is often not diagnosed immediately resultant delayed diagnosis and various complications. Foreign body aspiration can present as an acute life-threatening obstruction or initial symptoms followed by relatively asymptomatic period before the reappearance of symptoms.19
Age and Sex Children younger than 3 years are more susceptible for foreign body aspiration.10,16,24,25 Sehgal et al3 found that 52% of children with foreign body aspiration were between 1 and 3 years old. Similarly, a study from China has shown that 82.4% of patients with foreign body aspiration were between 1 and 3 years old.7 The propensity of 1
Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi, India Corresponding Author: Harpal Singh, MD, Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, Room No. 20, New Registrar Block, New Delhi 110001, India. Email: [email protected]
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Clinical Pediatrics XX(X)
oral exploration, lack of molar teeth, and poor swallowing coordination are the suggested factors responsible for these accidents in this younger population.26 Boys are more vulnerable and account for almost two thirds of foreign body accidents.7,16,24,27 The reason behind male predominance is not understood.
Clinical Presentation The most common symptom is paroxysmal cough, a natural defense mechanism to remove the foreign body from airways. Cough is typically present in 75% to 85% of patients3,7 and has high sensitivity (78% to 90%) but low specificity (33% to 38%) in diagnosing foreign body aspiration.3,7,8,28 History of choking is a predominant feature of foreign body aspiration and found in 80% to 90% of children.2,8 But some authors have observed it in a very few number of patients.16,29 Tomaske et al19 compared the sensitivity and specificity of chocking among early (2 weeks after symptoms onset) groups and found it more sensitive in early group (97.7% vs 48.6%) while more specific in late group (7.6% vs 88.6%). Absence of choking does not rule out the possibility of foreign body aspiration especially if other signs and symptoms favor the diagnosis of foreign body accident. Other clinical manifestation includes cyanosis, stridor, unilateral decreased air entry, fever, wheezing, and dyspnea, which may present in variable number of patients.16 The classical clinical triad of cough, wheezing, and decreased air entry is present in less than 40% of children.3,30 A group of authors observed the low sensitivity (26.5% to 42.6%) but high specificity (96% to 98%) of this triad.19
Types of Foreign Body The aspirated foreign body can be categorized broadly as organic and inorganic. Organic foreign bodies such as nuts and seeds are the most common type of foreign bodies in children.7,16,31 Other organic foreign bodies include food material, fruits, and bones. The most common inorganic foreign bodies aspirated in children are coins, pins, beads, small parts of toys, and pen caps.9,16 The organic foreign bodies produce more inflammatory reaction and may worsen the obstruction and shorten the duration of asymptomatic period. While inert inorganic material may remain asymptomatic for long time but some sharp objects may lead to trauma to airways or various air leak syndromes. The type of foreign body aspirated is affected by various social and cultural factors and varies from country to country. Studies from countries, including India, China, Turkey, Hong Kong, and Mexico have shown the peanut as the most common type of foreign body.3,6,7,17,27 A study
from Iran has found seeds as the most common type (61.5%) of foreign body while in European countries such as Italy the most common were dried nuts as well as inorganic type in some countries like Spain.16,32,33
Location of Foreign Body The most common site of lodgment of foreign body is right main bronchus (45% to 57%) followed by left main bronchus (18% to 40%), trachea (10% to 17%), and both bronchi.9,27 The clinical manifestation also depends on location of foreign body. Tracheal foreign body can present as variable degree of respiratory distress, stridor, or acute life-threatening obstruction. Foreign body in bronchial tree often presents as cough, unilateral decreased breath sounds, and wheezing.
Complications The presence of foreign body can lead to various complication including persistent cough, recurrent pneumonia, atelectasis, emphysema, laryngeal edema, laryngeal trauma, and hypoxic encephalopathy. This can also cause various air leak syndrome such as pneumothorax, hydropneumothorax, pneumomediastinum, and subcutaneous emphysema and long-term complications in the form of pleural thickening, bronchiectasis, and bronchial stenosis.3,34 Experiments in laboratory animals have demonstrated that foreign body lodged in the tracheobronchial tree can lead to acute inflammatory process followed by infiltration of chronic inflammatory cell. This later progressed to changes suggestive of bronchiectasis, with thickening of bronchial wall, cartilage damage and fibrosis.35 This sequence of events emphasizes the urgency of the diagnosis and management of foreign body aspiration.
Radiology Because of lack of specific of clinical manifestations, other diagnostic modalities are required to confirm the diagnosis of foreign body aspiration. Posteroanterior view of chest X-ray should be carried out in almost all the patients with suspected foreign body aspiration. Radioopaque foreign body can easily be picked up by radiological examination. The prevalence of radiotransparent foreign bodies is much higher and radiological findings may be normal in these patients. The indirect radiological findings, including overinflation, atelectasis, lung infiltrates, and consolidation should be carefully considered in the patients with radiotransparent foreign body aspiration. Sehgal et al3 reported overinflation (62.8%) as the most common radiological finding followed by atelectasis/collapse (50%), normal radiograph (30%), and radioopaque foreign body (4.2%). Similarly Saki et al16 found
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Singh and Parakh overinflation (31.9%) as the most common radiological finding followed by normal chest X-ray (25.8%), radioopaque foreign body (15.8%), bronchiectasis (13.8%), unilateral atelectasis (9.8%), and lobar pneumonia (2.9%). Cataneo et al36, however, obtained slightly different results in their study population. These authors identified atelectasis as the main radiological alteration (42%), which was followed by normal radiography, overinflation (18.9%), and radio-opaque foreign body (16.2%).36 Because of low sensitivity and specificity of chest X-ray, absence of radiological abnormalities does not exclude the diagnosis of tracheobronchial foreign body aspiration.37 Since the 1970s, flexible bronchoscopy has emerged as the main diagnostic modality in a suspected case of foreign body aspiration.38,39 Bronchoscopy should be used as a diagnostic method where possibility of foreign body cannot be ruled out by history, physical, and radiological examination. It not only diagnoses the condition but also gives detail about nature, location, and orientation of foreign body. In recent years, multidetector computed tomography (MDCT) scan with virtual bronchoscopy (VB) has emerged as an important diagnostic modality. VB is a relatively new, noninvasive diagnostic method that gives a 3-dimensional view of the internal walls of the tracheobronchial tree through the reconstruction of axial images. MDCT scan is faster with thinner slides and better resolution for 3-dimensional image construction as compared with conventional CT scan. The principal disadvantage of this procedure is radiation exposure, which can be reduced by minimizing the use of tomography scans and reducing the tube current.40-42 Adaletli et al43 investigated the potential use of MDCT with VB in the evaluation of foreign body aspiration in children and concluded that it provides the information regarding the exact location of obstructive pathology. If obstructive pathology found on VB, conventional bronchoscopy should be performed to confirm the diagnosis. They also concluded that conventional bronchoscopy may not be clinically useful in children without obstructive pathology on MDCT and VB.43 A group of authors from Turkey have compared the efficacy of MDCT and VB with multiplanar reformatted imaging and found that both provides the equally valuable information in diagnosing the foreign body aspiration with sensitivity, specificity, and accuracy of 88.9%, 91.7%, and 90.5%, respectively.44
Management Management of inhaled foreign body depends on the location of foreign body in the airways. Laryngeal or tracheal foreign body requires immediate management whereas right or left bronchial tree foreign bodies can be
dealt with less urgency. Although bronchoscopy should be carried out as soon as possible, without inadequate preparation it may lead to total airway obstruction with dangerous consequences, including death. It should be performed by adequately trained professionals with multidisciplinary team. Traditionally, rigid bronchoscopy is the procedure of choice for removal of tracheobronchial foreign body in children. The ability to control the airways, wide working channel, excellent optical telescopic visualization, wide variety of instruments to retrieve the foreign body, and availability of range of various sizes of bronchoscope have made it the gold standard modality for retrieval of tracheobronchial foreign bodies in children. The requirement of general anesthesia and inability to reach the peripheral airways are the major disadvantage of this procedure. In recent years, flexible bronchoscopy has gained the popularity among respiratory endoscopist as a first choice for retrieval of foreign bodies in the children. Cunanan45 in 1978 analyzed the clinical data of 300 adult patients with foreign body aspiration, treated with flexible bronchoscopy and reported 89% success. Swanson et al22 performed the flexible bronchoscopy in 24 children for removal of tracheobronchial foreign body with 100% success. Tang et al7 treated 1027 pediatric patient with foreign body aspiration by flexible bronchoscopy during 2000-2008. The authors removed the foreign bodies successfully in 91.3% of cases with very few complications.7 Flexible bronchoscopy has noteworthy advantages over rigid bronchoscopy. First, it is relatively easy and safe procedure in experienced hands. Second, it can be performed under sedation with local anesthesia avoiding the extra cost, risk, and morbidity of second invasive procedure such as rigid bronchoscopy under general anesthesia. Third, foreign body lodged in distal airway can be reached only by flexible bronchoscopy because of smaller diameter and flexibility. Fourth, endogenous foreign bodies such as mucus or blood plugs can be managed in better way by flexible bronchoscopy by vacuum aspiration and bronchoalveolar lavage, as compared with rigid bronchoscopy. Fifth, it is superior in mechanically ventilated or children with skull, jaw, or spine injury patients with minimal manipulation. The limitations of flexible bronchoscopy include the following: Foreign bodies that are too large to pass through the flexible bronchoscope, too smooth, foe example, rubber, which cannot be grasped by forceps, or those with sharp edges that might hurt the airway, cannot be retrieved. Complications associated with flexible bronchoscope are few and mostly nonserious. Tang et al7 reported transient hypoxia in 12.9% of patients, which was alleviated by oxygen supplementation or temporary cessation of
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procedure. Bleeding was reported in 1.7% with good response to local application of adrenaline. Bradycardia, air leak, including pneumomediastinum, subcutaneous emphysema, laryngeal edema, and laryngeal spasm were reported in very small number of patients.7 Although, the technological advancement in bronchoscopy has reduced the requirement of open surgical management but there are certain occasions where endoscopy can be abandoned in the favor of open surgical management. Various available surgical options include tracheostomy, thoracotomy, and bronchotomy and/or pulmonary resection. In the analysis of records of 6693 patients with foreign body, tracheostomy was performed in 2.0% while thoracotomy was done in 2.5% of patients. The indications for tracheostomy includes subglottic foreign body causing acute airway obstruction, too large foreign body to be removed through glottis, foreign body with sharp edges that can lead to injury to vocal cords and to secure the airway in chronic subglottic foreign body with associated granulation tissue, which tends to bleed on touch. Pulmonary resection was performed in cases with bronchiectasis, chronic infection, and lung abscess.46
Prevention Most of the foreign bodies in children are food particles causing acute airway obstruction and dangerous consequences, including death. Main preventive measure is to educate the parents regarding various physiological factors such as absence of moor teeth for chewing the solid foods and poor swallowing coordination, which can lead to foreign body accidents in children. Appropriate eating habits are also important to prevent these problems. Nuts and various fruits with seeds should be avoided in children younger than 4 years. The curiosity of oral exploration can lead to aspiration of inorganic material such as toy parts, pen caps, and so on. These materials should be kept out of reach of these preschool children. Most of the deaths due to foreign body aspiration occur in home only. So parents should be educated regarding the urgency of the condition and requirement of immediate hospitalization. Parents should also learn about Heimlich’s maneuver, which reduces the chances of fatal accidents. In conclusion, foreign body aspiration is a frequently encountered problem in children and requires early diagnosis and prompt management. Children younger than of 3 years, especially boys, are more commonly affected. Right bronchial tree is more commonly involved with a peanut as predominant cause of foreign body aspiration. Because of less specific clinical manifestation and radiological findings, threshold should be kept low for the diagnosis and immediate bronchoscopy should be carried out to rule out the diagnosis. Delayed diagnosis can lead to various long-term complications
and morbidity. Flexible bronchoscopy can be used as a procedure of choice to extract the foreign body because it is relatively easy and is usually associated with lesser complications in experienced hands. There is a requirement of development of specific clinical or radiological diagnostic criteria, which can help in diagnosing the condition at an earlier stage and resultant reduced associated mortality and morbidity. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Eren S, Balci AE, Dikici B, Doblan M, Eren MN. Foreign body aspiration in children: experience of 1160 cases. Ann Trop Paediatr. 2003;23:31-37. 2. al-Majed SA, Ashour M, al-Mobeireek AF, al-Hajjaj MS, Alzeer AH, al-Kattan K. Overlooked inhaled foreign bodies: late sequelae and the likelihood of recovery. Respir Med. 1997;91:293-296. 3. Sehgal A, Singh V, Chandra J, Mathur NN. Foreign body aspiration. Indian Pediatr. 2002;39:1006-1010. 4. Lakhkar B, Kini P, Shenoy V, Bhaskaranand N. Foreign body aspiration: Manipal experience. Indian Pediatr. 2000;37:193-195. 5. Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: clinical utility of flexible bronchoscopy. Postgrad Med J. 2002;78:399-403. 6. Ramírez-Figueroa JL, Gochicoa-Rangel LG, RamírezSan Juan DH, Vargas MH. Foreign body removal by flexible fiberoptic bronchoscopy in infants and children. Pediatr Pulmonol. 2005;40:392-397. 7. Tang LF, Xu YC, Wang YS, et al. Airway foreign body removal by flexible bronchoscopy: experience with 1027 children during 2000-2008. World J Pediatr. 2009;5:191-195. 8. Hoeve LJ, Rombout J, Pot DJ. Foreign body aspiration in children. The diagnostic value of signs, symptoms and pre-operative examination. Clin Otolaryngol Allied Sci. 1993;18:55-57. 9. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg. 1994;29:682-684. 10. Senkaya I, Sagdic K, Gebitekin C, Yilmaz M, Ozkan H, Cengiz M. Management of foreign body aspiration in infancy and childhood. A life-threatening problem. Turk J Pediatr. 1997;39:353-362. 11. Orji FT, Akpeh JO. Tracheobronchial foreign body aspiration in children: how reliable are clinical and radiological signs in the diagnosis? Clin Otolaryngol. 2010;35:479-485. 12. Sissokho B, Conessa C, Petrognani R. Rigid endoscopy and laryngo-tracheo-bronchial foreign bodies in children:
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Singh and Parakh observations apropos of 200 endoscopies conducted in a tropical setting [in French]. Med Trop (Mars). 1999;59:61-67. 13. Eroğlu A, Kürkçüoğlu IC, Karaoğlanoğlu N, Yekeler E, Aslan S, Başoğlu A. Tracheobronchial foreign bodies: a 10 year experience. Ulus Travma Acil Cerrahi Derg. 2003;9:262-266. 14. Zhijun C, Fugao Z, Niankai Z, Jingjing C. Therapeutic experience from 1428 patients with pediatric tracheobronchial foreign body. J Pediatr Surg. 2008;43:718-721. 15. Kiyan G, Gocmen B, Tugtepe H, Karakoc F, Dagli E, Dagli TE. Foreign body aspiration in children: the value of diagnostic criteria. Int J Pediatr Otorhinolaryngol. 2009;73:963-967. 16. Saki N, Nikakhlagh S, Rahim F, Abshirini H. Foreign body aspirations in infancy: a 20-year experience. Int J Med Sci. 2009;6:322-328. 17. Chik KK, Miu TY, Chan CW. Foreign body aspiration in Hong Kong Chinese children. Hong Kong Med J. 2009;15:6-11. 18. Cataneo AJ, Cataneo DC, Ruiz RL Jr. Management of tracheobronchial foreign body in children. Pediatr Surg Int. 2008;24:151-156. 19. Tomaske M, Gerber AC, Stocker S, Weiss M. Tracheobronchial foreign body aspiration in children— diagnostic value of symptoms and signs. Swiss Med Wkly. 2006;136:533-538. 20. Killian G. Meeting of the Society of Physicians of Freiburg Dec 17, 1897. Münch Med Wochenschr. 1989;45:378. 21. Aytaç A, Yurdakul Y, Ikizler C, Olga R, Saylam A. Inhalation of foreign bodies in children. J Thorac Cardiovasc Surg. 1977;74:145-151. 22. Swanson KL, Prakash UB, Midthun DE, et al. Flexible bronchoscopic management of airway foreign bodies in children. Chest. 2002;121:1695-1700. 23. Gibson SE, Shott SR. Foreign bodies of the upper aerodigestive tract. In: Cotton RT, Myer CM III, Shott SR, eds. The Pediatric Airway. An Interdisciplinary Approach. 1st ed. Philadelphia, PA: JB Lippincott; 1995:195-222. 24. Reilly JS, Cook SP, Stool D, Rider G. Prevention and management of aerodigestive foreign body injuries in childhood. Pediatr Clin North Am. 1996;43:1403-1411. 25. Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest. 1999;115:1357-1362. 26. Melaku G. Foreign body aspiration in children: experience from Ethiopia. East Afr Med J. 1996;73:459-462. 27. Oguzkaya F, Akcali Y, Kahraman C, Bilgin M, Sahin A. Tracheobronchial foreign body aspirations in childhood: a 10-year experience. Eur J Cardiothorac Surg. 1998;14:388-392. 28. Agarwal RK, Banerjee G, Shembish N, Jamal B, Kareemullah C, Swaleh A. Foreign bodies in the tracheobronchial tree: a review of 102 cases in Benghazi, Libya. Ann Trop Pediatr. 1988;8:213-216. 29. Alvarez-Buylla Blanco M, Martínez Morán A, Alvarez Paredes I, Martínez Vidal J. Bronchoscopy in children with foreign body aspiration [in Spanish]. Acta Otorrinolaringol Esp. 2008;59:183-189.
30. Denny MK, Berkas EM, Snider TH. Foreign body bronchiectasis. Dis Chest. 1968;53:613-616. 31. Carluccio F, Romeo R. Inhalation of foreign bodies: epidemiological data and clinical considerations in the light of a statistical review of 92 cases [in Italian]. Acta Otorhinolaryngol Ital. 1997;17:45-51. 32. Metrangolo S, Monetti C, Meneghini L, Zadra N, Giusti F. Eight years’ experience with foreign-body aspiration in children: what is really important for a timely diagnosis? J Pediatr Surg. 1999;34:1229-1231. 33. Ramos MB, Fernandez-Villar A, Rivo JE, et al. Extraction of airway foreign bodies in adults: experience from 19872008. Interact Cardiovasc Thorac Surg. 2009;9:402-405. 34. Steen KH, Zimmermann T. Tracheobronchial aspira tion of foreign bodies in children: a study of 94 cases. Laryngoscope. 1990;100:525-530. 35. Yildizeli B, Zonuzi F, Yuksel M, Kodalli N, Cakalagaoglu F, Kullu S. Effects of intrabronchial foreign body retention. Pediatr Pulmonol. 2002;33:362-367. 36. Cataneo AJM, Reibscheid SM, Ruiz Júnior RL, Ferrari GF. Foreign body in the tracheobronchial tree. Clin Pediatr (Phila). 1997;12:701-705. 37. Svedström E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children? Pediatr Radiol. 1989;19:520-522. 38. Shah MB, Bent JP, Vicencio AG, Veler H, Arens R, Parikh SR. Flexible bronchoscopy and interdisciplinary collaboration in pediatric large airway disease. Int J Pediatr Otorhinolaryngol. 2008;72:1771-1776. 39. Maffey AF, Berlinski A, Schkair JC, Teper AM. Flexible bronchoscopy in a pediatric pulmonology service. Arch Argent Pediatr. 2008;106:19-25. 40. Koşucu P, Ahmetoğlu A, Koramaz I, et al. Low-dose MDCT and virtual bronchoscopy in pediatric patients with foreign body aspiration. AJR Am J Roentgenol. 2004;183:1771-1777. 41. Haliloglu M, Ciftci AO, Oto A, et al. CT virtual bronchoscopy in the evaluation of children with suspected foreign body aspiration. Eur J Radiol. 2003;48:188-192. 42. Sodhi KS, Saxena AK, Singh M, Rao KL, Khandelwal N. CT virtual bronchoscopy: new non invasive tool in pediatric patients with foreign body aspiration. Indian J Pediatr. 2008;75:511-513. 43. Adaletli I, Kurugoglu S, Ulus S, et al. Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration. Pediatr Radiol. 2007;37:33-40. 44. Kocaoglu M, Bulakbasi N, Soylu K, Demirbag S, Tayfun C, Somuncu I. Thin-section axial multidetector computed tomography and multiplanar reformatted imaging of children with suspected foreign-body aspiration: Is virtual bronchoscopy overemphasized? Acta Radiol. 2006;47:746-751. 45. Cunanan OS. The flexible fiberoptic bronchoscope in foreign body removal. Experience in 300 cases. Chest. 1978;73:725-726. 46. Marks SC, Marsh BR, Dudgeon DL. Indication for open surgical removal of airway foreign bodies. Ann Otol Rhinol Laryngol. 1993;102:690-694.
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Tracheobronchial Foreign Body Aspiration in Children Harpal Singh and Ankit Parakh CLIN PEDIATR published online 17 October 2013 DOI: 10.1177/0009922813506259 The online version of this article can be found at: http://cpj.sagepub.com/content/early/2013/10/15/0009922813506259
Published by: http://www.sagepublications.com
Additional services and information for Clinical Pediatrics can be found at: Email Alerts: http://cpj.sagepub.com/cgi/alerts Subscriptions: http://cpj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Oct 17, 2013 What is This?
Downloaded from cpj.sagepub.com at Universitats-Landesbibliothek on November 16, 2013
506259
research-article2013
CPJXXX10.1177/0009922813506259Clinical PediatricsSingh and Parakh
Commentary
Tracheobronchial Foreign Body Aspiration in Children
Clinical Pediatrics XX(X) 1–5 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813506259 cpj.sagepub.com
Harpal Singh, MD1 and Ankit Parakh, MD, DNB, MNAMS1 Introduction Foreign body aspiration is a common pediatric problem and requires prompt diagnosis and management.1 The spectrum of manifestation of foreign body aspiration often varies from acute life-threatening airway obstruction to a persistent pneumonia, recurrent wheezing, or may remain asymptomatic for a longer period.2,3 Because of lack of specific clinical manifestation, diagnosis is often difficult and can lead to various serious and long-term complications.4 There is requirement of a specific clinical or radiological diagnostic criterion that can help health care personnel identify the accidents at an earlier stage even at a primary health care level. Rigid bronchoscopy is the first choice for foreign body removal. But recent literature has shown that fiberoptic bronchoscopy is a better and easier modality not only for diagnosis but also for retrieval foreign body from airways.5-7
Epidemiological Aspect The preliminary Medline search of literature till 2011 yielded more than 20000 cases of foreign body aspiration in children. Except for few studies, most of have shown consistency in age at presentation, sex of patient, symptomatology, location of foreign body, and type of foreign body.8-17 Although spectrum of radiological abnormalities is almost similar but predominant radiological manifestation has varied from study to study.3,18 Researches have been done on sensitivity and specificity of various clinical and radiological manifestations but till now no specific clinical or radiological diagnostic criteria has been established.15,19 The first bronchoscopy was done by Gustav Killian20 in 1897 with rigid esophagoscope and successfully removed a foreign body from a farmer’s airway. Further advancement in technology such as internal light source, image magnification, fiber-optic light source, and Hopkins telescope improved the image quality and successful removal rate of foreign body by bronchoscopy. Before the advancement of these technologies mortality rate was as high as 50%, which has been reduced now less than 1%.21 There is growing evidence in the favor of flexible bronchoscopy as a primary modality of removal of
foreign body aspiration in children. The clinical data of 39 children with tracheobronchial foreign bodies whose foreign body were removed in the Bronchoscopy Section of Mayo Clinic Rochester were analyzed. The flexible bronchoscope was used exclusively to extract tracheobronchial foreign bodies in 24 patients, and in 2 patients in whom the rigid bronchoscopic procedure was unsuccessful with minimal complication.22 Similarly, among 59 patients with foreign body aspiration, flexible bronchoscopy was attempted as an initial therapeutic procedure in 23 patients at tertiary level pediatric hospital in Mexico. The procedure was successful in 21 (91.3%) of patients.23 A larger analysis of flexible bronchoscopic removal of 1027children with foreign body aspiration has shown that it was successful in 938 (91.3%) patients with transient hypoxia and minimal bleeding as a complication in very few patients.7
Clinical Spectrum Foreign body aspiration is not an uncommon problem in pediatric practice. Because of lack of specific clinical manifestation, the condition is often not diagnosed immediately resultant delayed diagnosis and various complications. Foreign body aspiration can present as an acute life-threatening obstruction or initial symptoms followed by relatively asymptomatic period before the reappearance of symptoms.19
Age and Sex Children younger than 3 years are more susceptible for foreign body aspiration.10,16,24,25 Sehgal et al3 found that 52% of children with foreign body aspiration were between 1 and 3 years old. Similarly, a study from China has shown that 82.4% of patients with foreign body aspiration were between 1 and 3 years old.7 The propensity of 1
Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi, India Corresponding Author: Harpal Singh, MD, Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, Room No. 20, New Registrar Block, New Delhi 110001, India. Email: [email protected]
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oral exploration, lack of molar teeth, and poor swallowing coordination are the suggested factors responsible for these accidents in this younger population.26 Boys are more vulnerable and account for almost two thirds of foreign body accidents.7,16,24,27 The reason behind male predominance is not understood.
Clinical Presentation The most common symptom is paroxysmal cough, a natural defense mechanism to remove the foreign body from airways. Cough is typically present in 75% to 85% of patients3,7 and has high sensitivity (78% to 90%) but low specificity (33% to 38%) in diagnosing foreign body aspiration.3,7,8,28 History of choking is a predominant feature of foreign body aspiration and found in 80% to 90% of children.2,8 But some authors have observed it in a very few number of patients.16,29 Tomaske et al19 compared the sensitivity and specificity of chocking among early (2 weeks after symptoms onset) groups and found it more sensitive in early group (97.7% vs 48.6%) while more specific in late group (7.6% vs 88.6%). Absence of choking does not rule out the possibility of foreign body aspiration especially if other signs and symptoms favor the diagnosis of foreign body accident. Other clinical manifestation includes cyanosis, stridor, unilateral decreased air entry, fever, wheezing, and dyspnea, which may present in variable number of patients.16 The classical clinical triad of cough, wheezing, and decreased air entry is present in less than 40% of children.3,30 A group of authors observed the low sensitivity (26.5% to 42.6%) but high specificity (96% to 98%) of this triad.19
Types of Foreign Body The aspirated foreign body can be categorized broadly as organic and inorganic. Organic foreign bodies such as nuts and seeds are the most common type of foreign bodies in children.7,16,31 Other organic foreign bodies include food material, fruits, and bones. The most common inorganic foreign bodies aspirated in children are coins, pins, beads, small parts of toys, and pen caps.9,16 The organic foreign bodies produce more inflammatory reaction and may worsen the obstruction and shorten the duration of asymptomatic period. While inert inorganic material may remain asymptomatic for long time but some sharp objects may lead to trauma to airways or various air leak syndromes. The type of foreign body aspirated is affected by various social and cultural factors and varies from country to country. Studies from countries, including India, China, Turkey, Hong Kong, and Mexico have shown the peanut as the most common type of foreign body.3,6,7,17,27 A study
from Iran has found seeds as the most common type (61.5%) of foreign body while in European countries such as Italy the most common were dried nuts as well as inorganic type in some countries like Spain.16,32,33
Location of Foreign Body The most common site of lodgment of foreign body is right main bronchus (45% to 57%) followed by left main bronchus (18% to 40%), trachea (10% to 17%), and both bronchi.9,27 The clinical manifestation also depends on location of foreign body. Tracheal foreign body can present as variable degree of respiratory distress, stridor, or acute life-threatening obstruction. Foreign body in bronchial tree often presents as cough, unilateral decreased breath sounds, and wheezing.
Complications The presence of foreign body can lead to various complication including persistent cough, recurrent pneumonia, atelectasis, emphysema, laryngeal edema, laryngeal trauma, and hypoxic encephalopathy. This can also cause various air leak syndrome such as pneumothorax, hydropneumothorax, pneumomediastinum, and subcutaneous emphysema and long-term complications in the form of pleural thickening, bronchiectasis, and bronchial stenosis.3,34 Experiments in laboratory animals have demonstrated that foreign body lodged in the tracheobronchial tree can lead to acute inflammatory process followed by infiltration of chronic inflammatory cell. This later progressed to changes suggestive of bronchiectasis, with thickening of bronchial wall, cartilage damage and fibrosis.35 This sequence of events emphasizes the urgency of the diagnosis and management of foreign body aspiration.
Radiology Because of lack of specific of clinical manifestations, other diagnostic modalities are required to confirm the diagnosis of foreign body aspiration. Posteroanterior view of chest X-ray should be carried out in almost all the patients with suspected foreign body aspiration. Radioopaque foreign body can easily be picked up by radiological examination. The prevalence of radiotransparent foreign bodies is much higher and radiological findings may be normal in these patients. The indirect radiological findings, including overinflation, atelectasis, lung infiltrates, and consolidation should be carefully considered in the patients with radiotransparent foreign body aspiration. Sehgal et al3 reported overinflation (62.8%) as the most common radiological finding followed by atelectasis/collapse (50%), normal radiograph (30%), and radioopaque foreign body (4.2%). Similarly Saki et al16 found
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Singh and Parakh overinflation (31.9%) as the most common radiological finding followed by normal chest X-ray (25.8%), radioopaque foreign body (15.8%), bronchiectasis (13.8%), unilateral atelectasis (9.8%), and lobar pneumonia (2.9%). Cataneo et al36, however, obtained slightly different results in their study population. These authors identified atelectasis as the main radiological alteration (42%), which was followed by normal radiography, overinflation (18.9%), and radio-opaque foreign body (16.2%).36 Because of low sensitivity and specificity of chest X-ray, absence of radiological abnormalities does not exclude the diagnosis of tracheobronchial foreign body aspiration.37 Since the 1970s, flexible bronchoscopy has emerged as the main diagnostic modality in a suspected case of foreign body aspiration.38,39 Bronchoscopy should be used as a diagnostic method where possibility of foreign body cannot be ruled out by history, physical, and radiological examination. It not only diagnoses the condition but also gives detail about nature, location, and orientation of foreign body. In recent years, multidetector computed tomography (MDCT) scan with virtual bronchoscopy (VB) has emerged as an important diagnostic modality. VB is a relatively new, noninvasive diagnostic method that gives a 3-dimensional view of the internal walls of the tracheobronchial tree through the reconstruction of axial images. MDCT scan is faster with thinner slides and better resolution for 3-dimensional image construction as compared with conventional CT scan. The principal disadvantage of this procedure is radiation exposure, which can be reduced by minimizing the use of tomography scans and reducing the tube current.40-42 Adaletli et al43 investigated the potential use of MDCT with VB in the evaluation of foreign body aspiration in children and concluded that it provides the information regarding the exact location of obstructive pathology. If obstructive pathology found on VB, conventional bronchoscopy should be performed to confirm the diagnosis. They also concluded that conventional bronchoscopy may not be clinically useful in children without obstructive pathology on MDCT and VB.43 A group of authors from Turkey have compared the efficacy of MDCT and VB with multiplanar reformatted imaging and found that both provides the equally valuable information in diagnosing the foreign body aspiration with sensitivity, specificity, and accuracy of 88.9%, 91.7%, and 90.5%, respectively.44
Management Management of inhaled foreign body depends on the location of foreign body in the airways. Laryngeal or tracheal foreign body requires immediate management whereas right or left bronchial tree foreign bodies can be
dealt with less urgency. Although bronchoscopy should be carried out as soon as possible, without inadequate preparation it may lead to total airway obstruction with dangerous consequences, including death. It should be performed by adequately trained professionals with multidisciplinary team. Traditionally, rigid bronchoscopy is the procedure of choice for removal of tracheobronchial foreign body in children. The ability to control the airways, wide working channel, excellent optical telescopic visualization, wide variety of instruments to retrieve the foreign body, and availability of range of various sizes of bronchoscope have made it the gold standard modality for retrieval of tracheobronchial foreign bodies in children. The requirement of general anesthesia and inability to reach the peripheral airways are the major disadvantage of this procedure. In recent years, flexible bronchoscopy has gained the popularity among respiratory endoscopist as a first choice for retrieval of foreign bodies in the children. Cunanan45 in 1978 analyzed the clinical data of 300 adult patients with foreign body aspiration, treated with flexible bronchoscopy and reported 89% success. Swanson et al22 performed the flexible bronchoscopy in 24 children for removal of tracheobronchial foreign body with 100% success. Tang et al7 treated 1027 pediatric patient with foreign body aspiration by flexible bronchoscopy during 2000-2008. The authors removed the foreign bodies successfully in 91.3% of cases with very few complications.7 Flexible bronchoscopy has noteworthy advantages over rigid bronchoscopy. First, it is relatively easy and safe procedure in experienced hands. Second, it can be performed under sedation with local anesthesia avoiding the extra cost, risk, and morbidity of second invasive procedure such as rigid bronchoscopy under general anesthesia. Third, foreign body lodged in distal airway can be reached only by flexible bronchoscopy because of smaller diameter and flexibility. Fourth, endogenous foreign bodies such as mucus or blood plugs can be managed in better way by flexible bronchoscopy by vacuum aspiration and bronchoalveolar lavage, as compared with rigid bronchoscopy. Fifth, it is superior in mechanically ventilated or children with skull, jaw, or spine injury patients with minimal manipulation. The limitations of flexible bronchoscopy include the following: Foreign bodies that are too large to pass through the flexible bronchoscope, too smooth, foe example, rubber, which cannot be grasped by forceps, or those with sharp edges that might hurt the airway, cannot be retrieved. Complications associated with flexible bronchoscope are few and mostly nonserious. Tang et al7 reported transient hypoxia in 12.9% of patients, which was alleviated by oxygen supplementation or temporary cessation of
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Clinical Pediatrics XX(X)
procedure. Bleeding was reported in 1.7% with good response to local application of adrenaline. Bradycardia, air leak, including pneumomediastinum, subcutaneous emphysema, laryngeal edema, and laryngeal spasm were reported in very small number of patients.7 Although, the technological advancement in bronchoscopy has reduced the requirement of open surgical management but there are certain occasions where endoscopy can be abandoned in the favor of open surgical management. Various available surgical options include tracheostomy, thoracotomy, and bronchotomy and/or pulmonary resection. In the analysis of records of 6693 patients with foreign body, tracheostomy was performed in 2.0% while thoracotomy was done in 2.5% of patients. The indications for tracheostomy includes subglottic foreign body causing acute airway obstruction, too large foreign body to be removed through glottis, foreign body with sharp edges that can lead to injury to vocal cords and to secure the airway in chronic subglottic foreign body with associated granulation tissue, which tends to bleed on touch. Pulmonary resection was performed in cases with bronchiectasis, chronic infection, and lung abscess.46
Prevention Most of the foreign bodies in children are food particles causing acute airway obstruction and dangerous consequences, including death. Main preventive measure is to educate the parents regarding various physiological factors such as absence of moor teeth for chewing the solid foods and poor swallowing coordination, which can lead to foreign body accidents in children. Appropriate eating habits are also important to prevent these problems. Nuts and various fruits with seeds should be avoided in children younger than 4 years. The curiosity of oral exploration can lead to aspiration of inorganic material such as toy parts, pen caps, and so on. These materials should be kept out of reach of these preschool children. Most of the deaths due to foreign body aspiration occur in home only. So parents should be educated regarding the urgency of the condition and requirement of immediate hospitalization. Parents should also learn about Heimlich’s maneuver, which reduces the chances of fatal accidents. In conclusion, foreign body aspiration is a frequently encountered problem in children and requires early diagnosis and prompt management. Children younger than of 3 years, especially boys, are more commonly affected. Right bronchial tree is more commonly involved with a peanut as predominant cause of foreign body aspiration. Because of less specific clinical manifestation and radiological findings, threshold should be kept low for the diagnosis and immediate bronchoscopy should be carried out to rule out the diagnosis. Delayed diagnosis can lead to various long-term complications
and morbidity. Flexible bronchoscopy can be used as a procedure of choice to extract the foreign body because it is relatively easy and is usually associated with lesser complications in experienced hands. There is a requirement of development of specific clinical or radiological diagnostic criteria, which can help in diagnosing the condition at an earlier stage and resultant reduced associated mortality and morbidity. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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