Introduction
Aspiration of foreign body is common in children below 3 years of age (79%),1 with a higher incidence in boys (63%).2 Sometimes, FBA can be a significant cause of mortality in children younger than 6 years.3 This higher incidence in children has also been confirmed in a retrospective Brazilian study.4 Accidental foreign body aspiration is a very frequently occurring situation in paediatric age which may produce a great variety of symptoms of varying severity, or it even can be asymptomatic.
Around 40 % of patients present with breathlessness, coughing, wheezing, choking and decreased air inflow1, 5, 6. Some patients may present with fever, cyanosis, stridor, atelectasis, chronic coughing, recurrent pneumonia, and even death2.
Diagnosis of FBA begins with patient history and clinical signs and can be strengthened by radiographic findings. The most common indicators are air trapping, signs of infection, atelectasis, or radioopaque foreign body7. However, these findings can also occur in a patient without FBA. In addition, 24% of the patients with an endoscopically confirmed foreign body do not present with any abnormality at radiography. Radiology of thorax is used to find the location of foreign body. Hence, it is essential to perform bronchoscopy in children with all those clinical symptoms and signs, regardless of radiographic findings8. Multidisciplinary team work is essential for early and successful removal of foreign body. We report 35 cases of accidental vegetative and metallic foreign body aspiration.
Materials and Methods
This was a retrospective analysis of 35 cases of foreign body removal done between January 2018 to January 2020. The present study was approved by the ethical committee of this institution. We included those cases that had history of aspiration, sudden onset of breathlessness or choking sensation in a healthy person, recurrent respiratory infections with clinical or radiological evidence, and suspicion of foreign body. Patients with bronchial asthma, acute laryngo-tracheobronchitis, COPD, bronchiectasis were excluded from the study. Informed consent was taken from each and every patient.
Every case was documented with respect to age, sex, nature, site of foreign body lodgement, duration between inhalation or symptoms and admission in a hospital, clinical symptoms and signs, chest radiography findings, results and complications of bronchoscopy. Rigid bronchoscopy was performed after thorough clinical evaluation and radiography. In some patients with chronic or subtle symptoms with no history of foreign body aspiration, or patients with symptoms unresponsive to bronchodilator therapy, or history consistent with aspiration but no physical or x-ray signs, flexible bronchoscopy was performed to rule out any other lung pathology.
Foreign body removal was done using rigid bronchoscope under general anaesthesia, with induction by propofol, relaxation and apnoea with scoline, oxygenation with jet ventilation. Continuous monitoring of electrocardiogram, blood pressure, oxygen saturation by pulse oxymetry and precordial stethoscope auscultation was done. On visualization of the foreign body it was grasped with adequate forceps for each case and removed.
The bronchoscope was reintroduced for removal of any remaining fragments, aspiration of secretions and evaluation of any mucosal oedema or any injury. Intravenous steroids along with antibioticswere administered to decrease post-operative sub-glotticoedema. In few cases of vegetative foreign bodies tracheostomy was done as they get swelled up due to their hygroscopic action and successful decannulation was done on fifth post-operative day. Chest x-ray is repeated after 48 hours. Most of our patients were discharged on fifth post-operative day.
Results
35 patients of different age groups who underwent bronchoscopy for removal of foreign bodies in the airways were evaluated. The period of study was 2 years. The most common age group was between 1-6 years. Males have outnumbered females. (Table 1) Most of the patients attended hospital after 7 days of aspiration without any emergencies.8 patients came immediately after aspiration with a positive history of aspiration of foreign bodies by parents and relatives. (Table 2) History of aspiration and respiratory distress were the common presentation. Fever was present in those who presented late to the emergency department.(Table 3) About 25 cases (71.4%) had diminished or absent breath sounds followed by 12 cases (50%) of stridor, 15 cases (42.8%) diminished percussion notes. (Table 4)
Asymptomatic and clinically stable patients can present immediately after a choking event and with normal imaging. Inspiratory and expiratory or decubitus films of the chest may be helpful in establishing the diagnosis of FBA. (Figure 11, Figure 12, Figure 13, Figure 14) The common radiographic finding is obstructive emphysema. Other features are hyper inflated lung of the opposite side, Atelectasis, consolidation or a contralateral mediastinal shift. The commonest site of foreign body is right bronchus followed by left bronchus.(Table 5, Table 6) Most of the foreign bodies are vegetative in nature. (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10) They have to be removed under general anaesthesia using rigid bronchoscopes.(Figure 15) The commonest foreign body to be removed was a groundnut.(Table 7)
Table 1
Age and Gender distribution
| Age (Years) | No. of patients | Percentage (%) |
| 0-2 | 16 | 46 |
| 2-4 | 8 | 23 |
| 4-5 | 5 | 14 |
| 5-15 | 3 | 8.5 |
| >15 | 3 | 8.5 |
| Total | 35 | 100 % |
| Gender (Male/Female) | 19 / 10 | 65.5 / 34.5 |
Table 2
Time taken between aspiration and removal of foreign body
| Days | No. of patients | Present study (%) | Srppnath et al(%)9 |
| 0-1 | 8 | 23 | 14 |
| 1-7 | 14 | 40 | 28 |
| 7-14 | 7 | 20 | 32 |
| 15-30 | 5 | 14 | 25 |
| >30 | 1 | 3 | 1 |
Table 3
Symptoms presented by the patient
| Symptoms | No. of Patients | Present study (%) | Rajasekaran et al (%) 5 |
| History of aspiration | 30 | 86 | 62 |
| Breathlessness | 24 | 69 | 68 |
| Wheezing | 12 | 34 | 54 |
| Cough | 26 | 74 | 72 |
Table 4
Presenting signs
| Signs | No. of patients | Present study (%) | Naragund et al (%)10 |
| Diminished breath sounds | 25 | 71.4 | 72.7 |
| Decreased percussion note & Crepitation | 15 | 42.8 | 45.5 |
| Stridor | 22 | 62.9 | 50 |
| Rhonchi | 14 | 40 | 54.5 |
Table 5
Radiological findings
| Chest Radiology | No. of patients | Present study (%) | Rajasekaran et al(%) 5 |
| Obstructive emphysema | 18 | 51 | 58 |
| Consolidation | 7 | 20 | 6 |
| Collapse | 2 | 5 | 8 |
| Bronchopneumonia | 4 | 12 | 14 |
| Normal X-ray | 4 | 12 | 10 |
Table 6
Location of foreignbody
| Site of foreign body | No. of patients | Present Study (%) | Srppnath et al 9 |
| Right bronchus | 17 | 49 | 46 |
| Left bronchus | 14 | 40 | 46 |
| Subglottis | 2 | 6 | 2 |
| Trachea | 2 | 6 | 6 |
Table 7
Types of foreignbody removed by bronchoscopy
Complications
In 35 cases, it was possible to remove the foreignbodies successfully. In 3 cases bronchoscopy related complications such as laryngospasm with braycardia, laryngospasm with desaturation and pneumothorax was seen respectively. Patients were kept in ICU under keen observation and were then discharged.
Discussion
The clinical presentation of patient depends on type of foreign body, site of lodgement, size of foreign body, duration since hospital admission 11. Children below 2 years are more commonly affected. This age group is mostly affected because of predisposing factors like the smaller diameter of airway, the tendency to put objects into the mouth, immature dentition, immature swallowing coordination and activity while eating 12. In older children, anatomic abnormalities and neurologic disorders predispose to FBA13. It was found that in a study by Srppnath and VinayMahendrakarout of 225 patients, 50 cases (64%) of foreign body aspiration were found in children below 2 years of age group with 93 cases (20%)in the age group of 2-4 years9. The male: female ratio was 1.9:1.
It was observed that 23% of patients presented to ENT OPD within 24 hours of aspiration and maximum no. of patients (40%) consulted after one week with delayed symptoms of respiratory tract infections, fever, Pneumonia, respiratory distress. Most of the paediatric patients seek treatment in paediatric department. Misdiagnosis, lack of suspicion by the parents, fatigability of cough reflex after an acute choking episode, delayed respiratory symptoms are the factors causing a delay in proper treatment4, 14. 30 (86 %) out of 35 cases had positive history of foreign body aspiration. But the study done by Rothmann and Boeckman15 shows that out of 225 cases, 168 (74.9%) cases had history of accidental aspiration. Most of children below 4 years are vulnerable and usually do not give a history of aspiration. Vegetative foreign bodies predominate among infants and toddlers, whereas in older children metallicforeign bodies, plastics are more common16. Most objects aspirated by children are radiolucent, whereas only 18% to 20% of aspirated foreign bodies are radiopaque.Plastic pieces account for 5% to 15% of FBA and tend to remain in place longer because they are inert and radiolucent13, 15, 16.
A suspicion of foreign body aspiration is therein those patients who have chronic breathing symptoms. Computed tomography of the chest helps in localisation of radiolucent foreignbodies,location and size of the foreign body, lung pathology, and granulation. Rigid bronchoscopy is the gold standard for the safe removal of a foreign body in bronchus13, 17, 18.
Bronchoscope is again re-inserted to look for any remnants of foreign body and suctioning the trachea-bronchial secretions. The bronchoscope is connected to anaesthetic gas supply in one arm and the other is connected to light source and fibre-optic cable. This enables the anaesthetist and surgeons not to hurry and allow smooth passage of bronchoscope. There are three methods of anaesthesia for bronchoscopy 9, 19.
Anaesthesia with Spontaneous Respiration: After giving topical anaesthesia to larynx and trachea, halothane without muscle relax ant is used.
Anaesthesia with Apnoea and Oxygen Insufflation: For short bronchoscopic procedures complete/ relaxation can be maintained by intermittent doses of suxemethonium and insufflating oxygen at the rate of 6-10 Ltr/min, into the trachea through a small nasotracheal catheter placed with its tip close to the carina.
Anaesthesia with apnoea using Venturi Type injector for positive pressure ventilation: In this procedure, a small tube is attached to the bronchoscope and oxygen under pressure is injected intermittently. Adequate ventilation can be maintained for almost unlimited time in the apnoeic, relaxed patient by this method producing good condition for bronchoscopy without rise in PCO2 or fall in oxygen tension.
Bronchoscopy is done under general anaesthesia with induction by pentathol, relaxation and apnoea with scoline, Oxygenation with facemask. This is followed by introduction of bronchoscope and maintenance of oxygen with jet ventilation with repeat dose of scoline if necessary. Once the foreign body is localised, forceps like crocodile, alligator, and serrated, cupped, peanut are used for extracting the foreign body.20 The foreign bodies in subglottis have to be removed at the earliest as it causes respiratory emergency. In two of our cases, broken PVC tracheostomy tubes were removed from the trachea through the stomal opening. Post-operatively antibiotics, analgesics, oxygenation and steroids were administered to treat subglottic edema.
Conclusions
Foreign body aspiration is a challenge for otolaryngologists because of high incidence of mortality. Otolaryngologists should proceed for bronchoscopy once foreign body aspiration is suspected. Sander’s technique of jet ventilation is the best method of anaesthesia. Parents should be educated about the risks of particular food types and should minimize the availability of small pieces of articles and toys around toddlers.
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