An updated approach in the management of 50 patients with foreign body inhalation is presented. Certain risk factors that lead to complications and mortality due to endoscopic extraction of foreign bodies and thus determine prognosis were identified. Remedial measures to reduce morbidity and mortality due to bronchoscopic removal of foreign bodies are suggested. Fifty patients of suspected foreign body inhalation presented to a Unit of the Department of ENT, Head and Neck Surgery of Government Medical College associated SMHS Hospital Srinagar, Kashmir from March 2007 to June 2017. Of these, 49 patients were subjected to rigid tube bronchoscopy for removal of the aspirated foreign bodies and one coughed out the foreign body spontaneously during admission for bronchoscopy. History of foreign body inhalation was positive in 90% of patients and remaining was mostly referred from Paediatric Units with un-resolving collapse-consolidation of the lung. Whereas plain radiography of the chest and the soft tissues of neck were the primary imaging modality used in this study to detect the inhaled foreign bodies or their effects there are reports of virtual bronchoscopy being done with a multidetector computed tomography scanner in 3D image generation from axial cuts of the internal walls of the tracheobronchial tree in the management of patients suspected with foreign body aspiration. Bronchoscopy is a difficult and potentially hazardous procedure in the infant and young child. Telescopes and telescopic forceps were used during bronchoscopy to facilitate extraction of a foreign body inhaled. The type of a foreign body, site of its enlodgement and the complications encountered during its extraction were noted. During bronchoscopy the patients were connected to an ECG monitor and a pulse oximeter. 80% of the patients with foreign body inhalation were children in the age group of 0 - 5 years. There was a definite history of choking over the foreign body in 88% of the patients leading to acute respiratory distress in 46%. Cough alone or along with other symptoms occurred in most of the patients (96%). Persistent fever with respiratory symptoms unresponsive to treatment occurred in 38% of the patients with or without a positive history of foreign body inhalation. Right main bronchus was the commonest site of enlodgement of foreign body. In the present study, bean and peanut were the commonest types of foreign bodies inhaled (34%). Radiological findings in these patients include atelectasis with or without pneumonitis in 46.65% of the patients, normal chest/soft tissues of the neck in 24.45%, obstructive emphysema on the affected side in 24.45%, foreign body seen in the respiratory tract in 8.90% and bronchopneumonia in 2.22%. Complications associated with the endoscopic extraction of foreign bodies and the risk factors that lead to complications and mortality in patients with aspirated foreign bodies were identified in this study and the measures to reduce these complications and mortality rate to very low levels were suggested. Transient hypoxia, hypoxic bradycardia, transient cardiac arrest, bronchial perforation and death, laryngospasm, bronchospasm, subglottic oedema, reflex bradycardia and pneumothorax were among the few complications which occurred with the rigid endoscopic extraction of foreign bodies in the present study. Among the risk factors associated with the complications were prolonged bronchoscopy, semi-blind procedure, a vegetable foreign body, improper size and positioning of a bronchoscope and some other important factors which are detailed in the text of this paper to follow. Remedial measures on the basis of complications and the risk factors are suggested so as to decrease the morbidity and mortality due to endoscopic extraction of foreign bodies inhaled into the tracheobronchial tree.
Foreign bodies inhaled into the larynx and trachea can cause total respiratory obstruction and death within a few minutes if help is not ready to hand. Two engravings in Egypt record the performance of tracheostomy by Egyptians about five thousand and six hundred years ago [
to formation of lung abscess. In most cases of inhaled foreign body there is a definite history of choking followed by paroxysmal coughing which later subsides. Modern techniques of endoscopic removal of bronchial foreign bodies were the result of the advances made in early part of the twentieth century by Chevalier Jackson who succeeded in reducing mortality from the procedure significantly. The advent of ventilating bronchoscope, improvement in the illumination and magnification provided by Hopkins’ rod lens system, fibre optic bronchoscopy, virtual bronchoscopy [
This study is a prospective randomized clinical trial in which fifty patients of suspected foreign body inhalation who presented to the Department of ENT, Head and Neck Surgery of the Govt. Medical College associated SMHS Hospital Srinagar, Kashmir directly or through referral from other hospitals in the State over a period of 5 years from March 2007 to June 2017 were subjected to rigid tube bronchoscopy for removal of aspirated foreign bodies. Majority of the patients in this series were children. The youngest patient was 6 months old and the oldest was of 22 years of age. Infants or children with foreign bodies impacted in the larynx or in the trachea who presented with stridor, choking and coughing were subjected to emergency tracheostomy before bronchoscopy. Falling oxygen saturation after a prolonged bronchoscopy is usually indicative of subglottic oedema, bronchospasm or pneumothorax, and may also need airway assistance. Radiography of the chest before bronchoscopy was done in 46 patients (92%) and was repeated after the procedure in all of the patients who survived. The distribution of foreign bodies at various sites in the respiratory tract is depicted under observations. The type of foreign body and the complications encountered during the procedure were noted. Brochoscopes used for children relating the size of the instrument to the age of the child are tabulated below (
Age and sex distribution: Age of the patients with foreign body inhalation ranged from 6 months to 22 years, including five infants with age below 1 year. The average age of the patients was 3 years and 4 months. 80% of the patients belonged to the age group of 0 - 5 years. 74% of the patients were male and 26% were female.
Size marked on bronchoscope (I.D in mm) | External diameter (in mm) | Age range |
---|---|---|
2.5 | 4 | Premature/Neonate |
3 | 5 | 4 weeks - 3 months |
3.5 | 5.7 | 4 - 12 months |
4 | 7 | 12 - 36 months |
5 | 7.8 | 3 - 9 years |
6 | 8.2 | Over 9 years |
Age group (years) | No. of patients (%) | Male (%) | Female (%) |
---|---|---|---|
0 - 5 | 40 (80.00%) | 30 (60.00%) | 10 (20.00%) |
5 - 10 | 8 (16.00%) | 6 (12.00%) | 2 (4.00%) |
10 - 15 | 1 (2.00%) | 0 (0.00%) | 1 (2.00%) |
15 - 20 | 0 (0.00%) | 0 (0.00%) | 0 (0.00%) |
20 - 30 | 1 (2.00%) | 1 (2.00%) | 0 (0.00%) |
Total | 50 (10.00%) | 37 (74.00%) | 13 (26.00%) |
Clinical features: There was history of choking over the foreign body in 88 % of the patients leading to acute respiratory distress in 46%. Cough alone or along with other symptoms occurred in most of the patients (96%). Persistent fever with respiratory symptoms un-responsive to treatment occurred in 38% of the patients with or without a positive history of foreign body inhalation; and a loud wheeze in the chest was audible in 16%. Loud whistling sound was heard from a plastic whistle impacted in the right principal bronchus in one patient (2%). History of foreign body inhalation was positive in most of the patients (90%) and the remaining were mostly referred from the Paediatric Units of other hospitals with unresolving collapse-consolidation of the lung. Duration of enlodgement of foreign bodies ranged from 1 hour to 2 months. Decreased breath sounds on the affected side were the most common examination finding (78%).
Radiological signs: Of 50 patients with the history of inhalation of foreign body radiography of chest/soft tissues of neck was done in 45 patients and in the remaining 5 radiograph could not be obtained because of urgency of foreign body removal. Radiological signs due to the inhalation of foreign bodies in the present study included atelectasis of lung with or without consolidation in 46.67%, normal chest/soft tissues of neck in 24.44%, obstructive emphysema in 17.78%, foreign body seen in the respiratory tract in 8.89% (
Treatment: Larngeal foreign bodies in this study were successfully extracted by emergency tracheostomy followed by endoscopy in 6% of the total number of patients, direct laryngoscopy with Mackintosh laryngoscope in 4%, and rigid
Radiological sign | No. of Patients | % age |
---|---|---|
Atelectasis of lung with or without consolidation | 21 | 46.65 |
Normal chest/Soft tissues of neck | 11 | 24.45 |
Obstructive emphysema | 8 | 17.78 |
Foreign body seen | 4 | 8.90 |
Bronchopneumonia | 1 | 2.22 |
Total | 45 | 100 |
tube bronchoscopy without preliminary tracheostomy in 2% whereas a laryngeal foreign body was spontaneously coughed out by one patient (2%). Tracheal and bronchial foreign bodies were removed using different sizes of the metallic ventilation bronchoscope with respect to the age of the patient.
Type of the foreign body: Children can inhale whatever foreign material comes in their way. Of vegetable foreign bodies 80% of the patients inhaled beans, peanut and maize grains. Of inert foreign bodies plastic whistles and pen caps were commonly aspirated foreign bodies (18% of the patients).
Location of foreign body in the respiratory tract: Right main bronchus was the commonest site of enlodgement of foreign body (46% of the cases) in this study followed by left main bronchus (22%), trachea (12%), subglottis (8%), carina (4%), glottis (2%), glottis to subglottis (2%), all sites of respiratory tract (2%) and undetermined (2%).
Complications and risk factors: Complications associated with the endoscopic extraction of inhaled foreign bodies can be serious (
Foreign body inhalation is a major cause of accidental death during childhood [
Organic (reactive) foreign body | Inert (non-reactive) foreign body | ||||
---|---|---|---|---|---|
Type | No. of patients | % (of the total cases) | Type | No. of patients | % (of the total cases) |
Bean | 12 | 24 | Plastic whistle | 5 | 10 |
Peanut | 5 | 10 | Plastic pen cap | 4 | 8 |
Maize grain | 3 | 6 | Pill cover | 2 | 4 |
Almond shell | 3 | 6 | Scarf needle | 2 | 4 |
A piece of vegetable | 2 | 4 | Egg shell | 1 | 2 |
Cherry seed | 1 | 2 | Metallic bead | 1 | 2 |
Cover of peanut | 1 | 2 | |||
Pumpkin seed | 1 | 2 | |||
A piece of walnut | 1 | 2 | |||
A piece of waternut | 1 | 2 | |||
Pea seed | 1 | 2 | |||
Decomposed paper | 1 | 2 | |||
A piece of cashew nut | 1 | 2 | |||
A piece of coconut | 1 | 2 | |||
Bone piece | 1 | 2 |
Site | No. of patients | % |
---|---|---|
Right main bronchus | 23 | 46 |
Left main bronchus | 11 | 22 |
Trachea | 6 | 12 |
Subglottis | 4 | 8 |
Carina | 2 | 4 |
Glottis | 1 | 2 |
Glottis to subglottis | 1 | 2 |
All sites | 1 | 2 |
Undetermined (spontaneously coughed out) | 1 | 2 |
Total | 50 | 100 |
Complication | No. o patients | % of the total bronchoscopies/D.L | Associated risk factor/factors | No. of patients | % of the total bronchoscopies/D.L |
---|---|---|---|---|---|
Transient hypoxia | 3 | 6.12 | 1) Age below 1 year | 1 | 2.04 |
2) Pre-existing pneumonia due to delayed presentation/referral in an infant (below 1 year) | 1 | 2.04 | |||
3) Improper size and positioning of a bronchoscope | 1 | 2.04 | |||
Hypoxic bradycardia | 2 | 4.08 | 1) Age below 1 year | 1 | 2.04 |
2) Lighter plane of anaesthesial/less skilled anaesthetist) | 1 | 2.04 | |||
Transient cardiac arrest | 2 | 4.08 | 1) Vegetable foreign body necessitating prolonged bronchoscopy in an infant below 1 year | 1 | 2.04 |
2) Semiblind technique without using a telescope or telescopic forceps (thus prolonging the procedure) | 1 | 2.04 | |||
Cardiac arrest and death | 1 | 2.04 | Vegetable foreign body necessitating prolonged bronchoscopy | 1 | 2.04 |
Bronchial perforation and death | 2 | 4.08 | Less skilled bronchoscopist | 2 | 4.08 |
Reflex bradycardia | 1 | 2.04 | Age below 1 year | 1 | 2.04 |
Bronchospasm | 1 | 2.04 | Delayed referral with pre existing pneumonia | 1 | 2.04 |
Misdirection of bronchoscope into oesophagus | 1 | 2.04 | Less skilled bronchoscopist | 1 | 2.04 |
Laryngospasm | 1 | 2.04 | Less skilled bronchoscopist with laryngeal trauma | 1 | 2.04 |
Subglottic oedema | 1 | 2.04 | Vegetable foreign body necessitating prolonged bronchscopy | 1 | 2.04 |
Pneumothorax | 1 | 2.04 | Vegetable foreign body necessitating prolonged bronchloscopy | 1 | 2.04 |
Surgical emphysema neck, chest | 1 | 2.04 | Less skilled bronchoscopist with a traumatic procedure | 1 | 2.04 |
Cerebral anoxia and death | 1 | 2.04 | Vegetable foreign body necessitating a prolonged procedure | 1 | 2.04 |
Paralytic ileus | 1 | 2.04 | Vegetable foreign body necessitating a prolonged procedure forced ventilation for hypoxia (with mask) | 1 | 2.04 |
younger children more commonly than in adults seem to be the anatomic relations of the larynx in children which is high up and more posteriorly placed in the neck; difficulties in chewing due to the lack of molars; their tendency to put almost every object in mouth for exploring its texture and taste; shouting, crying and playing while eating which open the laryngeal inlet reflexly; recurrent upper respiratory infections, coughing and mouth breathing causing sharp intake of breath which follows a cough; and finally the poorly co-ordinated swallowing reflex. Male to female ratio in our study was nearly 3:1. In the studies made by Rothman and Boeckman [
The most common radiological sign in patients with foreign body inhalation in the present study were atelectasis of the lung with or without consolidation (46.6%) followed by normal chest/soft tissues of neck in 24.44%, obstructive emphysema in 17.78%, foreign body seen in the respiratory tract in 8.89% and bronchopneumonia in 2.22%. According to the study of Jennis Dennilidis et al. [
Anissa Berraies et al. (2015) while admitting rigid bronchoscopy to be a gold standard for the inhaled foreign body extraction comment that there is an increased role of flexible fibre-optic bronchoscopy in the treatment of inhaled foreign bodies in children for whom the diagnosis of foreign body aspiration is doubtful. They recommend performing a flexible endoscopy in all children with suspected foreign body aspiration, except those with respiratory distress or a radio-opaque foreign body. First, according to these authors, it will avoid unnecessary rigid bronchoscopy in children without foreign body, or with foreign body that is located in distil bronchus and is, therefore, difficult to remove using a rigid bronchoscope. Secondly, it will localise the foreign body and thus guide the bronchoscopist. In their experience, flexible bronchoscope was used for foreign body removal in cases where the ENT specialist had not seen the foreign body because it was distil, or when attempt to remove the foreign body by rigid bronchoscopy failed. Flexible bronchoscopy was not attempted by these authors for proximal foreign bodies, friable foreign bodies and when it can become blocked in the larynx.
Rodriguez H et al. [
Remedial measures to reduce morbidity and mortality and thus improve prognosis in the endoscopic extraction of the inhaled foreign bodies are summarised as below:
• Incidence of foreign body inhalation can be significantly decreased if public awareness about not keeping extraneous material accessible to young children is increased. Parents have fundamental role in providing constant supervision to children especially in their infancy. Children have a natural tendency to explore foreign material and often put it in mouth and can inhale it especially as their swallowing mechanism is also not mature and coordinated. Moreover, it is suggested, toys such as plastic whistles manufactured with the candies to allure children be totally withdrawn from the market.
• Early suspicion of foreign body inhalation and early referral to the endoscopist by the paediatricians, chest physicians or the general practitioners to whom the patient may initially present is highly emphasised on the basis of the present study because bronchoscopy on a child with pre-existing pneumonitis due to a neglected foreign body was observed to increase the risk of intraoperative hypoxaemia. Besides, delay in diagnosis of foreign body inhalation and its extraction can lead to irreversible changes in the lungs with increased morbidity and mortality.
• Review of literature on the management of suspected foreign body aspiration in children shows virtual bronchoscopy being done with a multidetector C.T. Scanner in 3D image generation from axial cuts of the internal walls of the tracheobroncheal tree which can indicate exact location of the foreign body and even preclude the need to submit patient to rigid bronchoscopy in the absence of a foreign body. Flexible fibre optic bronchoscopy has also been recommended with the same purpose (Anissa Barraies et al. 2015) in the management of suspected foreign body inhalation in all children except those with respiratory distress or a radio-opaque foreign body. Flexible bronchoscopy will avoid unnecessaryrigid bronchoscopy in children without foreign body or with a foreign body which is located in distil bronchus. Besides, fibre-optic bronchoscope will localize the foreign body and so guide the subsequent rigid tube endoscopy when indicated.
• The endoscopist must have thorough knowledge about the brocho-pulmonary anatomy at different ages of an individual.
• In the present study use of 10% lignocaine spray into the laryngeal interior shortly before introducing the bronchoscope was observed to lessen the incidence of reflex bradycardia and cardiac arrest dramatically. Atropine is also routinely given to the patients before induction of anaesthesia for bronchoscopy and also during bronchoscopy for the treatment of bradycardia. Succinylcholine given in a controlled dosage fashion during anaesthesia prevents laryngospasm. Besides, jet ventilation mode of anaesthesia for extraction of the inhaled foreign body has been reported to decrease the intraoperative hypoxaemia whereas the spontaneous mode increases it (Chen L. H. et al. 2009).
• The present study showed a vegetable foreign body such as a bean, groundnut or pea as a significant cause for complications due to bronchoscopic extraction (14%) as it often breaks down into multiple pieces during removal and may need several attempts at complete removal. Bronchoscopy on a younger child especially with history of a vegetable foreign body inhalation should not be attempted by a less skilled bronchoscopist/anaesthetist.
• Bronchoscopy should not be unnecessarily prolonged beyond about 20 minutes as it leads to bronchospasm and subglottic oedema and ultimately to complicated patient recovery due to hypoxaemia. The endoscope should be correctly positioned within the bronchus to aeriate the opposite lung. It must be of the proper size with respect to the age of the patient. It may have to be withdrawn to trachea during hypoxia for adequate ventilation before proceeding further, or alternatively may have to be withdrawn fully and the patient intubated and ventilated before the next attempt at bronchoscopy.
• Foreign bodies can be removed from the airway with speed and safety with telescopic optical forceps passed through the ventilating bronchoscope as these provide good visual control in locating the foreign body and its extraction.
• Falling oxygen saturation during or in the post operative period should be seriously taken notice of and managed effectively. Close co-operation between the endoscopist and the anaesthetist is mandatory. Similarly, other complications associated with bronchoscopy such as laryngospasm, pneumthorax and pneumonitis should be recognised and treated early enough.
The authors declare no conflicts of interest regarding the publication of this paper.
Sheikh, M.S., Afshan, S.G., Sheikh, M.M. and Bunafsha, S. (2019) Factors Influencing Prognosis in the Endoscopic Extraction of Foreign Bodies in Kashmiri Population. International Journal of Otolaryngology and Head & Neck Surgery, 8, 32-48. https://doi.org/10.4236/ijohns.2019.81005