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Inhalation of foreign bodies in children
Inhalation of foreign bodies in children Report of 500 cases Inhalation offoreign bodies is a major cause of accidental death during childhood. Aspiration offoreign bodies is common in children aged I to 3 years, especially in boys. A past history offoreign body aspiration is itself an indication for bronchoscopic examination of the airways, because some children with aspirated foreign bodies are without symptoms and chest x-ray films may not show abnormalities. Bronchoscopic removal of the foreign bodies requires close communication between the anesthesiologist and the endoscopist . Forgotten foreign bodies in the airways cause chronic pulmonary infections, allergic asthma, bronchiectatic changes, and lung abscess. Foreign bodies that cannot be grasped by bronchoscopic forceps should be removed by thoracotomy and bronchotomy. This report describes our experience in 500 children with suspected foreign body inhalation. We routinely use prednisolone, I to 2 mg. per kilogram, and nebulization just after bronchoscopic examination of the airways. This medication greatly diminishes the rate of postbronchoscopic complications such as laryngeal edema, which require tracheostomy. In our series of 500 cases, the incidence of postbronchoscopic tracheostomy is 1.4 per cent and the total mortality rate is 1.8 per cent.
Aydin Aytac, M.D., F.A.C.S., F.A.C.C.,* Yurdakul Yurdakul, M.D.,** Coskun Ikizler, M.D.,*** Riistem Olga, M.D.,*** and Argun Saylam, M.D.,*** Ankara, Turkey
ASPiration of foreign bodies is a very serious and vital problem in childhood, sometimes leading to sudden death. The National Safety Council of America accepted the inhalation of foreign bodies as the leading cause of accidental deaths at home in children younger than 6 years of age.' About 2,000 children die each year in the United States owing to the inhalation or ingestion of foreign bodies, 60 per cent of the children being under 4 years of age." Chevalier Jackson cited a 50 per cent mortality rate resulting from foreign bodies in the tracheobronchial tree in childhood before the introduction of bronchoscopic techniques to remove them." Since the first bronchoscopic removal of a From the Department of Pediatric Thoracic and Cardiovascular Surgery, Hacettepe University Hospitals, Ankara Turkey. Received for publication Sept. 16, 1976. Accepted for publication Oct. 28, 1976. Address for reprints: Prof. Dr. Aydin Aytac, Chief, Department of Pediatric Thoracic and Cardiovascular Surgery, Hacettepe University Hospitals, Hacettepe, Ankara, Turkey. *Professor and Chief. **Assistant Professor. ***Lecturer.
foreign body from the tracheobronchial tree by Gustav Kilian on March 30, 1897, the mortality rate had decreased to 7 per cent in 1968. The current mortality rate is about one per cent. 4 Improved anesthetic techniques certainly play an important role in the decrease of mortality rates.
Patients and methods Five hundred children underwent bronchoscopic examination because of suspected foreign body aspiration. Seventy-six per cent were boys and 24 per cent girls. Foreign bodies were found in 462 cases. Correlation between the history of the patients and bronchoscopic findings are shown in Table I. Most of the patients were referred to the hospital within 3 days after the aspiration of the foreign body. The longest time interval between the inhalation of the foreign body and admission to the clinic was 3 years, in a child who had aspirated a piece of wire. Most of the children between 1 and 7 years of age, frequently between 1 and 3 (Table II). Ninety-five per cent had acute respiratory distress, 3.5 per cent chronic infection or bronchiectasis or both, and 1.5 per cent allergic asthma on admission. Unilateral hyperaeration, normal chest x-ray films, loss of 145
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146 Aytac; et al.
Fig. 1. Total atelectasis of the right lung owing to bean aspiration.
Thoracic and Cardiovascular Surgery
Fig. 3. Drawing pin in the right main bronchus with distal atelectasis.
Table I. Correlation between the past history of the patients and the presence/absence offoreign bodies in 500 cases* Patients History
Foreign body
No.
Yes No Yes No
Present Present Absent Absent
446 16 26 12
I
%
89.2 3.2 5.2 2.4
"The shortest interval between aspirat ion and examination was a few minutes, the mean interval was I to 3 days , and the longest interval was 3 years.
Fig. 2. Bead in the right main bronchus . patency in air bronchograms with distal infiltration, and atelectasis were commonly found on roentgenologic examination (Table III). Some interesting x-ray films are shown in Figs . I to 7. Foreign bodies shown in these films were removed with a bronchoscope . Bronchoscopic procedures were performed with the child under general anesthesia after premedication with atropine, 0 .015 mg. per kilogram . Halothane and muscle-paralyzing agents were used during anesthesia. Airways were washed with isotonic saline solution after the removal of the foreign body and were aspirated to remove small fragments, especially nutty sub-
stances. Prednisolone I to 2 mg. per kilogram, was administered and nebulization was done immediately after the bronchoscopic procedure . A total of 451 foreign bodies were removed by bronchoscopic technique and II by thoracotomy and bronchotomy (Table IV). Lobectomy was performed in one case owing to bronchiectatic changes secondary to inhalation of a sunflower seed .
Findings The foreign body was located in the right main bronchus in 327 cases (70.7 per cent), in the left main bronchus in 86 cases (18.7 per cent), in the trachea near the bifurcation in 45 cases (9 .7 per cent), and in both bronchi in 4 cases (0.9 per cent) (bilateral localization). Complementary data in the removal of foreign bodies
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Inhalation offoreign bodies
Number 1 July, 1977
I47
Fig. 5. A nail, 5 em. long, in the right main bronchus. Fig. 4. Screw in the right main bronchus with distal atelectasis and infection.
Table II. Age distribution in foreign body aspiration
_______I-----ca-se-s----Age (yr.)
No .
%
0-1
52
IDA
1-3
277 142
55A 28A 5 0.8
3·7 7·10 > 10
25 4
are displayed in Table V. Watermelon seeds in summer and nutty substances in winter were the most frequently found foreign bodies (Table VI) . Results Nine patients died after the bronchoscopic procedure (1.8 per cent), irreversible cardiac arrest being the most common cause of death . Tracheostomy was performed in 7 cases because of laryngeal edema (1.4 per cent) . Other complications are given in Table VII. Discussion Inhalation of foreign bodies is common in children under 6 years of age, mostly between I and 3 years, although some cases of adults with forgotten foreign bodies in the airways for many years have been re-
Fig. 6. Tire valve of a bicycle in the left main bronchus. ported. 5 , 6 In our clinic, we have encountered only 2 adults with aspirated foreign bodies , both treated with the bronchoscope (rice in one patient and a piece of a dentist 's tool in the other) . The common clinical syndrome in most of the children is acute respiratory distress, characterized by sudden cyanosis, cough, and wheezing . Chronic infection, bronchiectasis, asthma, and bronchial stenosis predominate the clinical picture in patients with a long time interval between the inhalation of the foreign body and admission to the hospital (months and even years). Kiirklu and associates 7 reported foreign bodies in 8
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I 48
Aytac; et al.
Thoracic and Cardiovascular Surgery
Table IV. Methods of removal offoreign bodies in 462 cases Cases
Bronchoscopy Thoracotomy-bronchotom y"
No .
%
451 II
97.6 2.4
" Foreign bodies removed by thoracotomy: nail. 3 cases; tooth . 2 cases; sewing needle. 2 cases; chicken bone, 1 case; bead. I case; plastic plug of a bottle of eau-de-cologne , I case; sunflower seed . I case .
Fig. 7. A long hairpin in the left main bronchus .
Table III. Findingson plain chest x-ray films in foreign body aspiration* Major finding
Unilateral hyperaeration Normal x-ray film Loss of patency in air bronchograms and infiltration Atelectasi s Radiopaque foreign bodies Narrowing of tracheal lumen Mediastinal shift No x-ray film taken because of emergenc y Bronchiectasis and abscess Pneumomediastinum-pneumothorax
%
26 24 15 15 6 5 4 2.5 1.5 I
" More than one of these findings are present in some cases .
cases out of 500 patients with bronchiectasis (1.6 per cent) from Africa and in 8 cases out of 1,038 patients with bronchiectasis (0.7 per cent) from England. Vegetables (nutty substances or plants) are more dangerous than other kinds of foreign bodies (metallic and plastic material): They swell with the bronchial secretions, thus causing gradual mechanical obstruction, and they also cause allergic and chemical bronchitis (so called "vegetable bronchitis") as the result of absorption of antigenic proteins, organic acids, and oils which they contain .v to This fact was stated by Chevalier Jackson in his remark, .. All that wheezes is not asthma " (quoted by De Silva!') . A foreign body in the airways causes pneumonitis in some cases . Chronic obstructive pneumonitis is more likely to occur in obstruction of the lower lobe, and the
spread of infection to both lungs is common in obstruction of the upper lobe. 12 Four types of bronchial obstructions by foreign bodies have been described by Chatterji and Chatterji": I . The check-valve mechani sm, by which air is inhaled and cannot be expelled , causes unilateral hyperaeration (emphysema) on the affected side. 2. The stop-valve mechanism, caused either by a large foreign body or by a gradually swollen, small foreign body , leads to distal atelectasis . 3. The ball-valve mechanism, by which the foreign body dislodges during expiration and reimpacts during inspiration, leads to early atelectasis on the affected side. 4. The bypass-valve mechanism, caused by partial obstruction of the bronchial lumen, results in diminished aeration and opacity on the affected side . A foreign body may change its position and thus cause a variety of clinical presentations. A small foreign body may have no initial effects and may go unrecognized until later, when it causes pneumonia or allergy or both. A clear history of foreign body aspiration is itself an indication for bronchoscopic examination to confirm the diagnosis, because abnormalities may not be present in x-ray films and children may not always have typical symptoms. 14 Children with cough, wheezing, and decreased air entr y are candidates for bronchoscopic study , even when the history is noncontributory. Sharp , traumatizing bodies like glass, 'wire, a twig , or a needle may cause hemopty sis.P A large foreign body (coin, drawing pin, or safety pin) in the esophagus of a small child may lead to stridor and wheezing and thereby simulate an obstruction in the tracheobronchial tree." Vomiting and aspiration of the vomitus can cause acute respiratory distress and death . One of our patients, who had a coin in the upper part of the esophagus, died of a cardiac arrest in the ward while waiting to have it removed with an esophagoscope. Another patient, who had a large piece of watermelon in the upper part of the esophagus, had
Volume 74 Number 1 July, 1977
Inhalation offoreign bodies
Table VI. Foreign bodies found in 462 cases
Table V. Complementary data in removal of the foreign bodies
Cases
cases
~
--------------Repeated bronchoscopy for the removal of the foreign body* Bronchoscopy performed through previously created tracheostomy Foreign body could not be removed through vocal cords; removed through the tracheostomy (piece of bone) Foreign body not seen at bronchoscopy; removed from the bronchus during lobectomy due to bronchiectasis (sunflower seed)
_ _I~c-----
149
No.
No.
%
8
1.6
3
0.6 0.2
0.2
'Bean, 3 cases; bead, I case; sunflower seed, I case; roasted chick peas, I case; peanut, I case; metal rosette, I case.
Watermelon seeds Beans Sunflower seeds Roasted chick-peas Hazelnut Peanut Plastic material (i.e., plugs) Pumpkin seeds Beads Nails Pieces of bone Miscellaneous
%
181
39
11.4 8.6
53
40 28 26 26 16
14 13 10 7
48
_ _1Table VII. Complications in 500 cases
typical symptoms of tracheobronchial obstruction. Foreign bodies are usually located in the right main bronchus. Boys are more often affected than girls, possibly because boys are more active than girls during childhood. Chest x-ray films do not always contribute to the diagnosis. Radioopaque bodies can be detected in plain chest films. Radiolucent bodies can be diagnosed from the secondary pathological changes apparent in the chest films, such as the loss of patency in air bronchograms, infiltration, unilateral hyperaeration, and atelectasis. A normal chest x-ray film can be obtained in about one fourth of the cases. Bronchiectasis, abscess, and bronchial stenosis may develop if the foreign body is not removed for a long time. Taking x-ray films during both inspiration and expiration is useful in detecting pulmonary changes, but it is not always possible owing to the lack of coordination of a small child. Impairment in perfusion scanning of the lungs has also been described in cases of foreign body aspiration. 16 Spontaneous expectoration of inhaled foreign bodies occurs in only I to 2 per cent of the cases.:" Watermelon seeds in summer and nutty substances in winter are the most commonly encountered foreign bodies in Turkey and the Middle East. 9, 14, 17 It is difficult to remove nutty substances, because they are likely to fragment. If the particles fall into segmental orifices, follow-up x-ray films must be taken to avoid the complications caused by chronic irritation of the bronchus. 15 Repeated bronchoscopic examinations may be necessary in the aspiration of these materials. Grass seeds and twigs are difficult to see during bronchoscopic manipulations. Such foreign bodies are found in
Cases
Complications in 500 bronchoscopies Laryngeal edema needing tracheostomy Reversible cardiac arrest Pneumomediastinum-pneumothorax
No.
%
7 5 3
1.4
Complications in 12 thoracotomies Displacement of the foreign body (bead) to the contralateral hemithorax; thus foreign body could not be removed by thoracotomy; patient died of cardiac arrest Death Irreversible cardiac arrest Vomiting and aspiration Laryngeal edema Permanent bronchospasm Total
I
0.6 8
5 2 I I
9
1.8
lung specimens in patients subjected to pulmonary resection months or years after foreign body aspiration. Pyman'" reported 3 such cases, and we treated one, a patient who had inhaled a sunflower seed. Bronchoscopic removal of the foreign bodies is the treatment of choice, although some advise postural drainage for therapeutic purposes. IS Waiting for the spontaneous expectoration of a foreign body by postural drainage cannot be justified in modem practice, because this is a hazardous mode of treatment. The foreign body, dislodged from its original location, may obstruct a vital part of the airways like the trachea and cause the death of the child. Careful examination of the instruments before use is
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1 50 Ayta<; et at.
important to reduce the complications and to shorten the duration of the procedure, which is directly proportional with the morbidity and mortality rates. Good communication is necessary between the endoscopist and anesthesiologist. It is of great value to place the child in a feet up-head down position to take advantage of the aid of gravity in removal of the foreign body. Careful palpation of the pulse rate is mandatory throughout the procedure to prevent anoxic accidents and cardiac arrest. Bradycardia may occur during administration of the muscle-paralyzing agents. Aeration of both lungs when the bronchoscope is above the carinal level, combined with atropin administration, quickly restores the bradycardic pulse rate. Foreign bodies which cannot be grasped by endoscopic forceps, such as a nail, bead, or bone, are removed by thoracotomy and bronchotomy. Mobile, spherical substances like a bead can easily shift to the contralateral hemithorax during thoracotomy, as seen in one of our cases. Such accidents can be prevented by keeping the patient in the feet down-head up position during thoracotomy or by blocking the affected bronchus with endotracheal tubes. Digital compression of the bronchus proximal to the foreign body is useful during bronchotomy. A Fogarty catheter introduced through the bronchoscope may be useful in removing the endobronchial foreign bodies which cannot be held by endoscopic forceps. 19 The Fogarty catheter can be passed through the holes of a foreign body such as a bead to remove it, after the balloon has been inflated. We routinely use steroids (prednisolone, 1 to 2 mg. per kilogram) and nebulization just after using the bronchoscope, because we believe that these medications decrease the incidence of postbronchoscopic tracheostomy. The low incidence of tracheostomy in our series (1.4 per cent) supports this veiw. Routine use of steroids was also stressed by Cosculluela and Atienza.t? Kim 13 advised the routine use of sodium bicarbonate during bronchoscopic procedures to reduce the incidence of cardiac arrest. Bronchoscopic manipulations lasting longer than 30 minutes become traumatic, and subglottic edema develops necessitating tracheostomy. Harboyan and Nassif"? reported 36 instances of tracheostomy in 225 bronchoscopies, mostly in such traumatic cases. Longterm presence of foreign bodies in the bronchus may lead to stenosis of the bronchus, requiring bronchoplasty." Resection of the lung parenchyma is necessary in chronic cases in which there is bronchiectasis or abscess or both.
Thoracic and Cardiovascular Surgery
Mortality rates after bronchoscopic procedures are very low in current practice. The mortality rate was 3.8 per cent in our first 105 cases;':' and our current overall mortality rate is 1.8 per cent. REFERENCES
2 3
4
5
6
7
8 9
10
II 12
13
14 15 16
17
Tandon, R. K" Palney, N. L., Srivastava, V. K., and Wadhavan, V. P.: Foreign Body in Tracheobronchial Tree in Infancy and Childhood, Indian Pediatr. 10: 187, 1973. Benjamin, B., and Vandeleur, T.: Inhaled Foreign Bodies in Children, Med. J. Aust. 1: 355, 1974. Legent, F., Abgrall, H., and Baron, F.: Corps etranger tracheo-bronchiques, J. Fr. Otorhinolaryngol, 24: 17, 1975. Butenandt, I., and Mantel, K.: Die tracheobronchiale Fremdkorperaspiration im Kindesalter, Med. Klin. 69: 2017, 1974. Poulet, 1., Cocheton, 1. J., and Almosni, M.: Les corps etrangers bronchiques de I'adulte. A propos de neuf observations, Sem. Hop. Paris 48: 1719, 1972. Zajaczkowska, 1., Gluskowski, J., Byszewska, D., Tomaszkiewicz, R., Kochanowicz, J., Traczyk, K., Zych, D., and Lesiak, B.: Foreign Bodies in Bronchi in Adults, Gruzlica 41: 373, 1973. Kiirklii, E. U., Williams, M. A., and LeRoux, B. T.: Bronchiectasis Consequent Upon Foreign Body Retention, Thorax 28: 601, 1973. Fine, A. 1., and Abram, L. E.: Asthma and Foreign Bodies, Ann. Allergy 29: 217, 1971. Ural, T.: Foreign Bodies in the Airways and Esophagus in Children (in Turkish), Atatiirk U. Tip Biilteni 2: 206, 1970. Chatterji, S., and Chatterji, P.: The Management of Foreign Bodies in Air Passages, Anesthesia 27: 390, 1972. De Silva, S.: Intrabronchial Foreign Bodies in Children, Ceylon Med. J. 19: 154, 1974. Rananavare, M. M., Patwardhan, 1. R., and Gadgil, R. K.: Foreign Body Aspiration in Children, Indian J. Med. Sci. 26: 370, 1972. Kim, I. G., Brummitt, W. M., Humphry, A., Siomra, S. W., and Wallace, W. B.: Foreign Body in the Airway: A Review of 202 Cases, Laryngoscope 83: 347, 1973. Aspiration of Foreign Aytac, A., and Dokumaci, Bodies Among Children, Turk. J. Pediatr. 8: 157, 1966. Pyman, C.: Inhaled Foreign Bodies in Childhood: A Review of 230 Cases, Med. 1. Aust. 1: 62, 1971. Rudavsky, A. Z., Leonidas, J. c., and Abramson, A. L.: Lung Scanning for the Detection of Endobronchial Foreign Bodies in Infants and Children, Radiology 108: 629, 1973. Harboyan, G., and Nassif, R.: Tracheobronchial Foreign Bodies: A Review of 14 Years' Experience, J. Laryngol. Otol. 84: 403, 1970.
o.
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July, 1977
18 Cotton, E. K., Abrams, G., Vanhoutte, J., and Burrington, 1.: Removal of Aspirated Foreign Bodies by Inhalation and Postural Drainage: A Survey of 24 Cases, Clin. Pediatr. 12: 270, 1973. 19 Ullyot, D. G., and Norman, D. G.: The Fogarty Catheter: An Aid to Bronchoscopic Removal of Foreign Bodies, Ann. Thorae. Surg. 6: 185, 1968.
20 Cosculluela, L. C.; and Atienza, P. A.: Cuerpos extranos en vias respiratorias y digestiva en pediatria. Experiencia en 426 casos, Rev. Esp. Anestesiol. Reanim. 21: 458, 1974. 21 Burrington, J. D., and Cotton, E. K.: Removal of Foreign Bodies From the Tracheobronchial Tree, J. Pediatr. Surg. 7: 119, 1972.
Aydin Aytac, M.D., F.A.C.S., F.A.C.C.,* Yurdakul Yurdakul, M.D.,** Coskun Ikizler, M.D.,*** Riistem Olga, M.D.,*** and Argun Saylam, M.D.,*** Ankara, Turkey
ASPiration of foreign bodies is a very serious and vital problem in childhood, sometimes leading to sudden death. The National Safety Council of America accepted the inhalation of foreign bodies as the leading cause of accidental deaths at home in children younger than 6 years of age.' About 2,000 children die each year in the United States owing to the inhalation or ingestion of foreign bodies, 60 per cent of the children being under 4 years of age." Chevalier Jackson cited a 50 per cent mortality rate resulting from foreign bodies in the tracheobronchial tree in childhood before the introduction of bronchoscopic techniques to remove them." Since the first bronchoscopic removal of a From the Department of Pediatric Thoracic and Cardiovascular Surgery, Hacettepe University Hospitals, Ankara Turkey. Received for publication Sept. 16, 1976. Accepted for publication Oct. 28, 1976. Address for reprints: Prof. Dr. Aydin Aytac, Chief, Department of Pediatric Thoracic and Cardiovascular Surgery, Hacettepe University Hospitals, Hacettepe, Ankara, Turkey. *Professor and Chief. **Assistant Professor. ***Lecturer.
foreign body from the tracheobronchial tree by Gustav Kilian on March 30, 1897, the mortality rate had decreased to 7 per cent in 1968. The current mortality rate is about one per cent. 4 Improved anesthetic techniques certainly play an important role in the decrease of mortality rates.
Patients and methods Five hundred children underwent bronchoscopic examination because of suspected foreign body aspiration. Seventy-six per cent were boys and 24 per cent girls. Foreign bodies were found in 462 cases. Correlation between the history of the patients and bronchoscopic findings are shown in Table I. Most of the patients were referred to the hospital within 3 days after the aspiration of the foreign body. The longest time interval between the inhalation of the foreign body and admission to the clinic was 3 years, in a child who had aspirated a piece of wire. Most of the children between 1 and 7 years of age, frequently between 1 and 3 (Table II). Ninety-five per cent had acute respiratory distress, 3.5 per cent chronic infection or bronchiectasis or both, and 1.5 per cent allergic asthma on admission. Unilateral hyperaeration, normal chest x-ray films, loss of 145
The Journal of
146 Aytac; et al.
Fig. 1. Total atelectasis of the right lung owing to bean aspiration.
Thoracic and Cardiovascular Surgery
Fig. 3. Drawing pin in the right main bronchus with distal atelectasis.
Table I. Correlation between the past history of the patients and the presence/absence offoreign bodies in 500 cases* Patients History
Foreign body
No.
Yes No Yes No
Present Present Absent Absent
446 16 26 12
I
%
89.2 3.2 5.2 2.4
"The shortest interval between aspirat ion and examination was a few minutes, the mean interval was I to 3 days , and the longest interval was 3 years.
Fig. 2. Bead in the right main bronchus . patency in air bronchograms with distal infiltration, and atelectasis were commonly found on roentgenologic examination (Table III). Some interesting x-ray films are shown in Figs . I to 7. Foreign bodies shown in these films were removed with a bronchoscope . Bronchoscopic procedures were performed with the child under general anesthesia after premedication with atropine, 0 .015 mg. per kilogram . Halothane and muscle-paralyzing agents were used during anesthesia. Airways were washed with isotonic saline solution after the removal of the foreign body and were aspirated to remove small fragments, especially nutty sub-
stances. Prednisolone I to 2 mg. per kilogram, was administered and nebulization was done immediately after the bronchoscopic procedure . A total of 451 foreign bodies were removed by bronchoscopic technique and II by thoracotomy and bronchotomy (Table IV). Lobectomy was performed in one case owing to bronchiectatic changes secondary to inhalation of a sunflower seed .
Findings The foreign body was located in the right main bronchus in 327 cases (70.7 per cent), in the left main bronchus in 86 cases (18.7 per cent), in the trachea near the bifurcation in 45 cases (9 .7 per cent), and in both bronchi in 4 cases (0.9 per cent) (bilateral localization). Complementary data in the removal of foreign bodies
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Inhalation offoreign bodies
Number 1 July, 1977
I47
Fig. 5. A nail, 5 em. long, in the right main bronchus. Fig. 4. Screw in the right main bronchus with distal atelectasis and infection.
Table II. Age distribution in foreign body aspiration
_______I-----ca-se-s----Age (yr.)
No .
%
0-1
52
IDA
1-3
277 142
55A 28A 5 0.8
3·7 7·10 > 10
25 4
are displayed in Table V. Watermelon seeds in summer and nutty substances in winter were the most frequently found foreign bodies (Table VI) . Results Nine patients died after the bronchoscopic procedure (1.8 per cent), irreversible cardiac arrest being the most common cause of death . Tracheostomy was performed in 7 cases because of laryngeal edema (1.4 per cent) . Other complications are given in Table VII. Discussion Inhalation of foreign bodies is common in children under 6 years of age, mostly between I and 3 years, although some cases of adults with forgotten foreign bodies in the airways for many years have been re-
Fig. 6. Tire valve of a bicycle in the left main bronchus. ported. 5 , 6 In our clinic, we have encountered only 2 adults with aspirated foreign bodies , both treated with the bronchoscope (rice in one patient and a piece of a dentist 's tool in the other) . The common clinical syndrome in most of the children is acute respiratory distress, characterized by sudden cyanosis, cough, and wheezing . Chronic infection, bronchiectasis, asthma, and bronchial stenosis predominate the clinical picture in patients with a long time interval between the inhalation of the foreign body and admission to the hospital (months and even years). Kiirklu and associates 7 reported foreign bodies in 8
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I 48
Aytac; et al.
Thoracic and Cardiovascular Surgery
Table IV. Methods of removal offoreign bodies in 462 cases Cases
Bronchoscopy Thoracotomy-bronchotom y"
No .
%
451 II
97.6 2.4
" Foreign bodies removed by thoracotomy: nail. 3 cases; tooth . 2 cases; sewing needle. 2 cases; chicken bone, 1 case; bead. I case; plastic plug of a bottle of eau-de-cologne , I case; sunflower seed . I case .
Fig. 7. A long hairpin in the left main bronchus .
Table III. Findingson plain chest x-ray films in foreign body aspiration* Major finding
Unilateral hyperaeration Normal x-ray film Loss of patency in air bronchograms and infiltration Atelectasi s Radiopaque foreign bodies Narrowing of tracheal lumen Mediastinal shift No x-ray film taken because of emergenc y Bronchiectasis and abscess Pneumomediastinum-pneumothorax
%
26 24 15 15 6 5 4 2.5 1.5 I
" More than one of these findings are present in some cases .
cases out of 500 patients with bronchiectasis (1.6 per cent) from Africa and in 8 cases out of 1,038 patients with bronchiectasis (0.7 per cent) from England. Vegetables (nutty substances or plants) are more dangerous than other kinds of foreign bodies (metallic and plastic material): They swell with the bronchial secretions, thus causing gradual mechanical obstruction, and they also cause allergic and chemical bronchitis (so called "vegetable bronchitis") as the result of absorption of antigenic proteins, organic acids, and oils which they contain .v to This fact was stated by Chevalier Jackson in his remark, .. All that wheezes is not asthma " (quoted by De Silva!') . A foreign body in the airways causes pneumonitis in some cases . Chronic obstructive pneumonitis is more likely to occur in obstruction of the lower lobe, and the
spread of infection to both lungs is common in obstruction of the upper lobe. 12 Four types of bronchial obstructions by foreign bodies have been described by Chatterji and Chatterji": I . The check-valve mechani sm, by which air is inhaled and cannot be expelled , causes unilateral hyperaeration (emphysema) on the affected side. 2. The stop-valve mechanism, caused either by a large foreign body or by a gradually swollen, small foreign body , leads to distal atelectasis . 3. The ball-valve mechanism, by which the foreign body dislodges during expiration and reimpacts during inspiration, leads to early atelectasis on the affected side. 4. The bypass-valve mechanism, caused by partial obstruction of the bronchial lumen, results in diminished aeration and opacity on the affected side . A foreign body may change its position and thus cause a variety of clinical presentations. A small foreign body may have no initial effects and may go unrecognized until later, when it causes pneumonia or allergy or both. A clear history of foreign body aspiration is itself an indication for bronchoscopic examination to confirm the diagnosis, because abnormalities may not be present in x-ray films and children may not always have typical symptoms. 14 Children with cough, wheezing, and decreased air entr y are candidates for bronchoscopic study , even when the history is noncontributory. Sharp , traumatizing bodies like glass, 'wire, a twig , or a needle may cause hemopty sis.P A large foreign body (coin, drawing pin, or safety pin) in the esophagus of a small child may lead to stridor and wheezing and thereby simulate an obstruction in the tracheobronchial tree." Vomiting and aspiration of the vomitus can cause acute respiratory distress and death . One of our patients, who had a coin in the upper part of the esophagus, died of a cardiac arrest in the ward while waiting to have it removed with an esophagoscope. Another patient, who had a large piece of watermelon in the upper part of the esophagus, had
Volume 74 Number 1 July, 1977
Inhalation offoreign bodies
Table VI. Foreign bodies found in 462 cases
Table V. Complementary data in removal of the foreign bodies
Cases
cases
~
--------------Repeated bronchoscopy for the removal of the foreign body* Bronchoscopy performed through previously created tracheostomy Foreign body could not be removed through vocal cords; removed through the tracheostomy (piece of bone) Foreign body not seen at bronchoscopy; removed from the bronchus during lobectomy due to bronchiectasis (sunflower seed)
_ _I~c-----
149
No.
No.
%
8
1.6
3
0.6 0.2
0.2
'Bean, 3 cases; bead, I case; sunflower seed, I case; roasted chick peas, I case; peanut, I case; metal rosette, I case.
Watermelon seeds Beans Sunflower seeds Roasted chick-peas Hazelnut Peanut Plastic material (i.e., plugs) Pumpkin seeds Beads Nails Pieces of bone Miscellaneous
%
181
39
11.4 8.6
53
40 28 26 26 16
14 13 10 7
48
_ _1Table VII. Complications in 500 cases
typical symptoms of tracheobronchial obstruction. Foreign bodies are usually located in the right main bronchus. Boys are more often affected than girls, possibly because boys are more active than girls during childhood. Chest x-ray films do not always contribute to the diagnosis. Radioopaque bodies can be detected in plain chest films. Radiolucent bodies can be diagnosed from the secondary pathological changes apparent in the chest films, such as the loss of patency in air bronchograms, infiltration, unilateral hyperaeration, and atelectasis. A normal chest x-ray film can be obtained in about one fourth of the cases. Bronchiectasis, abscess, and bronchial stenosis may develop if the foreign body is not removed for a long time. Taking x-ray films during both inspiration and expiration is useful in detecting pulmonary changes, but it is not always possible owing to the lack of coordination of a small child. Impairment in perfusion scanning of the lungs has also been described in cases of foreign body aspiration. 16 Spontaneous expectoration of inhaled foreign bodies occurs in only I to 2 per cent of the cases.:" Watermelon seeds in summer and nutty substances in winter are the most commonly encountered foreign bodies in Turkey and the Middle East. 9, 14, 17 It is difficult to remove nutty substances, because they are likely to fragment. If the particles fall into segmental orifices, follow-up x-ray films must be taken to avoid the complications caused by chronic irritation of the bronchus. 15 Repeated bronchoscopic examinations may be necessary in the aspiration of these materials. Grass seeds and twigs are difficult to see during bronchoscopic manipulations. Such foreign bodies are found in
Cases
Complications in 500 bronchoscopies Laryngeal edema needing tracheostomy Reversible cardiac arrest Pneumomediastinum-pneumothorax
No.
%
7 5 3
1.4
Complications in 12 thoracotomies Displacement of the foreign body (bead) to the contralateral hemithorax; thus foreign body could not be removed by thoracotomy; patient died of cardiac arrest Death Irreversible cardiac arrest Vomiting and aspiration Laryngeal edema Permanent bronchospasm Total
I
0.6 8
5 2 I I
9
1.8
lung specimens in patients subjected to pulmonary resection months or years after foreign body aspiration. Pyman'" reported 3 such cases, and we treated one, a patient who had inhaled a sunflower seed. Bronchoscopic removal of the foreign bodies is the treatment of choice, although some advise postural drainage for therapeutic purposes. IS Waiting for the spontaneous expectoration of a foreign body by postural drainage cannot be justified in modem practice, because this is a hazardous mode of treatment. The foreign body, dislodged from its original location, may obstruct a vital part of the airways like the trachea and cause the death of the child. Careful examination of the instruments before use is
The Journal of
1 50 Ayta<; et at.
important to reduce the complications and to shorten the duration of the procedure, which is directly proportional with the morbidity and mortality rates. Good communication is necessary between the endoscopist and anesthesiologist. It is of great value to place the child in a feet up-head down position to take advantage of the aid of gravity in removal of the foreign body. Careful palpation of the pulse rate is mandatory throughout the procedure to prevent anoxic accidents and cardiac arrest. Bradycardia may occur during administration of the muscle-paralyzing agents. Aeration of both lungs when the bronchoscope is above the carinal level, combined with atropin administration, quickly restores the bradycardic pulse rate. Foreign bodies which cannot be grasped by endoscopic forceps, such as a nail, bead, or bone, are removed by thoracotomy and bronchotomy. Mobile, spherical substances like a bead can easily shift to the contralateral hemithorax during thoracotomy, as seen in one of our cases. Such accidents can be prevented by keeping the patient in the feet down-head up position during thoracotomy or by blocking the affected bronchus with endotracheal tubes. Digital compression of the bronchus proximal to the foreign body is useful during bronchotomy. A Fogarty catheter introduced through the bronchoscope may be useful in removing the endobronchial foreign bodies which cannot be held by endoscopic forceps. 19 The Fogarty catheter can be passed through the holes of a foreign body such as a bead to remove it, after the balloon has been inflated. We routinely use steroids (prednisolone, 1 to 2 mg. per kilogram) and nebulization just after using the bronchoscope, because we believe that these medications decrease the incidence of postbronchoscopic tracheostomy. The low incidence of tracheostomy in our series (1.4 per cent) supports this veiw. Routine use of steroids was also stressed by Cosculluela and Atienza.t? Kim 13 advised the routine use of sodium bicarbonate during bronchoscopic procedures to reduce the incidence of cardiac arrest. Bronchoscopic manipulations lasting longer than 30 minutes become traumatic, and subglottic edema develops necessitating tracheostomy. Harboyan and Nassif"? reported 36 instances of tracheostomy in 225 bronchoscopies, mostly in such traumatic cases. Longterm presence of foreign bodies in the bronchus may lead to stenosis of the bronchus, requiring bronchoplasty." Resection of the lung parenchyma is necessary in chronic cases in which there is bronchiectasis or abscess or both.
Thoracic and Cardiovascular Surgery
Mortality rates after bronchoscopic procedures are very low in current practice. The mortality rate was 3.8 per cent in our first 105 cases;':' and our current overall mortality rate is 1.8 per cent. REFERENCES
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14 15 16
17
Tandon, R. K" Palney, N. L., Srivastava, V. K., and Wadhavan, V. P.: Foreign Body in Tracheobronchial Tree in Infancy and Childhood, Indian Pediatr. 10: 187, 1973. Benjamin, B., and Vandeleur, T.: Inhaled Foreign Bodies in Children, Med. J. Aust. 1: 355, 1974. Legent, F., Abgrall, H., and Baron, F.: Corps etranger tracheo-bronchiques, J. Fr. Otorhinolaryngol, 24: 17, 1975. Butenandt, I., and Mantel, K.: Die tracheobronchiale Fremdkorperaspiration im Kindesalter, Med. Klin. 69: 2017, 1974. Poulet, 1., Cocheton, 1. J., and Almosni, M.: Les corps etrangers bronchiques de I'adulte. A propos de neuf observations, Sem. Hop. Paris 48: 1719, 1972. Zajaczkowska, 1., Gluskowski, J., Byszewska, D., Tomaszkiewicz, R., Kochanowicz, J., Traczyk, K., Zych, D., and Lesiak, B.: Foreign Bodies in Bronchi in Adults, Gruzlica 41: 373, 1973. Kiirklii, E. U., Williams, M. A., and LeRoux, B. T.: Bronchiectasis Consequent Upon Foreign Body Retention, Thorax 28: 601, 1973. Fine, A. 1., and Abram, L. E.: Asthma and Foreign Bodies, Ann. Allergy 29: 217, 1971. Ural, T.: Foreign Bodies in the Airways and Esophagus in Children (in Turkish), Atatiirk U. Tip Biilteni 2: 206, 1970. Chatterji, S., and Chatterji, P.: The Management of Foreign Bodies in Air Passages, Anesthesia 27: 390, 1972. De Silva, S.: Intrabronchial Foreign Bodies in Children, Ceylon Med. J. 19: 154, 1974. Rananavare, M. M., Patwardhan, 1. R., and Gadgil, R. K.: Foreign Body Aspiration in Children, Indian J. Med. Sci. 26: 370, 1972. Kim, I. G., Brummitt, W. M., Humphry, A., Siomra, S. W., and Wallace, W. B.: Foreign Body in the Airway: A Review of 202 Cases, Laryngoscope 83: 347, 1973. Aspiration of Foreign Aytac, A., and Dokumaci, Bodies Among Children, Turk. J. Pediatr. 8: 157, 1966. Pyman, C.: Inhaled Foreign Bodies in Childhood: A Review of 230 Cases, Med. 1. Aust. 1: 62, 1971. Rudavsky, A. Z., Leonidas, J. c., and Abramson, A. L.: Lung Scanning for the Detection of Endobronchial Foreign Bodies in Infants and Children, Radiology 108: 629, 1973. Harboyan, G., and Nassif, R.: Tracheobronchial Foreign Bodies: A Review of 14 Years' Experience, J. Laryngol. Otol. 84: 403, 1970.
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Inhalation offoreign bodies
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July, 1977
18 Cotton, E. K., Abrams, G., Vanhoutte, J., and Burrington, 1.: Removal of Aspirated Foreign Bodies by Inhalation and Postural Drainage: A Survey of 24 Cases, Clin. Pediatr. 12: 270, 1973. 19 Ullyot, D. G., and Norman, D. G.: The Fogarty Catheter: An Aid to Bronchoscopic Removal of Foreign Bodies, Ann. Thorae. Surg. 6: 185, 1968.
20 Cosculluela, L. C.; and Atienza, P. A.: Cuerpos extranos en vias respiratorias y digestiva en pediatria. Experiencia en 426 casos, Rev. Esp. Anestesiol. Reanim. 21: 458, 1974. 21 Burrington, J. D., and Cotton, E. K.: Removal of Foreign Bodies From the Tracheobronchial Tree, J. Pediatr. Surg. 7: 119, 1972.