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Rigid bronchoscopy for the suspicion of foreign body in the airway
International Journal of Pediatric Otorhinolaryngology (2006) 70, 823—828
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Rigid bronchoscopy for the suspicion of foreign body in the airway ˘an *, Ulku Tuncer, Levent Soylu, Lutfi Barlas Aydog ˘lu, Can Ozsahinoglu Mete Kirog Cukurova Universitesi Tip Fakultesi, Kulak Burun Bogaz Klinigi, Balcali, Adana 01330, Turkey Received 4 February 2005; received in revised form 16 September 2005; accepted 17 September 2005
KEYWORDS Airway foreign body; Bronchoscopy; Complications
Summary Objective: Airway foreign bodies present a diagnostic dilemma and has been recognized for many years. Since aspiration of foreign bodies can be a serious and sometimes fatal problem, early intervention and proper management is vital. Method: In this retrospective study, the results of 1887 bronchoscopies, which were performed between the years 1973 and 2004 for the suspicion of foreign body aspiration in children, were presented. Various instruments and techniques were used over 31-year period and rigid bronchoscopy was the preferred method of foreign body exctraction. Results: There were 1106 boys and 781 girls with the median age of 2.3 years. Seventy-four percent of patients were less than 3 years old. The most common type of foreign body (89.9%) was organic; watermelon seeds (39.7%) were the most frequent organic foreign bodies. Eight hundred and twenty-three patients (43.6%) were referred to our clinic within the first 24 h of the event while 4.5% of the patients were admitted to the hospital with the suspicion of foreign body in the airway later than one month. At bronchoscopy, a foreign body was identified in 79.1% of patients and no foreign body was seen in 20.9% of patients. Foreign bodies were encountered in 96.3% of the patients with positive history whereas 28.1% of the patients with negative history had foreign body. Of the patients with foreign bodies, 93.2% had positive history. Overall, the positive history was obtained from 85.2% of patients. The incidence of postbronchoscopic tracheotomy, thoracotomy, and overall mortality rate were 0.47, 0.15, and 0.21%, respectively. Conclusion: Otolaryngologists should consider foreign body aspiration in the airway in the differential diagnosis of any patient with the complaints of stridor, dyspnea, sudden onset of cough and intractable and recurrent lower respiratory tract infections. A careful history and physical examination were strong indicators of the
* Corresponding author. Tel.: +90 322 338 6527; fax: +90 322 338 6527. ˘an). E-mail address: [email protected] (L.B. Aydog 0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.09.010
˘an et al. L.B. Aydog
824
diagnosis and raised the index of suspicion of an aspirated foreign body. Timely intervention with the experienced surgical team would decrease the complication rate and mortality rate. However, prevention of aspiration with the education of parents and caregivers is very important. # 2005 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Airway foreign bodies (FBs) continue to be a diagnostic and therapeutic challenge for the otolaryngologists. Even though aspiration of FBs in the airway has been recognized for many years, undiagnosed and unsuspected FBs still occur in the airway, causing severe complications and delay in diagnosis. As the presence of FBs in the respiratory tract is an extremely serious and vital problem, it is imperative to ensure prompt and successful treatment. FB aspiration occurs predominantly in children aged 1—2 years. It is also a common cause of the accidental death at home in children under 6 years of age [1]. The first demonstration of the feasibility of bronchoscopy was the removal of a FB from a bronchus by Gustav Killian in 1897 [1]. Bronchoscopy, originally concerned in the removal of FBs, has become most useful in the diagnosis and treatment of diseases. The greatest contribution to the early development of bronchoscopy was the perfection of the distally-lighted bronchosope of Chevalier Jackson in 1905 [1]. The distal light eliminated the necessity of blind methods of procedure, added greater safety, and permitted the use of bronchosopes of smaller diameter, thereby making the the procedure more applicable in a much wider field. Since Gustav Killian’s first demonstration [2], peroral rigid endoscopy has been the standard approach for removal of FBs in the airway. Some authors have advocated other methods, including the Foley catheter technique [3,4], and flexible fiberoptic endoscopy [5] but rigid endoscopy remains the most widely used technique for removal of FBs in the airway [6]. This study describes the 31-year experience of our clinic with 1887 bronchoscopies for the suspicion of FB aspiration.
ings, delay for evaluation, bronchoscopic findings, and the types of FBs, and the complications were recorded. The patient was regarded as having a positive history if he or she was holding or eating the FB in the mouth or playing with it prior to the onset of symptoms and clinical signs. The diagnosis was confirmed by laryngoscopy and rigid bronchoscopy in close cooperation with the anesthesiologist, under general anesthesia. In this 31-year period, various instruments were used to exctract the FBs. Until the era of cold light bronchoscope, distally-lighted bronchosopes of Chevalier Jackson and later the Storz type ventilating bronchoscopes were used (Figs. 1 and 2). Moreover, for documentation and visualization of the procedure telescopes with camera attachments were used. When an aspirated FB causes no or minimal distal airway obstruction, time should be taken to fast; 4— 6 h for solids and 2 h for clear fluids. Induction of anesthesia by inhalation for rigid bronchoscopy is the preferred protocol by the anesthesiologists in our hospital. Following the induction, muscle-relaxant agents, which allow the use of balanced anesthesia, which in turn decreases anesthetic effects on cardiac output, are given. Balanced anesthesia was employed and spontaneous respirations were maintained when possible to avoid the possibility of forcing the FB deeper into the respiratory tract by positive pressure ventilation. The bronchoscope secured the airway and oxygenation was maintained through it. Following the evaluation
2. Materials and methods A retrospective chart review of children who had undergone laryngoscopies and bronchoscopies for the suspicion of airway FB from 1973 to 2004 was conducted at the department of Otolaryngology in Cukurova University Medical Faculty. Histories of the patients were carefully documented, physical examination and preoperative radiographic find-
Fig. 1 Jackson type pediatric bronchoscopes with foreign body forceps.
Rigid bronchoscopy for the suspicion of foreign body in the airway
825
Table 2 The time duration from aspiration of the foreign body to bronchoscopy Time delay (days) 0—1 2—7 8—14 15—30 >30
651 527 130 115 70
Total
Fig. 2 Comparison of two types of pediatric bronchoscopes.
of the laryngeal structures for the FB, bronchoscopies were performed to inspect the trachea and the bronchi. Extraction of FB was accomplished with McGill forceps if FB is at the larynx or with different kinds of FB forceps if FB is at trachea or distal to it. In such cases, the offending FB was retrieved with long forceps passed through the bronchoscope. Repeat bronchoscopies were performed following the removal of the FB to control any remaining fragment of the FB. Antibiotic and steroids were given to treat infection and laryngeal edema. The postbronchoscopic complications were compared between two groups; complications following the use of Jackson type bronchoscopes, and following the use of ventilating type bronchoscopes.
3. Results A total of 1887 bronchoscopies were performed at Department of Otolaryngology Cukurova University between 1973 and 2004. There were 1106 boys (58.6%) and 781 girls (41.4%). Their ages ranged from 5 days to 16 years with a median age of 2.3 years. Seventy-four percent of patients were less than 3 years old (Table 1). Eight hundred and twenty-three patients (43.6%) were referred to our clinic within the first 24 h of the
1493
%
Female
%
0—1 2—3 4—5 6—7 >7 Total
Total
268 568 143 51 72
14.2 30.1 7.6 2.7 3.8
185 375 110 34 81
9.8 19.9 5.8 1.8 4.3
453 943 253 85 153
1102
58.4
785
41.7
1887
% 24.0 50.0 13.4 4.5 8.1 100
43.6 35.3 8.7 7.7 4.7 100
Table 3 The presenting features of the patients with foreign body aspiration Symptom
Number of patients %
Sudden onset of coughing 1266 Dyspnea 910 Respiratory distress 521 Cyanosis 196 Other 130
Table 4 Male
%
event while 4.7% of the patients were admitted to the hospital with the suspicion of FB in the airway later than 1 month (Table 2). The most prominent symptoms were irritative cough (67.1%), dyspnea (48.2%) and shortness of breath (27.6%) (Table 3). Most patients experienced more than one symptom at admission. Decreased breath sounds, dyspnea, and wheezing were the most common findings in bronchial obstruction. Stridor, dyspnea, and cyanosis were most common in laryngeal obstruction. Chest radiographs were obtained in 1515 children and were abnormal in 65.5%. Due to the respiratory distress of the patients, chest radiographs were not obtained for the remaining 372 patients. The radiographic abnormalities of the patients were shown in Table 4. Of the patients with chest radiographs, only 6.6% demonstrated radioopaque FBs. Other radiographic abnormalities in the order of frequency included unilateral emphysema (32.2%), atelectasis (12.9%), and infiltration (10.1%). At bronchoscopy, a FB was identified in 79.1% of patients (619 girls and 874 boys) and no FB was seen
67.1 48.2 27.6 10.4 6.9
The radiographic findings of the patients
Table 1 Age and sex distribution of the patients Age
Number of patients
Number of patients Normal Unilateral amphysema Atelectasis Infiltration Radioopaque FB Combined
523 488 195 153 100 56 1515
% 34.5 32.2 12.9 10.1 6.6 3.7 100
˘an et al. L.B. Aydog
826 Table 5 Nature of the aspirated foreign bodies Foreign body Watermelon seeds Peanut Sunflower seeds Bean Nuts Other organic FBs Inorganic FBs Total
Number of patients 593 203 145 100 52 249 151 1493
4. Discussion
% 39.7 13.6 9.7 6.7 3.5 16.7 10.1 100
in 20.9% of patients (171 girls and 223 boys). FBs were encountered in 96.3% of the patients with positive history whereas 28.1% of the patients with negative history had FBs. Of the patients with FB, 93.2% had positive history. Overall, the positive history was obtained from 85.2% of patients. The most common type of FB (89.9%) was organic; watermelon seeds (39.7%) were the most frequent organic FBs. The other FBs extracted from the airway were documented in Table 5. Aspirated FBs were observed at the following locations; right main bronchus (43.7%), trachea (26.5%), left main bronchus (18.3%), larynx (4.9%) and carina (2.5%). FBs of 62 patients were removed from both of the bronchi because FBs were fragmented or multiple. Postbronchoscopy complications occurred in 18 patients. Postoperative subcutaneous emphysema was developed in two patients with complete recovery in 1 week. Tracheostomy was required in nine patients (0.47%); six tracheotomies because of respiratory distress following the extraction of FBs, and three tracheostomies to remove the FBs because their sizes would not let the FB to be exracted from the larynx. All of the patients were decannulated in the first postoperative week. Three patients (0.15%) underwent thoracotomy to remove the FBs (pins) lodged too peripherally to be extracted. All did well postoperatively and discharged in the first postoperative week. Four children who sufferred severe respiratory distress and cyanosis were taken to the operating room immediately for bronchoscopy but unfortunately they developed cardiopulmonary arrest without recovery. Overall mortality rate was 0.21%. When postbronchoscopic complications were compared between patients undergoing bronchoscopies with Jackson type bronchoscopes and Storz ventilating type bronchoscopes no significant differences were noted except the number of tracheotomies, being more common with Jackson type bronchoscopes (six versus three tracheotomies). Moreover, the duration of the operating time with Jackson type bronchoscopes was much longer.
The diagnosis of aspirated FBs in children may be difficult. Some patients have alarming symptoms of respiratory distress and present with urgent clinical problems, while others present with a chronic respiratory illness. A careful history and physical examination were strong indicators of the diagnosis and raised the index of suspicion of an aspirated foreign body. The rapid fatigue of cough reflex and the following asymptomatic phase tend to create a false sense of security, and the parents might forget the choking episode or consider it not so important to mention when the symptoms return. The time lag between the episode and the bronchoscopy is very important to avoid the morbidity and even the mortality of the procedure. Misdiagnosis and the lack of suspicion on the part of physicians contribute significantly to the delay. The patient undergoing rigid bronchoscopy was monitored and particular attention was paid to pulse oximetry readings, which will show desaturation before a change in skin color. The Storz type ventilating bronchoscopes for rigid bronchoscopy in children with FBs were used because this bronchoscope provides both an airway and a means of visualizing the airway. The great advantage of placing the Storz type bronchoscope without prior intubation is that the trachea is entered under continuos vision. This allows a subglottic or tracheal FB to be seen and reduces the risk of sudden obstruction from dislodging it. An endotracheal tube is not always necessary when this bronchoscope is used. The Hopkins rod telescopes allow excellent visualization of the airway and, with the addition of a video camera, allow everbody to see what is occurring. However the telescopes significantly decrease the lumen of the bronchoscopes. Although its incidence is the highest in children aged between 1 and 3 years, FB in the airway could be seen in the adult rarely. In this study, 1379 of 1856 children (74.3%) were between 5 days old and 3 years old, just as reported in the literature [1,6], and the ratio of male to female was in favor of males; 58.6 and 41.4%, respectively. There are many speculations regarding the pathophysiology of FB aspiration. These include lack of molars necessary for proper grinding of food, the tendency of infants and toddlers to explore the environment by placing objects (inappropriate foods or small toys) in their mouths, and inadequate chewing of food. Further, children often play, run, and laugh while eating and do not concentrate on chewing or swallowing. Also, immaturity of the mechanism that coordinates swallowing and respiration in young children may be another contributing factor in FB aspiration.
Rigid bronchoscopy for the suspicion of foreign body in the airway The positive history of airway FB has been reported between 43.9 and 75% in the literature [7]. The ratio of positive history in this study was 84.6%, higher than previous reports. This could be due to the careful and detailed history taken from the families. The parents or caregivers would mislead the physicians while taking the histories in order to protect themselves. While 1351 of 1403 (96.3%) patients with positive findings in the history had FBs in their airways, FBs were removed from 28.1% of patients without any positive findings. In the latter group, the number of FBs was low because bronchoscopies were performed to rule out the presence of FBs in patients with recurrent pulmonary infections and without any positive findings in the history. We would advise that in the absence of positive findings in the history, children with unexplained acute wheezing or coughing should also undergo bronchoscopy. Furthermore, patients with chronic pulmonary symptoms, whether due to nonresolving pulmonary infections or not, should also undergo diagnostic bronchoscopy. Of these patients, following the removal of FBs in 28.1% of them, patients did very well. This high percentage of FBs in patients without positive findings in the history, forced us to ask more detailed questions to search for the any positive signs. Interrogation of the parents reveals that often the episode of choking goes either unappreciated or unobserved especially who are left unattended. Even with the knowledge of FB aspiration, parents might not to give information. All possible consequences of aspiration and the benefits of early intervention were explained to the patients or the families of the patients if there were not any positive findings in the history. Sudden onset of cough, wheezing and dyspnea are the major symptoms of our patients. Different symptoms were reported in the literature as the most common symptoms of these patients. McGuirt et al. [8] reported that all of the patients had complained of sudden onset of cough. However, sudden onset of any of the combinations of these symptoms should alert the physicians. Chest radiograms are not always diagnostic for the FBs. Preoperative chest X-rays were normal in 34.5% of our patients and this ratio is in accordance with the ratios reported in the literature [9,10]. Since 1/3rd of these patients had normal radiologic findings detailed history plays a very special role in the diagnosis of FBs. The other radiologic findings were unilateral amphysema in 32.2%, atelectasis in 12.9% and pneumonic infiltration in 10.1% of our patients. Rothman and Boeckman [11] reported obstructive amphysema in 60%, atelectasis in 12% and pneumonic infiltration in 8% of 225 patients. In another
827
study, these percentages were reported as 61.9, 15.6 and 17.5% in 200 patients, respectively [12]. The reported incidence of radioopaque FBs in the literature varies between 8—15% however this ratio was 6.6% in this study [11,13—15]. This lower percentage in this study could be attributable to the higher incidence aspiration of watermelon seeds. Most airway FBs become lodged in the bronchi because their size and configuration allow passage through the larynx and trachea. Larger objects become impacted in the larynx or trachea. Bronchial FBs are more common in the right bronchus in adults, due to the position of the carina to the left of the midline and its lesser angle of divergence from the tracheal axis. The locations of the aspirated FBs in this study were; right main bronchus in 43.7%, left main bronchus in 26.5% and trachea in 18.3% of our patients. These percentages were similar with the literature even though some of the studies have reported that left main bronchus was the most common location of the FBs, or the equal frequency of FBs in the right and left main bronchi, with no clear explanation for these occurrences. A possible explanation for this discrepancy is due to the anatomical factors, as the right and left bronchus of a small child are more equal in size and angle of entry than they are in adults [11,16]. The most common type of FB (89.7%) was organic and the majority of them were watermelon seeds (39.5%), followed by peanuts, which were reported as the most common FB in the literature [11,12,17]. The facts that summer last longer and watermelon is one of the most common fruit produced and consumed in this part of Turkey would explain why watermelon seeds are the majority of the FBs in this study. The complication rate in this study is lower than the other studies [1,11,16]. The incidence of tracheostomy following bronchoscopy was 0.5%, and incidence of thoracotomy was 0.27% in this study. Fortunately, the incidence of mortality was 0.22%. Rothman and Boeckman [11] have reported the incidence of tracheostomy as 2.6% and thoracotomy as 1.3%. The tracheotomies were more common with Jackson type bronchoscopes because they were wider and repeat bronchoscopies were necessary for the removal of FBs, causing laryngeal edema more often. Moreover, the duration of the operating time with Jackson type bronchoscopes was longer. Thus, these factors probably have increased the number of tracheotomies with the Jackson type bronchoscopes. Thoracotomy incidence was 11.59% in another study [7]. Lower rate of complications in this study might be attributable to the management of the most of the patients within 24 h, watermelon seeds as the most common and easily exctractable
828 FB, and availability of the experienced team. The experience stemed form the fact that our clinic was the only center performing bronchoscopies until recently. The number of centers performing bronchoscopies increased, thus decreasing the number of pediatric bronchoscopies in our clinic over the years. With this experience and low complication rates, we consider the rigid bronchoscopy as the gold standard for managing FB aspiration. Also, in the literature, rigid bronchoscopy has been recommended for those found to have a FB or whose symptoms suggest a higher risk of foreign body [18—20]. In conclusion, in the diagnosis of FB aspiration in the airway, the history has a significant role. Symptoms of sudden onset of cough, dyspnea and respiratory stress, especially in children, should alert the physician for the suspicion of FB aspiration. Moreover, unresolved or recurrent lower respiratory tract infections despite intense medical therapy should raise the suspicion of FB in the airway and deserve diagnostic bronchoscopy. Pediatric bronchoscopy has made remarkable advances in endoscopic equipment and anesthesia for the past two decades. Nevertheless, skill of the surgeon and fully trained staff is still the most important part of the pediatric bronchoscopy.
References [1] A. Aytac, Y. Yurdakul, C. Ikizler, R. Olga, A. Saylam, Inhalation of foreign bodies in children, J. Thorac. Cardiovasc. Surg. 74 (1977) 145—151. [2] L.H. Clerf, Historical aspects of foreign bodies in the air and food passages, Ann. Otol. Rhinol. Laryngol. 61 (1952) 5— 17. [3] J.B. Campbell, L.C. Foley, A safe alternative to endoscopic removal of blunt esophageal foreign bodies, Arch. Otolaryngol. 109 (1983) 323—325. [4] S.Z. Rubin, D.L. Mueller, Removal of esophageal foreign bodies with a Foley balloon catheter under fluoroscopic control, Can. Med. Assoc. J. 137 (1987) 125—127. [5] D.W. Bending, Removal of blunt esophageal foreign bodies by flexible endoscopy without general anesthesia, Am. J. Dis. Child 140 (1986) 789—790.
˘an et al. L.B. Aydog [6] W.C. Hsu, T.S. Sheen, C.D. Lin, C.T. Tan, T.H. Yeh, S.Y. Lee, Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: A series of 3217 cases from 1970 to 1996, Otolaryngol. Head Neck Surg. 122 (2000) 450—454. [7] D. Weissberg, I. Scwartz, Foreign bodies in the tracheobronchial tree, Chest 91 (5) (1987) 730—733. [8] W.F. McGuirt, K.D. Holmes, R. Feehs, J.D. Browne, Tracheobronchial foreign bodies, Laryngoscope 98 (6 Pt 1) (1988) 615—618. [9] L. Mu, D. Sun, Radiological diagnosis of aspirated foreign bodies in children: Review of 343 cases, J. Laryngol. Otol. 104 (10) (1990) 778—782. [10] N.E. Wiseman, The diagnosis of foreign body aspiration in childhood, J. Pediatr. Surg. (1984) 531—535. [11] B.F. Rothman, C.R. Boeckman, Foreign bodies in the larynx and tracheobronchial tree in children. A review of 225 cases, Ann. Otol. Rhinol. Laryngol. (1980) 434—436. [12] S. Blazer, Y. Naveh, A. Friedman, Foreign body in the airway, Am. J. Dis. Child 19 (5) (1980) 68—71. [13] B. Singh, M. Kantu, G. Har-el, F.E. Lucente, Complications associated with 327 foreign bodies of the pharynxi larynx and esophagus, Ann. Otol. Rhinol. Laryngol. 106 (4) (1997) 301—304. [14] R. Deskin, G. Young, R. Hoffman, Management pediatric aspirated foreign bodies, Laryngoscope 107 (4) (1997) 540—543. [15] J. Reilty, J. Thompson, C. MacArthur, S. Pransky, D. Beste, M. Smith, S. Gray, S. Manning, M. Walter, C. Derkay, H. Muntz, E. Friedman, C.M. Myer, R. Seibert, K. Riding, J. Cuyler, W. Todd, R. Smith, Pediatric aerodigestive foreign body injuries are complications related to timeless of diagnosis, Laryngoscope 107 (1) (1997) 17—20. [16] D.W. Vane, J. Pritchard, C.W. Colville, K.W. West, H. Eigen, J.L. Grosfeld, Bronchoscopy for aspirated foreign bodies in children, Arch. Surg. 123 (7) (1988) 885—888. [17] S.R. Cohen, W.I. Herbert, G.B. Lewis, K.A. Geller, Foreign bodies in the airway: Five-year retrospective study with special reference to management, Ann. Otol. Rhinol. Laryngol. 89 (5 Pt 1) (1980) 437—442. [18] P.T. Farrell, Rigid bronchoscopy for foreign body removal: anaesthesia and ventilation, Pediatr. Anesth. 14 (2004) 84— 89. [19] A.K. Ayed, A.M. Jafar, A. Owayed, Foreign body aspiration in children: diagnosis and treatment, Pediatr. Surg. Int. 19 (2003) 485—488. [20] B. Tander, B. Kirdar, E. Aritu ¨rk, R. Rızalar, F. Bernay, Why nut? The aspiration of hazelnuts has become a public health problem among small children in the central and eastern Black Sea regions of Turkey, Pediatr. Surg. Int. 20 (2004) 502—504.
www.elsevier.com/locate/ijporl
Rigid bronchoscopy for the suspicion of foreign body in the airway ˘an *, Ulku Tuncer, Levent Soylu, Lutfi Barlas Aydog ˘lu, Can Ozsahinoglu Mete Kirog Cukurova Universitesi Tip Fakultesi, Kulak Burun Bogaz Klinigi, Balcali, Adana 01330, Turkey Received 4 February 2005; received in revised form 16 September 2005; accepted 17 September 2005
KEYWORDS Airway foreign body; Bronchoscopy; Complications
Summary Objective: Airway foreign bodies present a diagnostic dilemma and has been recognized for many years. Since aspiration of foreign bodies can be a serious and sometimes fatal problem, early intervention and proper management is vital. Method: In this retrospective study, the results of 1887 bronchoscopies, which were performed between the years 1973 and 2004 for the suspicion of foreign body aspiration in children, were presented. Various instruments and techniques were used over 31-year period and rigid bronchoscopy was the preferred method of foreign body exctraction. Results: There were 1106 boys and 781 girls with the median age of 2.3 years. Seventy-four percent of patients were less than 3 years old. The most common type of foreign body (89.9%) was organic; watermelon seeds (39.7%) were the most frequent organic foreign bodies. Eight hundred and twenty-three patients (43.6%) were referred to our clinic within the first 24 h of the event while 4.5% of the patients were admitted to the hospital with the suspicion of foreign body in the airway later than one month. At bronchoscopy, a foreign body was identified in 79.1% of patients and no foreign body was seen in 20.9% of patients. Foreign bodies were encountered in 96.3% of the patients with positive history whereas 28.1% of the patients with negative history had foreign body. Of the patients with foreign bodies, 93.2% had positive history. Overall, the positive history was obtained from 85.2% of patients. The incidence of postbronchoscopic tracheotomy, thoracotomy, and overall mortality rate were 0.47, 0.15, and 0.21%, respectively. Conclusion: Otolaryngologists should consider foreign body aspiration in the airway in the differential diagnosis of any patient with the complaints of stridor, dyspnea, sudden onset of cough and intractable and recurrent lower respiratory tract infections. A careful history and physical examination were strong indicators of the
* Corresponding author. Tel.: +90 322 338 6527; fax: +90 322 338 6527. ˘an). E-mail address: [email protected] (L.B. Aydog 0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.09.010
˘an et al. L.B. Aydog
824
diagnosis and raised the index of suspicion of an aspirated foreign body. Timely intervention with the experienced surgical team would decrease the complication rate and mortality rate. However, prevention of aspiration with the education of parents and caregivers is very important. # 2005 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Airway foreign bodies (FBs) continue to be a diagnostic and therapeutic challenge for the otolaryngologists. Even though aspiration of FBs in the airway has been recognized for many years, undiagnosed and unsuspected FBs still occur in the airway, causing severe complications and delay in diagnosis. As the presence of FBs in the respiratory tract is an extremely serious and vital problem, it is imperative to ensure prompt and successful treatment. FB aspiration occurs predominantly in children aged 1—2 years. It is also a common cause of the accidental death at home in children under 6 years of age [1]. The first demonstration of the feasibility of bronchoscopy was the removal of a FB from a bronchus by Gustav Killian in 1897 [1]. Bronchoscopy, originally concerned in the removal of FBs, has become most useful in the diagnosis and treatment of diseases. The greatest contribution to the early development of bronchoscopy was the perfection of the distally-lighted bronchosope of Chevalier Jackson in 1905 [1]. The distal light eliminated the necessity of blind methods of procedure, added greater safety, and permitted the use of bronchosopes of smaller diameter, thereby making the the procedure more applicable in a much wider field. Since Gustav Killian’s first demonstration [2], peroral rigid endoscopy has been the standard approach for removal of FBs in the airway. Some authors have advocated other methods, including the Foley catheter technique [3,4], and flexible fiberoptic endoscopy [5] but rigid endoscopy remains the most widely used technique for removal of FBs in the airway [6]. This study describes the 31-year experience of our clinic with 1887 bronchoscopies for the suspicion of FB aspiration.
ings, delay for evaluation, bronchoscopic findings, and the types of FBs, and the complications were recorded. The patient was regarded as having a positive history if he or she was holding or eating the FB in the mouth or playing with it prior to the onset of symptoms and clinical signs. The diagnosis was confirmed by laryngoscopy and rigid bronchoscopy in close cooperation with the anesthesiologist, under general anesthesia. In this 31-year period, various instruments were used to exctract the FBs. Until the era of cold light bronchoscope, distally-lighted bronchosopes of Chevalier Jackson and later the Storz type ventilating bronchoscopes were used (Figs. 1 and 2). Moreover, for documentation and visualization of the procedure telescopes with camera attachments were used. When an aspirated FB causes no or minimal distal airway obstruction, time should be taken to fast; 4— 6 h for solids and 2 h for clear fluids. Induction of anesthesia by inhalation for rigid bronchoscopy is the preferred protocol by the anesthesiologists in our hospital. Following the induction, muscle-relaxant agents, which allow the use of balanced anesthesia, which in turn decreases anesthetic effects on cardiac output, are given. Balanced anesthesia was employed and spontaneous respirations were maintained when possible to avoid the possibility of forcing the FB deeper into the respiratory tract by positive pressure ventilation. The bronchoscope secured the airway and oxygenation was maintained through it. Following the evaluation
2. Materials and methods A retrospective chart review of children who had undergone laryngoscopies and bronchoscopies for the suspicion of airway FB from 1973 to 2004 was conducted at the department of Otolaryngology in Cukurova University Medical Faculty. Histories of the patients were carefully documented, physical examination and preoperative radiographic find-
Fig. 1 Jackson type pediatric bronchoscopes with foreign body forceps.
Rigid bronchoscopy for the suspicion of foreign body in the airway
825
Table 2 The time duration from aspiration of the foreign body to bronchoscopy Time delay (days) 0—1 2—7 8—14 15—30 >30
651 527 130 115 70
Total
Fig. 2 Comparison of two types of pediatric bronchoscopes.
of the laryngeal structures for the FB, bronchoscopies were performed to inspect the trachea and the bronchi. Extraction of FB was accomplished with McGill forceps if FB is at the larynx or with different kinds of FB forceps if FB is at trachea or distal to it. In such cases, the offending FB was retrieved with long forceps passed through the bronchoscope. Repeat bronchoscopies were performed following the removal of the FB to control any remaining fragment of the FB. Antibiotic and steroids were given to treat infection and laryngeal edema. The postbronchoscopic complications were compared between two groups; complications following the use of Jackson type bronchoscopes, and following the use of ventilating type bronchoscopes.
3. Results A total of 1887 bronchoscopies were performed at Department of Otolaryngology Cukurova University between 1973 and 2004. There were 1106 boys (58.6%) and 781 girls (41.4%). Their ages ranged from 5 days to 16 years with a median age of 2.3 years. Seventy-four percent of patients were less than 3 years old (Table 1). Eight hundred and twenty-three patients (43.6%) were referred to our clinic within the first 24 h of the
1493
%
Female
%
0—1 2—3 4—5 6—7 >7 Total
Total
268 568 143 51 72
14.2 30.1 7.6 2.7 3.8
185 375 110 34 81
9.8 19.9 5.8 1.8 4.3
453 943 253 85 153
1102
58.4
785
41.7
1887
% 24.0 50.0 13.4 4.5 8.1 100
43.6 35.3 8.7 7.7 4.7 100
Table 3 The presenting features of the patients with foreign body aspiration Symptom
Number of patients %
Sudden onset of coughing 1266 Dyspnea 910 Respiratory distress 521 Cyanosis 196 Other 130
Table 4 Male
%
event while 4.7% of the patients were admitted to the hospital with the suspicion of FB in the airway later than 1 month (Table 2). The most prominent symptoms were irritative cough (67.1%), dyspnea (48.2%) and shortness of breath (27.6%) (Table 3). Most patients experienced more than one symptom at admission. Decreased breath sounds, dyspnea, and wheezing were the most common findings in bronchial obstruction. Stridor, dyspnea, and cyanosis were most common in laryngeal obstruction. Chest radiographs were obtained in 1515 children and were abnormal in 65.5%. Due to the respiratory distress of the patients, chest radiographs were not obtained for the remaining 372 patients. The radiographic abnormalities of the patients were shown in Table 4. Of the patients with chest radiographs, only 6.6% demonstrated radioopaque FBs. Other radiographic abnormalities in the order of frequency included unilateral emphysema (32.2%), atelectasis (12.9%), and infiltration (10.1%). At bronchoscopy, a FB was identified in 79.1% of patients (619 girls and 874 boys) and no FB was seen
67.1 48.2 27.6 10.4 6.9
The radiographic findings of the patients
Table 1 Age and sex distribution of the patients Age
Number of patients
Number of patients Normal Unilateral amphysema Atelectasis Infiltration Radioopaque FB Combined
523 488 195 153 100 56 1515
% 34.5 32.2 12.9 10.1 6.6 3.7 100
˘an et al. L.B. Aydog
826 Table 5 Nature of the aspirated foreign bodies Foreign body Watermelon seeds Peanut Sunflower seeds Bean Nuts Other organic FBs Inorganic FBs Total
Number of patients 593 203 145 100 52 249 151 1493
4. Discussion
% 39.7 13.6 9.7 6.7 3.5 16.7 10.1 100
in 20.9% of patients (171 girls and 223 boys). FBs were encountered in 96.3% of the patients with positive history whereas 28.1% of the patients with negative history had FBs. Of the patients with FB, 93.2% had positive history. Overall, the positive history was obtained from 85.2% of patients. The most common type of FB (89.9%) was organic; watermelon seeds (39.7%) were the most frequent organic FBs. The other FBs extracted from the airway were documented in Table 5. Aspirated FBs were observed at the following locations; right main bronchus (43.7%), trachea (26.5%), left main bronchus (18.3%), larynx (4.9%) and carina (2.5%). FBs of 62 patients were removed from both of the bronchi because FBs were fragmented or multiple. Postbronchoscopy complications occurred in 18 patients. Postoperative subcutaneous emphysema was developed in two patients with complete recovery in 1 week. Tracheostomy was required in nine patients (0.47%); six tracheotomies because of respiratory distress following the extraction of FBs, and three tracheostomies to remove the FBs because their sizes would not let the FB to be exracted from the larynx. All of the patients were decannulated in the first postoperative week. Three patients (0.15%) underwent thoracotomy to remove the FBs (pins) lodged too peripherally to be extracted. All did well postoperatively and discharged in the first postoperative week. Four children who sufferred severe respiratory distress and cyanosis were taken to the operating room immediately for bronchoscopy but unfortunately they developed cardiopulmonary arrest without recovery. Overall mortality rate was 0.21%. When postbronchoscopic complications were compared between patients undergoing bronchoscopies with Jackson type bronchoscopes and Storz ventilating type bronchoscopes no significant differences were noted except the number of tracheotomies, being more common with Jackson type bronchoscopes (six versus three tracheotomies). Moreover, the duration of the operating time with Jackson type bronchoscopes was much longer.
The diagnosis of aspirated FBs in children may be difficult. Some patients have alarming symptoms of respiratory distress and present with urgent clinical problems, while others present with a chronic respiratory illness. A careful history and physical examination were strong indicators of the diagnosis and raised the index of suspicion of an aspirated foreign body. The rapid fatigue of cough reflex and the following asymptomatic phase tend to create a false sense of security, and the parents might forget the choking episode or consider it not so important to mention when the symptoms return. The time lag between the episode and the bronchoscopy is very important to avoid the morbidity and even the mortality of the procedure. Misdiagnosis and the lack of suspicion on the part of physicians contribute significantly to the delay. The patient undergoing rigid bronchoscopy was monitored and particular attention was paid to pulse oximetry readings, which will show desaturation before a change in skin color. The Storz type ventilating bronchoscopes for rigid bronchoscopy in children with FBs were used because this bronchoscope provides both an airway and a means of visualizing the airway. The great advantage of placing the Storz type bronchoscope without prior intubation is that the trachea is entered under continuos vision. This allows a subglottic or tracheal FB to be seen and reduces the risk of sudden obstruction from dislodging it. An endotracheal tube is not always necessary when this bronchoscope is used. The Hopkins rod telescopes allow excellent visualization of the airway and, with the addition of a video camera, allow everbody to see what is occurring. However the telescopes significantly decrease the lumen of the bronchoscopes. Although its incidence is the highest in children aged between 1 and 3 years, FB in the airway could be seen in the adult rarely. In this study, 1379 of 1856 children (74.3%) were between 5 days old and 3 years old, just as reported in the literature [1,6], and the ratio of male to female was in favor of males; 58.6 and 41.4%, respectively. There are many speculations regarding the pathophysiology of FB aspiration. These include lack of molars necessary for proper grinding of food, the tendency of infants and toddlers to explore the environment by placing objects (inappropriate foods or small toys) in their mouths, and inadequate chewing of food. Further, children often play, run, and laugh while eating and do not concentrate on chewing or swallowing. Also, immaturity of the mechanism that coordinates swallowing and respiration in young children may be another contributing factor in FB aspiration.
Rigid bronchoscopy for the suspicion of foreign body in the airway The positive history of airway FB has been reported between 43.9 and 75% in the literature [7]. The ratio of positive history in this study was 84.6%, higher than previous reports. This could be due to the careful and detailed history taken from the families. The parents or caregivers would mislead the physicians while taking the histories in order to protect themselves. While 1351 of 1403 (96.3%) patients with positive findings in the history had FBs in their airways, FBs were removed from 28.1% of patients without any positive findings. In the latter group, the number of FBs was low because bronchoscopies were performed to rule out the presence of FBs in patients with recurrent pulmonary infections and without any positive findings in the history. We would advise that in the absence of positive findings in the history, children with unexplained acute wheezing or coughing should also undergo bronchoscopy. Furthermore, patients with chronic pulmonary symptoms, whether due to nonresolving pulmonary infections or not, should also undergo diagnostic bronchoscopy. Of these patients, following the removal of FBs in 28.1% of them, patients did very well. This high percentage of FBs in patients without positive findings in the history, forced us to ask more detailed questions to search for the any positive signs. Interrogation of the parents reveals that often the episode of choking goes either unappreciated or unobserved especially who are left unattended. Even with the knowledge of FB aspiration, parents might not to give information. All possible consequences of aspiration and the benefits of early intervention were explained to the patients or the families of the patients if there were not any positive findings in the history. Sudden onset of cough, wheezing and dyspnea are the major symptoms of our patients. Different symptoms were reported in the literature as the most common symptoms of these patients. McGuirt et al. [8] reported that all of the patients had complained of sudden onset of cough. However, sudden onset of any of the combinations of these symptoms should alert the physicians. Chest radiograms are not always diagnostic for the FBs. Preoperative chest X-rays were normal in 34.5% of our patients and this ratio is in accordance with the ratios reported in the literature [9,10]. Since 1/3rd of these patients had normal radiologic findings detailed history plays a very special role in the diagnosis of FBs. The other radiologic findings were unilateral amphysema in 32.2%, atelectasis in 12.9% and pneumonic infiltration in 10.1% of our patients. Rothman and Boeckman [11] reported obstructive amphysema in 60%, atelectasis in 12% and pneumonic infiltration in 8% of 225 patients. In another
827
study, these percentages were reported as 61.9, 15.6 and 17.5% in 200 patients, respectively [12]. The reported incidence of radioopaque FBs in the literature varies between 8—15% however this ratio was 6.6% in this study [11,13—15]. This lower percentage in this study could be attributable to the higher incidence aspiration of watermelon seeds. Most airway FBs become lodged in the bronchi because their size and configuration allow passage through the larynx and trachea. Larger objects become impacted in the larynx or trachea. Bronchial FBs are more common in the right bronchus in adults, due to the position of the carina to the left of the midline and its lesser angle of divergence from the tracheal axis. The locations of the aspirated FBs in this study were; right main bronchus in 43.7%, left main bronchus in 26.5% and trachea in 18.3% of our patients. These percentages were similar with the literature even though some of the studies have reported that left main bronchus was the most common location of the FBs, or the equal frequency of FBs in the right and left main bronchi, with no clear explanation for these occurrences. A possible explanation for this discrepancy is due to the anatomical factors, as the right and left bronchus of a small child are more equal in size and angle of entry than they are in adults [11,16]. The most common type of FB (89.7%) was organic and the majority of them were watermelon seeds (39.5%), followed by peanuts, which were reported as the most common FB in the literature [11,12,17]. The facts that summer last longer and watermelon is one of the most common fruit produced and consumed in this part of Turkey would explain why watermelon seeds are the majority of the FBs in this study. The complication rate in this study is lower than the other studies [1,11,16]. The incidence of tracheostomy following bronchoscopy was 0.5%, and incidence of thoracotomy was 0.27% in this study. Fortunately, the incidence of mortality was 0.22%. Rothman and Boeckman [11] have reported the incidence of tracheostomy as 2.6% and thoracotomy as 1.3%. The tracheotomies were more common with Jackson type bronchoscopes because they were wider and repeat bronchoscopies were necessary for the removal of FBs, causing laryngeal edema more often. Moreover, the duration of the operating time with Jackson type bronchoscopes was longer. Thus, these factors probably have increased the number of tracheotomies with the Jackson type bronchoscopes. Thoracotomy incidence was 11.59% in another study [7]. Lower rate of complications in this study might be attributable to the management of the most of the patients within 24 h, watermelon seeds as the most common and easily exctractable
828 FB, and availability of the experienced team. The experience stemed form the fact that our clinic was the only center performing bronchoscopies until recently. The number of centers performing bronchoscopies increased, thus decreasing the number of pediatric bronchoscopies in our clinic over the years. With this experience and low complication rates, we consider the rigid bronchoscopy as the gold standard for managing FB aspiration. Also, in the literature, rigid bronchoscopy has been recommended for those found to have a FB or whose symptoms suggest a higher risk of foreign body [18—20]. In conclusion, in the diagnosis of FB aspiration in the airway, the history has a significant role. Symptoms of sudden onset of cough, dyspnea and respiratory stress, especially in children, should alert the physician for the suspicion of FB aspiration. Moreover, unresolved or recurrent lower respiratory tract infections despite intense medical therapy should raise the suspicion of FB in the airway and deserve diagnostic bronchoscopy. Pediatric bronchoscopy has made remarkable advances in endoscopic equipment and anesthesia for the past two decades. Nevertheless, skill of the surgeon and fully trained staff is still the most important part of the pediatric bronchoscopy.
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