Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Foreign Body Aspiration Age is the most important factor in the incidence of FBA. Primarily this disease affects children < 4 yo (55-75% cases) and adults >50 yo. Children are at risk because of their curious natures, strong oral tendency and lack of molar teeth. In adults, FBA is usually associated with denture wear, alcohol use and other neurologic disorders.Acutely, patients with FBA may exhibit coughing paroxysms (59%), airway symptoms after having a FB in the mouth (85%), wheezing or "asthma" (57%), a croupy cough, choking, total airway obstruction or no symptoms at all (5%). Patients with a late presentation of FBA may have any of the acute symptoms or may have fever, dyspnea, hemoptysis, pneumonia, lung abscess, or pneumothorax. Although many patients present acutely, a significant number present at days or weeks after the event and so the diagnosis of FBA should be entertained in any patient with unexplained or recurrent pulmonary symptoms or those that do not respond to the usual treatments. In a study by Kim et al (1973) the time to diagnosis was divided as follows: 0 to 1 day - 45%; 1 to 7 days - 22%; 7 to 30 days - 14%; and >30 days - 17%. On physical exam these patients may have decreased breath sounds on the side of the FB side (50%), localized wheezing (40%), or they may be asymptomatic (40%).Further evaluation of a patient with a suspected FBA should include a chest radiograph (CXR). Specifically, a set of comparison inspiratory and expiratory radiographs is preferred. The most common finding on this exam is obstructive emphysema (39%) due to a ball-valving effect of the FB in the airway lumen causing airtrapping; this is often only evident on the expiratory film. CXR findings also associated with FBA include: pulmonary atelectasis (22%), pneumonia (20%), mediastinal shift, a visible radiopaque FB (13%) or a normal exam (10-20%).In some cases a high kV AP and lateral neck radiograph can help identify nasopharyngeal, oropharyngeal or laryngeal FB that could be missed by conventional CXR. Miscellaneous studies such as dynamic fluoroscopy, MRI, and contrast bronchograms may be indicated in specific cases. In the evaluation of a patient with possible FBA, one must consider the level of airway distress, the state of gastric emptying (time from last meal), and the composition of the FB (vegetable matter, sharp or caustic).Definitive diagnosis and treatment of a FBA depends on direct laryngoscopy and rigid bronchoscopy. The optimal situation for this is a controlled, well-equipped and well-prepared operative setting. Utilization of spontaneous ventilation, general anesthesia will help decrease operative morbidity. Nonendoscopic techniques are frequently discussed in the literature and are to be considered less than ideal and at significantly greater risk for complications and of failure to remove the FB. Thoracotomy may have to be considered in those cases of peripheral FBs that are unable to be removed endoscopically.Localization of the FB is suggested by the evaluation and confirmed at endoscopy. Statistically, FBA involves the hypopharynx - 5%, larynx/trachea - 12% and bronchi - 83%. Of bronchial FB, most (43%) are in the right mainstem, followed by the left mainstem (24%), right segmental bronchi (22%) and left segmental bronchi (11%.)At the time of endoscopy, following removal of the FB a "second look" should always be undertaken to identify multiple FBs, complications of FBA and iatrogenic injuries. Some cases of FBA are deserve special consideration. Vegetable matter FBA is more common in children and fever and pneumonitis is more common in these patients; these items tend to be radiolucent on CXR and their removal is more difficult due to their inherent soft, friable nature. Inert objects (coins or other metal objects, plastic items, various iatrogenic objects and pins and other sharp objects) are usually seen in slightly older children (especially toddlers.) These are frequently visible on CXR. Objects with points or sharp edges require special care in removal so as to avoid perforation or laceration of the airway. A calcified mass identified in the airway in an adult may be a broncholith, an extrabronchial calcified lymph node and bronchial perforation may result from attempts at removal. Caustic substances such as batteries require emergent removal to avoid an alkaline injury with its associated tissue liquefaction necrosis. Postoperatively most patients should be observed overnight for airway distress and adjunctive treatments may aid in recovery. Nebulizer mist and deep breathing exercises can help resolution of the atelectasis and surgical trauma. One should consider antibiotics in patients with fever, pneumonia preoperatively and those with vegetable matter aspiration. In some cases racemic epinephrine may be helpful acutely for postoperative respiratory symptoms. Routine use of intravenous or oral steroids is not indicated. Complications of FBA or the surgical treatment of FBA include airway edema and respiratory distress, post-obstructive pneumonia, post-obstructive hypoxemia, airway perforation, airway stenosis or scarring and a retained FB. Some of the Pearls and Pitfalls of FBA are
as follows: In summary, FBA is primarily a disease of children under 4 years old and adults over 50 years old. Frequently there is a history of FB aspiration with or without symptoms of wheezing or coughing. CXRs may show recurrent focal atelectasis, pneumonia or pneumonitis, but 10 - 20% are normal. Diagnosis and treatment depends on direct laryngoscopy and rigid bronchoscopy utilizing spontaneous ventilation anesthesia. After a FB has been removed a second look for multiple FB and airway injury should be performed. One should always be alert and prepared to treat complications.
Case Presentation A 22-month-old female toddler presented to the TCH Emergency Center in acute respiratory distress. On admission, she was sitting bolt upright on a stretcher with a respiration rate of 76, SaO2 (room air) = 92%, and significant nasal flaring and sternal-costal retractions; her other vital signs were stable. She was given supplemental oxygen and a chest x-ray revealed hyperinflation of the right lung with mediastinal shift to the left and a severely hypoinflated left lung. The Otolaryngology service was urgently consulted.At this point an interpreter became available and a history was obtained. Apparently, the child had been noted to have a coughing spell after eating some almonds approximately one week prior to admission and since that time had had an intermittent, dry, nonproductive cough. She had been noted to have increased difficulty breathing for two days prior to admission. She was otherwise in good health and there was no history of prior pulmonary problems.An emergent laryngoscopy and bronchoscopy was performed in the operating room at which time multiple almond fragments were found, impacted in multiple bronchi: left main bronchus, LUL bronchus x2, LLL bronchus and RML bronchus. Purulent secretions were identified draining from the RUL, RML, LLL. She remained intubated for 2 days with florid aspiration pneumonia and was treated with Timentin. She recovered uneventfully and was discharged home on her fifth hospital day. Bibliography Banerjee A. Laryngo-tracheo-bronchial foreign bodies in children. J Laryngol Otol 1988;102:1029-1032. Benjamin B, Vandalius T. Inhaled foreign bodies in children. Med J Aust 1974;1:355.Bunker PG. Foreign body complications. Laryngoscope 1961;71:903-927. Clerf LH. Historical aspects of foreign bodies in the air and food passages. Ann Otol Rhinol Laryngol 1952;61:5-17. Cohen SR, Herbert WI, Lewis GB Jr, Geller KA. 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