Resolution of severe bronchiectasis after removal of long-standing retained foreign body

The Lost Crown: A Case of an Aspirated Tooth Crown Causing Post-Obstructive Pneumonia

Non-asphyxiating foreign body aspiration (FBA) is an uncommon occurrence in adults, but it can lead to serious complications and sequelae. Diagnosis of FBA can be difficult as symptoms can mimic other respiratory diseases and the majority of foreign bodies are not visible on chest X-ray. We report a case of an older male who presented with respiratory failure secondary to pneumonia after aspiration of a dental crown. The patient improved after antibiotic therapy and removal of the foreign body by bronchoscopy. Our case is unusual because the diagnosis was delayed after the aspiration event because the patient was asymptomatic before presenting with pneumonia two years later. This case emphasizes the importance of early recognition and management of possible aspiration events to prevent life-threatening sequelae.

Delayed diagnosis of foreign body aspiration in children

AIMS

To assess the diagnostic and therapeutic difficulties as well as the long-term complications of prolonged endobronchial foreign body retention.

METHOD

Between January 2000 and May 2021, 794 patients with suspected foreign body aspiration (FBA) were hospitalized in our department. A total of 12 patients with a delayed diagnosis of over 1 month were included. FBAs were confirmed by flexible or rigid endoscopy. A retrospective analysis of medical records was performed.

RESULTS

Six male patients and six female patients were hospitalized due to prolonged FBA. The average age was 6.90 years (range: 1-13 years). The average duration of the foreign body retention was 2.60 years (2 months to 9 years). A choking event was found in eight cases. Coughing and wheezing were the main symptoms and signs. A misdiagnosis of asthma was made for five patients. Two atypical clinical presentations led to diagnosis of endobronchial foreign body, unilateral pleurisy, and hemoptysis. We report one case of an occult foreign body externalized spontaneously through a pneumo-pleuro-cutaneous fistula. The most common clinical and radiological findings were of pneumonia and atelectasis. Computed tomography showed localized bronchiectasis in three patients. FBAs were removed with a rigid bronchoscope in eight cases. Other extractions were carried out with a flexible endoscope. The foreign bodies were most frequently of vegetable origin, such as seeds and peanuts. A granulation tissue was observed in seven cases. Bronchial stenosis and bronchiectasis are the most common late complications. Only one patient needed a surgical intervention.

CONCLUSIONS

FBA should always be considered in the differential diagnosis of chronic or recurrent respiratory diseases, even in the absence of a previous choking event. Clinical and radiological findings should be carefully evaluated for a possible FBA. Delay in diagnosis and treatment of FBA should be avoided in order to prevent complications. Open surgery may be required when lung abscess has occurred.

A 68-year-old man with haemoptysis and extensive ipsilateral lung infiltrates

A 68-year-old male presented to the emergency department with a 24-h history of haemoptysis and fever. The patient also reported a productive cough for 5 years. He was a current smoker (smoking history of 80 pack-years) with an otherwise unremarkable past medical history. On examination, his respiratory rate was 24 breaths per min, heart rate was 120 beats per min, temperature 39.2°C and his oxyhaemoglobin saturation was 98% in room air. On auscultation, breath sounds were reduced and end-expiratory crackles were heard over the left lung. Physical examination was otherwise normal. Blood tests showed: white blood cells 14 500 cells·μL⁻¹ (neutrophils 12 000 cells·μL⁻¹, lymphocytes 1900 cells·μL⁻¹), haemoglobin 13.9 g·dL⁻¹, platelets 256 000 μL⁻¹, C-reactive protein (CRP) 128 mg·L⁻¹, erythrocyte sedimentation rate 90 mm·h⁻¹, normal electrolytes, urea 45 mg·dL⁻¹ and creatinine 1.22 mg·dL⁻¹.

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Recurrent Respiratory Tract Infection in a 24-Year-Old Female Secondary to a Foreign Body Aspiration

Foreign body aspiration (FBA) is a common problem necessitating prompt recognition and early treatment to minimize the potentially severe and sometimes fatal consequences. We presented a 24-year-old girl who was admitted for chronic cough and recurrent pneumonia associated with constitutional symptoms. She was feverish with a temperature of 39°C and had tachycardia and tachypnoea with an oxygen saturation of 98%. Investigations revealed leukocytosis. CXR showed right lower lobe consolidation, and CT thorax demonstrated collapse consolidation of the right middle and lower lobe, along with associated dilated segmental bronchioles and diffuse patch ground-glass opacity in both lung fields. Bronchoscopy revealed a pen cap at the entrance of the right lower lobe. Patient symptoms improved after removal of the foreign body. In patients with recurrent chest infection, the physician should check for the possibility of FBA and prompt for a referral to a tertiary center for further evaluation.

Task Force report: European Respiratory Society guidelines for the management of children and adolescents with bronchiectasis

There is increasing awareness of bronchiectasis in children and adolescents, a chronic pulmonary disorder associated with poor quality-of-life for the child/adolescent and their parents, recurrent exacerbations and costs to the family and health systems. Optimal treatment improves clinical outcomes. Several national guidelines exist, but there are no international guidelines.The European Respiratory Society (ERS) Task Force for the management of paediatric bronchiectasis sought to identify evidence-based management (investigation and treatment) strategies. It used the ERS standardised process that included a systematic review of the literature and application of the GRADE approach to define the quality of the evidence and level of recommendations.A multidisciplinary team of specialists in paediatric and adult respiratory medicine, infectious disease, physiotherapy, primary care, nursing, radiology, immunology, methodology, patient advocacy and parents of children/adolescents with bronchiectasis considered the most relevant clinical questions (for both clinicians and patients) related to managing paediatric bronchiectasis. Fourteen key clinical questions (7 "Patient, Intervention, Comparison, Outcome" [PICO] and 7 narrative) were generated. The outcomes for each PICO were decided by voting by the panel and parent advisory group.This guideline addresses the definition, diagnostic approach and antibiotic treatment of exacerbations, pathogen eradication, long-term antibiotic therapy, asthma-type therapies (inhaled corticosteroids, bronchodilators), mucoactive drugs, airway clearance, investigation of underlying causes of bronchiectasis, disease monitoring, factors to consider before surgical treatment and the reversibility and prevention of bronchiectasis in children/adolescents. Benchmarking quality of care for children/adolescents with bronchiectasis to improve clinical outcomes and evidence gaps for future research could be based on these recommendations.

An update on pediatric bronchiectasis

INTRODUCTION

The prevalence and awareness of bronchiectasis not related to cystic fibrosis (CF) is increasing and it is now recognized as a major cause of respiratory morbidity, mortality and healthcare utilization worldwide. The need to elucidate the early origins of bronchiectasis is increasingly appreciated and has been identified as an important research priority. Current treatments for pediatric bronchiectasis are limited to antimicrobials, airway clearance techniques and vaccination. Several new drugs targeting airway inflammation are currently in development. Areas covered: Current management of pediatric bronchiectasis, including discussion on therapeutics, non-pharmacological interventions and preventative and surveillance strategies are covered in this review. We describe selected adult and pediatric data on bronchiectasis treatments and briefly discuss emerging therapeutics in the field. Expert commentary: Despite the burden of disease, the number of studies evaluating potential treatments for bronchiectasis in children is extremely low and substantially disproportionate to that for CF. Research into the interactions between early life respiratory tract infections and the developing immune system in children is likely to reveal risk factors for bronchiectasis development and inform future preventative and therapeutic strategies. Tailoring interventions to childhood bronchiectasis is imperative to halt the disease in its origins and improve adult outcomes.

Complications of tracheobronchial foreign bodies

BACKGROUND/AIM

Tracheobronchial foreign bodies may cause several complications in the respiratory system. We aimed to present the complications of tracheobronchial foreign bodies.

MATERIALS AND METHODS

Between January 1990 and March 2015, 813 patients with suspected tracheobronchial foreign body aspiration were hospitalized in our department. Patients with complications related to foreign bodies in airways were included in this study. We retrospectively evaluated the records of patients according to symptoms, foreign body type, localizations, and complications.

RESULTS

A foreign body was found in 701 of 813 patients (86.2%). Complications related to foreign bodies settled in airways were seen in 96 patients (13.7%). The most common complications were atelectasis and pneumonia in 36 (5.1%) and 26 (3.7%) patients, respectively. Other complications were bronchiectasis (n = 12, 1.7%), cardiopulmonary arrest (n = 11, 1.6%), bronchostenosis (n = 3, 0.4%), death (n = 2, 0.3%), migration of foreign body (n = 2, 0.3%), pneumomediastinum (n = 2, 0.3%), tracheal perforation (n = 1, 0.15%), pneumothorax (n = 1, 0.15%), and hemoptysis (n = 1, 0.15%). Coughing (n = 74, 77.1%) and diminished respiratory sounds (59.3%, n = 57) were the most common findings.

CONCLUSION

Careful evaluation and rapid intervention are life-saving methods in tracheobronchial foreign body aspirations.

Non Cystic Fibrosis Bronchiectasis

Bronchiectasis is a pathological abnormality of the airways in which there is permanent dilatation and thickening of the airways. Precise incidence/prevalence in India is not known. Recent data suggests that about 1 % young children admitted in a hospital with pneumonia may develop bronchiectasis. Due to significant burden of pneumonia in young children in developing countries including India, it may be a significant problem that is possibly under recognized. Causes of bronchiectasis depend on the burden of respiratory infections and availability of the investigations for identification of the underlying cause. Post infectious causes are common in countries where infections are more common; however, since these countries are usually resource constrained and therefore, are not able to appropriately diagnose the other causes, leading to more than real overrepresentation of infections as a cause. In countries with less of infectious illnesses and good diagnostic facilities, malformations of airways, immune deficiency disorders and primary ciliary dyskinesia are common causes of bronchiectasis. High resolution CT scan of chest confirms the diagnosis. Treatment is supportive care and consists of maintenance of nutrition, airway clearance and antibiotics for exacerbations. Medical treatment is successful in the majority.

[Bronchial foreign bodies]

Coughing, wheezing, dyspnea and recurrent pneumonia can be signs of foreign body aspiration. About 80% of all foreign body aspirations occur in children, especially in infants between 1 and 3 years of age. Although most foreign bodies are found in the bronchi they are especially dangerous in the larynx or trachea. Foreign body aspiration is less common in adults, being confirmed in only about 1-2 of every 1,000 bronchoscopies. The most common foreign bodies are foods particles. Bronchoscopy is the method of choice for foreign body removal.

Resolution of extensive severe bronchiectasis in an infant

Bronchiectasis is, by definition, an irreversible condition. Following recent reports of reversible bronchiectasis in children, it has been suggested that the definition be broadened to include pre-bronchiectasis and transitional reversible states. We describe the case of a young infant who had extensive, severe bronchiectasis of unknown etiology that resolved following prolonged treatment with antibiotics and a tapering course of oral steroids. We suggest that the prolonged treatment may have played a role, perhaps by eradicating infection and thus enabling regeneration of bronchial anatomy.

Bronchiectasis secondary to primary immunodeficiency in children: longitudinal changes in structure and function

BACKGROUND

Primary immunodeficiency is a common cause of bronchiectasis in children. The term bronchiectasis suggests an irreversible process; however, disease progression following treatment is controversial. The aim of this study was to evaluate the progression of bronchiectasis in children with primary immunodeficiency after institution of treatment.

METHODS

A retrospective review of case notes of children with primary immunodeficiency was undertaken to identify patients with confirmed bronchiectasis. Children who had two high-resolution computed tomography scans of the chest (HRCT chest) with an interval of at least 2 years were identified. The HRCT-chest scans at diagnosis and follow up were scored using a Bhalla score. Spirometry results (FEV1, FVC, and FEV1:FVC ratios) were related to HRCT-chest scores, where available. Statistical analysis was by Wilcoxon signed rank test and Spearman's rank order correlation.

RESULTS

Eighteen subjects were studied. The diagnosis of primary immunodeficiency was established at median (range) age 3.4 (1-13) years, and bronchiectasis at 9.3 (3.1-13.8) years. There was no significant difference between baseline and follow-up median (range) HRCT-chest scores (6 [1-13] and 7.5 [0-15], P = 0.21) respectively. The follow-up FEV1 and FVC percent predicted median (range) were significantly higher than baseline (86% [49-124%] vs. 75% [36-93%], P < 0.005, and 86% [47-112%] vs. 78% [31-96%], P < 0.05), respectively; there was no significant difference between baseline and follow-up FEV(1):FVC ratios. There was no significant correlation between HRCT-chest score changes and FEV1 or FVC changes.

CONCLUSIONS

Bronchiectasis secondary to primary immunodeficiency in childhood is not always a progressive condition, suggesting a potential to slow or prevent disease progression with appropriate treatment.

From hemp seed and porcupine quill to HRCT: advances in the diagnosis and epidemiology of bronchiectasis

Over the last decade there has been a significant improvement in our ability to recognise non-cystic fibrosis (CF) bronchiectasis in children. The precise incidence is uncertain, and it varies greatly depending on the populations studied and the methods used to make the diagnosis. It is unlikely that many of the underlying causes of non-CF bronchiectasis will be eradicated in the near future, and so it must be expected that with ever improving technology this diagnosis will be made with increasing frequency. This emphasises the need to improve our understanding of the aetiology, pathophysiology, epidemiology, and management options for children with this group of conditions.

Extracellular matrix remodeling in children with airway foreign-body aspiration

The purpose of this study was to observe extracellular matrix remodeling in children with airway foreign-body aspiration (FBA) by detecting the expression of matrix metalloproteinase-9 (MMP-9), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), and hydroxyproline (HYP) in bronchoalveolar lavage fluid (BALF). Forty-six children with FBA and 12 control subjects from 2002-2003 were enrolled in this study. The former were divided into three subgroups according to duration of foreign-body (FB) retention (subgroup 1, <7 days; subgroup 2, 7-30 days; subgroup 3, >30 days). Cell count, and levels of MMP-9, TIMP-1, and HYP in BALF were measured. The total number of cells and differential counts detected in BALF did not differ significantly between patients and controls (P > 0.05), while mast cells were found only in the BALF of patients. The positive rates of MMP-9 in controls, subgroup 1, subgroup 2, and subgroup 3 were 33.3%, 62.5%, 80.0%, and 93.3%, respectively, with a significant difference (P = 0.006). The positive rate of TIMP-1 in controls and subgroups 1, 2, and 3 were 33.3%, 62.5%, 80.0%, and 93.3%, respectively, with a significant difference (P < 0.001) as well. HYP levels in subgroups 2 and 3 were significantly more increased than in subgroup 1 and controls (all P < 0.001). Levels of MMP-9, TIMP-1, and HYP in patients were positively correlated with duration of FB retention (all P < 0.05), and levels of MMP-9 and TIMP-1 were also positively correlated with percentage of mast cells in BALF (all P < 0.05). The differences in MMP-9 and TIMP-1 before and after FB removed were not significant (P > 0.05), while HYP levels decreased significantly after FB were removed (P = 0.001). Our findings support the hypothesis that FBA may contribute not only to mechanical airway obstruction, but also possibly to eventual airway remodeling by generation of MMPs and TIMPs.

Reversible bronchial dilatation in children: comparison of serial high-resolution computer tomography scans of the lungs

INTRODUCTION

Bronchiectasis is generally considered irreversible in the adult population, largely based on studies employing bronchography in cases with a significant clinical history. It is assumed, that the same is true for children. Few studies have examined the natural history of bronchiectasis in children and diagnostic criteria on high-resolution computer tomography of the lungs are derived from studies on adults. Frequently, bronchiectasis is reported in children in cases where localised bronchial dilatation is present, incorrectly labelling these children with an irreversible life-long condition.

OBJECTIVE

to evaluate changes in appearance of bronchial dilatation, unrelated to cystic fibrosis in children, as assessed by sequential high-resolution computer tomography (HRCT) of the lungs.

METHODS

The scans of 22 children with a radiological diagnosis of bronchiectasis, seen at Alder Hey Children's Hospital between 1994 and 2000, who had at least two CT scans of the lungs were reviewed by a single radiologist, who was blinded to the original report.

RESULTS

Following a median scan interval of 21 months (range 2-43), bronchial dilatation resolved completely in six children and there was improvement in appearances in a further eight, with medical treatment alone.

DISCUSSION

A radiological diagnosis of bronchiectasis should be considered with caution in children as diagnostic criteria derived from studies in adults have not been validated in children and the condition is generally considered irreversible.

Foreign body aspiration: clinical utility of flexible bronchoscopy

Foreign body aspiration is a worldwide health problem which often results in life threatening complications. More than two thirds of foreign body aspirations occur among children younger than 3 years. Organic materials such as nuts, seeds, and bones are most commonly aspirated. There is a wide range of clinical presentation, and often there is not a reliable witness to supply the clinical history, especially in children. Maintaining a high index of suspicion is therefore necessary for the diagnosis. None of the imaging methods employed in such cases are diagnostic, and bronchoscopy is frequently necessary for the diagnosis as well as the treatment. In adults, removal of the foreign body can be attempted during diagnostic examination with a fibreoptic bronchoscope under local anaesthesia, which may help to avoid any further invasive procedures with more complications. When diagnosis is delayed, complications of a retained foreign body such as unresolving pneumonia, lung abscess, recurrent haemoptysis, and bronchiectasis may necessitate a surgical resection. However, some of the late complications may resolve completely after the retrieval of the foreign body, therefore, a preoperative flexible bronchoscopy should always be considered in suitable cases.

Effects of intrabronchial foreign body retention

Unrecognized bronchial foreign bodies (Fbs) cause irreversible changes in the airways. However, the exact course of these changes is not well-known. We developed an animal model of bronchial obstruction to radiologically and histopathologically assess the development of postobstructive pulmonary changes. A piece of peanut was placed in the airways of 21 rabbits through a 2.5-mm rigid bronchoscope. Animals were divided into three groups (groups I-III) that were sacrificed on day 3,10, and 30 after Fb placement, respectively. Prior to sacrifice, since there were no differences between the groups prior to Fb placement, computerized tomography (CT) of the lung was taken, and the lungs were harvested for histologic analysis under light microscope. In group I, leukocyte infiltration around the bronchial wall (P = 0.0003) and edema (P = 0.0384) around the alveolar septa were the predominant histological findings. The CT scan was normal. In group II and group III, increased amounts of mononuclear cells and macrophage infiltration around the bronchial wall were observed (P = 0.0008, P = 0.0409, respectively). There were no differences in presence of granuloma formation, emphysema, atelectasis, or thickness of alveolar septa among the three groups. The CT scan of group II showed consolidations plus minimal bronchial dilatation in the involved lung of the rabbits (P not significant). Bronchial cartilage destruction was seen in 4 out of 7 rabbits in group III (P = 0.0071). We conclude that 30-day retention of intrabronchial peanut caused bronchial cartilage destruction and fibrosis that were attributed as bronchiectatic changes in the airways of the lung parenchyma. Therefore, any case with suspected foreign body aspiration should be treated immediately to prevent possible irreversible changes of the lungs.

Aerodigestive foreign bodies

Accidents with foreign bodies (FBs) are most common within the first two years of life. The airway FBs present a diagnostic dilemma as both the history and the investigations can be misleading. The persistent hypoxia presents a threat to life as does extraction. Moreover, the chemical pneumonitis induced by vegetative FB makes the situation even more worse. The FB of digestive tract are comparatively benign unless long standing. It is neither necessary for the airway FB to present with respiratory symptoms and signs nor for the FB of digestive tract to complain of dysphagia/throat pain. Oesophagoscopy may have to be done if an esophageal FB is causing only recurrent respiratory infections without dysphagia. The situation in dealing with FB varies from site to site in the aerodigestive tract. This article stresses the various dubious factors including the history, examination and investigation which can lead to misdiagnosis and also those problems which are encountered during planned extraction as well as post-operatively.

Non cystic fibrosis bronchiectasis

Bronchiectasis is becoming less common as the treatment for acute lower respiratory tract infections improves and immunization programmes decrease the frequency of pertussis and measles. However bronchiectasis is still a challenge to the paediatric chest physicians in many developing parts of the world and it remains a frequent problem being the final common pathway of several different lower respiratory tract insults such as cystic fibrosis, immunodeficiency, ciliary dyskinesia. Although the treatment of patients with bronchiectasis is primarily medical, surgical treatment is required in a small group of patients with recurrent episodes of pneumonia and atelectasis localized to one area, severe or recurrent hemoptysis and in those unresponsive to aggressive medical treatment with abnormal growth and development. There are unanswered questions about childhood bronchiectasis, mainly on aetiology and treatment which require more research.

Bronchiectasis: causes and management

Bronchiectasis is a condition representing abnormal and permanent dilatation and distortion of medium sized bronchi, usually accompanied by destruction of the airway wall. Post inflammatory bronchiectasis remains very common in the developing countries as a sequel to pulmonary tuberculosis, whooping cough, and severe measles (among other causes). Cystic fibrosis is the most common cause of generalized bronchiectasis in developed countries. Symptoms primarily are chronic cough and expectoration of foul smelling sputum. Bronchography was, until recently, the investigation of choice for the diagnosis of bronchiectasis and the gold standard against which the current best imaging technique HRCT (high resolution computed tomography) has been compared. Treatment includes prompt attention to acute exacerbations, management of airway secretions and control of airway hyperreactivity. Treatment is aimed at the non progression of the disease and complete cure if possible. The role of surgical therapy has evolved from early curative resection for all patients to a more palliative approach. Patients with advanced generalized bronchiectasis should be considered for lung transplantation.