Foreign body aspiration in children: experience of 1160 cases

Foreign body aspiration in children at University of Gondar Comprehensive Specialized Hospital, a two year retrospective study

Introduction

Foreign body aspiration (FBA) is defined as asphyxia, suffocation, or inhalation of items of food, such as bone and seed, and non-food, such as toys, into the respiratory tract. Aspiration of foreign bodies is an important and preventable cause of mortality and morbidity in children, especially those less than 3 years of age. The aim of this study was to analyse the clinical and radiological profile, modes of management, and outcomes of foreign body aspiration in children at the University of Gondar Comprehensive Specialized Hospital and identify areas of possible interventions for proper management of such cases.

Method

A retrospective review of the medical records of all patients suspected of foreign body aspiration at the University of Gondar Comprehensive Specialized Hospital (UoGCSH) from January 1, 2021, to January 1, 2023, G.C. was conducted. Clinico-radiological features, types and locations of foreign bodies, modes of management, and patient outcomes were studied.

Results

A total of 73 patients suspected of having a possible foreign body aspiration were identified. The median age of the patients was 24 months, with an IQR of 14 and 39, with 46 (75.3 %) being under 3 years of age. 45 (61.6 %) were male, while 28 (38.4 %) were female, making the M:F ratio 1.6:1. A foreign body aspiration history could be obtained in 68 (93.1 %) of the patients, while in 4 (5.9 %) of the cases, patients or their families were not aware of any kind of aspiration. Among the children presented, 65 (89 %) had a choking episode, coughing 66 (91 %), vomiting 63 (86.3 %), tachypnea 61 (83.6 %), and stridor 15 (20.5 %). The most common physical finding observed was nasal flaring along with subcostal and intercostal retraction in 59 (80.8 %), followed by decreased air entry in 40 (54.8 %), wheeze in 37 (50.7 %), and absent air entry in the affected side in 4 (5.5 %) of the patients. A chest x-ray was done on all patients. 28 (41.2 %) had normal chest x-rays. With regard to procedure-related complications, 3 (4.1 %) patients had cardiac arrest, 1 (1.36 %) had pneumothorax, and 1 patient died.

Conclusion

Any bronchopulmonary infection with an unusual course should be suspected of being the result of the aspiration of a foreign body. Increased public and professional awareness of the importance of early bronchoscopy in all suspected cases of foreign body aspiration is necessary. In order to lower the incidence, those providing care must be taught routine preventive measures.

Foreign Body Aspiration in Children-Retrospective Study and Management Novelties

Foreign body aspiration (FBA) is a frequent diagnosis in children. In the absence of other lung conditions, such as asthma or chronic pulmonary infections, this manifests as a sudden onset of cough, dyspnea, and wheezing. The differential diagnosis is based on a scoring system which takes into account the clinical picture as well as the radiologic aspects. The treatment that is considered the gold-standard for FBA in children remains to be rigid fibronchoscopy, however it comes with several potentially crucial local complications such as airway edema, bleeding, and bronchospasm, along inherent issues due to general anesthesia. Material and methods: Our study is a retrospective study analyzing the medical files of the cases from our hospital over the span of 9 years. The study group consisted of 242 patients aged 0-16 years diagnosed with foreign body aspiration in the Emergency Clinical Hospital for Children "Sfânta Maria" Iași, between January 2010-January 2018. Clinical and imaging data were extracted from the patients' observation sheets. Results: In our cohort, the distribution of children with foreign body aspiration was uneven, with the highest incidence being reported in children from rural areas (70% of cases), whereas the most affected age group was 1-3 years, amounting to 79% of all cases. The main symptoms which led to emergency admittance were coughing (33%) and dyspnea (22%). The most important factors that determined the unequal distribution were socio-economic status, which relates to a lack of adequate supervision by parents, as well as the consumption of food inappropriate for their age. Conclusions: Foreign body aspiration is a major medical emergency that may be associated with dramatic clinical manifestations. Several scoring algorithms designed to establish the need for bronchoscopy have been proposed, taking into account both the clinical and radiological results. The issue with asymptomatic or mild symptomatic cases, as well as difficulties managing cases with radiolucent foreign bodies, remains a challenge.

Comparison of chest X-ray interpretation by pediatric pulmonologists, pediatric radiologists, and pediatric residents in children with suspected foreign body aspiration-a retrospective cohort study

Chest X-ray (CXR) is an important tool in the assessment of children with suspected foreign body aspiration (FBA), although it can falsely be interpreted as normal in one-third of the cases. The aim of this study is to evaluate the positive predictive value of CXR in children hospitalized with suspected FBA, when interpreted by three disciplines: pediatric pulmonology, pediatric radiology, and pediatric residents. This is a retrospective study that included children aged 0-18 years, admitted with suspected FBA, between 2009 and 2020 in one tertiary center. All patients underwent CXR and a flexible/rigid bronchoscopy for the definitive diagnosis of FBA, up to 1 week apart. Two physicians from each discipline interpreted the CXR, independently. Intra-raters' and inter-raters' agreements were assessed. Sensitivity, specificity, and area under the curve (AUC) were calculated for each discipline. Four hundred seventy-three children were included in the study, 175 (37%) with FBA and 298 (63%) without FBA on flexible/rigid bronchoscopy. The most common radiological findings, as interpreted by a pediatric pulmonologist, were unilateral hyperinflation (47%), radiopaque FB (37.6%), lobar atelectasis (10.3%), unilateral hyperinflation with atelectasis (3.4%), and lobar consolidation (1.7%). Intra-raters' agreement ranged from 0.744 (p < 0.001) among pediatric pulmonologists to 0.326 (p < 0.001) among pediatric radiologists. AUC for predicting FBA based on a CXR was 0.81, 0.77, and 0.7 when interpreted by pediatric pulmonologists, pediatric residents, and radiologists, respectively (p < 0.001).

CONCLUSIONS

CXR has a high positive predictive value and independently predicts FBA in children; however, normal CXR should not rule out FBA. Predictability is variable among different disciplines.

WHAT IS KNOWN

• Chest X-ray is an important tool in the assessment of children with suspected foreign body aspiration (FBA). • Chest X-ray can be interpreted as normal in one-third of the cases.

WHAT IS NEW

• Chest X-ray independently predicts FBA in children, with a high positive predictive value. • The ability of chest x-ray to predict FBA in children differs between pediatric residents, pediatric radiologists, and pediatric pulmonologists.

Using Machine Learning Technique to Predict the Most Reliable Diagnostic Finding for Foreign Body Aspiration in Children: Symptoms, Chest X-ray, or Auscultation?

Foreign body aspiration (FBA) is one of the most critical and life-threatening pediatric emergency situations. Prompt diagnosis in these cases is very important as they are associated with high mortality among children. When diagnosing FBA, symptoms of the patient, auscultation findings, and chest X-ray findings are usually evaluated. In this study, we conducted a retrospective analysis of all the cases involving suspicion of FBA in children under the age of 18 years who were hospitalized in the Department of Pediatric Surgery at Denizli Pamukkale University Hospital, Turkey from January 2005 to September 2020. Instead of traditional statistical methods, we used machine learning techniques such as random forest and logistic regression to determine which finding was diagnostically the most reliable. The variables included in the analysis that were considered to be significant were as follows: symptoms, auscultation findings, chest X-ray findings, patient gender, age, location of the foreign body, and the time of admission. For the purpose of this study, we developed four different models. Model 1 included gender, age, time of admission, location, and symptoms as variables; the correct classification rate of the model was found to be 82.3%. Model 2 included auscultation findings in addition to Model 1, and the correct classification rate of the model was 84.8%. Model 3 included chest X-ray findings in addition to Model 1, and the correct classification rate of the model was 87.4%. Model 4, on the other hand, included both auscultation findings and chest X-ray findings in addition to Model 1, and the correct classification rate of the model was 87.6%. Based on our findings, a definitive diagnosis of FBA using only symptoms, auscultation findings, or chest X-ray findings in isolation does not seem possible. Additionally, using only symptoms and chest X-ray findings is also insufficient to make a diagnosis.

Management of Tracheo-Bronchial Foreign Bodies in Children: Our Experience

(1) To study the epidemiological profile of the patients. (2) To study the various modalities of investigations to arrive at confirmatory diagnosis. (3) To study the post-operative complications. It was a hospital based prospective study. A total of 36 paediatric patients were included in the study over a duration of 2 years (August 2017 to July 2019). Written informed consent was taken from the parent of each patient before performing bronchoscopy. All the patients were subjected to careful clinical examination and investigations required followed by emergency bronchoscopic removal of foreign body. The patients were followed up at 1 and 3 months after bronchoscopic removal. Amongst the 36 cases, 12 cases presented with airway emergency which addressed by bronchoscopic removal immediately. 10 cases presented with suggestive history of foreign body aspiration were subjected to clinical and radiological studies followed by bronchoscopic removal. 14 cases were referred from paediatric in-patient department who were being treated for unresolved LRTI. Early intervention is life saving if timely done. Unresolved LRTIs should be looked carefully to address missed foreign bodies. HRCT Thorax with 3-D reconstruction (Virtual Bronchoscopy) helps in exact localization of the foreign body. Experienced team of surgeons and anesthetist along with a ICU support is needed for efficient management.

Child requiring tracheostomy for removal of an airway foreign body at the tracheal bifurcation

Airway foreign bodies are typically removed orally using a rigid bronchoscope. We present a rare case of a foreign body at the tracheal bifurcation that required removal via tracheostomy. A child turned pale while eating nuts and was suspected to have choked on a foreign body. CT revealed a foreign body at the tracheal bifurcation. As his respiratory condition was unstable, tracheal intubation and removal were attempted using a rigid bronchoscope. Tracheal obstruction during oral removal resulted in respiratory failure and bradycardia. Following emergency tracheostomy, the foreign body was removed via the tracheal stoma after his respiratory condition stabilised. The patient was discharged 21 days later without neurological sequelae. To avoid hypoxaemia during airway foreign body removal, as in this case, assessing the size of the upper airway and foreign body is necessary. Tracheostomy and foreign body removal through the tracheal opening should be considered proactively.

Foreign Body Aspiration in Egyptian Children Clinical, Radiological and Bronchoscopic Findings

Purpose

Foreign body aspiration (FBA) is a frequent cause of childhood morbidity and mortality. Diagnosis of FBA is challenging in the absence of a witnessed aspiration event. The aim of this study was to determine the accuracy of presenting symptoms as well as physical and radiologic findings as predictors of FBA in children. Thus, indications for bronchoscopy could be determined in such cases.

Methods

This retrospective cohort study was conducted in the ENT department, Kafr-elsheikh University Hospital. The medical records of patients younger than 16 years old who underwent rigid bronchoscopy for suspected FBA were included. Data including age, gender, symptoms, physical examination findings, radiological features, nature and location of foreign body, and outcome of the bronchoscopy were collected.

Results

This study included 130 patients, 105 (80.8%) patients were positive for the presence of a foreign body in their airways. Foreign bodies were most frequently (43.8%) lodged in the right main bronchus, and nuts (66.7%), were the most commonly retrieved. Multivariate regression analysis identified the presence of suggestive signs or symptoms as independent predictors of FBA on rigid bronchoscopy.

Conclusion

Objective finding of clinical signs eg unilateral wheezes on chest examination in the presence of symptoms such as a sudden cough, dyspnea, and hoarseness could predict FBA and help physicians in deciding bronchoscopy.

A subglottic foreign body mimicking croup: A case report

INTRODUCTION

Foreign body (FB) aspiration is one of the causes of respiratory distress in infants is an extremely dangerous and potentially life-threatening event. The diagnosis of FB aspiration is difficult because the signs and symptoms vary according to the degree of airway blockage or location of the FB.

PATIENT CONCERNS

An 11-month-old female infant visited a hospital because of a sudden onset cough. She was relatively healthy without fever, rhinorrhea cyanosis, or poor feeding. On physical examination, auscultation revealed inspiratory stridor without wheezing and crackles.

DIAGNOSIS

Croup was suspected when considering the history, physical examination, and imaging. However, she did not respond to a 4-day course of treatment for croup. Flexible laryngoscopic examination was performed, and we identified a thin, flat, and sharp FB embedded in the subglottic region.

INTERVENTIONS

Emergency surgery was performed to remove the FB. Short-term intravenous corticosteroids and antibiotics were used to prevent laryngeal swelling and aspiration pneumonia.

OUTCOMES

One week after the procedure, the laryngeal mucosa had completely healed.

CONCLUSION

FB aspiration should be considered in an infant with an impression of croup. In particular, if there is no response to medical or conservative treatment for croup, further evaluation is needed.

Conservative management of iatrogenic tracheal rupture in a 19-month-old child

Up to date, only five cases of iatrogenic tracheal rupture during rigid bronchoscopy have been reported in children. Herein, we report the first case who has recovered with spontaneous respiration without intubation. Rigid bronchoscopy of a 19-month-old girl revealed a foreign body at the right main bronchus. While the bronchoscope was being withdrawn, we identified a 0.5-cm longitudinal mucosal laceration along the right wall of the membranous trachea. As her spontaneous respiration was adequate, she was treated conservatively. For the treatment of tracheal lacerations, while early surgical repair has traditionally been acceptable, evidence supporting conservative treatment is increasing, particularly in paediatric cases. If spontaneous respiration is sufficient, bridging the laceration with an endotracheal tube may not be required.

Risk Management and Recommendations for the Prevention of Fatal Foreign Body Aspiration: Four Cases Aged 1.5 to 3 Years and Mini-Review of the Literature

(1) Background: Foreign body aspiration (FBA) is a significant public health concern among the pediatric population, and fatalities are dramatic for families. It typically involves organic foreign bodies (mainly food) aspirated by children under three years old, usually at home or school. This review aimed to focus on the preventive measures around four actual cases of fatal foreign body aspiration, emphasizing the correct execution of the Heimlich maneuver and cardiopulmonary resuscitation, supervised mealtimes, and high-risk foods. (2) Methods: Four fatal cases of foreign body aspiration in children are presented here. The children were in a free environment, such as school, home, and the countryside, and were in the presence of teachers, parents, and a grandmother who did not supervise the children adequately. A literature review was performed via the MEDLINE database using the key terms: “foreign body aspiration,” “infant choking, 1.5 to 3 years,” “food and foreign body aspiration,” “common household,” “prevention of foreign body aspiration,” “guidelines,” “recommendations,” “training of caregivers (parents, educators),” “resuscitation,” “Heimlich maneuver,” and “disengagement of the upper airways.” We focused on the prevention of foreign body aspiration. (3) Results: a complete postmortem examination was performed. In three cases, the foreign bodies were food (mozzarella cheese, pear, or raw bean), while in one case, the foreign body was a pebble. (4) Conclusions: This review aimed to discuss recent scientific literature and provide a perspective on the benefits of a dedicated approach to the management of fatal foreign body aspiration in children by caregivers who usually have no experience with the best ways of supervising children in a safe environment, especially regarding the correct execution of resuscitation maneuvers, such as the Heimlich maneuver. Recommendation updates could improve healthcare quality in a pediatric setting and reduce medico-legal implications.

A Five-Year Review on Pediatric Foreign Body Aspiration

Introduction  Foreign body aspiration is a leading cause of accidental death in children. Clinical presentation varies from non-specific respiratory symptoms to respiratory failure making diagnosis challenging.

Objective  To review pediatric patients who underwent bronchoscopy due to suspicion of foreign body aspiration at a tertiary center in Malaysia.

Methods  We retrospectively studied patients < 11 years old who underwent bronchoscopy from 2008 to 2018.

Results  Over the 10-year period, 20 patients underwent bronchoscopy, and 16 were found to have foreign body aspiration with equal gender distribution. The most common age group was < 3 years old (75%). The most common clinical presentations were choking (82%) and stridor (31%). Foreign bodies were removed using flexible bronchoscope in 8 cases (50%), and difficulties were encountered in 6 cases (75%). Rigid ventilating bronchoscope was used in 8 cases (50%) with no difficulty. The most common object found was peanut (19%). The majority of foreign bodies were lodged in the right bronchus (43%). Eight patients (80%) received delayed treatment due to delayed diagnosis. The length of hospital stay was longer in the younger age groups.

Conclusion  Clinical presentation and chest radiograph findings were comparable across all age groups. The most difficulties encountered during foreign body removal were via flexible bronchoscope, in children < 3 years old. There was no significant correlation between age and type of foreign body aspiration. The majority of patients who received delayed treatment were < 3 years old. The length of hospital stay was longer in the younger age groups.

Tracheobronchial foreign body aspiration in children: A retrospective single-center cross-sectional study

Foreign body (FB) aspiration is a common and serious problem in childhood as it requires early recognition and treatment to avoid potentially lethal consequences. This study aimed to characterize the clinical and epidemiological features of airway FBs in a pediatric Chinese population.A retrospective review of medical records of children aged 0 to 14 years who attended with a diagnosis of FB aspiration the Shanghai Children's Hospital between January 2013 and December 2017 was carried out. Descriptive analysis was used to assess patient's demographics, clinical, radiographic, bronchoscopic findings, time to presentation, and characteristics of the FBs.Among the 200 patients included in the study, 92% were under 3 years of age, with a peak incidence of FB aspiration occurring between 1 and 2 years old. The male to female ratio was about 2.6:1. Twenty-three percent of the patients were admitted within 24 hours of the event, 40% within 1 week, 30% within 1 month, and 7% more than 1 month after aspiration. The most common presenting symptoms of laryngotracheal FBs were cough, dyspnea, and wheezing; those of bronchial FBs were cough, decreased air entry, and wheezing. Chest X-ray was normal in four-fifths of the children with laryngotracheal FBs, whereas most common abnormal X-ray findings in children with bronchial FBs were mediastinal shift, obstructive emphysema, and pneumonia. There was a trend that in children younger than 2 years FBs were more frequently found in the left bronchus, whereas in older children FBs were more frequently found in the right bronchus. Ninety-three percent of the removed FBs were organic materials such as food items and the most frequently aspirated FBs were peanuts. Flexible bronchoscopy was performed in 82.5% of the patients, while rigid bronchoscopy or direct laryngoscopy in 17.5% of the patients. Four patients were subjected to thoracic surgery and 1 died during rigid bronchoscopy due to acute respiratory failure.FBs is a frequent pathology among Chinese children. Tracheobronchial FBs should be strongly suspected in young children who have sudden onset of cough and wheezing episode, even when physical and radiographic evidence is absent.

An Adolescent With Progressive Shortness of Breath

Shortness of breath and wheezing are common presenting signs for children in the emergency department. In adolescence, it is often due to asthma or lower respiratory tract infections. We present a rare pediatric case of an adolescent with biphasic stridor and progressive exercise-induced shortness of breath who was found to have severe idiopathic subglottic stenosis.

Successful Management of Airway and Esophageal Foreign Body Obstruction in a Child

Foreign body asphyxia is a serious clinical problem with high morbidity and mortality rates. It is relatively common among children, especially those younger than 3 years, because they have a high risk of aspirating foreign bodies owing to their tendency to place objects in their mouth and lack of a well-developed swallowing reflex. Moreover, the neurologic outcome after out-of-hospital cardiac arrests (OHCA) in pediatric patients remains generally poor. Here, we report an unusual pediatric case of asphyxial OHCA caused by foreign bodies obstructing the airway, complicating esophageal foreign body, with a neurologically favorable outcome. This case highlights the importance of adequate treatment for pediatric patients with OHCA, as well as the prompt and efficient management for pediatric patients with foreign bodies obstructing the airway and esophagus.

Acute Respiratory Distress Syndrome immediately following the removal of an aspirated foreign body

Acute Respiratory Distress Syndrome (ARDS) is a form of diffuse lung injury with many potential etiologies, pneumonia being the most common cause developing outside of the hospital. Foreign body (FB) aspiration is a risk factor for pneumonia, and therefore, ARDS. Although these associations exist, the development of ARDS immediately following the removal of an aspirated FB appears quite rare.

We present the case of an 11 year old male who was found to have a right-sided, post-obstructive pneumonia secondary to an aspirated FB obstructing the bronchus intermedius. Relief of the obstruction allowed for rapid, endobronchial spread of infection and within 6 hours of FB removal, our patient developed severe ARDS requiring initiation of extracorporeal membrane oxygenation (ECMO). Streptococcus constellatus was isolated from lower respiratory cultures obtained during initial bronchoscopy.

[A neglected bronchial foreign body for 23 years]

Foreign body inhalation is a clinical emergency requiring prompt action to ensure speedy recovery and minimize the development of complications. It is more common in children than adults. We report a case of a neglected foreign body present in the bronchus of an adult for 23 years and treated as intermittent asthma. The diagnosis was revealed following the development of severe sepsis of a pulmonary origin. The foreign body was removed by rigid bronchoscopy, antibiotic therapy instituted and pre- and post-interventional respiratory physiotherapy carried out. Satisfactory progress was marked by the complete clearing of pulmonary suppuration, with only a small localized and asymptomatic focus of bronchial dilatation remaining. The persistence of chronic, unexplained respiratory complaints should prompt the use of imaging and endoscopy to exclude an endobronchial cause, especially to consider the possible presence of a previously unknown foreign body. Early diagnosis and intervention can help to avoid potentially serious complications.

Epidemiology of pediatric visits to the emergency department due to foreign body injuries in South Korea: Nationwide cross-sectional study

Foreign body (FB) injuries mainly occur in young children and may cause serious complications. The purpose of this study was to describe the epidemiological and clinical characteristics of FB injuries among children visiting the emergency department (ED) in South Korea and to compare the incidence and the ED results of FB injuries.Using data from the National Emergency Department Information System, FB injury-related ED visits among children (<7 years) between January 2010 and December 2014 were included. Epidemiological characteristics were analyzed in different age groups, and metropolises were compared with provinces regarding the incidence of ED visits, admission, and transfer of patients with FB injuries.In total, 51,406 pediatric patients with FB injuries visited 118 EDs over 5 years, and the annual incidence of FB injuries among children increased throughout the study period (215.1-436.5 per 100,000 population [<7 years], P for trend <.001). The most common anatomical site of the FB injury was the nose (18,479; 36.0%), followed by the pharynx (10,285; 20.0%). The most common age of patients was 1 year for alimentary tract, 2 years for nose, 1 year for respiratory tract, and 4 years for ear FB injuries. The overall admission rate was 1.8%, and the ICU admission rate was 0.04%. Four deaths occurred, and all of them were caused by respiratory FB injuries. The incidence of transfer of patients with FB injuries to other hospitals was higher in provinces than in metropolises.The incidence of FB injury-related ED visits among children younger than 7 years old in South Korea has been high and has been increasing recently. In particular, the incidence of FB injuries of the alimentary and respiratory tracts was high, especially around the age of 1. Preventive measures should be taken to decrease FB injuries among young children in South Korea.

Evaluation of foreign body aspiration cases in our pediatric intensive care unit: Single-center experience

Aim

Foreign body aspiration is one of the common home accidents that requires urgent diagnosis and treatment, especially in children aged between 1 and 3 years. The type, location, and obstruction level of the aspirated material, age of the patient, and time of diagnosis influence the severity of the clinical picture. In our study, we aimed to evaluate patients who underwent bronchoscopy in our clinic with a diagnosis of foreign body aspiration in light of literature data.

Material and Methods

The medical records of 87 patients who underwent rigid bronchoscopy with a prediagnosis of foreign body aspiration in Çukurova University, Faculty of Medicine, between January 2016 and August 2018, and were followed up in the pediatric intensive care unit after the procedure were examined retrospectively. The subjects were evaluated in terms of age, sex, primary referal center, time of presentation, symptoms at presentation, physical examination findings, radiologic investigations, type and location of foreign body, and duration of stay in the intensive care unit.

Results

A total of 87 patients were included in the study. Thirty-seven patients (42.5%) were female. The mean age was found as 33.73±39.44 (range, 5-202) months. The most common (74.7%) symptom at presentation was sudden onset of coughing. The foreign body aspirated was organic in 62.1% of patients. The most common foreign bodies aspirated were peanuts, with a rate of 19.5%. Four adolescent female patients underwent broncoscopy because they aspirated needles they held in their mouths while tying their headscarves. Interestingly, one patient aspirated a stone and one patient aspirated a parasite. The most frequent location of foreign body was the right main bronchus (n=27, 31%).

Conclusion

In the diagnosis of foreign body aspiration, the most important step is maintaining a high index of suspicion. Foreign body aspiration should be considered in patients who present with cough, respiratory distress or cyanosis, unilaterally diminished breath sounds, ronchi or stridor on physical examination, and air trapping on chest X-ray. Bronchoscopy is life-saving in the presence of any suspicious history suggestive foreign body aspiration or refractory pneumonia, even if a physical examination and radiologic findings are normal, especially in high-risk children between 1-3 years old.

Mistaken Asymptomatic Carinal Foreign Body in a Child

Foreign body aspirations are commonly seen in emergency departments (EDs) worldwide, presenting with cough, dyspnea, wheeze, and decreased air entry. Chest radiographs are commonly utilized diagnostic tools to confirm foreign object aspiration. The following is a case report of a child who presented in the ED with a carinal push-pin aspiration and a lack of respiratory symptoms; an extremely rare ED presentation of foreign body aspirations masquerading as a foreign body ingestion. This attests to the importance of conducting a lateral chest radiograph for diagnostic purposes to accurately interpret an esophageal or tracheal foreign body placement.

Death as a Consequence of Foreign Body Aspiration in Children

Aim:

To analyze the rate of mortality in children with foreign body aspiration (FBA).

Methods:

We outlined a retrospective review of hospital data of patients between 1971 and 2013. FBA occurring in children 0 year to 14 years was considered for inclusion (patient ages ranged from 0.6 to 15 years, with a median age of 2.2 years). The gender structure within the investigated cases was 75.8% males and 24.2% females. During the study period, 772 patients undergoing rigid bronchoscopy with the diagnosis of FBA were included. Deaths on arrival were excluded.

Results:

Total rate of mortality (for whole investigated period) was 0.785. For last fifteen years of the investigated period the rate of mortality was zero.

Conclusion:

For prevention of foreign body aspiration in children and its mortality should be taken two strategies: non-medical (alterations in product design and public education campaigns) and medical (education of medical staff and improvement of equipment).

Bronchoscopy for Pediatric Airway Foreign Body: Thirty-Day Adverse Outcomes in the ACS NSQIP-P

OBJECTIVES

(1) Describe outcomes of bronchoscopy with foreign body removal among children on the basis of a large standardized multi-institutional data set. (2) Identify factors associated with 30-day adverse events.

STUDY DESIGN

Cross-sectional analysis of a US national database.

SETTING

Public data set from the ACS NSQIP-P (American College of Surgeons National Surgical Quality Improvement Program-Pediatric) from 2012 to 2015.

SUBJECTS AND METHODS

Children <18 years old who underwent bronchoscopy with removal of foreign body were identified. Patient demographics, comorbidities, hospitalization factors, surgical characteristics, and 30-day postoperative adverse events, including complication and readmission, were analyzed. Multivariate logistic regression identified predictive factors for postoperative complications and prolonged length of stay.

RESULTS

A total of 275 children underwent bronchoscopic foreign body removal (n = 165 male, 60%; n = 75 nonwhite and/or Hispanic, 27%; mean age, 3.5 years [range, 0.63-17.9; median, 2.0]). Adverse events occurred among 10 children (4%). Seven had pulmonary-related complications, and 1 patient died. Three patients were readmitted; there were no reoperations. On multivariate analysis, preoperative pulmonary disease or need for pulmonary support (odds ratio [OR], 6.42; P = .04) predicted postoperative complications. Preoperative pulmonary compromise (OR, 8.10; P < .01), American Society of Anesthesiologists class 3 or 4 (OR, 4.13; P < .01), and prolonged operative time (OR, 3.05; P = .01) were associated with prolonged hospital stay.

CONCLUSION

Bronchoscopy for retrieval of foreign body among children has an overall low incidence of 30-day adverse events. Children with preoperative pulmonary compromise have a significantly higher risk of postoperative complications. These findings may be applied to optimize perioperative care and counsel parents and families.

A Rare Incidental Finding of a Foreign Body in the Nasopharynx during Adenotonsillectomy

Diverse foreign bodies may become lodged in the aerodigestive tract, and the discovery of such foreign bodies is an expected scenario for health-care practitioners. The foreign body insertion may be accidental or deliberate, and the object may be organic or inorganic. Most accidental foreign body aspirations occur in children, and some such cases are potential threats that go unnoticed. Very few cases of foreign bodies in the nasopharynx have been reported. Herein, we describe an unusual case in which a foreign body in a child's nasopharynx went unnoticed for 1 year and was detected intraoperatively.

Tracheobronchial Foreign Bodies in Children: The Role of Emergency Rigid Bronchoscopy

Foreign body aspiration (FBA) is a common and lethal accident in the pediatric age group. It requires early recognition and treatment by rigid bronchoscopy to avoid fatal outcomes. Objective. The aim of this study was to study the pattern of FBA in the tracheobronchial tree as well as the success rate of rigid bronchoscopy in children admitted to a single center and to analyze the relationship of the type of foreign body (FB) with patients' age, presentation, and complications. Methods. A retrospective cross-sectional study of FBA was conducted in children in the Sulaimani/Kurdistan region, Iraq, admitted to the emergency teaching hospital of the University of Sulaimani from January 2014 to March 2016. Result. Data of 83 patients between 6 months and 15 years old were studied. The most affected was the 1- to 5-year-old group. There was a slight female predominance (male to female ratio 0.93:1). The most common FB was sunflower seed (49.4%). History of choking was present in 92.8% of patients; 55.4% had normal air entry, and 37.3% had no added sound on chest auscultation. Normal chest X-ray (CXR) was found in 40% of patients. The most common site was the right bronchial tree (39.8%). Two patients needed mechanical ventilation; both of them died. There was a significant relationship between the type of FB (P = .013, .000, respectively). Conclusion. Medical history is the most important factor for reaching the diagnosis; bronchoscopy is mandatory if choking was witnessed, even if examination and CXR are normal. Organic material causes more local reaction than nonorganic material.

Bronchoscopy for foreign body aspiration and effects of nebulized albuterol and budesonide combination

Objective:

A foreign body aspiration in the tracheobronchial tree is a dangerous medical condition in the childhood period. Although rigid bronchoscopy is a safe procedure, it may cause complications. The aim of this study was to present our bronchoscopy experience and to evaluate the efficacy of pre-operative administration of nebulized albuterol and budesonide combination for reducing intra-operative complications in foreign body aspirated cases.

Methods:

In this retrospective study our pediatric cases in which a foreign body was removed from tracheobronchial tree in last 8 years were analyzed. After excluding the patients who needed emergent and negative bronchoscopies, the remaining clinically stable 84 patients were compared for the effects of preoperative administration of nebulized albuterol and budesonide combination on bronchoscopy complications.

Results:

There were 51 boys (60.3%) and 33 girls (39.7%). There were 38 children in the non-nebulized group and 46 children in the nebulized group. We found that the combined albuterol and budesonide nebulization decrease complications such as arterial oxygen desaturation (p<0.05), and bronchospasm (p<0.05) during the bronchoscopic intervention.

Conclusion:

Preoperative nebulization of albuterol and budesonide combination may decrease perioperative complications of bronchoscopy.

Review of tracheobronchial foreign body aspiration in the South African paediatric age group

Children, and in particular young children under the age of three, are the most vulnerable for aspiration and ingestion of foreign bodies (FBs). The Red Cross War Memorial Children's Hospital in Cape Town is the only children's hospital in South Africa and is unique in having a dedicated trauma unit for children under the age of 13 as part of its institution. Core activities of Childsafe South Africa (CSA), located at the hospital, are data accumulation and interpretation, development of educational programmes, health inculcation and advising in legislation involving child health. To achieve this task, CSA works in close co-operation with government, industry, non-governmental and community predicated organisations, community groups and individuals. A database of all children treated for trauma at CSA has been maintained since 1991; it currently contains detailed information of over 170,000 injuries in children under the age of 13. This review consists of a literature review combined with data from our database and aims to provide information on our experiences with tracheobronchial aspiration of FBs in children.

A straight pin foreign body in a child: ingested or aspirated?

BACKGROUND

Though foreign body (FB) aspiration or ingestion is not uncommon in children, a straight pin as the culprit FB is rarely seen. The nature of such a FB makes it sometimes difficult to diagnose and deal with, especially in children.

CASE REPORT

Here we present such a case who was initially misdiagnosed with FB ingestion but turned out to be an aspiration case. Moreover, its remote location from the hilum made a more invasive surgical retrieval inevitable. A thoracotomy was finally performed to retrieve the pin. And the postoperative course was uneventful.

CONCLUSION

For pediatric FB cases, especially in such a case, it is very important to diagnose timely and accurately. A multidisciplinary team approach would facilitate prompt and accurate diagnosis and potentially simplify treatment.

Importance of back blow maneuvers in a 6 month old patient with sudden upper airway obstruction

Foreign body aspiration in children under four years old is one of the most frequently observed reasons for accident related deaths. It is more common in this age group due to inadequate swallowing functions and exploration of objects with the mouth. The most frequently encountered foreign bodies are food and toy parts. Life threatening complete laryngeal obstruction is rarely observed. Dyspnea, hypersalivation, cough and cyanosis can be seen. The basic and life-saving treatment approach is complete removal of foreign body maneuvers in the sudden onset of total obstruction. Here we report a six-month old male, who ingested a foreign body and was treated with back blow maneuvers successfully. In this case we emphasized the importance of back blow maneuvers.

Congenital lobar emphysema presenting as an airway foreign body

We report here the case of a 15 months old girl presenting with clinical signs and radiological exams highly suggestive of a foreign body (FB) aspiration. Diagnostic endoscopy revealed an overlooked bronchial malformation responsible for a congenital lobar emphysema (CLE). CLE presenting after one year of age is rare and can easily be misdiagnosed. Therefore, the possibility of an overlooked CLE needs to be known and evoked as an alternative diagnosis when dealing with children presenting with suspected FB aspirations. We report on this unexpected, yet misleading presentation of CLE and review the available literature on the subject.

Imaging Acute Airway Obstruction in Infants and Children

Acute airway obstruction is much more common in infants and children than in adults because of their unique anatomic and physiologic features. Even in young patients with partial airway occlusion, symptoms can be severe and potentially life-threatening. Factors that predispose children to airway compromise include the orientation of their larynx, the narrow caliber of their trachea, and their weak intercostal muscles. Because the clinical manifestations of acute airway obstruction are often nonspecific, clinicians often rely on the findings at imaging to establish a diagnosis. Several key anatomic features of the pediatric airway make it particularly susceptible to respiratory distress, and the imaging recommendations for children suspected of having acute airway obstruction are presented. Although cross-sectional imaging may be helpful, the diagnosis can often be established by using radiographs alone. Radiographs of the chest and upper airway should be routinely acquired; however, for the child who is in severe distress, a single lateral radiographic view may be all that is necessary. The purpose of this article is to provide an imaging approach to acquired causes of acute airway obstruction in children, including (a) abnormalities affecting the upper portion of the airway, such as croup, acute epiglottitis, retropharyngeal infection, and foreign bodies, and (b) abnormalities affecting the lower portion of the airway, such as asthma, bronchiolitis, and foreign bodies. It is essential that the radiologist recognize key imaging findings and understand the pathophysiologic features of acute airway obstruction because in most cases, when the cause is identified, the condition responds well to prompt management.

Rigid bronchoscopy and balloon dilation for removal of aspirated thumbtacks: case series and literature review

OBJECTIVE

Aspirated thumbtacks can pose unique challenges during removal due to their shape. In particular, the flanges of the thumbtack can readily become trapped by the bronchial mucosa during extrication. We describe our experience of three children from whom aspirated thumbtacks were removed using rigid bronchoscopy following balloon dilation of the airway to reduce bronchial mucosa entrapment.

METHODS

This is a retrospective review of three pediatric otolaryngology cases.

RESULTS

In all three cases, the thumbtack was successfully removed from various sites within the lower respiratory tract. There were no iatrogenic complications, in particular bronchial wall injury leading to pneumothorax.

CONCLUSION

In cases of complicated airway foreign bodies, such as thumbtacks, airway dilation is a useful and safe maneuver that may help facilitate removal.

A potentially fatal complication that may occur during dental treatment: "foreign body aspiration"

Numerous systemic emergency situations, such as hypotension or allergic reactions, may be encountered during dental treatment. In addition, rare but life-threatening complications such as foreign body aspiration in the air passages may also be seen. Aspirated foreign bodies include teeth, implants, mechanical supports or materials used during procedures. We report two separate cases of aspiration risk developing during the course of dental treatment.

Ear, nose and throat foreign bodies: the experience of the Pediatric Hospital of Turin

AIM

Ear, nose and throat (ENT) foreign body (FB) injuries represent an emerging problem in the paediatric population because of their human and social costs. The aim of the study is the site-specific evaluation of FB injuries in the paediatric population referred to the emergency department of the Pediatric Hospital of Turin.

METHODS

This retrospective analysis was carried out sifting medical reports between 2002 and 2011. We collected information about 338 patients' FB characteristics, complications and hospitalisation.

RESULTS

The mean age was 4.2 ± 2.9 years. Nose and ear are the most involved anatomical sites, followed by pharynx, oesophagus and trachea-bronchi. The most common FBs are balls, beads and toys parts (29.6%), followed by fishbones (13.6%). A lower mean age is observed in tracheo-bronchial and oesophageal FBs. The 9.2% of cases reported complications.

CONCLUSIONS

A quick and proper diagnosis followed by an effective treatment of FB injuries and their complication is mandatory. Surveillance registries have a key role in prevention and management of FB injuries; useful information can be obtained also for nurse and ENT specialist training in order to create professionals ready to recognise and manage FB injuries in the most effective way.

Real-time video-assisted retrieval of airway foreign body in very young pediatric patients

Objectives

Advancements in medical endoscopy and techniques of rigid bronchoscopy for foreign body removal have enabled higher diagnostic accuracy, reduced morbidity and precise manipulation. However, in pediatric patients, endoscope-combined forceps may be too big to fit into the small sized airway. Here we present our method of endoscope assisted rigid bronchoscopy in pediatric patients and compare the clinical benefits with conventional naked-eye rigid bronchoscopy.

Methods

We used a 2.7 mm, 0° straight endoscope and small caliber grasping forceps with 3.0 to 4.5 mm sized rigid bronchoscopy for very young (<3 years of age) patients of foreign body aspiration. As an assistant held the rigid bronchoscope in situ, the operator could manipulate the endoscope and forceps bimanually. With endoscopic guidance, the foreign body retrieval was performed carefully. The clinical advantages were compared between our endoscope-assisted method (n=29) and the conventional bronchoscopy method (n=33) in terms of operation time and recovery (hospital stay).

Results

Bimanual endoscope-assisted rigid bronchoscopy method was technically feasible and safe. The operation time was less, compared to the conventional technique and the patients recovered more quickly. In all cases, our method completely removed the foreign body without need of a second bronchoscopy procedure.

Conclusion

Bimanual endoscope-assisted retrieval of airway foreign body in very young age pediatric patients was superior to the conventional naked-eye method concerning accurate manipulation and safety.

A retrospective study of anesthesia during rigid bronchoscopy for airway foreign body removal in children: propofol and sevoflurane with spontaneous ventilation

BACKGROUND

Tracheobronchial foreign body aspiration is a significant cause of childhood morbidity and mortality. We analyzed our experience in management of aspirated foreign bodies, including methods of anesthesia used, over a 4-year period.

METHODS

We retrospectively reviewed the records of tracheobronchial foreign body removal by rigid bronchoscopy with spontaneous ventilation in 435 children. All patients had received initial anesthesia with inhaled sevoflurane. One hundred and ninety-seven patients (Group PropRemi) then received intravenous propofol and remifentanyl for maintenance of anesthesia; the remaining 238 patients (Group PropSevo) received propofol and sevoflurane.

RESULTS

Tracheobronchial foreign body was found in 405 children (93.1%) and successfully removed from 402 (99.3%) children. Among three patients who failed bronchoscopy, one child suffered cardiac arrest and died during the bronchoscopy, and two required subsequent tracheotomy for foreign body removal. Adverse effects (intraoperative coughing, breath holding, body movement, bronchospasm, and laryngospasm) were significantly more frequent in Group PropRemi than in Group PropSevo. No complications such as bleeding, pneumothorax, pneumomediastinum, or the need for thoracotomy were encountered.

CONCLUSION

Sevoflurane induction followed by a combination of sevoflurane and continuous infusion of propofol resulted in fewer adverse events than sevoflurane induction followed by TIVA with propofol and remifentanyl during rigid bronchoscopy for airway foreign body removal in children with spontaneous ventilation.

Controlled ventilation or spontaneous respiration in anesthesia for tracheobronchial foreign body removal: a meta-analysis

BACKGROUND

Either controlled ventilation or spontaneous respiration is commonly used in general anesthesia for inhaled foreign body removal via rigid bronchoscopy. Controversy in the literature exists concerning which form of ventilation is optimally suited for bronchoscopy. We performed a meta-analysis to compare controlled ventilation and spontaneous respiration with respect to complications, operation time, and anesthesia recovery time.

METHODS

We searched MEDLINE (1946-2013) and the Cochrane Central Register of Controlled Trials, EMBASE. The articles were evaluated for validity, and the data on complications, including desaturation, laryngospasm, laryngeal edema, bucking and coughing, body movement, breath holding, operation time, and anesthesia recovery time, were extracted by the authors and summarized using odds ratios, mean differences, and 95% confidence intervals (CIs).

RESULTS

From the included studies, 423 subjects received controlled ventilation, whereas 441 subjects received spontaneous respiration. There was no significant difference in the incidence of desaturation between controlled ventilation and spontaneous respiration (odds ratio, 0.70; 95% CI, 0.30-1.63). However, the incidence of laryngospasm was lower when controlled ventilation was performed (OR, 0.27; 95% CI, 0.10-0.76). The operation time (mean difference, -9.07 min; 95% CI, -14.03 to -4.12) was shorter in the controlled ventilation group.

CONCLUSIONS

Current evidence does not show a preference for either controlled ventilation or spontaneous respiration, although laryngospasm has a lower incidence when controlled ventilation is performed. Additional clinical studies are required to substantiate this issue.