Foreign Body Inhalation in the Adult Population: Experience of 25,998 Bronchoscopies and Systematic Review of the Literature

Global, regional, and national assessment of foreign body aspiration (1990-2021): novel insights into incidence, mortality, and disability-adjusted life years

BACKGROUND

Foreign body aspiration (FBA) is a preventable yet underrecognized global health challenge, contributing to substantial clinical and economic burdens. Comprehensive and comparable analyses of FBA trends across diverse populations and socioeconomic contexts remain limited. Leveraging data from the 2021 Global Burden of Disease (GBD) Study, we provide an in-depth global, regional, and national analysis of FBA trends over the past three decades, including the first evaluation of disability-adjusted life years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs).

METHODS

We examined FBA incidence, mortality, and disease burden across regions, nations, ages, sexes, and Socio Demographic Index (SDI) levels from 1990 to 2021, calculating age-standardized incidence (ASIR) and death (ASDR) rates, as well as estimated annual percentage changes (EAPCs).

RESULTS

Globally, FBA incidence declined by 35.3% between 1990 and 2021 (EAPC: -2.02; 95% CI: -2.13 to -1.91), with marked reductions among children under 5 years of age. Nonetheless, total FBA-related deaths rose slightly from 99,329 (95% UI: 80,764-112,381) in 1990 to 103,915 (95% UI: 82,081-113,555) in 2021. While many regions showed improvement, countries such as Italy, Georgia, and Zimbabwe recorded increases in ASIRs. In 2021, children under 5 remained at highest risk of morbidity, while older adults (≥ 70 years), especially in high-income Asia Pacific and Western Europe, showed elevated mortality. Notably, younger children achieved substantial decreases in incidence, death, and DALYs, yet older populations faced modest rises in mortality and DALYs. Higher-SDI regions reported the greatest morbidity and mortality, and high-middle SDI regions exhibited the highest DALYs, YLLs, and YLDs, reflecting the influence of socioeconomic development on FBA burden.

CONCLUSIONS

Global FBA incidence declined from 1990 to 2021, yet the number of associated deaths continued to rise, indicating ongoing challenges in prevention and management. High- and middle-high SDI regions carried the greatest burden, with children under 5 and older adults (≥ 70 years) particularly affected. These patterns suggest that both advancing socioeconomic development and population aging influence FBA outcomes. Strengthening surveillance, improving emergency response, and implementing targeted, population-specific prevention strategies are essential for reducing the global FBA burden.

Navigating Challenges in Adult Airway Foreign Body Extraction: Retrospective Insights From Flexible Bronchoscopy

Background Airway foreign body aspiration is an emergency predominantly observed in children and the elderly. However, it also occurs in adults, presenting with a variety of symptoms. Both rigid and flexible bronchoscopies are employed for foreign body retrieval. In this context, we share our experience with foreign body extraction using flexible bronchoscopy in adult patients.  Methods  We conducted a retrospective study from January 2018 to August 2019 in the bronchoscopy suite of our institute's Department of Pulmonary Medicine. This study centered on the total bronchoscopies performed, the cases where foreign bodies were visualized, the location of these bodies, the techniques used for their retrieval, and the associated complications.  Results  In this retrospective analysis of 510 bronchoscopic procedures, 7.6% (n = 39) were conducted for the suspicion of foreign body aspiration. Foreign bodies were detected in 2.1% (n = 11) of these cases. The mean age of the patients was 44.27 ± 17.3 years, with 63.6% (n = 7) being male. Organically derived materials constituted the majority of the retrieved foreign bodies, accounting for 91% (n = 10) of cases. Flexible bronchoscopy facilitated the successful extraction of foreign bodies in 72.7% (n = 8) of these instances, albeit with some complications noted during the procedures. Conclusions  Diagnosis and management of airway foreign body aspiration in adults demand keen vigilance. Flexible bronchoscopy has showcased its effectiveness in foreign body extraction, highlighting its role as a primary intervention tool. Typically, a combination of extraction tools is utilized to remove airway foreign bodies.

Is There a Role for Bronchoscopy in Aspiration Pneumonia?

Aspiration represents the passage of oropharyngeal content to the lower respiratory tract. The interplay between the host and the aspirate proprieties determines the subsequent aspiration syndrome. A low pH, typical of gastric aspirate, favors chemical pneumonitis, whereas an increased bacterial inoculum causes aspiration pneumonia. About a quarter of patients with aspiration pneumonitis will develop a bacterial superinfection during the course of recovery. While antibiotic therapy is indicated for aspiration pneumonia, supportive care remains the cornerstone of treatment in aspiration pneumonitis. However, the overlapping clinical features of these syndromes lead to initiation of antimicrobial therapy in most cases of aspiration. Bronchoscopy can aid in clinical decision-making by direct airway visualization and also by providing access to a series of emerging biomarkers. Invasive microbiological studies increase diagnostic yield and enable a tailored antibiotic treatment. In conjunction with stewardship programs, invasive sampling and novel molecular diagnostics can decrease the amount of inappropriate antibiotic therapy. In the context of foreign body aspiration, bronchoscopy represents both diagnostic and treatment gold standard.

Chronic cough and noisy breathing: An 11-year journey to diagnosis and successful treatment

Foreign body aspiration in an uncommon entity in adults which often leads to delays in diagnosis. Adults with long-standing foreign bodies in the airway can result in various complications including bronchiectasis, atelectasis and lung fibrosis. We describe the case of a primary school teacher who was diagnosed with foreign body aspiration 11 years after the aspiration event. Delays in diagnosis led to her receiving multiple doses of antibiotics including a course of antituberculous therapy.

Unexpected spontaneous expectoration of a grass bur: A case report

Adult foreign body aspiration is rare and represents only 15%-25% of all foreign body aspirations and 1 in 400 bronchoscopy procedures. Typically, adults present non-emergently and exhibit non-specific symptoms, which makes the diagnosis of foreign body aspiration especially difficult when a history of aspiration cannot be elicited. We present a 63-year-old male with a past medical history of chronic obstructive pulmonary disease hospitalized for left thoracic empyema caused by the aspiration of a grass bur. Our patient did not recall the aspiration event and the diagnosis was further obfuscated by a lack of radiographic evidence and other distracting disease processes. Thus, this case exemplifies the rationale for maintaining a suspicion of foreign body aspiration even for patients with little historical or radiographic evidence to support the presence of a foreign body. This is particularly salient for patients with a tumultuous hospital course or those who fail to respond to treatment.

Evaluation of the Quality and Readability of Web-Based Information Regarding Foreign Bodies of the Ear, Nose, and Throat: Qualitative Content Analysis

BACKGROUND

Foreign body (FB) inhalation, ingestion, and insertion account for 11% of emergency admissions for ear, nose, and throat conditions. Children are disproportionately affected, and urgent intervention may be needed to maintain airway patency and prevent blood vessel occlusion. High-quality, readable online information could help reduce poor outcomes from FBs.

OBJECTIVE

We aim to evaluate the quality and readability of available online health information relating to FBs.

METHODS

In total, 6 search phrases were queried using the Google search engine. For each search term, the first 30 results were captured. Websites in the English language and displaying health information were included. The provider and country of origin were recorded. The modified 36-item Ensuring Quality Information for Patients tool was used to assess information quality. Readability was assessed using a combination of tools: Flesch Reading Ease score, Flesch-Kincaid Grade Level, Gunning-Fog Index, and Simple Measure of Gobbledygook.

RESULTS

After the removal of duplicates, 73 websites were assessed, with the majority originating from the United States (n=46, 63%). Overall, the quality of the content was of moderate quality, with a median Ensuring Quality Information for Patients score of 21 (IQR 18-25, maximum 29) out of a maximum possible score of 36. Precautionary measures were not mentioned on 41% (n=30) of websites and 30% (n=22) did not identify disk batteries as a risky FB. Red flags necessitating urgent care were identified on 95% (n=69) of websites, with 89% (n=65) advising patients to seek medical attention and 38% (n=28) advising on safe FB removal. Readability scores (Flesch Reading Ease score=12.4, Flesch-Kincaid Grade Level=6.2, Gunning-Fog Index=6.5, and Simple Measure of Gobbledygook=5.9 years) showed most websites (56%) were below the recommended sixth-grade level.

CONCLUSIONS

The current quality and readability of information regarding FBs is inadequate. More than half of the websites were above the recommended sixth-grade reading level, and important information regarding high-risk FBs such as disk batteries and magnets was frequently excluded. Strategies should be developed to improve access to high-quality information that informs patients and parents about risks and when to seek medical help. Strategies to promote high-quality websites in search results also have the potential to improve outcomes.

A pea in a peculiar place: Unusual case of left upper lobe bronchial foreign body

Key Clinical Message

Foreign body aspiration is common in old age, sometimes lodged in unusual locations like the left upper lobe bronchus when aspiration happens in a recumbent position. Computed tomography is the preferred diagnostic tool, while flexible bronchoscopy is effective for removing the foreign body.

Abstract

Tracheo-bronchial foreign body aspiration (FBA) is common in children and elderly, but often goes unnoticed due to vague symptoms and atypical imaging findings. We present a case of aspiration of pea in elderly presenting with acute symptoms. Computed tomography (CT) reveled an atypical site of foreign body (FB), that is left upper lobe bronchus and immediate removal of the FB was done using a flexible bronchoscope. The symptoms subsided after removal of the FB. Missed FBs can lead to chronic issues like pneumonia and airway obstruction. Advanced age, psychiatric illness, stroke, seizure disorder, and neuromuscular disease increase the risk of aspiration in older adults. Commonly, FBs get lodged in the right middle and lower lobes after aspiration due to vertical orientation of the airways. CT is a helpful tool for diagnosis of FBA and flexible bronchoscopy is effective in removal of the FB in elderly.

Usefulness of net retrieval devices for central airway obstruction caused by blood clots during extracorporeal membrane oxygenation: Case series

RATIONALE

Extracorporeal membrane oxygenation (ECMO) is the last trump card for severe respiratory failure. The main complications of ECMO are bleeding and thrombosis, both of which can be life-threatening. Large blood clots can cause central airway obstruction (CAO) during ECMO, and CAO should be removed as soon as possible because of asphyxiation. However, there is no comprehensive reports on its frequency and management. The purpose of this study is to share therapeutic experiences for rare and serious conditions and provide valuable insights.

PATIENT CONCERNS

We report 3 patients placed on ECMO for severe respiratory failure.

DIAGNOSIS

CAO due to large blood clots occurred during ECMO in all 3 patients.

INTERVENTIONS

Large blood clots were removed using flexible bronchoscopy, grasping forceps, and net retrieval devices in all 3 patients.

OUTCOMES

In all 3 patients, large blood clots were removed multiple times during ECMO. The patients' respiratory conditions improved and they were eventually weaned off the ECMO.

LESSONS

CAO due to large blood clots during ECMO is rare. The frequency of CAO requiring bronchoscopic removal was estimated to be approximately 1,5%. When this occurs, clots should be removed as soon as possible. Net retrieval devices are useful tools for the collection of large blood clots.

Lost and Found: A Case Report of the Journey of Two Teeth Into the Bronchus After a Road Tragedy

Traumatic foreign body aspiration (FBA) in adults is a rare yet potentially life-threatening event that requires prompt recognition and management to prevent adverse outcomes. While less common in adults compared to paediatric populations, traumatic FBA incidents often occur in occupational settings, post-trauma, or during high-risk activities, presenting with acute respiratory symptoms and varying degrees of airway obstruction. Diagnosis can be challenging due to the lack of classic symptoms and the potential for delayed presentation, necessitating a thorough history, a focused physical examination, and appropriate imaging techniques such as computed tomography (CT) and bronchoscopy. Prompt intervention is crucial to mitigating complications such as airway obstruction, pneumothorax, and respiratory compromise. Here, we describe an interesting case of a patient with a road traffic accident who aspirated two teeth and thought he lost them in this process. Surprisingly, two lost teeth were found after undergoing diagnostic procedures for mild shortness of breath, further causing aspiration pneumonitis.

CT Characteristics and Clinical Findings of Bronchopneumonia Caused by Pepper Aspiration

Purpose

To explore the computed tomography (CT) features of bronchopneumonia caused by pepper aspiration to improve the diagnosis.

Materials and Methods

28 adult patients diagnosed with obstructive pneumonia caused by pepper aspiration from January 2016 to September 2022 were enrolled. The CT characteristics of bronchial changes and pulmonary lesions caused by pepper were analyzed and summarized.

Results

Among 28 patients, the most common symptom was cough (26, 92.9%), followed by expectoration (23, 82.1%). Bronchoscopy revealed that peppers were mainly found in the bronchus of the right lower lobe (n = 18, 64.3%), followed by the bronchus of the left lower lobe (n = 5, 17.9%). In combination with bronchoscopy results, the pepper in the bronchus manifested as circular or V/U-shaped high-density, localized soft tissue, and flocculent opacification in 8 (28.6%), 16 (57.1%), and 3 (10.7%) cases on CT images, respectively. The bronchial wall around the pepper was thickened with localized occlusion (n = 19, 67.9%) and stenosis (n = 9, 32.1%). Regarding adjacent bronchi without peppers, extensive wall thickening with stenosis and/or occlusion was found in 23 (82.1%) cases. Distal pulmonary lesions frequently involved two or three segments (21, 75.0%) and mainly presented as patchy consolidation or atelectasis (24, 85.7%).

Conclusion

In combination to a history of eating peppers and clinical symptoms, bronchopneumonia caused by pepper should be highly suspected if U/V-shaped and annular high-density or localized soft tissue density is detected in the bronchi of the lower lobes, accompanied by extensive bronchial wall thickening, stenosis, or occlusion, and consolidation or atelectasis in multiple distal lung segments.

Artificial intelligence in the detection of non-biological materials

Artificial Intelligence (AI) has emerged as a transformative force within medical imaging, making significant strides within emergency radiology. Presently, there is a strong reliance on radiologists to accurately diagnose and characterize foreign bodies in a timely fashion, a task that can be readily augmented with AI tools. This article will first explore the most common clinical scenarios involving foreign bodies, such as retained surgical instruments, open and penetrating injuries, catheter and tube malposition, and foreign body ingestion and aspiration. By initially exploring the existing imaging techniques employed for diagnosing these conditions, the potential role of AI in detecting non-biological materials can be better elucidated. Yet, the heterogeneous nature of foreign bodies and limited data availability complicates the development of computer-aided detection models. Despite these challenges, integrating AI can potentially decrease radiologist workload, enhance diagnostic accuracy, and improve patient outcomes.

An Unusual Case Report of a Foreign Body (Fish Bone) in the Trachea

Tracheobronchial foreign body aspiration is a rare yet potentially life-threatening occurrence in adults, presenting with symptoms ranging from acute asphyxiation to coughing, breathlessness, or choking. These symptoms can be inconsistent and mimic chronic lung conditions like asthma or chronic obstructive pulmonary disease. Chest X-rays and computed tomography scans are valuable for diagnosing and locating the foreign body. However, bronchoscopy is the primary method for diagnosis and management. This case study describes a unique incident involving a fish bone lodged in the mid-trachea, emphasizing the critical importance of timely recognition and intervention.

Successful Removal of a Foreign Body Located in the Peripheral Airway Using Flexible Bronchoscopy with Virtual Bronchoscopy Navigation

A case in which a foreign body located in the peripheral airway of the lung was removed by flexible bronchoscopy using a virtual bronchoscopy navigation (VBN) system has been reported. The patient was a 60-year-old man. Chest radiography revealed an incidental foreign body in the left lower lung. Chest computed tomography with 1.0-mm slices was used to create a VBN system and confirm the foreign body in left B9biiαy, which was removed by flexible bronchoscopy. Thus, peripheral foreign bodies can be safely removed using flexible bronchoscopy by creating a VBN system in advance.

Removal of airway foreign body using flexible bronchoscopy in children

BACKGROUND

Flexible bronchoscopy is mainly used to diagnose airway foreign bodies (AFBs). Due to advances in pediatric anesthesia, many teams have considered the extraction of AFBs by flexible bronchoscopy. We aimed to assess the success of flexible bronchoscopy in AFB removal in children.

PATIENTS AND METHODS

We analyzed retrospectively the data of children admitted for AFB aspiration in the Pediatric Respiratory Diseases Department B of Abderrahmane Mami Hospital in Tunisia between January 2012 and December 2022. AFB removal was performed by flexible bronchoscopy through the use of a laryngeal mask airway (LMA) or intubation.

RESULTS

Of the 105 children included, AFB was removed by flexible bronchoscopy in 99 children (94.3 %). The mean age of the children was 32 months (9-150 months) with a sex ratio of 2:3. The foreign body was organic in 67 % of cases. Overall, 37 children underwent rigid bronchoscopy first (35.2 %). Flexible bronchoscopy was performed through the LMA in 77 cases (73 %) and after intubation in the other cases. Thoracic surgery was needed in two cases (1.9 %). Four infants expectorated the AFB after the procedure (3.8 %). Only two children developed laryngeal edema with transient oxygen desaturation.

CONCLUSION

AFB removal using a flexible bronchoscope is an efficient and safe procedure when performed by an experienced team. The recent use of LMA has facilitated the use of a larger bronchofiberscope and the insertion of multiple tools that can reach distal airways.

Foreign Body in the Tracheobronchial Tree as a Cause of Hemoptysis in an Adult Without Risk Factors for Aspiration: A Case Report

Although aspiration of a foreign body into the trachea and bronchi can occur in all age groups, it is more common in infants and young children. Foreign bodies in the tracheobronchial tree are uncommon in adults and mainly present in patients with dysphagia and an altered level of consciousness. The identification of foreign bodies in the tracheobronchial tree is frequently overlooked or delayed, leading patients to present later with chronic symptoms and potential complications. These complications may include persistent coughing, wheezing, obstructive pneumonitis, bronchiectasis, and abscess formation secondary to recurrent pulmonary infections. This article aims to present the case of a 27-year-old patient without risk factors for aspiration who has experienced recurrent self-limiting hemoptysis episodes for five years. Bronchoscopy revealed a foreign body at the entrance to the middle lobe bronchus. The presence of a foreign body in the tracheobronchial tree should be considered in any patient with recurrent hemoptysis. Bronchoscopy leads to accurate diagnosis, treatment, and prevention of complications.

Saviour tool now a foreign body

ABSTRACT

Foreign bodies are commonly seen in children, here presenting a case of a male adult with an impacted thumb pin in the left lower lobe bronchus. Extraction required fiber-optic bronchoscopy, failure of which led to thoracotomy with bronchotomy.

Development of organized pleural empyema as a result of occult foreign body aspiration

Foreign body (FB) aspiration is a rare incident in adults. Many patients cannot recall the episode of aspiration and are hospitalized with complications of an endobronchial FB.

Analysis of 108 flexible bronchoscopies for the removal of foreign bodies from the airways

OBJECTIVE

To describe the clinical, bronchoscopic, diagnostic, and therapeutic aspects between children and adults.

METHODS

This retrospective study compared the clinical and bronchoscopic characteristics of adults and children who underwent bronchoscopy for suspected foreign body aspiration. Data on sex, outpatient or emergency origin, bronchoscopy results, characteristics of the aspirated foreign body, and complications were analyzed.

RESULTS

In total, 108 patients were included in the analysis, with foreign body aspiration diagnosed in 69% of patients (30 children and 44 adults). In 91% of patients, there was a clinical history suggestive of aspiration. The mean age of the adults was 65.89 (±19.75) years, and that of the children was 2.28 (±1.78) years. Most of the children were under 3 years of age (80%), while adults were mostly 70 years of age or older (54.5%). Emergency care was more common among children than adults. The most common foreign bodies found in both age groups were organic bodies, primarily seeds. The most frequent locations of foreign bodies were the lobar bronchi in adults and the main bronchi in children. Flexible bronchoscopy is the primary method for diagnosis and treatment. Transient hypoxemia occurred particularly frequently in children (5%).

CONCLUSION

Foreign body aspiration, particularly that involving seeds, is more common in the extremes of age. A clinical history suggestive of aspiration is crucial in determining the need for bronchoscopy, which should be performed as early as possible. Flexible bronchoscopy is an effective and safe diagnostic technique.

Clove stalk aspiration: An unusual cause of chronic cough

Foreign body aspiration in adults is one of the uncommon causes of chronic cough and may be missed if the patient already has a known cause of chronic cough, but the same is not responding to therapy. A 72-year-old male patient, a known case of allergic rhinitis, presented with a history of cough for 6 months. There was unsatisfactory response to treatment with antibiotics, inhalational corticosteroids, oral corticosteroids, bronchodilators, and antireflux treatment. High-resolution computed tomography was normal. However, fiber optic bronchoscopy revealed a foreign body in the right lower lobe, which was removed and was identified as clove stalk. This led to rapid relief of symptoms. Clove stalk aspiration is an unusual foreign body causing chronic cough, which has not yet been reported.

Stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities on CT

High-attenuation pulmonary abnormalities are commonly seen on CT. These findings are increasingly encountered with the growing number of CT examinations and the wide availability of thin-slice images. The abnormalities include benign lesions, such as infectious granulomatous diseases and metabolic diseases, and malignant tumors, such as lung cancers and metastatic tumors. Due to the wide spectrum of diseases, the proper diagnosis of high-attenuation abnormalities can be challenging. The assessment of these abnormal findings requires scrutiny, and the treatment is imperative. Our proposed stepwise diagnostic algorithm consists of five steps. Step 1: Establish the presence or absence of metallic artifacts. Step 2: Identify associated nodular or mass-like soft tissue components. Step 3: Establish the presence of solitary or multiple lesions if identified in Step 2. Step 4: Ascertain the predominant distribution in the upper or lower lungs if not identified in Step 2. Step 5: Identify the morphological pattern, such as linear, consolidation, nodular, or micronodular if not identified in Step 4. These five steps to diagnosing high-attenuation abnormalities subdivide the lesions into nine categories. This stepwise radiologic diagnostic approach could help to narrow the differential diagnosis for various pulmonary high-attenuation abnormalities and to achieve a precise diagnosis.Critical relevance statement Our proposed stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities may help to recognize a variety of those high-attenuation findings, to determine whether the associated diseases require further investigation, and to guide appropriate patient management. Key points • To provide a stepwise diagnostic approach to high-attenuation pulmonary abnormalities.• To familiarize radiologists with the varying cause of high-attenuation pulmonary abnormalities.• To recognize which high-attenuation abnormalities require scrutiny and prompt treatment.

Uncapped Metered-Dose Inhalers: A Risk for Foreign Body Aspiration. A Case Report and Review of the Literature

The risk of foreign body aspiration associated with uncapped handheld metered-dose inhalers (MDIs) is underestimated. We report a case in which a plastic cable clip accidentally lodged in the mouthpiece of an uncapped pressurized MDI was aspirated during its use. A literature search revealed 16 other cases of foreign body aspiration associated with uncapped handheld inhalers, all but one of which were pressurized inhalers. Patients should be informed of the risk of foreign body aspiration associated with uncapped pocket inhalers. The use of an uncuffed armoured tracheal tube with a separate oxygen tubing during flexible bronchoscopy for foreign body removal ensures a safe airway. Foreign bodies that exceed the lumen size of the tracheal tube can be pulled to the distal opening with forceps and removed when the tube is withdrawn.

Accidental ingestion of a dental object during a periodontal surgical procedure on an IV sedated patient: Case management

INTRODUCTION

Foreign-body aspiration (FBA) and ingestion (FBI) are rare but serious events that occur in dental offices throughout the world every year. Such events can have significant medical, legal, and financial consequences for both the dental clinician and the patient. By presenting this case study, we aim to highlight the proper management and possible sequelae of such an event.

METHODS AND RESULTS

A 72-year-old woman underwent a dental procedure with intravenous sedation. In the process of dental treatment, a dental bur was accidentally ingested. The patient was promptly referred to an urgent care clinic, where serial abdominal radiographs were taken over several days to track the course of the bur through the digestive system. The bur was successfully removed without complication.

CONCLUSION

Prompt management and referral of dental FBA and FBI cases, followed by successful object retrieval, lead to uncomplicated resolution of the event.

KEY POINTS

Why is this case new information? This case presents the proper management of the FBA and FBI, particularly for IV sedated patients who require immediate action to mitigate and prevent serious complications. What are the keys to the successful management of this case and how can the risk of FBA and FBI be mitigated? The use of throat packs or rubber dams helps prevent foreign body aspiration and ingestion. Attaching floss to appliances and objects when appliances are used intraorally. (Specifically, to implant guide pins and implant screwdrivers.) Thorough isolation of the oropharynx from the mouth using a barrier, such as a gauze pad or rubber dam, during bracket placement, orthodontic appliance adjustment, and screwing or cementing of implant crowns Short and extra short implants should be connected by ligature to the implant handpiece. What are the primary limitations to success in this case? Lack of a throat pack Failure to confirm connection of bur to handpiece Patient's anatomy (redundant colon) preventing natural expulsion of the bur.

Extraction of large foreign bodies from the airway by gastrointestinal endoscopy

Foreign body aspiration is a worldwide health problem that often results in life-threatening complications. Although flexible bronchoscopy is a safe procedure for removal of foreign bodies, it is usually unsuccessful in removing large foreign bodies from the airway. Gastrointestinal (GI) endoscopy, which is frequently used to remove foreign bodies from the gastrointestinal tract, has not been reported for retrieval of airway foreign bodies. In this report, we described three successful cases of removal of large airway foreign bodies by GI endoscopy. To avoid rigid bronchoscopy, GI endoscopy can be considered if flexible bronchoscopy has failed to remove a large or heavy airway foreign body in adult patients.

Flexible Bronchoscopy Combined With an Airway Maneuver for Foreign Material Removal Under Invasive Mechanical Ventilation

We present a case of a patient who had aspirated a massive amount of food, leading to cardiac arrest, and had to be intubated because of severe hypoxemia. The hypoxemia persisted, regardless of the recruitment maneuvers, performance of flexible bronchoscopy, and suctioning through the ventilating tube, because we were unable to reach the left main bronchus (LMB), where the greatest amount was concentrated. However, we managed to overcome this problem by using a prototype handling technique to catheterize the LMB directly with the usage of the flexible bronchoscope. We introduce this handling technique for the removal of foreign material from the LMB, which will probably be really useful in emergency situations, because of its simplicity and effectiveness.

Unsolicited ejection of an aspirated metallic foreign body in an adult male: Rare case report

INTRODUCTION AND IMPORTANCE

Being an otorhinolaryngological emergency foreign body aspiration (FBA) has continued to be a great challenge to Otorhinolaryngologists. Foreign body inhalation poses life threatening challenges and its uncommon in adult unlike paediatric population. The recommended treatment for the aspirated foreign bodies is bronchoscopy. Unsolicited ejection of an aspirated foreign body is an uncommon encounter in clinical practice and few cases have been reported in the available literatures.

CASE PRESENTATION

A man aged 38-years was attended at the clinic with a history of inhaling a metallic foreign body a day prior visiting our hospital underwent unsolicited ejection following several bouts of dry irritating cough while preparations were in progress to send the patient to an operating theatre for emergency bronchoscopy coupled with removal of the foreign body.

CLINICAL DISCUSSION

The patient underwent unsolicited ejection of the metallic object following several episodes of dry cough and was then counseled to attend the scheduled follow up after 7-days and it was uneventful.

CONCLUSION

Despite being unsafe and not recommended to wait for unsolicited ejection of an aspirated foreign body, meticulous attention should be kept to patients while waiting for bronchoscopy since there are rare chances for unsolicited ejection of such aspirated foreign bodies.

G, SR K, S. R. Difficult Bronchoscopy and Foreign Body Removal: Our Experience

Background Foreign body in the airway is the most life-threatening situation. Most foreign bodies present as acute emergency and can be removed by endoscopy/bronchoscopy, while a few causes complication of a retained foreign body which requires emergency tracheostomy to secure airway followed by foreign body removal.

Case Presentation We report our experience in the management of three children who required tracheostomy through which bronchoscope was introduced and foreign body removed. All patients with unrecognized retained foreign body presented with respiratory distress with desaturation. Imaging was suggestive of atelectasis. After foreign body removal patients recovered well and decannulated by day 5.

Subglottis is the narrowest part of pediatric airway. As these foreign bodies were vegetative they are hygroscopic in nature and hence would not be able to remove the foreign body by bronchoscopic guidance. Hence, tracheostomy was done to provide access followed by bronchoscopic removal.

Conclusion Aspirated foreign body present challenges to the ear, nose, and throat surgeon. Newer techniques enable removal of foreign body easier. Tracheostomy combined with bronchoscopy can be a life-saving and easy to perform procedure which involves removal of foreign body at the same time.

Impression material lodged in the hypopharynx: A clinical report

Ingestion or aspiration of foreign objects may present as a significant complication with various common dental procedures. The most reported ingested or aspirated dental materials have included endodontic instruments and metal restorative and prosthetic materials, which can often be identified clinically and radiographically from their relative radiodensities. The authors present an unusual report of lodged impression material in the hypopharynx, which was not detectable radiographically.

Tracheobronchial tooth and dental prosthesis aspirations: 15 cases

BACKGROUND

Tracheobronchial foreign body is uncommon in adults. Among foreign body aspirations, tooth and dental prosthesis aspiration is a very rare condition. In the literature, dental aspiration is generally found as a case report and there is no single-center case series. In this study, we aimed to present our clinical experience in 15 cases with tooth and dental prosthesis aspiration.

METHODS

Data from 693 patients who presented to our hospital for foreign body aspiration between the years 2006 and 2022 were analyzed retrospectively. Fifteen cases who aspirated tooth and dental prostheses as foreign bodies were included in our study.

RESULTS

Foreign bodies were removed by rigid bronchoscopy in 12 (80%) cases and fiberoptic bronchoscopy in 2 (13.3%) cases. In one of our cases, foreign body was expected with cough.When evaluated in terms of foreign body, partial upper anterior tooth prosthesis in 5 (33.3%) cases, partial anterior lower tooth prosthesis in 2 (13.3%) cases, dental implant screw in 2 (13.3%) cases, lower molar crown in 1 (6.6%) case, lower jaw bridge prosthesis in 1(6.6%) case, upper jaw bridge prosthesis in 1(6.6%) case, broken tooth fragment in 1(6.6%) case, upper molar tooth crown coating in 1(6.6%) case and upper lateral incisor tooth in 1(6.6%) case were observed.

CONCLUSION

Dental aspirations can also occur in healthy adults. Anamnesis is the most important factor in diagnosis and diagnostic bronchoscopic procedures should be performed in cases where adequate anamnesis cannot be obtained.

Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting

BACKGROUND

Airway foreign body can be a life-threatening issue in pediatric and adult patients, and the majority of these patients will first present to the emergency department.

OBJECTIVE

This article provides a narrative review of the diagnosis and management of airway foreign bodies for the emergency clinician.

DISCUSSION

Foreign bodies in the upper and lower airways are potentially life threatening. This affects all age groups but is more common in pediatric patients. A history of a witnessed ingestion or aspiration event should raise the clinical suspicion for an aspirated foreign body. Patients with upper-airway foreign bodies are more likely to present in respiratory distress when compared with lower-airway foreign bodies, which often present with more subtle signs. Stridor, drooling, and wheezing suggest respiratory distress, but the presenting clinical picture is often unclear and may only include a cough. Immediate intervention is required in the patient with hemodynamic instability or respiratory distress. Airway management including laryngoscopy, fiberoptic bronchoscopy, and cricothyrotomy may be needed in these patients, with the emphasis on removing the obstructing foreign body and securing the airway. Specialist consultation can assist in retrieving the foreign body and managing the airway. If the patient is stable, imaging and specialist consultation for potential operating room intervention should be considered.

CONCLUSIONS

An understanding of the presentation, evaluation, and management of the patient with an airway foreign body is essential for emergency clinicians.

Surgical Emergencies in the ICU

Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.

Different Modalities Used in the Art of Managing Tracheobronchial Foreign Bodies

Introduction:

Foreign body aspiration is a commonly encountered and challenging emergency. Foreign body aspiration causes significant morbidity and mortality in the paediatric population. In adults, it is usually encountered in patients with impaired consciousness and in young females using pins to secure their veils. We aimed to analyse the incidence, type and site of foreign body, radiological presentation, complications and different modalities used in managing tracheobronchial foreign bodies (FBs).

Methods:

A prospective single centre cross-sectional study between December 2010 and December 2011 in the Department of Cardiothoracic Surgery at the University of Alexandria, Egypt.

Results:

Seventy-eight patients were included. The age of the patients ranged between 1.3 and 32 years, with a mean of 13.37± 7.67 years. Inorganic FBs were the most common aspirated FBs (66 patients, 84.62%). FBs were more frequently located in the left versus the right bronchial tree (44.9% vs. 43.6%). Rigid bronchoscopic extraction of foreign bodies was the most common modality of extraction and was seen in 60 patients (76.9%), followed by thoracotomy and postural drainage in eight patients each (10.3%). Complications were observed in 12 patients (15.4%). Most of the patients who presented with pin aspiration were teenagers (> 10 – 20 years) and adults (> 20 years). At the same time, nut aspiration was common in children below 10 years.

Conclusion:

The location of FBs in the tracheobronchial tree depends on the patient's age and physical position at the time of aspiration. Rigid bronchoscopy offers better manipulations inside a secured airway and is the preferred method for foreign body removal. If failed, then surgical extraction should be done as soon as possible.

Risk factors associated with radiolucent foreign body inhalation in adults: a 10-year retrospective cohort study

BACKGROUND

Foreign body aspiration (FBA) is a serious condition with high morbidity and mortality rates. Although chest radiography is generally the first radiologic modality used in diagnosis, a substantial percentage of foreign bodies are radiolucent in adults with diagnosis challenging.

METHODS

Retrospective review of adult patients with FBA diagnosed by flexible electronic bronchoscopy from 2012 to 2022 collecting demographics, history, hospital presentation, radiographic, and operative details. Risk factors associated with radiolucent foreign body inhalation in adults were explored using appropriate statistical methods.

RESULTS

Between 1 January 2012 and 1 January 2022, 114 adult patients diagnosed with FBA were enrolled. The median age of participants was 65 years (IQR 52-74). Multidetector computed tomography (MDCT) examinations identified 28 cases (25%) showing direct visualization of the foreign body (defined as the radiopaque group) and 86 cases (75%) in the radiolucent group. Multivariable stepwise linear regression analysis showed increased odds of radiolucent foreign body inhalation in adults associated with pneumonic patches in MDCT (OR 6.99; 95% CI 1.80-27.22; P = 0.005) and plants/meat foreign bodies (OR 6.17; 95% CI 1.12-33.96; P = 0.04). A witnessed choking history (OR 0.02; 95% CI 0-0.14; P < 0.001) was a protective factor of radiolucent foreign body inhalation in adults.

CONCLUSIONS

Unlike radiopaque FBA, in those presenting with a suspected radiolucent foreign body aspiration, the diagnosis is far more challenging. Risk factors such as lacking a choking history, non-resolving pneumonia (pneumonic patches) in MDCT findings, and plants/meat foreign bodies may help in the early diagnosis of radiolucent foreign body inhalation in adults. Further prospective multicenter studies should be conducted to validate the findings.

Foreign-body aspiration into the lower airways in adults; multicenter study

Background

Foreign-body aspiration is common in children aged 6 months to 3 years. However, with the aging population and increasing prevalence of disabilities such as hemiparesis and neuromuscular diseases in adults, an increased incidence of aspiration is expected.

Methods

This was a multicenter retrospective, observational study in four major referral hospitals in Daegu, South Korea, between 2000 and 2019. We included patients aged over 18 years who were evaluated for tracheobronchial foreign-body aspiration by flexible bronchoscopy. Comorbidities, type and location of foreign body, and radiologic findings were recorded.

Results

Of 138 patients who underwent flexible bronchoscopy for tracheobronchial foreign body aspiration, 91 (65.9%) were men; the mean age was 66.3 (range: 29–87) years. A history of definite choking was present in 60 (43.5%) patients. The most common site of the foreign body was the right bronchus intermedius (27.5%). The most common type of aspirated foreign body was teeth (37.7%), followed by chicken bone (15.2%), nuts (14.5%) and fish bone (9.4%). Iatrogenic events accounted for 37.0% of the cases of aspiration, and the foreign body was successfully removed by flexible bronchoscopy in 91.3% of cases.

Conclusion

Foreign-body aspiration is not rare, even in adults who do not have predisposing factors. Iatrogenic events accounted for about 40% of all cases of foreign body aspiration. In adults, flexible bronchoscopy is relatively safe and has a high success rate for foreign-body removal.

Concealed Foreign Body Shrouding Airway Mimicking Mass Causing Extubation Failure, Hypoxia, and Stridor

Foreign body (FB) aspiration can present with acute life-threatening asphyxiation to recurrent infections with lung damage. Although most esophageal FBs pass spontaneously, sharp ones can get embedded requiring treatment. Tracheobronchial FBs and hypopharyngeal FBs are occasionally seen as well. We present a case of an oropharyngeal FB presenting with signs of stroke, pulmonary embolism, pulseless, and causing airway compression and extubation failure. Old age and neurocognitive disability are important predisposing factors of FB airway obstruction (FBAO), with food being the most common cause. The classic triad of cough, dyspnea, and cyanosis is seen in only a small percentage of patients with FBAO. Laryngeal edema, soft tissue collapse, and laryngospasm are among the common causes of upper airway obstruction and extubation failure. Laryngeal traumatism that can occur during emergency intubations can cause post-extubation stridor that can be treated with corticosteroids. Dentures and blood have been reported to cause post-extubation complications but oropharyngeal FB causing airway compression and leading to extubation failure has not been reported before. We recommend FB to be considered in the differential diagnosis of immediate hypoxia and extubation failure regardless of the history of a witnessed aspiration event as it is an easily fixable cause and can be missed in the initial history of presentation. A high degree of suspicion for this should be maintained as it is easy to miss. Computed tomography of the neck can aid in the diagnosis.

An unusual tracheal foreign body residing for 15 years: A case report and review of literature

Airway foreign bodies are common in children, and usually present as emergencies. However, they may sometimes present late, due to a number of reasons. Chronic lodgement of foreign bodies in trachea is rarer than that in bronchial tree. Flexible and rigid bronchoscopies have revolutionized the management of foreign bodies at large. Here, we report a successful bronchoscopic management of an unusual foreign body residing in the trachea of a patient for 15 years.

Accidental Foreign Body Aspiration Through Tracheostomy Inlet; 26 cases

BACKGROUND

Foreign body aspiration from tracheostomy is very rare, and materials related to tracheostomy are usually aspirated. This condition, which can lead to serious complications, can be treated using bronchoscopic procedures. In this study, we aimed to present our clinical experience in foreign body aspiration via tracheostomy.

METHODS

Data from 26 patients who presented to our hospital for foreign body aspiration via tracheostomy from 2006 to 2020 were analyzed retrospectively.

RESULTS

Foreign bodies were removed by fiber optic bronchoscopy in 15 (57.7%) cases, by rigid bronchoscopy in 9 (34.6%) cases and both methods were used in 2 (7.7%) cases. During bronchoscopy, local anesthetic procedures were used in 13 (50%) cases and general anesthesia was used in 11 (42.3%) cases. No anesthesia was used in two (7.7%) patients who underwent bronchoscopy under intensive care conditions. While the mean operative time for flexible bronchoscopy was 8.77±0.83 (CI: 26.03-29.43) minutes, the mean operative time for rigid bronchoscopy was 27.73±2.53 (CI: 26.03-29.43) minutes.

CONCLUSION

Both rigid bronchoscopy and fiberoptic bronchoscopy (FOB) have advantages and disadvantages in foreign body removal. In our opinion, it is more reasonable to perform fiber optic bronchoscopy first in patients with a tracheostoma. In the light of our experiences, fiber optic bronchoscopy does not require general anesthesia and the operation time is shorter than rigid bronchoscopy. This feature makes fiber optic bronchoscopy advantageous.

Impacted gutkha presenting as an intrabronchial mass lesion leading to post-obstructive pneumonia

A 66-year-old man presented with a chief complaint of difficulty breathing and productive cough. CT scan of the chest revealed an endobronchial mass with associated “tree-in-bud” opacities. A bronchoscopic biopsy of the mass was performed due to clinical suspicion of malignancy. Microscopic examination revealed inflamed endobronchial mucosa, granulation tissue and abundant fragments of uncharacterized organic material, compatible with aspiration. Detailed history revealed a history of chewing “gutkha”, a form of smokeless tobacco comprising a mixture of betel nut and other condiments. Microscopic sections of a betel nut and the “gutkha mix” processed subsequently in the histology laboratory were found to be similar to the organic material found in the mass. Thus, a diagnosis of impacted betel nut mixture leading to post-obstructive pneumonia was rendered.

Acute-onset Breathlessness: An Unexpected Etiology?

Acute-onset breathlessness has multifactorial causes where early spotting of etiology assists in prompt treatment of these cases. Other than usual causes, an often-neglected cause, especially in adults, is non-asphyxiating foreign body aspiration. Here, we describe a case of a 40-year-old male who had aspirated an organic foreign body under alcohol intoxication and presented with symptoms of acute-onset breathlessness and severe hypoxia. Prompt diagnosis and bronchoscopy-guided removal result in a quick recovery of symptoms in the index patient.

The application of ambroxol hydrochloride combined with fiberoptic bronchoscopy in elderly patients with severe pneumonia: A meta-analysis and systematic review

BACKGROUND

The role of ambroxol hydrochloride combined with fiberoptic bronchoscopy in elderly patients with severe pneumonia remains unclear, we aimed to analyze this issue to provide evidences into the management of clinical pneumonia.

METHODS

We searched PubMed et al databases up to October 20, 2021 for the randomized controlled trials on the application of ambroxol hydrochloride combined with fiberoptic bronchoscopy in elderly patients with severe pneumonia. Related outcomes were extracted and analyzed. Review Manager 5.3 software was used for data analysis.

RESULTS

A total of 13 randomized controlled trials involving 1317 elderly patients (559 cases in the ambroxol hydrochloride + fiberoptic bronchoscopy group and 658 cases in the fiberoptic bronchoscopy group) with pneumonia were included. Meta-analyses indicated that the blood oxygen partial pressure [mean difference (MD) = 5.75, 95% confidence interval (CI) (3.80, 7.70)], blood oxygen saturation [MD = 6.43, 95% CI (4.39, 8.48)], oxygenation index [MD = 26.75, 95% CI (14.61, 38.89)] of experimental group was significantly higher than that of control group (all P < .001), the incidence of multiple organ failure [odds ratio = 0.42, 95% CI (0.31, 0.56), P < .001], mortality on day 28 [odds ratio = 0.44, 95% CI (0.33, 0.59)] of experimental group was significantly less than that of control group (all P < .001).

CONCLUSIONS

The high-dose ambroxol hydrochloride combined with fiberoptic bronchoscopy is beneficial to improve the patient's blood gas indicators, and reduce mortality in elderly patients with severe pneumonia.

A Patient with a Foreign Body in Mediastinum Which Penetrated into the Bronchus

We report a rare case of a patient who had a foreign body in the mediastinum and trachea caused by trauma due to epileptic seizures. A 52-year-old male had an epileptic seizure 3 months before visiting our hospital and had an injury on his neck caused by a broken glass cabinet. Computed tomography scan revealed a foreign body in the mediastinum and trachea. After a detailed discussion among members of the multidisciplinary team (MDT), surgery was successfully performed to remove the foreign body. This rare case may help provide a reference for diagnosing and treating a mediastinal and tracheobronchial foreign body.

Foreign body aspirations in dental clinics: a narrative review

Foreign body aspiration can produce a medical emergency. Obstruction of the airways can be life-threatening, and complications may develop in less-severe cases if it is left untreated. Although it is more prevalent in children by approximately three times, adults can still experience it, and it is more frequently related to healthcare in adults. Objects used in dental treatment are usually placed in the oral cavity and can be ingested or inhaled by accident. Dental treatment has been identified as an important cause of the misplacement of foreign bodies in the airway. However, few reports have been published on dentistry-related foreign body aspiration. This paper discusses the disease course, management, and clinical outcomes of foreign body aspiration, especially those associated with dentistry. The patient must be examined for respiratory distress. If the patient is unstable, urgent airway management and the maneuvers for removal should be performed. Radiographs and computed tomography can help identify and locate the object. The treatment of choice is often bronchoscopy, and both flexible and rigid endoscopes can be used depending on the situation. Preventive measures need to be implemented to avoid inhalation accidents given the potential consequences. Though the incidence is rare, healthcare levels need to be enhanced to avert morbidity and mortality. Radiological evaluation and bronchoscopy are vital for management.

[Treatment of patients with rare bronchial foreign body - spruce branch]

Spruce branch is a rare radiolucent bronchial foreign body. Despite modern imaging tests and endoscopic examination, this foreign body is often detected only intraoperatively. This study enrolled 4 patients with spruce branch aspiration. In the 4^th case, spruce branch was removed during rigid bronchoscopy that was associated with «lodging» type of foreign body. In two cases, spruce branch migrated to peripheral bronchial segments («extrusive» type) that required surgical treatment (thoracoscopy with resection of the right basal pyramid segments and wedge resection of the right lower lobe). The 3^rd case was the most interesting. Initially, the foreign body was «underlying», but it migrated after partial endoscopic removal that finally required right-sided lower lobectomy. This report describes the peculiarities of clinical course and management of patients with a rare type of radiolucent bronchial foreign body - spruce branch.