M. Boyd et al.
23. Deakin TA, Cade JE, Williams R et al. (Structured patient edu-
cation: the X-PERT program makes a difference. Diabet Med
2006; 9: 944–54.
24. Zeyfang A. Structured educational programs for geriatric
25. TuomilehtoJ. Diabetes—aproblemformillionsof people and
their families in the European Union. Diabetologia 1997; 8:
26. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-
management training in type 2 diabetes: a systematic review of
randomized controlled trials. Diabetes Care 2001; 24: 561–87.
28 November 2008
Age and Ageing 2009; 38: 396–400
Published electronically 28 April 2009
C ?The Author 2009. Published by Oxford University Press on behalf of the British Geriatrics Society.
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Prevalence of flexible bronchoscopic removal of
foreign bodies in the advanced elderly
MICHAEL BOYD1, FRANKLIN WATKINS2, SONAL SINGH3, EDWARD HAPONIK4, ARJUN CHATTERJEE4,
JOHN CONFORTI4, ROBERT CHIN JR4
1Section of Pulmonary, Critical Care, Environmental, and Sleep Medicine, Carilion Clinic, Roanoke, VA 24014, USA
2Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA
3Department of Internal Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA
4Section of Pulmonary, Critical Care, Allergy, and Immunological Diseases, Wake Forest University, Winston Salem, NC 27157,
Address correspondence to: M. Boyd, MD, Director of Bronchoscopy and Interventional Pulmonology, Carilion Clinic, 1906
Belleview Ave, Roanoke, VA 24014, USA. Email: firstname.lastname@example.org
Objectives: to define the likelihood and establish the overall safety and effectiveness of flexible bronchoscopy in the removal
of foreign bodies in the advanced elderly compared to those younger.
Design: a retrospective case–control analysis.
Setting: tertiary care academic hospital.
Population: 7,089 adults (age >18 years), including 949 (15%) advanced elderly (age >75 years), who underwent flexible
bronchoscopy between January 1995 and June 2007.
based on defined age groups (group 1, age <75 years and group 2, age >75 years) was performed.
Results: FBA requiring bronchoscopic removal was greater than three and a half times more likely in patients aged >75 years
compared to those younger (OR 3.78, CI 1.4–10: P <0.05). Flexible bronchoscopy was 87.5% effective in the removal of
foreign bodies in the advanced elderly and associated with no increase in adverse events.
Conclusion: bronchoscopic removal of foreign bodies is more likely in the advanced elderly when compared to those
younger. This implies that this population may be most at risk. Flexible bronchoscopy is a safe and effective initial diagnostic
and therapeutic approach in this age group.
Keywords: foreign body aspiration, elderly, advanced elderly, flexible bronchoscopy
Foreign body aspiration (FBA), defined as the introduction
of a large particulate material into the tracheobronchial tree,
is a rare event that increases with age [1–4]. Despite this age
association, the risk of FBA in older adults remains poorly
defined. The presence of cerebrovascular disease, heart
Prevalence of flexible bronchoscopic removal of foreign bodies in the advanced elderly
failure and lung disease as well as other factors such as dys-
phagia, dementia or sedating medication that affect the level
of consciousness all have been suggested to predispose older
adults to aspiration [5–9]. Whether these conditions affect
the likelihood of FBA remains unknown. Without prompt
tially life-threatening problems [1, 2, 10, 11]. Flexible bron-
choscopy (FB) is regularly performed to confirm and iden-
tify foreign bodies and is effective in FBA removal [12–14].
Althoughlarge case studies on FBA in adults havebeen pub-
lished [1–4], there is no specific literature addressing bron-
choscopic removal of foreign bodies in older adults despite
previous reports that bronchoscopy in this age group is gen-
erally safe and well tolerated [15–21]. The most common
indications reported for FB in older adults are pneumonia,
pulmonary infiltrates and possible neoplasm . Institu-
tional experience at Wake Forest University Baptist Medical
Center (WFUBMC) suggested that both diagnostic and ther-
apeutic bronchoscopic removal of foreign bodies occurred
study was designed to determine whether the very old were
more likely to undergo bronchoscopic removal of foreign
bodies and whether FB provides a safe and effective method
of foreign body removal in this age group. We reviewed the
last 12.5 years of experience at WFUBMC with therapeutic
bronchoscopy for the removal of foreign bodies (January
A retrospective case–control study examining broncho-
scopies related to FBA in very old adults was performed
at WFUBMC, a tertiary care academic medical centre.
Procedural logbooks from the bronchoscopy laboratory
were reviewed, documenting all adult bronchoscopies,
defined as age 18 years or older, from January 1995 to
June 2007. All procedures with the indication of FBA, both
suspected and known, were identified. A review of the paper
chart or electronic medical record was then performed to
verify whether suspected cases were true FBA events. Only
clearly documented or proven FBA events were included in
the final analysis. After all cases were identified, the medical
record was reviewed, and the following clinical characteristic
data were collected: age, gender, nature of material aspirated,
the presence or absence of radiological changes, presenting
symptoms, the presence of possible contributing risk factors
(underlying neurological disease, congestive heart failure or
pulmonary disease), the mechanism of foreign body removal
(flexible vs. rigid bronchoscopy), device (s) utilised for
removal, dosage and type of sedation utilised, complications
of bronchoscopy and outcome of the FBA event (survival).
Lastly, age and gender for all adult bronchoscopies per-
formed at WFUBMC during this same time period were
documented for comparison. Bronchoscopic procedures
identified due to recording errors or when the information
was protected. Safety of bronchoscopy was assessed by
reviewing procedural documentation (beginning from start
of bronchoscopic procedure to patient discharge from a
[defined as cardiovascular changes (i.e. alterations in heart
rate, heart rhythm or blood pressure) or reductions in pulse
oximetry that required additional treatment to complete
the procedure or that occurred in the recovery area after
procedure]. Effectiveness of bronchoscopic removal was
defined as identification and removal of the foreign body.
Case–control comparison was limited to age only. Two hun-
ExcelR ?(Redmond, WA, USA). This was accomplished by
a bronchoscopic procedure in the same year as each FBA
by placing patients into two age groups, group 1 (age <75
years) and group 2 (age ≥75 years) (Table 1). Comparison of
the clinical characteristics between group 1 and group 2 was
performed using Fisher’s exact test. The percentage of FBA
per total bronchoscopies per decade of age beginning at age
18 years (ages 18–24, 25–34, 35–44, 45–54, 55–64, 65–74,
75–84, 85+) was calculated. Lastly, the percentage of FBA
per bronchoscopies was analysed based on two age groups
yses were performed using Microsoft ExcelR ?with a P-value
<0.05 considered statistically significant.
During the study period of 12.5 years, 7,089 adult broncho-
scopies [4,082 (58%) males and 3,007 (42%) females] were
performed at WFUBMC. Fifteen per cent (949) of these
Twenty cases of true FBA requiring bronchoscopic removal
were identified (Table 1). This represents 0.28% of the total
bronchoscopies performed. The overall prevalence of FBA
in adults requiring FB was 1.67 cases per year. FBA occurred
in 11 male patients (55%) and 9 female patients (45%). Ages
peak prevalence of FBA, by the age distribution, occurred in
the age group of 75–84 years (30%). Forty per cent (8/20) of
all FBA events occurred in patients aged ≥75 years.
FBA and bronchoscopy based on age
and a half times more likely in patients aged ≥75 years
compared to those aged <75 years (OR 3.78, CI 1.4–10.0:
M. Boyd et al.
Table 1.FBA cases (n = 20)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 21F Pin Metallic object
2 25F PushpinMetallic object
326FSand Bibasilar airspace
5 39M Wood fragment None
6 45MPill fragmentRLL Atelectasis
7 58MPill fragment Diffuse airspace
Age Gender Aspirated materialRisk factorsRemoval Outcome
None NoneFlexible, FB not
Cough, wheezeNone Survived
8 61M ToothOpacity Right
13 76MPill No CXR Choking, cough,
1477FPill Atelectasis RLL
16 81M Button BatteryMetallic object
Soft tissue density
CHF, COPDFlexible Survived
1987M Soft tissue density
Group 1 (age <75 years), group 2 (age ≥75 years), foreign body aspiration (FBA), foreign body (FB), left lower lobe (LLL), right upper lobe (RUL), right middle
lobe, (RML), right lower lobe (RLL), chest X-ray (CXR).
P < 0.05). Further analysis comparing bronchoscopic
removal of aspirated foreign bodies in patients ≥65 years
to <65 years of age was not statistically significant (OR 2.4,
CI 0.96–6.0: P = 0.053). The percentage of FBA per bron-
choscopy per cohort (based on age) is shown in Table 2. Age
>85 years represented the highest cohort with 2/90 FBA
events per bronchoscopies (2.2%). The next highest 6/859
(0.08%) occurred in the age cohort of 45–54 years. The per
cent of FBA events per bronchoscopies was more than four
times greater for group 2 (age ≥75 years) compared to group
1 (age <75 years) (0.2% vs. 0.84%).
Safety and effectiveness of FB
FB for removal of foreign bodies in patients aged ≥75 years
was not associated with an increase in adverse events when
compared to those younger and was equally effective in both
groups. Minor complications associated with FB were iden-
tified in both groups, but not statistically different [decrease
in oxygen saturation: 1/12 (group 1) vs. 2/8 (group 2) and
transient hypotension: 1/12 (group 1) vs. 0/8 (group 2),
effectively. There were no major complications. Although
there were four deaths, none of these were associated with
FB [3/12 (group 1) vs. 1/8 (group 2), P = 0.62]. The overall
Prevalence of flexible bronchoscopic removal of foreign bodies in the advanced elderly
Table 2.Bronchoscopies and FBA by age cohorts
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BronchoscopiesFBA FBA/bronchoscopy (%)
Foreign body aspiration (FBA).
2, 87.5% (7/8), P = 1.0].
The clinical characteristics of patients are summarised in
Table 1. Between the two groups, choking was the only sta-
tistically significant presenting symptom, occurring in 50%
Fatal and non-fatal FBA occur rarely but are more often
present in the extremes of life (i.e. the very young and very
old) [1–4, 22]. The exact incidence of FBA in older adults
is not known. It is presumed that many cases go unrecog-
nised or resolve (expectorated) without medical attention.
Thus, defining the true incidence of FBA is not practical.
This study is the first to attempt to define the likelihood
of bronchoscopic removal of foreign bodies as it relates to
older age. Bronchoscopy performed to remove foreign bod-
ies was more than three and a half times as likely to occur in
those ≥75 years of age compared to those <75 years. This
implies that the likelihood of FBA may also be higher in
this age group compared to younger patients. Other studies
have suggested this as well. In a large 33-year retrospective
analysis of 60 adult patients, Limper et al. found that 42%
of FBA events requiring bronchoscopic removal occurred in
the seventh decade of life with a median age of 60 years .
with FBA and found that 19/43 events (40%) occurred in
the sixth decade . Baharloo and colleagues described their
and found a peak incidence occurring in the sixth decade of
life (28% of all adult cases) .
The 40% prevalence of FBA identified in the very old
adults in this study is in agreement with Limper, but does
differ by suggesting a higher median age than previously
reported (72 years compared to 60 years) . The increase of
an ageing population since Limper’s study may explain this
identified in this study is similar to previous studies (1.4–
2.86 FBA events/year) [1–4]. The peak prevalence of FBA
events occurred in the age group of 75–84 years and is also
comparable to Limper’s findings .
FB as an initial approach to foreign body removal was
safe and efficacious in both groups. The success of FB in
the removal of foreign bodies achieved in this study is sim-
ilar to previous reports [12–14]. More importantly, no dif-
ferences were found in procedure-associated complications
findings suggest that FB should be considered as the initial
diagnostic procedure as well as the therapeutic modality of
choice in the removal foreign bodies in very old adults. To
our knowledge, this is the first study to address the safety of
FB in FBA in older adults.
In reviewing clinical characteristics, choking was found
to occur only in group 2 patients and achieved a statistical
significance when compared to group 1. Choking combined
with intractable cough is commonly referred to as ‘pene-
tration syndrome’. Limper’s study suggested an occurrence
of penetration syndrome in both children and adults which
was reported in 49% of cases at initial presentation . It is
unclear in this study why penetration syndrome was found
patients’ symptoms. Although choking, cough and dyspnoea
do occur frequently, no symptom is reliably sensitive or spe-
cific for FBA. A presumptive diagnosis of FBA was based
upon a witnessed event or the patient history in the majority
of the cases presented in this study. Without a supportive
history, the diagnosis of FBA was often delayed by days to
month. An eventual diagnosis of FBA was obtained only
after persistence of respiratory symptoms, suggestive radio-
logical changes or an increased clinical suspicion. Therefore,
practitioners who care for very old adults should maintain a
Several limitations to this study must be recognised. The
experience is limited to FB performed at a single institution,
indications for bronchoscopy were available for review, the
data for analysis are dependent on the accuracy of documen-
tation. Despite the reported safety of FB in older patients,
there may be ‘age’ discrimination in performing FB in these
patients, decreasing the overall number of FB done in this
population. Other limitations of this study would include its
observational nature with a possible inability to distinguish
likely needed to determine what prognostic factors may con-
tribute to FBA in very old adults. This study shows that
although the prevalence of FB for FBA is low in all age
groups, there is significant clustering in older adults. Because
M. Boyd et al.
removal of foreign bodies.
With this in mind, older adults may be more likely to
experience FBA and thus a heightened clinical suspicion
should be maintained.
bodies in very old adults.
Choking is a common clinical characteristic in FBA, but
Very old adults are at a higher risk for bronchoscopic
FB is both safe and effective in the removal of foreign
Conflicts of interest
1. Limper AH, Prakash UB. Tracheobronchial foreign bodies in
adults. Ann Intern Med 1990; 112: 604–9.
2. Chen CH, Lai CL, Tsai TT et al. Foreign body aspiration into
the lower airway in Chinese adults. Chest 1997; 112: 129–
3. Baharloo F, Veyckemans F, Francis C et al. Tracheobronchial
foreign bodies: presentation and management in children and
adults. Chest 1999; 115: 1357–62.
4. Debeljak A, Sorli J, Music E et al. Bronchoscopic removal
of foreign bodies in adults: experience with 62 patients from
1974–1998. Eur Respir J 1999; 14: 792–5.
5. Nakagawa A, Sekizawa K, Nakajoh K et al. Silent cerebral
Med 2000; 247: 255–9.
6. Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in
the elderly. Chest 2003; 124: 328–36.
7. Shaw DW, Cook IJ, Gabb M et al. Influence of normal aging
on oral-pharyngeal and upper esophageal sphincter function
during swallowing. Am J Physiol 1995; 268(Pt 1): G389–96.
8. Vergis EN, Brennen C, Wagener M, Muder RR. Pneumonia in
and impact on survival. Arch Intern Med 2001; 161: 2378–81.
9. Shaker R, Li Q, Ren J et al. Coordination of deglutition and
263(Pt 1): G750–5.
10. Poukkula A, Routsalaimen EM, Jokinen K et al. Long-term
presence of a denture fragment in the airway (a report of two
cases). J Laryngol Otol 1988; 102: 190–3.
11. Patel S, Kazerooni EA. Case 31: foreign body aspiration—
chicken vertebra. Radiology 2001; 218: 523–5.
in adults. J Bronchology 2003; 10: 107–11.
13. Lan RS, Lee CH, Chiang YC et al. Use of fiberoptic bron-
choscopy to retrieve bronchial foreign bodies in adults. Am
Rev Respir Dis 1989; 140: 1734–7.
14. Surka A, Chin R, Conforti J. Bronchoscopic myths & legends:
airway foreign bodies. Clin Pulm Med 2006; 3: 209–11.
15. Hehn B, Haponik EF. Flexible bronchoscopy in the elderly.
Clin Chest Med 2001; 22: 301–9.
J Am Geriatr Soc 51: 917–22.
17. MacFarlane JT, Storr A, Smith WH. Safety, usefulness and
acceptability of fibreoptic bronchoscopy in the elderly. Age
Ageing 1981; 10: 127.
18. Brandstetter RD, Croce SA, Schiaffino E, Otero R, Iaquinta
FE. Flexible fiberoptic bronchoscopy in the elderly. NY State
J Med 1984; 84: 546–8.
19. O’Hickey S, Hilton AM. Fibreoptic bronchoscopy in the
elderly. Age Ageing 1987; 16: 229.
20. Knox AJ, Mascie-Taylor BH, Page RL. Fibreoptic bron-
choscopy in the elderly: four years’ experience. Br J Dis Chest
1988; 82: 290.
M, O’Neill SJ. The elderly tolerate fiberoptic bronchoscopy as
well as younger patients. J Bronchology 1997; 4: 115.
of Injury Facts. Chicago: National Safety Council Press, 2003;
Received 4 June 2008; accepted in revised form 11 February 2009