Foreign body in the bronchus in children: 22 years experience in a tertiary care paediatric centre

Abstract

Background:
Our objective was to assess types, presentation, duration of symptoms and usefulness of rigid bronchoscopy for diagnosis and treatment of bronchial foreign body (FB) in children.

Materials and methods:
Records of children with documented FB aspiration treated in Department of Paediatric Surgery from January 1991 to December 2012 were analysed retrospectively. Diagnosis was made on the basis of history, clinical examination, radiological evaluation and bronchoscopy.

Results:
A total of 196 children underwent emergency rigid bronchoscopy for suspected bronchial FB and in 173 cases FB was found. Out of 173 cases, 118 (68.21%) were males and 55 (31.79%) were females. Mean age was 3.7 years (range: 2 months-12 years) while mean duration of symptoms was 28 h (range: from 3 h to 4 months). Most common FB bronchus found was peanut 141 (81.50%). FB was localised to right bronchus in 112 (64.74%) cases while in 44 (25.43%) cases left bronchus was involved. In 17 (9.83%) cases FB was seen at carina only. Cough was the most common presenting symptom in 131 (75.72%) cases. The most common finding in chest X-ray was consolidation-collapse lung or emphysematous lung in 83 (47.97%) cases followed by the flattening of the diaphragm in 17 (9.83%) cases. In 35 (20.23%) cases chest X-ray was found to be normal. Pre-operative endotracheal intubation was done in 13 (7.51%) cases while 20 (11.56%) cases required post-operative mechanical ventilation.

Conclusion:
High index of suspicion should be kept for bronchial FB in children who present with suggestive history of FB ingestion even with normal physical and radiological evaluation.

Full text

African Journal of Paediatric Surgery
252 July-September 2014 / Vol 11 / Issue 3
Foreign body in the bronchus in children:
22 years experience in a tertiary care
paediatric centre
Shasanka Shekhar Panda, Minu Bajpai, Amit Singh, Dalim Kumar Baidya1, Manisha Jana2
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www.afrjpaedsurg.org
DOI:
10.4103/0189-6725.137336
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INTRODUCTION
Foreign body (FB) inhalation is a common serious problem
often seen in children from 6 months to 06 years of age
which if not treated in time can be life-threatening.[1-4]
Most commonly aspirated FB includes peanut, beetle nut,
vegetable seed, marbles, metallic and plastic toy wheels.
Appearance of sudden respiratory distress or coughing/
choking is a symptom of FB aspiration in an otherwise
healthy child. Majority of cases is purely accidental,
but can be occasionally homicidal especially when the
child is a girl. Not only the nature and site of FB, but also
the duration of symptoms plays a role in final survival
outcome. FB bronchus seems to be more fatal than
FB oesophagus in children. Operating surgeon should
always keep in mind the need of urgent tracheostomy or
thoracotomy with bronchotomy if rigid bronchoscopy fails
to retrieve the FB and child becomes clinically unstable.
Our objective was to assess types, presentation, duration
of symptoms and usefulness of rigid bronchoscopy for
diagnosis and treatment of bronchial FB in children.
MATERIALS AND METHODS
We retrospectively analysed our data from January
1991 to December 2012 of 173 patients who underwent
rigid bronchoscopy in emergency for FB aspiration
in Department of Paediatric Surgery. At the time of
presentation all patients were evaluated with a thorough
history, clinical examination, chest X-ray and arterial
blood gas. Stronger index of suspicion was kept in cases
of sudden onset of symptoms with inappropriate history
of FB aspiration or ingestion. Endotracheal intubation
was done in unstable cases before shifting to operation
theatre. Urgent bronchoscopy was performed with rigid
bronchoscope under general anaesthesia. Mechanical
ventilator support was provided for unstable patients.
Single dose of antibiotics were given in pre-operative
and post-operative period in all cases. Stable patients
were discharged within 24 h of procedure.
Departments of Pediatric Surgery, 1Anaesthesiology, and
2Radiodiagnosis, All India Institute of Medical Sciences,
New Delhi - 110 029, India
Address for correspondence:
Dr. Minu Bajpai,
Department of Paediatric Surgery,
All India Institute of Medical Sciences, New Delhi - 110 029, India.
E-mail: bajpai2@hotmail.com
ABSTRACT
Background: Our objective was to assess types,
presentation, duration of symptoms and usefulness
of rigid bronchoscopy for diagnosis and treatment
of bronchial foreign body (FB) in children. Materials
and Methods: Records of children with documented
FB aspiration treated in Department of Paediatric
Surgery from January 1991 to December 2012 were
analysed retrospectively. Diagnosis was made on
the basis of history, clinical examination, radiological
evaluation and bronchoscopy. Results: A total of 196
children underwent emergency rigid bronchoscopy
for suspected bronchial FB and in 173 cases FB was
found. Out of 173 cases, 118 (68.21%) were males
and 55 (31.79%) were females. Mean age was 3.7
years (range: 2 months-12 years) while mean duration
of symptoms was 28 h (range: from 3 h to 4 months).
Most common FB bronchus found was peanut 141
(81.50%). FB was localised to right bronchus in
112 (64.74%) cases while in 44 (25.43%) cases left
bronchus was involved. In 17 (9.83%) cases FB was
seen at carina only. Cough was the most common
presenting symptom in 131 (75.72%) cases. The most
common fi nding in chest X-ray was consolidation-
collapse lung or emphysematous lung in 83 (47.97%)
cases followed by the fl attening of the diaphragm in
17 (9.83%) cases. In 35 (20.23%) cases chest X-ray
was found to be normal. Pre-operative endotracheal
intubation was done in 13 (7.51%) cases while 20
(11.56%) cases required post-operative mechanical
ventilation. Conclusion: High index of suspicion
should be kept for bronchial FB in children who present
with suggestive history of FB ingestion even with
normal physical and radiological evaluation.
Key words: Children, foreign body bronchus,
bronchoscopy
Original Article
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Panda, et al.: Foreign body bronchus in children
253
July-September 2014 / Vol 11 / Issue 3
African Journal of Paediatric Surgery
RESULTS
A total of 196 patients with suspected FB aspiration
were admitted to Department of Paediatric Surgery, from
January 1991 to December 2012 and underwent rigid
bronchoscopy. Out of 196 patients, FB in different parts
of airway was found in 173 cases i.e., in 23 cases it was
negative bronchoscopy. Out of 173 positive bronchoscopy
cases, an over whelming majority was male 118 (68.21%)
while 55 (31.79%) were female with male to female ratio
of 2.1:1. The maximum incidents occurred at the age of
1-3 years [Table 1] with a value of cases 103 (59.54%). The
most common site of FB was right main bronchus in 112
(64.74%) patients followed by left main bronchus in 44
(25.43%) and in 17 (9.83%) cases at carina. Most common
presenting symptom in FB bronchus in our study was
cough [Table 2], found in 131 (75.72%) cases. Organic
foreign bodies (155 cases) were found most commonly
than inorganic foreign bodies (18 cases). Peanut was
most common FB bronchus seen in our study group in
141 (81.5%) cases [Table 3]. Consolidation-collapse or
emphysematous lung was found in 83 (47.97%) cases
followed by the flattening of diaphgram in 17 (9.83%)
cases [Table 4]. Most of the patients with symptoms of FB
bronchus reached our institute within 6-12 h [Table 5].
Mechanical ventilation was required in 13 (7.51%) cases
in the pre-operative period and 20 (11.56%) cases in the
post-operative period [Table 5]. Redo bronchoscopy was
done in 7 (4.05%) cases for retained FB. Mortality was seen
in 04 (2.31%) cases, 03 died pre-operatively while 01 died
in the post-operative period. Posterolateral thoracotomy
with bronchotomy was required in 05 (2.89%) cases while
tracheostomy was required in 02 (1.16%) cases.
Most common presenting symptom in 23 negative
bronchoscopy cases for suspected FB bronchus was
cough (15 cases) followed by cough and fever (6 cases),
fever and stridor (2 cases). On clinical examination,
patients had increased respiratory rate and effort but
air entry was equal in both sides of the chest. Chest
X-ray was normal in 15 cases presented with cough
only, showed increased bronchovascular markings with
few air bronchograms in cases presented with cough,
fever and stridor. In all cases despite normal imaging,
bronchoscopy was done due to history and symptoms
of suspected FB aspiration. In patients with fever and
stridor, epiglottis and glottis was oedematous and in all
other cases bronchoscopy was normal.
DISCUSSION
FB aspiration can present with a wide variety of
symptoms. Although it is sometimes asymptomatic,
mostly there exists cough, dyspnoea, haemoptysis and
even respiratory arrest. Clinical history and radiological
examinations are enough for the diagnosis but in some
cases, it is difficult to diagnose even by bronchoscopy.
Table 1: Age of children with foreign bodies in airway
Age in years Number of patients Percentage
<1 39 22.54
1-3 103 59.54
3-5 22 12.72
>5 09 05.20
Total 173 100
Table 2: Presenting symptoms of foreign bodies in children
Symptoms Number of patients Percentage
Cough 131 75.72
Dysponea 20 11.56
Wheezing 11 6.36
Cynosis 04 2.31
Choking 03 1.73
Stridor 02 1.16
Unresolved pulmonary infection 02 1.16
Total 173 100
Table 3: Types of foreign bodies in children
FB bronchus Number of patients Percentage
Peanut 141 81.50
Seed (fruit/vegetable) 14 8.1
Stone 11 6.36
Plastic 04 2.31
Metallic 03 1.73
Total 173 100
FB: Foreign body
Table 4: Radiological signs in foreign bodies in children
Radiological signs Number of patients Percentage
Consolidation-collapse or
emphysematous
83 47.97
Flattening of diaphragm 17 9.83
Atelectasis 17 9.83
Pneumonia 21 12.14
Normal 35 20.23
Total 173 100
Table 5: Durations of symptoms in tracheo-bronchial
foreign bodies in children
Symptoms
duration
Number of
patients
Percentage Mechanical
ventilation
pre-operative
Mechanical
ventilation
post-operative
<6 h 31 17.92 6 9
6-12 h 106 61.27 1 3
12-24 h 23 13.3 2 3
1-7 days 9 5.20 3 4
>7 days 4 2.31 1 1
Total 173 100 13 20
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Panda, et al.: Foreign body bronchus in children
African Journal of Paediatric Surgery
254 July-September 2014 / Vol 11 / Issue 3
ratio of accurate and early diagnosis.[15-18] Obstructive
emphysema was the most common radiological sign.
This is in agreement with various studies.[8,15,16] We used
the rigid bronchoscope in all cases due to its ability
to control and ventilate the airway, while removing
the offending FB. Rigid bronschoscopy is the best
modality of treatment in cases of FB is a universally
accepted statement.[19-21] There are units who have
claimed 80-90% of success in extracting foreign bodies
from children’s bronchial trees using the flexible
bronchoscopy technique.[22] One of the unquestionable
advantages of flexible bronchoscopes is the possibility
of reaching bronchi of smaller diameter, the segmental
and subsegmental ones. Divisi et al. believe that the
diagnostic effectiveness of flexible bronchoscopy
reaches 100%, whereas the effectiveness of object
extraction amounts to only 10%.[23] Our experience
with flexible bronchoscopy is limited as we always
performed rigid bronchoscopy whenever doubt about
FB aspiration exists. In our study group, the overall
success rate was 97.6%. All positive bronchoscopy
yielded FB and in 166 (95.9%) cases FB was removed
in a single attempt. Repeat bronchoscopy is needed
only if the first bronchoscopy is unsuccessful or when
granulomatous reaction is seen at the time of removal
of the FB or when there is persistent pneumonia.
In our study repeat bronchoscopy was required in
only 7 (4.0%) cases. In children with FB aspiration
duration of symptoms were not directly related to
the ventilatory requirement. Out of four mortality,
two of our cases who expired without undergoing
bronchoscopy had symptoms of <6 h duration while
one of them had symptoms for 12 h. Remaining one
who expired 14 days after bronchoscopy had symptoms
for 72 h. Although serious complications such as
mediastinal emphysema, atelectasis, pneumothorax,
tracheoesophageal fistula and bronchiectasis, have been
reported after bronchoscopy,[24] in our series we do not
find any such complications.
In our study, diagnostic bronchoscopy did not reveal any
FB in 23/196 (11%) cases. It is absolute that the presence
of negative bronchoscopy findings is mandatory with
a certain percentage, not to ignore the positive cases.
CONCLUSION
Diagnosis of FB in children is extremely challenging
especially in the absence of clear history and normal
physical examination, and because of its presentation which
can be mistaken as asthma or respiratory tract infection,
leading to delayed diagnosis and treatment, and can result
in intrabronchial granuloma formation. Therefore, early
A high index of suspicion must be maintained when
the child presents to a medical facility with symptoms
related either to the respiratory or gastrointestinal tract.
Respiratory distress is the most common manifestation
of an FB in the oesophagus in neonates and it can lead
to misdiagnosis of a respiratory disorder.[5] Despite
the improvement in anaesthetic and endoscopical
techniques, aspirated foreign bodies are responsible
for significant morbidity and mortality in children.
As they can mimic other pathological conditions
like croup, pneumonia and asthma, it is sometimes
mismanaged leading to further complications. The first
systematic or elaborate study of foreign bodies in airway
was attempted by Gross in 1854.[6] He emphasized
the importance of clinical history, especially the first
paroxysm, notably cough and a severe suffocation
which occurred with the aspiration of foreign object.
However, subsequent wheezing, cough, choking, and
sudden onset of asthma point towards a possible FB
aspiration. Recurrent or non-resolving pneumonia also
indicates the possibility of a FB aspiration. In children,
aspiration of foreign bodies lodged high in the tracheal
airway mimics viral croup. However, recurrence of
symptoms like stridor and wheezing after one successful
treatment with antibiotics and steroids should alert one
of a possible FB.[7] As reported in other series our study
group also has male predominance.[8-12] FB was more
in right main bronchus as reported by other authors
earlier.[13] This is explained by the anatomical features
of the right main bronchus, i.e., it is wider in diameter,
shorter in length and has more direct extension of the
trachea than the left bronchus.[11]
In our study group peanut outnumbered other various
FB, an observation made by others as well[9,10] indicating
that parents should be educated to abstain from
feeding nuts and seeds to young children who do not
have premolars or molars and cannot grind smaller
inhalable pieces effectively. Furthermore, they have
an immature protective reflex, compared with adults,
as children have narrower airways. Hence, morbidity
and mortality are higher in children.[14] The propensity
of finding a peanut in airways of children is probably
due to its availability and affordability when compared
with other nuts in north India especially in winter. Our
study showed a positive radiological findings in only of
83 (48%) cases, as compared to 62% each in two recent
studies.[15,16] Chaterjee et al. in 1972 first described the
X-ray findings in FB aspiration in children.[16] They also
emphasized that the sensitivity can be improved if chest
radiographs are taken in full expiration and inspiration.
Fluoroscopy can still improve upon this by showing
air trapping or mediastinal shift and can increase the
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Panda, et al.: Foreign body bronchus in children
255
July-September 2014 / Vol 11 / Issue 3
African Journal of Paediatric Surgery
Cite this article as: Panda SS, Bajpai M, Singh A, Baidya DK, Jana M.
Foreign body in the bronchus in children: 22 years experience in a tertiary
care paediatric centre. Afr J Paediatr Surg 2014;11:252-5.
Source of Support: Nil. Confl ict of Interest: None declared.
rigid bronchoscopy is very effective procedure for FB
removal with fewer complications. High index of suspicion
should be kept for bronchial FB in children who present
with suggestive history of FB inhalation even with normal
physical and radiological evaluation.
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