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184 © 2020 Archives of International Surgery | Published by Wolters Kluwer - Medknow
Late presenting foreign body and spontaneous
exhalation in children: Myth vs reality
ABSTRACT
Foreign body (FB) inhalation is frequent in infant and children. Prompt treatment is needed to avoid further complications. We here
report two cases of FB right bronchus with delayed presentation. The children had history of FB inhalation which was not properly
evaluated initially by their primary physicians. The children were brought to us due persistence of cough, vomiting and difficulty
in breathing. Following evaluation, chest x‑ray revealed FB in the airway of each of the patients, In both, there was accidental
dislodgement of the FB before the specific intervention.
Key words: Foreign body inhalation, Heimlich manoeuvre, tracheobronchial FB
Rashi, Amit Kumar, Amit K. Sinha, Bindey Kumar
Department of Pediatric Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
Address for correspondence: Dr. Amit K. Sinha,
Department of Paediatric Surgery,
AIIMS, Patna, Bihar, India.
E‑mail: amitsandilya1981@gmail.com
Received: 04 August 2019 Revised: 13 October 2019
Accepted: 04 November 2019 Published: 10 February 2020
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DOI:
10.4103/ais.ais_23_19
the FB enters and remained lodged over a period, it does
not come out on its own. Hence some form of intervention
such as bronchoscopy or open thoracotomy is needed. We
came across cases who had spontaneous dislodgement of
tracheobronchial FB on the 5th day. In the English literature,
to date, we have not come across a case of spontaneous
exhalation of a FB, which is presenting late, that is, more
than 4 days. We are reporting two cases of the FBs who were
presented after 4 days, and before definitive treatment,
both were exhaled spontaneously.
Case Reports
Case 1
A 4‑month‑old female child presented in the outpatient
department with complaints of cough, vomiting after feeds
and excessive cry for last 4 days. These complaints were
sudden in onset. An accompanying sibling told that she had
taken a nail in her mouth. The anxious mother consulted
Introduction
Foreign body (FB) inhalation is a very common emergency
in the pediatric age group. The reasons are their nature
to explore the environment, putting the objects into
their mouth and nose, the poorly developed cough reflex
and peculiar anatomic construction of oropharynx and
laryngopharynx.[1] Children usually present with shortness
of breath, and if neglected, as history is most of the
time elusive, lead to infection and sequelae.[2] There are
many emergency measures to tackle these FBs in the
tracheobronchial tree, for example, Heimlich maneuver,
keeping the child upside down, back thrust and even
manual removal on the spot.(references please). Once
How to cite this article: Rashi, Kumar A, Sinha AK, Kumar B. Late
presenting foreign body and spontaneous exhalation in children: Myth
vs reality. Arch Int Surg 2018;8:184-7.
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Case Report
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Rashi, et al.: Spontaneous exhalation of foreign body
Archives of International Surgery / Volume 8 / Issue 4 / October-December 2018 185
a local practitioner for this and reported the incident.
However, the child was given the symptomatic treatment by
the local practitioner without investigating the event. By the
next 48 h, child deteriorated. As she had repeated vomiting
and prolonged cough episodes, the parent visited Pediatric
emergency of a nearby government hospital. Chest X‑ray
was advised; it showed approximately two inches long
radiopaque shadow at bronchial junction extending into
the right bronchus [Figure 1]. The child was stabilized
and referred to our center for further management. On
admission and clinical evaluation, the child was afebrile
and pulse, blood pressure and temperature are within
normal limits with normal consciousness and activities.
The chest examination findings were normal except slight
decrease in air entry on right side. There was no history
of hemoptysis and vitals were normal. We planned an
emergency bronchoscopy. She had a vomiting tendency
while a resident doctor was trying to put the intravenous
line. The mother restrained the child by holding her below
the chest to vomit off the bed. During this sudden tactful
moment, she compressed the upper abdomen, and at the
same time, the child had a vigorous cough episode leading
to spontaneous dislodgment and exhalation of the nail. We
did a check chest X‑ray. It showed improvement in lung
fields and no FB in the tracheobronchial tree.
Case 2
A 10‑year‑old male presented to our OPD with complaint of
sudden onset cough. He was suspected of having inhaled a
small whistle while playing 5 days back. The patient had an
initial choking event but got relieved spontaneously after
10 min Figure 2. Parent consulted a physician. He was
advised for a chest X‑ray, which showed hyperinflation and
hyperlucency of the right side of hemithorax. The physician
suspected a FB in the right bronchus and referred the case
to our center. The patient had choking sensation to start
but due to passage of FB through right bronchus, it was
relieved. Chest X‑ray showed hyperinflation of right lung
field. The child was not under respiratory distress at the
time of presentation to our center. We admitted the patient
and planned a rigid bronchoscopy. During cannulation, the
patient cried with vigorous cough, which led to the sudden
expulsion of the FB [Figure 3]. Respiratory symptoms got
relieved soon after. We deferred bronchoscopy at that time
and planned a check bronchoscopy on the next day to look
for any remaining part of the FB on check bronchoscopy.
Both the major bronchus and trachea were clear. We
documented bronchoscopy finding as negative. We did a
check chest X‑ray. It showed improvement in lung fields.
Patient discharged on the next day.
Figure 3: Plastic whistle measuring 20 mm length
Figure 2: X‑ray chest AP view showing hyperination of right lung eld
indicating right lung eld
Discussion
A child with a foreign body in the airway faces the potential
risk for sudden airway obstruction and death.[2] FB inhalation
is a common serious problem often seen in children from
6 months to 6 years of age.[3] The incidence in our case was on a
very extreme side, that is, 4 months and 10 years. FB bronchus
seems to be fatal than FB esophagus in children.[3] The right
bronchus is the most common location for a FB lodgment in
the airway (58‑65%) followed by the left bronchus (22‑25%),
the trachea (16.1%), and most rarely in the larynx (2.8%).,[3,4]
In our case, FB was lodged in the right bronchus in both the
cases. This is due to straighter and shorter right bronchus in
the tracheobronchial tree. In our case, the first patient did not
Figure 1: (a) X-ray chest AP View showing radiopaque foreign body
in the right bronchus; (b) X-ray chest lateral view showing radiopaque
foreign body; (c) X-ray chest AP view after spontaneous removal of
foreign body
c
b
a
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Rashi, et al.: Spontaneous exhalation of foreign body
186 Archives of International Surgery / Volume 8 / Issue 4 / October-December 2018
present with difficulty in breathing/noisy breathing despite
the apparent size of the FB in the airway. That may due to
partial obstruction of air passage due to its cylindrical shape.
Commonly cited inorganic materials include pieces of
plastic, metal, beads, and pins.[4] The presenting symptoms
of patients with FBs in the airway can be quite variable,
ranging from an intermittent cough to sudden death. The
various authors found coughing, choking, or wheezing to be
among the initial symptoms after FB aspiration in 75–95%
of patients.[3,5] In our cases, the only presenting symptoms
were an initial cough followed vomiting after each feed.
Nausea and vomiting are not common accompaniment in FB
bronchus. Earlier studies reported obstructive emphysema
as the most common radiological sign.[3,6] We also reported
obstructive radiological sign in our case. In the first case,
there was incomplete obstruction, but in the second case,
it was complete.
The Heimlich maneuver (abdominal thrusts) is indicated
in children, whereas alternating back blows and chest
compressions are indicated in infants.[5] The Heimlich
maneuver proved to be useful in cases without any
respiratory complication.[7] A case report who aspirated
a throat lozenge that had been in his mouth resulted in
a complete airway obstruction resolved by back blows
alone.[8] The flow of fast‑moving air column can exert
pressure over the surface of a lodged FB leading to its
expulsion. If the obstruction occurs at the end of the
inspiratory cycle, the Heimlich maneuver and back blows
are likely to be effective, but if the obstruction occurs during
the initial stages of the inspiratory cycle, then these are
unlikely to be effective.[9]
As mentioned by Lima
et al
.,[9] thin, triangular objects
appear to cause only moderate respiratory distress
because air exchange around these objects is almost
regular in the initial stages. Although immediate
coughing occurs in all of these patients, the cough is
ineffective in expelling the object due to its relative
lack of surface upon which the air pressure can exert
force. However, in our case, the object was thin and
cylindrical, despite that it got expelled on accidental
Heimlich maneuver.
Earlier American Red Cross and the American Heart
Association recommended back slaps, and chest thrusts
with the infant positioned in a head‑down position
for choking.[10] Heimlich and Patrick challenged these
recommendations as being ineffective and dangerous.[11]
Abdominal thrusts (Heimlich maneuver) were recommended
for children older than 1 year.[10]
The reluctance for the Heimlich maneuver for emergency
management of all age groups with acute airway
obstruction is based on concern over causing visceral
injury. Traumatic ruptures of the stomach, esophagus,
jejunum, and mesentery have all been reported after
application of the Heimlich maneuver in adult patients.
There is genuine concern that more frequent injuries may
occur in infants, who have less skeletal protection for their
upper abdominal viscera. A significant liver rupture and
intraperitoneal hemorrhages reported in two infant cases
earlier.[2]
Conclusion
Two cases described here had a long history of inhalation of
FB. The spontaneous expulsion in the 1st case by maneuver
mimicking Heimlich and in the 2nd case spontaneous,
emphasize the importance of application of external
maneuver to be tried even if patient is reporting late with
emergency bronchoscopy set‑up ready.
Declaration of patient  consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not
be published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
References
1. Fong E. Case based pediatrics for medical students and
residents, chap. VIII Foreign Body Aspiration Author House
Bloomington.
2. Johnson DG, Condon VR. Foreign bodies in the pediatric
patient. Curr Probl Surg 1998;35:271‑379.
3. 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.
4. Hootnick JL, Schroeder JW. Glass in the glottis: A pediatric
case report. Int J Pediatr Otorhinolaryngol Extra 2015;10:4‑7.
5. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal
of aspirated foreign bodies in children. J Pediatr Surg
1994;29:682‑4.
6. Cohen SR, Herbert WI, Lewis GB Jr, Geller KA. Five‑year
retrospective study with special reference to management.
Ann Otol Rhinol Laryngol 1980;89:437‑42.
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Rashi, et al.: Spontaneous exhalation of foreign body
Archives of International Surgery / Volume 8 / Issue 4 / October-December 2018 187
7. Boussuges S, Maitrerobert P, Bost M. Use of the heimlich
maneuver on children in the rhone‑alpes area. Arch Fr
Pediatr 1985;42:733‑6.
8. Bradley RN, Epstein JL, Christiansen PM. Case report of an
acute foreign object airway obstruction resolved by back
blows alone. Heart Lung J Acute Crit Care 2015;44:544.
9. Lima JA. Laryngeal foreign bodies in children:
A persistent, lifethreatening problem. Laryngoscope
1989;99:415‑20.
10. Medicine C on PE. First aid for the choking child. Pediatrics
1993;92:477‑9.
11. Heimlich HJ. First aid for choking children: Back blows
and chest thrusts cause complications and death. Pediatrics
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ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
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