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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 381-386

Foreign body aspiration in children: what is variant in management?


1 Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Pulmonology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission09-Jul-2019
Date of Decision01-Aug-2019
Date of Acceptance03-Aug-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Mennat-Allah G El-Dahshan
Shebin El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_203_19

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  Abstract 

Objective
To evaluate children with foreign body aspiration (FBA) according to its incidence in pediatric, diagnostic tools, and the effectiveness of rigid bronchoscope.
Background
FBA is an important cause of morbidity and mortality in pediatrics. Management depends on the acuity of the presentation. Patients with evidence of complete upper airway obstruction should have age-appropriate basic life support maneuvers performed. Patients with partial obstruction who are able to maintain their airway but with potential for deterioration should be taken immediately to the operating room for removal whenever possible.
Patients and methods
In this prospective case series study, patients with suspected FBA up to 12 years old; presented to the Department of Otorhinolaryngology in Menoufia University Hospital in a period between April 2017 and September 2018 were enrolled to our work.
Results
Our study included 45 patients with different age groups prepared for bronchoscopic extraction. 43.9% of patients had right-sided foreign body (FB). Overall complications rate was 21.875%. These complications include hemoptysis, hoarseness of voice, laryngeal spasm, pulmonary edema, and temporary bronchospasm. Only one case failed to extract its FB.
Conclusion
It is concluded that the FB extraction in children occurred more for whom with low socioeconomic standard and higher number of siblings in one family. Rigid bronchoscope is used as diagnostic and therapeutic tool for patients with FBA to that could not be detected in radiological study.

Keywords: bronchi, bronchoscopy, foreign body


How to cite this article:
Atallah AT, Beheiry EA, Abdel-Shafy IA, Zamzam KM, El-Dahshan MAG. Foreign body aspiration in children: what is variant in management?. Menoufia Med J 2020;33:381-6

How to cite this URL:
Atallah AT, Beheiry EA, Abdel-Shafy IA, Zamzam KM, El-Dahshan MAG. Foreign body aspiration in children: what is variant in management?. Menoufia Med J [serial online] 2020 [cited 2020 Jul 14];33:381-6. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/381/287757




  Introduction Top


Foreign body aspiration (FBA) is an important cause of morbidity and mortality in pediatrics. Most cases occur in children younger than 3 years, and the classic triad of choking, cough, and unilateral wheezing or decreased air entry is seen in only a minority of patients. Oftentimes, the diagnosis can be challenging when an aspiration event is not directly witnessed[1].

When the initial chest examination, chest radiography, and blood gases are normal, bronchoscopy can identify large airway injury, a precursor to respiratory complications due to inhalational injury. The flexible bronchoscope has a great value in the diagnosis of inhalational injury without any complications[2].

The incidence of respiratory failure is significant after inhalational accidents, with hypoxemia, pneumonia, and respiratory failure with prolonged ventilatory support and extended hospitalization being common[3].

Bronchoscopic findings in patients with inhalational accidents include congestion, edema, mucosal ulceration, and necrosis. When the inhaled matter contains carbon-based soot, the carbon soot will adhere to the mucosal surfaces of all visible airways[4].

Management depends on the acuity of the presentation. Patients with evidence of complete upper airway obstruction should have age-appropriate basic life support maneuvers performed. Patients with partial obstruction who are able to maintain their airway but with potential for deterioration should be taken immediately to the operating room for removal whenever possible. Stable patients may have radiographic studies performed to assist in risk stratification. Patients in whom suspicion for FBA is high should undergo bronchoscopy, whereas a subset of low-risk patients may be observed. Delays in diagnosis increase the risk of complications[5].

FBA occurs when a foreign body (FB), often food, becomes accidentally lodged at a point within the hypopharynx or tracheobronchial tree. Aspiration varies in presentation ranging from complete upper airway obstruction and arrest to more indolent presentations related to the development of sequelae such as chronic pulmonary infections and bronchiectasis[6].

Most commonly FBA cases are suspected or witnessed, the patients are symptomatic, and they present acutely for evaluation. A high level of suspicion will aid in establishing a timely diagnosis and helps to prevent complications from missed cases. Seventy percent of FBA occurs in children younger than 3 years[7].

Aspirated FBs can be broadly categorized as food and nonfood items. Food and food-related items are by far the most commonly aspirated across all age groups, particularly peanuts, tree nuts, and seeds. Older children tend to aspirate nonfood materials such as pen caps and pins more frequently than do younger children[8].

The aim of this study is to evaluate the incidence, diagnosis, and therapeutic bronchoscopic intervention, of FBA, in children (up to 12 years old).


  Patients and Methods Top


Our prospective study was carried on the total of 45 children; with suspected FBA up to 12 years old; presenting to the Department of Otorhinolaryngology in Menoufia University Hospital in a period between April 2017 and September 2018 will be enrolled in the study. Patients below 12 years with suspected FBA and who were fit for the operation were included in our study. All patients were subjected to full history taking, general, chest, and otorhinolaryngological examination plus chest radiography and computed topography. Visualization of FB by the rigid bronchoscope was done for those could not be detected by radiological studies.

The study was approved by the scientific ethical committee of Menoufia Medical School, and the patients' parents signed written consent after they were informed about the nature of the study.

Outcomes

  1. Primary outcome: is to detect the incidence of FBA in children who presented with choking manifestations
  2. Secondary outcome: is to detect the main clinical presentation for patients presented with FBA
  3. Tertiary outcome: is to study factors affecting the occurrence of complications.


Operative technique

After taking written consent from every patient, all operations were done under inhalational anesthesia. An appropriate sized rigid ventilating bronchoscope with the light source was used. The patient is put in the proper position when intubating the airway with a rigid bronchoscope. A tooth guard was placed to protect the upper incisors. The patient was in the supine position with atlanto-occipital extension. This position elevates the larynx and creates linear alignment of oral, pharyngeal, and laryngeal axes. The bronchoscope was either used to elevate the epiglottis visualizing the vocal cords then introduced into the trachea under direct vision. Or, if this was difficult, laryngoscopy was done first then the appropriate size rigid bronchoscope was advanced into the trachea, ventilation was established and confirmed by the anesthesia team. The trachea was inspected completely till the primary carina. Then to enter the left main bronchus, the bronchoscope was positioned in the right angle of the mouth and the head rotated to the right, bringing the long axis of the bronchoscope and left main bronchus into alignment. Then to enter the right main bronchus, the head of the patient and the bronchoscope were rotated to the left. The location of the FB was approached slowly and carefully to avoid overriding or displacement.

Finally, the forceps holding the FB was removed. After extraction of the detected FB, the second look was done for other FBs, residual FB fragments. Patients were transferred to the postanesthesia recovery unit until full recovery and improvement in cardio-respiratory parameters. All children were re-examined especially otorhinolaryngologic examination, chest examination; chest radiography was done in some patients. They were put under observation and receiving broad-spectrum antibiotics, corticosteroids and mucolytic for 6–24 h after the procedure.

Statistical analysis

Data entry, processing, and statistical analysis were carried out using MedCalc, version 15.8. (Med. Calc, Ostend, Belgium). Tests of significance (χ2 tests, logistic regression analysis, and receiver operating characteristic curve analysis) were used. Data were presented, and suitable analysis was done according to the type of data (parametric and nonparametric) obtained for each variable. P values less than 0.05 (5%) was considered to be statistically significant. P value more than 0.05: nonsignificant, P value less than 0.05: significant, P value less than 0.01: highly significant.

Descriptive statistics were used in our study were frequency and percentage of non-numerical data plus mean ± SD and range for parametric numerical data, while median and interquartile range for nonparametric numerical data.

Correlation studies between postbronchoscopy outcomes (complication occurrence); and its relative independent predictors (sociodemographic, clinical, radiological, and bronchoscopic variables) will be conducted with logistic regression analysis. Predictor variables included in the regression model are age, sex, residence, socioeconomic status plus clinical, radiological, bronchoscopic data.


  Results Top


According to our study, 70% of the cases were below 1.5 years. Majority of cases were male (28 cases) as shown in [Table 1].
Table 1: Sociodemographic data

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The most presented clinical findings are choking (40 cases) plus cough and diminished air entry (35 cases for each one) as regards all clinical variables as shown in [Table 2].
Table 2: Clinical data

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Among 32 cases with localized FB, 13 FBs were located at right lung and 16 FB were located in the left lung plus another three of them were located centrally as regards side of FBs as shown in [Table 3].
Table 3: Bronchoscopic findings in patients with detected foreign body (32 patients)

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Seven cases only presented with postoperative complications which include hemoptysis, laryngeal spasm, pulmonary edema, and temporary bronchospasm as shown in [Table 4]. These presentations managed in a few days after the operation. Only one case prepared for bronchoscopic intervention and failed to extract its FB.
Table 4: Radiological data

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Logistic regression analysis shows that; after applying Forward method and entering some predictor variables; the increase in chocking events and the presence of radio-opaque FBs; had an independent effect on increasing the probability of complication occurrence; with significant statistical difference (P < 0.05, respectively) as shown in [Table 5],[Table 6],[Table 7].
Table 5: Nature of foreign body and onset of detection and its relation to complications

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Table 6: Complications after bronchoscopic intervention

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Table 7: Logistic regression model for the factors affecting complication occurrence using forward method

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  Discussion Top


Our study was done on 45 cases aged up to 12 years, while 30 cases were up to 36 months. These results came in agreement with Passali and colleagues; who reported that the fact that the highest prevalence of FB injuries is reported for children between 0 and 3 years of age depends primarily on the fact that young children explore objects using their mouth, are not able to distinguish edible objects from nonedible ones, their teeth are physiologically lacking (they have incisors to tear food, but not cuspids, with consequently difficulties in reducing food in a smooth bolus) and have poor swallowing coordination (compared with older children and adults)[9].

In 58 articles included in the review article, overall collecting 6757 cases, the number of males having experienced FB injuries was 4008. The pooled proportion is 60%; therefore, boys seem to outnumber girls among infants with unintentional FB injury. Both case series testify these airway FB injuries most commonly occur in young children, in fact, the 75% of cases collected in high-income countries and the 60% of those collected in low-middle income were between 0 and 3 years of age[10].

FBs were found in 23 (33%) of the 70 patients included in a study conducted by Haller and colleagues (45 boys, 25 girls; median age: 21.5 months). Diagnosis of FBA was made on the first intention in 22/23 (96%) and extraction was performed in 7/23 (30%) by flexible bronchoscopy. Rigid bronchoscopy was necessary for the extraction of the 16/23 (70%) remaining FBs. The rigid procedure was performed as the first intention in only two (3%) patients, and one of the two was negative. Seven clinical and radiologic signs were found to be significantly different between FB + and FB − groups: sudden choking, cyanosis, apnea, decreased breath sounds, atelectasis, mediastinal shift, and air trapping. Conversely, when none of these symptoms or signs and no clear history of sudden choking were present (in 15/70 patients), no FB was found[11].

Another study showed that the most common presenting symptoms were cough (88%), choking/gagging (67%), and wheezing (57%). Decreased breath sounds and wheezing on examination were independently associated with increased odds of a FB. Having a positive history, examination, and chest radiograph combined was 46% sensitive and 79% specific[12].

Among 40 patients who underwent rigid bronchoscopy in a study conducted by Acharya, 32 (80%) were found to have varieties of FBs in their airway while eight (20%) patients had negative bronchoscopy. The history of choking is the only clinical symptoms which came out to be statistically significant (P = 0.043)[13].

Mansour made a study showed that the rate of negative finding in rigid bronchoscopy in our study was as low as 15% (in only eight of 52 rigid bronchoscopies was the finding negative for FBA)[14].

The study done by Kiyan et al.[15] on 192 patients who underwent rigid bronchoscopy, with the presence of wheeze as a symptom, had the highest sensitivity at 87.7%, followed by unilateral decreased air entry on auscultation (i.e., 78.3%).

Regarding bronchoscopic data, our results came in agreement with Belcher et al.[16]; who mentioned that the gold standard for localization and removal of an aspirated FB is rigid ventilating bronchoscopy.

Hitter showed that chest radiography during inspiration and expiration, often performed as the first-line radiographic investigation, has a low sensitivity and specificity. In the absence of a radio-opaque FB, obstructive emphysema is the most specific radiographic sign. Airway fluoroscopy can complete chest radiography when radiographic signs are nonspecific[17].

There is aspiration of FBs in the present district: if it is related to the socioeconomic factors, family problems, if it is related to the education or ignorance of the parents or it is related to large numbers of children in the family. All the factors must be clarified to illustrate why there are such a high number of inhaled FBs.

Of 214 cases of FBs confirmed by bronchoscopy in a study conducted by Goyal and colleagues, 207 (96.7%) were successfully extracted. Of these 214 cases, 105 (49%) FBs were found on the right side, 81 (38%) FBs on the left side, and 28 (13%) FBs in the trachea as shown in our study[18].

As regards the complication rate, our results came in agreement with Naragund et al.[8].

Another study showed that complication rates during bronchoscopy ranged from 1 to 8%, with a mortality rate of less than 1%. The most common complications include laryngeal edema, bronchospasm requiring intubation or tracheostomy, pneumothorax, pneumomediastinum, tracheal or bronchial laceration, failure to remove the FB, hypoxic brain injury, and cardiac arrest[19].

Our results came in agreement with Ulla and colleagues; who reported that rigid bronchoscopy which is the gold standard in the diagnosis of FB airway, but flexible bronchoscopy had a much higher sensitivity for distal FB removal[20].


  Conclusion Top


It is concluded that the FB extraction in children occurred more for whom with low socioeconomic standard and higher number of siblings in one family. Rigid bronchoscope is used as diagnostic and therapeutic tool for patients with FB aspiration to that could not be detected in radiological study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Mansour B, Elias N. Foreign body aspiration in children with a focus on the role of flexible bronchoscopy: 5-year experience. Isr Med Assoc J 2015; 17 :599–603.  Back to cited text no. 14
    
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Kiyan G, Gocmen B, Tugtepe H, Karakoc F, Dagli E, Dagli TE. Foreign body aspiration in children: the value of diagnostic criteria. Int J Pediatr Otorhinolaryngol 2009; 73 :963–967.  Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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